High Cost Claims Summary
Company: ST LUCIE COUNTY SCHOOL BOARD
Group: 24936
High Cost Claims Threshold: 50000
Current Service Period: From 01/2014 to 12/2014
Current Paid Period: From 01/2014 to 03/2015
CURRENT
Rank
Inpatient
Div
Relationship
1
001
SUBSCRIBER
2
009
SPOUSE
3
SUBSCRIBER
4
001
SUBSCRIBER
5
R17
SUBSCRIBER
6
001
DEPENDENT
7
001
SUBSCRIBER
8
009
SPOUSE
9
R01
SUBSCRIBER
10
R17
SUBSCRIBER
Diagnosis Description
STEVENS-JOHNSON SYNDROME-TOXIC
EPIDERMAL NECROLYSIS OVERLAP
SYNDROME; OTHER POSTOPERATIVE
INFECTION; UNSPECIFIED SEPTICEMIA
PNEUMONIA DUE TO PARAINFLUENZA VIRUS;
MULTIPLE MYELOMA, WITHOUT MENTION OF
HAVING ACHIEVED REMISSION; OTHER
IMMUNOPROLIFERATIVE NEOPLASMS IN
REMISSION
ENCOUNTER FOR ANTINEOPLASTIC
CHEMOTHERAPY; ACUTE MYELOID LEUKEMIA,
WITHOUT MENTION OF HAVING ACHIEVED
REMISSION; MISSING OR UNKNOWN
DIAGNOSIS CODE
ACUTE MYOCARDIAL INFARCTION,
SUBENDOCARDIAL INFARCTION, INITIAL
EPISODE OF CARE; END STAGE RENAL
DISEASE; CORONARY ATHEROSCLEROSIS OF
UNSPECIFIED TYPE OF VESSEL, NATIVE OR
GRAFT
METHICILLIN RESISTANT STAPHYLOCOCCUS
AUREUS SEPTICEMIA; ATHEROSCLEROSIS OF
NATIVE ARTERIES OF THE EXTREMITIES WITH
GANGRENE; UNSPECIFIED PERIPHERAL
VASCULAR DISEASE
NEOPLASM OF UNSPECIFIED NATURE OF
BRAIN; SECONDARY DIABETES MELLITUS
WITHOUT MENTION OF COMPLICATION,
UNCONTROLLED; OTHER PULMONARY
EMBOLISM AND INFARCTION
MISSING OR UNKNOWN DIAGNOSIS CODE;
UNSPECIFIED VIRAL HEPATITIS C WITHOUT
HEPATIC COMA; CHRONIC HEPATITIS C
WITHOUT MENTION OF HEPATIC COMA
MALIGNANT NEOPLASM OF INTRAHEPATIC
BILE DUCTS; MALIGNANT NEOPLASM OF
BILIARY TRACT, PART UNSPECIFIED SITE;
RADIOTHERAPY
CRYPTOGENIC ORGANIZING PNEUMONIA;
HIGH GRADE MYELODYSPLASTIC SYNDROME
LESIONS; MYELODYSPLASTIC SYNDROME,
UNSPECIFIED
MISSING OR UNKNOWN DIAGNOSIS CODE;
*****; NECK SPRAIN AND STRAIN
Outpatient
Paid Amt
Visits
Professional
Paid Amt
Services
Paid Amt
Pharmacy
Days
Admits
# of Rx
107
6
$689,179.13
0
$0.00
634
$71,644.13
17
$3,566.79
$764,390.05
$2,833,572.40
75
5
$323,150.99
44
$88,931.28
446
$73,531.07
71
$4,832.44
$490,445.78
$955,905.25
100
5
$223,682.75
24
$17,179.52
307
$23,203.49
30
$12,184.30
$276,250.06
$1,122,246.60
21
2
$208,701.12
15
$24,256.13
204
$20,409.52
41
$2,485.53
$255,852.30
$1,428,425.65
61
5
$171,573.60
25
$18,989.74
315
$37,709.85
24
$1,354.89
$229,628.08
$1,421,891.59
51
4
$159,690.83
17
$16,272.82
331
$40,491.46
51
$5,171.00
$221,626.11
$868,401.38
0
0
$0.00
2
$4,997.00
14
$1,891.77
43
$193,896.10
$200,784.87
$212,337.48
7
2
$31,410.20
17
$72,503.83
336
$78,216.27
36
$7,296.76
$189,427.06
$378,883.53
36
1
$123,945.24
26
$32,866.46
179
$23,029.42
28
$7,045.42
$186,886.54
$377,327.13
0
0
$0.00
0
$0.00
49
$1,627.84
41
$183,581.43
$185,209.27
$206,853.61
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Paid Amt
Total Paid Amt Total Billed Amt
11
008
SUBSCRIBER
12
001
SUBSCRIBER
13
008
SUBSCRIBER
14
001
SUBSCRIBER
15
008
SUBSCRIBER
16
001
SUBSCRIBER
17
R17
SUBSCRIBER
18
001
SUBSCRIBER
19
001
SUBSCRIBER
20
R01
SUBSCRIBER
21
001
SUBSCRIBER
22
C01
SUBSCRIBER
23
001
SUBSCRIBER
MISSING OR UNKNOWN DIAGNOSIS CODE;
NONSPECIFIC ABNORMAL
ELECTROCARDIOGRAM (ECG) (EKG);
CERVICALGIA
MALIGNANT NEOPLASM OF BRONCHUS AND
LUNG, UNSPECIFIED SITE; HEMOPTYSIS,
UNSPECIFIED; MALIGNANT NEOPLASM OF
UPPER LOBE, BRONCHUS, OR LUNG
ABDOMINAL ANEURYSM WITHOUT MENTION
OF RUPTURE; THORACIC ANEURYSM WITHOUT
MENTION OF RUPTURE; CONGENITAL
ANOMALY OF AORTIC ARCH
MISSING OR UNKNOWN DIAGNOSIS CODE;
MULTIPLE MYELOMA, WITHOUT MENTION OF
HAVING ACHIEVED REMISSION; LUMP OR
MASS IN BREAST
ACUTE MYOCARDIAL INFARCTION,
SUBENDOCARDIAL INFARCTION, INITIAL
EPISODE OF CARE; MISSING OR UNKNOWN
DIAGNOSIS CODE; CORONARY
ATHEROSCLEROSIS OF NATIVE CORONARY
ARTERY
SEPTICEMIA DUE TO UNSPECIFIED GRAMNEGATIVE ORGANISM; CIRRHOSIS OF LIVER
WITHOUT MENTION OF ALCOHOL;
UNSPECIFIED SEPTICEMIA
ENCOUNTER FOR ANTINEOPLASTIC
CHEMOTHERAPY; NEUTROPENIA,
UNSPECIFIED; DUODENAL ULCER,
UNSPECIFIED AS ACUTE OR CHRONIC,
WITHOUT MENTION OF HEMORRHAGE OR
PERFORATION, WITH OBSTRUCTION
MALIGNANT NEOPLASM OF UPPER LOBE,
BRONCHUS, OR LUNG; CORONARY
ATHEROSCLEROSIS OF NATIVE CORONARY
ARTERY; MALIGNANT NEOPLASM OF
BRONCHUS AND LUNG, UNSPECIFIED SITE
*****; MISSING OR UNKNOWN DIAGNOSIS
CODE; NECK SPRAIN AND STRAIN
MISSING OR UNKNOWN DIAGNOSIS CODE;
PRIMARY PULMONARY HYPERTENSION;
HYPOXEMIA
MALIGNANT NEOPLASM OF CORPUS UTERI,
EXCEPT ISTHMUS; MALIGNANT NEOPLASM OF
OTHER SPECIFIED SITES OF BODY OF
UTERUS; DRUG INDUCED NEUTROPENIA
ACUTE PANCREATITIS; END STAGE RENAL
DISEASE; INFECTION AND INFLAMMATORY
REACTION DUE TO OTHER VASCULAR DEVICE,
IMPLANT, AND GRAFT
MALIGNANT NEOPLASM OF UPPER-OUTER
QUADRANT OF FEMALE BREAST; MALIGNANT
NEOPLASM OF BREAST (FEMALE),
UNSPECIFIED SITE; MISSING OR UNKNOWN
DIAGNOSIS CODE
0
0
$0.00
0
$0.00
75
$3,809.07
17
$150,933.14
$154,742.21
$167,767.11
14
1
$122,365.67
1
$2,540.25
76
$17,545.97
10
$249.87
$142,701.76
$483,100.96
11
1
$108,997.94
41
$9,916.11
97
$21,206.51
22
$545.82
$140,666.38
$433,162.58
0
0
$0.00
1
$0.00
33
$802.50
32
$136,896.15
$137,698.65
$142,457.96
8
2
$108,389.29
3
$614.89
99
$17,281.13
49
$10,917.59
$137,202.90
$309,073.20
21
6
$94,003.05
3
$10,830.84
158
$17,427.61
26
$661.99
$122,923.49
$361,220.72
17
2
$28,506.06
18
$85,989.53
109
$7,877.52
17
$224.90
$122,598.01
$363,411.75
4
1
$24,082.60
4
$16,761.39
384
$77,926.73
32
$649.01
$119,419.73
$404,167.59
31
2
$96,360.98
1
$1,704.40
155
$11,903.37
14
$8,295.45
$118,264.20
$506,022.68
0
0
$0.00
1
$7,226.42
68
$4,158.73
48
$104,416.30
$115,801.45
$139,911.76
14
2
$61,282.84
7
$4,976.73
407
$44,666.14
29
$1,431.01
$112,356.72
$573,738.11
35
4
$72,818.64
16
$32,233.52
47
$2,892.94
0
$0.00
$107,945.10
$1,470,127.78
2
1
$8,284.15
11
$12,001.13
165
$76,279.95
58
$8,954.54
$105,519.77
$256,094.04
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24
001
SPOUSE
25
008
SUBSCRIBER
26
001
SUBSCRIBER
27
001
SUBSCRIBER
28
001
SUBSCRIBER
29
001
SUBSCRIBER
30
001
SUBSCRIBER
31
001
SPOUSE
32
001
SUBSCRIBER
33
008
SUBSCRIBER
34
001
SUBSCRIBER
END STAGE RENAL DISEASE; DIABETES WITH
OTHER SPECIFIED MANIFESTATIONS, TYPE II
OR UNSPECIFIED TYPE, NOT STATED AS
UNCONTROLLED; DIABETES WITH OTHER
SPECIFIED MANIFESTATIONS, TYPE II OR
UNSPECIFIED TYPE, UNCONTROLLED
MALIGNANT NEOPLASM OF BREAST (FEMALE),
UNSPECIFIED SITE; SECONDARY MALIGNANT
NEOPLASM OF BRAIN AND SPINAL CORD;
CHEST PAIN, OTHER
EXUDATIVE SENILE MACULAR DEGENERATION
OF RETINA; PROLIFERATIVE DIABETIC
RETINOPATHY; MISSING OR UNKNOWN
DIAGNOSIS CODE
MALIGNANT NEOPLASM OF TAIL OF
PANCREAS; ENCOUNTER FOR
ANTINEOPLASTIC CHEMOTHERAPY;
MALIGNANT NEOPLASM OF PANCREAS, PART
UNSPECIFIED
LOCALIZED OSTEOARTHROSIS NOT SPECIFIED
WHETHER PRIMARY OR SECONDARY, LOWER
LEG; OSTEOARTHROSIS, UNSPECIFIED
WHETHER GENERALIZED OR LOCALIZED,
LOWER LEG; AFTERCARE FOLLOWING JOINT
REPLACEMENT
MALIGNANT NEOPLASM OF LOWER-OUTER
QUADRANT OF FEMALE BREAST; ENCOUNTER
FOR ANTINEOPLASTIC CHEMOTHERAPY;
DIFFUSE CYSTIC MASTOPATHY
INTERVERTEBRAL CERVICAL DISC DISORDER
WITH MYELOPATHY, CERVICAL REGION;
DISPLACEMENT OF CERVICAL
INTERVERTEBRAL DISC WITHOUT
MYELOPATHY; SPRAIN AND STRAIN OF
UNSPECIFIED SITE OF SHOULDER AND UPPER
ARM
MISSING OR UNKNOWN DIAGNOSIS CODE;
CERVICAL SPONDYLOSIS WITH MYELOPATHY;
INTERVERTEBRAL CERVICAL DISC DISORDER
WITH MYELOPATHY, CERVICAL REGION
ACUTE MYOCARDIAL INFARCTION OF
ANTEROLATERAL WALL, INITIAL EPISODE OF
CARE; ACUTE MYOCARDIAL INFARCTION,
UNSPECIFIED SITE, EPISODE OF CARE
UNSPECIFIED; UNSPECIFIED MONONEURITIS
OF LOWER LIMB
PRIMARY LOCALIZED OSTEOARTHROSIS,
LOWER LEG; ATRIAL FIBRILLATION;
OSTEOARTHROSIS, UNSPECIFIED WHETHER
GENERALIZED OR LOCALIZED, LOWER LEG
LOCALIZED OSTEOARTHROSIS NOT SPECIFIED
WHETHER PRIMARY OR SECONDARY, LOWER
LEG; MISSING OR UNKNOWN DIAGNOSIS
CODE; URINARY TRACT INFECTION, SITE NOT
SPECIFIED
12
1
$18,423.38
176
$71,189.62
100
$14,254.83
12
$26.66
$103,894.49
$1,145,466.53
9
2
$31,734.05
2
$6,300.00
130
$63,993.98
17
$396.98
$102,425.01
$452,895.05
0
0
$0.00
2
$1,885.68
362
$88,415.68
15
$3,799.14
$94,100.50
$303,533.32
8
2
$33,115.51
8
$40,420.58
194
$17,605.90
54
$1,014.62
$92,156.61
$317,684.94
16
1
$82,736.97
2
$1,377.64
53
$6,056.80
38
$902.42
$91,073.83
$178,774.04
0
0
$0.00
2
$6,500.90
238
$80,977.80
11
$1,634.94
$89,113.64
$230,639.72
3
1
$63,132.32
9
$2,161.99
83
$19,755.64
23
$141.89
$85,191.84
$326,274.63
0
0
$0.00
9
$6,230.81
53
$8,872.05
65
$66,980.60
$82,083.46
$130,856.55
7
1
$61,855.66
2
$6,090.00
52
$9,419.75
74
$3,153.22
$80,518.63
$187,001.97
6
1
$30,633.15
10
$28,575.23
106
$16,204.15
24
$2,049.92
$77,462.45
$356,845.14
6
2
$60,791.38
7
$4,141.40
84
$6,526.90
37
$5,393.43
$76,853.11
$248,087.50
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35
001
SUBSCRIBER
36
C01
SUBSCRIBER
37
001
DEPENDENT
38
008
SUBSCRIBER
39
001
SUBSCRIBER
40
R01
SUBSCRIBER
41
008
SUBSCRIBER
42
001
SUBSCRIBER
43
001
SUBSCRIBER
44
001
SUBSCRIBER
45
001
SUBSCRIBER
46
008
SUBSCRIBER
47
R01
SUBSCRIBER
INFECTION AND INFLAMMATORY REACTION
DUE TO INTERNAL JOINT PROSTHESIS; OTHER
ACQUIRED DEFORMITIES OF KNEE; INFECTION
AND INFLAMMATORY REACTION DUE TO
OTHER INTERNAL ORTHOPEDIC DEVICE,
IMPLANT, AND GRAFT
OTHER MECHANICAL COMPLICATION OF
PROSTHETIC JOINT IMPLANT; DISPLACEMENT
OF CERVICAL INTERVERTEBRAL DISC
WITHOUT MYELOPATHY; CERVICALGIA
SCOLIOSIS (AND KYPHOSCOLIOSIS),
IDIOPATHIC; UNSPECIFIED MYALGIA AND
MYOSITIS; SICKLE-CELL THALASSEMIA
WITHOUT CRISIS
MALIGNANT NEOPLASM OF DESCENDING
COLON; VARICOSE VEINS OF LOWER
EXTREMITIES WITH ULCER; ENCOUNTER FOR
ANTINEOPLASTIC CHEMOTHERAPY
MISSING OR UNKNOWN DIAGNOSIS CODE;
MULTIPLE SCLEROSIS; DIABETES MELLITUS
WITHOUT MENTION OF COMPLICATION, TYPE I
[JUVENILE TYPE], NOT STATED AS
UNCONTROLLED
MISSING OR UNKNOWN DIAGNOSIS CODE;
CORONARY ATHEROSCLEROSIS OF NATIVE
CORONARY ARTERY; OTHER AND
UNSPECIFIED ANGINA PECTORIS
NONSPECIFIC ABNORMAL RESULTS OF LIVER
FUNCTION STUDY; UNSPECIFIED HEPATITIS;
INTERMEDIATE CORONARY SYNDROME
LOCALIZED OSTEOARTHROSIS NOT SPECIFIED
WHETHER PRIMARY OR SECONDARY, LOWER
LEG; PRIMARY LOCALIZED OSTEOARTHROSIS,
LOWER LEG; OSTEOARTHROSIS, UNSPECIFIED
WHETHER GENERALIZED OR LOCALIZED,
LOWER LEG
INTRACEREBRAL HEMORRHAGE; MISSING OR
UNKNOWN DIAGNOSIS CODE; UNSPECIFIED
INTRACRANIAL HEMORRHAGE
ACUTE MYOCARDIAL INFARCTION,
SUBENDOCARDIAL INFARCTION, INITIAL
EPISODE OF CARE; CHEST PAIN, OTHER;
OCCLUSION AND STENOSIS OF CAROTID
ARTERY WITHOUT MENTION OF CEREBRAL
INFARCTION
OSTEOARTHROSIS, UNSPECIFIED WHETHER
GENERALIZED OR LOCALIZED, LOWER LEG;
MISSING OR UNKNOWN DIAGNOSIS CODE;
LUMBAGO
HEMORRHAGE COMPLICATING A PROCEDURE;
OTHER AND UNSPECIFIED OVARIAN CYST;
OTHER ANTEPARTUM HEMORRHAGE, WITH
DELIVERY
MISSING OR UNKNOWN DIAGNOSIS CODE;
MULTIPLE SCLEROSIS; OTHER SCREENING
MAMMOGRAM
5
2
$40,152.95
35
$7,812.21
168
$27,088.04
44
$531.38
$75,584.58
$167,207.64
4
2
$54,333.23
17
$4,326.08
125
$14,312.53
112
$2,203.79
$75,175.63
$396,741.59
4
1
$51,715.61
2
$5,883.68
51
$17,297.21
4
$12.52
$74,909.02
$394,354.80
0
0
$0.00
35
$30,338.99
104
$36,594.04
28
$7,855.06
$74,788.09
$142,763.66
0
0
$0.00
0
$0.00
39
$2,717.83
67
$70,080.62
$72,798.45
$85,469.90
0
0
$0.00
1
$7,371.60
26
$1,647.44
51
$63,435.82
$72,454.86
$94,096.29
11
3
$41,997.49
3
$11,031.14
198
$12,669.49
66
$6,052.39
$71,750.51
$233,531.24
8
2
$58,553.31
5
$2,469.33
128
$10,432.85
16
$181.04
$71,636.53
$261,066.77
6
1
$19,633.68
10
$17,610.17
95
$8,771.05
58
$24,879.03
$70,893.93
$210,630.26
8
1
$54,081.51
1
$8,150.00
57
$6,979.59
17
$136.10
$69,347.20
$288,961.06
4
1
$31,500.00
35
$15,516.19
111
$12,242.25
100
$10,002.10
$69,260.54
$270,162.14
4
2
$41,695.23
6
$12,145.89
44
$12,551.75
15
$142.48
$66,535.35
$173,174.54
0
0
$0.00
0
$0.00
21
$2,248.48
50
$64,021.37
$66,269.85
$72,634.97
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48
001
SUBSCRIBER
49
001
SUBSCRIBER
50
001
SPOUSE
51
001
SUBSCRIBER
52
001
SUBSCRIBER
53
001
SPOUSE
54
001
SUBSCRIBER
55
008
SUBSCRIBER
56
002
SUBSCRIBER
57
001
SPOUSE
58
R01
SUBSCRIBER
59
SUBSCRIBER
60
001
SUBSCRIBER
61
008
SUBSCRIBER
62
008
SUBSCRIBER
63
R01
SUBSCRIBER
UNSPECIFIED CAUSES OF ENCEPHALITIS,
MYELITIS, AND ENCEPHALOMYELITIS;
URINARY TRACT INFECTION, SITE NOT
SPECIFIED; NEOPLASM OF UNCERTAIN
BEHAVIOR OF BRAIN AND SPINAL CORD
MISSING OR UNKNOWN DIAGNOSIS CODE;
*****; ESSENTIAL HYPERTENSION, BENIGN
MISSING OR UNKNOWN DIAGNOSIS CODE;
NEOPLASM OF UNCERTAIN BEHAVIOR OF
SKIN; CHRONIC INFLAMMATORY
DEMYELINATING POLYNEURITIS
INFECTION AND INFLAMMATORY REACTION
DUE TO OTHER INTERNAL PROSTHETIC
DEVICE, IMPLANT, AND GRAFT; *****;
PROPHYLACTIC BREAST REMOVAL
MISSING OR UNKNOWN DIAGNOSIS CODE;
BRONCHIECTASIS WITHOUT ACUTE
EXACERBATION; NONSPECIFIC ABNORMAL
ELECTROCARDIOGRAM (ECG) (EKG)
MISSING OR UNKNOWN DIAGNOSIS CODE;
ALLERGIC RHINITIS DUE TO OTHER
ALLERGEN; TETANUS-DIPHTHERIA [TD] [DT]
UNSPECIFIED SEPTICEMIA; MISSING OR
UNKNOWN DIAGNOSIS CODE; DIABETES WITH
HYPEROSMOLARITY, TYPE II OR UNSPECIFIED
TYPE, UNCONTROLLED
MALIGNANT NEOPLASM OF CORPUS UTERI,
EXCEPT ISTHMUS; LEIOMYOMA OF UTERUS,
UNSPECIFIED; ABDOMINAL PAIN, LEFT LOWER
QUADRANT
OTHER PSORIASIS; MISSING OR UNKNOWN
DIAGNOSIS CODE; CHEST PAIN, UNSPECIFIED
CORONARY ATHEROSCLEROSIS OF NATIVE
CORONARY ARTERY; CLOSED FRACTURE OF
ACROMIAL PROCESS OF SCAPULA; MISSING
OR UNKNOWN DIAGNOSIS CODE
MISSING OR UNKNOWN DIAGNOSIS CODE;
MACULAR PUCKERING OF RETINA; OTHER
SCREENING MAMMOGRAM
LOCALIZED OSTEOARTHROSIS NOT SPECIFIED
WHETHER PRIMARY OR SECONDARY, LOWER
LEG; PRIMARY LOCALIZED OSTEOARTHROSIS,
LOWER LEG; INJURY, OTHER AND
UNSPECIFIED, KNEE, LEG, ANKLE, AND FOOT
ATRIOVENTRICULAR BLOCK, COMPLETE;
MISSING OR UNKNOWN DIAGNOSIS CODE;
MALIGNANT NEOPLASM OF LOWER-INNER
QUADRANT OF FEMALE BREAST
MISSING OR UNKNOWN DIAGNOSIS CODE;
LEIOMYOMA OF UTERUS, UNSPECIFIED;
OTHER NONSPECIFIC ABNORMAL
CARDIOVASCULAR SYSTEM FUNCTION STUDY
PRIMARY LOCALIZED OSTEOARTHROSIS,
LOWER LEG; BARRETT'S ESOPHAGUS;
CERVICOBRACHIAL SYNDROME (DIFFUSE)
INCISIONAL VENTRAL HERNIA, WITH
GANGRENE; DISRUPTION OF EXTERNAL
OPERATION (SURGICAL) WOUND;
UNSPECIFIED INTESTINAL OBSTRUCTION
10
2
$42,816.20
7
$6,429.16
111
$16,192.09
0
0
$0.00
0
$0.00
17
$345.03
0
0
$0.00
0
$0.00
25
5
1
$35,869.03
8
$15,245.17
0
0
$0.00
0
0
0
$0.00
7
2
5
$240.47
$65,677.92
$256,148.15
111
$65,327.94
$65,672.97
$72,049.12
$1,885.38
38
$63,404.42
$65,289.80
$71,053.99
90
$12,937.22
38
$378.42
$64,429.84
$302,595.23
$0.00
39
$1,821.39
67
$62,343.56
$64,164.95
$75,204.69
0
$0.00
64
$1,034.28
14
$62,478.80
$63,513.08
$66,657.80
$37,468.14
4
$5,269.25
63
$9,127.30
52
$10,976.76
$62,841.45
$123,951.48
2
$40,316.92
5
$9,459.18
73
$11,534.97
33
$1,108.93
$62,420.00
$178,888.61
0
0
$0.00
1
$5,359.86
31
$41,705.20
25
$15,196.96
$62,262.02
$101,763.38
0
0
$0.00
5
$46,349.35
94
$11,649.59
42
$3,316.82
$61,315.76
$226,631.14
0
0
$0.00
0
$0.00
22
$355.52
12
$60,123.24
$60,478.76
$62,889.61
10
2
$39,619.32
8
$4,903.61
182
$14,465.91
51
$1,246.10
$60,234.94
$316,936.55
6
1
$43,922.61
3
$1,726.89
201
$11,715.14
43
$2,793.03
$60,157.67
$167,625.39
3
1
$15,750.00
4
$10,817.80
78
$7,848.81
70
$25,060.71
$59,477.32
$163,613.80
9
2
$38,309.80
3
$2,064.68
206
$16,926.93
97
$1,544.52
$58,845.93
$259,193.55
6
1
$47,767.26
1
$3,360.00
34
$7,585.84
15
$127.13
$58,840.23
$227,932.68
This Florida Blue report is proprietary and confidential. Report Run: 03/16/2016 12:18 PM Page 1 of 1
9
64
R01
SUBSCRIBER
65
001
SPOUSE
66
R18
SPOUSE
67
009
DEPENDENT
68
001
SUBSCRIBER
69
001
SUBSCRIBER
70
008
SUBSCRIBER
71
009
SPOUSE
72
008
SUBSCRIBER
73
001
SUBSCRIBER
74
001
SUBSCRIBER
75
008
SUBSCRIBER
76
008
SUBSCRIBER
77
001
SUBSCRIBER
MALIGNANT CARCINOID TUMOR OF THE
CECUM; MALIGNANT CARCINOID TUMOR OF
THE SMALL INTESTINE, UNSPECIFIED
PORTION; BENIGN CARCINOID TUMOR OF THE
SMALL INTESTINE, UNSPECIFIED PORTION
FITTING AND ADJUSTMENT OF AUTOMATIC
IMPLANTABLE CARDIAC DEFIBRILLATOR;
MISSING OR UNKNOWN DIAGNOSIS CODE;
SQUAMOUS CELL CARCINOMA OF SKIN OF
EAR AND EXTERNAL AUDITORY CANAL
MALIGNANT NEOPLASM OF KIDNEY, EXCEPT
PELVIS; NUCLEAR SCLEROSIS; UNSPECIFIED
DISORDER OF KIDNEY AND URETER
TWIN, MATE LIVEBORN, BORN IN HOSPITAL,
DELIVERED BY CESAREAN DELIVERY; 33-34
COMPLETED WEEKS OF GESTATION;
HYPOCALCEMIA
PRIMARY LOCALIZED OSTEOARTHROSIS,
LOWER LEG; ATRIAL FIBRILLATION; OTHER
SPECIFIED REHABILITATION PROCEDURE
MALIGNANT NEOPLASM OF UPPER-OUTER
QUADRANT OF FEMALE BREAST; MISSING OR
UNKNOWN DIAGNOSIS CODE; ENCOUNTER
FOR ANTINEOPLASTIC CHEMOTHERAPY
CALCULUS OF KIDNEY; INTESTINAL OR
PERITONEAL ADHESIONS WITH OBSTRUCTION
(POSTOPERATIVE) (POSTINFECTION);
EXCESSIVE OR FREQUENT MENSTRUATION
HEADACHE; SQUAMOUS CELL CARCINOMA OF
SCALP AND SKIN OF NECK; ACTINIC
KERATOSIS
INJURY, OTHER AND UNSPECIFIED, OTHER
SPECIFIED SITES, INCLUDING MULTIPLE;
CLOSED FRACTURE OF EIGHT OR MORE RIBS;
CLOSED FRACTURE OF RIB(S), UNSPECIFIED
ACQUIRED ABSENCE OF BREAST AND NIPPLE;
MALIGNANT NEOPLASM OF LOWER-OUTER
QUADRANT OF FEMALE BREAST; ENCOUNTER
FOR ANTINEOPLASTIC CHEMOTHERAPY
DIVERTICULITIS OF COLON (WITHOUT
MENTION OF HEMORRHAGE); PNEUMONIA,
ORGANISM UNSPECIFIED; MISSING OR
UNKNOWN DIAGNOSIS CODE
MECHANICAL LOOSENING OF PROSTHETIC
JOINT; TEAR OF MEDIAL CARTILAGE OR
MENISCUS OF KNEE, CURRENT; DISLOCATION
OF PROSTHETIC JOINT
ACUTE VENOUS EMBOLISM AND THROMBOSIS
OF DEEP VESSELS OF PROXIMAL LOWER
EXTREMITY; AFTERCARE FOLLOWING
SURGERY OF THE CIRCULATORY SYSTEM,
NEC; MISSING OR UNKNOWN DIAGNOSIS
CODE
MISSING OR UNKNOWN DIAGNOSIS CODE;
FAMILY HISTORY OF MALIGNANT NEOPLASM
OF GASTROINTESTINAL TRACT; SPECIAL
SCREENING FOR MALIGNANT NEOPLASMS,
COLON
0
0
$0.00
4
$13,556.98
35
$45,014.40
0
$0.00
$58,571.38
$102,914.59
0
0
$0.00
11
$23,426.13
143
$21,290.27
72
$12,995.83
$57,712.23
$194,693.69
4
1
$41,615.85
4
$4,432.21
86
$10,073.98
13
$828.02
$56,950.06
$129,271.16
13
1
$31,723.92
2
$576.00
51
$24,213.73
1
$110.18
$56,623.83
$105,739.61
5
2
$45,468.85
2
$3,261.40
44
$4,759.44
14
$2,886.87
$56,376.56
$148,558.22
0
0
$0.00
4
$2,911.74
235
$34,132.04
34
$19,131.68
$56,175.46
$96,221.74
3
1
$13,324.35
9
$29,772.32
91
$11,556.31
39
$1,265.70
$55,918.68
$224,485.89
4
1
$33,553.21
8
$17,473.00
31
$3,475.36
45
$1,050.02
$55,551.59
$99,685.76
4
1
$12,615.85
3
$442.35
37
$41,905.98
10
$0.00
$54,964.18
$87,853.45
0
0
$0.00
1
$23,286.89
73
$30,003.49
30
$358.27
$53,648.65
$139,327.86
12
2
$38,070.80
0
$0.00
103
$7,994.80
43
$7,231.68
$53,297.28
$166,374.91
3
1
$35,007.12
5
$9,993.23
34
$8,063.38
13
$42.43
$53,106.16
$242,348.57
4
1
$45,552.48
6
$1,106.67
46
$3,533.06
20
$915.86
$51,108.07
$155,542.20
0
0
$0.00
1
$721.80
11
$1,076.93
29
$48,983.07
$50,781.80
$58,622.43
This Florida Blue report is proprietary and confidential. Report Run: 03/16/2016 12:18 PM Page 1 of 1
78
Total
008
LOCALIZED OSTEOARTHROSIS NOT SPECIFIED
WHETHER PRIMARY OR SECONDARY, LOWER
SUBSCRIBER LEG; PRIMARY LOCALIZED OSTEOARTHROSIS,
LOWER LEG; AFTERCARE FOLLOWING JOINT
REPLACEMENT
6
2
855
105
$39,504.90
$4,110,787.12
7
772
$1,951.84
$1,002,218.63
88
9,748
$8,702.78
$1,596,095.57
This Florida Blue report is proprietary and confidential. Report Run: 03/16/2016 12:18 PM Page 1 of 1
14
2,828
$334.33
$50,493.85
$262,106.08
$1,652,419.70
$8,361,521.02
$26,971,836.44
This Florida Blue report is proprietary and confidential. Report Run: 03/16/2016 12:18 PM Page 1 of 1