High Cost Claims Summary
Company: ST LUCIE COUNTY SCHOOL BOARD
Group: 24936
High Cost Claims Threshold: 50000
Current Service Period: From 01/2015 to 12/2015
Current Paid Period: From 01/2015 to 02/2016
CURRENT
Rank
Inpatient
Div
Relationship
1
008
SUBSCRIBER
2
R01
SUBSCRIBER
3
R01
SUBSCRIBER
4
001
SPOUSE
5
R01
SUBSCRIBER
6
001
SUBSCRIBER
7
001
SUBSCRIBER
8
001
SPOUSE
9
009
SPOUSE
10
009
SUBSCRIBER
11
001
SUBSCRIBER
Diagnosis Description
ACUTE INFECTIVE POLYNEURITIS; CHRONIC
INFLAMMATORY DEMYELINATING
POLYNEURITIS; ACUTE UPPER RESPIRATORY
INFECTIONS OF UNSPECIFIED SITE
MISSING OR UNKNOWN DIAGNOSIS CODE;
OTHER CHRONIC PULMONARY HEART
DISEASES; PRIMARY PULMONARY
HYPERTENSION
MITRAL VALVE DISORDERS; CONGENITAL
MITRAL INSUFFICIENCY; HEMATOMA
COMPLICATING A PROCEDURE
DIABETES WITH OTHER SPECIFIED
MANIFESTATIONS, TYPE II OR UNSPECIFIED
TYPE, NOT STATED AS UNCONTROLLED;
HYPERTENSIVE CHRONIC KIDNEY DISEASE,
MALIGNANT, WITH CHRONIC KIDNEY DISEASE
STAGE I THROUGH STAGE IV, OR
UNSPECIFIED; *****
UNSPECIFIED SEPTICEMIA; MISSING OR
UNKNOWN DIAGNOSIS CODE; UNSPECIFIED
ANEMIA
ACUTE AND CHRONIC RESPIRATORY FAILURE;
OTHER SPECIFIED REHABILITATION
PROCEDURE; PNEUMONIA, ORGANISM
UNSPECIFIED
SPINAL STENOSIS IN CERVICAL REGION;
BRACHIAL NEURITIS OR RADICULITIS NOS;
OTHER MALAISE AND FATIGUE
END STAGE RENAL DISEASE; DIABETES WITH
OTHER SPECIFIED MANIFESTATIONS, TYPE II
OR UNSPECIFIED TYPE, NOT STATED AS
UNCONTROLLED; CONCUSSION WITH LOSS OF
CONSCIOUSNESS OF UNSPECIFIED DURATION
ENCOUNTER FOR ANTINEOPLASTIC
CHEMOTHERAPY; CHEST PAIN, OTHER; ACUTE
MONOCYTIC LEUKEMIA IN REMISSION
ACUTE MYELOID LEUKEMIA, WITHOUT
MENTION OF HAVING ACHIEVED REMISSION;
ACUTE PHARYNGITIS; MISSING OR UNKNOWN
DIAGNOSIS CODE
MALIGNANT NEOPLASM OF BREAST (FEMALE),
UNSPECIFIED SITE; MALIGNANT NEOPLASM OF
LOWER-INNER QUADRANT OF FEMALE
BREAST; MISSING OR UNKNOWN DIAGNOSIS
CODE
Paid Amt
Outpatient
Visits
Professional
Paid Amt
Services
Days
Admits
52
4
$431,329.37
4
$12,742.00
161
$16,299.38
12
$298.54
$460,669.29
$2,628,060.34
13
1
$12,014.15
1
$549.00
147
$22,973.78
85
$331,083.85
$366,620.78
$498,555.79
5
1
$193,187.88
6
$1,368.33
95
$17,753.99
18
$1,439.21
$213,749.41
$510,543.58
22
6
$113,718.52
13
$29,369.26
544
$31,465.22
83
$9,275.62
$183,828.62
$532,914.72
17
3
$166,680.00
0
$0.00
125
$2,657.85
109
$2,805.91
$172,143.76
$332,578.87
42
3
$147,391.17
3
$921.33
161
$14,862.33
45
$3,409.02
$166,583.85
$606,507.39
6
2
$36,079.83
36
$81,074.17
266
$34,538.20
66
$2,288.80
$153,981.00
$570,159.61
2
1
$32,015.15
234
$92,858.34
83
$12,618.06
18
$1,100.59
$138,592.14
$1,246,437.09
24
2
$66,345.90
16
$39,009.50
238
$22,435.39
17
$1,693.78
$129,484.57
$324,887.98
27
1
$127,778.08
0
$0.00
$266.54
2
$2.63
$128,047.25
$264,004.79
5
1
$9,321.06
9
$32,486.90
$55,720.69
83
$25,210.53
$122,739.18
$518,449.70
5
227
Paid Amt
Pharmacy
# of Rx
This Florida Blue report is proprietary and confidential. Report Run: 03/16/2016 12:20 PM Page 1 of 1
Paid Amt
Total Paid Amt Total Billed Amt
12
008
SUBSCRIBER
13
001
SUBSCRIBER
14
001
SUBSCRIBER
15
001
SPOUSE
16
001
SUBSCRIBER
17
001
SPOUSE
18
001
SUBSCRIBER
19
009
SUBSCRIBER
20
001
SPOUSE
21
R01
SUBSCRIBER
22
008
SUBSCRIBER
23
008
SUBSCRIBER
24
001
SUBSCRIBER
25
001
SUBSCRIBER
26
001
SUBSCRIBER
LOCALIZED OSTEOARTHROSIS NOT SPECIFIED
WHETHER PRIMARY OR SECONDARY, LOWER
LEG; OTHER SPECIFIED REHABILITATION
PROCEDURE; OSTEOARTHROSIS,
UNSPECIFIED WHETHER GENERALIZED OR
LOCALIZED, LOWER LEG
UNSPECIFIED SEPTICEMIA; MISSING OR
UNKNOWN DIAGNOSIS CODE; JAUNDICE,
UNSPECIFIED, NOT OF NEWBORN
ABDOMINAL PAIN, LEFT UPPER QUADRANT;
INTESTINAL INFECTIONS DUE TO
CLOSTRIDIUM DIFFICILE; OTHER PULMONARY
EMBOLISM AND INFARCTION
ACUTE RESPIRATORY FAILURE FOLLOWING
TRAUMA AND SURGERY; *****; *****
ATRIAL FIBRILLATION; MISSING OR UNKNOWN
DIAGNOSIS CODE; PALPITATIONS
OTHER SPECIFIED CIRCULATORY SYSTEM
DISORDERS; ATHEROSCLEROSIS OF NATIVE
ARTERIES OF THE EXTREMITIES,
UNSPECIFIED; UNSPECIFIED PERIPHERAL
VASCULAR DISEASE
MALIGNANT NEOPLASM OF OVARY;
NEUTROPENIA, UNSPECIFIED; OTHER
PANCYTOPENIA
LOCALIZED OSTEOARTHROSIS NOT SPECIFIED
WHETHER PRIMARY OR SECONDARY, LOWER
LEG; OSTEOARTHROSIS, UNSPECIFIED
WHETHER GENERALIZED OR LOCALIZED,
LOWER LEG; OTHER SPECIFIED
REHABILITATION PROCEDURE
MALIGNANT NEOPLASM OF COLON,
UNSPECIFIED SITE; HYDRONEPHROSIS;
MALIGNANT NEOPLASM OF CECUM
MISSING OR UNKNOWN DIAGNOSIS CODE;
HEMORRHAGE OF RECTUM AND ANUS;
PERSONAL HISTORY OF COLONIC POLYPS
SUBARACHNOID HEMORRHAGE; ACUTE
MYOCARDIAL INFARCTION, UNSPECIFIED SITE,
INITIAL EPISODE OF CARE; CARDIAC ARREST
ACUTE MYOCARDIAL INFARCTION OF OTHER
ANTERIOR WALL, INITIAL EPISODE OF CARE;
ACUTE MYOCARDIAL INFARCTION,
UNSPECIFIED SITE, INITIAL EPISODE OF CARE;
ACUTE MYOCARDIAL INFARCTION OF OTHER
SPECIFIED SITES, INITIAL EPISODE OF CARE
MISSING OR UNKNOWN DIAGNOSIS CODE;
MALIGNANT NEOPLASM OF UPPER-OUTER
QUADRANT OF FEMALE BREAST; MALIGNANT
NEOPLASM OF BREAST (FEMALE),
UNSPECIFIED SITE
MALIGNANT NEOPLASM OF BREAST (FEMALE),
UNSPECIFIED SITE; MALIGNANT NEOPLASM OF
UPPER-OUTER QUADRANT OF FEMALE
BREAST; MISSING OR UNKNOWN DIAGNOSIS
CODE
UNSPECIFIED SEPTICEMIA; MISSING OR
UNKNOWN DIAGNOSIS CODE; INFECTIOUS
COLITIS, ENTERITIS, AND GASTROENTERITIS
20
2
$85,701.12
9
$12,074.99
135
$15,806.37
22
$123.29
$113,705.77
$384,741.62
21
1
$74,151.01
3
$1,888.67
153
$11,819.91
63
$21,313.09
$109,172.68
$829,242.05
42
4
$78,279.31
3
$652.30
122
$13,132.10
37
$14,234.46
$106,298.17
$355,633.39
10
2
$98,155.30
1
$3,515.00
46
$3,727.40
9
$13.99
$105,411.69
$281,770.50
0
0
$0.00
5
$85,619.42
56
$17,879.48
18
$723.48
$104,222.38
$503,983.70
6
2
$83,715.88
1
$6,289.08
38
$5,945.78
30
$3,714.48
$99,665.22
$400,978.48
13
4
$41,807.11
13
$16,528.21
221
$39,508.06
32
$444.66
$98,288.04
$260,665.12
13
2
$65,938.58
40
$15,122.31
86
$11,827.66
26
$281.74
$93,170.29
$306,413.97
7
1
$42,090.46
3
$16,472.98
336
$26,758.92
38
$6,641.79
$91,964.15
$518,804.50
0
0
$0.00
2
$769.78
79
$3,905.40
58
$87,227.68
$91,902.86
$113,524.17
7
1
$78,214.59
1
$4,393.00
56
$5,719.23
2
$0.00
$88,326.82
$225,733.99
3
1
$67,456.50
21
$4,728.52
49
$14,001.06
25
$1,294.42
$87,480.50
$173,281.50
3
1
$12,880.46
19
$12,634.73
224
$30,621.66
77
$31,317.55
$87,454.40
$307,352.30
0
0
$0.00
39
$36,811.58
148
$42,034.36
32
$7,244.13
$86,090.07
$202,719.87
18
4
$66,360.93
3
$1,507.60
86
$10,859.16
40
$7,100.15
$85,827.84
$281,864.04
This Florida Blue report is proprietary and confidential. Report Run: 03/16/2016 12:20 PM Page 1 of 1
27
008
28
001
29
008
30
001
31
001
32
001
33
008
34
008
35
001
36
008
37
001
38
R01
39
001
40
001
CARCINOMA IN SITU OF COLON; MISSING OR
SUBSCRIBER UNKNOWN DIAGNOSIS CODE; BENIGN
NEOPLASM OF COLON
PRIMARY LOCALIZED OSTEOARTHROSIS,
LOWER LEG; LOCALIZED OSTEOARTHROSIS
SUBSCRIBER NOT SPECIFIED WHETHER PRIMARY OR
SECONDARY, PELVIC REGION AND THIGH;
MISSING OR UNKNOWN DIAGNOSIS CODE
MISSING OR UNKNOWN DIAGNOSIS CODE;
LOCALIZED OSTEOARTHROSIS NOT SPECIFIED
WHETHER PRIMARY OR SECONDARY, LOWER
SUBSCRIBER
LEG; OSTEOARTHROSIS, UNSPECIFIED
WHETHER GENERALIZED OR LOCALIZED,
LOWER LEG
MISSING OR UNKNOWN DIAGNOSIS CODE;
SPOUSE
MULTIPLE SCLEROSIS; CARDIOMEGALY
MISSING OR UNKNOWN DIAGNOSIS CODE;
SUBSCRIBER
*****; *****
UNSPECIFIED OSTEOMYELITIS, OTHER
SPECIFIED SITES; THORACIC OR
SUBSCRIBER
LUMBOSACRAL NEURITIS OR RADICULITIS,
UNSPECIFIED; SCIATICA
MALIGNANT NEOPLASM OF UPPER-OUTER
QUADRANT OF FEMALE BREAST; DIFFUSE
SUBSCRIBER
CYSTIC MASTOPATHY; ENCOUNTER FOR
OTHER SPECIFIED AFTERCARE
MISSING OR UNKNOWN DIAGNOSIS CODE;
OTHER LEUKEMIA OF UNSPECIFIED CELL
TYPE, WITHOUT MENTION OF HAVING
SUBSCRIBER
ACHIEVED REMISSION; MALIGNANT
NEOPLASM OF UPPER-OUTER QUADRANT OF
FEMALE BREAST
MALIGNANT NEOPLASM OF UPPER LOBE,
BRONCHUS, OR LUNG; UNSPECIFIED
CEREBRAL ARTERY OCCLUSION WITH
SUBSCRIBER
CEREBRAL INFARCTION; SECONDARY
MALIGNANT NEOPLASM OF OTHER PARTS OF
NERVOUS SYSTEM
LOCALIZED OSTEOARTHROSIS NOT SPECIFIED
WHETHER PRIMARY OR SECONDARY, PELVIC
SUBSCRIBER REGION AND THIGH; HEMORRHAGE
COMPLICATING A PROCEDURE; OTHER
INTERNAL DERANGEMENT OF KNEE
MISSING OR UNKNOWN DIAGNOSIS CODE;
ALLERGIC RHINITIS DUE TO OTHER
SPOUSE
ALLERGEN; ROUTINE GENERAL MEDICAL
EXAMINATION AT HEALTH CARE FACILITY
MISSING OR UNKNOWN DIAGNOSIS CODE;
SUBSCRIBER OTHER AND UNSPECIFIED ANGINA PECTORIS;
MITRAL VALVE DISORDERS
MISSING OR UNKNOWN DIAGNOSIS CODE;
SUBSCRIBER DIARRHEA; MULTIPLE MYELOMA, WITHOUT
MENTION OF HAVING ACHIEVED REMISSION
UNSPECIFIED ESSENTIAL HYPERTENSION;
SUBSCRIBER OTHER SPECIFIED CARDIAC DYSRHYTHMIAS;
CHEST PAIN, OTHER
6
1
$48,278.03
1
$315.00
62
$5,250.10
68
$28,405.70
$82,248.83
$151,332.33
8
2
$62,220.15
10
$2,557.87
67
$11,402.25
24
$5,289.09
$81,469.36
$397,828.51
7
1
$32,394.67
8
$1,497.67
104
$8,887.71
81
$37,340.44
$80,120.49
$376,058.47
0
0
$0.00
0
$0.00
38
$1,236.54
40
$77,822.15
$79,058.69
$83,243.00
0
0
$0.00
0
$0.00
8
$125.52
115
$78,889.10
$79,014.62
$81,795.02
14
2
$54,041.83
6
$791.22
160
$21,408.38
34
$523.94
$76,765.37
$297,037.46
0
0
$0.00
4
$21,750.74
159
$51,298.56
18
$2,106.14
$75,155.44
$288,679.57
0
0
$0.00
0
$0.00
101
$2,196.40
7
$72,138.57
$74,334.97
$103,320.83
20
2
$49,721.70
2
$2,573.37
119
$21,038.14
19
$762.51
$74,095.72
$347,414.25
6
2
$50,403.16
14
$9,392.34
121
$12,631.75
25
$401.54
$72,828.79
$232,196.02
0
0
$0.00
0
$0.00
63
$1,604.27
17
$70,394.41
$71,998.68
$75,013.83
0
0
$0.00
0
$0.00
17
$949.87
50
$71,021.96
$71,971.83
$77,854.35
0
0
$0.00
1
$260.90
47
$1,647.03
23
$68,524.52
$70,432.45
$76,902.40
5
2
$28,068.30
6
$28,907.82
100
$12,113.95
22
$1,052.32
$70,142.39
$257,468.28
This Florida Blue report is proprietary and confidential. Report Run: 03/16/2016 12:20 PM Page 1 of 1
MISSING OR UNKNOWN DIAGNOSIS CODE;
MULTIPLE SCLEROSIS; DIABETES MELLITUS
WITHOUT MENTION OF COMPLICATION, TYPE I
[JUVENILE TYPE], NOT STATED AS
UNCONTROLLED
CONGESTIVE HEART FAILURE, UNSPECIFIED;
SHORTNESS OF BREATH; CHEST PAIN,
UNSPECIFIED
CERVICALGIA; DISPLACEMENT OF CERVICAL
INTERVERTEBRAL DISC WITHOUT
MYELOPATHY; DISORDER OF BONE AND
CARTILAGE, UNSPECIFIED
MISSING OR UNKNOWN DIAGNOSIS CODE;
COMPLICATIONS OF MEDICAL CARE, NEC,
INFECTION FOLLOWING OTHER INFUSION,
INJECTION, TRANSFUSION, OR VACCINATION;
ANGIONEUROTIC EDEMA NOT ELSEWHERE
CLASSIFIED
INTESTINAL OR PERITONEAL ADHESIONS
WITH OBSTRUCTION (POSTOPERATIVE)
(POSTINFECTION); ABDOMINAL PAIN,
UNSPECIFIED SITE; INCISIONAL HERNIA
WITHOUT MENTION OF OBSTRUCTION OR
GANGRENE
MISSING OR UNKNOWN DIAGNOSIS CODE;
VILLONODULAR SYNOVITIS, LOWER LEG;
CHRONIC INFLAMMATORY DEMYELINATING
POLYNEURITIS
LOCALIZED OSTEOARTHROSIS NOT SPECIFIED
WHETHER PRIMARY OR SECONDARY, LOWER
LEG; MISSING OR UNKNOWN DIAGNOSIS
CODE; EFFUSION OF LOWER LEG JOINT
MULTIPLE MYELOMA, WITHOUT MENTION OF
HAVING ACHIEVED REMISSION; MISSING OR
UNKNOWN DIAGNOSIS CODE; PNEUMONIA
DUE TO RESPIRATORY SYNCYTIAL VIRUS
MISSING OR UNKNOWN DIAGNOSIS CODE;
RHEUMATOID ARTHRITIS; ESOPHAGEAL
REFLUX
41
001
SUBSCRIBER
42
008
SUBSCRIBER
43
008
SUBSCRIBER
44
008
SUBSCRIBER
45
008
SUBSCRIBER
46
001
SPOUSE
47
001
SUBSCRIBER
48
009
SPOUSE
49
008
SUBSCRIBER
008
MALIGNANT NEOPLASM OF BREAST (FEMALE),
UNSPECIFIED SITE; ENCOUNTER FOR
SUBSCRIBER
ANTINEOPLASTIC CHEMOTHERAPY; FITTING
AND ADJUSTMENT OF VASCULAR CATHETER
50
51
009
52
001
53
001
OTHER SPECIFIED FORMS OF CHRONIC
ISCHEMIC HEART DISEASE; CORONARY
SPOUSE
ATHEROSCLEROSIS OF NATIVE CORONARY
ARTERY; OTHER PRIMARY
CARDIOMYOPATHIES
DIVERTICULOSIS OF COLON (WITHOUT
MENTION OF HEMORRHAGE); ABDOMINAL
SUBSCRIBER
PAIN, UNSPECIFIED SITE; OTHER AND
UNSPECIFIED OVARIAN CYST
ATRIAL FIBRILLATION; MISSING OR UNKNOWN
SUBSCRIBER DIAGNOSIS CODE; SUPERFICIAL INJURY OF
CORNEA
0
0
$0.00
0
$0.00
43
$2,724.79
58
$66,467.32
$69,192.11
$77,112.04
9
3
$63,728.88
0
$0.00
64
$5,046.45
18
$291.11
$69,066.44
$139,004.12
1
1
$53,517.57
5
$1,929.40
113
$12,839.15
11
$465.51
$68,751.63
$143,256.88
7
2
$27,080.36
2
$1,470.80
95
$8,957.56
46
$29,194.02
$66,702.74
$126,733.08
12
1
$62,183.53
0
$0.00
40
$4,298.93
5
$42.90
$66,525.36
$285,965.20
0
0
$0.00
0
$0.00
28
$1,216.22
32
$65,198.01
$66,414.23
$70,751.39
3
1
$32,422.53
7
$5,287.92
62
$6,446.52
22
$19,580.56
$63,737.53
$167,580.95
7
1
$8,977.06
13
$18,335.65
234
$16,399.41
72
$18,503.01
$62,215.13
$179,994.40
0
0
$0.00
1
$1,344.99
176
$12,969.40
88
$46,794.01
$61,108.40
$95,569.05
0
0
$0.00
2
$3,223.09
126
$56,664.84
9
$960.34
$60,848.27
$128,013.36
0
0
$0.00
2
$55,935.22
25
$3,816.32
20
$55.02
$59,806.56
$171,214.96
7
1
$47,068.59
4
$3,816.90
65
$7,136.79
46
$1,643.52
$59,665.80
$149,608.33
2
1
$9,984.98
4
$37,945.56
52
$8,840.46
11
$2,458.92
$59,229.92
$183,316.43
This Florida Blue report is proprietary and confidential. Report Run: 03/16/2016 12:20 PM Page 1 of 1
54
R01
SUBSCRIBER
55
001
SUBSCRIBER
56
001
SPOUSE
57
008
SUBSCRIBER
58
001
SUBSCRIBER
59
008
SUBSCRIBER
60
009
SPOUSE
61
008
SUBSCRIBER
62
001
SUBSCRIBER
63
001
SUBSCRIBER
64
001
SUBSCRIBER
65
001
SUBSCRIBER
66
R01
SUBSCRIBER
67
001
SUBSCRIBER
MALIGNANT CARCINOID TUMOR OF THE
CECUM; MALIGNANT CARCINOID TUMOR OF
THE SMALL INTESTINE, UNSPECIFIED
PORTION; SECONDARY MALIGNANT
NEOPLASM OF LIVER
PRIMARY LOCALIZED OSTEOARTHROSIS,
LOWER LEG; UNSPECIFIED VIRAL INFECTION,
IN CONDITIONS CLASSIFIED ELSEWHERE AND
OF UNSPECIFIED SITE; DIVERTICULITIS OF
COLON (WITHOUT MENTION OF
HEMORRHAGE)
INTERMEDIATE CORONARY SYNDROME;
PRECORDIAL PAIN; INTERNAL HEMORRHOIDS
WITH OTHER COMPLICATION
CALCULUS OF GALLBLADDER WITH ACUTE
CHOLECYSTITIS, WITHOUT MENTION OF
OBSTRUCTION; ASTHMA, UNSPECIFIED WITH
STATUS ASTHMATICUS; MISSING OR
UNKNOWN DIAGNOSIS CODE
EXUDATIVE SENILE MACULAR DEGENERATION
OF RETINA; CELLULITIS AND ABSCESS OF
TRUNK; PROLIFERATIVE DIABETIC
RETINOPATHY
MISSING OR UNKNOWN DIAGNOSIS CODE;
SYNCOPE AND COLLAPSE; MULTIPLE
SCLEROSIS
OTHER MECHANICAL COMPLICATION OF
OTHER INTERNAL ORTHOPEDIC DEVICE,
IMPLANT, AND GRAFT; BLOOD IN STOOL;
SPINAL STENOSIS OF LUMBAR REGION,
WITHOUT NEUROGENIC CLAUDICATION
MALIGNANT NEOPLASM OF PROSTATE;
MISSING OR UNKNOWN DIAGNOSIS CODE;
OTHER AND UNSPECIFIED ANGINA PECTORIS
MALIGNANT NEOPLASM OF UPPER-OUTER
QUADRANT OF FEMALE BREAST; MALIGNANT
NEOPLASM OF AXILLARY TAIL OF FEMALE
BREAST; ENCOUNTER FOR ANTINEOPLASTIC
CHEMOTHERAPY
CORONARY ATHEROSCLEROSIS OF NATIVE
CORONARY ARTERY; CHEST PAIN,
UNSPECIFIED; MISSING OR UNKNOWN
DIAGNOSIS CODE
OTHER SPECIFIED CARDIAC DYSRHYTHMIAS;
PAROXYSMAL SUPRAVENTRICULAR
TACHYCARDIA; MISSING OR UNKNOWN
DIAGNOSIS CODE
TRIGEMINAL NEURALGIA; DISRUPTION OF
EXTERNAL OPERATION (SURGICAL) WOUND;
OTHER NERVOUS SYSTEM COMPLICATIONS
MALIGNANT NEOPLASM OF ASCENDING
COLON; MISSING OR UNKNOWN DIAGNOSIS
CODE; BENIGN NEOPLASM OF COLON
INFECTION AND INFLAMMATORY REACTION
DUE TO CARDIAC DEVICE, IMPLANT, AND
GRAFT; MITRAL VALVE DISORDERS; CARDIAC
ARREST
0
0
$0.00
1
$3,403.01
28
$54,958.53
0
$0.00
$58,361.54
$178,067.11
10
3
$44,099.56
2
$3,855.80
83
$9,446.10
33
$861.69
$58,263.15
$229,926.87
3
1
$8,240.12
7
$36,647.61
110
$5,757.25
28
$7,336.85
$57,981.83
$204,258.05
13
2
$39,149.92
1
$2,998.00
109
$8,974.65
32
$5,646.01
$56,768.58
$235,804.48
3
1
$17,264.72
2
$3,008.30
145
$34,002.74
11
$2,224.96
$56,500.72
$166,271.31
0
0
$0.00
3
$6,099.51
82
$5,155.94
37
$44,527.06
$55,782.51
$90,003.81
2
1
$29,971.88
13
$15,654.66
39
$9,600.94
16
$73.11
$55,300.59
$244,343.27
0
0
$0.00
45
$43,454.24
105
$10,038.75
24
$841.40
$54,334.39
$177,432.36
1
1
$10,348.31
1
$329.00
268
$41,605.32
17
$1,146.12
$53,428.75
$228,457.99
1
1
$15,750.00
2
$30,063.84
39
$3,733.88
39
$3,129.98
$52,677.70
$141,495.55
1
1
$44,665.13
5
$4,280.23
21
$2,489.68
9
$39.25
$51,474.29
$100,068.53
8
3
$36,810.48
4
$1,864.50
42
$11,504.01
34
$1,109.24
$51,288.23
$144,579.55
8
1
$43,580.49
2
$691.35
64
$5,113.35
9
$1,727.91
$51,113.10
$224,583.37
6
1
$29,560.57
5
$11,397.50
55
$9,457.34
22
$460.39
$50,875.80
$357,457.45
This Florida Blue report is proprietary and confidential. Report Run: 03/16/2016 12:20 PM Page 1 of 1
68
001
SPOUSE
69
009
DEPENDENT
70
001
SUBSCRIBER
71
001
SUBSCRIBER
72
001
SPOUSE
73
008
SUBSCRIBER
74
001
SUBSCRIBER
Total
MISSING OR UNKNOWN DIAGNOSIS CODE;
ACUTE ON CHRONIC COMBINED SYSTOLIC
AND DIASTOLIC HEART FAILURE; CALCULUS
OF GALLBLADDER WITH ACUTE
CHOLECYSTITIS, WITHOUT MENTION OF
OBSTRUCTION
UNSPECIFIED SEPTICEMIA; HB-SS DISEASE
WITH CRISIS; ACUTE PHARYNGITIS
MISSING OR UNKNOWN DIAGNOSIS CODE;
RHEUMATOID ARTHRITIS; LEUKOCYTOSIS,
UNSPECIFIED
BENIGN NEOPLASM OF COLON; MISSING OR
UNKNOWN DIAGNOSIS CODE; CALCULUS OF
GALLBLADDER WITHOUT MENTION OF
CHOLECYSTITIS OR OBSTRUCTION
CONGENITAL ANOMALY OF
CEREBROVASCULAR SYSTEM; AFTERCARE
FOLLOWING SURGERY OF THE CIRCULATORY
SYSTEM, NEC; CEREBRAL ANEURYSM,
NONRUPTURED
MISSING OR UNKNOWN DIAGNOSIS CODE;
HEADACHE; OTHER AND UNSPECIFIED ANGINA
PECTORIS
MALIGNANT NEOPLASM OF CERVIX UTERI,
UNSPECIFIED SITE; MALIGNANT NEOPLASM OF
VAGINA; PAPANICOLAOU SMEAR OF CERVIX
WITH HIGH GRADE SQUAMOUS
INTRAEPITHELIAL LESION (HGSIL)
2
1
$9,296.45
12
$12,804.48
116
$10,901.92
82
$17,776.47
$50,779.32
$407,683.19
18
3
$39,874.20
2
$3,218.04
81
$7,113.65
9
$4.81
$50,210.70
$596,704.59
0
0
$0.00
0
$0.00
16
$10,531.97
36
$39,609.00
$50,140.97
$63,562.09
5
1
$41,921.64
1
$315.00
34
$5,448.48
67
$2,351.55
$50,036.67
$106,857.32
1
1
$27,468.37
4
$11,942.97
59
$10,416.17
19
$208.49
$50,036.00
$423,305.84
0
0
$0.00
1
$2,176.22
80
$3,547.22
50
$44,306.99
$50,030.43
$68,225.62
2
1
$14,500.70
2
$24,569.71
27
$10,915.73
6
$29.29
$50,015.43
$170,403.58
576
96
$3,213,206.24
692
$925,497.43
7,779
$1,500,020.60
$6,693,723.18
$22,503,565.50
$1,054,998.91
This Florida Blue report is proprietary and confidential. Report Run: 03/16/2016 12:20 PM Page 1 of 1
2,608
This Florida Blue report is proprietary and confidential. Report Run: 03/16/2016 12:20 PM Page 1 of 1