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Top 20 Benefits
ITS Outpatient Surgery - Exempt
Nursery, Per-Diem
Office - Practitioner Visit Specialist
Other - Laboratory
Intensive Care
Radiology Services, Office
Ambulatory Surgery
Laboratory Servics, Inpatient Facility
Medical Emergency, ER
Pharmacy, Inpatient Facility
Private Room and Board
Laboratory Services, Outpatient Facility-Type of B
Operating Room Services - Other Operating Room , I
Laboratory Services, Outpatient Facility
Injections
Override-Ambulatory Surgery-Facility
Office - Practitioner Visit Primary Care
SPRX-Provider Administered-Authed
Room and Board
Drugs Requiring Specific ID-Detailed Coding, OPFac
$0
$50,000
$100,000
$150,000
$200,000
$250,000
$300,000
$350,000
TOP CONDITION
MEMBER PAID
# OF
CLAIM
SERVICE
LINES
PLAN PAID
BENEFIT
BENEFIT
CODE
Poisoning & toxic drug effects, w comorb
$7,849.32
1,320
$348,987.34
Drugs Requiring Specific
ID-Detailed Coding, OPFac
FRXS
Jt degen -back, w comp, w comorb, w surg
$13,211.94
47
$249,484.73
Room and Board
FSRB
Psoriasis, wo comp, w comorb
$5,280.00
38
$188,485.46
SPRX-Provider
Administered-Authed
SPR4
Adult rheumatoid arthritis, wo comp, wo
comorb
$183,546.89
3,917
$175,986.63
Office - Practitioner Visit
Primary Care
VPCP
Hernias exc hiatal, wo comp, w surg
$70,383.56
167
$164,424.71
Override-Ambulatory
Surgery-Facility
FOSA
Thrombocytopenia, w comp, wo comorb,
wo surg
$8,834.71
2,125
$159,913.91
Injections
INJ
Oth hematologic dis, wo surg
$32,023.22
4,122
$157,290.31
Laboratory Services,
Outpatient Facility
FLAB
Brain trauma, w comp, w comorb, w surg
$1,257.66
45
$139,636.60
Operating Room Services -
Other Operating Room , I
FORI
Alcohol dependence, w comorb
$2,946.78
795
$136,282.71
Laboratory Services,
Outpatient Facility-Type
of B
FLB
Jt degen -knee L/leg, wo comp, wo
comorb, w surg
$15,066.79
30
$131,597.71
Private Room and Board
FPRB
Page 35 of 41
Incurred: 2/1/2016 to 1/31/2017
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