hospital_name,last_updated_on,version,hospital_location,hospital_address,license_number|GA,"To the best of its knowledge and belief, the hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date indicated.",,,,,,,,,,,,,,,,,,,,,,
Stephens County Hospital,2024-07-01,2.0.0,Stephens County Hospital,"163 Hospital Road Toccoa, GA 30577",586001667,TRUE,,,,,,,,,,,,,,,,,,,,,,
SERVICE DESCRIPTION,CATEGORY,BILLING MSDRG | CPT | HCPCS,ITEM/SERVICE DESCRIPTION,BILLING REVENUE CODE,GROSS CHARGES,AETNA PLAN,AETNA REIMBURSEMENT METHOD,AMERIGROUP PLAN,AMERIGROUP REIMBURSEMENT METHOD,BCBS PLAN,BCBS REIMBURSEMENT METHOD,CARESOURCE PLAN,CARESOURCE REIMBURSEMENT METHOD,CIGNA PLAN,CIGNA REIMBURSEMENT METHOD,MEDICAID PLAN,MEDICAID REIMBURSEMENT METHOD,MEDICARE plan,MEDICARE REIMBURSEMENT METHOD,PEACHSTATE MEDICAID plan,PEACHSTATE MEDICAID REIMBURSEMENT METHOD,UHC plan,UHC REIMBURSEMENT METHOD,WELLCARE MEDICAID plan,WELLCARE MEDICAID REIMBURSEMENT METHOD,De-Identified Minimum Negotiated Rate,De-Identified Maximum Negotiated Rate,DISCOUNTED CASH PRICE
Outpatient Medical Services,LAB,36415,Collection of venous blood by venipuncture,300,17.84,15.16,Pays at 85% of Billed charges for outpatient setting,5.74,Pays at 32.15% of Total Billed charges,14.28,Pays at 80.03% of Total Billed charges,8.74,Pays at 102% of Medicare OPPS Rate,16.06,Pays at 90% of Total Billed charges,5.74,Pays at 32.15% of Total Billed charges,8.57,Pays at 100% of Medicare OPPS Rate,5.74,Pays at 32.15% of Total Billed charges,15.7,Pays at 88% of Total Billed charges,5.91,Pays at 33.11% of Total Billed charges,5.74,16.06,10.70
Outpatient Medical Services,LAB,36415,Collection of venous blood by venipuncture,300,20.75,17.64,Pays at 85% of Billed charges for outpatient setting,6.67,Pays at 32.15% of Total Billed charges,16.61,Pays at 80.03% of Total Billed charges,8.74,Pays at 102% of Medicare OPPS Rate,18.68,Pays at 90% of Total Billed charges,6.67,Pays at 32.15% of Total Billed charges,8.57,Pays at 100% of Medicare OPPS Rate,6.67,Pays at 32.15% of Total Billed charges,18.26,Pays at 88% of Total Billed charges,6.87,Pays at 33.11% of Total Billed charges,6.67,18.68,12.45
Outpatient Medical Services,LAB,36415,Collection of venous blood by venipuncture,300,21.75,18.49,Pays at 85% of Billed charges for outpatient setting,6.99,Pays at 32.15% of Total Billed charges,17.41,Pays at 80.03% of Total Billed charges,8.74,Pays at 102% of Medicare OPPS Rate,19.58,Pays at 90% of Total Billed charges,6.99,Pays at 32.15% of Total Billed charges,8.57,Pays at 100% of Medicare OPPS Rate,6.99,Pays at 32.15% of Total Billed charges,19.14,Pays at 88% of Total Billed charges,7.2,Pays at 33.11% of Total Billed charges,6.99,19.58,13.05
Outpatient Medical Services,LAB,36600,ARTERIAL SPECIMEN COLLECT,300,10,8.5,Pays at 85% of Billed charges for outpatient setting,3.22,Pays at 32.15% of Total Billed charges,8,Pays at 80.03% of Total Billed charges,111.31,Pays at 102% of Medicare OPPS Rate,9,Pays at 90% of Total Billed charges,3.22,Pays at 32.15% of Total Billed charges,109.13,Pays at 100% of Medicare OPPS Rate,3.22,Pays at 32.15% of Total Billed charges,8.8,Pays at 88% of Total Billed charges,3.31,Pays at 33.11% of Total Billed charges,3.22,111.31,6.00
Outpatient Medical Services,LAB,80048,Basic metabolic panel,300,44.08,37.47,Pays at 85% of Billed charges for outpatient setting,10.65,Pays at 100% of GA Medicaid Fee Schedule,35.28,Pays at 80.03% of Total Billed charges,8.62,Pays at 102% of Medicare OPPS Rate,39.67,Pays at 90% of Total Billed charges,10.65,Pays at 100% of GA Medicaid Fee Schedule,8.46,Pays at 100% of Medicare OPPS Rate,10.65,Pays at 100% of GA Medicaid Fee Schedule,38.79,Pays at 88% of Total Billed charges,10.97,Pays at 103% of GA Medicaid Fee Schedule,8.46,39.67,26.45
Outpatient Medical Services,LAB,80048,Basic metabolic panel,300,53.75,45.69,Pays at 85% of Billed charges for outpatient setting,10.65,Pays at 100% of GA Medicaid Fee Schedule,43.02,Pays at 80.03% of Total Billed charges,8.62,Pays at 102% of Medicare OPPS Rate,48.38,Pays at 90% of Total Billed charges,10.65,Pays at 100% of GA Medicaid Fee Schedule,8.46,Pays at 100% of Medicare OPPS Rate,10.65,Pays at 100% of GA Medicaid Fee Schedule,47.3,Pays at 88% of Total Billed charges,10.97,Pays at 103% of GA Medicaid Fee Schedule,8.46,48.38,32.25
Outpatient Medical Services,LAB,80050,General health panel,300,245.25,208.46,Pays at 85% of Billed charges for outpatient setting,78.85,Pays at 32.15% of Total Billed charges,196.27,Pays at 80.03% of Total Billed charges,245.25,Not Applicable,220.73,Pays at 90% of Total Billed charges,78.85,Pays at 32.15% of Total Billed charges,245.25,Not Applicable,78.85,Pays at 32.15% of Total Billed charges,215.82,Pays at 88% of Total Billed charges,81.2,Pays at 33.11% of Total Billed charges,78.85,245.25,147.15
Outpatient Medical Services,LAB,80051,"Blood test panel for electrolytes (sodium potassium, chloride, carbon dioxide)",300,36.25,30.81,Pays at 85% of Billed charges for outpatient setting,8.82,Pays at 100% of GA Medicaid Fee Schedule,29.01,Pays at 80.03% of Total Billed charges,7.15,Pays at 102% of Medicare OPPS Rate,32.63,Pays at 90% of Total Billed charges,8.82,Pays at 100% of GA Medicaid Fee Schedule,7.01,Pays at 100% of Medicare OPPS Rate,8.82,Pays at 100% of GA Medicaid Fee Schedule,31.9,Pays at 88% of Total Billed charges,9.08,Pays at 103% of GA Medicaid Fee Schedule,7.01,32.63,21.75
Outpatient Medical Services,LAB,80053,"Blood test, comprehensive group of blood chemicals",300,97.58,82.94,Pays at 85% of Billed charges for outpatient setting,13.29,Pays at 100% of GA Medicaid Fee Schedule,78.09,Pays at 80.03% of Total Billed charges,10.77,Pays at 102% of Medicare OPPS Rate,87.82,Pays at 90% of Total Billed charges,13.29,Pays at 100% of GA Medicaid Fee Schedule,10.56,Pays at 100% of Medicare OPPS Rate,13.29,Pays at 100% of GA Medicaid Fee Schedule,85.87,Pays at 88% of Total Billed charges,13.69,Pays at 103% of GA Medicaid Fee Schedule,10.56,87.82,58.55
Outpatient Medical Services,LAB,80055,Obstetric blood test panel,300,25,21.25,Pays at 85% of Billed charges for outpatient setting,28.08,Pays at 100% of GA Medicaid Fee Schedule,20.01,Pays at 80.03% of Total Billed charges,48.76,Pays at 102% of Medicare OPPS Rate,22.5,Pays at 90% of Total Billed charges,28.08,Pays at 100% of GA Medicaid Fee Schedule,47.81,Pays at 100% of Medicare OPPS Rate,28.08,Pays at 100% of GA Medicaid Fee Schedule,22,Pays at 88% of Total Billed charges,28.92,Pays at 103% of GA Medicaid Fee Schedule,20.01,48.76,15.00
Outpatient Medical Services,LAB,80061,"Blood test, lipids (cholesterol and triglycerides)",300,49.2,41.82,Pays at 85% of Billed charges for outpatient setting,16.85,Pays at 100% of GA Medicaid Fee Schedule,39.37,Pays at 80.03% of Total Billed charges,13.65,Pays at 102% of Medicare OPPS Rate,44.28,Pays at 90% of Total Billed charges,16.85,Pays at 100% of GA Medicaid Fee Schedule,13.39,Pays at 100% of Medicare OPPS Rate,16.85,Pays at 100% of GA Medicaid Fee Schedule,43.3,Pays at 88% of Total Billed charges,17.36,Pays at 103% of GA Medicaid Fee Schedule,13.39,44.28,29.52
Outpatient Medical Services,LAB,80069,Kidney function panel test,300,77.75,66.09,Pays at 85% of Billed charges for outpatient setting,10.92,Pays at 100% of GA Medicaid Fee Schedule,62.22,Pays at 80.03% of Total Billed charges,8.85,Pays at 102% of Medicare OPPS Rate,69.98,Pays at 90% of Total Billed charges,10.92,Pays at 100% of GA Medicaid Fee Schedule,8.68,Pays at 100% of Medicare OPPS Rate,10.92,Pays at 100% of GA Medicaid Fee Schedule,68.42,Pays at 88% of Total Billed charges,11.25,Pays at 103% of GA Medicaid Fee Schedule,8.68,69.98,46.65
Outpatient Medical Services,LAB,80074,Acute hepatitis panel,300,104,88.4,Pays at 85% of Billed charges for outpatient setting,59.89,Pays at 100% of GA Medicaid Fee Schedule,83.23,Pays at 80.03% of Total Billed charges,48.58,Pays at 102% of Medicare OPPS Rate,93.6,Pays at 90% of Total Billed charges,59.89,Pays at 100% of GA Medicaid Fee Schedule,47.63,Pays at 100% of Medicare OPPS Rate,59.89,Pays at 100% of GA Medicaid Fee Schedule,91.52,Pays at 88% of Total Billed charges,61.69,Pays at 103% of GA Medicaid Fee Schedule,47.63,93.6,62.40
Outpatient Medical Services,LAB,80074,Acute hepatitis panel,300,124.85,106.12,Pays at 85% of Billed charges for outpatient setting,59.89,Pays at 100% of GA Medicaid Fee Schedule,99.92,Pays at 80.03% of Total Billed charges,48.58,Pays at 102% of Medicare OPPS Rate,112.37,Pays at 90% of Total Billed charges,59.89,Pays at 100% of GA Medicaid Fee Schedule,47.63,Pays at 100% of Medicare OPPS Rate,59.89,Pays at 100% of GA Medicaid Fee Schedule,109.87,Pays at 88% of Total Billed charges,61.69,Pays at 103% of GA Medicaid Fee Schedule,47.63,112.37,74.91
Outpatient Medical Services,LAB,80076,Liver function blood test panel,300,69.25,58.86,Pays at 85% of Billed charges for outpatient setting,10.28,Pays at 100% of GA Medicaid Fee Schedule,55.42,Pays at 80.03% of Total Billed charges,8.33,Pays at 102% of Medicare OPPS Rate,62.33,Pays at 90% of Total Billed charges,10.28,Pays at 100% of GA Medicaid Fee Schedule,8.17,Pays at 100% of Medicare OPPS Rate,10.28,Pays at 100% of GA Medicaid Fee Schedule,60.94,Pays at 88% of Total Billed charges,10.59,Pays at 103% of GA Medicaid Fee Schedule,8.17,62.33,41.55
Outpatient Medical Services,LAB,80101,"TRICYCLIC ANTIDEPRESSANTS, SERUM  (MAYO)",300,55.5,47.18,Pays at 85% of Billed charges for outpatient setting,17.84,Pays at 32.15% of Total Billed charges,44.42,Pays at 80.03% of Total Billed charges,NA,Not Applicable,49.95,Pays at 90% of Total Billed charges,17.84,Pays at 32.15% of Total Billed charges,NA,Not Applicable,17.84,Pays at 32.15% of Total Billed charges,48.84,Pays at 88% of Total Billed charges,18.38,Pays at 33.11% of Total Billed charges,17.84,49.95,33.30
Outpatient Medical Services,LAB,80145,ADALIMUMAB QN REFLEX AB SERUM (MAYO),300,398.02,338.32,Pays at 85% of Billed charges for outpatient setting,30.86,Pays at 100% of GA Medicaid Fee Schedule,318.54,Pays at 80.03% of Total Billed charges,39.34,Pays at 102% of Medicare OPPS Rate,358.22,Pays at 90% of Total Billed charges,30.86,Pays at 100% of GA Medicaid Fee Schedule,38.57,Pays at 100% of Medicare OPPS Rate,30.86,Pays at 100% of GA Medicaid Fee Schedule,350.26,Pays at 88% of Total Billed charges,31.79,Pays at 103% of GA Medicaid Fee Schedule,30.86,358.22,238.81
Outpatient Medical Services,LAB,80150,AMIKACIN TROUGH,300,82.75,70.34,Pays at 85% of Billed charges for outpatient setting,18.95,Pays at 100% of GA Medicaid Fee Schedule,66.22,Pays at 80.03% of Total Billed charges,15.38,Pays at 102% of Medicare OPPS Rate,74.48,Pays at 90% of Total Billed charges,18.95,Pays at 100% of GA Medicaid Fee Schedule,15.08,Pays at 100% of Medicare OPPS Rate,18.95,Pays at 100% of GA Medicaid Fee Schedule,72.82,Pays at 88% of Total Billed charges,19.52,Pays at 103% of GA Medicaid Fee Schedule,15.08,74.48,49.65
Outpatient Medical Services,LAB,80150,AMIKACIN PEAK,300,82.75,70.34,Pays at 85% of Billed charges for outpatient setting,18.95,Pays at 100% of GA Medicaid Fee Schedule,66.22,Pays at 80.03% of Total Billed charges,15.38,Pays at 102% of Medicare OPPS Rate,74.48,Pays at 90% of Total Billed charges,18.95,Pays at 100% of GA Medicaid Fee Schedule,15.08,Pays at 100% of Medicare OPPS Rate,18.95,Pays at 100% of GA Medicaid Fee Schedule,72.82,Pays at 88% of Total Billed charges,19.52,Pays at 103% of GA Medicaid Fee Schedule,15.08,74.48,49.65
Outpatient Medical Services,LAB,80154,"TEMAZEPAM, RESTORIL   (MAYO)",300,123,104.55,Pays at 85% of Billed charges for outpatient setting,39.54,Pays at 32.15% of Total Billed charges,98.44,Pays at 80.03% of Total Billed charges,NA,Not Applicable,110.7,Pays at 90% of Total Billed charges,39.54,Pays at 32.15% of Total Billed charges,NA,Not Applicable,39.54,Pays at 32.15% of Total Billed charges,108.24,Pays at 88% of Total Billed charges,40.73,Pays at 33.11% of Total Billed charges,39.54,110.7,73.80
Outpatient Medical Services,LAB,80154,"ROHIPNOL, FLUNITRAZEPAM   (MAYO)",300,182.75,155.34,Pays at 85% of Billed charges for outpatient setting,58.75,Pays at 32.15% of Total Billed charges,146.25,Pays at 80.03% of Total Billed charges,NA,Not Applicable,164.48,Pays at 90% of Total Billed charges,58.75,Pays at 32.15% of Total Billed charges,NA,Not Applicable,58.75,Pays at 32.15% of Total Billed charges,160.82,Pays at 88% of Total Billed charges,60.51,Pays at 33.11% of Total Billed charges,58.75,164.48,109.65
Outpatient Medical Services,LAB,80154,XANAX  (MAYO),300,207,175.95,Pays at 85% of Billed charges for outpatient setting,66.55,Pays at 32.15% of Total Billed charges,165.66,Pays at 80.03% of Total Billed charges,NA,Not Applicable,186.3,Pays at 90% of Total Billed charges,66.55,Pays at 32.15% of Total Billed charges,NA,Not Applicable,66.55,Pays at 32.15% of Total Billed charges,182.16,Pays at 88% of Total Billed charges,68.54,Pays at 33.11% of Total Billed charges,66.55,186.3,124.20
Outpatient Medical Services,LAB,80155,CAFFEINE LEVEL  (MAYO),300,101.25,86.06,Pays at 85% of Billed charges for outpatient setting,15.44,Pays at 100% of GA Medicaid Fee Schedule,81.03,Pays at 80.03% of Total Billed charges,39.34,Pays at 102% of Medicare OPPS Rate,91.13,Pays at 90% of Total Billed charges,15.44,Pays at 100% of GA Medicaid Fee Schedule,38.57,Pays at 100% of Medicare OPPS Rate,15.44,Pays at 100% of GA Medicaid Fee Schedule,89.1,Pays at 88% of Total Billed charges,15.9,Pays at 103% of GA Medicaid Fee Schedule,15.44,91.13,60.75
Outpatient Medical Services,LAB,80156,TEGRETOL (CARBAMAZEPINE),300,60,51,Pays at 85% of Billed charges for outpatient setting,18.31,Pays at 100% of GA Medicaid Fee Schedule,48.02,Pays at 80.03% of Total Billed charges,14.86,Pays at 102% of Medicare OPPS Rate,54,Pays at 90% of Total Billed charges,18.31,Pays at 100% of GA Medicaid Fee Schedule,14.57,Pays at 100% of Medicare OPPS Rate,18.31,Pays at 100% of GA Medicaid Fee Schedule,52.8,Pays at 88% of Total Billed charges,18.86,Pays at 103% of GA Medicaid Fee Schedule,14.57,54,36.00
Outpatient Medical Services,LAB,80157,CARBATROL (CARBAM FREE/TOTAL)    MAYO,300,111,94.35,Pays at 85% of Billed charges for outpatient setting,12.5,Pays at 100% of GA Medicaid Fee Schedule,88.83,Pays at 80.03% of Total Billed charges,13.51,Pays at 102% of Medicare OPPS Rate,99.9,Pays at 90% of Total Billed charges,12.5,Pays at 100% of GA Medicaid Fee Schedule,13.25,Pays at 100% of Medicare OPPS Rate,12.5,Pays at 100% of GA Medicaid Fee Schedule,97.68,Pays at 88% of Total Billed charges,12.88,Pays at 103% of GA Medicaid Fee Schedule,12.5,99.9,66.60
Outpatient Medical Services,LAB,80158,CYCLOSPORINE BLOOD   MAYO,300,37.75,32.09,Pays at 85% of Billed charges for outpatient setting,7.5,Pays at 100% of GA Medicaid Fee Schedule,30.21,Pays at 80.03% of Total Billed charges,18.41,Pays at 102% of Medicare OPPS Rate,33.98,Pays at 90% of Total Billed charges,7.5,Pays at 100% of GA Medicaid Fee Schedule,18.05,Pays at 100% of Medicare OPPS Rate,7.5,Pays at 100% of GA Medicaid Fee Schedule,33.22,Pays at 88% of Total Billed charges,7.73,Pays at 103% of GA Medicaid Fee Schedule,7.5,33.98,22.65
Outpatient Medical Services,LAB,80159,CLOZARIL (CLOZAPINE)  (MAYO),300,45.5,38.68,Pays at 85% of Billed charges for outpatient setting,20.18,Pays at 100% of GA Medicaid Fee Schedule,36.41,Pays at 80.03% of Total Billed charges,20.55,Pays at 102% of Medicare OPPS Rate,40.95,Pays at 90% of Total Billed charges,20.18,Pays at 100% of GA Medicaid Fee Schedule,20.14,Pays at 100% of Medicare OPPS Rate,20.18,Pays at 100% of GA Medicaid Fee Schedule,40.04,Pays at 88% of Total Billed charges,20.79,Pays at 103% of GA Medicaid Fee Schedule,20.14,40.95,27.30
Outpatient Medical Services,LAB,80162,DIGOXIN,300,65.94,56.05,Pays at 85% of Billed charges for outpatient setting,16.7,Pays at 100% of GA Medicaid Fee Schedule,52.77,Pays at 80.03% of Total Billed charges,13.54,Pays at 102% of Medicare OPPS Rate,59.35,Pays at 90% of Total Billed charges,16.7,Pays at 100% of GA Medicaid Fee Schedule,13.28,Pays at 100% of Medicare OPPS Rate,16.7,Pays at 100% of GA Medicaid Fee Schedule,58.03,Pays at 88% of Total Billed charges,17.2,Pays at 103% of GA Medicaid Fee Schedule,13.28,59.35,39.56
Outpatient Medical Services,LAB,80164,FREE VALPROIC ACID  (MAYO),300,29.5,25.08,Pays at 85% of Billed charges for outpatient setting,14.27,Pays at 100% of GA Medicaid Fee Schedule,23.61,Pays at 80.03% of Total Billed charges,13.81,Pays at 102% of Medicare OPPS Rate,26.55,Pays at 90% of Total Billed charges,14.27,Pays at 100% of GA Medicaid Fee Schedule,13.54,Pays at 100% of Medicare OPPS Rate,14.27,Pays at 100% of GA Medicaid Fee Schedule,25.96,Pays at 88% of Total Billed charges,14.7,Pays at 103% of GA Medicaid Fee Schedule,13.54,26.55,17.70
Outpatient Medical Services,LAB,80164,VALPROIC ACID (DEPAKENE),300,67.7,57.55,Pays at 85% of Billed charges for outpatient setting,14.27,Pays at 100% of GA Medicaid Fee Schedule,54.18,Pays at 80.03% of Total Billed charges,13.81,Pays at 102% of Medicare OPPS Rate,60.93,Pays at 90% of Total Billed charges,14.27,Pays at 100% of GA Medicaid Fee Schedule,13.54,Pays at 100% of Medicare OPPS Rate,14.27,Pays at 100% of GA Medicaid Fee Schedule,59.58,Pays at 88% of Total Billed charges,14.7,Pays at 103% of GA Medicaid Fee Schedule,13.54,60.93,40.62
Outpatient Medical Services,LAB,80165,"VALPROIC ACID, FREE SERUM  (MAYO)",300,26.75,22.74,Pays at 85% of Billed charges for outpatient setting,12.36,Pays at 100% of GA Medicaid Fee Schedule,21.41,Pays at 80.03% of Total Billed charges,13.81,Pays at 102% of Medicare OPPS Rate,24.08,Pays at 90% of Total Billed charges,12.36,Pays at 100% of GA Medicaid Fee Schedule,13.54,Pays at 100% of Medicare OPPS Rate,12.36,Pays at 100% of GA Medicaid Fee Schedule,23.54,Pays at 88% of Total Billed charges,12.73,Pays at 103% of GA Medicaid Fee Schedule,12.36,24.08,16.05
Outpatient Medical Services,LAB,80168,"ETHOSUXIMDE, SERUM  (MAYO)",300,62.75,53.34,Pays at 85% of Billed charges for outpatient setting,20.55,Pays at 100% of GA Medicaid Fee Schedule,50.22,Pays at 80.03% of Total Billed charges,16.66,Pays at 102% of Medicare OPPS Rate,56.48,Pays at 90% of Total Billed charges,20.55,Pays at 100% of GA Medicaid Fee Schedule,16.34,Pays at 100% of Medicare OPPS Rate,20.55,Pays at 100% of GA Medicaid Fee Schedule,55.22,Pays at 88% of Total Billed charges,21.17,Pays at 103% of GA Medicaid Fee Schedule,16.34,56.48,37.65
Outpatient Medical Services,LAB,80169,EVEROLIMUS  (MAYO),300,99.04,84.18,Pays at 85% of Billed charges for outpatient setting,14.98,Pays at 100% of GA Medicaid Fee Schedule,79.26,Pays at 80.03% of Total Billed charges,14,Pays at 102% of Medicare OPPS Rate,89.14,Pays at 90% of Total Billed charges,14.98,Pays at 100% of GA Medicaid Fee Schedule,13.73,Pays at 100% of Medicare OPPS Rate,14.98,Pays at 100% of GA Medicaid Fee Schedule,87.16,Pays at 88% of Total Billed charges,15.43,Pays at 103% of GA Medicaid Fee Schedule,13.73,89.14,59.42
Outpatient Medical Services,LAB,80170,GENTAMICIN PEAK,300,77.75,66.09,Pays at 85% of Billed charges for outpatient setting,20.61,Pays at 100% of GA Medicaid Fee Schedule,62.22,Pays at 80.03% of Total Billed charges,16.7,Pays at 102% of Medicare OPPS Rate,69.98,Pays at 90% of Total Billed charges,20.61,Pays at 100% of GA Medicaid Fee Schedule,16.38,Pays at 100% of Medicare OPPS Rate,20.61,Pays at 100% of GA Medicaid Fee Schedule,68.42,Pays at 88% of Total Billed charges,21.23,Pays at 103% of GA Medicaid Fee Schedule,16.38,69.98,46.65
Outpatient Medical Services,LAB,80170,GENTAMICIN RANDOM,300,77.75,66.09,Pays at 85% of Billed charges for outpatient setting,20.61,Pays at 100% of GA Medicaid Fee Schedule,62.22,Pays at 80.03% of Total Billed charges,16.7,Pays at 102% of Medicare OPPS Rate,69.98,Pays at 90% of Total Billed charges,20.61,Pays at 100% of GA Medicaid Fee Schedule,16.38,Pays at 100% of Medicare OPPS Rate,20.61,Pays at 100% of GA Medicaid Fee Schedule,68.42,Pays at 88% of Total Billed charges,21.23,Pays at 103% of GA Medicaid Fee Schedule,16.38,69.98,46.65
Outpatient Medical Services,LAB,80170,GENTAMICIN TROUGH,300,81.9,69.62,Pays at 85% of Billed charges for outpatient setting,20.61,Pays at 100% of GA Medicaid Fee Schedule,65.54,Pays at 80.03% of Total Billed charges,16.7,Pays at 102% of Medicare OPPS Rate,73.71,Pays at 90% of Total Billed charges,20.61,Pays at 100% of GA Medicaid Fee Schedule,16.38,Pays at 100% of Medicare OPPS Rate,20.61,Pays at 100% of GA Medicaid Fee Schedule,72.07,Pays at 88% of Total Billed charges,21.23,Pays at 103% of GA Medicaid Fee Schedule,16.38,73.71,49.14
Outpatient Medical Services,LAB,80171,GABAPENTIN (NEURONTIN) URINE  (MAYO),300,56,47.6,Pays at 85% of Billed charges for outpatient setting,14.47,Pays at 100% of GA Medicaid Fee Schedule,44.82,Pays at 80.03% of Total Billed charges,22.1,Pays at 102% of Medicare OPPS Rate,50.4,Pays at 90% of Total Billed charges,14.47,Pays at 100% of GA Medicaid Fee Schedule,21.67,Pays at 100% of Medicare OPPS Rate,14.47,Pays at 100% of GA Medicaid Fee Schedule,49.28,Pays at 88% of Total Billed charges,14.9,Pays at 103% of GA Medicaid Fee Schedule,14.47,50.4,33.60
Outpatient Medical Services,LAB,80173,HALOPERIDOL LEVEL  (MAYO),300,100.5,85.43,Pays at 85% of Billed charges for outpatient setting,18.31,Pays at 100% of GA Medicaid Fee Schedule,80.43,Pays at 80.03% of Total Billed charges,16.09,Pays at 102% of Medicare OPPS Rate,90.45,Pays at 90% of Total Billed charges,18.31,Pays at 100% of GA Medicaid Fee Schedule,15.78,Pays at 100% of Medicare OPPS Rate,18.31,Pays at 100% of GA Medicaid Fee Schedule,88.44,Pays at 88% of Total Billed charges,18.86,Pays at 103% of GA Medicaid Fee Schedule,15.78,90.45,60.30
Outpatient Medical Services,LAB,80175,LAMICTAL (LAMOTRIGINE)  (MAYO),300,42.5,36.13,Pays at 85% of Billed charges for outpatient setting,14.47,Pays at 100% of GA Medicaid Fee Schedule,34.01,Pays at 80.03% of Total Billed charges,13.51,Pays at 102% of Medicare OPPS Rate,38.25,Pays at 90% of Total Billed charges,14.47,Pays at 100% of GA Medicaid Fee Schedule,13.25,Pays at 100% of Medicare OPPS Rate,14.47,Pays at 100% of GA Medicaid Fee Schedule,37.4,Pays at 88% of Total Billed charges,14.9,Pays at 103% of GA Medicaid Fee Schedule,13.25,38.25,25.50
Outpatient Medical Services,LAB,80176,LIDOCAINE  (MAYO),300,84,71.4,Pays at 85% of Billed charges for outpatient setting,18.47,Pays at 100% of GA Medicaid Fee Schedule,67.23,Pays at 80.03% of Total Billed charges,14.98,Pays at 102% of Medicare OPPS Rate,75.6,Pays at 90% of Total Billed charges,18.47,Pays at 100% of GA Medicaid Fee Schedule,14.69,Pays at 100% of Medicare OPPS Rate,18.47,Pays at 100% of GA Medicaid Fee Schedule,73.92,Pays at 88% of Total Billed charges,19.02,Pays at 103% of GA Medicaid Fee Schedule,14.69,75.6,50.40
Outpatient Medical Services,LAB,80177,KEPPRA (LEVETIRACETAM)  (MAYO),300,42.5,36.13,Pays at 85% of Billed charges for outpatient setting,14.47,Pays at 100% of GA Medicaid Fee Schedule,34.01,Pays at 80.03% of Total Billed charges,13.51,Pays at 102% of Medicare OPPS Rate,38.25,Pays at 90% of Total Billed charges,14.47,Pays at 100% of GA Medicaid Fee Schedule,13.25,Pays at 100% of Medicare OPPS Rate,14.47,Pays at 100% of GA Medicaid Fee Schedule,37.4,Pays at 88% of Total Billed charges,14.9,Pays at 103% of GA Medicaid Fee Schedule,13.25,38.25,25.50
Outpatient Medical Services,LAB,80178,LITHIUM (MAYO),300,40.25,34.21,Pays at 85% of Billed charges for outpatient setting,8.32,Pays at 100% of GA Medicaid Fee Schedule,32.21,Pays at 80.03% of Total Billed charges,6.74,Pays at 102% of Medicare OPPS Rate,36.23,Pays at 90% of Total Billed charges,8.32,Pays at 100% of GA Medicaid Fee Schedule,6.61,Pays at 100% of Medicare OPPS Rate,8.32,Pays at 100% of GA Medicaid Fee Schedule,35.42,Pays at 88% of Total Billed charges,8.57,Pays at 103% of GA Medicaid Fee Schedule,6.61,36.23,24.15
Outpatient Medical Services,LAB,80180,MYCOPHENOLIC ACID SERUM  (MAYO),300,331.25,281.56,Pays at 85% of Billed charges for outpatient setting,6.5,Pays at 100% of GA Medicaid Fee Schedule,265.1,Pays at 80.03% of Total Billed charges,18.41,Pays at 102% of Medicare OPPS Rate,298.13,Pays at 90% of Total Billed charges,6.5,Pays at 100% of GA Medicaid Fee Schedule,18.05,Pays at 100% of Medicare OPPS Rate,6.5,Pays at 100% of GA Medicaid Fee Schedule,291.5,Pays at 88% of Total Billed charges,6.7,Pays at 103% of GA Medicaid Fee Schedule,6.5,298.13,198.75
Outpatient Medical Services,LAB,80183,"TENHYDROXY CARBAMEZAPENE, TRILEPTOL MAYO",300,32.69,27.79,Pays at 85% of Billed charges for outpatient setting,14.47,Pays at 100% of GA Medicaid Fee Schedule,26.16,Pays at 80.03% of Total Billed charges,13.51,Pays at 102% of Medicare OPPS Rate,29.42,Pays at 90% of Total Billed charges,14.47,Pays at 100% of GA Medicaid Fee Schedule,13.25,Pays at 100% of Medicare OPPS Rate,14.47,Pays at 100% of GA Medicaid Fee Schedule,28.77,Pays at 88% of Total Billed charges,14.9,Pays at 103% of GA Medicaid Fee Schedule,13.25,29.42,19.61
Outpatient Medical Services,LAB,80183,OXCARBAZEPINE METABOLITE  (MAYO),300,42.5,36.13,Pays at 85% of Billed charges for outpatient setting,14.47,Pays at 100% of GA Medicaid Fee Schedule,34.01,Pays at 80.03% of Total Billed charges,13.51,Pays at 102% of Medicare OPPS Rate,38.25,Pays at 90% of Total Billed charges,14.47,Pays at 100% of GA Medicaid Fee Schedule,13.25,Pays at 100% of Medicare OPPS Rate,14.47,Pays at 100% of GA Medicaid Fee Schedule,37.4,Pays at 88% of Total Billed charges,14.9,Pays at 103% of GA Medicaid Fee Schedule,13.25,38.25,25.50
Outpatient Medical Services,LAB,80184,PHENOBARBITAL,300,45.5,38.68,Pays at 85% of Billed charges for outpatient setting,14.41,Pays at 100% of GA Medicaid Fee Schedule,36.41,Pays at 80.03% of Total Billed charges,15.6,Pays at 102% of Medicare OPPS Rate,40.95,Pays at 90% of Total Billed charges,14.41,Pays at 100% of GA Medicaid Fee Schedule,15.3,Pays at 100% of Medicare OPPS Rate,14.41,Pays at 100% of GA Medicaid Fee Schedule,40.04,Pays at 88% of Total Billed charges,14.84,Pays at 103% of GA Medicaid Fee Schedule,14.41,40.95,27.30
Outpatient Medical Services,LAB,80185,DILANTIN (PHENYTOIN),300,77.75,66.09,Pays at 85% of Billed charges for outpatient setting,16.67,Pays at 100% of GA Medicaid Fee Schedule,62.22,Pays at 80.03% of Total Billed charges,13.51,Pays at 102% of Medicare OPPS Rate,69.98,Pays at 90% of Total Billed charges,16.67,Pays at 100% of GA Medicaid Fee Schedule,13.25,Pays at 100% of Medicare OPPS Rate,16.67,Pays at 100% of GA Medicaid Fee Schedule,68.42,Pays at 88% of Total Billed charges,17.17,Pays at 103% of GA Medicaid Fee Schedule,13.25,69.98,46.65
Outpatient Medical Services,LAB,80186,FREE PHENYTOIN   (MAYO),300,87.75,74.59,Pays at 85% of Billed charges for outpatient setting,17.31,Pays at 100% of GA Medicaid Fee Schedule,70.23,Pays at 80.03% of Total Billed charges,14.03,Pays at 102% of Medicare OPPS Rate,78.98,Pays at 90% of Total Billed charges,17.31,Pays at 100% of GA Medicaid Fee Schedule,13.76,Pays at 100% of Medicare OPPS Rate,17.31,Pays at 100% of GA Medicaid Fee Schedule,77.22,Pays at 88% of Total Billed charges,17.83,Pays at 103% of GA Medicaid Fee Schedule,13.76,78.98,52.65
Outpatient Medical Services,LAB,80188,PRIMIDONE SERUM  (MAYO),300,103.25,87.76,Pays at 85% of Billed charges for outpatient setting,20.86,Pays at 100% of GA Medicaid Fee Schedule,82.63,Pays at 80.03% of Total Billed charges,16.92,Pays at 102% of Medicare OPPS Rate,92.93,Pays at 90% of Total Billed charges,20.86,Pays at 100% of GA Medicaid Fee Schedule,16.59,Pays at 100% of Medicare OPPS Rate,20.86,Pays at 100% of GA Medicaid Fee Schedule,90.86,Pays at 88% of Total Billed charges,21.49,Pays at 103% of GA Medicaid Fee Schedule,16.59,92.93,61.95
Outpatient Medical Services,LAB,80192,PROCAINAMIDE LEVEL  (MAYO),300,93.25,79.26,Pays at 85% of Billed charges for outpatient setting,21.07,Pays at 100% of GA Medicaid Fee Schedule,74.63,Pays at 80.03% of Total Billed charges,17.08,Pays at 102% of Medicare OPPS Rate,83.93,Pays at 90% of Total Billed charges,21.07,Pays at 100% of GA Medicaid Fee Schedule,16.75,Pays at 100% of Medicare OPPS Rate,21.07,Pays at 100% of GA Medicaid Fee Schedule,82.06,Pays at 88% of Total Billed charges,21.7,Pays at 103% of GA Medicaid Fee Schedule,16.75,83.93,55.95
Outpatient Medical Services,LAB,80194,QUINIDINE  (MAYO),300,79.25,67.36,Pays at 85% of Billed charges for outpatient setting,18.35,Pays at 100% of GA Medicaid Fee Schedule,63.42,Pays at 80.03% of Total Billed charges,14.89,Pays at 102% of Medicare OPPS Rate,71.33,Pays at 90% of Total Billed charges,18.35,Pays at 100% of GA Medicaid Fee Schedule,14.6,Pays at 100% of Medicare OPPS Rate,18.35,Pays at 100% of GA Medicaid Fee Schedule,69.74,Pays at 88% of Total Billed charges,18.9,Pays at 103% of GA Medicaid Fee Schedule,14.6,71.33,47.55
Outpatient Medical Services,LAB,80195,"RAPAMYCIN, SIROLIMUS (MAYO)",300,176.65,150.15,Pays at 85% of Billed charges for outpatient setting,17.25,Pays at 100% of GA Medicaid Fee Schedule,141.37,Pays at 80.03% of Total Billed charges,14,Pays at 102% of Medicare OPPS Rate,158.99,Pays at 90% of Total Billed charges,17.25,Pays at 100% of GA Medicaid Fee Schedule,13.73,Pays at 100% of Medicare OPPS Rate,17.25,Pays at 100% of GA Medicaid Fee Schedule,155.45,Pays at 88% of Total Billed charges,17.77,Pays at 103% of GA Medicaid Fee Schedule,13.73,158.99,105.99
Outpatient Medical Services,LAB,80197,Test is used to measure the amount of the drug in the blood to determine whether the concentration has reached a therapeutic level and is below the to,300,43.5,36.98,Pays at 85% of Billed charges for outpatient setting,17.25,Pays at 100% of GA Medicaid Fee Schedule,34.81,Pays at 80.03% of Total Billed charges,14,Pays at 102% of Medicare OPPS Rate,39.15,Pays at 90% of Total Billed charges,17.25,Pays at 100% of GA Medicaid Fee Schedule,13.73,Pays at 100% of Medicare OPPS Rate,17.25,Pays at 100% of GA Medicaid Fee Schedule,38.28,Pays at 88% of Total Billed charges,17.77,Pays at 103% of GA Medicaid Fee Schedule,13.73,39.15,26.10
Outpatient Medical Services,LAB,80198,THEOPHYLLINE,300,51.75,43.99,Pays at 85% of Billed charges for outpatient setting,17.79,Pays at 100% of GA Medicaid Fee Schedule,41.42,Pays at 80.03% of Total Billed charges,14.42,Pays at 102% of Medicare OPPS Rate,46.58,Pays at 90% of Total Billed charges,17.79,Pays at 100% of GA Medicaid Fee Schedule,14.14,Pays at 100% of Medicare OPPS Rate,17.79,Pays at 100% of GA Medicaid Fee Schedule,45.54,Pays at 88% of Total Billed charges,18.32,Pays at 103% of GA Medicaid Fee Schedule,14.14,46.58,31.05
Outpatient Medical Services,LAB,80199,"TIAGABENE, GABITRIL  (MAYO)",300,122.25,103.91,Pays at 85% of Billed charges for outpatient setting,6.55,Pays at 100% of GA Medicaid Fee Schedule,97.84,Pays at 80.03% of Total Billed charges,27.65,Pays at 102% of Medicare OPPS Rate,110.03,Pays at 90% of Total Billed charges,6.55,Pays at 100% of GA Medicaid Fee Schedule,27.11,Pays at 100% of Medicare OPPS Rate,6.55,Pays at 100% of GA Medicaid Fee Schedule,107.58,Pays at 88% of Total Billed charges,6.75,Pays at 103% of GA Medicaid Fee Schedule,6.55,110.03,73.35
Outpatient Medical Services,LAB,80200,TOBRAMYCIN TROUGH,300,77.75,66.09,Pays at 85% of Billed charges for outpatient setting,18.84,Pays at 100% of GA Medicaid Fee Schedule,62.22,Pays at 80.03% of Total Billed charges,16.45,Pays at 102% of Medicare OPPS Rate,69.98,Pays at 90% of Total Billed charges,18.84,Pays at 100% of GA Medicaid Fee Schedule,16.13,Pays at 100% of Medicare OPPS Rate,18.84,Pays at 100% of GA Medicaid Fee Schedule,68.42,Pays at 88% of Total Billed charges,19.41,Pays at 103% of GA Medicaid Fee Schedule,16.13,69.98,46.65
Outpatient Medical Services,LAB,80200,TOBRAMYCIN PEAK,300,77.75,66.09,Pays at 85% of Billed charges for outpatient setting,18.84,Pays at 100% of GA Medicaid Fee Schedule,62.22,Pays at 80.03% of Total Billed charges,16.45,Pays at 102% of Medicare OPPS Rate,69.98,Pays at 90% of Total Billed charges,18.84,Pays at 100% of GA Medicaid Fee Schedule,16.13,Pays at 100% of Medicare OPPS Rate,18.84,Pays at 100% of GA Medicaid Fee Schedule,68.42,Pays at 88% of Total Billed charges,19.41,Pays at 103% of GA Medicaid Fee Schedule,16.13,69.98,46.65
Outpatient Medical Services,LAB,80200,..TOBRAMYCIN,300,103.5,87.98,Pays at 85% of Billed charges for outpatient setting,18.84,Pays at 100% of GA Medicaid Fee Schedule,82.83,Pays at 80.03% of Total Billed charges,16.45,Pays at 102% of Medicare OPPS Rate,93.15,Pays at 90% of Total Billed charges,18.84,Pays at 100% of GA Medicaid Fee Schedule,16.13,Pays at 100% of Medicare OPPS Rate,18.84,Pays at 100% of GA Medicaid Fee Schedule,91.08,Pays at 88% of Total Billed charges,19.41,Pays at 103% of GA Medicaid Fee Schedule,16.13,93.15,62.10
Outpatient Medical Services,LAB,80201,"TOPIRAMATE, TOPAMAX  (MAYO)",300,50.75,43.14,Pays at 85% of Billed charges for outpatient setting,14.99,Pays at 100% of GA Medicaid Fee Schedule,40.62,Pays at 80.03% of Total Billed charges,12.15,Pays at 102% of Medicare OPPS Rate,45.68,Pays at 90% of Total Billed charges,14.99,Pays at 100% of GA Medicaid Fee Schedule,11.92,Pays at 100% of Medicare OPPS Rate,14.99,Pays at 100% of GA Medicaid Fee Schedule,44.66,Pays at 88% of Total Billed charges,15.44,Pays at 103% of GA Medicaid Fee Schedule,11.92,45.68,30.45
Outpatient Medical Services,LAB,80202,VANCOMYCIN TROUGH,300,63.76,54.2,Pays at 85% of Billed charges for outpatient setting,14.27,Pays at 100% of GA Medicaid Fee Schedule,51.03,Pays at 80.03% of Total Billed charges,13.81,Pays at 102% of Medicare OPPS Rate,57.38,Pays at 90% of Total Billed charges,14.27,Pays at 100% of GA Medicaid Fee Schedule,13.54,Pays at 100% of Medicare OPPS Rate,14.27,Pays at 100% of GA Medicaid Fee Schedule,56.11,Pays at 88% of Total Billed charges,14.7,Pays at 103% of GA Medicaid Fee Schedule,13.54,57.38,38.26
Outpatient Medical Services,LAB,80202,VANCOMYCIN RANDOM,300,77,65.45,Pays at 85% of Billed charges for outpatient setting,14.27,Pays at 100% of GA Medicaid Fee Schedule,61.62,Pays at 80.03% of Total Billed charges,13.81,Pays at 102% of Medicare OPPS Rate,69.3,Pays at 90% of Total Billed charges,14.27,Pays at 100% of GA Medicaid Fee Schedule,13.54,Pays at 100% of Medicare OPPS Rate,14.27,Pays at 100% of GA Medicaid Fee Schedule,67.76,Pays at 88% of Total Billed charges,14.7,Pays at 103% of GA Medicaid Fee Schedule,13.54,69.3,46.20
Outpatient Medical Services,LAB,80202,VANCOMYCIN PEAK,300,77,65.45,Pays at 85% of Billed charges for outpatient setting,14.27,Pays at 100% of GA Medicaid Fee Schedule,61.62,Pays at 80.03% of Total Billed charges,13.81,Pays at 102% of Medicare OPPS Rate,69.3,Pays at 90% of Total Billed charges,14.27,Pays at 100% of GA Medicaid Fee Schedule,13.54,Pays at 100% of Medicare OPPS Rate,14.27,Pays at 100% of GA Medicaid Fee Schedule,67.76,Pays at 88% of Total Billed charges,14.7,Pays at 103% of GA Medicaid Fee Schedule,13.54,69.3,46.20
Outpatient Medical Services,LAB,80203,ZONISAMIDE  (MAYO),300,83,70.55,Pays at 85% of Billed charges for outpatient setting,14.47,Pays at 100% of GA Medicaid Fee Schedule,66.42,Pays at 80.03% of Total Billed charges,13.51,Pays at 102% of Medicare OPPS Rate,74.7,Pays at 90% of Total Billed charges,14.47,Pays at 100% of GA Medicaid Fee Schedule,13.25,Pays at 100% of Medicare OPPS Rate,14.47,Pays at 100% of GA Medicaid Fee Schedule,73.04,Pays at 88% of Total Billed charges,14.9,Pays at 103% of GA Medicaid Fee Schedule,13.25,74.7,49.80
Outpatient Medical Services,LAB,80299,AMIODARONE   (MAYO),300,37.75,32.09,Pays at 85% of Billed charges for outpatient setting,15.14,Pays at 100% of GA Medicaid Fee Schedule,30.21,Pays at 80.03% of Total Billed charges,19.01,Pays at 102% of Medicare OPPS Rate,33.98,Pays at 90% of Total Billed charges,15.14,Pays at 100% of GA Medicaid Fee Schedule,18.64,Pays at 100% of Medicare OPPS Rate,15.14,Pays at 100% of GA Medicaid Fee Schedule,33.22,Pays at 88% of Total Billed charges,15.59,Pays at 103% of GA Medicaid Fee Schedule,15.14,33.98,22.65
Outpatient Medical Services,LAB,80299,METHOTREXATE  (MAYO),300,41.25,35.06,Pays at 85% of Billed charges for outpatient setting,15.14,Pays at 100% of GA Medicaid Fee Schedule,33.01,Pays at 80.03% of Total Billed charges,19.01,Pays at 102% of Medicare OPPS Rate,37.13,Pays at 90% of Total Billed charges,15.14,Pays at 100% of GA Medicaid Fee Schedule,18.64,Pays at 100% of Medicare OPPS Rate,15.14,Pays at 100% of GA Medicaid Fee Schedule,36.3,Pays at 88% of Total Billed charges,15.59,Pays at 103% of GA Medicaid Fee Schedule,15.14,37.13,24.75
Outpatient Medical Services,LAB,80299,TRAZODONE   (MAYO),300,68.25,58.01,Pays at 85% of Billed charges for outpatient setting,15.14,Pays at 100% of GA Medicaid Fee Schedule,54.62,Pays at 80.03% of Total Billed charges,19.01,Pays at 102% of Medicare OPPS Rate,61.43,Pays at 90% of Total Billed charges,15.14,Pays at 100% of GA Medicaid Fee Schedule,18.64,Pays at 100% of Medicare OPPS Rate,15.14,Pays at 100% of GA Medicaid Fee Schedule,60.06,Pays at 88% of Total Billed charges,15.59,Pays at 103% of GA Medicaid Fee Schedule,15.14,61.43,40.95
Outpatient Medical Services,LAB,80299,FELBAMATE LEVEL  (MAYO),300,77.75,66.09,Pays at 85% of Billed charges for outpatient setting,15.14,Pays at 100% of GA Medicaid Fee Schedule,62.22,Pays at 80.03% of Total Billed charges,19.01,Pays at 102% of Medicare OPPS Rate,69.98,Pays at 90% of Total Billed charges,15.14,Pays at 100% of GA Medicaid Fee Schedule,18.64,Pays at 100% of Medicare OPPS Rate,15.14,Pays at 100% of GA Medicaid Fee Schedule,68.42,Pays at 88% of Total Billed charges,15.59,Pays at 103% of GA Medicaid Fee Schedule,15.14,69.98,46.65
Outpatient Medical Services,LAB,80299,FLECAINIDE LEVEL  (MAYO),300,78.75,66.94,Pays at 85% of Billed charges for outpatient setting,15.14,Pays at 100% of GA Medicaid Fee Schedule,63.02,Pays at 80.03% of Total Billed charges,19.01,Pays at 102% of Medicare OPPS Rate,70.88,Pays at 90% of Total Billed charges,15.14,Pays at 100% of GA Medicaid Fee Schedule,18.64,Pays at 100% of Medicare OPPS Rate,15.14,Pays at 100% of GA Medicaid Fee Schedule,69.3,Pays at 88% of Total Billed charges,15.59,Pays at 103% of GA Medicaid Fee Schedule,15.14,70.88,47.25
Outpatient Medical Services,LAB,80299,VENLAFAXINE  (MAYO),300,84,71.4,Pays at 85% of Billed charges for outpatient setting,15.14,Pays at 100% of GA Medicaid Fee Schedule,67.23,Pays at 80.03% of Total Billed charges,19.01,Pays at 102% of Medicare OPPS Rate,75.6,Pays at 90% of Total Billed charges,15.14,Pays at 100% of GA Medicaid Fee Schedule,18.64,Pays at 100% of Medicare OPPS Rate,15.14,Pays at 100% of GA Medicaid Fee Schedule,73.92,Pays at 88% of Total Billed charges,15.59,Pays at 103% of GA Medicaid Fee Schedule,15.14,75.6,50.40
Outpatient Medical Services,LAB,80299,"ALDACTONE LEVEL (NMS),  (MAYO)",300,105.5,89.68,Pays at 85% of Billed charges for outpatient setting,15.14,Pays at 100% of GA Medicaid Fee Schedule,84.43,Pays at 80.03% of Total Billed charges,19.01,Pays at 102% of Medicare OPPS Rate,94.95,Pays at 90% of Total Billed charges,15.14,Pays at 100% of GA Medicaid Fee Schedule,18.64,Pays at 100% of Medicare OPPS Rate,15.14,Pays at 100% of GA Medicaid Fee Schedule,92.84,Pays at 88% of Total Billed charges,15.59,Pays at 103% of GA Medicaid Fee Schedule,15.14,94.95,63.30
Outpatient Medical Services,LAB,80299,"PAXIL, PAROXETINE  (MAYO)",300,110.5,93.93,Pays at 85% of Billed charges for outpatient setting,15.14,Pays at 100% of GA Medicaid Fee Schedule,88.43,Pays at 80.03% of Total Billed charges,19.01,Pays at 102% of Medicare OPPS Rate,99.45,Pays at 90% of Total Billed charges,15.14,Pays at 100% of GA Medicaid Fee Schedule,18.64,Pays at 100% of Medicare OPPS Rate,15.14,Pays at 100% of GA Medicaid Fee Schedule,97.24,Pays at 88% of Total Billed charges,15.59,Pays at 103% of GA Medicaid Fee Schedule,15.14,99.45,66.30
Outpatient Medical Services,LAB,80299,STREPTOMYCIN LEVEL (SERUM)   MAYO,300,143.5,121.98,Pays at 85% of Billed charges for outpatient setting,15.14,Pays at 100% of GA Medicaid Fee Schedule,114.84,Pays at 80.03% of Total Billed charges,19.01,Pays at 102% of Medicare OPPS Rate,129.15,Pays at 90% of Total Billed charges,15.14,Pays at 100% of GA Medicaid Fee Schedule,18.64,Pays at 100% of Medicare OPPS Rate,15.14,Pays at 100% of GA Medicaid Fee Schedule,126.28,Pays at 88% of Total Billed charges,15.59,Pays at 103% of GA Medicaid Fee Schedule,15.14,129.15,86.10
Outpatient Medical Services,LAB,80299,PROPAFENONE  (MAYO),300,145,123.25,Pays at 85% of Billed charges for outpatient setting,15.14,Pays at 100% of GA Medicaid Fee Schedule,116.04,Pays at 80.03% of Total Billed charges,19.01,Pays at 102% of Medicare OPPS Rate,130.5,Pays at 90% of Total Billed charges,15.14,Pays at 100% of GA Medicaid Fee Schedule,18.64,Pays at 100% of Medicare OPPS Rate,15.14,Pays at 100% of GA Medicaid Fee Schedule,127.6,Pays at 88% of Total Billed charges,15.59,Pays at 103% of GA Medicaid Fee Schedule,15.14,130.5,87.00
Outpatient Medical Services,LAB,80299,VORICONAZOLE (MAYO),300,158.5,134.73,Pays at 85% of Billed charges for outpatient setting,15.14,Pays at 100% of GA Medicaid Fee Schedule,126.85,Pays at 80.03% of Total Billed charges,19.01,Pays at 102% of Medicare OPPS Rate,142.65,Pays at 90% of Total Billed charges,15.14,Pays at 100% of GA Medicaid Fee Schedule,18.64,Pays at 100% of Medicare OPPS Rate,15.14,Pays at 100% of GA Medicaid Fee Schedule,139.48,Pays at 88% of Total Billed charges,15.59,Pays at 103% of GA Medicaid Fee Schedule,15.14,142.65,95.10
Outpatient Medical Services,LAB,80299,"WARFARIN, COUMADIN  (MAYO)",300,164.25,139.61,Pays at 85% of Billed charges for outpatient setting,15.14,Pays at 100% of GA Medicaid Fee Schedule,131.45,Pays at 80.03% of Total Billed charges,19.01,Pays at 102% of Medicare OPPS Rate,147.83,Pays at 90% of Total Billed charges,15.14,Pays at 100% of GA Medicaid Fee Schedule,18.64,Pays at 100% of Medicare OPPS Rate,15.14,Pays at 100% of GA Medicaid Fee Schedule,144.54,Pays at 88% of Total Billed charges,15.59,Pays at 103% of GA Medicaid Fee Schedule,15.14,147.83,98.55
Outpatient Medical Services,LAB,80299,LACOSAMIDE  (MAYO),300,207.75,176.59,Pays at 85% of Billed charges for outpatient setting,15.14,Pays at 100% of GA Medicaid Fee Schedule,166.26,Pays at 80.03% of Total Billed charges,19.01,Pays at 102% of Medicare OPPS Rate,186.98,Pays at 90% of Total Billed charges,15.14,Pays at 100% of GA Medicaid Fee Schedule,18.64,Pays at 100% of Medicare OPPS Rate,15.14,Pays at 100% of GA Medicaid Fee Schedule,182.82,Pays at 88% of Total Billed charges,15.59,Pays at 103% of GA Medicaid Fee Schedule,15.14,186.98,124.65
Outpatient Medical Services,LAB,80299,LEFLUNOMIDE (TERIFLUNOMIDE)  (MAYO),300,281.5,239.28,Pays at 85% of Billed charges for outpatient setting,15.14,Pays at 100% of GA Medicaid Fee Schedule,225.28,Pays at 80.03% of Total Billed charges,19.01,Pays at 102% of Medicare OPPS Rate,253.35,Pays at 90% of Total Billed charges,15.14,Pays at 100% of GA Medicaid Fee Schedule,18.64,Pays at 100% of Medicare OPPS Rate,15.14,Pays at 100% of GA Medicaid Fee Schedule,247.72,Pays at 88% of Total Billed charges,15.59,Pays at 103% of GA Medicaid Fee Schedule,15.14,253.35,168.90
Outpatient Medical Services,LAB,80301,ATN -UPS,300,43.25,36.76,Pays at 85% of Billed charges for outpatient setting,13.9,Pays at 32.15% of Total Billed charges,34.61,Pays at 80.03% of Total Billed charges,NA,Not Applicable,38.93,Pays at 90% of Total Billed charges,13.9,Pays at 32.15% of Total Billed charges,NA,Not Applicable,13.9,Pays at 32.15% of Total Billed charges,38.06,Pays at 88% of Total Billed charges,14.32,Pays at 33.11% of Total Billed charges,13.9,38.93,25.95
Outpatient Medical Services,LAB,80301,SINGLE DRUG CLASS BY DMC  (MAYO),300,63.5,53.98,Pays at 85% of Billed charges for outpatient setting,20.42,Pays at 32.15% of Total Billed charges,50.82,Pays at 80.03% of Total Billed charges,NA,Not Applicable,57.15,Pays at 90% of Total Billed charges,20.42,Pays at 32.15% of Total Billed charges,NA,Not Applicable,20.42,Pays at 32.15% of Total Billed charges,55.88,Pays at 88% of Total Billed charges,21.02,Pays at 33.11% of Total Billed charges,20.42,57.15,38.10
Outpatient Medical Services,LAB,80301,SINGLE DRUG CLASS BY DMC  (MAYO),300,63.5,53.98,Pays at 85% of Billed charges for outpatient setting,20.42,Pays at 32.15% of Total Billed charges,50.82,Pays at 80.03% of Total Billed charges,NA,Not Applicable,57.15,Pays at 90% of Total Billed charges,20.42,Pays at 32.15% of Total Billed charges,NA,Not Applicable,20.42,Pays at 32.15% of Total Billed charges,55.88,Pays at 88% of Total Billed charges,21.02,Pays at 33.11% of Total Billed charges,20.42,57.15,38.10
Outpatient Medical Services,LAB,80301,SINGLE DRUG CLASS BY DMC  (MAYO),300,63.5,53.98,Pays at 85% of Billed charges for outpatient setting,20.42,Pays at 32.15% of Total Billed charges,50.82,Pays at 80.03% of Total Billed charges,NA,Not Applicable,57.15,Pays at 90% of Total Billed charges,20.42,Pays at 32.15% of Total Billed charges,NA,Not Applicable,20.42,Pays at 32.15% of Total Billed charges,55.88,Pays at 88% of Total Billed charges,21.02,Pays at 33.11% of Total Billed charges,20.42,57.15,38.10
Outpatient Medical Services,LAB,80301,DRUG SCREEN 9-PANEL,300,75.25,63.96,Pays at 85% of Billed charges for outpatient setting,24.19,Pays at 32.15% of Total Billed charges,60.22,Pays at 80.03% of Total Billed charges,NA,Not Applicable,67.73,Pays at 90% of Total Billed charges,24.19,Pays at 32.15% of Total Billed charges,NA,Not Applicable,24.19,Pays at 32.15% of Total Billed charges,66.22,Pays at 88% of Total Billed charges,24.92,Pays at 33.11% of Total Billed charges,24.19,67.73,45.15
Outpatient Medical Services,LAB,80301,DRUG SCREEN CLASS LIST A,300,103,87.55,Pays at 85% of Billed charges for outpatient setting,33.11,Pays at 32.15% of Total Billed charges,82.43,Pays at 80.03% of Total Billed charges,NA,Not Applicable,92.7,Pays at 90% of Total Billed charges,33.11,Pays at 32.15% of Total Billed charges,NA,Not Applicable,33.11,Pays at 32.15% of Total Billed charges,90.64,Pays at 88% of Total Billed charges,34.1,Pays at 33.11% of Total Billed charges,33.11,92.7,61.80
Outpatient Medical Services,LAB,80301,SYNTHETIC MARIJUANA SCREEN  (MAYO),300,110.5,93.93,Pays at 85% of Billed charges for outpatient setting,35.53,Pays at 32.15% of Total Billed charges,88.43,Pays at 80.03% of Total Billed charges,NA,Not Applicable,99.45,Pays at 90% of Total Billed charges,35.53,Pays at 32.15% of Total Billed charges,NA,Not Applicable,35.53,Pays at 32.15% of Total Billed charges,97.24,Pays at 88% of Total Billed charges,36.59,Pays at 33.11% of Total Billed charges,35.53,99.45,66.30
Outpatient Medical Services,LAB,80301,"DRUG SCREEN 5, MECONIUM  (MAYO)",300,122.25,103.91,Pays at 85% of Billed charges for outpatient setting,39.3,Pays at 32.15% of Total Billed charges,97.84,Pays at 80.03% of Total Billed charges,NA,Not Applicable,110.03,Pays at 90% of Total Billed charges,39.3,Pays at 32.15% of Total Billed charges,NA,Not Applicable,39.3,Pays at 32.15% of Total Billed charges,107.58,Pays at 88% of Total Billed charges,40.48,Pays at 33.11% of Total Billed charges,39.3,110.03,73.35
Outpatient Medical Services,LAB,80301,"DRUG SCREEN, QL, EACH",300,122.25,103.91,Pays at 85% of Billed charges for outpatient setting,39.3,Pays at 32.15% of Total Billed charges,97.84,Pays at 80.03% of Total Billed charges,NA,Not Applicable,110.03,Pays at 90% of Total Billed charges,39.3,Pays at 32.15% of Total Billed charges,NA,Not Applicable,39.3,Pays at 32.15% of Total Billed charges,107.58,Pays at 88% of Total Billed charges,40.48,Pays at 33.11% of Total Billed charges,39.3,110.03,73.35
Outpatient Medical Services,LAB,80301,OUT-PATIENT DRUG SCREEN,300,150,127.5,Pays at 85% of Billed charges for outpatient setting,48.23,Pays at 32.15% of Total Billed charges,120.05,Pays at 80.03% of Total Billed charges,NA,Not Applicable,135,Pays at 90% of Total Billed charges,48.23,Pays at 32.15% of Total Billed charges,NA,Not Applicable,48.23,Pays at 32.15% of Total Billed charges,132,Pays at 88% of Total Billed charges,49.67,Pays at 33.11% of Total Billed charges,48.23,135,90.00
Outpatient Medical Services,LAB,80301,SEXUAL ASSAULT SCREEN MAYO,300,363,308.55,Pays at 85% of Billed charges for outpatient setting,116.7,Pays at 32.15% of Total Billed charges,290.51,Pays at 80.03% of Total Billed charges,NA,Not Applicable,326.7,Pays at 90% of Total Billed charges,116.7,Pays at 32.15% of Total Billed charges,NA,Not Applicable,116.7,Pays at 32.15% of Total Billed charges,319.44,Pays at 88% of Total Billed charges,120.19,Pays at 33.11% of Total Billed charges,116.7,326.7,217.80
Outpatient Medical Services,LAB,80302,"FENTANYL, URINE   (MAYO)",300,134.5,114.33,Pays at 85% of Billed charges for outpatient setting,43.24,Pays at 32.15% of Total Billed charges,107.64,Pays at 80.03% of Total Billed charges,NA,Not Applicable,121.05,Pays at 90% of Total Billed charges,43.24,Pays at 32.15% of Total Billed charges,NA,Not Applicable,43.24,Pays at 32.15% of Total Billed charges,118.36,Pays at 88% of Total Billed charges,44.53,Pays at 33.11% of Total Billed charges,43.24,121.05,80.70
Outpatient Medical Services,LAB,80302,"ETHYLENE GLUCURONIDE SCREEN, U  (MAYO)",300,145,123.25,Pays at 85% of Billed charges for outpatient setting,46.62,Pays at 32.15% of Total Billed charges,116.04,Pays at 80.03% of Total Billed charges,NA,Not Applicable,130.5,Pays at 90% of Total Billed charges,46.62,Pays at 32.15% of Total Billed charges,NA,Not Applicable,46.62,Pays at 32.15% of Total Billed charges,127.6,Pays at 88% of Total Billed charges,48.01,Pays at 33.11% of Total Billed charges,46.62,130.5,87.00
Outpatient Medical Services,LAB,80304,SINGLE DRUG CLASS BY TLC  (MAYO),300,63.5,53.98,Pays at 85% of Billed charges for outpatient setting,20.42,Pays at 32.15% of Total Billed charges,50.82,Pays at 80.03% of Total Billed charges,NA,Not Applicable,57.15,Pays at 90% of Total Billed charges,20.42,Pays at 32.15% of Total Billed charges,NA,Not Applicable,20.42,Pays at 32.15% of Total Billed charges,55.88,Pays at 88% of Total Billed charges,21.02,Pays at 33.11% of Total Billed charges,20.42,57.15,38.10
Outpatient Medical Services,LAB,80304,SINGLE DRUG CLASS BY TLC  (MAYO),300,63.5,53.98,Pays at 85% of Billed charges for outpatient setting,20.42,Pays at 32.15% of Total Billed charges,50.82,Pays at 80.03% of Total Billed charges,NA,Not Applicable,57.15,Pays at 90% of Total Billed charges,20.42,Pays at 32.15% of Total Billed charges,NA,Not Applicable,20.42,Pays at 32.15% of Total Billed charges,55.88,Pays at 88% of Total Billed charges,21.02,Pays at 33.11% of Total Billed charges,20.42,57.15,38.10
Outpatient Medical Services,LAB,80304,SINGLE DRUG CLASS BY TLC  (MAYO),300,63.5,53.98,Pays at 85% of Billed charges for outpatient setting,20.42,Pays at 32.15% of Total Billed charges,50.82,Pays at 80.03% of Total Billed charges,NA,Not Applicable,57.15,Pays at 90% of Total Billed charges,20.42,Pays at 32.15% of Total Billed charges,NA,Not Applicable,20.42,Pays at 32.15% of Total Billed charges,55.88,Pays at 88% of Total Billed charges,21.02,Pays at 33.11% of Total Billed charges,20.42,57.15,38.10
Outpatient Medical Services,LAB,80304,SINGLE DRUG CLASS BY TLC  (MAYO),300,63.5,53.98,Pays at 85% of Billed charges for outpatient setting,20.42,Pays at 32.15% of Total Billed charges,50.82,Pays at 80.03% of Total Billed charges,NA,Not Applicable,57.15,Pays at 90% of Total Billed charges,20.42,Pays at 32.15% of Total Billed charges,NA,Not Applicable,20.42,Pays at 32.15% of Total Billed charges,55.88,Pays at 88% of Total Billed charges,21.02,Pays at 33.11% of Total Billed charges,20.42,57.15,38.10
Outpatient Medical Services,LAB,80304,DRUG SCREEN PRESCRIPTION/OTC (MAYO),300,73,62.05,Pays at 85% of Billed charges for outpatient setting,23.47,Pays at 32.15% of Total Billed charges,58.42,Pays at 80.03% of Total Billed charges,NA,Not Applicable,65.7,Pays at 90% of Total Billed charges,23.47,Pays at 32.15% of Total Billed charges,NA,Not Applicable,23.47,Pays at 32.15% of Total Billed charges,64.24,Pays at 88% of Total Billed charges,24.17,Pays at 33.11% of Total Billed charges,23.47,65.7,43.80
Outpatient Medical Services,LAB,80304,OUT-PATIENT DRUG SCREEN II  W/ALCOHOL,300,155.25,131.96,Pays at 85% of Billed charges for outpatient setting,49.91,Pays at 32.15% of Total Billed charges,124.25,Pays at 80.03% of Total Billed charges,NA,Not Applicable,139.73,Pays at 90% of Total Billed charges,49.91,Pays at 32.15% of Total Billed charges,NA,Not Applicable,49.91,Pays at 32.15% of Total Billed charges,136.62,Pays at 88% of Total Billed charges,51.4,Pays at 33.11% of Total Billed charges,49.91,139.73,93.15
Outpatient Medical Services,LAB,80307,Testing for presence of drug,300,26,22.1,Pays at 85% of Billed charges for outpatient setting,61.16,Pays at 100% of GA Medicaid Fee Schedule,20.81,Pays at 80.03% of Total Billed charges,63.38,Pays at 102% of Medicare OPPS Rate,23.4,Pays at 90% of Total Billed charges,61.16,Pays at 100% of GA Medicaid Fee Schedule,62.14,Pays at 100% of Medicare OPPS Rate,61.16,Pays at 100% of GA Medicaid Fee Schedule,22.88,Pays at 88% of Total Billed charges,62.99,Pays at 103% of GA Medicaid Fee Schedule,20.81,63.38,15.60
Outpatient Medical Services,LAB,80307,Testing for presence of drug,300,55.5,47.18,Pays at 85% of Billed charges for outpatient setting,61.16,Pays at 100% of GA Medicaid Fee Schedule,44.42,Pays at 80.03% of Total Billed charges,63.38,Pays at 102% of Medicare OPPS Rate,49.95,Pays at 90% of Total Billed charges,61.16,Pays at 100% of GA Medicaid Fee Schedule,62.14,Pays at 100% of Medicare OPPS Rate,61.16,Pays at 100% of GA Medicaid Fee Schedule,48.84,Pays at 88% of Total Billed charges,62.99,Pays at 103% of GA Medicaid Fee Schedule,44.42,63.38,33.30
Outpatient Medical Services,LAB,80307,Testing for presence of drug,300,103.5,87.98,Pays at 85% of Billed charges for outpatient setting,61.16,Pays at 100% of GA Medicaid Fee Schedule,82.83,Pays at 80.03% of Total Billed charges,63.38,Pays at 102% of Medicare OPPS Rate,93.15,Pays at 90% of Total Billed charges,61.16,Pays at 100% of GA Medicaid Fee Schedule,62.14,Pays at 100% of Medicare OPPS Rate,61.16,Pays at 100% of GA Medicaid Fee Schedule,91.08,Pays at 88% of Total Billed charges,62.99,Pays at 103% of GA Medicaid Fee Schedule,61.16,93.15,62.10
Outpatient Medical Services,LAB,80307,Testing for presence of drug,300,127.39,108.28,Pays at 85% of Billed charges for outpatient setting,61.16,Pays at 100% of GA Medicaid Fee Schedule,101.95,Pays at 80.03% of Total Billed charges,63.38,Pays at 102% of Medicare OPPS Rate,114.65,Pays at 90% of Total Billed charges,61.16,Pays at 100% of GA Medicaid Fee Schedule,62.14,Pays at 100% of Medicare OPPS Rate,61.16,Pays at 100% of GA Medicaid Fee Schedule,112.1,Pays at 88% of Total Billed charges,62.99,Pays at 103% of GA Medicaid Fee Schedule,61.16,114.65,76.43
Outpatient Medical Services,LAB,80307,Testing for presence of drug,300,152.73,129.82,Pays at 85% of Billed charges for outpatient setting,61.16,Pays at 100% of GA Medicaid Fee Schedule,122.23,Pays at 80.03% of Total Billed charges,63.38,Pays at 102% of Medicare OPPS Rate,137.46,Pays at 90% of Total Billed charges,61.16,Pays at 100% of GA Medicaid Fee Schedule,62.14,Pays at 100% of Medicare OPPS Rate,61.16,Pays at 100% of GA Medicaid Fee Schedule,134.4,Pays at 88% of Total Billed charges,62.99,Pays at 103% of GA Medicaid Fee Schedule,61.16,137.46,91.64
Outpatient Medical Services,LAB,80307,Testing for presence of drug,300,152.73,129.82,Pays at 85% of Billed charges for outpatient setting,61.16,Pays at 100% of GA Medicaid Fee Schedule,122.23,Pays at 80.03% of Total Billed charges,63.38,Pays at 102% of Medicare OPPS Rate,137.46,Pays at 90% of Total Billed charges,61.16,Pays at 100% of GA Medicaid Fee Schedule,62.14,Pays at 100% of Medicare OPPS Rate,61.16,Pays at 100% of GA Medicaid Fee Schedule,134.4,Pays at 88% of Total Billed charges,62.99,Pays at 103% of GA Medicaid Fee Schedule,61.16,137.46,91.64
Outpatient Medical Services,LAB,80307,Testing for presence of drug,300,179,152.15,Pays at 85% of Billed charges for outpatient setting,61.16,Pays at 100% of GA Medicaid Fee Schedule,143.25,Pays at 80.03% of Total Billed charges,63.38,Pays at 102% of Medicare OPPS Rate,161.1,Pays at 90% of Total Billed charges,61.16,Pays at 100% of GA Medicaid Fee Schedule,62.14,Pays at 100% of Medicare OPPS Rate,61.16,Pays at 100% of GA Medicaid Fee Schedule,157.52,Pays at 88% of Total Billed charges,62.99,Pays at 103% of GA Medicaid Fee Schedule,61.16,161.1,107.40
Outpatient Medical Services,LAB,80307,Testing for presence of drug,300,186.25,158.31,Pays at 85% of Billed charges for outpatient setting,61.16,Pays at 100% of GA Medicaid Fee Schedule,149.06,Pays at 80.03% of Total Billed charges,63.38,Pays at 102% of Medicare OPPS Rate,167.63,Pays at 90% of Total Billed charges,61.16,Pays at 100% of GA Medicaid Fee Schedule,62.14,Pays at 100% of Medicare OPPS Rate,61.16,Pays at 100% of GA Medicaid Fee Schedule,163.9,Pays at 88% of Total Billed charges,62.99,Pays at 103% of GA Medicaid Fee Schedule,61.16,167.63,111.75
Outpatient Medical Services,LAB,80307,Testing for presence of drug,300,186.25,158.31,Pays at 85% of Billed charges for outpatient setting,61.16,Pays at 100% of GA Medicaid Fee Schedule,149.06,Pays at 80.03% of Total Billed charges,63.38,Pays at 102% of Medicare OPPS Rate,167.63,Pays at 90% of Total Billed charges,61.16,Pays at 100% of GA Medicaid Fee Schedule,62.14,Pays at 100% of Medicare OPPS Rate,61.16,Pays at 100% of GA Medicaid Fee Schedule,163.9,Pays at 88% of Total Billed charges,62.99,Pays at 103% of GA Medicaid Fee Schedule,61.16,167.63,111.75
Outpatient Medical Services,LAB,80320,"..ALCOHOL, ETHANOL URINE",300,46.5,39.53,Pays at 85% of Billed charges for outpatient setting,13.59,Pays at 100% of GA Medicaid Fee Schedule,37.21,Pays at 80.03% of Total Billed charges,NA,Not Applicable,41.85,Pays at 90% of Total Billed charges,13.59,Pays at 100% of GA Medicaid Fee Schedule,NA,Not Applicable,13.59,Pays at 100% of GA Medicaid Fee Schedule,40.92,Pays at 88% of Total Billed charges,14,Pays at 103% of GA Medicaid Fee Schedule,13.59,41.85,27.90
Outpatient Medical Services,LAB,80320,LEGAL BLOOD ALCOHOL / URINE DRUG SCREEN,300,82.81,70.39,Pays at 85% of Billed charges for outpatient setting,13.59,Pays at 100% of GA Medicaid Fee Schedule,66.27,Pays at 80.03% of Total Billed charges,NA,Not Applicable,74.53,Pays at 90% of Total Billed charges,13.59,Pays at 100% of GA Medicaid Fee Schedule,NA,Not Applicable,13.59,Pays at 100% of GA Medicaid Fee Schedule,72.87,Pays at 88% of Total Billed charges,14,Pays at 103% of GA Medicaid Fee Schedule,13.59,74.53,49.69
Outpatient Medical Services,LAB,80320,VOLATILE SCREEN BLOOD (MAYO),300,102.5,87.13,Pays at 85% of Billed charges for outpatient setting,13.59,Pays at 100% of GA Medicaid Fee Schedule,82.03,Pays at 80.03% of Total Billed charges,NA,Not Applicable,92.25,Pays at 90% of Total Billed charges,13.59,Pays at 100% of GA Medicaid Fee Schedule,NA,Not Applicable,13.59,Pays at 100% of GA Medicaid Fee Schedule,90.2,Pays at 88% of Total Billed charges,14,Pays at 103% of GA Medicaid Fee Schedule,13.59,92.25,61.50
Outpatient Medical Services,LAB,80321,PHOSPHATIDYLETHANOL PETH FFPET (MAYO),300,191.25,162.56,Pays at 85% of Billed charges for outpatient setting,13.59,Pays at 100% of GA Medicaid Fee Schedule,153.06,Pays at 80.03% of Total Billed charges,NA,Not Applicable,172.13,Pays at 90% of Total Billed charges,13.59,Pays at 100% of GA Medicaid Fee Schedule,NA,Not Applicable,13.59,Pays at 100% of GA Medicaid Fee Schedule,168.3,Pays at 88% of Total Billed charges,14,Pays at 103% of GA Medicaid Fee Schedule,13.59,172.13,114.75
Outpatient Medical Services,LAB,80323,"NICOTINE & METABOLITES, SERUM   (MAYO)",300,98.25,83.51,Pays at 85% of Billed charges for outpatient setting,37.75,Pays at 100% of GA Medicaid Fee Schedule,78.63,Pays at 80.03% of Total Billed charges,NA,Not Applicable,88.43,Pays at 90% of Total Billed charges,37.75,Pays at 100% of GA Medicaid Fee Schedule,NA,Not Applicable,37.75,Pays at 100% of GA Medicaid Fee Schedule,86.46,Pays at 88% of Total Billed charges,38.88,Pays at 103% of GA Medicaid Fee Schedule,37.75,88.43,58.95
Outpatient Medical Services,LAB,80323,"NICOTINE & METABOLITES, URINE (MAYO)",300,132.26,112.42,Pays at 85% of Billed charges for outpatient setting,37.75,Pays at 100% of GA Medicaid Fee Schedule,105.85,Pays at 80.03% of Total Billed charges,NA,Not Applicable,119.03,Pays at 90% of Total Billed charges,37.75,Pays at 100% of GA Medicaid Fee Schedule,NA,Not Applicable,37.75,Pays at 100% of GA Medicaid Fee Schedule,116.39,Pays at 88% of Total Billed charges,38.88,Pays at 103% of GA Medicaid Fee Schedule,37.75,119.03,79.36
Outpatient Medical Services,LAB,80324,..AMPHETAMINES CONFIRMATION  (MAYO),300,87.75,74.59,Pays at 85% of Billed charges for outpatient setting,19.55,Pays at 100% of GA Medicaid Fee Schedule,70.23,Pays at 80.03% of Total Billed charges,NA,Not Applicable,78.98,Pays at 90% of Total Billed charges,19.55,Pays at 100% of GA Medicaid Fee Schedule,NA,Not Applicable,19.55,Pays at 100% of GA Medicaid Fee Schedule,77.22,Pays at 88% of Total Billed charges,20.14,Pays at 103% of GA Medicaid Fee Schedule,19.55,78.98,52.65
Outpatient Medical Services,LAB,80324,DRUG SCREEN AMPHETAMINES (MAYO),300,115.25,97.96,Pays at 85% of Billed charges for outpatient setting,19.55,Pays at 100% of GA Medicaid Fee Schedule,92.23,Pays at 80.03% of Total Billed charges,NA,Not Applicable,103.73,Pays at 90% of Total Billed charges,19.55,Pays at 100% of GA Medicaid Fee Schedule,NA,Not Applicable,19.55,Pays at 100% of GA Medicaid Fee Schedule,101.42,Pays at 88% of Total Billed charges,20.14,Pays at 103% of GA Medicaid Fee Schedule,19.55,103.73,69.15
Outpatient Medical Services,LAB,80324,AMPHETAMINES DRUG SCREEN 1/2 (MAYO),300,127,107.95,Pays at 85% of Billed charges for outpatient setting,19.55,Pays at 100% of GA Medicaid Fee Schedule,101.64,Pays at 80.03% of Total Billed charges,NA,Not Applicable,114.3,Pays at 90% of Total Billed charges,19.55,Pays at 100% of GA Medicaid Fee Schedule,NA,Not Applicable,19.55,Pays at 100% of GA Medicaid Fee Schedule,111.76,Pays at 88% of Total Billed charges,20.14,Pays at 103% of GA Medicaid Fee Schedule,19.55,114.3,76.20
Outpatient Medical Services,LAB,80324,METHAMPHETAMINES METABOLITE  (MAYO),300,204.25,173.61,Pays at 85% of Billed charges for outpatient setting,19.55,Pays at 100% of GA Medicaid Fee Schedule,163.46,Pays at 80.03% of Total Billed charges,NA,Not Applicable,183.83,Pays at 90% of Total Billed charges,19.55,Pays at 100% of GA Medicaid Fee Schedule,NA,Not Applicable,19.55,Pays at 100% of GA Medicaid Fee Schedule,179.74,Pays at 88% of Total Billed charges,20.14,Pays at 103% of GA Medicaid Fee Schedule,19.55,183.83,122.55
Outpatient Medical Services,LAB,80324,LISDEXAMFETAMINE DIMESYLATE  (MAYO),300,237.5,201.88,Pays at 85% of Billed charges for outpatient setting,19.55,Pays at 100% of GA Medicaid Fee Schedule,190.07,Pays at 80.03% of Total Billed charges,NA,Not Applicable,213.75,Pays at 90% of Total Billed charges,19.55,Pays at 100% of GA Medicaid Fee Schedule,NA,Not Applicable,19.55,Pays at 100% of GA Medicaid Fee Schedule,209,Pays at 88% of Total Billed charges,20.14,Pays at 103% of GA Medicaid Fee Schedule,19.55,213.75,142.50
Outpatient Medical Services,LAB,80327,"DIHYDROSETOSTERONE, SERUM  (MAYO)",300,256.75,218.24,Pays at 85% of Billed charges for outpatient setting,32.46,Pays at 100% of GA Medicaid Fee Schedule,205.48,Pays at 80.03% of Total Billed charges,NA,Not Applicable,231.08,Pays at 90% of Total Billed charges,32.46,Pays at 100% of GA Medicaid Fee Schedule,NA,Not Applicable,32.46,Pays at 100% of GA Medicaid Fee Schedule,225.94,Pays at 88% of Total Billed charges,33.43,Pays at 103% of GA Medicaid Fee Schedule,32.46,231.08,154.05
Outpatient Medical Services,LAB,80332,"FLUOXETINE, PROZAC  (MAYO)",300,47.25,40.16,Pays at 85% of Billed charges for outpatient setting,15.19,Pays at 32.15% of Total Billed charges,37.81,Pays at 80.03% of Total Billed charges,NA,Not Applicable,42.53,Pays at 90% of Total Billed charges,15.19,Pays at 32.15% of Total Billed charges,NA,Not Applicable,15.19,Pays at 32.15% of Total Billed charges,41.58,Pays at 88% of Total Billed charges,15.64,Pays at 33.11% of Total Billed charges,15.19,42.53,28.35
Outpatient Medical Services,LAB,80332,"ANTIDEPRESSANTS, SERTRALINE  (MAYO)",300,110,93.5,Pays at 85% of Billed charges for outpatient setting,35.37,Pays at 32.15% of Total Billed charges,88.03,Pays at 80.03% of Total Billed charges,NA,Not Applicable,99,Pays at 90% of Total Billed charges,35.37,Pays at 32.15% of Total Billed charges,NA,Not Applicable,35.37,Pays at 32.15% of Total Billed charges,96.8,Pays at 88% of Total Billed charges,36.42,Pays at 33.11% of Total Billed charges,35.37,99,66.00
Outpatient Medical Services,LAB,80335,NORTRIPTYLINE   (MAYO),300,22.25,18.91,Pays at 85% of Billed charges for outpatient setting,22.51,Pays at 100% of GA Medicaid Fee Schedule,17.81,Pays at 80.03% of Total Billed charges,NA,Not Applicable,20.03,Pays at 90% of Total Billed charges,22.51,Pays at 100% of GA Medicaid Fee Schedule,NA,Not Applicable,22.51,Pays at 100% of GA Medicaid Fee Schedule,19.58,Pays at 88% of Total Billed charges,23.19,Pays at 103% of GA Medicaid Fee Schedule,17.81,23.19,13.35
Outpatient Medical Services,LAB,80345,BARBITURATES CONFIRMATION  (MAYO),300,135.25,114.96,Pays at 85% of Billed charges for outpatient setting,14.41,Pays at 100% of GA Medicaid Fee Schedule,108.24,Pays at 80.03% of Total Billed charges,NA,Not Applicable,121.73,Pays at 90% of Total Billed charges,14.41,Pays at 100% of GA Medicaid Fee Schedule,NA,Not Applicable,14.41,Pays at 100% of GA Medicaid Fee Schedule,119.02,Pays at 88% of Total Billed charges,14.84,Pays at 103% of GA Medicaid Fee Schedule,14.41,121.73,81.15
Outpatient Medical Services,LAB,80346,CLONAZEPAM (KLONOPIN) (MAYO),300,66.5,56.53,Pays at 85% of Billed charges for outpatient setting,23.26,Pays at 100% of GA Medicaid Fee Schedule,53.22,Pays at 80.03% of Total Billed charges,NA,Not Applicable,59.85,Pays at 90% of Total Billed charges,23.26,Pays at 100% of GA Medicaid Fee Schedule,NA,Not Applicable,23.26,Pays at 100% of GA Medicaid Fee Schedule,58.52,Pays at 88% of Total Billed charges,23.96,Pays at 103% of GA Medicaid Fee Schedule,23.26,59.85,39.90
Outpatient Medical Services,LAB,80346,BENZODIAZEPINE CONFIRMATION  (MAYO),300,99.5,84.58,Pays at 85% of Billed charges for outpatient setting,23.26,Pays at 100% of GA Medicaid Fee Schedule,79.63,Pays at 80.03% of Total Billed charges,NA,Not Applicable,89.55,Pays at 90% of Total Billed charges,23.26,Pays at 100% of GA Medicaid Fee Schedule,NA,Not Applicable,23.26,Pays at 100% of GA Medicaid Fee Schedule,87.56,Pays at 88% of Total Billed charges,23.96,Pays at 103% of GA Medicaid Fee Schedule,23.26,89.55,59.70
Outpatient Medical Services,LAB,80347,"BENZODIAZEPINES, 13 OR MORE  (MAYO)",300,111,94.35,Pays at 85% of Billed charges for outpatient setting,23.26,Pays at 100% of GA Medicaid Fee Schedule,88.83,Pays at 80.03% of Total Billed charges,NA,Not Applicable,99.9,Pays at 90% of Total Billed charges,23.26,Pays at 100% of GA Medicaid Fee Schedule,NA,Not Applicable,23.26,Pays at 100% of GA Medicaid Fee Schedule,97.68,Pays at 88% of Total Billed charges,23.96,Pays at 103% of GA Medicaid Fee Schedule,23.26,99.9,66.60
Outpatient Medical Services,LAB,80349,"CARBOXY-THC CONFIRM, MECONIUM  (MAYO)",300,204.54,173.86,Pays at 85% of Billed charges for outpatient setting,65.76,Pays at 32.15% of Total Billed charges,163.69,Pays at 80.03% of Total Billed charges,NA,Not Applicable,184.09,Pays at 90% of Total Billed charges,65.76,Pays at 32.15% of Total Billed charges,NA,Not Applicable,65.76,Pays at 32.15% of Total Billed charges,180,Pays at 88% of Total Billed charges,67.72,Pays at 33.11% of Total Billed charges,65.76,184.09,122.72
Outpatient Medical Services,LAB,80349,MARIJUANA (THC) DRUG CONFIRMAT  (MAYO),300,229.25,194.86,Pays at 85% of Billed charges for outpatient setting,73.7,Pays at 32.15% of Total Billed charges,183.47,Pays at 80.03% of Total Billed charges,NA,Not Applicable,206.33,Pays at 90% of Total Billed charges,73.7,Pays at 32.15% of Total Billed charges,NA,Not Applicable,73.7,Pays at 32.15% of Total Billed charges,201.74,Pays at 88% of Total Billed charges,75.9,Pays at 33.11% of Total Billed charges,73.7,206.33,137.55
Outpatient Medical Services,LAB,80353,COCAINE & METABOLITE CONFIRM.  (MAYO),300,73.75,62.69,Pays at 85% of Billed charges for outpatient setting,12.06,Pays at 100% of GA Medicaid Fee Schedule,59.02,Pays at 80.03% of Total Billed charges,NA,Not Applicable,66.38,Pays at 90% of Total Billed charges,12.06,Pays at 100% of GA Medicaid Fee Schedule,NA,Not Applicable,12.06,Pays at 100% of GA Medicaid Fee Schedule,64.9,Pays at 88% of Total Billed charges,12.42,Pays at 103% of GA Medicaid Fee Schedule,12.06,66.38,44.25
Outpatient Medical Services,LAB,80353,"COCAINE/METAB. CONFIRM, MECONIUM  (MAYO)",300,214,181.9,Pays at 85% of Billed charges for outpatient setting,12.06,Pays at 100% of GA Medicaid Fee Schedule,171.26,Pays at 80.03% of Total Billed charges,NA,Not Applicable,192.6,Pays at 90% of Total Billed charges,12.06,Pays at 100% of GA Medicaid Fee Schedule,NA,Not Applicable,12.06,Pays at 100% of GA Medicaid Fee Schedule,188.32,Pays at 88% of Total Billed charges,12.42,Pays at 103% of GA Medicaid Fee Schedule,12.06,192.6,128.40
Outpatient Medical Services,LAB,80355,AMITRIPTYLINE  & NORTRIPTYLINE  (MAYO),300,38.25,32.51,Pays at 85% of Billed charges for outpatient setting,12.3,Pays at 32.15% of Total Billed charges,30.61,Pays at 80.03% of Total Billed charges,NA,Not Applicable,34.43,Pays at 90% of Total Billed charges,12.3,Pays at 32.15% of Total Billed charges,NA,Not Applicable,12.3,Pays at 32.15% of Total Billed charges,33.66,Pays at 88% of Total Billed charges,12.66,Pays at 33.11% of Total Billed charges,12.3,34.43,22.95
Outpatient Medical Services,LAB,80355,"DOXEPIN, S/P  (MAYO)",300,81.75,69.49,Pays at 85% of Billed charges for outpatient setting,26.28,Pays at 32.15% of Total Billed charges,65.42,Pays at 80.03% of Total Billed charges,NA,Not Applicable,73.58,Pays at 90% of Total Billed charges,26.28,Pays at 32.15% of Total Billed charges,NA,Not Applicable,26.28,Pays at 32.15% of Total Billed charges,71.94,Pays at 88% of Total Billed charges,27.07,Pays at 33.11% of Total Billed charges,26.28,73.58,49.05
Outpatient Medical Services,LAB,80355,IMIPRAMINE & DESIPRAMINE  (MAYO),300,88.75,75.44,Pays at 85% of Billed charges for outpatient setting,28.53,Pays at 32.15% of Total Billed charges,71.03,Pays at 80.03% of Total Billed charges,NA,Not Applicable,79.88,Pays at 90% of Total Billed charges,28.53,Pays at 32.15% of Total Billed charges,NA,Not Applicable,28.53,Pays at 32.15% of Total Billed charges,78.1,Pays at 88% of Total Billed charges,29.39,Pays at 33.11% of Total Billed charges,28.53,79.88,53.25
Outpatient Medical Services,LAB,80358,METHADONE CONFIRMATION   (MAYO),300,355.43,302.12,Pays at 85% of Billed charges for outpatient setting,20.53,Pays at 100% of GA Medicaid Fee Schedule,284.45,Pays at 80.03% of Total Billed charges,NA,Not Applicable,319.89,Pays at 90% of Total Billed charges,20.53,Pays at 100% of GA Medicaid Fee Schedule,NA,Not Applicable,20.53,Pays at 100% of GA Medicaid Fee Schedule,312.78,Pays at 88% of Total Billed charges,21.15,Pays at 103% of GA Medicaid Fee Schedule,20.53,319.89,213.26
Outpatient Medical Services,LAB,80359,"METHYLENEDIOXYAMPHETAMINES, MDA  (MAYO)",300,84.75,72.04,Pays at 85% of Billed charges for outpatient setting,27.25,Pays at 32.15% of Total Billed charges,67.83,Pays at 80.03% of Total Billed charges,NA,Not Applicable,76.28,Pays at 90% of Total Billed charges,27.25,Pays at 32.15% of Total Billed charges,NA,Not Applicable,27.25,Pays at 32.15% of Total Billed charges,74.58,Pays at 88% of Total Billed charges,28.06,Pays at 33.11% of Total Billed charges,27.25,76.28,50.85
Outpatient Medical Services,LAB,80361,OPIATES 1 OR MORE  (MAYO),300,111.52,94.79,Pays at 85% of Billed charges for outpatient setting,25.97,Pays at 100% of GA Medicaid Fee Schedule,89.25,Pays at 80.03% of Total Billed charges,NA,Not Applicable,100.37,Pays at 90% of Total Billed charges,25.97,Pays at 100% of GA Medicaid Fee Schedule,NA,Not Applicable,25.97,Pays at 100% of GA Medicaid Fee Schedule,98.14,Pays at 88% of Total Billed charges,26.75,Pays at 103% of GA Medicaid Fee Schedule,25.97,100.37,66.91
Outpatient Medical Services,LAB,80362,"DEMEROL, MEPERIDINE  (MAYO)",300,118.25,100.51,Pays at 85% of Billed charges for outpatient setting,24.47,Pays at 100% of GA Medicaid Fee Schedule,94.64,Pays at 80.03% of Total Billed charges,NA,Not Applicable,106.43,Pays at 90% of Total Billed charges,24.47,Pays at 100% of GA Medicaid Fee Schedule,NA,Not Applicable,24.47,Pays at 100% of GA Medicaid Fee Schedule,104.06,Pays at 88% of Total Billed charges,25.2,Pays at 103% of GA Medicaid Fee Schedule,24.47,106.43,70.95
Outpatient Medical Services,LAB,80364,"OPIATES, QT  (MAYO)",300,150,127.5,Pays at 85% of Billed charges for outpatient setting,24.47,Pays at 100% of GA Medicaid Fee Schedule,120.05,Pays at 80.03% of Total Billed charges,NA,Not Applicable,135,Pays at 90% of Total Billed charges,24.47,Pays at 100% of GA Medicaid Fee Schedule,NA,Not Applicable,24.47,Pays at 100% of GA Medicaid Fee Schedule,132,Pays at 88% of Total Billed charges,25.2,Pays at 103% of GA Medicaid Fee Schedule,24.47,135,90.00
Outpatient Medical Services,LAB,80364,"OPIATES, QT  (MAYO)",300,160.75,136.64,Pays at 85% of Billed charges for outpatient setting,24.47,Pays at 100% of GA Medicaid Fee Schedule,128.65,Pays at 80.03% of Total Billed charges,NA,Not Applicable,144.68,Pays at 90% of Total Billed charges,24.47,Pays at 100% of GA Medicaid Fee Schedule,NA,Not Applicable,24.47,Pays at 100% of GA Medicaid Fee Schedule,141.46,Pays at 88% of Total Billed charges,25.2,Pays at 103% of GA Medicaid Fee Schedule,24.47,144.68,96.45
Outpatient Medical Services,LAB,80365,DRUG SCREENING OXYCODONE  (MAYO),300,93.02,79.07,Pays at 85% of Billed charges for outpatient setting,29.91,Pays at 32.15% of Total Billed charges,74.44,Pays at 80.03% of Total Billed charges,NA,Not Applicable,83.72,Pays at 90% of Total Billed charges,29.91,Pays at 32.15% of Total Billed charges,NA,Not Applicable,29.91,Pays at 32.15% of Total Billed charges,81.86,Pays at 88% of Total Billed charges,30.8,Pays at 33.11% of Total Billed charges,29.91,83.72,55.81
Outpatient Medical Services,LAB,80365,"OXYCODONE, SERUM   (MAYO)",300,118.5,100.73,Pays at 85% of Billed charges for outpatient setting,38.1,Pays at 32.15% of Total Billed charges,94.84,Pays at 80.03% of Total Billed charges,NA,Not Applicable,106.65,Pays at 90% of Total Billed charges,38.1,Pays at 32.15% of Total Billed charges,NA,Not Applicable,38.1,Pays at 32.15% of Total Billed charges,104.28,Pays at 88% of Total Billed charges,39.24,Pays at 33.11% of Total Billed charges,38.1,106.65,71.10
Outpatient Medical Services,LAB,80365,MORPHINE  (MAYO),300,196.5,167.03,Pays at 85% of Billed charges for outpatient setting,63.17,Pays at 32.15% of Total Billed charges,157.26,Pays at 80.03% of Total Billed charges,NA,Not Applicable,176.85,Pays at 90% of Total Billed charges,63.17,Pays at 32.15% of Total Billed charges,NA,Not Applicable,63.17,Pays at 32.15% of Total Billed charges,172.92,Pays at 88% of Total Billed charges,65.06,Pays at 33.11% of Total Billed charges,63.17,176.85,117.90
Outpatient Medical Services,LAB,80365,OXYCODONE METABOLITE CONF URINE  (MAYO),300,209,177.65,Pays at 85% of Billed charges for outpatient setting,67.19,Pays at 32.15% of Total Billed charges,167.26,Pays at 80.03% of Total Billed charges,NA,Not Applicable,188.1,Pays at 90% of Total Billed charges,67.19,Pays at 32.15% of Total Billed charges,NA,Not Applicable,67.19,Pays at 32.15% of Total Billed charges,183.92,Pays at 88% of Total Billed charges,69.2,Pays at 33.11% of Total Billed charges,67.19,188.1,125.40
Outpatient Medical Services,LAB,80373,TRAMADOL AND METABOLITE  (MAYO),300,63,53.55,Pays at 85% of Billed charges for outpatient setting,20.25,Pays at 32.15% of Total Billed charges,50.42,Pays at 80.03% of Total Billed charges,NA,Not Applicable,56.7,Pays at 90% of Total Billed charges,20.25,Pays at 32.15% of Total Billed charges,NA,Not Applicable,20.25,Pays at 32.15% of Total Billed charges,55.44,Pays at 88% of Total Billed charges,20.86,Pays at 33.11% of Total Billed charges,20.25,56.7,37.80
Outpatient Medical Services,LAB,80375,AMANTADINE (SYMMETREL) (MAYO),300,142.5,121.13,Pays at 85% of Billed charges for outpatient setting,18.25,Pays at 100% of GA Medicaid Fee Schedule,114.04,Pays at 80.03% of Total Billed charges,NA,Not Applicable,128.25,Pays at 90% of Total Billed charges,18.25,Pays at 100% of GA Medicaid Fee Schedule,NA,Not Applicable,18.25,Pays at 100% of GA Medicaid Fee Schedule,125.4,Pays at 88% of Total Billed charges,18.8,Pays at 103% of GA Medicaid Fee Schedule,18.25,128.25,85.50
Outpatient Medical Services,LAB,80375,PROCARDIA LEVEL  (MAYO),300,322,273.7,Pays at 85% of Billed charges for outpatient setting,18.25,Pays at 100% of GA Medicaid Fee Schedule,257.7,Pays at 80.03% of Total Billed charges,NA,Not Applicable,289.8,Pays at 90% of Total Billed charges,18.25,Pays at 100% of GA Medicaid Fee Schedule,NA,Not Applicable,18.25,Pays at 100% of GA Medicaid Fee Schedule,283.36,Pays at 88% of Total Billed charges,18.8,Pays at 103% of GA Medicaid Fee Schedule,18.25,289.8,193.20
Outpatient Medical Services,LAB,81001,Manual urinalysis test with examination with or without using microscope,300,23.78,20.21,Pays at 85% of Billed charges for outpatient setting,3.99,Pays at 100% of GA Medicaid Fee Schedule,19.03,Pays at 80.03% of Total Billed charges,3.23,Pays at 102% of Medicare OPPS Rate,21.4,Pays at 90% of Total Billed charges,3.99,Pays at 100% of GA Medicaid Fee Schedule,3.17,Pays at 100% of Medicare OPPS Rate,3.99,Pays at 100% of GA Medicaid Fee Schedule,20.93,Pays at 88% of Total Billed charges,4.11,Pays at 103% of GA Medicaid Fee Schedule,3.17,21.4,14.27
Outpatient Medical Services,LAB,81002,Manual urinalysis test with examination without using microscope,300,29.25,24.86,Pays at 85% of Billed charges for outpatient setting,3.21,Pays at 100% of GA Medicaid Fee Schedule,23.41,Pays at 80.03% of Total Billed charges,3.54,Pays at 102% of Medicare OPPS Rate,26.33,Pays at 90% of Total Billed charges,3.21,Pays at 100% of GA Medicaid Fee Schedule,3.48,Pays at 100% of Medicare OPPS Rate,3.21,Pays at 100% of GA Medicaid Fee Schedule,25.74,Pays at 88% of Total Billed charges,3.31,Pays at 103% of GA Medicaid Fee Schedule,3.21,26.33,17.55
Outpatient Medical Services,LAB,81002,Manual urinalysis test with examination without using microscope,300,48.25,41.01,Pays at 85% of Billed charges for outpatient setting,3.21,Pays at 100% of GA Medicaid Fee Schedule,38.61,Pays at 80.03% of Total Billed charges,3.54,Pays at 102% of Medicare OPPS Rate,43.43,Pays at 90% of Total Billed charges,3.21,Pays at 100% of GA Medicaid Fee Schedule,3.48,Pays at 100% of Medicare OPPS Rate,3.21,Pays at 100% of GA Medicaid Fee Schedule,42.46,Pays at 88% of Total Billed charges,3.31,Pays at 103% of GA Medicaid Fee Schedule,3.21,43.43,28.95
Outpatient Medical Services,LAB,81015,..URINALYSIS-MICRO,300,26.4,22.44,Pays at 85% of Billed charges for outpatient setting,3.82,Pays at 100% of GA Medicaid Fee Schedule,21.13,Pays at 80.03% of Total Billed charges,3.11,Pays at 102% of Medicare OPPS Rate,23.76,Pays at 90% of Total Billed charges,3.82,Pays at 100% of GA Medicaid Fee Schedule,3.05,Pays at 100% of Medicare OPPS Rate,3.82,Pays at 100% of GA Medicaid Fee Schedule,23.23,Pays at 88% of Total Billed charges,3.93,Pays at 103% of GA Medicaid Fee Schedule,3.05,23.76,15.84
Outpatient Medical Services,LAB,81015,..URINALYSIS- MICROSCOPIC,300,28,23.8,Pays at 85% of Billed charges for outpatient setting,3.82,Pays at 100% of GA Medicaid Fee Schedule,22.41,Pays at 80.03% of Total Billed charges,3.11,Pays at 102% of Medicare OPPS Rate,25.2,Pays at 90% of Total Billed charges,3.82,Pays at 100% of GA Medicaid Fee Schedule,3.05,Pays at 100% of Medicare OPPS Rate,3.82,Pays at 100% of GA Medicaid Fee Schedule,24.64,Pays at 88% of Total Billed charges,3.93,Pays at 103% of GA Medicaid Fee Schedule,3.05,25.2,16.80
Outpatient Medical Services,LAB,81206,BCR/ABL1 (t(9;22)) TRANS; MAJOR  (MAYO),310,278.98,237.13,Pays at 85% of Billed charges for outpatient setting,98.4,Pays at 100% of GA Medicaid Fee Schedule,223.27,Pays at 80.03% of Total Billed charges,167.23,Pays at 102% of Medicare OPPS Rate,251.08,Pays at 90% of Total Billed charges,98.4,Pays at 100% of GA Medicaid Fee Schedule,163.96,Pays at 100% of Medicare OPPS Rate,98.4,Pays at 100% of GA Medicaid Fee Schedule,245.5,Pays at 88% of Total Billed charges,101.35,Pays at 103% of GA Medicaid Fee Schedule,98.4,251.08,167.39
Outpatient Medical Services,LAB,81207,BCR/ABL1 (t(9;22)) TRANS; MINOR  (MAYO),310,278.98,237.13,Pays at 85% of Billed charges for outpatient setting,98.4,Pays at 100% of GA Medicaid Fee Schedule,223.27,Pays at 80.03% of Total Billed charges,147.73,Pays at 102% of Medicare OPPS Rate,251.08,Pays at 90% of Total Billed charges,98.4,Pays at 100% of GA Medicaid Fee Schedule,144.84,Pays at 100% of Medicare OPPS Rate,98.4,Pays at 100% of GA Medicaid Fee Schedule,245.5,Pays at 88% of Total Billed charges,101.35,Pays at 103% of GA Medicaid Fee Schedule,98.4,251.08,167.39
Outpatient Medical Services,LAB,81208,BCR/ABL1 (t(9;22)) TRANS; OTHER  (MAYO),310,278.98,237.13,Pays at 85% of Billed charges for outpatient setting,98.4,Pays at 100% of GA Medicaid Fee Schedule,223.27,Pays at 80.03% of Total Billed charges,218.91,Pays at 102% of Medicare OPPS Rate,251.08,Pays at 90% of Total Billed charges,98.4,Pays at 100% of GA Medicaid Fee Schedule,214.62,Pays at 100% of Medicare OPPS Rate,98.4,Pays at 100% of GA Medicaid Fee Schedule,245.5,Pays at 88% of Total Billed charges,101.35,Pays at 103% of GA Medicaid Fee Schedule,98.4,251.08,167.39
Outpatient Medical Services,LAB,81219,CALRECTICULIIN MUTATION EXON 9 (CSI),300,560,476,Pays at 85% of Billed charges for outpatient setting,132.54,Pays at 100% of GA Medicaid Fee Schedule,448.17,Pays at 80.03% of Total Billed charges,124.06,Pays at 102% of Medicare OPPS Rate,504,Pays at 90% of Total Billed charges,132.54,Pays at 100% of GA Medicaid Fee Schedule,121.63,Pays at 100% of Medicare OPPS Rate,132.54,Pays at 100% of GA Medicaid Fee Schedule,492.8,Pays at 88% of Total Billed charges,136.52,Pays at 103% of GA Medicaid Fee Schedule,121.63,504,336.00
Outpatient Medical Services,LAB,81219,MPN CALR WITH REFLEX TO MPL (MAYO),300,965.25,820.46,Pays at 85% of Billed charges for outpatient setting,132.54,Pays at 100% of GA Medicaid Fee Schedule,772.49,Pays at 80.03% of Total Billed charges,124.06,Pays at 102% of Medicare OPPS Rate,868.73,Pays at 90% of Total Billed charges,132.54,Pays at 100% of GA Medicaid Fee Schedule,121.63,Pays at 100% of Medicare OPPS Rate,132.54,Pays at 100% of GA Medicaid Fee Schedule,849.42,Pays at 88% of Total Billed charges,136.52,Pays at 103% of GA Medicaid Fee Schedule,121.63,868.73,579.15
Outpatient Medical Services,LAB,81219,MPN CALR GENE MUTATION EXON 9 (MAYO),300,999.5,849.58,Pays at 85% of Billed charges for outpatient setting,132.54,Pays at 100% of GA Medicaid Fee Schedule,799.9,Pays at 80.03% of Total Billed charges,124.06,Pays at 102% of Medicare OPPS Rate,899.55,Pays at 90% of Total Billed charges,132.54,Pays at 100% of GA Medicaid Fee Schedule,121.63,Pays at 100% of Medicare OPPS Rate,132.54,Pays at 100% of GA Medicaid Fee Schedule,879.56,Pays at 88% of Total Billed charges,136.52,Pays at 103% of GA Medicaid Fee Schedule,121.63,899.55,599.70
Outpatient Medical Services,LAB,81225,CYTOCHROME P450 2C19 GENOTYPE  (MAYO),300,1017.5,864.88,Pays at 85% of Billed charges for outpatient setting,244,Pays at 100% of GA Medicaid Fee Schedule,814.31,Pays at 80.03% of Total Billed charges,297.18,Pays at 102% of Medicare OPPS Rate,915.75,Pays at 90% of Total Billed charges,244,Pays at 100% of GA Medicaid Fee Schedule,291.36,Pays at 100% of Medicare OPPS Rate,244,Pays at 100% of GA Medicaid Fee Schedule,895.4,Pays at 88% of Total Billed charges,251.32,Pays at 103% of GA Medicaid Fee Schedule,244,915.75,610.50
Outpatient Medical Services,LAB,81229,CHROMOSOMAL MICROARRAY   (MAYO),300,3000.25,2550.21,Pays at 85% of Billed charges for outpatient setting,2320,Pays at 100% of GA Medicaid Fee Schedule,2401.1,Pays at 80.03% of Total Billed charges,1183.2,Pays at 102% of Medicare OPPS Rate,2700.23,Pays at 90% of Total Billed charges,2320,Pays at 100% of GA Medicaid Fee Schedule,1160,Pays at 100% of Medicare OPPS Rate,2320,Pays at 100% of GA Medicaid Fee Schedule,2640.22,Pays at 88% of Total Billed charges,2389.6,Pays at 103% of GA Medicaid Fee Schedule,1160,2700.23,1800.15
Outpatient Medical Services,LAB,81240,PROTHROMBIN G20210A  MUTATION  (MAYO),300,165.75,140.89,Pays at 85% of Billed charges for outpatient setting,40,Pays at 100% of GA Medicaid Fee Schedule,132.65,Pays at 80.03% of Total Billed charges,67,Pays at 102% of Medicare OPPS Rate,149.18,Pays at 90% of Total Billed charges,40,Pays at 100% of GA Medicaid Fee Schedule,65.69,Pays at 100% of Medicare OPPS Rate,40,Pays at 100% of GA Medicaid Fee Schedule,145.86,Pays at 88% of Total Billed charges,41.2,Pays at 103% of GA Medicaid Fee Schedule,40,149.18,99.45
Outpatient Medical Services,LAB,81240,PROTHROM GENE ANALYSIS  (MAYO),300,169.75,144.29,Pays at 85% of Billed charges for outpatient setting,40,Pays at 100% of GA Medicaid Fee Schedule,135.85,Pays at 80.03% of Total Billed charges,67,Pays at 102% of Medicare OPPS Rate,152.78,Pays at 90% of Total Billed charges,40,Pays at 100% of GA Medicaid Fee Schedule,65.69,Pays at 100% of Medicare OPPS Rate,40,Pays at 100% of GA Medicaid Fee Schedule,149.38,Pays at 88% of Total Billed charges,41.2,Pays at 103% of GA Medicaid Fee Schedule,40,152.78,101.85
Outpatient Medical Services,LAB,81241,"FACTOR V LEIDEN, R506Q  (MAYO)",300,585.75,497.89,Pays at 85% of Billed charges for outpatient setting,40,Pays at 100% of GA Medicaid Fee Schedule,468.78,Pays at 80.03% of Total Billed charges,74.83,Pays at 102% of Medicare OPPS Rate,527.18,Pays at 90% of Total Billed charges,40,Pays at 100% of GA Medicaid Fee Schedule,73.37,Pays at 100% of Medicare OPPS Rate,40,Pays at 100% of GA Medicaid Fee Schedule,515.46,Pays at 88% of Total Billed charges,41.2,Pays at 103% of GA Medicaid Fee Schedule,40,527.18,351.45
Outpatient Medical Services,LAB,81256,HFE GENE ANALYSIS  (MAYO),300,574,487.9,Pays at 85% of Billed charges for outpatient setting,40,Pays at 100% of GA Medicaid Fee Schedule,459.37,Pays at 80.03% of Total Billed charges,66.66,Pays at 102% of Medicare OPPS Rate,516.6,Pays at 90% of Total Billed charges,40,Pays at 100% of GA Medicaid Fee Schedule,65.36,Pays at 100% of Medicare OPPS Rate,40,Pays at 100% of GA Medicaid Fee Schedule,505.12,Pays at 88% of Total Billed charges,41.2,Pays at 103% of GA Medicaid Fee Schedule,40,516.6,344.40
Outpatient Medical Services,LAB,81257,ALPHA-GLOBIN GENE ANALYSIS  (MAYO),300,604.5,513.83,Pays at 85% of Billed charges for outpatient setting,188,Pays at 100% of GA Medicaid Fee Schedule,483.78,Pays at 80.03% of Total Billed charges,104.3,Pays at 102% of Medicare OPPS Rate,544.05,Pays at 90% of Total Billed charges,188,Pays at 100% of GA Medicaid Fee Schedule,102.26,Pays at 100% of Medicare OPPS Rate,188,Pays at 100% of GA Medicaid Fee Schedule,531.96,Pays at 88% of Total Billed charges,193.64,Pays at 103% of GA Medicaid Fee Schedule,102.26,544.05,362.70
Outpatient Medical Services,LAB,81257,HEMOGLOBIN ELECTR. MOLECULAR  (MAYO),300,620.75,527.64,Pays at 85% of Billed charges for outpatient setting,188,Pays at 100% of GA Medicaid Fee Schedule,496.79,Pays at 80.03% of Total Billed charges,104.3,Pays at 102% of Medicare OPPS Rate,558.68,Pays at 90% of Total Billed charges,188,Pays at 100% of GA Medicaid Fee Schedule,102.26,Pays at 100% of Medicare OPPS Rate,188,Pays at 100% of GA Medicaid Fee Schedule,546.26,Pays at 88% of Total Billed charges,193.64,Pays at 103% of GA Medicaid Fee Schedule,102.26,558.68,372.45
Outpatient Medical Services,LAB,81270,JAK2 V617F MUTATION (CSI),300,560,476,Pays at 85% of Billed charges for outpatient setting,72,Pays at 100% of GA Medicaid Fee Schedule,448.17,Pays at 80.03% of Total Billed charges,93.49,Pays at 102% of Medicare OPPS Rate,504,Pays at 90% of Total Billed charges,72,Pays at 100% of GA Medicaid Fee Schedule,91.66,Pays at 100% of Medicare OPPS Rate,72,Pays at 100% of GA Medicaid Fee Schedule,492.8,Pays at 88% of Total Billed charges,74.16,Pays at 103% of GA Medicaid Fee Schedule,72,504,336.00
Outpatient Medical Services,LAB,81270,JAK2 V617F MUTATION DETECTION  (MAYO),300,572.25,486.41,Pays at 85% of Billed charges for outpatient setting,72,Pays at 100% of GA Medicaid Fee Schedule,457.97,Pays at 80.03% of Total Billed charges,93.49,Pays at 102% of Medicare OPPS Rate,515.03,Pays at 90% of Total Billed charges,72,Pays at 100% of GA Medicaid Fee Schedule,91.66,Pays at 100% of Medicare OPPS Rate,72,Pays at 100% of GA Medicaid Fee Schedule,503.58,Pays at 88% of Total Billed charges,74.16,Pays at 103% of GA Medicaid Fee Schedule,72,515.03,343.35
Outpatient Medical Services,LAB,81270,"PCV, JAK2 V617F, JAK2, EXON 12-15 (MAYO)",300,670.25,569.71,Pays at 85% of Billed charges for outpatient setting,72,Pays at 100% of GA Medicaid Fee Schedule,536.4,Pays at 80.03% of Total Billed charges,93.49,Pays at 102% of Medicare OPPS Rate,603.23,Pays at 90% of Total Billed charges,72,Pays at 100% of GA Medicaid Fee Schedule,91.66,Pays at 100% of Medicare OPPS Rate,72,Pays at 100% of GA Medicaid Fee Schedule,589.82,Pays at 88% of Total Billed charges,74.16,Pays at 103% of GA Medicaid Fee Schedule,72,603.23,402.15
Outpatient Medical Services,LAB,81280,LONG QT SYN MULT-GENE PANEL  (MAYO),300,3352.25,2849.41,Pays at 85% of Billed charges for outpatient setting,1077.75,Pays at 32.15% of Total Billed charges,2682.81,Pays at 80.03% of Total Billed charges,NA,Not Applicable,3017.03,Pays at 90% of Total Billed charges,1077.75,Pays at 32.15% of Total Billed charges,NA,Not Applicable,1077.75,Pays at 32.15% of Total Billed charges,2949.98,Pays at 88% of Total Billed charges,1109.93,Pays at 33.11% of Total Billed charges,1077.75,3017.03,2011.35
Outpatient Medical Services,LAB,81313,PCA3  ASSAY  (MAYO),300,394.25,335.11,Pays at 85% of Billed charges for outpatient setting,126.75,Pays at 32.15% of Total Billed charges,315.52,Pays at 80.03% of Total Billed charges,260.15,Pays at 102% of Medicare OPPS Rate,354.83,Pays at 90% of Total Billed charges,126.75,Pays at 32.15% of Total Billed charges,255.05,Pays at 100% of Medicare OPPS Rate,126.75,Pays at 32.15% of Total Billed charges,346.94,Pays at 88% of Total Billed charges,130.54,Pays at 33.11% of Total Billed charges,126.75,354.83,236.55
Outpatient Medical Services,LAB,81331,PRADER-WILLI/ANGELMAN SYNDROME  (MAYO),300,601,510.85,Pays at 85% of Billed charges for outpatient setting,40,Pays at 100% of GA Medicaid Fee Schedule,480.98,Pays at 80.03% of Total Billed charges,52.09,Pays at 102% of Medicare OPPS Rate,540.9,Pays at 90% of Total Billed charges,40,Pays at 100% of GA Medicaid Fee Schedule,51.07,Pays at 100% of Medicare OPPS Rate,40,Pays at 100% of GA Medicaid Fee Schedule,528.88,Pays at 88% of Total Billed charges,41.2,Pays at 103% of GA Medicaid Fee Schedule,40,540.9,360.60
Outpatient Medical Services,LAB,81374,HLA  A29 BLOOD  (MAYO),300,311.5,264.78,Pays at 85% of Billed charges for outpatient setting,98.4,Pays at 100% of GA Medicaid Fee Schedule,249.29,Pays at 80.03% of Total Billed charges,75.81,Pays at 102% of Medicare OPPS Rate,280.35,Pays at 90% of Total Billed charges,98.4,Pays at 100% of GA Medicaid Fee Schedule,74.33,Pays at 100% of Medicare OPPS Rate,98.4,Pays at 100% of GA Medicaid Fee Schedule,274.12,Pays at 88% of Total Billed charges,101.35,Pays at 103% of GA Medicaid Fee Schedule,74.33,280.35,186.90
Outpatient Medical Services,LAB,81402,MPL MUTATION EXON 10  (CSI),300,418.6,355.81,Pays at 85% of Billed charges for outpatient setting,164,Pays at 100% of GA Medicaid Fee Schedule,335.01,Pays at 80.03% of Total Billed charges,153.33,Pays at 102% of Medicare OPPS Rate,376.74,Pays at 90% of Total Billed charges,164,Pays at 100% of GA Medicaid Fee Schedule,150.33,Pays at 100% of Medicare OPPS Rate,164,Pays at 100% of GA Medicaid Fee Schedule,368.37,Pays at 88% of Total Billed charges,168.92,Pays at 103% of GA Medicaid Fee Schedule,150.33,376.74,251.16
Outpatient Medical Services,LAB,81403,MPL EXON 10 MUTATION (MAYO),300,721.75,613.49,Pays at 85% of Billed charges for outpatient setting,188,Pays at 100% of GA Medicaid Fee Schedule,577.62,Pays at 80.03% of Total Billed charges,188.9,Pays at 102% of Medicare OPPS Rate,649.58,Pays at 90% of Total Billed charges,188,Pays at 100% of GA Medicaid Fee Schedule,185.2,Pays at 100% of Medicare OPPS Rate,188,Pays at 100% of GA Medicaid Fee Schedule,635.14,Pays at 88% of Total Billed charges,193.64,Pays at 103% of GA Medicaid Fee Schedule,185.2,649.58,433.05
Outpatient Medical Services,LAB,81406,UBE3A GENE ANALYSIS  (MAYO),300,1927.25,1638.16,Pays at 85% of Billed charges for outpatient setting,520,Pays at 100% of GA Medicaid Fee Schedule,1542.38,Pays at 80.03% of Total Billed charges,288.53,Pays at 102% of Medicare OPPS Rate,1734.53,Pays at 90% of Total Billed charges,520,Pays at 100% of GA Medicaid Fee Schedule,282.88,Pays at 100% of Medicare OPPS Rate,520,Pays at 100% of GA Medicaid Fee Schedule,1695.98,Pays at 88% of Total Billed charges,535.6,Pays at 103% of GA Medicaid Fee Schedule,282.88,1734.53,1156.35
Outpatient Medical Services,LAB,81406,"ATP7B, ATPASE  (MAYO)",300,2995.75,2546.39,Pays at 85% of Billed charges for outpatient setting,520,Pays at 100% of GA Medicaid Fee Schedule,2397.5,Pays at 80.03% of Total Billed charges,288.53,Pays at 102% of Medicare OPPS Rate,2696.18,Pays at 90% of Total Billed charges,520,Pays at 100% of GA Medicaid Fee Schedule,282.88,Pays at 100% of Medicare OPPS Rate,520,Pays at 100% of GA Medicaid Fee Schedule,2636.26,Pays at 88% of Total Billed charges,535.6,Pays at 103% of GA Medicaid Fee Schedule,282.88,2696.18,1797.45
Outpatient Medical Services,LAB,81406,POLYCSYTIC KIDNEY DISEASE2  (MAYO),300,3823,3249.55,Pays at 85% of Billed charges for outpatient setting,520,Pays at 100% of GA Medicaid Fee Schedule,3059.55,Pays at 80.03% of Total Billed charges,288.53,Pays at 102% of Medicare OPPS Rate,3440.7,Pays at 90% of Total Billed charges,520,Pays at 100% of GA Medicaid Fee Schedule,282.88,Pays at 100% of Medicare OPPS Rate,520,Pays at 100% of GA Medicaid Fee Schedule,3364.24,Pays at 88% of Total Billed charges,535.6,Pays at 103% of GA Medicaid Fee Schedule,282.88,3440.7,2293.80
Outpatient Medical Services,LAB,81407,POLYCSYTIC KIDNEY DISEASE1  (MAYO),300,3823,3249.55,Pays at 85% of Billed charges for outpatient setting,960,Pays at 100% of GA Medicaid Fee Schedule,3059.55,Pays at 80.03% of Total Billed charges,863.19,Pays at 102% of Medicare OPPS Rate,3440.7,Pays at 90% of Total Billed charges,960,Pays at 100% of GA Medicaid Fee Schedule,846.27,Pays at 100% of Medicare OPPS Rate,960,Pays at 100% of GA Medicaid Fee Schedule,3364.24,Pays at 88% of Total Billed charges,988.8,Pays at 103% of GA Medicaid Fee Schedule,846.27,3440.7,2293.80
Outpatient Medical Services,LAB,81432,BRCANEXT-EXPANDED (MAYO),300,3087.5,2624.38,Pays at 85% of Billed charges for outpatient setting,992.63,Pays at 32.15% of Total Billed charges,2470.93,Pays at 80.03% of Total Billed charges,692.63,Pays at 102% of Medicare OPPS Rate,2778.75,Pays at 90% of Total Billed charges,992.63,Pays at 32.15% of Total Billed charges,679.05,Pays at 100% of Medicare OPPS Rate,992.63,Pays at 32.15% of Total Billed charges,2717,Pays at 88% of Total Billed charges,1022.27,Pays at 33.11% of Total Billed charges,679.05,2778.75,1852.50
Outpatient Medical Services,LAB,81479,PKD INTERPRETATION   (MAYO),300,962.5,818.13,Pays at 85% of Billed charges for outpatient setting,890.08,Pays at 100% of GA Medicaid Fee Schedule,770.29,Pays at 80.03% of Total Billed charges,NA,Not Applicable,866.25,Pays at 90% of Total Billed charges,890.08,Pays at 100% of GA Medicaid Fee Schedule,NA,Not Applicable,890.08,Pays at 100% of GA Medicaid Fee Schedule,847,Pays at 88% of Total Billed charges,916.78,Pays at 103% of GA Medicaid Fee Schedule,770.29,916.78,577.50
Outpatient Medical Services,LAB,81511,"ALPHA FETOPROTEIN, MATERNAL  (MAYO)",300,397.5,337.88,Pays at 85% of Billed charges for outpatient setting,122.8,Pays at 100% of GA Medicaid Fee Schedule,318.12,Pays at 80.03% of Total Billed charges,156.57,Pays at 102% of Medicare OPPS Rate,357.75,Pays at 90% of Total Billed charges,122.8,Pays at 100% of GA Medicaid Fee Schedule,153.5,Pays at 100% of Medicare OPPS Rate,122.8,Pays at 100% of GA Medicaid Fee Schedule,349.8,Pays at 88% of Total Billed charges,126.48,Pays at 103% of GA Medicaid Fee Schedule,122.8,357.75,238.50
Outpatient Medical Services,LAB,81511,"QUADSCREEN, AFP  (MAYO)",300,406.75,345.74,Pays at 85% of Billed charges for outpatient setting,122.8,Pays at 100% of GA Medicaid Fee Schedule,325.52,Pays at 80.03% of Total Billed charges,156.57,Pays at 102% of Medicare OPPS Rate,366.08,Pays at 90% of Total Billed charges,122.8,Pays at 100% of GA Medicaid Fee Schedule,153.5,Pays at 100% of Medicare OPPS Rate,122.8,Pays at 100% of GA Medicaid Fee Schedule,357.94,Pays at 88% of Total Billed charges,126.48,Pays at 103% of GA Medicaid Fee Schedule,122.8,366.08,244.05
Outpatient Medical Services,LAB,82009,ACETONE,300,19.75,16.79,Pays at 85% of Billed charges for outpatient setting,4.13,Pays at 100% of GA Medicaid Fee Schedule,15.81,Pays at 80.03% of Total Billed charges,4.61,Pays at 102% of Medicare OPPS Rate,17.78,Pays at 90% of Total Billed charges,4.13,Pays at 100% of GA Medicaid Fee Schedule,4.51,Pays at 100% of Medicare OPPS Rate,4.13,Pays at 100% of GA Medicaid Fee Schedule,17.38,Pays at 88% of Total Billed charges,4.25,Pays at 103% of GA Medicaid Fee Schedule,4.13,17.78,11.85
Outpatient Medical Services,LAB,82010,"BETA - HYDROXYBUTYRATE,  (MAYO)",300,54.75,46.54,Pays at 85% of Billed charges for outpatient setting,10.28,Pays at 100% of GA Medicaid Fee Schedule,43.82,Pays at 80.03% of Total Billed charges,8.33,Pays at 102% of Medicare OPPS Rate,49.28,Pays at 90% of Total Billed charges,10.28,Pays at 100% of GA Medicaid Fee Schedule,8.17,Pays at 100% of Medicare OPPS Rate,10.28,Pays at 100% of GA Medicaid Fee Schedule,48.18,Pays at 88% of Total Billed charges,10.59,Pays at 103% of GA Medicaid Fee Schedule,8.17,49.28,32.85
Outpatient Medical Services,LAB,82017,ACYLCARNITINE  (MAYO),300,79.25,67.36,Pays at 85% of Billed charges for outpatient setting,21.21,Pays at 100% of GA Medicaid Fee Schedule,63.42,Pays at 80.03% of Total Billed charges,17.2,Pays at 102% of Medicare OPPS Rate,71.33,Pays at 90% of Total Billed charges,21.21,Pays at 100% of GA Medicaid Fee Schedule,16.87,Pays at 100% of Medicare OPPS Rate,21.21,Pays at 100% of GA Medicaid Fee Schedule,69.74,Pays at 88% of Total Billed charges,21.85,Pays at 103% of GA Medicaid Fee Schedule,16.87,71.33,47.55
Outpatient Medical Services,LAB,82024,"ADRENOCORTICOTROPIC HORMO, ACTH  (MAYO)",300,123.25,104.76,Pays at 85% of Billed charges for outpatient setting,48.57,Pays at 100% of GA Medicaid Fee Schedule,98.64,Pays at 80.03% of Total Billed charges,39.39,Pays at 102% of Medicare OPPS Rate,110.93,Pays at 90% of Total Billed charges,48.57,Pays at 100% of GA Medicaid Fee Schedule,38.61,Pays at 100% of Medicare OPPS Rate,48.57,Pays at 100% of GA Medicaid Fee Schedule,108.46,Pays at 88% of Total Billed charges,50.03,Pays at 103% of GA Medicaid Fee Schedule,38.61,110.93,73.95
Outpatient Medical Services,LAB,82030,"CYCLIC AMP, URINARY EXCRETION  (MAYO)",300,146.5,124.53,Pays at 85% of Billed charges for outpatient setting,32.45,Pays at 100% of GA Medicaid Fee Schedule,117.24,Pays at 80.03% of Total Billed charges,26.31,Pays at 102% of Medicare OPPS Rate,131.85,Pays at 90% of Total Billed charges,32.45,Pays at 100% of GA Medicaid Fee Schedule,25.8,Pays at 100% of Medicare OPPS Rate,32.45,Pays at 100% of GA Medicaid Fee Schedule,128.92,Pays at 88% of Total Billed charges,33.42,Pays at 103% of GA Medicaid Fee Schedule,25.8,131.85,87.90
Outpatient Medical Services,LAB,82040,ALBUMIN,300,24.6,20.91,Pays at 85% of Billed charges for outpatient setting,3.62,Pays at 100% of GA Medicaid Fee Schedule,19.69,Pays at 80.03% of Total Billed charges,5.04,Pays at 102% of Medicare OPPS Rate,22.14,Pays at 90% of Total Billed charges,3.62,Pays at 100% of GA Medicaid Fee Schedule,4.95,Pays at 100% of Medicare OPPS Rate,3.62,Pays at 100% of GA Medicaid Fee Schedule,21.65,Pays at 88% of Total Billed charges,3.73,Pays at 103% of GA Medicaid Fee Schedule,3.62,22.14,14.76
Outpatient Medical Services,LAB,82042,"ALBUMIN, CSF  (MAYO)",300,22.25,18.91,Pays at 85% of Billed charges for outpatient setting,6.51,Pays at 100% of GA Medicaid Fee Schedule,17.81,Pays at 80.03% of Total Billed charges,7.93,Pays at 102% of Medicare OPPS Rate,20.03,Pays at 90% of Total Billed charges,6.51,Pays at 100% of GA Medicaid Fee Schedule,7.78,Pays at 100% of Medicare OPPS Rate,6.51,Pays at 100% of GA Medicaid Fee Schedule,19.58,Pays at 88% of Total Billed charges,6.71,Pays at 103% of GA Medicaid Fee Schedule,6.51,20.03,13.35
Outpatient Medical Services,LAB,82042,"BODY FLUID, ALBUMIN  (MAYO)",300,58,49.3,Pays at 85% of Billed charges for outpatient setting,6.51,Pays at 100% of GA Medicaid Fee Schedule,46.42,Pays at 80.03% of Total Billed charges,7.93,Pays at 102% of Medicare OPPS Rate,52.2,Pays at 90% of Total Billed charges,6.51,Pays at 100% of GA Medicaid Fee Schedule,7.78,Pays at 100% of Medicare OPPS Rate,6.51,Pays at 100% of GA Medicaid Fee Schedule,51.04,Pays at 88% of Total Billed charges,6.71,Pays at 103% of GA Medicaid Fee Schedule,6.51,52.2,34.80
Outpatient Medical Services,LAB,82043,Urine test to measure albumin,300,28.09,23.88,Pays at 85% of Billed charges for outpatient setting,7.28,Pays at 100% of GA Medicaid Fee Schedule,22.48,Pays at 80.03% of Total Billed charges,5.89,Pays at 102% of Medicare OPPS Rate,25.28,Pays at 90% of Total Billed charges,7.28,Pays at 100% of GA Medicaid Fee Schedule,5.78,Pays at 100% of Medicare OPPS Rate,7.28,Pays at 100% of GA Medicaid Fee Schedule,24.72,Pays at 88% of Total Billed charges,7.5,Pays at 103% of GA Medicaid Fee Schedule,5.78,25.28,16.85
Outpatient Medical Services,LAB,82043,Urine test to measure albumin,300,49.75,42.29,Pays at 85% of Billed charges for outpatient setting,7.28,Pays at 100% of GA Medicaid Fee Schedule,39.81,Pays at 80.03% of Total Billed charges,5.89,Pays at 102% of Medicare OPPS Rate,44.78,Pays at 90% of Total Billed charges,7.28,Pays at 100% of GA Medicaid Fee Schedule,5.78,Pays at 100% of Medicare OPPS Rate,7.28,Pays at 100% of GA Medicaid Fee Schedule,43.78,Pays at 88% of Total Billed charges,7.5,Pays at 103% of GA Medicaid Fee Schedule,5.78,44.78,29.85
Outpatient Medical Services,LAB,82043,Urine test to measure albumin,300,109.35,92.95,Pays at 85% of Billed charges for outpatient setting,7.28,Pays at 100% of GA Medicaid Fee Schedule,87.51,Pays at 80.03% of Total Billed charges,5.89,Pays at 102% of Medicare OPPS Rate,98.42,Pays at 90% of Total Billed charges,7.28,Pays at 100% of GA Medicaid Fee Schedule,5.78,Pays at 100% of Medicare OPPS Rate,7.28,Pays at 100% of GA Medicaid Fee Schedule,96.23,Pays at 88% of Total Billed charges,7.5,Pays at 103% of GA Medicaid Fee Schedule,5.78,98.42,65.61
Outpatient Medical Services,LAB,82055,"ALCOHOL, SALIVA",300,66.25,56.31,Pays at 85% of Billed charges for outpatient setting,21.3,Pays at 32.15% of Total Billed charges,53.02,Pays at 80.03% of Total Billed charges,NA,Not Applicable,59.63,Pays at 90% of Total Billed charges,21.3,Pays at 32.15% of Total Billed charges,NA,Not Applicable,21.3,Pays at 32.15% of Total Billed charges,58.3,Pays at 88% of Total Billed charges,21.94,Pays at 33.11% of Total Billed charges,21.3,59.63,39.75
Outpatient Medical Services,LAB,82075,ALCOHOL BREATH CONFIRMATION,300,46,39.1,Pays at 85% of Billed charges for outpatient setting,14.79,Pays at 32.15% of Total Billed charges,36.81,Pays at 80.03% of Total Billed charges,30.6,Pays at 102% of Medicare OPPS Rate,41.4,Pays at 90% of Total Billed charges,14.79,Pays at 32.15% of Total Billed charges,30,Pays at 100% of Medicare OPPS Rate,14.79,Pays at 32.15% of Total Billed charges,40.48,Pays at 88% of Total Billed charges,15.23,Pays at 33.11% of Total Billed charges,14.79,41.4,27.60
Outpatient Medical Services,LAB,82075,ALCOHOL BREATH,300,51.75,43.99,Pays at 85% of Billed charges for outpatient setting,16.64,Pays at 32.15% of Total Billed charges,41.42,Pays at 80.03% of Total Billed charges,30.6,Pays at 102% of Medicare OPPS Rate,46.58,Pays at 90% of Total Billed charges,16.64,Pays at 32.15% of Total Billed charges,30,Pays at 100% of Medicare OPPS Rate,16.64,Pays at 32.15% of Total Billed charges,45.54,Pays at 88% of Total Billed charges,17.13,Pays at 33.11% of Total Billed charges,16.64,46.58,31.05
Outpatient Medical Services,LAB,82077,ALCOHOL-ETHANOL BLOOD,300,39.57,33.63,Pays at 85% of Billed charges for outpatient setting,13.82,Pays at 100% of GA Medicaid Fee Schedule,31.67,Pays at 80.03% of Total Billed charges,17.61,Pays at 102% of Medicare OPPS Rate,35.61,Pays at 90% of Total Billed charges,13.82,Pays at 100% of GA Medicaid Fee Schedule,17.27,Pays at 100% of Medicare OPPS Rate,13.82,Pays at 100% of GA Medicaid Fee Schedule,34.82,Pays at 88% of Total Billed charges,14.23,Pays at 103% of GA Medicaid Fee Schedule,13.82,35.61,23.74
Outpatient Medical Services,LAB,82085,ALDOLASE  (MAYO),300,31,26.35,Pays at 85% of Billed charges for outpatient setting,12.2,Pays at 100% of GA Medicaid Fee Schedule,24.81,Pays at 80.03% of Total Billed charges,9.9,Pays at 102% of Medicare OPPS Rate,27.9,Pays at 90% of Total Billed charges,12.2,Pays at 100% of GA Medicaid Fee Schedule,9.71,Pays at 100% of Medicare OPPS Rate,12.2,Pays at 100% of GA Medicaid Fee Schedule,27.28,Pays at 88% of Total Billed charges,12.57,Pays at 103% of GA Medicaid Fee Schedule,9.71,27.9,18.60
Outpatient Medical Services,LAB,82088,"ALDOSTERONE, URINE  (MAYO)",300,105,89.25,Pays at 85% of Billed charges for outpatient setting,51.25,Pays at 100% of GA Medicaid Fee Schedule,84.03,Pays at 80.03% of Total Billed charges,41.56,Pays at 102% of Medicare OPPS Rate,94.5,Pays at 90% of Total Billed charges,51.25,Pays at 100% of GA Medicaid Fee Schedule,40.75,Pays at 100% of Medicare OPPS Rate,51.25,Pays at 100% of GA Medicaid Fee Schedule,92.4,Pays at 88% of Total Billed charges,52.79,Pays at 103% of GA Medicaid Fee Schedule,40.75,94.5,63.00
Outpatient Medical Services,LAB,82088,"ALDOSTERONE, SERUM  (MAYO)",300,130.5,110.93,Pays at 85% of Billed charges for outpatient setting,51.25,Pays at 100% of GA Medicaid Fee Schedule,104.44,Pays at 80.03% of Total Billed charges,41.56,Pays at 102% of Medicare OPPS Rate,117.45,Pays at 90% of Total Billed charges,51.25,Pays at 100% of GA Medicaid Fee Schedule,40.75,Pays at 100% of Medicare OPPS Rate,51.25,Pays at 100% of GA Medicaid Fee Schedule,114.84,Pays at 88% of Total Billed charges,52.79,Pays at 103% of GA Medicaid Fee Schedule,40.75,117.45,78.30
Outpatient Medical Services,LAB,82103,ALPHA I ANTITRYPSIN  (MAYO),300,139.73,118.77,Pays at 85% of Billed charges for outpatient setting,16.89,Pays at 100% of GA Medicaid Fee Schedule,111.83,Pays at 80.03% of Total Billed charges,13.7,Pays at 102% of Medicare OPPS Rate,125.76,Pays at 90% of Total Billed charges,16.89,Pays at 100% of GA Medicaid Fee Schedule,13.44,Pays at 100% of Medicare OPPS Rate,16.89,Pays at 100% of GA Medicaid Fee Schedule,122.96,Pays at 88% of Total Billed charges,17.4,Pays at 103% of GA Medicaid Fee Schedule,13.44,125.76,83.84
Outpatient Medical Services,LAB,82104,ALPHA 1 ANTITRYPSIN PHENOTYPING  (MAYO),300,46.5,39.53,Pays at 85% of Billed charges for outpatient setting,18.18,Pays at 100% of GA Medicaid Fee Schedule,37.21,Pays at 80.03% of Total Billed charges,14.74,Pays at 102% of Medicare OPPS Rate,41.85,Pays at 90% of Total Billed charges,18.18,Pays at 100% of GA Medicaid Fee Schedule,14.46,Pays at 100% of Medicare OPPS Rate,18.18,Pays at 100% of GA Medicaid Fee Schedule,40.92,Pays at 88% of Total Billed charges,18.73,Pays at 103% of GA Medicaid Fee Schedule,14.46,41.85,27.90
Outpatient Medical Services,LAB,82105,"ALPHA FETOPROTEIN, TUMOR MARKER  (MAYO)",300,53.75,45.69,Pays at 85% of Billed charges for outpatient setting,21.1,Pays at 100% of GA Medicaid Fee Schedule,43.02,Pays at 80.03% of Total Billed charges,17.1,Pays at 102% of Medicare OPPS Rate,48.38,Pays at 90% of Total Billed charges,21.1,Pays at 100% of GA Medicaid Fee Schedule,16.77,Pays at 100% of Medicare OPPS Rate,21.1,Pays at 100% of GA Medicaid Fee Schedule,47.3,Pays at 88% of Total Billed charges,21.73,Pays at 103% of GA Medicaid Fee Schedule,16.77,48.38,32.25
Outpatient Medical Services,LAB,82106,ALPHA FETOPROTE (AFP) AMFL  (MAYO),300,83,70.55,Pays at 85% of Billed charges for outpatient setting,21.1,Pays at 100% of GA Medicaid Fee Schedule,66.42,Pays at 80.03% of Total Billed charges,17.34,Pays at 102% of Medicare OPPS Rate,74.7,Pays at 90% of Total Billed charges,21.1,Pays at 100% of GA Medicaid Fee Schedule,17,Pays at 100% of Medicare OPPS Rate,21.1,Pays at 100% of GA Medicaid Fee Schedule,73.04,Pays at 88% of Total Billed charges,21.73,Pays at 103% of GA Medicaid Fee Schedule,17,74.7,49.80
Outpatient Medical Services,LAB,82108,ALUMINUM  (MAYO),300,75.5,64.18,Pays at 85% of Billed charges for outpatient setting,21.2,Pays at 100% of GA Medicaid Fee Schedule,60.42,Pays at 80.03% of Total Billed charges,25.98,Pays at 102% of Medicare OPPS Rate,67.95,Pays at 90% of Total Billed charges,21.2,Pays at 100% of GA Medicaid Fee Schedule,25.48,Pays at 100% of Medicare OPPS Rate,21.2,Pays at 100% of GA Medicaid Fee Schedule,66.44,Pays at 88% of Total Billed charges,21.84,Pays at 103% of GA Medicaid Fee Schedule,21.2,67.95,45.30
Outpatient Medical Services,LAB,82127,URINE METABOLIC SCREEN,300,160,136,Pays at 85% of Billed charges for outpatient setting,17.43,Pays at 100% of GA Medicaid Fee Schedule,128.05,Pays at 80.03% of Total Billed charges,14.46,Pays at 102% of Medicare OPPS Rate,144,Pays at 90% of Total Billed charges,17.43,Pays at 100% of GA Medicaid Fee Schedule,14.18,Pays at 100% of Medicare OPPS Rate,17.43,Pays at 100% of GA Medicaid Fee Schedule,140.8,Pays at 88% of Total Billed charges,17.95,Pays at 103% of GA Medicaid Fee Schedule,14.18,144,96.00
Outpatient Medical Services,LAB,82128,INBORN ERRORS OF METABOLISM   MAYO,300,101.25,86.06,Pays at 85% of Billed charges for outpatient setting,17.43,Pays at 100% of GA Medicaid Fee Schedule,81.03,Pays at 80.03% of Total Billed charges,14.14,Pays at 102% of Medicare OPPS Rate,91.13,Pays at 90% of Total Billed charges,17.43,Pays at 100% of GA Medicaid Fee Schedule,13.87,Pays at 100% of Medicare OPPS Rate,17.43,Pays at 100% of GA Medicaid Fee Schedule,89.1,Pays at 88% of Total Billed charges,17.95,Pays at 103% of GA Medicaid Fee Schedule,13.87,91.13,60.75
Outpatient Medical Services,LAB,82128,AMINO ACID SCREEN QL(PLASMA)  (MAYO),300,122,103.7,Pays at 85% of Billed charges for outpatient setting,17.43,Pays at 100% of GA Medicaid Fee Schedule,97.64,Pays at 80.03% of Total Billed charges,14.14,Pays at 102% of Medicare OPPS Rate,109.8,Pays at 90% of Total Billed charges,17.43,Pays at 100% of GA Medicaid Fee Schedule,13.87,Pays at 100% of Medicare OPPS Rate,17.43,Pays at 100% of GA Medicaid Fee Schedule,107.36,Pays at 88% of Total Billed charges,17.95,Pays at 103% of GA Medicaid Fee Schedule,13.87,109.8,73.20
Outpatient Medical Services,LAB,82131,"AMINO ACID, PLASMA, QT  (MAYO)",300,239.75,203.79,Pays at 85% of Billed charges for outpatient setting,21.21,Pays at 100% of GA Medicaid Fee Schedule,191.87,Pays at 80.03% of Total Billed charges,23.43,Pays at 102% of Medicare OPPS Rate,215.78,Pays at 90% of Total Billed charges,21.21,Pays at 100% of GA Medicaid Fee Schedule,22.98,Pays at 100% of Medicare OPPS Rate,21.21,Pays at 100% of GA Medicaid Fee Schedule,210.98,Pays at 88% of Total Billed charges,21.85,Pays at 103% of GA Medicaid Fee Schedule,21.21,215.78,143.85
Outpatient Medical Services,LAB,82135,"AMINOLEVULINIC ACID (ALA), URINE  (MAYO)",300,121.25,103.06,Pays at 85% of Billed charges for outpatient setting,20.7,Pays at 100% of GA Medicaid Fee Schedule,97.04,Pays at 80.03% of Total Billed charges,16.77,Pays at 102% of Medicare OPPS Rate,109.13,Pays at 90% of Total Billed charges,20.7,Pays at 100% of GA Medicaid Fee Schedule,16.45,Pays at 100% of Medicare OPPS Rate,20.7,Pays at 100% of GA Medicaid Fee Schedule,106.7,Pays at 88% of Total Billed charges,21.32,Pays at 103% of GA Medicaid Fee Schedule,16.45,109.13,72.75
Outpatient Medical Services,LAB,82135,"AMINOLEVULINIC ACID, URINE  (MAYO)",300,121.25,103.06,Pays at 85% of Billed charges for outpatient setting,20.7,Pays at 100% of GA Medicaid Fee Schedule,97.04,Pays at 80.03% of Total Billed charges,16.77,Pays at 102% of Medicare OPPS Rate,109.13,Pays at 90% of Total Billed charges,20.7,Pays at 100% of GA Medicaid Fee Schedule,16.45,Pays at 100% of Medicare OPPS Rate,20.7,Pays at 100% of GA Medicaid Fee Schedule,106.7,Pays at 88% of Total Billed charges,21.32,Pays at 103% of GA Medicaid Fee Schedule,16.45,109.13,72.75
Outpatient Medical Services,LAB,82136,"CYSTINURIA PROFILE, 24 HR  (MAYO)",300,177.25,150.66,Pays at 85% of Billed charges for outpatient setting,21.21,Pays at 100% of GA Medicaid Fee Schedule,141.85,Pays at 80.03% of Total Billed charges,20,Pays at 102% of Medicare OPPS Rate,159.53,Pays at 90% of Total Billed charges,21.21,Pays at 100% of GA Medicaid Fee Schedule,19.61,Pays at 100% of Medicare OPPS Rate,21.21,Pays at 100% of GA Medicaid Fee Schedule,155.98,Pays at 88% of Total Billed charges,21.85,Pays at 103% of GA Medicaid Fee Schedule,19.61,159.53,106.35
Outpatient Medical Services,LAB,82139,"AMINO ACID, URINE, QT  (MAYO)",300,313.5,266.48,Pays at 85% of Billed charges for outpatient setting,21.21,Pays at 100% of GA Medicaid Fee Schedule,250.89,Pays at 80.03% of Total Billed charges,17.2,Pays at 102% of Medicare OPPS Rate,282.15,Pays at 90% of Total Billed charges,21.21,Pays at 100% of GA Medicaid Fee Schedule,16.87,Pays at 100% of Medicare OPPS Rate,21.21,Pays at 100% of GA Medicaid Fee Schedule,275.88,Pays at 88% of Total Billed charges,21.85,Pays at 103% of GA Medicaid Fee Schedule,16.87,282.15,188.10
Outpatient Medical Services,LAB,82140,AMMONIA,300,47.56,40.43,Pays at 85% of Billed charges for outpatient setting,12.44,Pays at 100% of GA Medicaid Fee Schedule,38.06,Pays at 80.03% of Total Billed charges,14.86,Pays at 102% of Medicare OPPS Rate,42.8,Pays at 90% of Total Billed charges,12.44,Pays at 100% of GA Medicaid Fee Schedule,14.57,Pays at 100% of Medicare OPPS Rate,12.44,Pays at 100% of GA Medicaid Fee Schedule,41.85,Pays at 88% of Total Billed charges,12.81,Pays at 103% of GA Medicaid Fee Schedule,12.44,42.8,28.54
Outpatient Medical Services,LAB,82150,"AMYLASE, URINE",300,31.25,26.56,Pays at 85% of Billed charges for outpatient setting,8.15,Pays at 100% of GA Medicaid Fee Schedule,25.01,Pays at 80.03% of Total Billed charges,6.6,Pays at 102% of Medicare OPPS Rate,28.13,Pays at 90% of Total Billed charges,8.15,Pays at 100% of GA Medicaid Fee Schedule,6.48,Pays at 100% of Medicare OPPS Rate,8.15,Pays at 100% of GA Medicaid Fee Schedule,27.5,Pays at 88% of Total Billed charges,8.39,Pays at 103% of GA Medicaid Fee Schedule,6.48,28.13,18.75
Outpatient Medical Services,LAB,82150,AMYLASE,300,36.25,30.81,Pays at 85% of Billed charges for outpatient setting,8.15,Pays at 100% of GA Medicaid Fee Schedule,29.01,Pays at 80.03% of Total Billed charges,6.6,Pays at 102% of Medicare OPPS Rate,32.63,Pays at 90% of Total Billed charges,8.15,Pays at 100% of GA Medicaid Fee Schedule,6.48,Pays at 100% of Medicare OPPS Rate,8.15,Pays at 100% of GA Medicaid Fee Schedule,31.9,Pays at 88% of Total Billed charges,8.39,Pays at 103% of GA Medicaid Fee Schedule,6.48,32.63,21.75
Outpatient Medical Services,LAB,82150,"AMYLASE, BODY FLUID  (MAYO)",300,67.75,57.59,Pays at 85% of Billed charges for outpatient setting,8.15,Pays at 100% of GA Medicaid Fee Schedule,54.22,Pays at 80.03% of Total Billed charges,6.6,Pays at 102% of Medicare OPPS Rate,60.98,Pays at 90% of Total Billed charges,8.15,Pays at 100% of GA Medicaid Fee Schedule,6.48,Pays at 100% of Medicare OPPS Rate,8.15,Pays at 100% of GA Medicaid Fee Schedule,59.62,Pays at 88% of Total Billed charges,8.39,Pays at 103% of GA Medicaid Fee Schedule,6.48,60.98,40.65
Outpatient Medical Services,LAB,82150,AMYLASE ISOENZYMES  (MAYO),300,84.75,72.04,Pays at 85% of Billed charges for outpatient setting,8.15,Pays at 100% of GA Medicaid Fee Schedule,67.83,Pays at 80.03% of Total Billed charges,6.6,Pays at 102% of Medicare OPPS Rate,76.28,Pays at 90% of Total Billed charges,8.15,Pays at 100% of GA Medicaid Fee Schedule,6.48,Pays at 100% of Medicare OPPS Rate,8.15,Pays at 100% of GA Medicaid Fee Schedule,74.58,Pays at 88% of Total Billed charges,8.39,Pays at 103% of GA Medicaid Fee Schedule,6.48,76.28,50.85
Outpatient Medical Services,LAB,82154,3A  ANDROSTANEDIOL G  (MAYO),300,244,207.4,Pays at 85% of Billed charges for outpatient setting,36.26,Pays at 100% of GA Medicaid Fee Schedule,195.27,Pays at 80.03% of Total Billed charges,29.4,Pays at 102% of Medicare OPPS Rate,219.6,Pays at 90% of Total Billed charges,36.26,Pays at 100% of GA Medicaid Fee Schedule,28.83,Pays at 100% of Medicare OPPS Rate,36.26,Pays at 100% of GA Medicaid Fee Schedule,214.72,Pays at 88% of Total Billed charges,37.35,Pays at 103% of GA Medicaid Fee Schedule,28.83,219.6,146.40
Outpatient Medical Services,LAB,82157,ANDROSTENDIONE  (MAYO),300,56.25,47.81,Pays at 85% of Billed charges for outpatient setting,36.81,Pays at 100% of GA Medicaid Fee Schedule,45.02,Pays at 80.03% of Total Billed charges,29.86,Pays at 102% of Medicare OPPS Rate,50.63,Pays at 90% of Total Billed charges,36.81,Pays at 100% of GA Medicaid Fee Schedule,29.28,Pays at 100% of Medicare OPPS Rate,36.81,Pays at 100% of GA Medicaid Fee Schedule,49.5,Pays at 88% of Total Billed charges,37.91,Pays at 103% of GA Medicaid Fee Schedule,29.28,50.63,33.75
Outpatient Medical Services,LAB,82164,..TEST ANCA,300,25,21.25,Pays at 85% of Billed charges for outpatient setting,18.35,Pays at 100% of GA Medicaid Fee Schedule,20.01,Pays at 80.03% of Total Billed charges,14.89,Pays at 102% of Medicare OPPS Rate,22.5,Pays at 90% of Total Billed charges,18.35,Pays at 100% of GA Medicaid Fee Schedule,14.6,Pays at 100% of Medicare OPPS Rate,18.35,Pays at 100% of GA Medicaid Fee Schedule,22,Pays at 88% of Total Billed charges,18.9,Pays at 103% of GA Medicaid Fee Schedule,14.6,22.5,15.00
Outpatient Medical Services,LAB,82164,..TEST PHENYTOIN FREE AND TOTAL,300,25,21.25,Pays at 85% of Billed charges for outpatient setting,18.35,Pays at 100% of GA Medicaid Fee Schedule,20.01,Pays at 80.03% of Total Billed charges,14.89,Pays at 102% of Medicare OPPS Rate,22.5,Pays at 90% of Total Billed charges,18.35,Pays at 100% of GA Medicaid Fee Schedule,14.6,Pays at 100% of Medicare OPPS Rate,18.35,Pays at 100% of GA Medicaid Fee Schedule,22,Pays at 88% of Total Billed charges,18.9,Pays at 103% of GA Medicaid Fee Schedule,14.6,22.5,15.00
Outpatient Medical Services,LAB,82164,..TEST HEMOCHROMATOSIS HFE,300,25,21.25,Pays at 85% of Billed charges for outpatient setting,18.35,Pays at 100% of GA Medicaid Fee Schedule,20.01,Pays at 80.03% of Total Billed charges,14.89,Pays at 102% of Medicare OPPS Rate,22.5,Pays at 90% of Total Billed charges,18.35,Pays at 100% of GA Medicaid Fee Schedule,14.6,Pays at 100% of Medicare OPPS Rate,18.35,Pays at 100% of GA Medicaid Fee Schedule,22,Pays at 88% of Total Billed charges,18.9,Pays at 103% of GA Medicaid Fee Schedule,14.6,22.5,15.00
Outpatient Medical Services,LAB,82164,..TEST ACE,300,25,21.25,Pays at 85% of Billed charges for outpatient setting,18.35,Pays at 100% of GA Medicaid Fee Schedule,20.01,Pays at 80.03% of Total Billed charges,14.89,Pays at 102% of Medicare OPPS Rate,22.5,Pays at 90% of Total Billed charges,18.35,Pays at 100% of GA Medicaid Fee Schedule,14.6,Pays at 100% of Medicare OPPS Rate,18.35,Pays at 100% of GA Medicaid Fee Schedule,22,Pays at 88% of Total Billed charges,18.9,Pays at 103% of GA Medicaid Fee Schedule,14.6,22.5,15.00
Outpatient Medical Services,LAB,82164,..TEST 25 HYDROXY D2 AND D3,300,25,21.25,Pays at 85% of Billed charges for outpatient setting,18.35,Pays at 100% of GA Medicaid Fee Schedule,20.01,Pays at 80.03% of Total Billed charges,14.89,Pays at 102% of Medicare OPPS Rate,22.5,Pays at 90% of Total Billed charges,18.35,Pays at 100% of GA Medicaid Fee Schedule,14.6,Pays at 100% of Medicare OPPS Rate,18.35,Pays at 100% of GA Medicaid Fee Schedule,22,Pays at 88% of Total Billed charges,18.9,Pays at 103% of GA Medicaid Fee Schedule,14.6,22.5,15.00
Outpatient Medical Services,LAB,82164,..TEST ENDOMYSIAL ABS,300,25,21.25,Pays at 85% of Billed charges for outpatient setting,18.35,Pays at 100% of GA Medicaid Fee Schedule,20.01,Pays at 80.03% of Total Billed charges,14.89,Pays at 102% of Medicare OPPS Rate,22.5,Pays at 90% of Total Billed charges,18.35,Pays at 100% of GA Medicaid Fee Schedule,14.6,Pays at 100% of Medicare OPPS Rate,18.35,Pays at 100% of GA Medicaid Fee Schedule,22,Pays at 88% of Total Billed charges,18.9,Pays at 103% of GA Medicaid Fee Schedule,14.6,22.5,15.00
Outpatient Medical Services,LAB,82164,..TEST HER2 QUANT,300,25,21.25,Pays at 85% of Billed charges for outpatient setting,18.35,Pays at 100% of GA Medicaid Fee Schedule,20.01,Pays at 80.03% of Total Billed charges,14.89,Pays at 102% of Medicare OPPS Rate,22.5,Pays at 90% of Total Billed charges,18.35,Pays at 100% of GA Medicaid Fee Schedule,14.6,Pays at 100% of Medicare OPPS Rate,18.35,Pays at 100% of GA Medicaid Fee Schedule,22,Pays at 88% of Total Billed charges,18.9,Pays at 103% of GA Medicaid Fee Schedule,14.6,22.5,15.00
Outpatient Medical Services,LAB,82164,..TEST IHC AUTOMATED,300,25,21.25,Pays at 85% of Billed charges for outpatient setting,18.35,Pays at 100% of GA Medicaid Fee Schedule,20.01,Pays at 80.03% of Total Billed charges,14.89,Pays at 102% of Medicare OPPS Rate,22.5,Pays at 90% of Total Billed charges,18.35,Pays at 100% of GA Medicaid Fee Schedule,14.6,Pays at 100% of Medicare OPPS Rate,18.35,Pays at 100% of GA Medicaid Fee Schedule,22,Pays at 88% of Total Billed charges,18.9,Pays at 103% of GA Medicaid Fee Schedule,14.6,22.5,15.00
Outpatient Medical Services,LAB,82164,..TEST MISC1,300,25,21.25,Pays at 85% of Billed charges for outpatient setting,18.35,Pays at 100% of GA Medicaid Fee Schedule,20.01,Pays at 80.03% of Total Billed charges,14.89,Pays at 102% of Medicare OPPS Rate,22.5,Pays at 90% of Total Billed charges,18.35,Pays at 100% of GA Medicaid Fee Schedule,14.6,Pays at 100% of Medicare OPPS Rate,18.35,Pays at 100% of GA Medicaid Fee Schedule,22,Pays at 88% of Total Billed charges,18.9,Pays at 103% of GA Medicaid Fee Schedule,14.6,22.5,15.00
Outpatient Medical Services,LAB,82164,"ANGIOTENSIN CONV ENZYME, ACE  (MAYO)",300,46.5,39.53,Pays at 85% of Billed charges for outpatient setting,18.35,Pays at 100% of GA Medicaid Fee Schedule,37.21,Pays at 80.03% of Total Billed charges,14.89,Pays at 102% of Medicare OPPS Rate,41.85,Pays at 90% of Total Billed charges,18.35,Pays at 100% of GA Medicaid Fee Schedule,14.6,Pays at 100% of Medicare OPPS Rate,18.35,Pays at 100% of GA Medicaid Fee Schedule,40.92,Pays at 88% of Total Billed charges,18.9,Pays at 103% of GA Medicaid Fee Schedule,14.6,41.85,27.90
Outpatient Medical Services,LAB,82172,APOLIPOPROTEIN B-100  (MAYO),300,35.25,29.96,Pays at 85% of Billed charges for outpatient setting,19.49,Pays at 100% of GA Medicaid Fee Schedule,28.21,Pays at 80.03% of Total Billed charges,21.51,Pays at 102% of Medicare OPPS Rate,31.73,Pays at 90% of Total Billed charges,19.49,Pays at 100% of GA Medicaid Fee Schedule,21.09,Pays at 100% of Medicare OPPS Rate,19.49,Pays at 100% of GA Medicaid Fee Schedule,31.02,Pays at 88% of Total Billed charges,20.07,Pays at 103% of GA Medicaid Fee Schedule,19.49,31.73,21.15
Outpatient Medical Services,LAB,82172,FIBROSURE APOLIPOPROTEIN  (MAYO),300,143.75,122.19,Pays at 85% of Billed charges for outpatient setting,19.49,Pays at 100% of GA Medicaid Fee Schedule,115.04,Pays at 80.03% of Total Billed charges,21.51,Pays at 102% of Medicare OPPS Rate,129.38,Pays at 90% of Total Billed charges,19.49,Pays at 100% of GA Medicaid Fee Schedule,21.09,Pays at 100% of Medicare OPPS Rate,19.49,Pays at 100% of GA Medicaid Fee Schedule,126.5,Pays at 88% of Total Billed charges,20.07,Pays at 103% of GA Medicaid Fee Schedule,19.49,129.38,86.25
Outpatient Medical Services,LAB,82175,"ARSENIC, BLOOD  (MAYO)",300,60.5,51.43,Pays at 85% of Billed charges for outpatient setting,23.86,Pays at 100% of GA Medicaid Fee Schedule,48.42,Pays at 80.03% of Total Billed charges,19.34,Pays at 102% of Medicare OPPS Rate,54.45,Pays at 90% of Total Billed charges,23.86,Pays at 100% of GA Medicaid Fee Schedule,18.97,Pays at 100% of Medicare OPPS Rate,23.86,Pays at 100% of GA Medicaid Fee Schedule,53.24,Pays at 88% of Total Billed charges,24.58,Pays at 103% of GA Medicaid Fee Schedule,18.97,54.45,36.30
Outpatient Medical Services,LAB,82175,ARSENIC/CREATININE RATIO URINE  (MAYO),300,101.5,86.28,Pays at 85% of Billed charges for outpatient setting,23.86,Pays at 100% of GA Medicaid Fee Schedule,81.23,Pays at 80.03% of Total Billed charges,19.34,Pays at 102% of Medicare OPPS Rate,91.35,Pays at 90% of Total Billed charges,23.86,Pays at 100% of GA Medicaid Fee Schedule,18.97,Pays at 100% of Medicare OPPS Rate,23.86,Pays at 100% of GA Medicaid Fee Schedule,89.32,Pays at 88% of Total Billed charges,24.58,Pays at 103% of GA Medicaid Fee Schedule,18.97,91.35,60.90
Outpatient Medical Services,LAB,82175,"ARSENIC, URINE  (MAYO)",300,105,89.25,Pays at 85% of Billed charges for outpatient setting,23.86,Pays at 100% of GA Medicaid Fee Schedule,84.03,Pays at 80.03% of Total Billed charges,19.34,Pays at 102% of Medicare OPPS Rate,94.5,Pays at 90% of Total Billed charges,23.86,Pays at 100% of GA Medicaid Fee Schedule,18.97,Pays at 100% of Medicare OPPS Rate,23.86,Pays at 100% of GA Medicaid Fee Schedule,92.4,Pays at 88% of Total Billed charges,24.58,Pays at 103% of GA Medicaid Fee Schedule,18.97,94.5,63.00
Outpatient Medical Services,LAB,82180,ASCORBIC ACID (MAYO),300,58.5,49.73,Pays at 85% of Billed charges for outpatient setting,11.11,Pays at 100% of GA Medicaid Fee Schedule,46.82,Pays at 80.03% of Total Billed charges,10.08,Pays at 102% of Medicare OPPS Rate,52.65,Pays at 90% of Total Billed charges,11.11,Pays at 100% of GA Medicaid Fee Schedule,9.89,Pays at 100% of Medicare OPPS Rate,11.11,Pays at 100% of GA Medicaid Fee Schedule,51.48,Pays at 88% of Total Billed charges,11.44,Pays at 103% of GA Medicaid Fee Schedule,9.89,52.65,35.10
Outpatient Medical Services,LAB,82232,BETA 2 MICROGLOBULIN  (MAYO),300,17,14.45,Pays at 85% of Billed charges for outpatient setting,20.35,Pays at 100% of GA Medicaid Fee Schedule,13.61,Pays at 80.03% of Total Billed charges,16.5,Pays at 102% of Medicare OPPS Rate,15.3,Pays at 90% of Total Billed charges,20.35,Pays at 100% of GA Medicaid Fee Schedule,16.18,Pays at 100% of Medicare OPPS Rate,20.35,Pays at 100% of GA Medicaid Fee Schedule,14.96,Pays at 88% of Total Billed charges,20.96,Pays at 103% of GA Medicaid Fee Schedule,13.61,20.96,10.20
Outpatient Medical Services,LAB,82232,MYCOPLASMA HOMINIS PCR  (MAYO),300,179.5,152.58,Pays at 85% of Billed charges for outpatient setting,20.35,Pays at 100% of GA Medicaid Fee Schedule,143.65,Pays at 80.03% of Total Billed charges,16.5,Pays at 102% of Medicare OPPS Rate,161.55,Pays at 90% of Total Billed charges,20.35,Pays at 100% of GA Medicaid Fee Schedule,16.18,Pays at 100% of Medicare OPPS Rate,20.35,Pays at 100% of GA Medicaid Fee Schedule,157.96,Pays at 88% of Total Billed charges,20.96,Pays at 103% of GA Medicaid Fee Schedule,16.18,161.55,107.70
Outpatient Medical Services,LAB,82239,"BILE ACIDS, TOTAL  (MAYO)",300,83.75,71.19,Pays at 85% of Billed charges for outpatient setting,21.55,Pays at 100% of GA Medicaid Fee Schedule,67.03,Pays at 80.03% of Total Billed charges,17.46,Pays at 102% of Medicare OPPS Rate,75.38,Pays at 90% of Total Billed charges,21.55,Pays at 100% of GA Medicaid Fee Schedule,17.12,Pays at 100% of Medicare OPPS Rate,21.55,Pays at 100% of GA Medicaid Fee Schedule,73.7,Pays at 88% of Total Billed charges,22.2,Pays at 103% of GA Medicaid Fee Schedule,17.12,75.38,50.25
Outpatient Medical Services,LAB,82247,NEWBORN BILI PANEL,300,12.55,10.67,Pays at 85% of Billed charges for outpatient setting,6.32,Pays at 100% of GA Medicaid Fee Schedule,10.04,Pays at 80.03% of Total Billed charges,5.12,Pays at 102% of Medicare OPPS Rate,11.3,Pays at 90% of Total Billed charges,6.32,Pays at 100% of GA Medicaid Fee Schedule,5.01,Pays at 100% of Medicare OPPS Rate,6.32,Pays at 100% of GA Medicaid Fee Schedule,11.04,Pays at 88% of Total Billed charges,6.51,Pays at 103% of GA Medicaid Fee Schedule,5.01,11.3,7.53
Outpatient Medical Services,LAB,82247,FIBROSURE BILIRUBIN TOTAL (MAYO),300,20.75,17.64,Pays at 85% of Billed charges for outpatient setting,6.32,Pays at 100% of GA Medicaid Fee Schedule,16.61,Pays at 80.03% of Total Billed charges,5.12,Pays at 102% of Medicare OPPS Rate,18.68,Pays at 90% of Total Billed charges,6.32,Pays at 100% of GA Medicaid Fee Schedule,5.01,Pays at 100% of Medicare OPPS Rate,6.32,Pays at 100% of GA Medicaid Fee Schedule,18.26,Pays at 88% of Total Billed charges,6.51,Pays at 103% of GA Medicaid Fee Schedule,5.01,18.68,12.45
Outpatient Medical Services,LAB,82247,"BILIRUBIN, TOTAL",300,30,25.5,Pays at 85% of Billed charges for outpatient setting,6.32,Pays at 100% of GA Medicaid Fee Schedule,24.01,Pays at 80.03% of Total Billed charges,5.12,Pays at 102% of Medicare OPPS Rate,27,Pays at 90% of Total Billed charges,6.32,Pays at 100% of GA Medicaid Fee Schedule,5.01,Pays at 100% of Medicare OPPS Rate,6.32,Pays at 100% of GA Medicaid Fee Schedule,26.4,Pays at 88% of Total Billed charges,6.51,Pays at 103% of GA Medicaid Fee Schedule,5.01,27,18.00
Outpatient Medical Services,LAB,82247,...BILIRUBIN  NEWBORN,300,90,76.5,Pays at 85% of Billed charges for outpatient setting,6.32,Pays at 100% of GA Medicaid Fee Schedule,72.03,Pays at 80.03% of Total Billed charges,5.12,Pays at 102% of Medicare OPPS Rate,81,Pays at 90% of Total Billed charges,6.32,Pays at 100% of GA Medicaid Fee Schedule,5.01,Pays at 100% of Medicare OPPS Rate,6.32,Pays at 100% of GA Medicaid Fee Schedule,79.2,Pays at 88% of Total Billed charges,6.51,Pays at 103% of GA Medicaid Fee Schedule,5.01,81,54.00
Outpatient Medical Services,LAB,82247,"BILIRUBIN, BODY FLUID  (MAYO)",300,157.5,133.88,Pays at 85% of Billed charges for outpatient setting,6.32,Pays at 100% of GA Medicaid Fee Schedule,126.05,Pays at 80.03% of Total Billed charges,5.12,Pays at 102% of Medicare OPPS Rate,141.75,Pays at 90% of Total Billed charges,6.32,Pays at 100% of GA Medicaid Fee Schedule,5.01,Pays at 100% of Medicare OPPS Rate,6.32,Pays at 100% of GA Medicaid Fee Schedule,138.6,Pays at 88% of Total Billed charges,6.51,Pays at 103% of GA Medicaid Fee Schedule,5.01,141.75,94.50
Outpatient Medical Services,LAB,82248,Measurement of direct bilirubin,300,24.6,20.91,Pays at 85% of Billed charges for outpatient setting,6.32,Pays at 100% of GA Medicaid Fee Schedule,19.69,Pays at 80.03% of Total Billed charges,5.12,Pays at 102% of Medicare OPPS Rate,22.14,Pays at 90% of Total Billed charges,6.32,Pays at 100% of GA Medicaid Fee Schedule,5.01,Pays at 100% of Medicare OPPS Rate,6.32,Pays at 100% of GA Medicaid Fee Schedule,21.65,Pays at 88% of Total Billed charges,6.51,Pays at 103% of GA Medicaid Fee Schedule,5.01,22.14,14.76
Outpatient Medical Services,LAB,82270,OCCULT BLOOD,300,12.71,10.8,Pays at 85% of Billed charges for outpatient setting,4.04,Pays at 100% of GA Medicaid Fee Schedule,10.17,Pays at 80.03% of Total Billed charges,4.46,Pays at 102% of Medicare OPPS Rate,11.44,Pays at 90% of Total Billed charges,4.04,Pays at 100% of GA Medicaid Fee Schedule,4.38,Pays at 100% of Medicare OPPS Rate,4.04,Pays at 100% of GA Medicaid Fee Schedule,11.18,Pays at 88% of Total Billed charges,4.16,Pays at 103% of GA Medicaid Fee Schedule,4.04,11.44,7.63
Outpatient Medical Services,LAB,82271,OCCULT BLOOD (GASTRIC),300,13.5,11.48,Pays at 85% of Billed charges for outpatient setting,4.04,Pays at 100% of GA Medicaid Fee Schedule,10.8,Pays at 80.03% of Total Billed charges,5.42,Pays at 102% of Medicare OPPS Rate,12.15,Pays at 90% of Total Billed charges,4.04,Pays at 100% of GA Medicaid Fee Schedule,5.32,Pays at 100% of Medicare OPPS Rate,4.04,Pays at 100% of GA Medicaid Fee Schedule,11.88,Pays at 88% of Total Billed charges,4.16,Pays at 103% of GA Medicaid Fee Schedule,4.04,12.15,8.10
Outpatient Medical Services,LAB,82300,CADMIUM/CREATININE RATIO URINE  (MAYO),300,124.25,105.61,Pays at 85% of Billed charges for outpatient setting,29.1,Pays at 100% of GA Medicaid Fee Schedule,99.44,Pays at 80.03% of Total Billed charges,24.11,Pays at 102% of Medicare OPPS Rate,111.83,Pays at 90% of Total Billed charges,29.1,Pays at 100% of GA Medicaid Fee Schedule,23.64,Pays at 100% of Medicare OPPS Rate,29.1,Pays at 100% of GA Medicaid Fee Schedule,109.34,Pays at 88% of Total Billed charges,29.97,Pays at 103% of GA Medicaid Fee Schedule,23.64,111.83,74.55
Outpatient Medical Services,LAB,82306,Blood test to monitor vitamin D levels,300,77.29,65.7,Pays at 85% of Billed charges for outpatient setting,37.22,Pays at 100% of GA Medicaid Fee Schedule,61.86,Pays at 80.03% of Total Billed charges,30.19,Pays at 102% of Medicare OPPS Rate,69.56,Pays at 90% of Total Billed charges,37.22,Pays at 100% of GA Medicaid Fee Schedule,29.6,Pays at 100% of Medicare OPPS Rate,37.22,Pays at 100% of GA Medicaid Fee Schedule,68.02,Pays at 88% of Total Billed charges,38.34,Pays at 103% of GA Medicaid Fee Schedule,29.6,69.56,46.37
Outpatient Medical Services,LAB,82306,Blood test to monitor vitamin D levels,300,94.25,80.11,Pays at 85% of Billed charges for outpatient setting,37.22,Pays at 100% of GA Medicaid Fee Schedule,75.43,Pays at 80.03% of Total Billed charges,30.19,Pays at 102% of Medicare OPPS Rate,84.83,Pays at 90% of Total Billed charges,37.22,Pays at 100% of GA Medicaid Fee Schedule,29.6,Pays at 100% of Medicare OPPS Rate,37.22,Pays at 100% of GA Medicaid Fee Schedule,82.94,Pays at 88% of Total Billed charges,38.34,Pays at 103% of GA Medicaid Fee Schedule,29.6,84.83,56.55
Outpatient Medical Services,LAB,82308,"CALCITONIN, SERUM  (MAYO)",300,86,73.1,Pays at 85% of Billed charges for outpatient setting,33.67,Pays at 100% of GA Medicaid Fee Schedule,68.83,Pays at 80.03% of Total Billed charges,27.32,Pays at 102% of Medicare OPPS Rate,77.4,Pays at 90% of Total Billed charges,33.67,Pays at 100% of GA Medicaid Fee Schedule,26.79,Pays at 100% of Medicare OPPS Rate,33.67,Pays at 100% of GA Medicaid Fee Schedule,75.68,Pays at 88% of Total Billed charges,34.68,Pays at 103% of GA Medicaid Fee Schedule,26.79,77.4,51.60
Outpatient Medical Services,LAB,82310,"CALCIUM, SERUM",300,30,25.5,Pays at 85% of Billed charges for outpatient setting,6.35,Pays at 100% of GA Medicaid Fee Schedule,24.01,Pays at 80.03% of Total Billed charges,5.26,Pays at 102% of Medicare OPPS Rate,27,Pays at 90% of Total Billed charges,6.35,Pays at 100% of GA Medicaid Fee Schedule,5.16,Pays at 100% of Medicare OPPS Rate,6.35,Pays at 100% of GA Medicaid Fee Schedule,26.4,Pays at 88% of Total Billed charges,6.54,Pays at 103% of GA Medicaid Fee Schedule,5.16,27,18.00
Outpatient Medical Services,LAB,82330,"CALCIUM, IONIZED  (MAYO)",300,43.5,36.98,Pays at 85% of Billed charges for outpatient setting,17.18,Pays at 100% of GA Medicaid Fee Schedule,34.81,Pays at 80.03% of Total Billed charges,13.95,Pays at 102% of Medicare OPPS Rate,39.15,Pays at 90% of Total Billed charges,17.18,Pays at 100% of GA Medicaid Fee Schedule,13.68,Pays at 100% of Medicare OPPS Rate,17.18,Pays at 100% of GA Medicaid Fee Schedule,38.28,Pays at 88% of Total Billed charges,17.7,Pays at 103% of GA Medicaid Fee Schedule,13.68,39.15,26.10
Outpatient Medical Services,LAB,82340,"CALCIUM, 24HR URINE  (MAYO)",300,33.5,28.48,Pays at 85% of Billed charges for outpatient setting,7.59,Pays at 100% of GA Medicaid Fee Schedule,26.81,Pays at 80.03% of Total Billed charges,6.15,Pays at 102% of Medicare OPPS Rate,30.15,Pays at 90% of Total Billed charges,7.59,Pays at 100% of GA Medicaid Fee Schedule,6.03,Pays at 100% of Medicare OPPS Rate,7.59,Pays at 100% of GA Medicaid Fee Schedule,29.48,Pays at 88% of Total Billed charges,7.82,Pays at 103% of GA Medicaid Fee Schedule,6.03,30.15,20.10
Outpatient Medical Services,LAB,82340,URINE CALCIUM (RANDOM) (MAYO),300,36,30.6,Pays at 85% of Billed charges for outpatient setting,7.59,Pays at 100% of GA Medicaid Fee Schedule,28.81,Pays at 80.03% of Total Billed charges,6.15,Pays at 102% of Medicare OPPS Rate,32.4,Pays at 90% of Total Billed charges,7.59,Pays at 100% of GA Medicaid Fee Schedule,6.03,Pays at 100% of Medicare OPPS Rate,7.59,Pays at 100% of GA Medicaid Fee Schedule,31.68,Pays at 88% of Total Billed charges,7.82,Pays at 103% of GA Medicaid Fee Schedule,6.03,32.4,21.60
Outpatient Medical Services,LAB,82340,"URINE CALCIUM, 24HR  (MAYO)",300,70,59.5,Pays at 85% of Billed charges for outpatient setting,7.59,Pays at 100% of GA Medicaid Fee Schedule,56.02,Pays at 80.03% of Total Billed charges,6.15,Pays at 102% of Medicare OPPS Rate,63,Pays at 90% of Total Billed charges,7.59,Pays at 100% of GA Medicaid Fee Schedule,6.03,Pays at 100% of Medicare OPPS Rate,7.59,Pays at 100% of GA Medicaid Fee Schedule,61.6,Pays at 88% of Total Billed charges,7.82,Pays at 103% of GA Medicaid Fee Schedule,6.03,63,42.00
Outpatient Medical Services,LAB,82355,STONE  QL ANALYSIS,300,260.5,221.43,Pays at 85% of Billed charges for outpatient setting,14.55,Pays at 100% of GA Medicaid Fee Schedule,208.48,Pays at 80.03% of Total Billed charges,11.81,Pays at 102% of Medicare OPPS Rate,234.45,Pays at 90% of Total Billed charges,14.55,Pays at 100% of GA Medicaid Fee Schedule,11.58,Pays at 100% of Medicare OPPS Rate,14.55,Pays at 100% of GA Medicaid Fee Schedule,229.24,Pays at 88% of Total Billed charges,14.99,Pays at 103% of GA Medicaid Fee Schedule,11.58,234.45,156.30
Outpatient Medical Services,LAB,82360,"STONE QT ANALYSIS, CHEMICAL",300,41.5,35.28,Pays at 85% of Billed charges for outpatient setting,16.19,Pays at 100% of GA Medicaid Fee Schedule,33.21,Pays at 80.03% of Total Billed charges,13.12,Pays at 102% of Medicare OPPS Rate,37.35,Pays at 90% of Total Billed charges,16.19,Pays at 100% of GA Medicaid Fee Schedule,12.87,Pays at 100% of Medicare OPPS Rate,16.19,Pays at 100% of GA Medicaid Fee Schedule,36.52,Pays at 88% of Total Billed charges,16.68,Pays at 103% of GA Medicaid Fee Schedule,12.87,37.35,24.90
Outpatient Medical Services,LAB,82360,CALCULI ANALYSIS & GROSS (LOUIS HERRING),300,92.5,78.63,Pays at 85% of Billed charges for outpatient setting,16.19,Pays at 100% of GA Medicaid Fee Schedule,74.03,Pays at 80.03% of Total Billed charges,13.12,Pays at 102% of Medicare OPPS Rate,83.25,Pays at 90% of Total Billed charges,16.19,Pays at 100% of GA Medicaid Fee Schedule,12.87,Pays at 100% of Medicare OPPS Rate,16.19,Pays at 100% of GA Medicaid Fee Schedule,81.4,Pays at 88% of Total Billed charges,16.68,Pays at 103% of GA Medicaid Fee Schedule,12.87,83.25,55.50
Outpatient Medical Services,LAB,82373,CARBOHYDRATE DEF TRANSFERRIN  (MAYO),300,120,102,Pays at 85% of Billed charges for outpatient setting,7.55,Pays at 100% of GA Medicaid Fee Schedule,96.04,Pays at 80.03% of Total Billed charges,18.42,Pays at 102% of Medicare OPPS Rate,108,Pays at 90% of Total Billed charges,7.55,Pays at 100% of GA Medicaid Fee Schedule,18.05,Pays at 100% of Medicare OPPS Rate,7.55,Pays at 100% of GA Medicaid Fee Schedule,105.6,Pays at 88% of Total Billed charges,7.78,Pays at 103% of GA Medicaid Fee Schedule,7.55,108,72.00
Outpatient Medical Services,LAB,82374,CO2 (BICARBONATE),300,18.75,15.94,Pays at 85% of Billed charges for outpatient setting,6.15,Pays at 100% of GA Medicaid Fee Schedule,15.01,Pays at 80.03% of Total Billed charges,4.97,Pays at 102% of Medicare OPPS Rate,16.88,Pays at 90% of Total Billed charges,6.15,Pays at 100% of GA Medicaid Fee Schedule,4.88,Pays at 100% of Medicare OPPS Rate,6.15,Pays at 100% of GA Medicaid Fee Schedule,16.5,Pays at 88% of Total Billed charges,6.33,Pays at 103% of GA Medicaid Fee Schedule,4.88,16.88,11.25
Outpatient Medical Services,LAB,82374,URINE BICARBONATE  (MAYO),300,118.25,100.51,Pays at 85% of Billed charges for outpatient setting,6.15,Pays at 100% of GA Medicaid Fee Schedule,94.64,Pays at 80.03% of Total Billed charges,4.97,Pays at 102% of Medicare OPPS Rate,106.43,Pays at 90% of Total Billed charges,6.15,Pays at 100% of GA Medicaid Fee Schedule,4.88,Pays at 100% of Medicare OPPS Rate,6.15,Pays at 100% of GA Medicaid Fee Schedule,104.06,Pays at 88% of Total Billed charges,6.33,Pays at 103% of GA Medicaid Fee Schedule,4.88,106.43,70.95
Outpatient Medical Services,LAB,82375,TEST CARBOXYHEMOGLOBIN,300,129.25,109.86,Pays at 85% of Billed charges for outpatient setting,3.62,Pays at 100% of GA Medicaid Fee Schedule,103.44,Pays at 80.03% of Total Billed charges,12.56,Pays at 102% of Medicare OPPS Rate,116.33,Pays at 90% of Total Billed charges,3.62,Pays at 100% of GA Medicaid Fee Schedule,12.32,Pays at 100% of Medicare OPPS Rate,3.62,Pays at 100% of GA Medicaid Fee Schedule,113.74,Pays at 88% of Total Billed charges,3.73,Pays at 103% of GA Medicaid Fee Schedule,3.62,116.33,77.55
Outpatient Medical Services,LAB,82375,TEST METHEMOGLOBIN,300,129.25,109.86,Pays at 85% of Billed charges for outpatient setting,3.62,Pays at 100% of GA Medicaid Fee Schedule,103.44,Pays at 80.03% of Total Billed charges,12.56,Pays at 102% of Medicare OPPS Rate,116.33,Pays at 90% of Total Billed charges,3.62,Pays at 100% of GA Medicaid Fee Schedule,12.32,Pays at 100% of Medicare OPPS Rate,3.62,Pays at 100% of GA Medicaid Fee Schedule,113.74,Pays at 88% of Total Billed charges,3.73,Pays at 103% of GA Medicaid Fee Schedule,3.62,116.33,77.55
Outpatient Medical Services,LAB,82375,CARBOXYHEMOGLOBIN,300,129.5,110.08,Pays at 85% of Billed charges for outpatient setting,3.62,Pays at 100% of GA Medicaid Fee Schedule,103.64,Pays at 80.03% of Total Billed charges,12.56,Pays at 102% of Medicare OPPS Rate,116.55,Pays at 90% of Total Billed charges,3.62,Pays at 100% of GA Medicaid Fee Schedule,12.32,Pays at 100% of Medicare OPPS Rate,3.62,Pays at 100% of GA Medicaid Fee Schedule,113.96,Pays at 88% of Total Billed charges,3.73,Pays at 103% of GA Medicaid Fee Schedule,3.62,116.55,77.70
Outpatient Medical Services,LAB,82378,CEA (MAYO),300,74.11,62.99,Pays at 85% of Billed charges for outpatient setting,23.86,Pays at 100% of GA Medicaid Fee Schedule,59.31,Pays at 80.03% of Total Billed charges,19.33,Pays at 102% of Medicare OPPS Rate,66.7,Pays at 90% of Total Billed charges,23.86,Pays at 100% of GA Medicaid Fee Schedule,18.96,Pays at 100% of Medicare OPPS Rate,23.86,Pays at 100% of GA Medicaid Fee Schedule,65.22,Pays at 88% of Total Billed charges,24.58,Pays at 103% of GA Medicaid Fee Schedule,18.96,66.7,44.47
Outpatient Medical Services,LAB,82378,"CEA, PERITONEAL FLUID  (MAYO)",300,261.66,222.41,Pays at 85% of Billed charges for outpatient setting,23.86,Pays at 100% of GA Medicaid Fee Schedule,209.41,Pays at 80.03% of Total Billed charges,19.33,Pays at 102% of Medicare OPPS Rate,235.49,Pays at 90% of Total Billed charges,23.86,Pays at 100% of GA Medicaid Fee Schedule,18.96,Pays at 100% of Medicare OPPS Rate,23.86,Pays at 100% of GA Medicaid Fee Schedule,230.26,Pays at 88% of Total Billed charges,24.58,Pays at 103% of GA Medicaid Fee Schedule,18.96,235.49,157.00
Outpatient Medical Services,LAB,82378,"CEA, PLEURAL FLUID  (MAYO)",300,311,264.35,Pays at 85% of Billed charges for outpatient setting,23.86,Pays at 100% of GA Medicaid Fee Schedule,248.89,Pays at 80.03% of Total Billed charges,19.33,Pays at 102% of Medicare OPPS Rate,279.9,Pays at 90% of Total Billed charges,23.86,Pays at 100% of GA Medicaid Fee Schedule,18.96,Pays at 100% of Medicare OPPS Rate,23.86,Pays at 100% of GA Medicaid Fee Schedule,273.68,Pays at 88% of Total Billed charges,24.58,Pays at 103% of GA Medicaid Fee Schedule,18.96,279.9,186.60
Outpatient Medical Services,LAB,82379,CARNITINE  (MAYO),300,50,42.5,Pays at 85% of Billed charges for outpatient setting,21.21,Pays at 100% of GA Medicaid Fee Schedule,40.02,Pays at 80.03% of Total Billed charges,17.2,Pays at 102% of Medicare OPPS Rate,45,Pays at 90% of Total Billed charges,21.21,Pays at 100% of GA Medicaid Fee Schedule,16.87,Pays at 100% of Medicare OPPS Rate,21.21,Pays at 100% of GA Medicaid Fee Schedule,44,Pays at 88% of Total Billed charges,21.85,Pays at 103% of GA Medicaid Fee Schedule,16.87,45,30.00
Outpatient Medical Services,LAB,82380,CAROTENE  (MAYO),300,44.25,37.61,Pays at 85% of Billed charges for outpatient setting,11.6,Pays at 100% of GA Medicaid Fee Schedule,35.41,Pays at 80.03% of Total Billed charges,9.4,Pays at 102% of Medicare OPPS Rate,39.83,Pays at 90% of Total Billed charges,11.6,Pays at 100% of GA Medicaid Fee Schedule,9.22,Pays at 100% of Medicare OPPS Rate,11.6,Pays at 100% of GA Medicaid Fee Schedule,38.94,Pays at 88% of Total Billed charges,11.95,Pays at 103% of GA Medicaid Fee Schedule,9.22,39.83,26.55
Outpatient Medical Services,LAB,82384,"CATECHOLAMINE FREE, PLASMA(FRACTIONATED)",300,56.5,48.03,Pays at 85% of Billed charges for outpatient setting,31.75,Pays at 100% of GA Medicaid Fee Schedule,45.22,Pays at 80.03% of Total Billed charges,25.75,Pays at 102% of Medicare OPPS Rate,50.85,Pays at 90% of Total Billed charges,31.75,Pays at 100% of GA Medicaid Fee Schedule,25.25,Pays at 100% of Medicare OPPS Rate,31.75,Pays at 100% of GA Medicaid Fee Schedule,49.72,Pays at 88% of Total Billed charges,32.7,Pays at 103% of GA Medicaid Fee Schedule,25.25,50.85,33.90
Outpatient Medical Services,LAB,82384,"CATECHOLAMINE FREE, URINE (FRACTIONATED)",300,80.75,68.64,Pays at 85% of Billed charges for outpatient setting,31.75,Pays at 100% of GA Medicaid Fee Schedule,64.62,Pays at 80.03% of Total Billed charges,25.75,Pays at 102% of Medicare OPPS Rate,72.68,Pays at 90% of Total Billed charges,31.75,Pays at 100% of GA Medicaid Fee Schedule,25.25,Pays at 100% of Medicare OPPS Rate,31.75,Pays at 100% of GA Medicaid Fee Schedule,71.06,Pays at 88% of Total Billed charges,32.7,Pays at 103% of GA Medicaid Fee Schedule,25.25,72.68,48.45
Outpatient Medical Services,LAB,82390,CERULOPLASMIN  (MAYO),300,34.25,29.11,Pays at 85% of Billed charges for outpatient setting,13.51,Pays at 100% of GA Medicaid Fee Schedule,27.41,Pays at 80.03% of Total Billed charges,10.95,Pays at 102% of Medicare OPPS Rate,30.83,Pays at 90% of Total Billed charges,13.51,Pays at 100% of GA Medicaid Fee Schedule,10.74,Pays at 100% of Medicare OPPS Rate,13.51,Pays at 100% of GA Medicaid Fee Schedule,30.14,Pays at 88% of Total Billed charges,13.92,Pays at 103% of GA Medicaid Fee Schedule,10.74,30.83,20.55
Outpatient Medical Services,LAB,82397,"PTH RELATED PEPTIDE, PTHRP  (MAYO)",300,54.75,46.54,Pays at 85% of Billed charges for outpatient setting,17.77,Pays at 100% of GA Medicaid Fee Schedule,43.82,Pays at 80.03% of Total Billed charges,14.4,Pays at 102% of Medicare OPPS Rate,49.28,Pays at 90% of Total Billed charges,17.77,Pays at 100% of GA Medicaid Fee Schedule,14.12,Pays at 100% of Medicare OPPS Rate,17.77,Pays at 100% of GA Medicaid Fee Schedule,48.18,Pays at 88% of Total Billed charges,18.3,Pays at 103% of GA Medicaid Fee Schedule,14.12,49.28,32.85
Outpatient Medical Services,LAB,82435,CHLORIDE,300,18.75,15.94,Pays at 85% of Billed charges for outpatient setting,5.78,Pays at 100% of GA Medicaid Fee Schedule,15.01,Pays at 80.03% of Total Billed charges,4.69,Pays at 102% of Medicare OPPS Rate,16.88,Pays at 90% of Total Billed charges,5.78,Pays at 100% of GA Medicaid Fee Schedule,4.59,Pays at 100% of Medicare OPPS Rate,5.78,Pays at 100% of GA Medicaid Fee Schedule,16.5,Pays at 88% of Total Billed charges,5.95,Pays at 103% of GA Medicaid Fee Schedule,4.59,16.88,11.25
Outpatient Medical Services,LAB,82436,"URINE CHLORIDE, RANDOM",300,18.75,15.94,Pays at 85% of Billed charges for outpatient setting,6.32,Pays at 100% of GA Medicaid Fee Schedule,15.01,Pays at 80.03% of Total Billed charges,5.86,Pays at 102% of Medicare OPPS Rate,16.88,Pays at 90% of Total Billed charges,6.32,Pays at 100% of GA Medicaid Fee Schedule,5.75,Pays at 100% of Medicare OPPS Rate,6.32,Pays at 100% of GA Medicaid Fee Schedule,16.5,Pays at 88% of Total Billed charges,6.51,Pays at 103% of GA Medicaid Fee Schedule,5.75,16.88,11.25
Outpatient Medical Services,LAB,82436,"CHLORIDE, 24HR URINE  (MAYO)",300,26,22.1,Pays at 85% of Billed charges for outpatient setting,6.32,Pays at 100% of GA Medicaid Fee Schedule,20.81,Pays at 80.03% of Total Billed charges,5.86,Pays at 102% of Medicare OPPS Rate,23.4,Pays at 90% of Total Billed charges,6.32,Pays at 100% of GA Medicaid Fee Schedule,5.75,Pays at 100% of Medicare OPPS Rate,6.32,Pays at 100% of GA Medicaid Fee Schedule,22.88,Pays at 88% of Total Billed charges,6.51,Pays at 103% of GA Medicaid Fee Schedule,5.75,23.4,15.60
Outpatient Medical Services,LAB,82436,"URINE CHLORIDE, 24HR",300,33.5,28.48,Pays at 85% of Billed charges for outpatient setting,6.32,Pays at 100% of GA Medicaid Fee Schedule,26.81,Pays at 80.03% of Total Billed charges,5.86,Pays at 102% of Medicare OPPS Rate,30.15,Pays at 90% of Total Billed charges,6.32,Pays at 100% of GA Medicaid Fee Schedule,5.75,Pays at 100% of Medicare OPPS Rate,6.32,Pays at 100% of GA Medicaid Fee Schedule,29.48,Pays at 88% of Total Billed charges,6.51,Pays at 103% of GA Medicaid Fee Schedule,5.75,30.15,20.10
Outpatient Medical Services,LAB,82438,"CHLORIDE, FECES, QT  (MAYO)",300,31.5,26.78,Pays at 85% of Billed charges for outpatient setting,6.15,Pays at 100% of GA Medicaid Fee Schedule,25.21,Pays at 80.03% of Total Billed charges,5.1,Pays at 102% of Medicare OPPS Rate,28.35,Pays at 90% of Total Billed charges,6.15,Pays at 100% of GA Medicaid Fee Schedule,5,Pays at 100% of Medicare OPPS Rate,6.15,Pays at 100% of GA Medicaid Fee Schedule,27.72,Pays at 88% of Total Billed charges,6.33,Pays at 103% of GA Medicaid Fee Schedule,5,28.35,18.90
Outpatient Medical Services,LAB,82438,"CHLORIDE, BODY FLUID  (MAYO)",300,46,39.1,Pays at 85% of Billed charges for outpatient setting,6.15,Pays at 100% of GA Medicaid Fee Schedule,36.81,Pays at 80.03% of Total Billed charges,5.1,Pays at 102% of Medicare OPPS Rate,41.4,Pays at 90% of Total Billed charges,6.15,Pays at 100% of GA Medicaid Fee Schedule,5,Pays at 100% of Medicare OPPS Rate,6.15,Pays at 100% of GA Medicaid Fee Schedule,40.48,Pays at 88% of Total Billed charges,6.33,Pays at 103% of GA Medicaid Fee Schedule,5,41.4,27.60
Outpatient Medical Services,LAB,82465,"CHOLESTEROL, TOTAL, CDC  (MAYO)",300,13.25,11.26,Pays at 85% of Billed charges for outpatient setting,5.47,Pays at 100% of GA Medicaid Fee Schedule,10.6,Pays at 80.03% of Total Billed charges,4.43,Pays at 102% of Medicare OPPS Rate,11.93,Pays at 90% of Total Billed charges,5.47,Pays at 100% of GA Medicaid Fee Schedule,4.34,Pays at 100% of Medicare OPPS Rate,5.47,Pays at 100% of GA Medicaid Fee Schedule,11.66,Pays at 88% of Total Billed charges,5.63,Pays at 103% of GA Medicaid Fee Schedule,4.34,11.93,7.95
Outpatient Medical Services,LAB,82465,CHOLESTEROL,300,30,25.5,Pays at 85% of Billed charges for outpatient setting,5.47,Pays at 100% of GA Medicaid Fee Schedule,24.01,Pays at 80.03% of Total Billed charges,4.43,Pays at 102% of Medicare OPPS Rate,27,Pays at 90% of Total Billed charges,5.47,Pays at 100% of GA Medicaid Fee Schedule,4.34,Pays at 100% of Medicare OPPS Rate,5.47,Pays at 100% of GA Medicaid Fee Schedule,26.4,Pays at 88% of Total Billed charges,5.63,Pays at 103% of GA Medicaid Fee Schedule,4.34,27,18.00
Outpatient Medical Services,LAB,82480,PSEUDOCHOLINESTERASE  (MAYO),300,53.25,45.26,Pays at 85% of Billed charges for outpatient setting,9.91,Pays at 100% of GA Medicaid Fee Schedule,42.62,Pays at 80.03% of Total Billed charges,8.02,Pays at 102% of Medicare OPPS Rate,47.93,Pays at 90% of Total Billed charges,9.91,Pays at 100% of GA Medicaid Fee Schedule,7.87,Pays at 100% of Medicare OPPS Rate,9.91,Pays at 100% of GA Medicaid Fee Schedule,46.86,Pays at 88% of Total Billed charges,10.21,Pays at 103% of GA Medicaid Fee Schedule,7.87,47.93,31.95
Outpatient Medical Services,LAB,82482,"ACETYLCHOLINESTERASE, RBC  (MAYO)",300,116.75,99.24,Pays at 85% of Billed charges for outpatient setting,9.67,Pays at 100% of GA Medicaid Fee Schedule,93.44,Pays at 80.03% of Total Billed charges,10,Pays at 102% of Medicare OPPS Rate,105.08,Pays at 90% of Total Billed charges,9.67,Pays at 100% of GA Medicaid Fee Schedule,9.81,Pays at 100% of Medicare OPPS Rate,9.67,Pays at 100% of GA Medicaid Fee Schedule,102.74,Pays at 88% of Total Billed charges,9.96,Pays at 103% of GA Medicaid Fee Schedule,9.67,105.08,70.05
Outpatient Medical Services,LAB,82495,"CHROMIUM, SERUM  (MAYO)",300,46.5,39.53,Pays at 85% of Billed charges for outpatient setting,25.51,Pays at 100% of GA Medicaid Fee Schedule,37.21,Pays at 80.03% of Total Billed charges,20.68,Pays at 102% of Medicare OPPS Rate,41.85,Pays at 90% of Total Billed charges,25.51,Pays at 100% of GA Medicaid Fee Schedule,20.28,Pays at 100% of Medicare OPPS Rate,25.51,Pays at 100% of GA Medicaid Fee Schedule,40.92,Pays at 88% of Total Billed charges,26.28,Pays at 103% of GA Medicaid Fee Schedule,20.28,41.85,27.90
Outpatient Medical Services,LAB,82507,"CITRATE EXCRETION, 24HR URINE  (MAYO)",300,33.75,28.69,Pays at 85% of Billed charges for outpatient setting,34.97,Pays at 100% of GA Medicaid Fee Schedule,27.01,Pays at 80.03% of Total Billed charges,28.35,Pays at 102% of Medicare OPPS Rate,30.38,Pays at 90% of Total Billed charges,34.97,Pays at 100% of GA Medicaid Fee Schedule,27.8,Pays at 100% of Medicare OPPS Rate,34.97,Pays at 100% of GA Medicaid Fee Schedule,29.7,Pays at 88% of Total Billed charges,36.02,Pays at 103% of GA Medicaid Fee Schedule,27.01,36.02,20.25
Outpatient Medical Services,LAB,82507,"CITRATE, URINE (24 HR)  (MAYO)",300,70,59.5,Pays at 85% of Billed charges for outpatient setting,34.97,Pays at 100% of GA Medicaid Fee Schedule,56.02,Pays at 80.03% of Total Billed charges,28.35,Pays at 102% of Medicare OPPS Rate,63,Pays at 90% of Total Billed charges,34.97,Pays at 100% of GA Medicaid Fee Schedule,27.8,Pays at 100% of Medicare OPPS Rate,34.97,Pays at 100% of GA Medicaid Fee Schedule,61.6,Pays at 88% of Total Billed charges,36.02,Pays at 103% of GA Medicaid Fee Schedule,27.8,63,42.00
Outpatient Medical Services,LAB,82507,"URINE CITRATE, 24 HR EXCRETION  (MAYO)",300,70,59.5,Pays at 85% of Billed charges for outpatient setting,34.97,Pays at 100% of GA Medicaid Fee Schedule,56.02,Pays at 80.03% of Total Billed charges,28.35,Pays at 102% of Medicare OPPS Rate,63,Pays at 90% of Total Billed charges,34.97,Pays at 100% of GA Medicaid Fee Schedule,27.8,Pays at 100% of Medicare OPPS Rate,34.97,Pays at 100% of GA Medicaid Fee Schedule,61.6,Pays at 88% of Total Billed charges,36.02,Pays at 103% of GA Medicaid Fee Schedule,27.8,63,42.00
Outpatient Medical Services,LAB,82507,"CITRIC ACID, SERUM  MAYO",300,70,59.5,Pays at 85% of Billed charges for outpatient setting,34.97,Pays at 100% of GA Medicaid Fee Schedule,56.02,Pays at 80.03% of Total Billed charges,28.35,Pays at 102% of Medicare OPPS Rate,63,Pays at 90% of Total Billed charges,34.97,Pays at 100% of GA Medicaid Fee Schedule,27.8,Pays at 100% of Medicare OPPS Rate,34.97,Pays at 100% of GA Medicaid Fee Schedule,61.6,Pays at 88% of Total Billed charges,36.02,Pays at 103% of GA Medicaid Fee Schedule,27.8,63,42.00
Outpatient Medical Services,LAB,82523,"N-TELEPEPTIDE, URINE  (MAYO)",300,50.75,43.14,Pays at 85% of Billed charges for outpatient setting,23.5,Pays at 100% of GA Medicaid Fee Schedule,40.62,Pays at 80.03% of Total Billed charges,19.05,Pays at 102% of Medicare OPPS Rate,45.68,Pays at 90% of Total Billed charges,23.5,Pays at 100% of GA Medicaid Fee Schedule,18.68,Pays at 100% of Medicare OPPS Rate,23.5,Pays at 100% of GA Medicaid Fee Schedule,44.66,Pays at 88% of Total Billed charges,24.21,Pays at 103% of GA Medicaid Fee Schedule,18.68,45.68,30.45
Outpatient Medical Services,LAB,82523,BETA-CTx  (MAYO),300,70.25,59.71,Pays at 85% of Billed charges for outpatient setting,23.5,Pays at 100% of GA Medicaid Fee Schedule,56.22,Pays at 80.03% of Total Billed charges,19.05,Pays at 102% of Medicare OPPS Rate,63.23,Pays at 90% of Total Billed charges,23.5,Pays at 100% of GA Medicaid Fee Schedule,18.68,Pays at 100% of Medicare OPPS Rate,23.5,Pays at 100% of GA Medicaid Fee Schedule,61.82,Pays at 88% of Total Billed charges,24.21,Pays at 103% of GA Medicaid Fee Schedule,18.68,63.23,42.15
Outpatient Medical Services,LAB,82523,N-TELEPEPTIDE SERUM  (MAYO),300,224.5,190.83,Pays at 85% of Billed charges for outpatient setting,23.5,Pays at 100% of GA Medicaid Fee Schedule,179.67,Pays at 80.03% of Total Billed charges,19.05,Pays at 102% of Medicare OPPS Rate,202.05,Pays at 90% of Total Billed charges,23.5,Pays at 100% of GA Medicaid Fee Schedule,18.68,Pays at 100% of Medicare OPPS Rate,23.5,Pays at 100% of GA Medicaid Fee Schedule,197.56,Pays at 88% of Total Billed charges,24.21,Pays at 103% of GA Medicaid Fee Schedule,18.68,202.05,134.70
Outpatient Medical Services,LAB,82525,"COPPER, SERUM  (MAYO)",300,39.25,33.36,Pays at 85% of Billed charges for outpatient setting,15.61,Pays at 100% of GA Medicaid Fee Schedule,31.41,Pays at 80.03% of Total Billed charges,12.65,Pays at 102% of Medicare OPPS Rate,35.33,Pays at 90% of Total Billed charges,15.61,Pays at 100% of GA Medicaid Fee Schedule,12.41,Pays at 100% of Medicare OPPS Rate,15.61,Pays at 100% of GA Medicaid Fee Schedule,34.54,Pays at 88% of Total Billed charges,16.08,Pays at 103% of GA Medicaid Fee Schedule,12.41,35.33,23.55
Outpatient Medical Services,LAB,82525,"COPPER, URINE 24 HOUR (MAYO)",300,92.79,78.87,Pays at 85% of Billed charges for outpatient setting,15.61,Pays at 100% of GA Medicaid Fee Schedule,74.26,Pays at 80.03% of Total Billed charges,12.65,Pays at 102% of Medicare OPPS Rate,83.51,Pays at 90% of Total Billed charges,15.61,Pays at 100% of GA Medicaid Fee Schedule,12.41,Pays at 100% of Medicare OPPS Rate,15.61,Pays at 100% of GA Medicaid Fee Schedule,81.66,Pays at 88% of Total Billed charges,16.08,Pays at 103% of GA Medicaid Fee Schedule,12.41,83.51,55.67
Outpatient Medical Services,LAB,82530,"FREE CORTISOL, 24-HR URINE  (MAYO)",300,44.25,37.61,Pays at 85% of Billed charges for outpatient setting,21.02,Pays at 100% of GA Medicaid Fee Schedule,35.41,Pays at 80.03% of Total Billed charges,17.04,Pays at 102% of Medicare OPPS Rate,39.83,Pays at 90% of Total Billed charges,21.02,Pays at 100% of GA Medicaid Fee Schedule,16.71,Pays at 100% of Medicare OPPS Rate,21.02,Pays at 100% of GA Medicaid Fee Schedule,38.94,Pays at 88% of Total Billed charges,21.65,Pays at 103% of GA Medicaid Fee Schedule,16.71,39.83,26.55
Outpatient Medical Services,LAB,82530,"CORTISOL, URINE 24 HR (MAYO)",300,53.75,45.69,Pays at 85% of Billed charges for outpatient setting,21.02,Pays at 100% of GA Medicaid Fee Schedule,43.02,Pays at 80.03% of Total Billed charges,17.04,Pays at 102% of Medicare OPPS Rate,48.38,Pays at 90% of Total Billed charges,21.02,Pays at 100% of GA Medicaid Fee Schedule,16.71,Pays at 100% of Medicare OPPS Rate,21.02,Pays at 100% of GA Medicaid Fee Schedule,47.3,Pays at 88% of Total Billed charges,21.65,Pays at 103% of GA Medicaid Fee Schedule,16.71,48.38,32.25
Outpatient Medical Services,LAB,82530,"FREE CORTISOL, URINE  (MAYO)",300,83.75,71.19,Pays at 85% of Billed charges for outpatient setting,21.02,Pays at 100% of GA Medicaid Fee Schedule,67.03,Pays at 80.03% of Total Billed charges,17.04,Pays at 102% of Medicare OPPS Rate,75.38,Pays at 90% of Total Billed charges,21.02,Pays at 100% of GA Medicaid Fee Schedule,16.71,Pays at 100% of Medicare OPPS Rate,21.02,Pays at 100% of GA Medicaid Fee Schedule,73.7,Pays at 88% of Total Billed charges,21.65,Pays at 103% of GA Medicaid Fee Schedule,16.71,75.38,50.25
Outpatient Medical Services,LAB,82530,"FREE CORTISOL, SERUM  (MAYO)",300,111,94.35,Pays at 85% of Billed charges for outpatient setting,21.02,Pays at 100% of GA Medicaid Fee Schedule,88.83,Pays at 80.03% of Total Billed charges,17.04,Pays at 102% of Medicare OPPS Rate,99.9,Pays at 90% of Total Billed charges,21.02,Pays at 100% of GA Medicaid Fee Schedule,16.71,Pays at 100% of Medicare OPPS Rate,21.02,Pays at 100% of GA Medicaid Fee Schedule,97.68,Pays at 88% of Total Billed charges,21.65,Pays at 103% of GA Medicaid Fee Schedule,16.71,99.9,66.60
Outpatient Medical Services,LAB,82533,CORTISONE  (MAYO),300,83.75,71.19,Pays at 85% of Billed charges for outpatient setting,20.5,Pays at 100% of GA Medicaid Fee Schedule,67.03,Pays at 80.03% of Total Billed charges,16.62,Pays at 102% of Medicare OPPS Rate,75.38,Pays at 90% of Total Billed charges,20.5,Pays at 100% of GA Medicaid Fee Schedule,16.3,Pays at 100% of Medicare OPPS Rate,20.5,Pays at 100% of GA Medicaid Fee Schedule,73.7,Pays at 88% of Total Billed charges,21.12,Pays at 103% of GA Medicaid Fee Schedule,16.3,75.38,50.25
Outpatient Medical Services,LAB,82533,"CORTISOL, SERUM (MAYO)",300,118.59,100.8,Pays at 85% of Billed charges for outpatient setting,20.5,Pays at 100% of GA Medicaid Fee Schedule,94.91,Pays at 80.03% of Total Billed charges,16.62,Pays at 102% of Medicare OPPS Rate,106.73,Pays at 90% of Total Billed charges,20.5,Pays at 100% of GA Medicaid Fee Schedule,16.3,Pays at 100% of Medicare OPPS Rate,20.5,Pays at 100% of GA Medicaid Fee Schedule,104.36,Pays at 88% of Total Billed charges,21.12,Pays at 103% of GA Medicaid Fee Schedule,16.3,106.73,71.15
Outpatient Medical Services,LAB,82533,CORTISOL SALIVA (MAYO),300,127.83,108.66,Pays at 85% of Billed charges for outpatient setting,20.5,Pays at 100% of GA Medicaid Fee Schedule,102.3,Pays at 80.03% of Total Billed charges,16.62,Pays at 102% of Medicare OPPS Rate,115.05,Pays at 90% of Total Billed charges,20.5,Pays at 100% of GA Medicaid Fee Schedule,16.3,Pays at 100% of Medicare OPPS Rate,20.5,Pays at 100% of GA Medicaid Fee Schedule,112.49,Pays at 88% of Total Billed charges,21.12,Pays at 103% of GA Medicaid Fee Schedule,16.3,115.05,76.70
Outpatient Medical Services,LAB,82542,"PROPOXYPHENE LEVEL, DARVON  (MAYO)",300,60.5,51.43,Pays at 85% of Billed charges for outpatient setting,7.55,Pays at 100% of GA Medicaid Fee Schedule,48.42,Pays at 80.03% of Total Billed charges,24.57,Pays at 102% of Medicare OPPS Rate,54.45,Pays at 90% of Total Billed charges,7.55,Pays at 100% of GA Medicaid Fee Schedule,24.09,Pays at 100% of Medicare OPPS Rate,7.55,Pays at 100% of GA Medicaid Fee Schedule,53.24,Pays at 88% of Total Billed charges,7.78,Pays at 103% of GA Medicaid Fee Schedule,7.55,54.45,36.30
Outpatient Medical Services,LAB,82542,SULFONYLUREAS   (MAYO),300,144.75,123.04,Pays at 85% of Billed charges for outpatient setting,7.55,Pays at 100% of GA Medicaid Fee Schedule,115.84,Pays at 80.03% of Total Billed charges,24.57,Pays at 102% of Medicare OPPS Rate,130.28,Pays at 90% of Total Billed charges,7.55,Pays at 100% of GA Medicaid Fee Schedule,24.09,Pays at 100% of Medicare OPPS Rate,7.55,Pays at 100% of GA Medicaid Fee Schedule,127.38,Pays at 88% of Total Billed charges,7.78,Pays at 103% of GA Medicaid Fee Schedule,7.55,130.28,86.85
Outpatient Medical Services,LAB,82542,DEXAMETHASONE  (MAYO),300,167.75,142.59,Pays at 85% of Billed charges for outpatient setting,7.55,Pays at 100% of GA Medicaid Fee Schedule,134.25,Pays at 80.03% of Total Billed charges,24.57,Pays at 102% of Medicare OPPS Rate,150.98,Pays at 90% of Total Billed charges,7.55,Pays at 100% of GA Medicaid Fee Schedule,24.09,Pays at 100% of Medicare OPPS Rate,7.55,Pays at 100% of GA Medicaid Fee Schedule,147.62,Pays at 88% of Total Billed charges,7.78,Pays at 103% of GA Medicaid Fee Schedule,7.55,150.98,100.65
Outpatient Medical Services,LAB,82542,"THIOPURINE METABOLITE, 6-TGN  (MAYO)",300,208.25,177.01,Pays at 85% of Billed charges for outpatient setting,7.55,Pays at 100% of GA Medicaid Fee Schedule,166.66,Pays at 80.03% of Total Billed charges,24.57,Pays at 102% of Medicare OPPS Rate,187.43,Pays at 90% of Total Billed charges,7.55,Pays at 100% of GA Medicaid Fee Schedule,24.09,Pays at 100% of Medicare OPPS Rate,7.55,Pays at 100% of GA Medicaid Fee Schedule,183.26,Pays at 88% of Total Billed charges,7.78,Pays at 103% of GA Medicaid Fee Schedule,7.55,187.43,124.95
Outpatient Medical Services,LAB,82542,"THIOPURINE METABOLITE, 6-MMPN  (MAYO)",300,208.25,177.01,Pays at 85% of Billed charges for outpatient setting,7.55,Pays at 100% of GA Medicaid Fee Schedule,166.66,Pays at 80.03% of Total Billed charges,24.57,Pays at 102% of Medicare OPPS Rate,187.43,Pays at 90% of Total Billed charges,7.55,Pays at 100% of GA Medicaid Fee Schedule,24.09,Pays at 100% of Medicare OPPS Rate,7.55,Pays at 100% of GA Medicaid Fee Schedule,183.26,Pays at 88% of Total Billed charges,7.78,Pays at 103% of GA Medicaid Fee Schedule,7.55,187.43,124.95
Outpatient Medical Services,LAB,82542,"CoENZYME Q10, Co10  (MAYO)",300,247.75,210.59,Pays at 85% of Billed charges for outpatient setting,7.55,Pays at 100% of GA Medicaid Fee Schedule,198.27,Pays at 80.03% of Total Billed charges,24.57,Pays at 102% of Medicare OPPS Rate,222.98,Pays at 90% of Total Billed charges,7.55,Pays at 100% of GA Medicaid Fee Schedule,24.09,Pays at 100% of Medicare OPPS Rate,7.55,Pays at 100% of GA Medicaid Fee Schedule,218.02,Pays at 88% of Total Billed charges,7.78,Pays at 103% of GA Medicaid Fee Schedule,7.55,222.98,148.65
Outpatient Medical Services,LAB,82542,BILE ACIDS-FRACTIONATED & TOTAL ( MAYO),300,262.5,223.13,Pays at 85% of Billed charges for outpatient setting,7.55,Pays at 100% of GA Medicaid Fee Schedule,210.08,Pays at 80.03% of Total Billed charges,24.57,Pays at 102% of Medicare OPPS Rate,236.25,Pays at 90% of Total Billed charges,7.55,Pays at 100% of GA Medicaid Fee Schedule,24.09,Pays at 100% of Medicare OPPS Rate,7.55,Pays at 100% of GA Medicaid Fee Schedule,231,Pays at 88% of Total Billed charges,7.78,Pays at 103% of GA Medicaid Fee Schedule,7.55,236.25,157.50
Outpatient Medical Services,LAB,82542,PYRIDOXAL 5-PHOSPHATE (CSF)  (MAYO),300,284,241.4,Pays at 85% of Billed charges for outpatient setting,7.55,Pays at 100% of GA Medicaid Fee Schedule,227.29,Pays at 80.03% of Total Billed charges,24.57,Pays at 102% of Medicare OPPS Rate,255.6,Pays at 90% of Total Billed charges,7.55,Pays at 100% of GA Medicaid Fee Schedule,24.09,Pays at 100% of Medicare OPPS Rate,7.55,Pays at 100% of GA Medicaid Fee Schedule,249.92,Pays at 88% of Total Billed charges,7.78,Pays at 103% of GA Medicaid Fee Schedule,7.55,255.6,170.40
Outpatient Medical Services,LAB,82542,CLONIDINE  (MAYO),300,433.5,368.48,Pays at 85% of Billed charges for outpatient setting,7.55,Pays at 100% of GA Medicaid Fee Schedule,346.93,Pays at 80.03% of Total Billed charges,24.57,Pays at 102% of Medicare OPPS Rate,390.15,Pays at 90% of Total Billed charges,7.55,Pays at 100% of GA Medicaid Fee Schedule,24.09,Pays at 100% of Medicare OPPS Rate,7.55,Pays at 100% of GA Medicaid Fee Schedule,381.48,Pays at 88% of Total Billed charges,7.78,Pays at 103% of GA Medicaid Fee Schedule,7.55,390.15,260.10
Outpatient Medical Services,LAB,82542,FATTY ACID COMPREHENSIVE  (MAYO),300,599.25,509.36,Pays at 85% of Billed charges for outpatient setting,7.55,Pays at 100% of GA Medicaid Fee Schedule,479.58,Pays at 80.03% of Total Billed charges,24.57,Pays at 102% of Medicare OPPS Rate,539.33,Pays at 90% of Total Billed charges,7.55,Pays at 100% of GA Medicaid Fee Schedule,24.09,Pays at 100% of Medicare OPPS Rate,7.55,Pays at 100% of GA Medicaid Fee Schedule,527.34,Pays at 88% of Total Billed charges,7.78,Pays at 103% of GA Medicaid Fee Schedule,7.55,539.33,359.55
Outpatient Medical Services,LAB,82550,CPK,300,24.6,20.91,Pays at 85% of Billed charges for outpatient setting,6.35,Pays at 100% of GA Medicaid Fee Schedule,19.69,Pays at 80.03% of Total Billed charges,6.64,Pays at 102% of Medicare OPPS Rate,22.14,Pays at 90% of Total Billed charges,6.35,Pays at 100% of GA Medicaid Fee Schedule,6.51,Pays at 100% of Medicare OPPS Rate,6.35,Pays at 100% of GA Medicaid Fee Schedule,21.65,Pays at 88% of Total Billed charges,6.54,Pays at 103% of GA Medicaid Fee Schedule,6.35,22.14,14.76
Outpatient Medical Services,LAB,82552,zCK ISOENZYME SERUM  (MAYO),300,40,34,Pays at 85% of Billed charges for outpatient setting,16.84,Pays at 100% of GA Medicaid Fee Schedule,32.01,Pays at 80.03% of Total Billed charges,13.65,Pays at 102% of Medicare OPPS Rate,36,Pays at 90% of Total Billed charges,16.84,Pays at 100% of GA Medicaid Fee Schedule,13.39,Pays at 100% of Medicare OPPS Rate,16.84,Pays at 100% of GA Medicaid Fee Schedule,35.2,Pays at 88% of Total Billed charges,17.35,Pays at 103% of GA Medicaid Fee Schedule,13.39,36,24.00
Outpatient Medical Services,LAB,82552,CPK ISOENZYMES  (MAYO),300,60.75,51.64,Pays at 85% of Billed charges for outpatient setting,16.84,Pays at 100% of GA Medicaid Fee Schedule,48.62,Pays at 80.03% of Total Billed charges,13.65,Pays at 102% of Medicare OPPS Rate,54.68,Pays at 90% of Total Billed charges,16.84,Pays at 100% of GA Medicaid Fee Schedule,13.39,Pays at 100% of Medicare OPPS Rate,16.84,Pays at 100% of GA Medicaid Fee Schedule,53.46,Pays at 88% of Total Billed charges,17.35,Pays at 103% of GA Medicaid Fee Schedule,13.39,54.68,36.45
Outpatient Medical Services,LAB,82553,Blood test to detect heart enzymes,300,24.6,20.91,Pays at 85% of Billed charges for outpatient setting,14.52,Pays at 100% of GA Medicaid Fee Schedule,19.69,Pays at 80.03% of Total Billed charges,11.78,Pays at 102% of Medicare OPPS Rate,22.14,Pays at 90% of Total Billed charges,14.52,Pays at 100% of GA Medicaid Fee Schedule,11.55,Pays at 100% of Medicare OPPS Rate,14.52,Pays at 100% of GA Medicaid Fee Schedule,21.65,Pays at 88% of Total Billed charges,14.96,Pays at 103% of GA Medicaid Fee Schedule,11.55,22.14,14.76
Outpatient Medical Services,LAB,82565,"CREATININE, SERUM",300,24.6,20.91,Pays at 85% of Billed charges for outpatient setting,6.35,Pays at 100% of GA Medicaid Fee Schedule,19.69,Pays at 80.03% of Total Billed charges,5.22,Pays at 102% of Medicare OPPS Rate,22.14,Pays at 90% of Total Billed charges,6.35,Pays at 100% of GA Medicaid Fee Schedule,5.12,Pays at 100% of Medicare OPPS Rate,6.35,Pays at 100% of GA Medicaid Fee Schedule,21.65,Pays at 88% of Total Billed charges,6.54,Pays at 103% of GA Medicaid Fee Schedule,5.12,22.14,14.76
Outpatient Medical Services,LAB,82565,DAILY - CREATININE,300,30,25.5,Pays at 85% of Billed charges for outpatient setting,6.35,Pays at 100% of GA Medicaid Fee Schedule,24.01,Pays at 80.03% of Total Billed charges,5.22,Pays at 102% of Medicare OPPS Rate,27,Pays at 90% of Total Billed charges,6.35,Pays at 100% of GA Medicaid Fee Schedule,5.12,Pays at 100% of Medicare OPPS Rate,6.35,Pays at 100% of GA Medicaid Fee Schedule,26.4,Pays at 88% of Total Billed charges,6.54,Pays at 103% of GA Medicaid Fee Schedule,5.12,27,18.00
Outpatient Medical Services,LAB,82570,Test to measure creatinine in the urine,300,24.6,20.91,Pays at 85% of Billed charges for outpatient setting,6.51,Pays at 100% of GA Medicaid Fee Schedule,19.69,Pays at 80.03% of Total Billed charges,5.28,Pays at 102% of Medicare OPPS Rate,22.14,Pays at 90% of Total Billed charges,6.51,Pays at 100% of GA Medicaid Fee Schedule,5.18,Pays at 100% of Medicare OPPS Rate,6.51,Pays at 100% of GA Medicaid Fee Schedule,21.65,Pays at 88% of Total Billed charges,6.71,Pays at 103% of GA Medicaid Fee Schedule,5.18,22.14,14.76
Outpatient Medical Services,LAB,82570,Test to measure creatinine in the urine,300,27.25,23.16,Pays at 85% of Billed charges for outpatient setting,6.51,Pays at 100% of GA Medicaid Fee Schedule,21.81,Pays at 80.03% of Total Billed charges,5.28,Pays at 102% of Medicare OPPS Rate,24.53,Pays at 90% of Total Billed charges,6.51,Pays at 100% of GA Medicaid Fee Schedule,5.18,Pays at 100% of Medicare OPPS Rate,6.51,Pays at 100% of GA Medicaid Fee Schedule,23.98,Pays at 88% of Total Billed charges,6.71,Pays at 103% of GA Medicaid Fee Schedule,5.18,24.53,16.35
Outpatient Medical Services,LAB,82570,Test to measure creatinine in the urine,300,28,23.8,Pays at 85% of Billed charges for outpatient setting,6.51,Pays at 100% of GA Medicaid Fee Schedule,22.41,Pays at 80.03% of Total Billed charges,5.28,Pays at 102% of Medicare OPPS Rate,25.2,Pays at 90% of Total Billed charges,6.51,Pays at 100% of GA Medicaid Fee Schedule,5.18,Pays at 100% of Medicare OPPS Rate,6.51,Pays at 100% of GA Medicaid Fee Schedule,24.64,Pays at 88% of Total Billed charges,6.71,Pays at 103% of GA Medicaid Fee Schedule,5.18,25.2,16.80
Outpatient Medical Services,LAB,82570,Test to measure creatinine in the urine,300,40.25,34.21,Pays at 85% of Billed charges for outpatient setting,6.51,Pays at 100% of GA Medicaid Fee Schedule,32.21,Pays at 80.03% of Total Billed charges,5.28,Pays at 102% of Medicare OPPS Rate,36.23,Pays at 90% of Total Billed charges,6.51,Pays at 100% of GA Medicaid Fee Schedule,5.18,Pays at 100% of Medicare OPPS Rate,6.51,Pays at 100% of GA Medicaid Fee Schedule,35.42,Pays at 88% of Total Billed charges,6.71,Pays at 103% of GA Medicaid Fee Schedule,5.18,36.23,24.15
Outpatient Medical Services,LAB,82575,CREATININE CLEARANCE,300,65.25,55.46,Pays at 85% of Billed charges for outpatient setting,11.88,Pays at 100% of GA Medicaid Fee Schedule,52.22,Pays at 80.03% of Total Billed charges,9.64,Pays at 102% of Medicare OPPS Rate,58.73,Pays at 90% of Total Billed charges,11.88,Pays at 100% of GA Medicaid Fee Schedule,9.46,Pays at 100% of Medicare OPPS Rate,11.88,Pays at 100% of GA Medicaid Fee Schedule,57.42,Pays at 88% of Total Billed charges,12.24,Pays at 103% of GA Medicaid Fee Schedule,9.46,58.73,39.15
Outpatient Medical Services,LAB,82595,CRYOGLOBULIN  (MAYO),300,99.75,84.79,Pays at 85% of Billed charges for outpatient setting,8.14,Pays at 100% of GA Medicaid Fee Schedule,79.83,Pays at 80.03% of Total Billed charges,6.59,Pays at 102% of Medicare OPPS Rate,89.78,Pays at 90% of Total Billed charges,8.14,Pays at 100% of GA Medicaid Fee Schedule,6.47,Pays at 100% of Medicare OPPS Rate,8.14,Pays at 100% of GA Medicaid Fee Schedule,87.78,Pays at 88% of Total Billed charges,8.38,Pays at 103% of GA Medicaid Fee Schedule,6.47,89.78,59.85
Outpatient Medical Services,LAB,82600,CYANIDE (MAYO),300,64.5,54.83,Pays at 85% of Billed charges for outpatient setting,24.4,Pays at 100% of GA Medicaid Fee Schedule,51.62,Pays at 80.03% of Total Billed charges,19.78,Pays at 102% of Medicare OPPS Rate,58.05,Pays at 90% of Total Billed charges,24.4,Pays at 100% of GA Medicaid Fee Schedule,19.39,Pays at 100% of Medicare OPPS Rate,24.4,Pays at 100% of GA Medicaid Fee Schedule,56.76,Pays at 88% of Total Billed charges,25.13,Pays at 103% of GA Medicaid Fee Schedule,19.39,58.05,38.70
Outpatient Medical Services,LAB,82600,CYANIDE BLOOD  (MAYO),300,87,73.95,Pays at 85% of Billed charges for outpatient setting,24.4,Pays at 100% of GA Medicaid Fee Schedule,69.63,Pays at 80.03% of Total Billed charges,19.78,Pays at 102% of Medicare OPPS Rate,78.3,Pays at 90% of Total Billed charges,24.4,Pays at 100% of GA Medicaid Fee Schedule,19.39,Pays at 100% of Medicare OPPS Rate,24.4,Pays at 100% of GA Medicaid Fee Schedule,76.56,Pays at 88% of Total Billed charges,25.13,Pays at 103% of GA Medicaid Fee Schedule,19.39,78.3,52.20
Outpatient Medical Services,LAB,82600,"NBT, NITROBLUE TETRAZOLIUM  (MAYO)",300,272.5,231.63,Pays at 85% of Billed charges for outpatient setting,24.4,Pays at 100% of GA Medicaid Fee Schedule,218.08,Pays at 80.03% of Total Billed charges,19.78,Pays at 102% of Medicare OPPS Rate,245.25,Pays at 90% of Total Billed charges,24.4,Pays at 100% of GA Medicaid Fee Schedule,19.39,Pays at 100% of Medicare OPPS Rate,24.4,Pays at 100% of GA Medicaid Fee Schedule,239.8,Pays at 88% of Total Billed charges,25.13,Pays at 103% of GA Medicaid Fee Schedule,19.39,245.25,163.50
Outpatient Medical Services,LAB,82607,Blood test to measure B-12,300,47.13,40.06,Pays at 85% of Billed charges for outpatient setting,18.95,Pays at 100% of GA Medicaid Fee Schedule,37.72,Pays at 80.03% of Total Billed charges,15.38,Pays at 102% of Medicare OPPS Rate,42.42,Pays at 90% of Total Billed charges,18.95,Pays at 100% of GA Medicaid Fee Schedule,15.08,Pays at 100% of Medicare OPPS Rate,18.95,Pays at 100% of GA Medicaid Fee Schedule,41.47,Pays at 88% of Total Billed charges,19.52,Pays at 103% of GA Medicaid Fee Schedule,15.08,42.42,28.28
Outpatient Medical Services,LAB,82607,Blood test to measure B-12,300,114.7,97.5,Pays at 85% of Billed charges for outpatient setting,18.95,Pays at 100% of GA Medicaid Fee Schedule,91.79,Pays at 80.03% of Total Billed charges,15.38,Pays at 102% of Medicare OPPS Rate,103.23,Pays at 90% of Total Billed charges,18.95,Pays at 100% of GA Medicaid Fee Schedule,15.08,Pays at 100% of Medicare OPPS Rate,18.95,Pays at 100% of GA Medicaid Fee Schedule,100.94,Pays at 88% of Total Billed charges,19.52,Pays at 103% of GA Medicaid Fee Schedule,15.08,103.23,68.82
Outpatient Medical Services,LAB,82607,Blood test to measure B-12,300,119.17,101.29,Pays at 85% of Billed charges for outpatient setting,18.95,Pays at 100% of GA Medicaid Fee Schedule,95.37,Pays at 80.03% of Total Billed charges,15.38,Pays at 102% of Medicare OPPS Rate,107.25,Pays at 90% of Total Billed charges,18.95,Pays at 100% of GA Medicaid Fee Schedule,15.08,Pays at 100% of Medicare OPPS Rate,18.95,Pays at 100% of GA Medicaid Fee Schedule,104.87,Pays at 88% of Total Billed charges,19.52,Pays at 103% of GA Medicaid Fee Schedule,15.08,107.25,71.50
Outpatient Medical Services,LAB,82607,Blood test to measure B-12,300,143.75,122.19,Pays at 85% of Billed charges for outpatient setting,18.95,Pays at 100% of GA Medicaid Fee Schedule,115.04,Pays at 80.03% of Total Billed charges,15.38,Pays at 102% of Medicare OPPS Rate,129.38,Pays at 90% of Total Billed charges,18.95,Pays at 100% of GA Medicaid Fee Schedule,15.08,Pays at 100% of Medicare OPPS Rate,18.95,Pays at 100% of GA Medicaid Fee Schedule,126.5,Pays at 88% of Total Billed charges,19.52,Pays at 103% of GA Medicaid Fee Schedule,15.08,129.38,86.25
Outpatient Medical Services,LAB,82615,ANTI-DNase B TITER  (MAYO),300,90.09,76.58,Pays at 85% of Billed charges for outpatient setting,10.27,Pays at 100% of GA Medicaid Fee Schedule,72.1,Pays at 80.03% of Total Billed charges,9.74,Pays at 102% of Medicare OPPS Rate,81.08,Pays at 90% of Total Billed charges,10.27,Pays at 100% of GA Medicaid Fee Schedule,9.55,Pays at 100% of Medicare OPPS Rate,10.27,Pays at 100% of GA Medicaid Fee Schedule,79.28,Pays at 88% of Total Billed charges,10.58,Pays at 103% of GA Medicaid Fee Schedule,9.55,81.08,54.05
Outpatient Medical Services,LAB,82626,DHEA  (MAYO),300,150.99,128.34,Pays at 85% of Billed charges for outpatient setting,31.78,Pays at 100% of GA Medicaid Fee Schedule,120.84,Pays at 80.03% of Total Billed charges,25.77,Pays at 102% of Medicare OPPS Rate,135.89,Pays at 90% of Total Billed charges,31.78,Pays at 100% of GA Medicaid Fee Schedule,25.27,Pays at 100% of Medicare OPPS Rate,31.78,Pays at 100% of GA Medicaid Fee Schedule,132.87,Pays at 88% of Total Billed charges,32.73,Pays at 103% of GA Medicaid Fee Schedule,25.27,135.89,90.59
Outpatient Medical Services,LAB,82627,Blood test to measure an enzyme in the blood,300,71.5,60.78,Pays at 85% of Billed charges for outpatient setting,27.96,Pays at 100% of GA Medicaid Fee Schedule,57.22,Pays at 80.03% of Total Billed charges,22.67,Pays at 102% of Medicare OPPS Rate,64.35,Pays at 90% of Total Billed charges,27.96,Pays at 100% of GA Medicaid Fee Schedule,22.23,Pays at 100% of Medicare OPPS Rate,27.96,Pays at 100% of GA Medicaid Fee Schedule,62.92,Pays at 88% of Total Billed charges,28.8,Pays at 103% of GA Medicaid Fee Schedule,22.23,64.35,42.90
Outpatient Medical Services,LAB,82634,11-DEOXYCORTISOL  (MAYO),300,149.75,127.29,Pays at 85% of Billed charges for outpatient setting,36.81,Pays at 100% of GA Medicaid Fee Schedule,119.84,Pays at 80.03% of Total Billed charges,29.86,Pays at 102% of Medicare OPPS Rate,134.78,Pays at 90% of Total Billed charges,36.81,Pays at 100% of GA Medicaid Fee Schedule,29.28,Pays at 100% of Medicare OPPS Rate,36.81,Pays at 100% of GA Medicaid Fee Schedule,131.78,Pays at 88% of Total Billed charges,37.91,Pays at 103% of GA Medicaid Fee Schedule,29.28,134.78,89.85
Outpatient Medical Services,LAB,82652,VITAMIN D 1-25 D-OH  (MAYO),300,123.25,104.76,Pays at 85% of Billed charges for outpatient setting,48.4,Pays at 100% of GA Medicaid Fee Schedule,98.64,Pays at 80.03% of Total Billed charges,39.27,Pays at 102% of Medicare OPPS Rate,110.93,Pays at 90% of Total Billed charges,48.4,Pays at 100% of GA Medicaid Fee Schedule,38.5,Pays at 100% of Medicare OPPS Rate,48.4,Pays at 100% of GA Medicaid Fee Schedule,108.46,Pays at 88% of Total Billed charges,49.85,Pays at 103% of GA Medicaid Fee Schedule,38.5,110.93,73.95
Outpatient Medical Services,LAB,82657,NEUTROPHIL OXIDATIVE BURST  (MAYO),300,192.75,163.84,Pays at 85% of Billed charges for outpatient setting,7.55,Pays at 100% of GA Medicaid Fee Schedule,154.26,Pays at 80.03% of Total Billed charges,22.61,Pays at 102% of Medicare OPPS Rate,173.48,Pays at 90% of Total Billed charges,7.55,Pays at 100% of GA Medicaid Fee Schedule,22.17,Pays at 100% of Medicare OPPS Rate,7.55,Pays at 100% of GA Medicaid Fee Schedule,169.62,Pays at 88% of Total Billed charges,7.78,Pays at 103% of GA Medicaid Fee Schedule,7.55,173.48,115.65
Outpatient Medical Services,LAB,82657,"ALPHA-GALACTOSIDASE, SERUM  (MAYO)",300,206.5,175.53,Pays at 85% of Billed charges for outpatient setting,7.55,Pays at 100% of GA Medicaid Fee Schedule,165.26,Pays at 80.03% of Total Billed charges,22.61,Pays at 102% of Medicare OPPS Rate,185.85,Pays at 90% of Total Billed charges,7.55,Pays at 100% of GA Medicaid Fee Schedule,22.17,Pays at 100% of Medicare OPPS Rate,7.55,Pays at 100% of GA Medicaid Fee Schedule,181.72,Pays at 88% of Total Billed charges,7.78,Pays at 103% of GA Medicaid Fee Schedule,7.55,185.85,123.90
Outpatient Medical Services,LAB,82657,"HEXOKINASE, B  (MAYO)",300,228,193.8,Pays at 85% of Billed charges for outpatient setting,7.55,Pays at 100% of GA Medicaid Fee Schedule,182.47,Pays at 80.03% of Total Billed charges,22.61,Pays at 102% of Medicare OPPS Rate,205.2,Pays at 90% of Total Billed charges,7.55,Pays at 100% of GA Medicaid Fee Schedule,22.17,Pays at 100% of Medicare OPPS Rate,7.55,Pays at 100% of GA Medicaid Fee Schedule,200.64,Pays at 88% of Total Billed charges,7.78,Pays at 103% of GA Medicaid Fee Schedule,7.55,205.2,136.80
Outpatient Medical Services,LAB,82657,THIOPURINE   (MAYO),300,468.25,398.01,Pays at 85% of Billed charges for outpatient setting,7.55,Pays at 100% of GA Medicaid Fee Schedule,374.74,Pays at 80.03% of Total Billed charges,22.61,Pays at 102% of Medicare OPPS Rate,421.43,Pays at 90% of Total Billed charges,7.55,Pays at 100% of GA Medicaid Fee Schedule,22.17,Pays at 100% of Medicare OPPS Rate,7.55,Pays at 100% of GA Medicaid Fee Schedule,412.06,Pays at 88% of Total Billed charges,7.78,Pays at 103% of GA Medicaid Fee Schedule,7.55,421.43,280.95
Outpatient Medical Services,LAB,82664,"ELECTROPHORETIC TECH, NES  (MAYO)",300,87.5,74.38,Pays at 85% of Billed charges for outpatient setting,43.2,Pays at 100% of GA Medicaid Fee Schedule,70.03,Pays at 80.03% of Total Billed charges,62.73,Pays at 102% of Medicare OPPS Rate,78.75,Pays at 90% of Total Billed charges,43.2,Pays at 100% of GA Medicaid Fee Schedule,61.5,Pays at 100% of Medicare OPPS Rate,43.2,Pays at 100% of GA Medicaid Fee Schedule,77,Pays at 88% of Total Billed charges,44.5,Pays at 103% of GA Medicaid Fee Schedule,43.2,78.75,52.50
Outpatient Medical Services,LAB,82668,ERYTHROPOIETIN  (MAYO),300,60,51,Pays at 85% of Billed charges for outpatient setting,23.63,Pays at 100% of GA Medicaid Fee Schedule,48.02,Pays at 80.03% of Total Billed charges,19.16,Pays at 102% of Medicare OPPS Rate,54,Pays at 90% of Total Billed charges,23.63,Pays at 100% of GA Medicaid Fee Schedule,18.79,Pays at 100% of Medicare OPPS Rate,23.63,Pays at 100% of GA Medicaid Fee Schedule,52.8,Pays at 88% of Total Billed charges,24.34,Pays at 103% of GA Medicaid Fee Schedule,18.79,54,36.00
Outpatient Medical Services,LAB,82670,Blood test to measure a type of estrogen in the blood,300,89,75.65,Pays at 85% of Billed charges for outpatient setting,35.14,Pays at 100% of GA Medicaid Fee Schedule,71.23,Pays at 80.03% of Total Billed charges,28.49,Pays at 102% of Medicare OPPS Rate,80.1,Pays at 90% of Total Billed charges,35.14,Pays at 100% of GA Medicaid Fee Schedule,27.94,Pays at 100% of Medicare OPPS Rate,35.14,Pays at 100% of GA Medicaid Fee Schedule,78.32,Pays at 88% of Total Billed charges,36.19,Pays at 103% of GA Medicaid Fee Schedule,27.94,80.1,53.40
Outpatient Medical Services,LAB,82670,Blood test to measure a type of estrogen in the blood,300,154,130.9,Pays at 85% of Billed charges for outpatient setting,35.14,Pays at 100% of GA Medicaid Fee Schedule,123.25,Pays at 80.03% of Total Billed charges,28.49,Pays at 102% of Medicare OPPS Rate,138.6,Pays at 90% of Total Billed charges,35.14,Pays at 100% of GA Medicaid Fee Schedule,27.94,Pays at 100% of Medicare OPPS Rate,35.14,Pays at 100% of GA Medicaid Fee Schedule,135.52,Pays at 88% of Total Billed charges,36.19,Pays at 103% of GA Medicaid Fee Schedule,27.94,138.6,92.40
Outpatient Medical Services,LAB,82672,"ESTROGENS, TOTAL  (MAYO)",300,69.25,58.86,Pays at 85% of Billed charges for outpatient setting,20.94,Pays at 100% of GA Medicaid Fee Schedule,55.42,Pays at 80.03% of Total Billed charges,22.13,Pays at 102% of Medicare OPPS Rate,62.33,Pays at 90% of Total Billed charges,20.94,Pays at 100% of GA Medicaid Fee Schedule,21.7,Pays at 100% of Medicare OPPS Rate,20.94,Pays at 100% of GA Medicaid Fee Schedule,60.94,Pays at 88% of Total Billed charges,21.57,Pays at 103% of GA Medicaid Fee Schedule,20.94,62.33,41.55
Outpatient Medical Services,LAB,82677,ESTRIOL  (MAYO),300,77.75,66.09,Pays at 85% of Billed charges for outpatient setting,30.41,Pays at 100% of GA Medicaid Fee Schedule,62.22,Pays at 80.03% of Total Billed charges,24.66,Pays at 102% of Medicare OPPS Rate,69.98,Pays at 90% of Total Billed charges,30.41,Pays at 100% of GA Medicaid Fee Schedule,24.18,Pays at 100% of Medicare OPPS Rate,30.41,Pays at 100% of GA Medicaid Fee Schedule,68.42,Pays at 88% of Total Billed charges,31.32,Pays at 103% of GA Medicaid Fee Schedule,24.18,69.98,46.65
Outpatient Medical Services,LAB,82679,ESTRONE  (MAYO),300,82.75,70.34,Pays at 85% of Billed charges for outpatient setting,31.39,Pays at 100% of GA Medicaid Fee Schedule,66.22,Pays at 80.03% of Total Billed charges,25.44,Pays at 102% of Medicare OPPS Rate,74.48,Pays at 90% of Total Billed charges,31.39,Pays at 100% of GA Medicaid Fee Schedule,24.95,Pays at 100% of Medicare OPPS Rate,31.39,Pays at 100% of GA Medicaid Fee Schedule,72.82,Pays at 88% of Total Billed charges,32.33,Pays at 103% of GA Medicaid Fee Schedule,24.95,74.48,49.65
Outpatient Medical Services,LAB,82710,"FECAL FAT, QT  (MAYO)",300,53.75,45.69,Pays at 85% of Billed charges for outpatient setting,21.12,Pays at 100% of GA Medicaid Fee Schedule,43.02,Pays at 80.03% of Total Billed charges,17.13,Pays at 102% of Medicare OPPS Rate,48.38,Pays at 90% of Total Billed charges,21.12,Pays at 100% of GA Medicaid Fee Schedule,16.8,Pays at 100% of Medicare OPPS Rate,21.12,Pays at 100% of GA Medicaid Fee Schedule,47.3,Pays at 88% of Total Billed charges,21.75,Pays at 103% of GA Medicaid Fee Schedule,16.8,48.38,32.25
Outpatient Medical Services,LAB,82728,Test to determine level of iron in the blood,300,53.51,45.48,Pays at 85% of Billed charges for outpatient setting,17.13,Pays at 100% of GA Medicaid Fee Schedule,42.82,Pays at 80.03% of Total Billed charges,13.9,Pays at 102% of Medicare OPPS Rate,48.16,Pays at 90% of Total Billed charges,17.13,Pays at 100% of GA Medicaid Fee Schedule,13.63,Pays at 100% of Medicare OPPS Rate,17.13,Pays at 100% of GA Medicaid Fee Schedule,47.09,Pays at 88% of Total Billed charges,17.64,Pays at 103% of GA Medicaid Fee Schedule,13.63,48.16,32.11
Outpatient Medical Services,LAB,82728,Test to determine level of iron in the blood,300,72,61.2,Pays at 85% of Billed charges for outpatient setting,17.13,Pays at 100% of GA Medicaid Fee Schedule,57.62,Pays at 80.03% of Total Billed charges,13.9,Pays at 102% of Medicare OPPS Rate,64.8,Pays at 90% of Total Billed charges,17.13,Pays at 100% of GA Medicaid Fee Schedule,13.63,Pays at 100% of Medicare OPPS Rate,17.13,Pays at 100% of GA Medicaid Fee Schedule,63.36,Pays at 88% of Total Billed charges,17.64,Pays at 103% of GA Medicaid Fee Schedule,13.63,64.8,43.20
Outpatient Medical Services,LAB,82731,FETAL FIBRONECTIN,300,339.5,288.58,Pays at 85% of Billed charges for outpatient setting,80.99,Pays at 100% of GA Medicaid Fee Schedule,271.7,Pays at 80.03% of Total Billed charges,65.69,Pays at 102% of Medicare OPPS Rate,305.55,Pays at 90% of Total Billed charges,80.99,Pays at 100% of GA Medicaid Fee Schedule,64.41,Pays at 100% of Medicare OPPS Rate,80.99,Pays at 100% of GA Medicaid Fee Schedule,298.76,Pays at 88% of Total Billed charges,83.42,Pays at 103% of GA Medicaid Fee Schedule,64.41,305.55,203.70
Outpatient Medical Services,LAB,82746,FOLATE(MAYO),300,111.8,95.03,Pays at 85% of Billed charges for outpatient setting,18.49,Pays at 100% of GA Medicaid Fee Schedule,89.47,Pays at 80.03% of Total Billed charges,14.99,Pays at 102% of Medicare OPPS Rate,100.62,Pays at 90% of Total Billed charges,18.49,Pays at 100% of GA Medicaid Fee Schedule,14.7,Pays at 100% of Medicare OPPS Rate,18.49,Pays at 100% of GA Medicaid Fee Schedule,98.38,Pays at 88% of Total Billed charges,19.04,Pays at 103% of GA Medicaid Fee Schedule,14.7,100.62,67.08
Outpatient Medical Services,LAB,82746,FOLATE (MAYO),300,119.17,101.29,Pays at 85% of Billed charges for outpatient setting,18.49,Pays at 100% of GA Medicaid Fee Schedule,95.37,Pays at 80.03% of Total Billed charges,14.99,Pays at 102% of Medicare OPPS Rate,107.25,Pays at 90% of Total Billed charges,18.49,Pays at 100% of GA Medicaid Fee Schedule,14.7,Pays at 100% of Medicare OPPS Rate,18.49,Pays at 100% of GA Medicaid Fee Schedule,104.87,Pays at 88% of Total Billed charges,19.04,Pays at 103% of GA Medicaid Fee Schedule,14.7,107.25,71.50
Outpatient Medical Services,LAB,82747,"....FOLATE, RBC  (MAYO)",300,135.25,114.96,Pays at 85% of Billed charges for outpatient setting,21.78,Pays at 100% of GA Medicaid Fee Schedule,108.24,Pays at 80.03% of Total Billed charges,18,Pays at 102% of Medicare OPPS Rate,121.73,Pays at 90% of Total Billed charges,21.78,Pays at 100% of GA Medicaid Fee Schedule,17.64,Pays at 100% of Medicare OPPS Rate,21.78,Pays at 100% of GA Medicaid Fee Schedule,119.02,Pays at 88% of Total Billed charges,22.43,Pays at 103% of GA Medicaid Fee Schedule,17.64,121.73,81.15
Outpatient Medical Services,LAB,82757,"FRUCTOSE, SEMEN  (MAYO)",300,105,89.25,Pays at 85% of Billed charges for outpatient setting,21.82,Pays at 100% of GA Medicaid Fee Schedule,84.03,Pays at 80.03% of Total Billed charges,17.68,Pays at 102% of Medicare OPPS Rate,94.5,Pays at 90% of Total Billed charges,21.82,Pays at 100% of GA Medicaid Fee Schedule,17.34,Pays at 100% of Medicare OPPS Rate,21.82,Pays at 100% of GA Medicaid Fee Schedule,92.4,Pays at 88% of Total Billed charges,22.47,Pays at 103% of GA Medicaid Fee Schedule,17.34,94.5,63.00
Outpatient Medical Services,LAB,82784,Test to determine levels of immunoglobulins in the blood,300,22.25,18.91,Pays at 85% of Billed charges for outpatient setting,11.69,Pays at 100% of GA Medicaid Fee Schedule,17.81,Pays at 80.03% of Total Billed charges,9.48,Pays at 102% of Medicare OPPS Rate,20.03,Pays at 90% of Total Billed charges,11.69,Pays at 100% of GA Medicaid Fee Schedule,9.3,Pays at 100% of Medicare OPPS Rate,11.69,Pays at 100% of GA Medicaid Fee Schedule,19.58,Pays at 88% of Total Billed charges,12.04,Pays at 103% of GA Medicaid Fee Schedule,9.3,20.03,13.35
Outpatient Medical Services,LAB,82784,Test to determine levels of immunoglobulins in the blood,300,30,25.5,Pays at 85% of Billed charges for outpatient setting,11.69,Pays at 100% of GA Medicaid Fee Schedule,24.01,Pays at 80.03% of Total Billed charges,9.48,Pays at 102% of Medicare OPPS Rate,27,Pays at 90% of Total Billed charges,11.69,Pays at 100% of GA Medicaid Fee Schedule,9.3,Pays at 100% of Medicare OPPS Rate,11.69,Pays at 100% of GA Medicaid Fee Schedule,26.4,Pays at 88% of Total Billed charges,12.04,Pays at 103% of GA Medicaid Fee Schedule,9.3,27,18.00
Outpatient Medical Services,LAB,82784,Test to determine levels of immunoglobulins in the blood,300,30,25.5,Pays at 85% of Billed charges for outpatient setting,11.69,Pays at 100% of GA Medicaid Fee Schedule,24.01,Pays at 80.03% of Total Billed charges,9.48,Pays at 102% of Medicare OPPS Rate,27,Pays at 90% of Total Billed charges,11.69,Pays at 100% of GA Medicaid Fee Schedule,9.3,Pays at 100% of Medicare OPPS Rate,11.69,Pays at 100% of GA Medicaid Fee Schedule,26.4,Pays at 88% of Total Billed charges,12.04,Pays at 103% of GA Medicaid Fee Schedule,9.3,27,18.00
Outpatient Medical Services,LAB,82784,Test to determine levels of immunoglobulins in the blood,300,30,25.5,Pays at 85% of Billed charges for outpatient setting,11.69,Pays at 100% of GA Medicaid Fee Schedule,24.01,Pays at 80.03% of Total Billed charges,9.48,Pays at 102% of Medicare OPPS Rate,27,Pays at 90% of Total Billed charges,11.69,Pays at 100% of GA Medicaid Fee Schedule,9.3,Pays at 100% of Medicare OPPS Rate,11.69,Pays at 100% of GA Medicaid Fee Schedule,26.4,Pays at 88% of Total Billed charges,12.04,Pays at 103% of GA Medicaid Fee Schedule,9.3,27,18.00
Outpatient Medical Services,LAB,82784,Test to determine levels of immunoglobulins in the blood,300,40,34,Pays at 85% of Billed charges for outpatient setting,11.69,Pays at 100% of GA Medicaid Fee Schedule,32.01,Pays at 80.03% of Total Billed charges,9.48,Pays at 102% of Medicare OPPS Rate,36,Pays at 90% of Total Billed charges,11.69,Pays at 100% of GA Medicaid Fee Schedule,9.3,Pays at 100% of Medicare OPPS Rate,11.69,Pays at 100% of GA Medicaid Fee Schedule,35.2,Pays at 88% of Total Billed charges,12.04,Pays at 103% of GA Medicaid Fee Schedule,9.3,36,24.00
Outpatient Medical Services,LAB,82784,Test to determine levels of immunoglobulins in the blood,300,71,60.35,Pays at 85% of Billed charges for outpatient setting,11.69,Pays at 100% of GA Medicaid Fee Schedule,56.82,Pays at 80.03% of Total Billed charges,9.48,Pays at 102% of Medicare OPPS Rate,63.9,Pays at 90% of Total Billed charges,11.69,Pays at 100% of GA Medicaid Fee Schedule,9.3,Pays at 100% of Medicare OPPS Rate,11.69,Pays at 100% of GA Medicaid Fee Schedule,62.48,Pays at 88% of Total Billed charges,12.04,Pays at 103% of GA Medicaid Fee Schedule,9.3,63.9,42.60
Outpatient Medical Services,LAB,82785,"IMMUNOGLOBULIN E, IGE  (MAYO)",300,21.25,18.06,Pays at 85% of Billed charges for outpatient setting,20.71,Pays at 100% of GA Medicaid Fee Schedule,17.01,Pays at 80.03% of Total Billed charges,16.78,Pays at 102% of Medicare OPPS Rate,19.13,Pays at 90% of Total Billed charges,20.71,Pays at 100% of GA Medicaid Fee Schedule,16.46,Pays at 100% of Medicare OPPS Rate,20.71,Pays at 100% of GA Medicaid Fee Schedule,18.7,Pays at 88% of Total Billed charges,21.33,Pays at 103% of GA Medicaid Fee Schedule,16.46,21.33,12.75
Outpatient Medical Services,LAB,82785,"RAST, CHILDHOOD PANEL  (MAYO)",300,223.25,189.76,Pays at 85% of Billed charges for outpatient setting,20.71,Pays at 100% of GA Medicaid Fee Schedule,178.67,Pays at 80.03% of Total Billed charges,16.78,Pays at 102% of Medicare OPPS Rate,200.93,Pays at 90% of Total Billed charges,20.71,Pays at 100% of GA Medicaid Fee Schedule,16.46,Pays at 100% of Medicare OPPS Rate,20.71,Pays at 100% of GA Medicaid Fee Schedule,196.46,Pays at 88% of Total Billed charges,21.33,Pays at 103% of GA Medicaid Fee Schedule,16.46,200.93,133.95
Outpatient Medical Services,LAB,82785,"RAST, SOUTHEASTERN PANEL  (MAYO)",300,354.75,301.54,Pays at 85% of Billed charges for outpatient setting,20.71,Pays at 100% of GA Medicaid Fee Schedule,283.91,Pays at 80.03% of Total Billed charges,16.78,Pays at 102% of Medicare OPPS Rate,319.28,Pays at 90% of Total Billed charges,20.71,Pays at 100% of GA Medicaid Fee Schedule,16.46,Pays at 100% of Medicare OPPS Rate,20.71,Pays at 100% of GA Medicaid Fee Schedule,312.18,Pays at 88% of Total Billed charges,21.33,Pays at 103% of GA Medicaid Fee Schedule,16.46,319.28,212.85
Outpatient Medical Services,LAB,82787,IGG1 SUBCLASS  (MAYO),300,26,22.1,Pays at 85% of Billed charges for outpatient setting,10.08,Pays at 100% of GA Medicaid Fee Schedule,20.81,Pays at 80.03% of Total Billed charges,8.18,Pays at 102% of Medicare OPPS Rate,23.4,Pays at 90% of Total Billed charges,10.08,Pays at 100% of GA Medicaid Fee Schedule,8.02,Pays at 100% of Medicare OPPS Rate,10.08,Pays at 100% of GA Medicaid Fee Schedule,22.88,Pays at 88% of Total Billed charges,10.38,Pays at 103% of GA Medicaid Fee Schedule,8.02,23.4,15.60
Outpatient Medical Services,LAB,82787,IGG2 SUBCLASS  (MAYO),300,26,22.1,Pays at 85% of Billed charges for outpatient setting,10.08,Pays at 100% of GA Medicaid Fee Schedule,20.81,Pays at 80.03% of Total Billed charges,8.18,Pays at 102% of Medicare OPPS Rate,23.4,Pays at 90% of Total Billed charges,10.08,Pays at 100% of GA Medicaid Fee Schedule,8.02,Pays at 100% of Medicare OPPS Rate,10.08,Pays at 100% of GA Medicaid Fee Schedule,22.88,Pays at 88% of Total Billed charges,10.38,Pays at 103% of GA Medicaid Fee Schedule,8.02,23.4,15.60
Outpatient Medical Services,LAB,82787,IGG3 SUBCLASS  (MAYO),300,26,22.1,Pays at 85% of Billed charges for outpatient setting,10.08,Pays at 100% of GA Medicaid Fee Schedule,20.81,Pays at 80.03% of Total Billed charges,8.18,Pays at 102% of Medicare OPPS Rate,23.4,Pays at 90% of Total Billed charges,10.08,Pays at 100% of GA Medicaid Fee Schedule,8.02,Pays at 100% of Medicare OPPS Rate,10.08,Pays at 100% of GA Medicaid Fee Schedule,22.88,Pays at 88% of Total Billed charges,10.38,Pays at 103% of GA Medicaid Fee Schedule,8.02,23.4,15.60
Outpatient Medical Services,LAB,82787,IGG4 SUBCLASS  (MAYO),300,26,22.1,Pays at 85% of Billed charges for outpatient setting,10.08,Pays at 100% of GA Medicaid Fee Schedule,20.81,Pays at 80.03% of Total Billed charges,8.18,Pays at 102% of Medicare OPPS Rate,23.4,Pays at 90% of Total Billed charges,10.08,Pays at 100% of GA Medicaid Fee Schedule,8.02,Pays at 100% of Medicare OPPS Rate,10.08,Pays at 100% of GA Medicaid Fee Schedule,22.88,Pays at 88% of Total Billed charges,10.38,Pays at 103% of GA Medicaid Fee Schedule,8.02,23.4,15.60
Outpatient Medical Services,LAB,82800,PH BLOOD (VENOUS),300,28,23.8,Pays at 85% of Billed charges for outpatient setting,10.65,Pays at 100% of GA Medicaid Fee Schedule,22.41,Pays at 80.03% of Total Billed charges,11.22,Pays at 102% of Medicare OPPS Rate,25.2,Pays at 90% of Total Billed charges,10.65,Pays at 100% of GA Medicaid Fee Schedule,11,Pays at 100% of Medicare OPPS Rate,10.65,Pays at 100% of GA Medicaid Fee Schedule,24.64,Pays at 88% of Total Billed charges,10.97,Pays at 103% of GA Medicaid Fee Schedule,10.65,25.2,16.80
Outpatient Medical Services,LAB,82803,Test to measure arterial blood gases,300,179.99,152.99,Pays at 85% of Billed charges for outpatient setting,24.34,Pays at 100% of GA Medicaid Fee Schedule,144.05,Pays at 80.03% of Total Billed charges,26.59,Pays at 102% of Medicare OPPS Rate,161.99,Pays at 90% of Total Billed charges,24.34,Pays at 100% of GA Medicaid Fee Schedule,26.07,Pays at 100% of Medicare OPPS Rate,24.34,Pays at 100% of GA Medicaid Fee Schedule,158.39,Pays at 88% of Total Billed charges,25.07,Pays at 103% of GA Medicaid Fee Schedule,24.34,161.99,107.99
Outpatient Medical Services,LAB,82803,Test to measure arterial blood gases,300,212,180.2,Pays at 85% of Billed charges for outpatient setting,24.34,Pays at 100% of GA Medicaid Fee Schedule,169.66,Pays at 80.03% of Total Billed charges,26.59,Pays at 102% of Medicare OPPS Rate,190.8,Pays at 90% of Total Billed charges,24.34,Pays at 100% of GA Medicaid Fee Schedule,26.07,Pays at 100% of Medicare OPPS Rate,24.34,Pays at 100% of GA Medicaid Fee Schedule,186.56,Pays at 88% of Total Billed charges,25.07,Pays at 103% of GA Medicaid Fee Schedule,24.34,190.8,127.20
Outpatient Medical Services,LAB,82803,Test to measure arterial blood gases,300,219.5,186.58,Pays at 85% of Billed charges for outpatient setting,24.34,Pays at 100% of GA Medicaid Fee Schedule,175.67,Pays at 80.03% of Total Billed charges,26.59,Pays at 102% of Medicare OPPS Rate,197.55,Pays at 90% of Total Billed charges,24.34,Pays at 100% of GA Medicaid Fee Schedule,26.07,Pays at 100% of Medicare OPPS Rate,24.34,Pays at 100% of GA Medicaid Fee Schedule,193.16,Pays at 88% of Total Billed charges,25.07,Pays at 103% of GA Medicaid Fee Schedule,24.34,197.55,131.70
Outpatient Medical Services,LAB,82805,TEST CO-OXIMETRY,300,86,73.1,Pays at 85% of Billed charges for outpatient setting,35.69,Pays at 100% of GA Medicaid Fee Schedule,68.83,Pays at 80.03% of Total Billed charges,80.34,Pays at 102% of Medicare OPPS Rate,77.4,Pays at 90% of Total Billed charges,35.69,Pays at 100% of GA Medicaid Fee Schedule,78.77,Pays at 100% of Medicare OPPS Rate,35.69,Pays at 100% of GA Medicaid Fee Schedule,75.68,Pays at 88% of Total Billed charges,36.76,Pays at 103% of GA Medicaid Fee Schedule,35.69,80.34,51.60
Outpatient Medical Services,LAB,82805,CO-OXIMETRY,300,86,73.1,Pays at 85% of Billed charges for outpatient setting,35.69,Pays at 100% of GA Medicaid Fee Schedule,68.83,Pays at 80.03% of Total Billed charges,80.34,Pays at 102% of Medicare OPPS Rate,77.4,Pays at 90% of Total Billed charges,35.69,Pays at 100% of GA Medicaid Fee Schedule,78.77,Pays at 100% of Medicare OPPS Rate,35.69,Pays at 100% of GA Medicaid Fee Schedule,75.68,Pays at 88% of Total Billed charges,36.76,Pays at 103% of GA Medicaid Fee Schedule,35.69,80.34,51.60
Outpatient Medical Services,LAB,82941,GASTRIN LEVEL  (MAYO),300,29.25,24.86,Pays at 85% of Billed charges for outpatient setting,22.18,Pays at 100% of GA Medicaid Fee Schedule,23.41,Pays at 80.03% of Total Billed charges,17.98,Pays at 102% of Medicare OPPS Rate,26.33,Pays at 90% of Total Billed charges,22.18,Pays at 100% of GA Medicaid Fee Schedule,17.63,Pays at 100% of Medicare OPPS Rate,22.18,Pays at 100% of GA Medicaid Fee Schedule,25.74,Pays at 88% of Total Billed charges,22.85,Pays at 103% of GA Medicaid Fee Schedule,17.63,26.33,17.55
Outpatient Medical Services,LAB,82943,"GLUCAGON, PLASMA  (MAYO)",300,80.5,68.43,Pays at 85% of Billed charges for outpatient setting,17.97,Pays at 100% of GA Medicaid Fee Schedule,64.42,Pays at 80.03% of Total Billed charges,14.57,Pays at 102% of Medicare OPPS Rate,72.45,Pays at 90% of Total Billed charges,17.97,Pays at 100% of GA Medicaid Fee Schedule,14.29,Pays at 100% of Medicare OPPS Rate,17.97,Pays at 100% of GA Medicaid Fee Schedule,70.84,Pays at 88% of Total Billed charges,18.51,Pays at 103% of GA Medicaid Fee Schedule,14.29,72.45,48.30
Outpatient Medical Services,LAB,82945,"GLUCOSE, URINE QL",300,35,29.75,Pays at 85% of Billed charges for outpatient setting,4.93,Pays at 100% of GA Medicaid Fee Schedule,28.01,Pays at 80.03% of Total Billed charges,4,Pays at 102% of Medicare OPPS Rate,31.5,Pays at 90% of Total Billed charges,4.93,Pays at 100% of GA Medicaid Fee Schedule,3.93,Pays at 100% of Medicare OPPS Rate,4.93,Pays at 100% of GA Medicaid Fee Schedule,30.8,Pays at 88% of Total Billed charges,5.08,Pays at 103% of GA Medicaid Fee Schedule,3.93,31.5,21.00
Outpatient Medical Services,LAB,82945,"BODY FLUID, GLUCOSE  (MAYO)",300,60,51,Pays at 85% of Billed charges for outpatient setting,4.93,Pays at 100% of GA Medicaid Fee Schedule,48.02,Pays at 80.03% of Total Billed charges,4,Pays at 102% of Medicare OPPS Rate,54,Pays at 90% of Total Billed charges,4.93,Pays at 100% of GA Medicaid Fee Schedule,3.93,Pays at 100% of Medicare OPPS Rate,4.93,Pays at 100% of GA Medicaid Fee Schedule,52.8,Pays at 88% of Total Billed charges,5.08,Pays at 103% of GA Medicaid Fee Schedule,3.93,54,36.00
Outpatient Medical Services,LAB,82947,Quantitative measure of glucose build up in the blood over time,300,15,12.75,Pays at 85% of Billed charges for outpatient setting,4.93,Pays at 100% of GA Medicaid Fee Schedule,12,Pays at 80.03% of Total Billed charges,4,Pays at 102% of Medicare OPPS Rate,13.5,Pays at 90% of Total Billed charges,4.93,Pays at 100% of GA Medicaid Fee Schedule,3.93,Pays at 100% of Medicare OPPS Rate,4.93,Pays at 100% of GA Medicaid Fee Schedule,13.2,Pays at 88% of Total Billed charges,5.08,Pays at 103% of GA Medicaid Fee Schedule,3.93,13.5,9.00
Outpatient Medical Services,LAB,82947,Quantitative measure of glucose build up in the blood over time,300,28.91,24.57,Pays at 85% of Billed charges for outpatient setting,4.93,Pays at 100% of GA Medicaid Fee Schedule,23.14,Pays at 80.03% of Total Billed charges,4,Pays at 102% of Medicare OPPS Rate,26.02,Pays at 90% of Total Billed charges,4.93,Pays at 100% of GA Medicaid Fee Schedule,3.93,Pays at 100% of Medicare OPPS Rate,4.93,Pays at 100% of GA Medicaid Fee Schedule,25.44,Pays at 88% of Total Billed charges,5.08,Pays at 103% of GA Medicaid Fee Schedule,3.93,26.02,17.35
Outpatient Medical Services,LAB,82947,Quantitative measure of glucose build up in the blood over time,300,35,29.75,Pays at 85% of Billed charges for outpatient setting,4.93,Pays at 100% of GA Medicaid Fee Schedule,28.01,Pays at 80.03% of Total Billed charges,4,Pays at 102% of Medicare OPPS Rate,31.5,Pays at 90% of Total Billed charges,4.93,Pays at 100% of GA Medicaid Fee Schedule,3.93,Pays at 100% of Medicare OPPS Rate,4.93,Pays at 100% of GA Medicaid Fee Schedule,30.8,Pays at 88% of Total Billed charges,5.08,Pays at 103% of GA Medicaid Fee Schedule,3.93,31.5,21.00
Outpatient Medical Services,LAB,82947,Quantitative measure of glucose build up in the blood over time,300,35,29.75,Pays at 85% of Billed charges for outpatient setting,4.93,Pays at 100% of GA Medicaid Fee Schedule,28.01,Pays at 80.03% of Total Billed charges,4,Pays at 102% of Medicare OPPS Rate,31.5,Pays at 90% of Total Billed charges,4.93,Pays at 100% of GA Medicaid Fee Schedule,3.93,Pays at 100% of Medicare OPPS Rate,4.93,Pays at 100% of GA Medicaid Fee Schedule,30.8,Pays at 88% of Total Billed charges,5.08,Pays at 103% of GA Medicaid Fee Schedule,3.93,31.5,21.00
Outpatient Medical Services,LAB,82947,Quantitative measure of glucose build up in the blood over time,300,35.25,29.96,Pays at 85% of Billed charges for outpatient setting,4.93,Pays at 100% of GA Medicaid Fee Schedule,28.21,Pays at 80.03% of Total Billed charges,4,Pays at 102% of Medicare OPPS Rate,31.73,Pays at 90% of Total Billed charges,4.93,Pays at 100% of GA Medicaid Fee Schedule,3.93,Pays at 100% of Medicare OPPS Rate,4.93,Pays at 100% of GA Medicaid Fee Schedule,31.02,Pays at 88% of Total Billed charges,5.08,Pays at 103% of GA Medicaid Fee Schedule,3.93,31.73,21.15
Outpatient Medical Services,LAB,82950,Test of glucose level in the blood,300,34,28.9,Pays at 85% of Billed charges for outpatient setting,5.98,Pays at 100% of GA Medicaid Fee Schedule,27.21,Pays at 80.03% of Total Billed charges,4.84,Pays at 102% of Medicare OPPS Rate,30.6,Pays at 90% of Total Billed charges,5.98,Pays at 100% of GA Medicaid Fee Schedule,4.75,Pays at 100% of Medicare OPPS Rate,5.98,Pays at 100% of GA Medicaid Fee Schedule,29.92,Pays at 88% of Total Billed charges,6.16,Pays at 103% of GA Medicaid Fee Schedule,4.75,30.6,20.40
Outpatient Medical Services,LAB,82950,Test of glucose level in the blood,300,34,28.9,Pays at 85% of Billed charges for outpatient setting,5.98,Pays at 100% of GA Medicaid Fee Schedule,27.21,Pays at 80.03% of Total Billed charges,4.84,Pays at 102% of Medicare OPPS Rate,30.6,Pays at 90% of Total Billed charges,5.98,Pays at 100% of GA Medicaid Fee Schedule,4.75,Pays at 100% of Medicare OPPS Rate,5.98,Pays at 100% of GA Medicaid Fee Schedule,29.92,Pays at 88% of Total Billed charges,6.16,Pays at 103% of GA Medicaid Fee Schedule,4.75,30.6,20.40
Outpatient Medical Services,LAB,82950,Test of glucose level in the blood,300,61,51.85,Pays at 85% of Billed charges for outpatient setting,5.98,Pays at 100% of GA Medicaid Fee Schedule,48.82,Pays at 80.03% of Total Billed charges,4.84,Pays at 102% of Medicare OPPS Rate,54.9,Pays at 90% of Total Billed charges,5.98,Pays at 100% of GA Medicaid Fee Schedule,4.75,Pays at 100% of Medicare OPPS Rate,5.98,Pays at 100% of GA Medicaid Fee Schedule,53.68,Pays at 88% of Total Billed charges,6.16,Pays at 103% of GA Medicaid Fee Schedule,4.75,54.9,36.60
Outpatient Medical Services,LAB,82950,Test of glucose level in the blood,300,61,51.85,Pays at 85% of Billed charges for outpatient setting,5.98,Pays at 100% of GA Medicaid Fee Schedule,48.82,Pays at 80.03% of Total Billed charges,4.84,Pays at 102% of Medicare OPPS Rate,54.9,Pays at 90% of Total Billed charges,5.98,Pays at 100% of GA Medicaid Fee Schedule,4.75,Pays at 100% of Medicare OPPS Rate,5.98,Pays at 100% of GA Medicaid Fee Schedule,53.68,Pays at 88% of Total Billed charges,6.16,Pays at 103% of GA Medicaid Fee Schedule,4.75,54.9,36.60
Outpatient Medical Services,LAB,82951,Test to predict likelihood of gestational diabetes,300,100.5,85.43,Pays at 85% of Billed charges for outpatient setting,16.19,Pays at 100% of GA Medicaid Fee Schedule,80.43,Pays at 80.03% of Total Billed charges,13.12,Pays at 102% of Medicare OPPS Rate,90.45,Pays at 90% of Total Billed charges,16.19,Pays at 100% of GA Medicaid Fee Schedule,12.87,Pays at 100% of Medicare OPPS Rate,16.19,Pays at 100% of GA Medicaid Fee Schedule,88.44,Pays at 88% of Total Billed charges,16.68,Pays at 103% of GA Medicaid Fee Schedule,12.87,90.45,60.30
Outpatient Medical Services,LAB,82951,Test to predict likelihood of gestational diabetes,300,117.25,99.66,Pays at 85% of Billed charges for outpatient setting,16.19,Pays at 100% of GA Medicaid Fee Schedule,93.84,Pays at 80.03% of Total Billed charges,13.12,Pays at 102% of Medicare OPPS Rate,105.53,Pays at 90% of Total Billed charges,16.19,Pays at 100% of GA Medicaid Fee Schedule,12.87,Pays at 100% of Medicare OPPS Rate,16.19,Pays at 100% of GA Medicaid Fee Schedule,103.18,Pays at 88% of Total Billed charges,16.68,Pays at 103% of GA Medicaid Fee Schedule,12.87,105.53,70.35
Outpatient Medical Services,LAB,82951,Test to predict likelihood of gestational diabetes,300,134,113.9,Pays at 85% of Billed charges for outpatient setting,16.19,Pays at 100% of GA Medicaid Fee Schedule,107.24,Pays at 80.03% of Total Billed charges,13.12,Pays at 102% of Medicare OPPS Rate,120.6,Pays at 90% of Total Billed charges,16.19,Pays at 100% of GA Medicaid Fee Schedule,12.87,Pays at 100% of Medicare OPPS Rate,16.19,Pays at 100% of GA Medicaid Fee Schedule,117.92,Pays at 88% of Total Billed charges,16.68,Pays at 103% of GA Medicaid Fee Schedule,12.87,120.6,80.40
Outpatient Medical Services,LAB,82951,Test to predict likelihood of gestational diabetes,300,150.75,128.14,Pays at 85% of Billed charges for outpatient setting,16.19,Pays at 100% of GA Medicaid Fee Schedule,120.65,Pays at 80.03% of Total Billed charges,13.12,Pays at 102% of Medicare OPPS Rate,135.68,Pays at 90% of Total Billed charges,16.19,Pays at 100% of GA Medicaid Fee Schedule,12.87,Pays at 100% of Medicare OPPS Rate,16.19,Pays at 100% of GA Medicaid Fee Schedule,132.66,Pays at 88% of Total Billed charges,16.68,Pays at 103% of GA Medicaid Fee Schedule,12.87,135.68,90.45
Outpatient Medical Services,LAB,82952,..GLUCOSE EACH,300,27.75,23.59,Pays at 85% of Billed charges for outpatient setting,4.93,Pays at 100% of GA Medicaid Fee Schedule,22.21,Pays at 80.03% of Total Billed charges,3.99,Pays at 102% of Medicare OPPS Rate,24.98,Pays at 90% of Total Billed charges,4.93,Pays at 100% of GA Medicaid Fee Schedule,3.92,Pays at 100% of Medicare OPPS Rate,4.93,Pays at 100% of GA Medicaid Fee Schedule,24.42,Pays at 88% of Total Billed charges,5.08,Pays at 103% of GA Medicaid Fee Schedule,3.92,24.98,16.65
Outpatient Medical Services,LAB,82955,"GLUCOSE-6-PHOSPHATE DEHYD, QT  (MAYO)",300,122.25,103.91,Pays at 85% of Billed charges for outpatient setting,9.82,Pays at 100% of GA Medicaid Fee Schedule,97.84,Pays at 80.03% of Total Billed charges,9.89,Pays at 102% of Medicare OPPS Rate,110.03,Pays at 90% of Total Billed charges,9.82,Pays at 100% of GA Medicaid Fee Schedule,9.69,Pays at 100% of Medicare OPPS Rate,9.82,Pays at 100% of GA Medicaid Fee Schedule,107.58,Pays at 88% of Total Billed charges,10.11,Pays at 103% of GA Medicaid Fee Schedule,9.69,110.03,73.35
Outpatient Medical Services,LAB,82962,BLOOD GLUCOSE CHECK,300,10.25,8.71,Pays at 85% of Billed charges for outpatient setting,2.94,Pays at 100% of GA Medicaid Fee Schedule,8.2,Pays at 80.03% of Total Billed charges,3.34,Pays at 102% of Medicare OPPS Rate,9.23,Pays at 90% of Total Billed charges,2.94,Pays at 100% of GA Medicaid Fee Schedule,3.28,Pays at 100% of Medicare OPPS Rate,2.94,Pays at 100% of GA Medicaid Fee Schedule,9.02,Pays at 88% of Total Billed charges,3.03,Pays at 103% of GA Medicaid Fee Schedule,2.94,9.23,6.15
Outpatient Medical Services,LAB,82977,FIBROSURE GGT (MAYO),300,22.75,19.34,Pays at 85% of Billed charges for outpatient setting,6.35,Pays at 100% of GA Medicaid Fee Schedule,18.21,Pays at 80.03% of Total Billed charges,7.34,Pays at 102% of Medicare OPPS Rate,20.48,Pays at 90% of Total Billed charges,6.35,Pays at 100% of GA Medicaid Fee Schedule,7.2,Pays at 100% of Medicare OPPS Rate,6.35,Pays at 100% of GA Medicaid Fee Schedule,20.02,Pays at 88% of Total Billed charges,6.54,Pays at 103% of GA Medicaid Fee Schedule,6.35,20.48,13.65
Outpatient Medical Services,LAB,82977,GAMMA GT (GGT),300,36,30.6,Pays at 85% of Billed charges for outpatient setting,6.35,Pays at 100% of GA Medicaid Fee Schedule,28.81,Pays at 80.03% of Total Billed charges,7.34,Pays at 102% of Medicare OPPS Rate,32.4,Pays at 90% of Total Billed charges,6.35,Pays at 100% of GA Medicaid Fee Schedule,7.2,Pays at 100% of Medicare OPPS Rate,6.35,Pays at 100% of GA Medicaid Fee Schedule,31.68,Pays at 88% of Total Billed charges,6.54,Pays at 103% of GA Medicaid Fee Schedule,6.35,32.4,21.60
Outpatient Medical Services,LAB,82978,"GLUTATHIONE, B  (MAYO)",300,341.5,290.28,Pays at 85% of Billed charges for outpatient setting,17.92,Pays at 100% of GA Medicaid Fee Schedule,273.3,Pays at 80.03% of Total Billed charges,15.75,Pays at 102% of Medicare OPPS Rate,307.35,Pays at 90% of Total Billed charges,17.92,Pays at 100% of GA Medicaid Fee Schedule,15.45,Pays at 100% of Medicare OPPS Rate,17.92,Pays at 100% of GA Medicaid Fee Schedule,300.52,Pays at 88% of Total Billed charges,18.46,Pays at 103% of GA Medicaid Fee Schedule,15.45,307.35,204.90
Outpatient Medical Services,LAB,82985,FRUCTOSAMINE  (MAYO),300,72.25,61.41,Pays at 85% of Billed charges for outpatient setting,18.95,Pays at 100% of GA Medicaid Fee Schedule,57.82,Pays at 80.03% of Total Billed charges,17.09,Pays at 102% of Medicare OPPS Rate,65.03,Pays at 90% of Total Billed charges,18.95,Pays at 100% of GA Medicaid Fee Schedule,16.76,Pays at 100% of Medicare OPPS Rate,18.95,Pays at 100% of GA Medicaid Fee Schedule,63.58,Pays at 88% of Total Billed charges,19.52,Pays at 103% of GA Medicaid Fee Schedule,16.76,65.03,43.35
Outpatient Medical Services,LAB,82985,ALPHA-1 ACID GLYCOPROTEIN  (MAYO),300,98.5,83.73,Pays at 85% of Billed charges for outpatient setting,18.95,Pays at 100% of GA Medicaid Fee Schedule,78.83,Pays at 80.03% of Total Billed charges,17.09,Pays at 102% of Medicare OPPS Rate,88.65,Pays at 90% of Total Billed charges,18.95,Pays at 100% of GA Medicaid Fee Schedule,16.76,Pays at 100% of Medicare OPPS Rate,18.95,Pays at 100% of GA Medicaid Fee Schedule,86.68,Pays at 88% of Total Billed charges,19.52,Pays at 103% of GA Medicaid Fee Schedule,16.76,88.65,59.10
Outpatient Medical Services,LAB,83001,Test of hormone in the blood,300,54.75,46.54,Pays at 85% of Billed charges for outpatient setting,23.37,Pays at 100% of GA Medicaid Fee Schedule,43.82,Pays at 80.03% of Total Billed charges,18.95,Pays at 102% of Medicare OPPS Rate,49.28,Pays at 90% of Total Billed charges,23.37,Pays at 100% of GA Medicaid Fee Schedule,18.57,Pays at 100% of Medicare OPPS Rate,23.37,Pays at 100% of GA Medicaid Fee Schedule,48.18,Pays at 88% of Total Billed charges,24.07,Pays at 103% of GA Medicaid Fee Schedule,18.57,49.28,32.85
Outpatient Medical Services,LAB,83001,Test of hormone in the blood,300,59,50.15,Pays at 85% of Billed charges for outpatient setting,23.37,Pays at 100% of GA Medicaid Fee Schedule,47.22,Pays at 80.03% of Total Billed charges,18.95,Pays at 102% of Medicare OPPS Rate,53.1,Pays at 90% of Total Billed charges,23.37,Pays at 100% of GA Medicaid Fee Schedule,18.57,Pays at 100% of Medicare OPPS Rate,23.37,Pays at 100% of GA Medicaid Fee Schedule,51.92,Pays at 88% of Total Billed charges,24.07,Pays at 103% of GA Medicaid Fee Schedule,18.57,53.1,35.40
Outpatient Medical Services,LAB,83002,Test of hormone in the blood,300,59,50.15,Pays at 85% of Billed charges for outpatient setting,23.29,Pays at 100% of GA Medicaid Fee Schedule,47.22,Pays at 80.03% of Total Billed charges,18.89,Pays at 102% of Medicare OPPS Rate,53.1,Pays at 90% of Total Billed charges,23.29,Pays at 100% of GA Medicaid Fee Schedule,18.52,Pays at 100% of Medicare OPPS Rate,23.29,Pays at 100% of GA Medicaid Fee Schedule,51.92,Pays at 88% of Total Billed charges,23.99,Pays at 103% of GA Medicaid Fee Schedule,18.52,53.1,35.40
Outpatient Medical Services,LAB,83003,GROWTH HORMONE  (MAYO),300,24.5,20.83,Pays at 85% of Billed charges for outpatient setting,17.9,Pays at 100% of GA Medicaid Fee Schedule,19.61,Pays at 80.03% of Total Billed charges,17,Pays at 102% of Medicare OPPS Rate,22.05,Pays at 90% of Total Billed charges,17.9,Pays at 100% of GA Medicaid Fee Schedule,16.67,Pays at 100% of Medicare OPPS Rate,17.9,Pays at 100% of GA Medicaid Fee Schedule,21.56,Pays at 88% of Total Billed charges,18.44,Pays at 103% of GA Medicaid Fee Schedule,16.67,22.05,14.70
Outpatient Medical Services,LAB,83010,HAPTOGLOBIN  (MAYO),300,40.25,34.21,Pays at 85% of Billed charges for outpatient setting,4.69,Pays at 100% of GA Medicaid Fee Schedule,32.21,Pays at 80.03% of Total Billed charges,12.83,Pays at 102% of Medicare OPPS Rate,36.23,Pays at 90% of Total Billed charges,4.69,Pays at 100% of GA Medicaid Fee Schedule,12.58,Pays at 100% of Medicare OPPS Rate,4.69,Pays at 100% of GA Medicaid Fee Schedule,35.42,Pays at 88% of Total Billed charges,4.83,Pays at 103% of GA Medicaid Fee Schedule,4.69,36.23,24.15
Outpatient Medical Services,LAB,83010,FIBROSURE HAPTOGLOBIN QUANT (MAYO),300,105.5,89.68,Pays at 85% of Billed charges for outpatient setting,4.69,Pays at 100% of GA Medicaid Fee Schedule,84.43,Pays at 80.03% of Total Billed charges,12.83,Pays at 102% of Medicare OPPS Rate,94.95,Pays at 90% of Total Billed charges,4.69,Pays at 100% of GA Medicaid Fee Schedule,12.58,Pays at 100% of Medicare OPPS Rate,4.69,Pays at 100% of GA Medicaid Fee Schedule,92.84,Pays at 88% of Total Billed charges,4.83,Pays at 103% of GA Medicaid Fee Schedule,4.69,94.95,63.30
Outpatient Medical Services,LAB,83015,"HEAVY METAL SCREEN, URINE 24 HR  (MAYO)",300,108.75,92.44,Pays at 85% of Billed charges for outpatient setting,23.68,Pays at 100% of GA Medicaid Fee Schedule,87.03,Pays at 80.03% of Total Billed charges,21.35,Pays at 102% of Medicare OPPS Rate,97.88,Pays at 90% of Total Billed charges,23.68,Pays at 100% of GA Medicaid Fee Schedule,20.94,Pays at 100% of Medicare OPPS Rate,23.68,Pays at 100% of GA Medicaid Fee Schedule,95.7,Pays at 88% of Total Billed charges,24.39,Pays at 103% of GA Medicaid Fee Schedule,20.94,97.88,65.25
Outpatient Medical Services,LAB,83015,"HEAVY METAL SCREEN, BLOOD  (MAYO)",300,108.75,92.44,Pays at 85% of Billed charges for outpatient setting,23.68,Pays at 100% of GA Medicaid Fee Schedule,87.03,Pays at 80.03% of Total Billed charges,21.35,Pays at 102% of Medicare OPPS Rate,97.88,Pays at 90% of Total Billed charges,23.68,Pays at 100% of GA Medicaid Fee Schedule,20.94,Pays at 100% of Medicare OPPS Rate,23.68,Pays at 100% of GA Medicaid Fee Schedule,95.7,Pays at 88% of Total Billed charges,24.39,Pays at 103% of GA Medicaid Fee Schedule,20.94,97.88,65.25
Outpatient Medical Services,LAB,83018,THALLIUM  (MAYO),300,70,59.5,Pays at 85% of Billed charges for outpatient setting,27.61,Pays at 100% of GA Medicaid Fee Schedule,56.02,Pays at 80.03% of Total Billed charges,22.39,Pays at 102% of Medicare OPPS Rate,63,Pays at 90% of Total Billed charges,27.61,Pays at 100% of GA Medicaid Fee Schedule,21.96,Pays at 100% of Medicare OPPS Rate,27.61,Pays at 100% of GA Medicaid Fee Schedule,61.6,Pays at 88% of Total Billed charges,28.44,Pays at 103% of GA Medicaid Fee Schedule,21.96,63,42.00
Outpatient Medical Services,LAB,83018,"COBALT, SERUM  (MAYO)",300,106,90.1,Pays at 85% of Billed charges for outpatient setting,27.61,Pays at 100% of GA Medicaid Fee Schedule,84.83,Pays at 80.03% of Total Billed charges,22.39,Pays at 102% of Medicare OPPS Rate,95.4,Pays at 90% of Total Billed charges,27.61,Pays at 100% of GA Medicaid Fee Schedule,21.96,Pays at 100% of Medicare OPPS Rate,27.61,Pays at 100% of GA Medicaid Fee Schedule,93.28,Pays at 88% of Total Billed charges,28.44,Pays at 103% of GA Medicaid Fee Schedule,21.96,95.4,63.60
Outpatient Medical Services,LAB,83020,HGB ELECTROPHORESIS BLOOD  (MAYO),300,96.25,81.81,Pays at 85% of Billed charges for outpatient setting,12.29,Pays at 100% of GA Medicaid Fee Schedule,77.03,Pays at 80.03% of Total Billed charges,13.12,Pays at 102% of Medicare OPPS Rate,86.63,Pays at 90% of Total Billed charges,12.29,Pays at 100% of GA Medicaid Fee Schedule,12.87,Pays at 100% of Medicare OPPS Rate,12.29,Pays at 100% of GA Medicaid Fee Schedule,84.7,Pays at 88% of Total Billed charges,12.66,Pays at 103% of GA Medicaid Fee Schedule,12.29,86.63,57.75
Outpatient Medical Services,LAB,83021,HGB A2 AND F  (MAYO),300,154.25,131.11,Pays at 85% of Billed charges for outpatient setting,7.55,Pays at 100% of GA Medicaid Fee Schedule,123.45,Pays at 80.03% of Total Billed charges,18.42,Pays at 102% of Medicare OPPS Rate,138.83,Pays at 90% of Total Billed charges,7.55,Pays at 100% of GA Medicaid Fee Schedule,18.05,Pays at 100% of Medicare OPPS Rate,7.55,Pays at 100% of GA Medicaid Fee Schedule,135.74,Pays at 88% of Total Billed charges,7.78,Pays at 103% of GA Medicaid Fee Schedule,7.55,138.83,92.55
Outpatient Medical Services,LAB,83036,Blood test to measure average blood glucose levels for past 2-3 months,300,43.26,36.77,Pays at 85% of Billed charges for outpatient setting,12.2,Pays at 100% of GA Medicaid Fee Schedule,34.62,Pays at 80.03% of Total Billed charges,9.9,Pays at 102% of Medicare OPPS Rate,38.93,Pays at 90% of Total Billed charges,12.2,Pays at 100% of GA Medicaid Fee Schedule,9.71,Pays at 100% of Medicare OPPS Rate,12.2,Pays at 100% of GA Medicaid Fee Schedule,38.07,Pays at 88% of Total Billed charges,12.57,Pays at 103% of GA Medicaid Fee Schedule,9.71,38.93,25.96
Outpatient Medical Services,LAB,83050,METHEMOGLOBIN,300,129.25,109.86,Pays at 85% of Billed charges for outpatient setting,9.21,Pays at 100% of GA Medicaid Fee Schedule,103.44,Pays at 80.03% of Total Billed charges,8.36,Pays at 102% of Medicare OPPS Rate,116.33,Pays at 90% of Total Billed charges,9.21,Pays at 100% of GA Medicaid Fee Schedule,8.19,Pays at 100% of Medicare OPPS Rate,9.21,Pays at 100% of GA Medicaid Fee Schedule,113.74,Pays at 88% of Total Billed charges,9.49,Pays at 103% of GA Medicaid Fee Schedule,8.19,116.33,77.55
Outpatient Medical Services,LAB,83051,"HEMOGLOBIN, PLASMA  (MAYO)",300,68.75,58.44,Pays at 85% of Billed charges for outpatient setting,9.19,Pays at 100% of GA Medicaid Fee Schedule,55.02,Pays at 80.03% of Total Billed charges,7.45,Pays at 102% of Medicare OPPS Rate,61.88,Pays at 90% of Total Billed charges,9.19,Pays at 100% of GA Medicaid Fee Schedule,7.31,Pays at 100% of Medicare OPPS Rate,9.19,Pays at 100% of GA Medicaid Fee Schedule,60.5,Pays at 88% of Total Billed charges,9.47,Pays at 103% of GA Medicaid Fee Schedule,7.31,61.88,41.25
Outpatient Medical Services,LAB,83068,"UNSTABLE HEMOGLOBIN, B  (MAYO)",300,74.75,63.54,Pays at 85% of Billed charges for outpatient setting,10.65,Pays at 100% of GA Medicaid Fee Schedule,59.82,Pays at 80.03% of Total Billed charges,9.65,Pays at 102% of Medicare OPPS Rate,67.28,Pays at 90% of Total Billed charges,10.65,Pays at 100% of GA Medicaid Fee Schedule,9.47,Pays at 100% of Medicare OPPS Rate,10.65,Pays at 100% of GA Medicaid Fee Schedule,65.78,Pays at 88% of Total Billed charges,10.97,Pays at 103% of GA Medicaid Fee Schedule,9.47,67.28,44.85
Outpatient Medical Services,LAB,83070,"HEMOSIDERIN, URINE  (MAYO)",300,49.75,42.29,Pays at 85% of Billed charges for outpatient setting,5.98,Pays at 100% of GA Medicaid Fee Schedule,39.81,Pays at 80.03% of Total Billed charges,4.84,Pays at 102% of Medicare OPPS Rate,44.78,Pays at 90% of Total Billed charges,5.98,Pays at 100% of GA Medicaid Fee Schedule,4.75,Pays at 100% of Medicare OPPS Rate,5.98,Pays at 100% of GA Medicaid Fee Schedule,43.78,Pays at 88% of Total Billed charges,6.16,Pays at 103% of GA Medicaid Fee Schedule,4.75,44.78,29.85
Outpatient Medical Services,LAB,83088,"HISTAMINE, WHOLE BLOOD   (MAYO)",300,115.5,98.18,Pays at 85% of Billed charges for outpatient setting,37.13,Pays at 100% of GA Medicaid Fee Schedule,92.43,Pays at 80.03% of Total Billed charges,30.12,Pays at 102% of Medicare OPPS Rate,103.95,Pays at 90% of Total Billed charges,37.13,Pays at 100% of GA Medicaid Fee Schedule,29.53,Pays at 100% of Medicare OPPS Rate,37.13,Pays at 100% of GA Medicaid Fee Schedule,101.64,Pays at 88% of Total Billed charges,38.24,Pays at 103% of GA Medicaid Fee Schedule,29.53,103.95,69.30
Outpatient Medical Services,LAB,83088,"HISTAMINE, URINE  (MAYO)",300,150.25,127.71,Pays at 85% of Billed charges for outpatient setting,37.13,Pays at 100% of GA Medicaid Fee Schedule,120.25,Pays at 80.03% of Total Billed charges,30.12,Pays at 102% of Medicare OPPS Rate,135.23,Pays at 90% of Total Billed charges,37.13,Pays at 100% of GA Medicaid Fee Schedule,29.53,Pays at 100% of Medicare OPPS Rate,37.13,Pays at 100% of GA Medicaid Fee Schedule,132.22,Pays at 88% of Total Billed charges,38.24,Pays at 103% of GA Medicaid Fee Schedule,29.53,135.23,90.15
Outpatient Medical Services,LAB,83088,HISTAMINE  PLASMA  (MAYO),300,199.5,169.58,Pays at 85% of Billed charges for outpatient setting,37.13,Pays at 100% of GA Medicaid Fee Schedule,159.66,Pays at 80.03% of Total Billed charges,30.12,Pays at 102% of Medicare OPPS Rate,179.55,Pays at 90% of Total Billed charges,37.13,Pays at 100% of GA Medicaid Fee Schedule,29.53,Pays at 100% of Medicare OPPS Rate,37.13,Pays at 100% of GA Medicaid Fee Schedule,175.56,Pays at 88% of Total Billed charges,38.24,Pays at 103% of GA Medicaid Fee Schedule,29.53,179.55,119.70
Outpatient Medical Services,LAB,83090,"HOMOCYSTEINE,SERUM  (MAYO)",300,53.75,45.69,Pays at 85% of Billed charges for outpatient setting,21.21,Pays at 100% of GA Medicaid Fee Schedule,43.02,Pays at 80.03% of Total Billed charges,18.27,Pays at 102% of Medicare OPPS Rate,48.38,Pays at 90% of Total Billed charges,21.21,Pays at 100% of GA Medicaid Fee Schedule,17.92,Pays at 100% of Medicare OPPS Rate,21.21,Pays at 100% of GA Medicaid Fee Schedule,47.3,Pays at 88% of Total Billed charges,21.85,Pays at 103% of GA Medicaid Fee Schedule,17.92,48.38,32.25
Outpatient Medical Services,LAB,83090,"HOMOCYSTEINE, URINE  (MAYO)",300,125.25,106.46,Pays at 85% of Billed charges for outpatient setting,21.21,Pays at 100% of GA Medicaid Fee Schedule,100.24,Pays at 80.03% of Total Billed charges,18.27,Pays at 102% of Medicare OPPS Rate,112.73,Pays at 90% of Total Billed charges,21.21,Pays at 100% of GA Medicaid Fee Schedule,17.92,Pays at 100% of Medicare OPPS Rate,21.21,Pays at 100% of GA Medicaid Fee Schedule,110.22,Pays at 88% of Total Billed charges,21.85,Pays at 103% of GA Medicaid Fee Schedule,17.92,112.73,75.15
Outpatient Medical Services,LAB,83150,"HOMOVANILIC ACID, URINE  (MAYO)",300,51.25,43.56,Pays at 85% of Billed charges for outpatient setting,24.34,Pays at 100% of GA Medicaid Fee Schedule,41.02,Pays at 80.03% of Total Billed charges,22.85,Pays at 102% of Medicare OPPS Rate,46.13,Pays at 90% of Total Billed charges,24.34,Pays at 100% of GA Medicaid Fee Schedule,22.41,Pays at 100% of Medicare OPPS Rate,24.34,Pays at 100% of GA Medicaid Fee Schedule,45.1,Pays at 88% of Total Billed charges,25.07,Pays at 103% of GA Medicaid Fee Schedule,22.41,46.13,30.75
Outpatient Medical Services,LAB,83497,"SEROTONIN, 5-HIAA  24HR URINE  (MAYO)",300,41.5,35.28,Pays at 85% of Billed charges for outpatient setting,16.21,Pays at 100% of GA Medicaid Fee Schedule,33.21,Pays at 80.03% of Total Billed charges,13.15,Pays at 102% of Medicare OPPS Rate,37.35,Pays at 90% of Total Billed charges,16.21,Pays at 100% of GA Medicaid Fee Schedule,12.9,Pays at 100% of Medicare OPPS Rate,16.21,Pays at 100% of GA Medicaid Fee Schedule,36.52,Pays at 88% of Total Billed charges,16.7,Pays at 103% of GA Medicaid Fee Schedule,12.9,37.35,24.90
Outpatient Medical Services,LAB,83497,"SEROTONIN, 5-HIAA  RANDOM  (MAYO)",300,90,76.5,Pays at 85% of Billed charges for outpatient setting,16.21,Pays at 100% of GA Medicaid Fee Schedule,72.03,Pays at 80.03% of Total Billed charges,13.15,Pays at 102% of Medicare OPPS Rate,81,Pays at 90% of Total Billed charges,16.21,Pays at 100% of GA Medicaid Fee Schedule,12.9,Pays at 100% of Medicare OPPS Rate,16.21,Pays at 100% of GA Medicaid Fee Schedule,79.2,Pays at 88% of Total Billed charges,16.7,Pays at 103% of GA Medicaid Fee Schedule,12.9,81,54.00
Outpatient Medical Services,LAB,83498,PROGESTERONE 17-OH  (MAYO),300,201.75,171.49,Pays at 85% of Billed charges for outpatient setting,34.16,Pays at 100% of GA Medicaid Fee Schedule,161.46,Pays at 80.03% of Total Billed charges,27.71,Pays at 102% of Medicare OPPS Rate,181.58,Pays at 90% of Total Billed charges,34.16,Pays at 100% of GA Medicaid Fee Schedule,27.17,Pays at 100% of Medicare OPPS Rate,34.16,Pays at 100% of GA Medicaid Fee Schedule,177.54,Pays at 88% of Total Billed charges,35.18,Pays at 103% of GA Medicaid Fee Schedule,27.17,181.58,121.05
Outpatient Medical Services,LAB,83505,"HYDROXYPROLINE, TOTAL  (MAYO)",300,70.5,59.93,Pays at 85% of Billed charges for outpatient setting,30.56,Pays at 100% of GA Medicaid Fee Schedule,56.42,Pays at 80.03% of Total Billed charges,24.78,Pays at 102% of Medicare OPPS Rate,63.45,Pays at 90% of Total Billed charges,30.56,Pays at 100% of GA Medicaid Fee Schedule,24.3,Pays at 100% of Medicare OPPS Rate,30.56,Pays at 100% of GA Medicaid Fee Schedule,62.04,Pays at 88% of Total Billed charges,31.48,Pays at 103% of GA Medicaid Fee Schedule,24.3,63.45,42.30
Outpatient Medical Services,LAB,83505,HYDROXYZINE (VISTARIL)  (MAYO),300,86,73.1,Pays at 85% of Billed charges for outpatient setting,30.56,Pays at 100% of GA Medicaid Fee Schedule,68.83,Pays at 80.03% of Total Billed charges,24.78,Pays at 102% of Medicare OPPS Rate,77.4,Pays at 90% of Total Billed charges,30.56,Pays at 100% of GA Medicaid Fee Schedule,24.3,Pays at 100% of Medicare OPPS Rate,30.56,Pays at 100% of GA Medicaid Fee Schedule,75.68,Pays at 88% of Total Billed charges,31.48,Pays at 103% of GA Medicaid Fee Schedule,24.3,77.4,51.60
Outpatient Medical Services,LAB,83516,Chemical test of the blood to measure presence or concentration of a substance in the blood,300,37.25,31.66,Pays at 85% of Billed charges for outpatient setting,13.45,Pays at 100% of GA Medicaid Fee Schedule,29.81,Pays at 80.03% of Total Billed charges,11.76,Pays at 102% of Medicare OPPS Rate,33.53,Pays at 90% of Total Billed charges,13.45,Pays at 100% of GA Medicaid Fee Schedule,11.53,Pays at 100% of Medicare OPPS Rate,13.45,Pays at 100% of GA Medicaid Fee Schedule,32.78,Pays at 88% of Total Billed charges,13.85,Pays at 103% of GA Medicaid Fee Schedule,11.53,33.53,22.35
Outpatient Medical Services,LAB,83516,Chemical test of the blood to measure presence or concentration of a substance in the blood,300,37.25,31.66,Pays at 85% of Billed charges for outpatient setting,13.45,Pays at 100% of GA Medicaid Fee Schedule,29.81,Pays at 80.03% of Total Billed charges,11.76,Pays at 102% of Medicare OPPS Rate,33.53,Pays at 90% of Total Billed charges,13.45,Pays at 100% of GA Medicaid Fee Schedule,11.53,Pays at 100% of Medicare OPPS Rate,13.45,Pays at 100% of GA Medicaid Fee Schedule,32.78,Pays at 88% of Total Billed charges,13.85,Pays at 103% of GA Medicaid Fee Schedule,11.53,33.53,22.35
Outpatient Medical Services,LAB,83516,Chemical test of the blood to measure presence or concentration of a substance in the blood,300,37.25,31.66,Pays at 85% of Billed charges for outpatient setting,13.45,Pays at 100% of GA Medicaid Fee Schedule,29.81,Pays at 80.03% of Total Billed charges,11.76,Pays at 102% of Medicare OPPS Rate,33.53,Pays at 90% of Total Billed charges,13.45,Pays at 100% of GA Medicaid Fee Schedule,11.53,Pays at 100% of Medicare OPPS Rate,13.45,Pays at 100% of GA Medicaid Fee Schedule,32.78,Pays at 88% of Total Billed charges,13.85,Pays at 103% of GA Medicaid Fee Schedule,11.53,33.53,22.35
Outpatient Medical Services,LAB,83516,Chemical test of the blood to measure presence or concentration of a substance in the blood,300,37.25,31.66,Pays at 85% of Billed charges for outpatient setting,13.45,Pays at 100% of GA Medicaid Fee Schedule,29.81,Pays at 80.03% of Total Billed charges,11.76,Pays at 102% of Medicare OPPS Rate,33.53,Pays at 90% of Total Billed charges,13.45,Pays at 100% of GA Medicaid Fee Schedule,11.53,Pays at 100% of Medicare OPPS Rate,13.45,Pays at 100% of GA Medicaid Fee Schedule,32.78,Pays at 88% of Total Billed charges,13.85,Pays at 103% of GA Medicaid Fee Schedule,11.53,33.53,22.35
Outpatient Medical Services,LAB,83516,Chemical test of the blood to measure presence or concentration of a substance in the blood,300,53.75,45.69,Pays at 85% of Billed charges for outpatient setting,13.45,Pays at 100% of GA Medicaid Fee Schedule,43.02,Pays at 80.03% of Total Billed charges,11.76,Pays at 102% of Medicare OPPS Rate,48.38,Pays at 90% of Total Billed charges,13.45,Pays at 100% of GA Medicaid Fee Schedule,11.53,Pays at 100% of Medicare OPPS Rate,13.45,Pays at 100% of GA Medicaid Fee Schedule,47.3,Pays at 88% of Total Billed charges,13.85,Pays at 103% of GA Medicaid Fee Schedule,11.53,48.38,32.25
Outpatient Medical Services,LAB,83516,Chemical test of the blood to measure presence or concentration of a substance in the blood,300,55,46.75,Pays at 85% of Billed charges for outpatient setting,13.45,Pays at 100% of GA Medicaid Fee Schedule,44.02,Pays at 80.03% of Total Billed charges,11.76,Pays at 102% of Medicare OPPS Rate,49.5,Pays at 90% of Total Billed charges,13.45,Pays at 100% of GA Medicaid Fee Schedule,11.53,Pays at 100% of Medicare OPPS Rate,13.45,Pays at 100% of GA Medicaid Fee Schedule,48.4,Pays at 88% of Total Billed charges,13.85,Pays at 103% of GA Medicaid Fee Schedule,11.53,49.5,33.00
Outpatient Medical Services,LAB,83516,Chemical test of the blood to measure presence or concentration of a substance in the blood,300,55,46.75,Pays at 85% of Billed charges for outpatient setting,13.45,Pays at 100% of GA Medicaid Fee Schedule,44.02,Pays at 80.03% of Total Billed charges,11.76,Pays at 102% of Medicare OPPS Rate,49.5,Pays at 90% of Total Billed charges,13.45,Pays at 100% of GA Medicaid Fee Schedule,11.53,Pays at 100% of Medicare OPPS Rate,13.45,Pays at 100% of GA Medicaid Fee Schedule,48.4,Pays at 88% of Total Billed charges,13.85,Pays at 103% of GA Medicaid Fee Schedule,11.53,49.5,33.00
Outpatient Medical Services,LAB,83516,Chemical test of the blood to measure presence or concentration of a substance in the blood,300,64.75,55.04,Pays at 85% of Billed charges for outpatient setting,13.45,Pays at 100% of GA Medicaid Fee Schedule,51.82,Pays at 80.03% of Total Billed charges,11.76,Pays at 102% of Medicare OPPS Rate,58.28,Pays at 90% of Total Billed charges,13.45,Pays at 100% of GA Medicaid Fee Schedule,11.53,Pays at 100% of Medicare OPPS Rate,13.45,Pays at 100% of GA Medicaid Fee Schedule,56.98,Pays at 88% of Total Billed charges,13.85,Pays at 103% of GA Medicaid Fee Schedule,11.53,58.28,38.85
Outpatient Medical Services,LAB,83516,Chemical test of the blood to measure presence or concentration of a substance in the blood,300,71.86,61.08,Pays at 85% of Billed charges for outpatient setting,13.45,Pays at 100% of GA Medicaid Fee Schedule,57.51,Pays at 80.03% of Total Billed charges,11.76,Pays at 102% of Medicare OPPS Rate,64.67,Pays at 90% of Total Billed charges,13.45,Pays at 100% of GA Medicaid Fee Schedule,11.53,Pays at 100% of Medicare OPPS Rate,13.45,Pays at 100% of GA Medicaid Fee Schedule,63.24,Pays at 88% of Total Billed charges,13.85,Pays at 103% of GA Medicaid Fee Schedule,11.53,64.67,43.12
Outpatient Medical Services,LAB,83516,Chemical test of the blood to measure presence or concentration of a substance in the blood,300,110.12,93.6,Pays at 85% of Billed charges for outpatient setting,13.45,Pays at 100% of GA Medicaid Fee Schedule,88.13,Pays at 80.03% of Total Billed charges,11.76,Pays at 102% of Medicare OPPS Rate,99.11,Pays at 90% of Total Billed charges,13.45,Pays at 100% of GA Medicaid Fee Schedule,11.53,Pays at 100% of Medicare OPPS Rate,13.45,Pays at 100% of GA Medicaid Fee Schedule,96.91,Pays at 88% of Total Billed charges,13.85,Pays at 103% of GA Medicaid Fee Schedule,11.53,99.11,66.07
Outpatient Medical Services,LAB,83516,Chemical test of the blood to measure presence or concentration of a substance in the blood,300,169.75,144.29,Pays at 85% of Billed charges for outpatient setting,13.45,Pays at 100% of GA Medicaid Fee Schedule,135.85,Pays at 80.03% of Total Billed charges,11.76,Pays at 102% of Medicare OPPS Rate,152.78,Pays at 90% of Total Billed charges,13.45,Pays at 100% of GA Medicaid Fee Schedule,11.53,Pays at 100% of Medicare OPPS Rate,13.45,Pays at 100% of GA Medicaid Fee Schedule,149.38,Pays at 88% of Total Billed charges,13.85,Pays at 103% of GA Medicaid Fee Schedule,11.53,152.78,101.85
Outpatient Medical Services,LAB,83516,Chemical test of the blood to measure presence or concentration of a substance in the blood,300,199.08,169.22,Pays at 85% of Billed charges for outpatient setting,13.45,Pays at 100% of GA Medicaid Fee Schedule,159.32,Pays at 80.03% of Total Billed charges,11.76,Pays at 102% of Medicare OPPS Rate,179.17,Pays at 90% of Total Billed charges,13.45,Pays at 100% of GA Medicaid Fee Schedule,11.53,Pays at 100% of Medicare OPPS Rate,13.45,Pays at 100% of GA Medicaid Fee Schedule,175.19,Pays at 88% of Total Billed charges,13.85,Pays at 103% of GA Medicaid Fee Schedule,11.53,179.17,119.45
Outpatient Medical Services,LAB,83516,Chemical test of the blood to measure presence or concentration of a substance in the blood,300,374.25,318.11,Pays at 85% of Billed charges for outpatient setting,13.45,Pays at 100% of GA Medicaid Fee Schedule,299.51,Pays at 80.03% of Total Billed charges,11.76,Pays at 102% of Medicare OPPS Rate,336.83,Pays at 90% of Total Billed charges,13.45,Pays at 100% of GA Medicaid Fee Schedule,11.53,Pays at 100% of Medicare OPPS Rate,13.45,Pays at 100% of GA Medicaid Fee Schedule,329.34,Pays at 88% of Total Billed charges,13.85,Pays at 103% of GA Medicaid Fee Schedule,11.53,336.83,224.55
Outpatient Medical Services,LAB,83519,IgF-BP3  (MAYO),300,56.25,47.81,Pays at 85% of Billed charges for outpatient setting,16.99,Pays at 100% of GA Medicaid Fee Schedule,45.02,Pays at 80.03% of Total Billed charges,18.76,Pays at 102% of Medicare OPPS Rate,50.63,Pays at 90% of Total Billed charges,16.99,Pays at 100% of GA Medicaid Fee Schedule,18.39,Pays at 100% of Medicare OPPS Rate,16.99,Pays at 100% of GA Medicaid Fee Schedule,49.5,Pays at 88% of Total Billed charges,17.5,Pays at 103% of GA Medicaid Fee Schedule,16.99,50.63,33.75
Outpatient Medical Services,LAB,83519,ACETYLCHOLINE RECEPTOR BINDING AB (MAYO),300,147,124.95,Pays at 85% of Billed charges for outpatient setting,16.99,Pays at 100% of GA Medicaid Fee Schedule,117.64,Pays at 80.03% of Total Billed charges,18.76,Pays at 102% of Medicare OPPS Rate,132.3,Pays at 90% of Total Billed charges,16.99,Pays at 100% of GA Medicaid Fee Schedule,18.39,Pays at 100% of Medicare OPPS Rate,16.99,Pays at 100% of GA Medicaid Fee Schedule,129.36,Pays at 88% of Total Billed charges,17.5,Pays at 103% of GA Medicaid Fee Schedule,16.99,132.3,88.20
Outpatient Medical Services,LAB,83519,NEURONAL (V-G) K+ CHANNEL AB (MAYO),300,147,124.95,Pays at 85% of Billed charges for outpatient setting,16.99,Pays at 100% of GA Medicaid Fee Schedule,117.64,Pays at 80.03% of Total Billed charges,18.76,Pays at 102% of Medicare OPPS Rate,132.3,Pays at 90% of Total Billed charges,16.99,Pays at 100% of GA Medicaid Fee Schedule,18.39,Pays at 100% of Medicare OPPS Rate,16.99,Pays at 100% of GA Medicaid Fee Schedule,129.36,Pays at 88% of Total Billed charges,17.5,Pays at 103% of GA Medicaid Fee Schedule,16.99,132.3,88.20
Outpatient Medical Services,LAB,83519,N-TYPE CALCIUM CHANNEL AB (MAYO),300,147,124.95,Pays at 85% of Billed charges for outpatient setting,16.99,Pays at 100% of GA Medicaid Fee Schedule,117.64,Pays at 80.03% of Total Billed charges,18.76,Pays at 102% of Medicare OPPS Rate,132.3,Pays at 90% of Total Billed charges,16.99,Pays at 100% of GA Medicaid Fee Schedule,18.39,Pays at 100% of Medicare OPPS Rate,16.99,Pays at 100% of GA Medicaid Fee Schedule,129.36,Pays at 88% of Total Billed charges,17.5,Pays at 103% of GA Medicaid Fee Schedule,16.99,132.3,88.20
Outpatient Medical Services,LAB,83519,P/Q-TYPE CALCIUM CHANNEL AB (MAYO),300,147,124.95,Pays at 85% of Billed charges for outpatient setting,16.99,Pays at 100% of GA Medicaid Fee Schedule,117.64,Pays at 80.03% of Total Billed charges,18.76,Pays at 102% of Medicare OPPS Rate,132.3,Pays at 90% of Total Billed charges,16.99,Pays at 100% of GA Medicaid Fee Schedule,18.39,Pays at 100% of Medicare OPPS Rate,16.99,Pays at 100% of GA Medicaid Fee Schedule,129.36,Pays at 88% of Total Billed charges,17.5,Pays at 103% of GA Medicaid Fee Schedule,16.99,132.3,88.20
Outpatient Medical Services,LAB,83519,ACHR GANGLIONIC NEURONAL AB (MAYO),300,147,124.95,Pays at 85% of Billed charges for outpatient setting,16.99,Pays at 100% of GA Medicaid Fee Schedule,117.64,Pays at 80.03% of Total Billed charges,18.76,Pays at 102% of Medicare OPPS Rate,132.3,Pays at 90% of Total Billed charges,16.99,Pays at 100% of GA Medicaid Fee Schedule,18.39,Pays at 100% of Medicare OPPS Rate,16.99,Pays at 100% of GA Medicaid Fee Schedule,129.36,Pays at 88% of Total Billed charges,17.5,Pays at 103% of GA Medicaid Fee Schedule,16.99,132.3,88.20
Outpatient Medical Services,LAB,83519,"PANCREATIC POLYPEPTIDE, PLASMA  (MAYO)",300,171.25,145.56,Pays at 85% of Billed charges for outpatient setting,16.99,Pays at 100% of GA Medicaid Fee Schedule,137.05,Pays at 80.03% of Total Billed charges,18.76,Pays at 102% of Medicare OPPS Rate,154.13,Pays at 90% of Total Billed charges,16.99,Pays at 100% of GA Medicaid Fee Schedule,18.39,Pays at 100% of Medicare OPPS Rate,16.99,Pays at 100% of GA Medicaid Fee Schedule,150.7,Pays at 88% of Total Billed charges,17.5,Pays at 103% of GA Medicaid Fee Schedule,16.99,154.13,102.75
Outpatient Medical Services,LAB,83519,PEPSINOGEN  (MAYO),300,208.75,177.44,Pays at 85% of Billed charges for outpatient setting,16.99,Pays at 100% of GA Medicaid Fee Schedule,167.06,Pays at 80.03% of Total Billed charges,18.76,Pays at 102% of Medicare OPPS Rate,187.88,Pays at 90% of Total Billed charges,16.99,Pays at 100% of GA Medicaid Fee Schedule,18.39,Pays at 100% of Medicare OPPS Rate,16.99,Pays at 100% of GA Medicaid Fee Schedule,183.7,Pays at 88% of Total Billed charges,17.5,Pays at 103% of GA Medicaid Fee Schedule,16.99,187.88,125.25
Outpatient Medical Services,LAB,83519,INSULIN-LIKE GROWTH FACTOR II (MAYO),300,262.25,222.91,Pays at 85% of Billed charges for outpatient setting,16.99,Pays at 100% of GA Medicaid Fee Schedule,209.88,Pays at 80.03% of Total Billed charges,18.76,Pays at 102% of Medicare OPPS Rate,236.03,Pays at 90% of Total Billed charges,16.99,Pays at 100% of GA Medicaid Fee Schedule,18.39,Pays at 100% of Medicare OPPS Rate,16.99,Pays at 100% of GA Medicaid Fee Schedule,230.78,Pays at 88% of Total Billed charges,17.5,Pays at 103% of GA Medicaid Fee Schedule,16.99,236.03,157.35
Outpatient Medical Services,LAB,83519,PTH AB  (MAYO),300,298,253.3,Pays at 85% of Billed charges for outpatient setting,16.99,Pays at 100% of GA Medicaid Fee Schedule,238.49,Pays at 80.03% of Total Billed charges,18.76,Pays at 102% of Medicare OPPS Rate,268.2,Pays at 90% of Total Billed charges,16.99,Pays at 100% of GA Medicaid Fee Schedule,18.39,Pays at 100% of Medicare OPPS Rate,16.99,Pays at 100% of GA Medicaid Fee Schedule,262.24,Pays at 88% of Total Billed charges,17.5,Pays at 103% of GA Medicaid Fee Schedule,16.99,268.2,178.80
Outpatient Medical Services,LAB,83519,"ELASTASE, STOOL  (MAYO)",300,374.75,318.54,Pays at 85% of Billed charges for outpatient setting,16.99,Pays at 100% of GA Medicaid Fee Schedule,299.91,Pays at 80.03% of Total Billed charges,18.76,Pays at 102% of Medicare OPPS Rate,337.28,Pays at 90% of Total Billed charges,16.99,Pays at 100% of GA Medicaid Fee Schedule,18.39,Pays at 100% of Medicare OPPS Rate,16.99,Pays at 100% of GA Medicaid Fee Schedule,329.78,Pays at 88% of Total Billed charges,17.5,Pays at 103% of GA Medicaid Fee Schedule,16.99,337.28,224.85
Outpatient Medical Services,LAB,83519,GROWTH HORMONE RELEASING HORMONE  (MAYO),300,375,318.75,Pays at 85% of Billed charges for outpatient setting,16.99,Pays at 100% of GA Medicaid Fee Schedule,300.11,Pays at 80.03% of Total Billed charges,18.76,Pays at 102% of Medicare OPPS Rate,337.5,Pays at 90% of Total Billed charges,16.99,Pays at 100% of GA Medicaid Fee Schedule,18.39,Pays at 100% of Medicare OPPS Rate,16.99,Pays at 100% of GA Medicaid Fee Schedule,330,Pays at 88% of Total Billed charges,17.5,Pays at 103% of GA Medicaid Fee Schedule,16.99,337.5,225.00
Outpatient Medical Services,LAB,83519,"MuSK AUTO ANTIBODY, SERUM",300,1700,1445,Pays at 85% of Billed charges for outpatient setting,16.99,Pays at 100% of GA Medicaid Fee Schedule,1360.51,Pays at 80.03% of Total Billed charges,18.76,Pays at 102% of Medicare OPPS Rate,1530,Pays at 90% of Total Billed charges,16.99,Pays at 100% of GA Medicaid Fee Schedule,18.39,Pays at 100% of Medicare OPPS Rate,16.99,Pays at 100% of GA Medicaid Fee Schedule,1496,Pays at 88% of Total Billed charges,17.5,Pays at 103% of GA Medicaid Fee Schedule,16.99,1530,1020.00
Outpatient Medical Services,LAB,83520,ANTI-GLOMERULAR BASEMENT  (MAYO),300,54.5,46.33,Pays at 85% of Billed charges for outpatient setting,16.28,Pays at 100% of GA Medicaid Fee Schedule,43.62,Pays at 80.03% of Total Billed charges,17.61,Pays at 102% of Medicare OPPS Rate,49.05,Pays at 90% of Total Billed charges,16.28,Pays at 100% of GA Medicaid Fee Schedule,17.27,Pays at 100% of Medicare OPPS Rate,16.28,Pays at 100% of GA Medicaid Fee Schedule,47.96,Pays at 88% of Total Billed charges,16.77,Pays at 103% of GA Medicaid Fee Schedule,16.28,49.05,32.70
Outpatient Medical Services,LAB,83520,ALPHA SUBUNIT PITUITARY MARKER  (MAYO),300,64,54.4,Pays at 85% of Billed charges for outpatient setting,16.28,Pays at 100% of GA Medicaid Fee Schedule,51.22,Pays at 80.03% of Total Billed charges,17.61,Pays at 102% of Medicare OPPS Rate,57.6,Pays at 90% of Total Billed charges,16.28,Pays at 100% of GA Medicaid Fee Schedule,17.27,Pays at 100% of Medicare OPPS Rate,16.28,Pays at 100% of GA Medicaid Fee Schedule,56.32,Pays at 88% of Total Billed charges,16.77,Pays at 103% of GA Medicaid Fee Schedule,16.28,57.6,38.40
Outpatient Medical Services,LAB,83520,C. DIFFICLE TOXIN GENE PCR  (MAYO),300,78,66.3,Pays at 85% of Billed charges for outpatient setting,16.28,Pays at 100% of GA Medicaid Fee Schedule,62.42,Pays at 80.03% of Total Billed charges,17.61,Pays at 102% of Medicare OPPS Rate,70.2,Pays at 90% of Total Billed charges,16.28,Pays at 100% of GA Medicaid Fee Schedule,17.27,Pays at 100% of Medicare OPPS Rate,16.28,Pays at 100% of GA Medicaid Fee Schedule,68.64,Pays at 88% of Total Billed charges,16.77,Pays at 103% of GA Medicaid Fee Schedule,16.28,70.2,46.80
Outpatient Medical Services,LAB,83520,"SOMATOMEDIN-C, PLASMA",300,85,72.25,Pays at 85% of Billed charges for outpatient setting,16.28,Pays at 100% of GA Medicaid Fee Schedule,68.03,Pays at 80.03% of Total Billed charges,17.61,Pays at 102% of Medicare OPPS Rate,76.5,Pays at 90% of Total Billed charges,16.28,Pays at 100% of GA Medicaid Fee Schedule,17.27,Pays at 100% of Medicare OPPS Rate,16.28,Pays at 100% of GA Medicaid Fee Schedule,74.8,Pays at 88% of Total Billed charges,16.77,Pays at 103% of GA Medicaid Fee Schedule,16.28,76.5,51.00
Outpatient Medical Services,LAB,83520,DISOPYRAMIDE LEVEL  (MAYO),300,114.25,97.11,Pays at 85% of Billed charges for outpatient setting,16.28,Pays at 100% of GA Medicaid Fee Schedule,91.43,Pays at 80.03% of Total Billed charges,17.61,Pays at 102% of Medicare OPPS Rate,102.83,Pays at 90% of Total Billed charges,16.28,Pays at 100% of GA Medicaid Fee Schedule,17.27,Pays at 100% of Medicare OPPS Rate,16.28,Pays at 100% of GA Medicaid Fee Schedule,100.54,Pays at 88% of Total Billed charges,16.77,Pays at 103% of GA Medicaid Fee Schedule,16.28,102.83,68.55
Outpatient Medical Services,LAB,83520,TRYPTASE  (MAYO),300,120.75,102.64,Pays at 85% of Billed charges for outpatient setting,16.28,Pays at 100% of GA Medicaid Fee Schedule,96.64,Pays at 80.03% of Total Billed charges,17.61,Pays at 102% of Medicare OPPS Rate,108.68,Pays at 90% of Total Billed charges,16.28,Pays at 100% of GA Medicaid Fee Schedule,17.27,Pays at 100% of Medicare OPPS Rate,16.28,Pays at 100% of GA Medicaid Fee Schedule,106.26,Pays at 88% of Total Billed charges,16.77,Pays at 103% of GA Medicaid Fee Schedule,16.28,108.68,72.45
Outpatient Medical Services,LAB,83520,"STRIATIONAL, STRIATED MUSCLE AB  (MAYO)",300,137.75,117.09,Pays at 85% of Billed charges for outpatient setting,16.28,Pays at 100% of GA Medicaid Fee Schedule,110.24,Pays at 80.03% of Total Billed charges,17.61,Pays at 102% of Medicare OPPS Rate,123.98,Pays at 90% of Total Billed charges,16.28,Pays at 100% of GA Medicaid Fee Schedule,17.27,Pays at 100% of Medicare OPPS Rate,16.28,Pays at 100% of GA Medicaid Fee Schedule,121.22,Pays at 88% of Total Billed charges,16.77,Pays at 103% of GA Medicaid Fee Schedule,16.28,123.98,82.65
Outpatient Medical Services,LAB,83520,INHIBIN A  (MAYO),300,137.75,117.09,Pays at 85% of Billed charges for outpatient setting,16.28,Pays at 100% of GA Medicaid Fee Schedule,110.24,Pays at 80.03% of Total Billed charges,17.61,Pays at 102% of Medicare OPPS Rate,123.98,Pays at 90% of Total Billed charges,16.28,Pays at 100% of GA Medicaid Fee Schedule,17.27,Pays at 100% of Medicare OPPS Rate,16.28,Pays at 100% of GA Medicaid Fee Schedule,121.22,Pays at 88% of Total Billed charges,16.77,Pays at 103% of GA Medicaid Fee Schedule,16.28,123.98,82.65
Outpatient Medical Services,LAB,83520,INTERLEUKIN 6 (IL-6)  (MAYO),300,145,123.25,Pays at 85% of Billed charges for outpatient setting,16.28,Pays at 100% of GA Medicaid Fee Schedule,116.04,Pays at 80.03% of Total Billed charges,17.61,Pays at 102% of Medicare OPPS Rate,130.5,Pays at 90% of Total Billed charges,16.28,Pays at 100% of GA Medicaid Fee Schedule,17.27,Pays at 100% of Medicare OPPS Rate,16.28,Pays at 100% of GA Medicaid Fee Schedule,127.6,Pays at 88% of Total Billed charges,16.77,Pays at 103% of GA Medicaid Fee Schedule,16.28,130.5,87.00
Outpatient Medical Services,LAB,83520,ANTI-SACCHAROMYCES-CEREVISIAE IGA  (MAYO,300,172,146.2,Pays at 85% of Billed charges for outpatient setting,16.28,Pays at 100% of GA Medicaid Fee Schedule,137.65,Pays at 80.03% of Total Billed charges,17.61,Pays at 102% of Medicare OPPS Rate,154.8,Pays at 90% of Total Billed charges,16.28,Pays at 100% of GA Medicaid Fee Schedule,17.27,Pays at 100% of Medicare OPPS Rate,16.28,Pays at 100% of GA Medicaid Fee Schedule,151.36,Pays at 88% of Total Billed charges,16.77,Pays at 103% of GA Medicaid Fee Schedule,16.28,154.8,103.20
Outpatient Medical Services,LAB,83520,COLLAGEN TYPE II AB  (MAYO),300,174.75,148.54,Pays at 85% of Billed charges for outpatient setting,16.28,Pays at 100% of GA Medicaid Fee Schedule,139.85,Pays at 80.03% of Total Billed charges,17.61,Pays at 102% of Medicare OPPS Rate,157.28,Pays at 90% of Total Billed charges,16.28,Pays at 100% of GA Medicaid Fee Schedule,17.27,Pays at 100% of Medicare OPPS Rate,16.28,Pays at 100% of GA Medicaid Fee Schedule,153.78,Pays at 88% of Total Billed charges,16.77,Pays at 103% of GA Medicaid Fee Schedule,16.28,157.28,104.85
Outpatient Medical Services,LAB,83520,GANGLIOSIDE AB (ANTI-GM1)  (MAYO),300,205.75,174.89,Pays at 85% of Billed charges for outpatient setting,16.28,Pays at 100% of GA Medicaid Fee Schedule,164.66,Pays at 80.03% of Total Billed charges,17.61,Pays at 102% of Medicare OPPS Rate,185.18,Pays at 90% of Total Billed charges,16.28,Pays at 100% of GA Medicaid Fee Schedule,17.27,Pays at 100% of Medicare OPPS Rate,16.28,Pays at 100% of GA Medicaid Fee Schedule,181.06,Pays at 88% of Total Billed charges,16.77,Pays at 103% of GA Medicaid Fee Schedule,16.28,185.18,123.45
Outpatient Medical Services,LAB,83520,"ANTIMULLERIAN HORMONE, SERUM  (MAYO)",300,217.75,185.09,Pays at 85% of Billed charges for outpatient setting,16.28,Pays at 100% of GA Medicaid Fee Schedule,174.27,Pays at 80.03% of Total Billed charges,17.61,Pays at 102% of Medicare OPPS Rate,195.98,Pays at 90% of Total Billed charges,16.28,Pays at 100% of GA Medicaid Fee Schedule,17.27,Pays at 100% of Medicare OPPS Rate,16.28,Pays at 100% of GA Medicaid Fee Schedule,191.62,Pays at 88% of Total Billed charges,16.77,Pays at 103% of GA Medicaid Fee Schedule,16.28,195.98,130.65
Outpatient Medical Services,LAB,83520,"PLASMINOGEN ACTIVATOR, PAI-1  (MAYO)",300,276.25,234.81,Pays at 85% of Billed charges for outpatient setting,16.28,Pays at 100% of GA Medicaid Fee Schedule,221.08,Pays at 80.03% of Total Billed charges,17.61,Pays at 102% of Medicare OPPS Rate,248.63,Pays at 90% of Total Billed charges,16.28,Pays at 100% of GA Medicaid Fee Schedule,17.27,Pays at 100% of Medicare OPPS Rate,16.28,Pays at 100% of GA Medicaid Fee Schedule,243.1,Pays at 88% of Total Billed charges,16.77,Pays at 103% of GA Medicaid Fee Schedule,16.28,248.63,165.75
Outpatient Medical Services,LAB,83520,"MONOCLONAL GAMMOPATHY, DIAGNOSTIC (MAYO)",300,297.17,252.59,Pays at 85% of Billed charges for outpatient setting,16.28,Pays at 100% of GA Medicaid Fee Schedule,237.83,Pays at 80.03% of Total Billed charges,17.61,Pays at 102% of Medicare OPPS Rate,267.45,Pays at 90% of Total Billed charges,16.28,Pays at 100% of GA Medicaid Fee Schedule,17.27,Pays at 100% of Medicare OPPS Rate,16.28,Pays at 100% of GA Medicaid Fee Schedule,261.51,Pays at 88% of Total Billed charges,16.77,Pays at 103% of GA Medicaid Fee Schedule,16.28,267.45,178.30
Outpatient Medical Services,LAB,83520,SULFATIDE AUTOANTIBODY (MAYO),300,756.25,642.81,Pays at 85% of Billed charges for outpatient setting,16.28,Pays at 100% of GA Medicaid Fee Schedule,605.23,Pays at 80.03% of Total Billed charges,17.61,Pays at 102% of Medicare OPPS Rate,680.63,Pays at 90% of Total Billed charges,16.28,Pays at 100% of GA Medicaid Fee Schedule,17.27,Pays at 100% of Medicare OPPS Rate,16.28,Pays at 100% of GA Medicaid Fee Schedule,665.5,Pays at 88% of Total Billed charges,16.77,Pays at 103% of GA Medicaid Fee Schedule,16.28,680.63,453.75
Outpatient Medical Services,LAB,83525,"INSULIN, TOTAL SERUM  (MAYO)",300,30.25,25.71,Pays at 85% of Billed charges for outpatient setting,14.38,Pays at 100% of GA Medicaid Fee Schedule,24.21,Pays at 80.03% of Total Billed charges,11.65,Pays at 102% of Medicare OPPS Rate,27.23,Pays at 90% of Total Billed charges,14.38,Pays at 100% of GA Medicaid Fee Schedule,11.43,Pays at 100% of Medicare OPPS Rate,14.38,Pays at 100% of GA Medicaid Fee Schedule,26.62,Pays at 88% of Total Billed charges,14.81,Pays at 103% of GA Medicaid Fee Schedule,11.43,27.23,18.15
Outpatient Medical Services,LAB,83525,INSULIN  (MAYO),300,36.25,30.81,Pays at 85% of Billed charges for outpatient setting,14.38,Pays at 100% of GA Medicaid Fee Schedule,29.01,Pays at 80.03% of Total Billed charges,11.65,Pays at 102% of Medicare OPPS Rate,32.63,Pays at 90% of Total Billed charges,14.38,Pays at 100% of GA Medicaid Fee Schedule,11.43,Pays at 100% of Medicare OPPS Rate,14.38,Pays at 100% of GA Medicaid Fee Schedule,31.9,Pays at 88% of Total Billed charges,14.81,Pays at 103% of GA Medicaid Fee Schedule,11.43,32.63,21.75
Outpatient Medical Services,LAB,83527,".INSULIN, FREE SERUM  (MAYO)",300,34.25,29.11,Pays at 85% of Billed charges for outpatient setting,16.28,Pays at 100% of GA Medicaid Fee Schedule,27.41,Pays at 80.03% of Total Billed charges,13.2,Pays at 102% of Medicare OPPS Rate,30.83,Pays at 90% of Total Billed charges,16.28,Pays at 100% of GA Medicaid Fee Schedule,12.95,Pays at 100% of Medicare OPPS Rate,16.28,Pays at 100% of GA Medicaid Fee Schedule,30.14,Pays at 88% of Total Billed charges,16.77,Pays at 103% of GA Medicaid Fee Schedule,12.95,30.83,20.55
Outpatient Medical Services,LAB,83528,INTRINSIC FACTOR  (MAYO),300,66.25,56.31,Pays at 85% of Billed charges for outpatient setting,20,Pays at 100% of GA Medicaid Fee Schedule,53.02,Pays at 80.03% of Total Billed charges,20.21,Pays at 102% of Medicare OPPS Rate,59.63,Pays at 90% of Total Billed charges,20,Pays at 100% of GA Medicaid Fee Schedule,19.82,Pays at 100% of Medicare OPPS Rate,20,Pays at 100% of GA Medicaid Fee Schedule,58.3,Pays at 88% of Total Billed charges,20.6,Pays at 103% of GA Medicaid Fee Schedule,19.82,59.63,39.75
Outpatient Medical Services,LAB,83540,Blood test to measure the amount of iron that is in transit in the body,300,33.01,28.06,Pays at 85% of Billed charges for outpatient setting,8.15,Pays at 100% of GA Medicaid Fee Schedule,26.42,Pays at 80.03% of Total Billed charges,6.59,Pays at 102% of Medicare OPPS Rate,29.71,Pays at 90% of Total Billed charges,8.15,Pays at 100% of GA Medicaid Fee Schedule,6.47,Pays at 100% of Medicare OPPS Rate,8.15,Pays at 100% of GA Medicaid Fee Schedule,29.05,Pays at 88% of Total Billed charges,8.39,Pays at 103% of GA Medicaid Fee Schedule,6.47,29.71,19.81
Outpatient Medical Services,LAB,83540,Blood test to measure the amount of iron that is in transit in the body,300,213.25,181.26,Pays at 85% of Billed charges for outpatient setting,8.15,Pays at 100% of GA Medicaid Fee Schedule,170.66,Pays at 80.03% of Total Billed charges,6.59,Pays at 102% of Medicare OPPS Rate,191.93,Pays at 90% of Total Billed charges,8.15,Pays at 100% of GA Medicaid Fee Schedule,6.47,Pays at 100% of Medicare OPPS Rate,8.15,Pays at 100% of GA Medicaid Fee Schedule,187.66,Pays at 88% of Total Billed charges,8.39,Pays at 103% of GA Medicaid Fee Schedule,6.47,191.93,127.95
Outpatient Medical Services,LAB,83582,17 KETOGENIC STEROIDS  (MAYO),300,113.25,96.26,Pays at 85% of Billed charges for outpatient setting,17.82,Pays at 100% of GA Medicaid Fee Schedule,90.63,Pays at 80.03% of Total Billed charges,15.77,Pays at 102% of Medicare OPPS Rate,101.93,Pays at 90% of Total Billed charges,17.82,Pays at 100% of GA Medicaid Fee Schedule,15.47,Pays at 100% of Medicare OPPS Rate,17.82,Pays at 100% of GA Medicaid Fee Schedule,99.66,Pays at 88% of Total Billed charges,18.35,Pays at 103% of GA Medicaid Fee Schedule,15.47,101.93,67.95
Outpatient Medical Services,LAB,83605,"LACTIC ACID, ARTERIAL",300,72.16,61.34,Pays at 85% of Billed charges for outpatient setting,13.43,Pays at 100% of GA Medicaid Fee Schedule,57.75,Pays at 80.03% of Total Billed charges,11.8,Pays at 102% of Medicare OPPS Rate,64.94,Pays at 90% of Total Billed charges,13.43,Pays at 100% of GA Medicaid Fee Schedule,11.57,Pays at 100% of Medicare OPPS Rate,13.43,Pays at 100% of GA Medicaid Fee Schedule,63.5,Pays at 88% of Total Billed charges,13.83,Pays at 103% of GA Medicaid Fee Schedule,11.57,64.94,43.30
Outpatient Medical Services,LAB,83605,LACTIC ACID,300,73.8,62.73,Pays at 85% of Billed charges for outpatient setting,13.43,Pays at 100% of GA Medicaid Fee Schedule,59.06,Pays at 80.03% of Total Billed charges,11.8,Pays at 102% of Medicare OPPS Rate,66.42,Pays at 90% of Total Billed charges,13.43,Pays at 100% of GA Medicaid Fee Schedule,11.57,Pays at 100% of Medicare OPPS Rate,13.43,Pays at 100% of GA Medicaid Fee Schedule,64.94,Pays at 88% of Total Billed charges,13.83,Pays at 103% of GA Medicaid Fee Schedule,11.57,66.42,44.28
Outpatient Medical Services,LAB,83605,"LACTATE, BODY FLUID  (MAYO)",300,94,79.9,Pays at 85% of Billed charges for outpatient setting,13.43,Pays at 100% of GA Medicaid Fee Schedule,75.23,Pays at 80.03% of Total Billed charges,11.8,Pays at 102% of Medicare OPPS Rate,84.6,Pays at 90% of Total Billed charges,13.43,Pays at 100% of GA Medicaid Fee Schedule,11.57,Pays at 100% of Medicare OPPS Rate,13.43,Pays at 100% of GA Medicaid Fee Schedule,82.72,Pays at 88% of Total Billed charges,13.83,Pays at 103% of GA Medicaid Fee Schedule,11.57,84.6,56.40
Outpatient Medical Services,LAB,83615,LDH,300,30.2,25.67,Pays at 85% of Billed charges for outpatient setting,6.35,Pays at 100% of GA Medicaid Fee Schedule,24.17,Pays at 80.03% of Total Billed charges,6.16,Pays at 102% of Medicare OPPS Rate,27.18,Pays at 90% of Total Billed charges,6.35,Pays at 100% of GA Medicaid Fee Schedule,6.04,Pays at 100% of Medicare OPPS Rate,6.35,Pays at 100% of GA Medicaid Fee Schedule,26.58,Pays at 88% of Total Billed charges,6.54,Pays at 103% of GA Medicaid Fee Schedule,6.04,27.18,18.12
Outpatient Medical Services,LAB,83615,"BODY FLUID, LACTATE DEHYDROGENASE (MAYO)",300,61,51.85,Pays at 85% of Billed charges for outpatient setting,6.35,Pays at 100% of GA Medicaid Fee Schedule,48.82,Pays at 80.03% of Total Billed charges,6.16,Pays at 102% of Medicare OPPS Rate,54.9,Pays at 90% of Total Billed charges,6.35,Pays at 100% of GA Medicaid Fee Schedule,6.04,Pays at 100% of Medicare OPPS Rate,6.35,Pays at 100% of GA Medicaid Fee Schedule,53.68,Pays at 88% of Total Billed charges,6.54,Pays at 103% of GA Medicaid Fee Schedule,6.04,54.9,36.60
Outpatient Medical Services,LAB,83625,LDH ISOENZYMES  (MAYO),300,60,51,Pays at 85% of Billed charges for outpatient setting,14.55,Pays at 100% of GA Medicaid Fee Schedule,48.02,Pays at 80.03% of Total Billed charges,13.04,Pays at 102% of Medicare OPPS Rate,54,Pays at 90% of Total Billed charges,14.55,Pays at 100% of GA Medicaid Fee Schedule,12.79,Pays at 100% of Medicare OPPS Rate,14.55,Pays at 100% of GA Medicaid Fee Schedule,52.8,Pays at 88% of Total Billed charges,14.99,Pays at 103% of GA Medicaid Fee Schedule,12.79,54,36.00
Outpatient Medical Services,LAB,83630,"LACTOFERRIN, QL, STOOL",300,79.06,67.2,Pays at 85% of Billed charges for outpatient setting,13.45,Pays at 100% of GA Medicaid Fee Schedule,63.27,Pays at 80.03% of Total Billed charges,20.09,Pays at 102% of Medicare OPPS Rate,71.15,Pays at 90% of Total Billed charges,13.45,Pays at 100% of GA Medicaid Fee Schedule,19.7,Pays at 100% of Medicare OPPS Rate,13.45,Pays at 100% of GA Medicaid Fee Schedule,69.57,Pays at 88% of Total Billed charges,13.85,Pays at 103% of GA Medicaid Fee Schedule,13.45,71.15,47.44
Outpatient Medical Services,LAB,83630,"LACTOFERRIN, FECAL (MAYO)",300,250,212.5,Pays at 85% of Billed charges for outpatient setting,13.45,Pays at 100% of GA Medicaid Fee Schedule,200.08,Pays at 80.03% of Total Billed charges,20.09,Pays at 102% of Medicare OPPS Rate,225,Pays at 90% of Total Billed charges,13.45,Pays at 100% of GA Medicaid Fee Schedule,19.7,Pays at 100% of Medicare OPPS Rate,13.45,Pays at 100% of GA Medicaid Fee Schedule,220,Pays at 88% of Total Billed charges,13.85,Pays at 103% of GA Medicaid Fee Schedule,13.45,225,150.00
Outpatient Medical Services,LAB,83655,Blood test to determine the concentration of lead in the blood,300,47.75,40.59,Pays at 85% of Billed charges for outpatient setting,10,Pays at 100% of GA Medicaid Fee Schedule,38.21,Pays at 80.03% of Total Billed charges,12.35,Pays at 102% of Medicare OPPS Rate,42.98,Pays at 90% of Total Billed charges,10,Pays at 100% of GA Medicaid Fee Schedule,12.11,Pays at 100% of Medicare OPPS Rate,10,Pays at 100% of GA Medicaid Fee Schedule,42.02,Pays at 88% of Total Billed charges,10.3,Pays at 103% of GA Medicaid Fee Schedule,10,42.98,28.65
Outpatient Medical Services,LAB,83655,Blood test to determine the concentration of lead in the blood,300,47.81,40.64,Pays at 85% of Billed charges for outpatient setting,10,Pays at 100% of GA Medicaid Fee Schedule,38.26,Pays at 80.03% of Total Billed charges,12.35,Pays at 102% of Medicare OPPS Rate,43.03,Pays at 90% of Total Billed charges,10,Pays at 100% of GA Medicaid Fee Schedule,12.11,Pays at 100% of Medicare OPPS Rate,10,Pays at 100% of GA Medicaid Fee Schedule,42.07,Pays at 88% of Total Billed charges,10.3,Pays at 103% of GA Medicaid Fee Schedule,10,43.03,28.69
Outpatient Medical Services,LAB,83655,Blood test to determine the concentration of lead in the blood,300,62.5,53.13,Pays at 85% of Billed charges for outpatient setting,10,Pays at 100% of GA Medicaid Fee Schedule,50.02,Pays at 80.03% of Total Billed charges,12.35,Pays at 102% of Medicare OPPS Rate,56.25,Pays at 90% of Total Billed charges,10,Pays at 100% of GA Medicaid Fee Schedule,12.11,Pays at 100% of Medicare OPPS Rate,10,Pays at 100% of GA Medicaid Fee Schedule,55,Pays at 88% of Total Billed charges,10.3,Pays at 103% of GA Medicaid Fee Schedule,10,56.25,37.50
Outpatient Medical Services,LAB,83655,Blood test to determine the concentration of lead in the blood,300,65.25,55.46,Pays at 85% of Billed charges for outpatient setting,10,Pays at 100% of GA Medicaid Fee Schedule,52.22,Pays at 80.03% of Total Billed charges,12.35,Pays at 102% of Medicare OPPS Rate,58.73,Pays at 90% of Total Billed charges,10,Pays at 100% of GA Medicaid Fee Schedule,12.11,Pays at 100% of Medicare OPPS Rate,10,Pays at 100% of GA Medicaid Fee Schedule,57.42,Pays at 88% of Total Billed charges,10.3,Pays at 103% of GA Medicaid Fee Schedule,10,58.73,39.15
Outpatient Medical Services,LAB,83661,L/S RATIO  (MAYO),300,127.5,108.38,Pays at 85% of Billed charges for outpatient setting,27.64,Pays at 100% of GA Medicaid Fee Schedule,102.04,Pays at 80.03% of Total Billed charges,22.42,Pays at 102% of Medicare OPPS Rate,114.75,Pays at 90% of Total Billed charges,27.64,Pays at 100% of GA Medicaid Fee Schedule,21.99,Pays at 100% of Medicare OPPS Rate,27.64,Pays at 100% of GA Medicaid Fee Schedule,112.2,Pays at 88% of Total Billed charges,28.47,Pays at 103% of GA Medicaid Fee Schedule,21.99,114.75,76.50
Outpatient Medical Services,LAB,83690,LIPASE,300,34.45,29.28,Pays at 85% of Billed charges for outpatient setting,8.66,Pays at 100% of GA Medicaid Fee Schedule,27.57,Pays at 80.03% of Total Billed charges,7.02,Pays at 102% of Medicare OPPS Rate,31.01,Pays at 90% of Total Billed charges,8.66,Pays at 100% of GA Medicaid Fee Schedule,6.89,Pays at 100% of Medicare OPPS Rate,8.66,Pays at 100% of GA Medicaid Fee Schedule,30.32,Pays at 88% of Total Billed charges,8.92,Pays at 103% of GA Medicaid Fee Schedule,6.89,31.01,20.67
Outpatient Medical Services,LAB,83690,"LIPASE, BODY FLUID  (MAYO)",300,51,43.35,Pays at 85% of Billed charges for outpatient setting,8.66,Pays at 100% of GA Medicaid Fee Schedule,40.82,Pays at 80.03% of Total Billed charges,7.02,Pays at 102% of Medicare OPPS Rate,45.9,Pays at 90% of Total Billed charges,8.66,Pays at 100% of GA Medicaid Fee Schedule,6.89,Pays at 100% of Medicare OPPS Rate,8.66,Pays at 100% of GA Medicaid Fee Schedule,44.88,Pays at 88% of Total Billed charges,8.92,Pays at 103% of GA Medicaid Fee Schedule,6.89,45.9,30.60
Outpatient Medical Services,LAB,83695,LIPO PROTEIN A  (MAYO),300,28.25,24.01,Pays at 85% of Billed charges for outpatient setting,16.28,Pays at 100% of GA Medicaid Fee Schedule,22.61,Pays at 80.03% of Total Billed charges,14.6,Pays at 102% of Medicare OPPS Rate,25.43,Pays at 90% of Total Billed charges,16.28,Pays at 100% of GA Medicaid Fee Schedule,14.32,Pays at 100% of Medicare OPPS Rate,16.28,Pays at 100% of GA Medicaid Fee Schedule,24.86,Pays at 88% of Total Billed charges,16.77,Pays at 103% of GA Medicaid Fee Schedule,14.32,25.43,16.95
Outpatient Medical Services,LAB,83701,VAP-CHOLESTEROL  (MAYO),300,45.05,38.29,Pays at 85% of Billed charges for outpatient setting,31.21,Pays at 100% of GA Medicaid Fee Schedule,36.05,Pays at 80.03% of Total Billed charges,34.53,Pays at 102% of Medicare OPPS Rate,40.55,Pays at 90% of Total Billed charges,31.21,Pays at 100% of GA Medicaid Fee Schedule,33.86,Pays at 100% of Medicare OPPS Rate,31.21,Pays at 100% of GA Medicaid Fee Schedule,39.64,Pays at 88% of Total Billed charges,32.15,Pays at 103% of GA Medicaid Fee Schedule,31.21,40.55,27.03
Outpatient Medical Services,LAB,83704,LIPO PROTEIN PARTICLE PROFILE   (MAYO),300,70,59.5,Pays at 85% of Billed charges for outpatient setting,39.67,Pays at 100% of GA Medicaid Fee Schedule,56.02,Pays at 80.03% of Total Billed charges,34.87,Pays at 102% of Medicare OPPS Rate,63,Pays at 90% of Total Billed charges,39.67,Pays at 100% of GA Medicaid Fee Schedule,34.19,Pays at 100% of Medicare OPPS Rate,39.67,Pays at 100% of GA Medicaid Fee Schedule,61.6,Pays at 88% of Total Billed charges,40.86,Pays at 103% of GA Medicaid Fee Schedule,34.19,63,42.00
Outpatient Medical Services,LAB,83704,LDL & HDL PARTICLES NMR   (MAYO),300,71.75,60.99,Pays at 85% of Billed charges for outpatient setting,39.67,Pays at 100% of GA Medicaid Fee Schedule,57.42,Pays at 80.03% of Total Billed charges,34.87,Pays at 102% of Medicare OPPS Rate,64.58,Pays at 90% of Total Billed charges,39.67,Pays at 100% of GA Medicaid Fee Schedule,34.19,Pays at 100% of Medicare OPPS Rate,39.67,Pays at 100% of GA Medicaid Fee Schedule,63.14,Pays at 88% of Total Billed charges,40.86,Pays at 103% of GA Medicaid Fee Schedule,34.19,64.58,43.05
Outpatient Medical Services,LAB,83718,Blood test to measure the level of lipoproteins in the blood,300,19,16.15,Pays at 85% of Billed charges for outpatient setting,10.3,Pays at 100% of GA Medicaid Fee Schedule,15.21,Pays at 80.03% of Total Billed charges,8.35,Pays at 102% of Medicare OPPS Rate,17.1,Pays at 90% of Total Billed charges,10.3,Pays at 100% of GA Medicaid Fee Schedule,8.19,Pays at 100% of Medicare OPPS Rate,10.3,Pays at 100% of GA Medicaid Fee Schedule,16.72,Pays at 88% of Total Billed charges,10.61,Pays at 103% of GA Medicaid Fee Schedule,8.19,17.1,11.40
Outpatient Medical Services,LAB,83718,Blood test to measure the level of lipoproteins in the blood,300,38.5,32.73,Pays at 85% of Billed charges for outpatient setting,10.3,Pays at 100% of GA Medicaid Fee Schedule,30.81,Pays at 80.03% of Total Billed charges,8.35,Pays at 102% of Medicare OPPS Rate,34.65,Pays at 90% of Total Billed charges,10.3,Pays at 100% of GA Medicaid Fee Schedule,8.19,Pays at 100% of Medicare OPPS Rate,10.3,Pays at 100% of GA Medicaid Fee Schedule,33.88,Pays at 88% of Total Billed charges,10.61,Pays at 103% of GA Medicaid Fee Schedule,8.19,34.65,23.10
Outpatient Medical Services,LAB,83721,LDL CHOLESTEROL DIRECT (MAYO),300,93.75,79.69,Pays at 85% of Billed charges for outpatient setting,12,Pays at 100% of GA Medicaid Fee Schedule,75.03,Pays at 80.03% of Total Billed charges,10.71,Pays at 102% of Medicare OPPS Rate,84.38,Pays at 90% of Total Billed charges,12,Pays at 100% of GA Medicaid Fee Schedule,10.5,Pays at 100% of Medicare OPPS Rate,12,Pays at 100% of GA Medicaid Fee Schedule,82.5,Pays at 88% of Total Billed charges,12.36,Pays at 103% of GA Medicaid Fee Schedule,10.5,84.38,56.25
Outpatient Medical Services,LAB,83735,"MAGNESIUM, 24HR URINE  (MAYO)",300,20.25,17.21,Pays at 85% of Billed charges for outpatient setting,8.42,Pays at 100% of GA Medicaid Fee Schedule,16.21,Pays at 80.03% of Total Billed charges,6.83,Pays at 102% of Medicare OPPS Rate,18.23,Pays at 90% of Total Billed charges,8.42,Pays at 100% of GA Medicaid Fee Schedule,6.7,Pays at 100% of Medicare OPPS Rate,8.42,Pays at 100% of GA Medicaid Fee Schedule,17.82,Pays at 88% of Total Billed charges,8.67,Pays at 103% of GA Medicaid Fee Schedule,6.7,18.23,12.15
Outpatient Medical Services,LAB,83735,MAGNESIUM,300,38.95,33.11,Pays at 85% of Billed charges for outpatient setting,8.42,Pays at 100% of GA Medicaid Fee Schedule,31.17,Pays at 80.03% of Total Billed charges,6.83,Pays at 102% of Medicare OPPS Rate,35.06,Pays at 90% of Total Billed charges,8.42,Pays at 100% of GA Medicaid Fee Schedule,6.7,Pays at 100% of Medicare OPPS Rate,8.42,Pays at 100% of GA Medicaid Fee Schedule,34.28,Pays at 88% of Total Billed charges,8.67,Pays at 103% of GA Medicaid Fee Schedule,6.7,35.06,23.37
Outpatient Medical Services,LAB,83735,"MAGNESIUM, 24HR  (MAYO)",300,42.25,35.91,Pays at 85% of Billed charges for outpatient setting,8.42,Pays at 100% of GA Medicaid Fee Schedule,33.81,Pays at 80.03% of Total Billed charges,6.83,Pays at 102% of Medicare OPPS Rate,38.03,Pays at 90% of Total Billed charges,8.42,Pays at 100% of GA Medicaid Fee Schedule,6.7,Pays at 100% of Medicare OPPS Rate,8.42,Pays at 100% of GA Medicaid Fee Schedule,37.18,Pays at 88% of Total Billed charges,8.67,Pays at 103% of GA Medicaid Fee Schedule,6.7,38.03,25.35
Outpatient Medical Services,LAB,83735,"MAGNESIUM, URINE RANDOM  (MAYO)",300,42.25,35.91,Pays at 85% of Billed charges for outpatient setting,8.42,Pays at 100% of GA Medicaid Fee Schedule,33.81,Pays at 80.03% of Total Billed charges,6.83,Pays at 102% of Medicare OPPS Rate,38.03,Pays at 90% of Total Billed charges,8.42,Pays at 100% of GA Medicaid Fee Schedule,6.7,Pays at 100% of Medicare OPPS Rate,8.42,Pays at 100% of GA Medicaid Fee Schedule,37.18,Pays at 88% of Total Billed charges,8.67,Pays at 103% of GA Medicaid Fee Schedule,6.7,38.03,25.35
Outpatient Medical Services,LAB,83735,"MAGNESIUM, FECES, QT  (MAYO)",300,43.5,36.98,Pays at 85% of Billed charges for outpatient setting,8.42,Pays at 100% of GA Medicaid Fee Schedule,34.81,Pays at 80.03% of Total Billed charges,6.83,Pays at 102% of Medicare OPPS Rate,39.15,Pays at 90% of Total Billed charges,8.42,Pays at 100% of GA Medicaid Fee Schedule,6.7,Pays at 100% of Medicare OPPS Rate,8.42,Pays at 100% of GA Medicaid Fee Schedule,38.28,Pays at 88% of Total Billed charges,8.67,Pays at 103% of GA Medicaid Fee Schedule,6.7,39.15,26.10
Outpatient Medical Services,LAB,83735,"MAGNESIUM, RBC  (MAYO)",300,44.25,37.61,Pays at 85% of Billed charges for outpatient setting,8.42,Pays at 100% of GA Medicaid Fee Schedule,35.41,Pays at 80.03% of Total Billed charges,6.83,Pays at 102% of Medicare OPPS Rate,39.83,Pays at 90% of Total Billed charges,8.42,Pays at 100% of GA Medicaid Fee Schedule,6.7,Pays at 100% of Medicare OPPS Rate,8.42,Pays at 100% of GA Medicaid Fee Schedule,38.94,Pays at 88% of Total Billed charges,8.67,Pays at 103% of GA Medicaid Fee Schedule,6.7,39.83,26.55
Outpatient Medical Services,LAB,83735,"LAXATIVE ASSAY, STOOL  (MAYO)",300,279.5,237.58,Pays at 85% of Billed charges for outpatient setting,8.42,Pays at 100% of GA Medicaid Fee Schedule,223.68,Pays at 80.03% of Total Billed charges,6.83,Pays at 102% of Medicare OPPS Rate,251.55,Pays at 90% of Total Billed charges,8.42,Pays at 100% of GA Medicaid Fee Schedule,6.7,Pays at 100% of Medicare OPPS Rate,8.42,Pays at 100% of GA Medicaid Fee Schedule,245.96,Pays at 88% of Total Billed charges,8.67,Pays at 103% of GA Medicaid Fee Schedule,6.7,251.55,167.70
Outpatient Medical Services,LAB,83785,"MANGANESE, SERUM  (MAYO)",300,52,44.2,Pays at 85% of Billed charges for outpatient setting,30.92,Pays at 100% of GA Medicaid Fee Schedule,41.62,Pays at 80.03% of Total Billed charges,27.18,Pays at 102% of Medicare OPPS Rate,46.8,Pays at 90% of Total Billed charges,30.92,Pays at 100% of GA Medicaid Fee Schedule,26.65,Pays at 100% of Medicare OPPS Rate,30.92,Pays at 100% of GA Medicaid Fee Schedule,45.76,Pays at 88% of Total Billed charges,31.85,Pays at 103% of GA Medicaid Fee Schedule,26.65,46.8,31.20
Outpatient Medical Services,LAB,83789,"PYRIDOXIC ACID, PA  (MAYO)",300,62,52.7,Pays at 85% of Billed charges for outpatient setting,7.55,Pays at 100% of GA Medicaid Fee Schedule,49.62,Pays at 80.03% of Total Billed charges,24.59,Pays at 102% of Medicare OPPS Rate,55.8,Pays at 90% of Total Billed charges,7.55,Pays at 100% of GA Medicaid Fee Schedule,24.11,Pays at 100% of Medicare OPPS Rate,7.55,Pays at 100% of GA Medicaid Fee Schedule,54.56,Pays at 88% of Total Billed charges,7.78,Pays at 103% of GA Medicaid Fee Schedule,7.55,55.8,37.20
Outpatient Medical Services,LAB,83789,HB VARIANT BY MASS SPEC  (MAYO),300,225,191.25,Pays at 85% of Billed charges for outpatient setting,7.55,Pays at 100% of GA Medicaid Fee Schedule,180.07,Pays at 80.03% of Total Billed charges,24.59,Pays at 102% of Medicare OPPS Rate,202.5,Pays at 90% of Total Billed charges,7.55,Pays at 100% of GA Medicaid Fee Schedule,24.11,Pays at 100% of Medicare OPPS Rate,7.55,Pays at 100% of GA Medicaid Fee Schedule,198,Pays at 88% of Total Billed charges,7.78,Pays at 103% of GA Medicaid Fee Schedule,7.55,202.5,135.00
Outpatient Medical Services,LAB,83825,MERCURY BLOOD (MAYO),300,61.5,52.28,Pays at 85% of Billed charges for outpatient setting,20.45,Pays at 100% of GA Medicaid Fee Schedule,49.22,Pays at 80.03% of Total Billed charges,16.58,Pays at 102% of Medicare OPPS Rate,55.35,Pays at 90% of Total Billed charges,20.45,Pays at 100% of GA Medicaid Fee Schedule,16.26,Pays at 100% of Medicare OPPS Rate,20.45,Pays at 100% of GA Medicaid Fee Schedule,54.12,Pays at 88% of Total Billed charges,21.06,Pays at 103% of GA Medicaid Fee Schedule,16.26,55.35,36.90
Outpatient Medical Services,LAB,83825,"MERCURY, URINE  (MAYO)",300,61.5,52.28,Pays at 85% of Billed charges for outpatient setting,20.45,Pays at 100% of GA Medicaid Fee Schedule,49.22,Pays at 80.03% of Total Billed charges,16.58,Pays at 102% of Medicare OPPS Rate,55.35,Pays at 90% of Total Billed charges,20.45,Pays at 100% of GA Medicaid Fee Schedule,16.26,Pays at 100% of Medicare OPPS Rate,20.45,Pays at 100% of GA Medicaid Fee Schedule,54.12,Pays at 88% of Total Billed charges,21.06,Pays at 103% of GA Medicaid Fee Schedule,16.26,55.35,36.90
Outpatient Medical Services,LAB,83825,MERCURY/CREATININE RATIO URINE  (MAYO),300,87,73.95,Pays at 85% of Billed charges for outpatient setting,20.45,Pays at 100% of GA Medicaid Fee Schedule,69.63,Pays at 80.03% of Total Billed charges,16.58,Pays at 102% of Medicare OPPS Rate,78.3,Pays at 90% of Total Billed charges,20.45,Pays at 100% of GA Medicaid Fee Schedule,16.26,Pays at 100% of Medicare OPPS Rate,20.45,Pays at 100% of GA Medicaid Fee Schedule,76.56,Pays at 88% of Total Billed charges,21.06,Pays at 103% of GA Medicaid Fee Schedule,16.26,78.3,52.20
Outpatient Medical Services,LAB,83835,"METANEPHRINES FRACT RANDOM, U  (MAYO)",300,38.75,32.94,Pays at 85% of Billed charges for outpatient setting,21.3,Pays at 100% of GA Medicaid Fee Schedule,31.01,Pays at 80.03% of Total Billed charges,17.27,Pays at 102% of Medicare OPPS Rate,34.88,Pays at 90% of Total Billed charges,21.3,Pays at 100% of GA Medicaid Fee Schedule,16.94,Pays at 100% of Medicare OPPS Rate,21.3,Pays at 100% of GA Medicaid Fee Schedule,34.1,Pays at 88% of Total Billed charges,21.94,Pays at 103% of GA Medicaid Fee Schedule,16.94,34.88,23.25
Outpatient Medical Services,LAB,83835,"METANEPHRINES FRACT 24 HR, URINE  (MAYO)",300,53.75,45.69,Pays at 85% of Billed charges for outpatient setting,21.3,Pays at 100% of GA Medicaid Fee Schedule,43.02,Pays at 80.03% of Total Billed charges,17.27,Pays at 102% of Medicare OPPS Rate,48.38,Pays at 90% of Total Billed charges,21.3,Pays at 100% of GA Medicaid Fee Schedule,16.94,Pays at 100% of Medicare OPPS Rate,21.3,Pays at 100% of GA Medicaid Fee Schedule,47.3,Pays at 88% of Total Billed charges,21.94,Pays at 103% of GA Medicaid Fee Schedule,16.94,48.38,32.25
Outpatient Medical Services,LAB,83835,METANEPHRINES FRACT.  PLASMA  (MAYO),300,53.75,45.69,Pays at 85% of Billed charges for outpatient setting,21.3,Pays at 100% of GA Medicaid Fee Schedule,43.02,Pays at 80.03% of Total Billed charges,17.27,Pays at 102% of Medicare OPPS Rate,48.38,Pays at 90% of Total Billed charges,21.3,Pays at 100% of GA Medicaid Fee Schedule,16.94,Pays at 100% of Medicare OPPS Rate,21.3,Pays at 100% of GA Medicaid Fee Schedule,47.3,Pays at 88% of Total Billed charges,21.94,Pays at 103% of GA Medicaid Fee Schedule,16.94,48.38,32.25
Outpatient Medical Services,LAB,83873,CSF MYELIN BASIC PROTEIN   MAYO,300,51,43.35,Pays at 85% of Billed charges for outpatient setting,21.64,Pays at 100% of GA Medicaid Fee Schedule,40.82,Pays at 80.03% of Total Billed charges,17.54,Pays at 102% of Medicare OPPS Rate,45.9,Pays at 90% of Total Billed charges,21.64,Pays at 100% of GA Medicaid Fee Schedule,17.2,Pays at 100% of Medicare OPPS Rate,21.64,Pays at 100% of GA Medicaid Fee Schedule,44.88,Pays at 88% of Total Billed charges,22.29,Pays at 103% of GA Medicaid Fee Schedule,17.2,45.9,30.60
Outpatient Medical Services,LAB,83874,"...MYOGLOBIN, URINE  (MAYO)",300,36.75,31.24,Pays at 85% of Billed charges for outpatient setting,16.24,Pays at 100% of GA Medicaid Fee Schedule,29.41,Pays at 80.03% of Total Billed charges,13.17,Pays at 102% of Medicare OPPS Rate,33.08,Pays at 90% of Total Billed charges,16.24,Pays at 100% of GA Medicaid Fee Schedule,12.92,Pays at 100% of Medicare OPPS Rate,16.24,Pays at 100% of GA Medicaid Fee Schedule,32.34,Pays at 88% of Total Billed charges,16.73,Pays at 103% of GA Medicaid Fee Schedule,12.92,33.08,22.05
Outpatient Medical Services,LAB,83874,"MYOGLOBIN, URINE  (MAYO)",300,41.5,35.28,Pays at 85% of Billed charges for outpatient setting,16.24,Pays at 100% of GA Medicaid Fee Schedule,33.21,Pays at 80.03% of Total Billed charges,13.17,Pays at 102% of Medicare OPPS Rate,37.35,Pays at 90% of Total Billed charges,16.24,Pays at 100% of GA Medicaid Fee Schedule,12.92,Pays at 100% of Medicare OPPS Rate,16.24,Pays at 100% of GA Medicaid Fee Schedule,36.52,Pays at 88% of Total Billed charges,16.73,Pays at 103% of GA Medicaid Fee Schedule,12.92,37.35,24.90
Outpatient Medical Services,LAB,83874,MYOGLOBIN SERUM  (MAYO),300,46.5,39.53,Pays at 85% of Billed charges for outpatient setting,16.24,Pays at 100% of GA Medicaid Fee Schedule,37.21,Pays at 80.03% of Total Billed charges,13.17,Pays at 102% of Medicare OPPS Rate,41.85,Pays at 90% of Total Billed charges,16.24,Pays at 100% of GA Medicaid Fee Schedule,12.92,Pays at 100% of Medicare OPPS Rate,16.24,Pays at 100% of GA Medicaid Fee Schedule,40.92,Pays at 88% of Total Billed charges,16.73,Pays at 103% of GA Medicaid Fee Schedule,12.92,41.85,27.90
Outpatient Medical Services,LAB,83880,Blood test used to diagnose heart failure,300,80.57,68.48,Pays at 85% of Billed charges for outpatient setting,42.69,Pays at 100% of GA Medicaid Fee Schedule,64.48,Pays at 80.03% of Total Billed charges,40.04,Pays at 102% of Medicare OPPS Rate,72.51,Pays at 90% of Total Billed charges,42.69,Pays at 100% of GA Medicaid Fee Schedule,39.26,Pays at 100% of Medicare OPPS Rate,42.69,Pays at 100% of GA Medicaid Fee Schedule,70.9,Pays at 88% of Total Billed charges,43.97,Pays at 103% of GA Medicaid Fee Schedule,39.26,72.51,48.34
Outpatient Medical Services,LAB,83880,Blood test used to diagnose heart failure,300,112,95.2,Pays at 85% of Billed charges for outpatient setting,42.69,Pays at 100% of GA Medicaid Fee Schedule,89.63,Pays at 80.03% of Total Billed charges,40.04,Pays at 102% of Medicare OPPS Rate,100.8,Pays at 90% of Total Billed charges,42.69,Pays at 100% of GA Medicaid Fee Schedule,39.26,Pays at 100% of Medicare OPPS Rate,42.69,Pays at 100% of GA Medicaid Fee Schedule,98.56,Pays at 88% of Total Billed charges,43.97,Pays at 103% of GA Medicaid Fee Schedule,39.26,100.8,67.20
Outpatient Medical Services,LAB,83883,FIBROSURE NEPHELOMETRY NOT SPEC  (MAYO),300,113.75,96.69,Pays at 85% of Billed charges for outpatient setting,17.1,Pays at 100% of GA Medicaid Fee Schedule,91.03,Pays at 80.03% of Total Billed charges,13.87,Pays at 102% of Medicare OPPS Rate,102.38,Pays at 90% of Total Billed charges,17.1,Pays at 100% of GA Medicaid Fee Schedule,13.6,Pays at 100% of Medicare OPPS Rate,17.1,Pays at 100% of GA Medicaid Fee Schedule,100.1,Pays at 88% of Total Billed charges,17.61,Pays at 103% of GA Medicaid Fee Schedule,13.6,102.38,68.25
Outpatient Medical Services,LAB,83883,".KAPPA FREE LIGHT CHAIN, SERUM  (MAYO)",300,198.35,168.6,Pays at 85% of Billed charges for outpatient setting,17.1,Pays at 100% of GA Medicaid Fee Schedule,158.74,Pays at 80.03% of Total Billed charges,13.87,Pays at 102% of Medicare OPPS Rate,178.52,Pays at 90% of Total Billed charges,17.1,Pays at 100% of GA Medicaid Fee Schedule,13.6,Pays at 100% of Medicare OPPS Rate,17.1,Pays at 100% of GA Medicaid Fee Schedule,174.55,Pays at 88% of Total Billed charges,17.61,Pays at 103% of GA Medicaid Fee Schedule,13.6,178.52,119.01
Outpatient Medical Services,LAB,83883,".LAMBDA FREE LIGHT CHAIN, SERUM  (MAYO)",300,198.35,168.6,Pays at 85% of Billed charges for outpatient setting,17.1,Pays at 100% of GA Medicaid Fee Schedule,158.74,Pays at 80.03% of Total Billed charges,13.87,Pays at 102% of Medicare OPPS Rate,178.52,Pays at 90% of Total Billed charges,17.1,Pays at 100% of GA Medicaid Fee Schedule,13.6,Pays at 100% of Medicare OPPS Rate,17.1,Pays at 100% of GA Medicaid Fee Schedule,174.55,Pays at 88% of Total Billed charges,17.61,Pays at 103% of GA Medicaid Fee Schedule,13.6,178.52,119.01
Outpatient Medical Services,LAB,83890,CYSTIC FIBROSIS SCREEN  (MAYO),300,236.5,201.03,Pays at 85% of Billed charges for outpatient setting,76.03,Pays at 32.15% of Total Billed charges,189.27,Pays at 80.03% of Total Billed charges,236.5,Not Applicable,212.85,Pays at 90% of Total Billed charges,76.03,Pays at 32.15% of Total Billed charges,236.5,Not Applicable,76.03,Pays at 32.15% of Total Billed charges,208.12,Pays at 88% of Total Billed charges,78.31,Pays at 33.11% of Total Billed charges,76.03,236.5,141.90
Outpatient Medical Services,LAB,83891,"THROMBOPHILIA SCREEN, INHERITED  (MAYO)",300,573.75,487.69,Pays at 85% of Billed charges for outpatient setting,184.46,Pays at 32.15% of Total Billed charges,459.17,Pays at 80.03% of Total Billed charges,573.75,Not Applicable,516.38,Pays at 90% of Total Billed charges,184.46,Pays at 32.15% of Total Billed charges,573.75,Not Applicable,184.46,Pays at 32.15% of Total Billed charges,504.9,Pays at 88% of Total Billed charges,189.97,Pays at 33.11% of Total Billed charges,184.46,573.75,344.25
Outpatient Medical Services,LAB,83896,MTHFR MUTATION B PANEL  (MAYO),300,132.75,112.84,Pays at 85% of Billed charges for outpatient setting,42.68,Pays at 32.15% of Total Billed charges,106.24,Pays at 80.03% of Total Billed charges,132.75,Not Applicable,119.48,Pays at 90% of Total Billed charges,42.68,Pays at 32.15% of Total Billed charges,132.75,Not Applicable,42.68,Pays at 32.15% of Total Billed charges,116.82,Pays at 88% of Total Billed charges,43.95,Pays at 33.11% of Total Billed charges,42.68,132.75,79.65
Outpatient Medical Services,LAB,83896,"MYOTONIC DYSTROPHY, MOLECULAR ANALYSIS",300,438.75,372.94,Pays at 85% of Billed charges for outpatient setting,141.06,Pays at 32.15% of Total Billed charges,351.13,Pays at 80.03% of Total Billed charges,438.75,Not Applicable,394.88,Pays at 90% of Total Billed charges,141.06,Pays at 32.15% of Total Billed charges,438.75,Not Applicable,141.06,Pays at 32.15% of Total Billed charges,386.1,Pays at 88% of Total Billed charges,145.27,Pays at 33.11% of Total Billed charges,141.06,438.75,263.25
Outpatient Medical Services,LAB,83898,"T-CELL GENE, PCR  (MAYO)",300,343.25,291.76,Pays at 85% of Billed charges for outpatient setting,110.35,Pays at 32.15% of Total Billed charges,274.7,Pays at 80.03% of Total Billed charges,343.25,Not Applicable,308.93,Pays at 90% of Total Billed charges,110.35,Pays at 32.15% of Total Billed charges,343.25,Not Applicable,110.35,Pays at 32.15% of Total Billed charges,302.06,Pays at 88% of Total Billed charges,113.65,Pays at 33.11% of Total Billed charges,110.35,343.25,205.95
Outpatient Medical Services,LAB,83898,"HERPES, PCR, CSF  (MAYO)",300,420.5,357.43,Pays at 85% of Billed charges for outpatient setting,135.19,Pays at 32.15% of Total Billed charges,336.53,Pays at 80.03% of Total Billed charges,420.5,Not Applicable,378.45,Pays at 90% of Total Billed charges,135.19,Pays at 32.15% of Total Billed charges,420.5,Not Applicable,135.19,Pays at 32.15% of Total Billed charges,370.04,Pays at 88% of Total Billed charges,139.23,Pays at 33.11% of Total Billed charges,135.19,420.5,252.30
Outpatient Medical Services,LAB,83915,PYRIMIDINE 5 NUCLEOTIDASE  (MAYO),300,492.25,418.41,Pays at 85% of Billed charges for outpatient setting,14.02,Pays at 100% of GA Medicaid Fee Schedule,393.95,Pays at 80.03% of Total Billed charges,11.37,Pays at 102% of Medicare OPPS Rate,443.03,Pays at 90% of Total Billed charges,14.02,Pays at 100% of GA Medicaid Fee Schedule,11.15,Pays at 100% of Medicare OPPS Rate,14.02,Pays at 100% of GA Medicaid Fee Schedule,433.18,Pays at 88% of Total Billed charges,14.44,Pays at 103% of GA Medicaid Fee Schedule,11.15,443.03,295.35
Outpatient Medical Services,LAB,83916,CSF BANDS  (MAYO),300,41.75,35.49,Pays at 85% of Billed charges for outpatient setting,25.28,Pays at 100% of GA Medicaid Fee Schedule,33.41,Pays at 80.03% of Total Billed charges,27.93,Pays at 102% of Medicare OPPS Rate,37.58,Pays at 90% of Total Billed charges,25.28,Pays at 100% of GA Medicaid Fee Schedule,27.39,Pays at 100% of Medicare OPPS Rate,25.28,Pays at 100% of GA Medicaid Fee Schedule,36.74,Pays at 88% of Total Billed charges,26.04,Pays at 103% of GA Medicaid Fee Schedule,25.28,37.58,25.05
Outpatient Medical Services,LAB,83916,SERUM BANDS  (MAYO),300,41.75,35.49,Pays at 85% of Billed charges for outpatient setting,25.28,Pays at 100% of GA Medicaid Fee Schedule,33.41,Pays at 80.03% of Total Billed charges,27.93,Pays at 102% of Medicare OPPS Rate,37.58,Pays at 90% of Total Billed charges,25.28,Pays at 100% of GA Medicaid Fee Schedule,27.39,Pays at 100% of Medicare OPPS Rate,25.28,Pays at 100% of GA Medicaid Fee Schedule,36.74,Pays at 88% of Total Billed charges,26.04,Pays at 103% of GA Medicaid Fee Schedule,25.28,37.58,25.05
Outpatient Medical Services,LAB,83919,"ORGANIC ACID SCREEN, URINE  (MAYO)",300,91,77.35,Pays at 85% of Billed charges for outpatient setting,20.7,Pays at 100% of GA Medicaid Fee Schedule,72.83,Pays at 80.03% of Total Billed charges,16.77,Pays at 102% of Medicare OPPS Rate,81.9,Pays at 90% of Total Billed charges,20.7,Pays at 100% of GA Medicaid Fee Schedule,16.45,Pays at 100% of Medicare OPPS Rate,20.7,Pays at 100% of GA Medicaid Fee Schedule,80.08,Pays at 88% of Total Billed charges,21.32,Pays at 103% of GA Medicaid Fee Schedule,16.45,81.9,54.60
Outpatient Medical Services,LAB,83921,"METHYLMALONIC ACID, MMA, SERUM  (MAYO)",300,54.75,46.54,Pays at 85% of Billed charges for outpatient setting,20.7,Pays at 100% of GA Medicaid Fee Schedule,43.82,Pays at 80.03% of Total Billed charges,21.63,Pays at 102% of Medicare OPPS Rate,49.28,Pays at 90% of Total Billed charges,20.7,Pays at 100% of GA Medicaid Fee Schedule,21.21,Pays at 100% of Medicare OPPS Rate,20.7,Pays at 100% of GA Medicaid Fee Schedule,48.18,Pays at 88% of Total Billed charges,21.32,Pays at 103% of GA Medicaid Fee Schedule,20.7,49.28,32.85
Outpatient Medical Services,LAB,83921,"METHYLMALONIC ACID, QN, SERUM  (MAYO)",300,54.75,46.54,Pays at 85% of Billed charges for outpatient setting,20.7,Pays at 100% of GA Medicaid Fee Schedule,43.82,Pays at 80.03% of Total Billed charges,21.63,Pays at 102% of Medicare OPPS Rate,49.28,Pays at 90% of Total Billed charges,20.7,Pays at 100% of GA Medicaid Fee Schedule,21.21,Pays at 100% of Medicare OPPS Rate,20.7,Pays at 100% of GA Medicaid Fee Schedule,48.18,Pays at 88% of Total Billed charges,21.32,Pays at 103% of GA Medicaid Fee Schedule,20.7,49.28,32.85
Outpatient Medical Services,LAB,83925,CODEINE  (MAYO),300,85.75,72.89,Pays at 85% of Billed charges for outpatient setting,27.57,Pays at 32.15% of Total Billed charges,68.63,Pays at 80.03% of Total Billed charges,85.75,Not Applicable,77.18,Pays at 90% of Total Billed charges,27.57,Pays at 32.15% of Total Billed charges,85.75,Not Applicable,27.57,Pays at 32.15% of Total Billed charges,75.46,Pays at 88% of Total Billed charges,28.39,Pays at 33.11% of Total Billed charges,27.57,85.75,51.45
Outpatient Medical Services,LAB,83930,OSMOLALITY SERUM  (MAYO),300,27,22.95,Pays at 85% of Billed charges for outpatient setting,8.32,Pays at 100% of GA Medicaid Fee Schedule,21.61,Pays at 80.03% of Total Billed charges,6.74,Pays at 102% of Medicare OPPS Rate,24.3,Pays at 90% of Total Billed charges,8.32,Pays at 100% of GA Medicaid Fee Schedule,6.61,Pays at 100% of Medicare OPPS Rate,8.32,Pays at 100% of GA Medicaid Fee Schedule,23.76,Pays at 88% of Total Billed charges,8.57,Pays at 103% of GA Medicaid Fee Schedule,6.61,24.3,16.20
Outpatient Medical Services,LAB,83930,"OSMOLALITY, BODY FLUID  (MAYO)",300,42,35.7,Pays at 85% of Billed charges for outpatient setting,8.32,Pays at 100% of GA Medicaid Fee Schedule,33.61,Pays at 80.03% of Total Billed charges,6.74,Pays at 102% of Medicare OPPS Rate,37.8,Pays at 90% of Total Billed charges,8.32,Pays at 100% of GA Medicaid Fee Schedule,6.61,Pays at 100% of Medicare OPPS Rate,8.32,Pays at 100% of GA Medicaid Fee Schedule,36.96,Pays at 88% of Total Billed charges,8.57,Pays at 103% of GA Medicaid Fee Schedule,6.61,37.8,25.20
Outpatient Medical Services,LAB,83930,"OSMOLALITY, FECAL  (MAYO)",300,45,38.25,Pays at 85% of Billed charges for outpatient setting,8.32,Pays at 100% of GA Medicaid Fee Schedule,36.01,Pays at 80.03% of Total Billed charges,6.74,Pays at 102% of Medicare OPPS Rate,40.5,Pays at 90% of Total Billed charges,8.32,Pays at 100% of GA Medicaid Fee Schedule,6.61,Pays at 100% of Medicare OPPS Rate,8.32,Pays at 100% of GA Medicaid Fee Schedule,39.6,Pays at 88% of Total Billed charges,8.57,Pays at 103% of GA Medicaid Fee Schedule,6.61,40.5,27.00
Outpatient Medical Services,LAB,83935,"OSMOLALITY, 24HR URINE  (MAYO)",300,15,12.75,Pays at 85% of Billed charges for outpatient setting,8.57,Pays at 100% of GA Medicaid Fee Schedule,12,Pays at 80.03% of Total Billed charges,6.95,Pays at 102% of Medicare OPPS Rate,13.5,Pays at 90% of Total Billed charges,8.57,Pays at 100% of GA Medicaid Fee Schedule,6.82,Pays at 100% of Medicare OPPS Rate,8.57,Pays at 100% of GA Medicaid Fee Schedule,13.2,Pays at 88% of Total Billed charges,8.83,Pays at 103% of GA Medicaid Fee Schedule,6.82,13.5,9.00
Outpatient Medical Services,LAB,83935,"OSMOLALITY, URINE  (MAYO)",300,29.69,25.24,Pays at 85% of Billed charges for outpatient setting,8.57,Pays at 100% of GA Medicaid Fee Schedule,23.76,Pays at 80.03% of Total Billed charges,6.95,Pays at 102% of Medicare OPPS Rate,26.72,Pays at 90% of Total Billed charges,8.57,Pays at 100% of GA Medicaid Fee Schedule,6.82,Pays at 100% of Medicare OPPS Rate,8.57,Pays at 100% of GA Medicaid Fee Schedule,26.13,Pays at 88% of Total Billed charges,8.83,Pays at 103% of GA Medicaid Fee Schedule,6.82,26.72,17.81
Outpatient Medical Services,LAB,83945,"OXALATE, 24HR URINE  (MAYO)",300,20,17,Pays at 85% of Billed charges for outpatient setting,16.19,Pays at 100% of GA Medicaid Fee Schedule,16.01,Pays at 80.03% of Total Billed charges,14.73,Pays at 102% of Medicare OPPS Rate,18,Pays at 90% of Total Billed charges,16.19,Pays at 100% of GA Medicaid Fee Schedule,14.45,Pays at 100% of Medicare OPPS Rate,16.19,Pays at 100% of GA Medicaid Fee Schedule,17.6,Pays at 88% of Total Billed charges,16.68,Pays at 103% of GA Medicaid Fee Schedule,14.45,18,12.00
Outpatient Medical Services,LAB,83945,"OXALATE, URINE  (MAYO)",300,97.75,83.09,Pays at 85% of Billed charges for outpatient setting,16.19,Pays at 100% of GA Medicaid Fee Schedule,78.23,Pays at 80.03% of Total Billed charges,14.73,Pays at 102% of Medicare OPPS Rate,87.98,Pays at 90% of Total Billed charges,16.19,Pays at 100% of GA Medicaid Fee Schedule,14.45,Pays at 100% of Medicare OPPS Rate,16.19,Pays at 100% of GA Medicaid Fee Schedule,86.02,Pays at 88% of Total Billed charges,16.68,Pays at 103% of GA Medicaid Fee Schedule,14.45,87.98,58.65
Outpatient Medical Services,LAB,83970,PTH C-TERMINAL  (MAYO),300,74,62.9,Pays at 85% of Billed charges for outpatient setting,51.9,Pays at 100% of GA Medicaid Fee Schedule,59.22,Pays at 80.03% of Total Billed charges,42.1,Pays at 102% of Medicare OPPS Rate,66.6,Pays at 90% of Total Billed charges,51.9,Pays at 100% of GA Medicaid Fee Schedule,41.28,Pays at 100% of Medicare OPPS Rate,51.9,Pays at 100% of GA Medicaid Fee Schedule,65.12,Pays at 88% of Total Billed charges,53.46,Pays at 103% of GA Medicaid Fee Schedule,41.28,66.6,44.40
Outpatient Medical Services,LAB,83970,"PTH, INTACT  (MAYO)",300,107.83,91.66,Pays at 85% of Billed charges for outpatient setting,51.9,Pays at 100% of GA Medicaid Fee Schedule,86.3,Pays at 80.03% of Total Billed charges,42.1,Pays at 102% of Medicare OPPS Rate,97.05,Pays at 90% of Total Billed charges,51.9,Pays at 100% of GA Medicaid Fee Schedule,41.28,Pays at 100% of Medicare OPPS Rate,51.9,Pays at 100% of GA Medicaid Fee Schedule,94.89,Pays at 88% of Total Billed charges,53.46,Pays at 103% of GA Medicaid Fee Schedule,41.28,97.05,64.70
Outpatient Medical Services,LAB,83986,"PH, 24HR URINE  (MAYO)",300,20,17,Pays at 85% of Billed charges for outpatient setting,4.5,Pays at 100% of GA Medicaid Fee Schedule,16.01,Pays at 80.03% of Total Billed charges,3.65,Pays at 102% of Medicare OPPS Rate,18,Pays at 90% of Total Billed charges,4.5,Pays at 100% of GA Medicaid Fee Schedule,3.58,Pays at 100% of Medicare OPPS Rate,4.5,Pays at 100% of GA Medicaid Fee Schedule,17.6,Pays at 88% of Total Billed charges,4.64,Pays at 103% of GA Medicaid Fee Schedule,3.58,18,12.00
Outpatient Medical Services,LAB,83986,PH (BODY FLUID) (MAYO),300,28.5,24.23,Pays at 85% of Billed charges for outpatient setting,4.5,Pays at 100% of GA Medicaid Fee Schedule,22.81,Pays at 80.03% of Total Billed charges,3.65,Pays at 102% of Medicare OPPS Rate,25.65,Pays at 90% of Total Billed charges,4.5,Pays at 100% of GA Medicaid Fee Schedule,3.58,Pays at 100% of Medicare OPPS Rate,4.5,Pays at 100% of GA Medicaid Fee Schedule,25.08,Pays at 88% of Total Billed charges,4.64,Pays at 103% of GA Medicaid Fee Schedule,3.58,25.65,17.10
Outpatient Medical Services,LAB,83986,"PH, STOOL  (MAYO)",300,47.5,40.38,Pays at 85% of Billed charges for outpatient setting,4.5,Pays at 100% of GA Medicaid Fee Schedule,38.01,Pays at 80.03% of Total Billed charges,3.65,Pays at 102% of Medicare OPPS Rate,42.75,Pays at 90% of Total Billed charges,4.5,Pays at 100% of GA Medicaid Fee Schedule,3.58,Pays at 100% of Medicare OPPS Rate,4.5,Pays at 100% of GA Medicaid Fee Schedule,41.8,Pays at 88% of Total Billed charges,4.64,Pays at 103% of GA Medicaid Fee Schedule,3.58,42.75,28.50
Outpatient Medical Services,LAB,83992,PHENCYCLIDINE CONFIRMATION  (MAYO),300,156.75,133.24,Pays at 85% of Billed charges for outpatient setting,18.49,Pays at 100% of GA Medicaid Fee Schedule,125.45,Pays at 80.03% of Total Billed charges,156.75,Not Applicable,141.08,Pays at 90% of Total Billed charges,18.49,Pays at 100% of GA Medicaid Fee Schedule,156.75,Not Applicable,18.49,Pays at 100% of GA Medicaid Fee Schedule,137.94,Pays at 88% of Total Billed charges,19.04,Pays at 103% of GA Medicaid Fee Schedule,18.49,156.75,94.05
Outpatient Medical Services,LAB,83993,"CALPROTECTIN, STOOL  (MAYO)",300,319.5,271.58,Pays at 85% of Billed charges for outpatient setting,24.68,Pays at 100% of GA Medicaid Fee Schedule,255.7,Pays at 80.03% of Total Billed charges,20.02,Pays at 102% of Medicare OPPS Rate,287.55,Pays at 90% of Total Billed charges,24.68,Pays at 100% of GA Medicaid Fee Schedule,19.63,Pays at 100% of Medicare OPPS Rate,24.68,Pays at 100% of GA Medicaid Fee Schedule,281.16,Pays at 88% of Total Billed charges,25.42,Pays at 103% of GA Medicaid Fee Schedule,19.63,287.55,191.70
Outpatient Medical Services,LAB,84030,PKU,300,15,12.75,Pays at 85% of Billed charges for outpatient setting,6.92,Pays at 100% of GA Medicaid Fee Schedule,12,Pays at 80.03% of Total Billed charges,5.61,Pays at 102% of Medicare OPPS Rate,13.5,Pays at 90% of Total Billed charges,6.92,Pays at 100% of GA Medicaid Fee Schedule,5.5,Pays at 100% of Medicare OPPS Rate,6.92,Pays at 100% of GA Medicaid Fee Schedule,13.2,Pays at 88% of Total Billed charges,7.13,Pays at 103% of GA Medicaid Fee Schedule,5.5,13.5,9.00
Outpatient Medical Services,LAB,84066,ACID PHOSPHATASE PROSTAT  (MAYO),300,37.75,32.09,Pays at 85% of Billed charges for outpatient setting,12.15,Pays at 100% of GA Medicaid Fee Schedule,30.21,Pays at 80.03% of Total Billed charges,9.85,Pays at 102% of Medicare OPPS Rate,33.98,Pays at 90% of Total Billed charges,12.15,Pays at 100% of GA Medicaid Fee Schedule,9.66,Pays at 100% of Medicare OPPS Rate,12.15,Pays at 100% of GA Medicaid Fee Schedule,33.22,Pays at 88% of Total Billed charges,12.51,Pays at 103% of GA Medicaid Fee Schedule,9.66,33.98,22.65
Outpatient Medical Services,LAB,84075,ALKALINE PHOSPHATASE,300,30,25.5,Pays at 85% of Billed charges for outpatient setting,6.35,Pays at 100% of GA Medicaid Fee Schedule,24.01,Pays at 80.03% of Total Billed charges,5.28,Pays at 102% of Medicare OPPS Rate,27,Pays at 90% of Total Billed charges,6.35,Pays at 100% of GA Medicaid Fee Schedule,5.18,Pays at 100% of Medicare OPPS Rate,6.35,Pays at 100% of GA Medicaid Fee Schedule,26.4,Pays at 88% of Total Billed charges,6.54,Pays at 103% of GA Medicaid Fee Schedule,5.18,27,18.00
Outpatient Medical Services,LAB,84080,"ALK. PHOS, BONE SPECIFIC  (MAYO)",300,99.25,84.36,Pays at 85% of Billed charges for outpatient setting,18.59,Pays at 100% of GA Medicaid Fee Schedule,79.43,Pays at 80.03% of Total Billed charges,15.07,Pays at 102% of Medicare OPPS Rate,89.33,Pays at 90% of Total Billed charges,18.59,Pays at 100% of GA Medicaid Fee Schedule,14.78,Pays at 100% of Medicare OPPS Rate,18.59,Pays at 100% of GA Medicaid Fee Schedule,87.34,Pays at 88% of Total Billed charges,19.15,Pays at 103% of GA Medicaid Fee Schedule,14.78,89.33,59.55
Outpatient Medical Services,LAB,84080,ALKALINE PHOSHATASE ISOENZYMES  (MAYO),300,112.5,95.63,Pays at 85% of Billed charges for outpatient setting,18.59,Pays at 100% of GA Medicaid Fee Schedule,90.03,Pays at 80.03% of Total Billed charges,15.07,Pays at 102% of Medicare OPPS Rate,101.25,Pays at 90% of Total Billed charges,18.59,Pays at 100% of GA Medicaid Fee Schedule,14.78,Pays at 100% of Medicare OPPS Rate,18.59,Pays at 100% of GA Medicaid Fee Schedule,99,Pays at 88% of Total Billed charges,19.15,Pays at 103% of GA Medicaid Fee Schedule,14.78,101.25,67.50
Outpatient Medical Services,LAB,84081,PHOSPHATIDYLGLYCEROL  (MAYO),300,96,81.6,Pays at 85% of Billed charges for outpatient setting,20.78,Pays at 100% of GA Medicaid Fee Schedule,76.83,Pays at 80.03% of Total Billed charges,16.85,Pays at 102% of Medicare OPPS Rate,86.4,Pays at 90% of Total Billed charges,20.78,Pays at 100% of GA Medicaid Fee Schedule,16.52,Pays at 100% of Medicare OPPS Rate,20.78,Pays at 100% of GA Medicaid Fee Schedule,84.48,Pays at 88% of Total Billed charges,21.4,Pays at 103% of GA Medicaid Fee Schedule,16.52,86.4,57.60
Outpatient Medical Services,LAB,84087,GLU PHOS ISOMERASE ERYTHRO  (MAYO),300,130.5,110.93,Pays at 85% of Billed charges for outpatient setting,12.98,Pays at 100% of GA Medicaid Fee Schedule,104.44,Pays at 80.03% of Total Billed charges,10.94,Pays at 102% of Medicare OPPS Rate,117.45,Pays at 90% of Total Billed charges,12.98,Pays at 100% of GA Medicaid Fee Schedule,10.73,Pays at 100% of Medicare OPPS Rate,12.98,Pays at 100% of GA Medicaid Fee Schedule,114.84,Pays at 88% of Total Billed charges,13.37,Pays at 103% of GA Medicaid Fee Schedule,10.73,117.45,78.30
Outpatient Medical Services,LAB,84100,"PHOSPHORUS, BLOOD",300,24.6,20.91,Pays at 85% of Billed charges for outpatient setting,5.97,Pays at 100% of GA Medicaid Fee Schedule,19.69,Pays at 80.03% of Total Billed charges,4.83,Pays at 102% of Medicare OPPS Rate,22.14,Pays at 90% of Total Billed charges,5.97,Pays at 100% of GA Medicaid Fee Schedule,4.74,Pays at 100% of Medicare OPPS Rate,5.97,Pays at 100% of GA Medicaid Fee Schedule,21.65,Pays at 88% of Total Billed charges,6.15,Pays at 103% of GA Medicaid Fee Schedule,4.74,22.14,14.76
Outpatient Medical Services,LAB,84100,"PHOSPHOROUS, FECES, QT  (MAYO)",300,30.75,26.14,Pays at 85% of Billed charges for outpatient setting,5.97,Pays at 100% of GA Medicaid Fee Schedule,24.61,Pays at 80.03% of Total Billed charges,4.83,Pays at 102% of Medicare OPPS Rate,27.68,Pays at 90% of Total Billed charges,5.97,Pays at 100% of GA Medicaid Fee Schedule,4.74,Pays at 100% of Medicare OPPS Rate,5.97,Pays at 100% of GA Medicaid Fee Schedule,27.06,Pays at 88% of Total Billed charges,6.15,Pays at 103% of GA Medicaid Fee Schedule,4.74,27.68,18.45
Outpatient Medical Services,LAB,84105,"PHOSPHOROUS, 24HR URINE  (MAYO)",300,29,24.65,Pays at 85% of Billed charges for outpatient setting,6.51,Pays at 100% of GA Medicaid Fee Schedule,23.21,Pays at 80.03% of Total Billed charges,5.89,Pays at 102% of Medicare OPPS Rate,26.1,Pays at 90% of Total Billed charges,6.51,Pays at 100% of GA Medicaid Fee Schedule,5.78,Pays at 100% of Medicare OPPS Rate,6.51,Pays at 100% of GA Medicaid Fee Schedule,25.52,Pays at 88% of Total Billed charges,6.71,Pays at 103% of GA Medicaid Fee Schedule,5.78,26.1,17.40
Outpatient Medical Services,LAB,84105,"PHOSPHOROUS,  URINE 24 HR  (MAYO)",300,60,51,Pays at 85% of Billed charges for outpatient setting,6.51,Pays at 100% of GA Medicaid Fee Schedule,48.02,Pays at 80.03% of Total Billed charges,5.89,Pays at 102% of Medicare OPPS Rate,54,Pays at 90% of Total Billed charges,6.51,Pays at 100% of GA Medicaid Fee Schedule,5.78,Pays at 100% of Medicare OPPS Rate,6.51,Pays at 100% of GA Medicaid Fee Schedule,52.8,Pays at 88% of Total Billed charges,6.71,Pays at 103% of GA Medicaid Fee Schedule,5.78,54,36.00
Outpatient Medical Services,LAB,84110,PORPHOBILINOGEN QT  (MAYO),300,51.25,43.56,Pays at 85% of Billed charges for outpatient setting,10.62,Pays at 100% of GA Medicaid Fee Schedule,41.02,Pays at 80.03% of Total Billed charges,8.6,Pays at 102% of Medicare OPPS Rate,46.13,Pays at 90% of Total Billed charges,10.62,Pays at 100% of GA Medicaid Fee Schedule,8.44,Pays at 100% of Medicare OPPS Rate,10.62,Pays at 100% of GA Medicaid Fee Schedule,45.1,Pays at 88% of Total Billed charges,10.94,Pays at 103% of GA Medicaid Fee Schedule,8.44,46.13,30.75
Outpatient Medical Services,LAB,84110,"PORPHYRINS, URINE QT RANDOM (MAYO)",300,51.75,43.99,Pays at 85% of Billed charges for outpatient setting,10.62,Pays at 100% of GA Medicaid Fee Schedule,41.42,Pays at 80.03% of Total Billed charges,8.6,Pays at 102% of Medicare OPPS Rate,46.58,Pays at 90% of Total Billed charges,10.62,Pays at 100% of GA Medicaid Fee Schedule,8.44,Pays at 100% of Medicare OPPS Rate,10.62,Pays at 100% of GA Medicaid Fee Schedule,45.54,Pays at 88% of Total Billed charges,10.94,Pays at 103% of GA Medicaid Fee Schedule,8.44,46.58,31.05
Outpatient Medical Services,LAB,84112,"AMNISURE, PAMG-1",300,253.5,215.48,Pays at 85% of Billed charges for outpatient setting,72.51,Pays at 100% of GA Medicaid Fee Schedule,202.88,Pays at 80.03% of Total Billed charges,100.07,Pays at 102% of Medicare OPPS Rate,228.15,Pays at 90% of Total Billed charges,72.51,Pays at 100% of GA Medicaid Fee Schedule,98.11,Pays at 100% of Medicare OPPS Rate,72.51,Pays at 100% of GA Medicaid Fee Schedule,223.08,Pays at 88% of Total Billed charges,74.69,Pays at 103% of GA Medicaid Fee Schedule,72.51,228.15,152.10
Outpatient Medical Services,LAB,84119,"PORPHYRINS, URINE QL  (MAYO)",300,22.5,19.13,Pays at 85% of Billed charges for outpatient setting,10.83,Pays at 100% of GA Medicaid Fee Schedule,18.01,Pays at 80.03% of Total Billed charges,13.62,Pays at 102% of Medicare OPPS Rate,20.25,Pays at 90% of Total Billed charges,10.83,Pays at 100% of GA Medicaid Fee Schedule,13.36,Pays at 100% of Medicare OPPS Rate,10.83,Pays at 100% of GA Medicaid Fee Schedule,19.8,Pays at 88% of Total Billed charges,11.15,Pays at 103% of GA Medicaid Fee Schedule,10.83,20.25,13.50
Outpatient Medical Services,LAB,84126,"PORPHYRINS, FECES  (MAYO)",300,287.5,244.38,Pays at 85% of Billed charges for outpatient setting,32.03,Pays at 100% of GA Medicaid Fee Schedule,230.09,Pays at 80.03% of Total Billed charges,39.89,Pays at 102% of Medicare OPPS Rate,258.75,Pays at 90% of Total Billed charges,32.03,Pays at 100% of GA Medicaid Fee Schedule,39.11,Pays at 100% of Medicare OPPS Rate,32.03,Pays at 100% of GA Medicaid Fee Schedule,253,Pays at 88% of Total Billed charges,32.99,Pays at 103% of GA Medicaid Fee Schedule,32.03,258.75,172.50
Outpatient Medical Services,LAB,84132,"POTASSIUM, BLOOD",300,15.38,13.07,Pays at 85% of Billed charges for outpatient setting,5.78,Pays at 100% of GA Medicaid Fee Schedule,12.31,Pays at 80.03% of Total Billed charges,4.85,Pays at 102% of Medicare OPPS Rate,13.84,Pays at 90% of Total Billed charges,5.78,Pays at 100% of GA Medicaid Fee Schedule,4.76,Pays at 100% of Medicare OPPS Rate,5.78,Pays at 100% of GA Medicaid Fee Schedule,13.53,Pays at 88% of Total Billed charges,5.95,Pays at 103% of GA Medicaid Fee Schedule,4.76,13.84,9.23
Outpatient Medical Services,LAB,84133,"POTASSIUM, 24HR URINE  (MAYO)",300,23.6,20.06,Pays at 85% of Billed charges for outpatient setting,5.41,Pays at 100% of GA Medicaid Fee Schedule,18.89,Pays at 80.03% of Total Billed charges,4.82,Pays at 102% of Medicare OPPS Rate,21.24,Pays at 90% of Total Billed charges,5.41,Pays at 100% of GA Medicaid Fee Schedule,4.73,Pays at 100% of Medicare OPPS Rate,5.41,Pays at 100% of GA Medicaid Fee Schedule,20.77,Pays at 88% of Total Billed charges,5.57,Pays at 103% of GA Medicaid Fee Schedule,4.73,21.24,14.16
Outpatient Medical Services,LAB,84133,"URINE POTASSIUM, RANDOM",300,33,28.05,Pays at 85% of Billed charges for outpatient setting,5.41,Pays at 100% of GA Medicaid Fee Schedule,26.41,Pays at 80.03% of Total Billed charges,4.82,Pays at 102% of Medicare OPPS Rate,29.7,Pays at 90% of Total Billed charges,5.41,Pays at 100% of GA Medicaid Fee Schedule,4.73,Pays at 100% of Medicare OPPS Rate,5.41,Pays at 100% of GA Medicaid Fee Schedule,29.04,Pays at 88% of Total Billed charges,5.57,Pays at 103% of GA Medicaid Fee Schedule,4.73,29.7,19.80
Outpatient Medical Services,LAB,84133,"POTASSIUM, URINE 24HR",300,33.5,28.48,Pays at 85% of Billed charges for outpatient setting,5.41,Pays at 100% of GA Medicaid Fee Schedule,26.81,Pays at 80.03% of Total Billed charges,4.82,Pays at 102% of Medicare OPPS Rate,30.15,Pays at 90% of Total Billed charges,5.41,Pays at 100% of GA Medicaid Fee Schedule,4.73,Pays at 100% of Medicare OPPS Rate,5.41,Pays at 100% of GA Medicaid Fee Schedule,29.48,Pays at 88% of Total Billed charges,5.57,Pays at 103% of GA Medicaid Fee Schedule,4.73,30.15,20.10
Outpatient Medical Services,LAB,84134,Blood test to measure level of prealbumin,300,58.74,49.93,Pays at 85% of Billed charges for outpatient setting,18.34,Pays at 100% of GA Medicaid Fee Schedule,47.01,Pays at 80.03% of Total Billed charges,14.88,Pays at 102% of Medicare OPPS Rate,52.87,Pays at 90% of Total Billed charges,18.34,Pays at 100% of GA Medicaid Fee Schedule,14.59,Pays at 100% of Medicare OPPS Rate,18.34,Pays at 100% of GA Medicaid Fee Schedule,51.69,Pays at 88% of Total Billed charges,18.89,Pays at 103% of GA Medicaid Fee Schedule,14.59,52.87,35.24
Outpatient Medical Services,LAB,84140,PREGNELONE  (MAYO),300,154,130.9,Pays at 85% of Billed charges for outpatient setting,26,Pays at 100% of GA Medicaid Fee Schedule,123.25,Pays at 80.03% of Total Billed charges,21.08,Pays at 102% of Medicare OPPS Rate,138.6,Pays at 90% of Total Billed charges,26,Pays at 100% of GA Medicaid Fee Schedule,20.67,Pays at 100% of Medicare OPPS Rate,26,Pays at 100% of GA Medicaid Fee Schedule,135.52,Pays at 88% of Total Billed charges,26.78,Pays at 103% of GA Medicaid Fee Schedule,20.67,138.6,92.40
Outpatient Medical Services,LAB,84143,HYDROXYPREGNENOLONE 17  (MAYO),300,187.25,159.16,Pays at 85% of Billed charges for outpatient setting,28.7,Pays at 100% of GA Medicaid Fee Schedule,149.86,Pays at 80.03% of Total Billed charges,23.26,Pays at 102% of Medicare OPPS Rate,168.53,Pays at 90% of Total Billed charges,28.7,Pays at 100% of GA Medicaid Fee Schedule,22.81,Pays at 100% of Medicare OPPS Rate,28.7,Pays at 100% of GA Medicaid Fee Schedule,164.78,Pays at 88% of Total Billed charges,29.56,Pays at 103% of GA Medicaid Fee Schedule,22.81,168.53,112.35
Outpatient Medical Services,LAB,84144,PROGESTERONE  (MAYO),300,66.25,56.31,Pays at 85% of Billed charges for outpatient setting,25.61,Pays at 100% of GA Medicaid Fee Schedule,53.02,Pays at 80.03% of Total Billed charges,21.27,Pays at 102% of Medicare OPPS Rate,59.63,Pays at 90% of Total Billed charges,25.61,Pays at 100% of GA Medicaid Fee Schedule,20.86,Pays at 100% of Medicare OPPS Rate,25.61,Pays at 100% of GA Medicaid Fee Schedule,58.3,Pays at 88% of Total Billed charges,26.38,Pays at 103% of GA Medicaid Fee Schedule,20.86,59.63,39.75
Outpatient Medical Services,LAB,84145,"PROCALCITONIN, SERUM  (MAYO)",300,211.25,179.56,Pays at 85% of Billed charges for outpatient setting,24.06,Pays at 100% of GA Medicaid Fee Schedule,169.06,Pays at 80.03% of Total Billed charges,27.76,Pays at 102% of Medicare OPPS Rate,190.13,Pays at 90% of Total Billed charges,24.06,Pays at 100% of GA Medicaid Fee Schedule,27.22,Pays at 100% of Medicare OPPS Rate,24.06,Pays at 100% of GA Medicaid Fee Schedule,185.9,Pays at 88% of Total Billed charges,24.78,Pays at 103% of GA Medicaid Fee Schedule,24.06,190.13,126.75
Outpatient Medical Services,LAB,84146,"MACROPROLACTIN, S  (MAYO)",300,38.76,32.95,Pays at 85% of Billed charges for outpatient setting,24.37,Pays at 100% of GA Medicaid Fee Schedule,31.02,Pays at 80.03% of Total Billed charges,19.76,Pays at 102% of Medicare OPPS Rate,34.88,Pays at 90% of Total Billed charges,24.37,Pays at 100% of GA Medicaid Fee Schedule,19.38,Pays at 100% of Medicare OPPS Rate,24.37,Pays at 100% of GA Medicaid Fee Schedule,34.11,Pays at 88% of Total Billed charges,25.1,Pays at 103% of GA Medicaid Fee Schedule,19.38,34.88,23.26
Outpatient Medical Services,LAB,84146,PROLACTIN  (MAYO),300,62,52.7,Pays at 85% of Billed charges for outpatient setting,24.37,Pays at 100% of GA Medicaid Fee Schedule,49.62,Pays at 80.03% of Total Billed charges,19.76,Pays at 102% of Medicare OPPS Rate,55.8,Pays at 90% of Total Billed charges,24.37,Pays at 100% of GA Medicaid Fee Schedule,19.38,Pays at 100% of Medicare OPPS Rate,24.37,Pays at 100% of GA Medicaid Fee Schedule,54.56,Pays at 88% of Total Billed charges,25.1,Pays at 103% of GA Medicaid Fee Schedule,19.38,55.8,37.20
Outpatient Medical Services,LAB,84146,"PROLACTIN, TOTAL S (MAYO)",300,84.75,72.04,Pays at 85% of Billed charges for outpatient setting,24.37,Pays at 100% of GA Medicaid Fee Schedule,67.83,Pays at 80.03% of Total Billed charges,19.76,Pays at 102% of Medicare OPPS Rate,76.28,Pays at 90% of Total Billed charges,24.37,Pays at 100% of GA Medicaid Fee Schedule,19.38,Pays at 100% of Medicare OPPS Rate,24.37,Pays at 100% of GA Medicaid Fee Schedule,74.58,Pays at 88% of Total Billed charges,25.1,Pays at 103% of GA Medicaid Fee Schedule,19.38,76.28,50.85
Outpatient Medical Services,LAB,84146,"PROLACTIN, UNPRECIPITATE, S  (MAYO)",300,84.75,72.04,Pays at 85% of Billed charges for outpatient setting,24.37,Pays at 100% of GA Medicaid Fee Schedule,67.83,Pays at 80.03% of Total Billed charges,19.76,Pays at 102% of Medicare OPPS Rate,76.28,Pays at 90% of Total Billed charges,24.37,Pays at 100% of GA Medicaid Fee Schedule,19.38,Pays at 100% of Medicare OPPS Rate,24.37,Pays at 100% of GA Medicaid Fee Schedule,74.58,Pays at 88% of Total Billed charges,25.1,Pays at 103% of GA Medicaid Fee Schedule,19.38,76.28,50.85
Outpatient Medical Services,LAB,84150,PROSTAGLANDIN  (MAYO),300,124.25,105.61,Pays at 85% of Billed charges for outpatient setting,31.39,Pays at 100% of GA Medicaid Fee Schedule,99.44,Pays at 80.03% of Total Billed charges,42.6,Pays at 102% of Medicare OPPS Rate,111.83,Pays at 90% of Total Billed charges,31.39,Pays at 100% of GA Medicaid Fee Schedule,41.77,Pays at 100% of Medicare OPPS Rate,31.39,Pays at 100% of GA Medicaid Fee Schedule,109.34,Pays at 88% of Total Billed charges,32.33,Pays at 103% of GA Medicaid Fee Schedule,31.39,111.83,74.55
Outpatient Medical Services,LAB,84153,PSA (prostate specific antigen),300,59,50.15,Pays at 85% of Billed charges for outpatient setting,23.13,Pays at 100% of GA Medicaid Fee Schedule,47.22,Pays at 80.03% of Total Billed charges,18.75,Pays at 102% of Medicare OPPS Rate,53.1,Pays at 90% of Total Billed charges,23.13,Pays at 100% of GA Medicaid Fee Schedule,18.39,Pays at 100% of Medicare OPPS Rate,23.13,Pays at 100% of GA Medicaid Fee Schedule,51.92,Pays at 88% of Total Billed charges,23.82,Pays at 103% of GA Medicaid Fee Schedule,18.39,53.1,35.40
Outpatient Medical Services,LAB,84153,PSA (prostate specific antigen),300,81.56,69.33,Pays at 85% of Billed charges for outpatient setting,23.13,Pays at 100% of GA Medicaid Fee Schedule,65.27,Pays at 80.03% of Total Billed charges,18.75,Pays at 102% of Medicare OPPS Rate,73.4,Pays at 90% of Total Billed charges,23.13,Pays at 100% of GA Medicaid Fee Schedule,18.39,Pays at 100% of Medicare OPPS Rate,23.13,Pays at 100% of GA Medicaid Fee Schedule,71.77,Pays at 88% of Total Billed charges,23.82,Pays at 103% of GA Medicaid Fee Schedule,18.39,73.4,48.94
Outpatient Medical Services,LAB,84153,PSA (prostate specific antigen),300,105.75,89.89,Pays at 85% of Billed charges for outpatient setting,23.13,Pays at 100% of GA Medicaid Fee Schedule,84.63,Pays at 80.03% of Total Billed charges,18.75,Pays at 102% of Medicare OPPS Rate,95.18,Pays at 90% of Total Billed charges,23.13,Pays at 100% of GA Medicaid Fee Schedule,18.39,Pays at 100% of Medicare OPPS Rate,23.13,Pays at 100% of GA Medicaid Fee Schedule,93.06,Pays at 88% of Total Billed charges,23.82,Pays at 103% of GA Medicaid Fee Schedule,18.39,95.18,63.45
Outpatient Medical Services,LAB,84153,PSA (prostate specific antigen),300,112,95.2,Pays at 85% of Billed charges for outpatient setting,23.13,Pays at 100% of GA Medicaid Fee Schedule,89.63,Pays at 80.03% of Total Billed charges,18.75,Pays at 102% of Medicare OPPS Rate,100.8,Pays at 90% of Total Billed charges,23.13,Pays at 100% of GA Medicaid Fee Schedule,18.39,Pays at 100% of Medicare OPPS Rate,23.13,Pays at 100% of GA Medicaid Fee Schedule,98.56,Pays at 88% of Total Billed charges,23.82,Pays at 103% of GA Medicaid Fee Schedule,18.39,100.8,67.20
Outpatient Medical Services,LAB,84154,PSA (prostate specific antigen) measurement,300,57,48.45,Pays at 85% of Billed charges for outpatient setting,23.13,Pays at 100% of GA Medicaid Fee Schedule,45.62,Pays at 80.03% of Total Billed charges,18.75,Pays at 102% of Medicare OPPS Rate,51.3,Pays at 90% of Total Billed charges,23.13,Pays at 100% of GA Medicaid Fee Schedule,18.39,Pays at 100% of Medicare OPPS Rate,23.13,Pays at 100% of GA Medicaid Fee Schedule,50.16,Pays at 88% of Total Billed charges,23.82,Pays at 103% of GA Medicaid Fee Schedule,18.39,51.3,34.20
Outpatient Medical Services,LAB,84155,"PROTEIN,TOTAL, SERUM",300,30,25.5,Pays at 85% of Billed charges for outpatient setting,4.61,Pays at 100% of GA Medicaid Fee Schedule,24.01,Pays at 80.03% of Total Billed charges,3.74,Pays at 102% of Medicare OPPS Rate,27,Pays at 90% of Total Billed charges,4.61,Pays at 100% of GA Medicaid Fee Schedule,3.67,Pays at 100% of Medicare OPPS Rate,4.61,Pays at 100% of GA Medicaid Fee Schedule,26.4,Pays at 88% of Total Billed charges,4.75,Pays at 103% of GA Medicaid Fee Schedule,3.67,27,18.00
Outpatient Medical Services,LAB,84155,..BODY FLUID PROTEIN,300,51.75,43.99,Pays at 85% of Billed charges for outpatient setting,4.61,Pays at 100% of GA Medicaid Fee Schedule,41.42,Pays at 80.03% of Total Billed charges,3.74,Pays at 102% of Medicare OPPS Rate,46.58,Pays at 90% of Total Billed charges,4.61,Pays at 100% of GA Medicaid Fee Schedule,3.67,Pays at 100% of Medicare OPPS Rate,4.61,Pays at 100% of GA Medicaid Fee Schedule,45.54,Pays at 88% of Total Billed charges,4.75,Pays at 103% of GA Medicaid Fee Schedule,3.67,46.58,31.05
Outpatient Medical Services,LAB,84156,"URINE PROTEIN, RANDOM",300,30,25.5,Pays at 85% of Billed charges for outpatient setting,4.61,Pays at 100% of GA Medicaid Fee Schedule,24.01,Pays at 80.03% of Total Billed charges,3.74,Pays at 102% of Medicare OPPS Rate,27,Pays at 90% of Total Billed charges,4.61,Pays at 100% of GA Medicaid Fee Schedule,3.67,Pays at 100% of Medicare OPPS Rate,4.61,Pays at 100% of GA Medicaid Fee Schedule,26.4,Pays at 88% of Total Billed charges,4.75,Pays at 103% of GA Medicaid Fee Schedule,3.67,27,18.00
Outpatient Medical Services,LAB,84156,URINE PROTEIN 24HR,300,40.25,34.21,Pays at 85% of Billed charges for outpatient setting,4.61,Pays at 100% of GA Medicaid Fee Schedule,32.21,Pays at 80.03% of Total Billed charges,3.74,Pays at 102% of Medicare OPPS Rate,36.23,Pays at 90% of Total Billed charges,4.61,Pays at 100% of GA Medicaid Fee Schedule,3.67,Pays at 100% of Medicare OPPS Rate,4.61,Pays at 100% of GA Medicaid Fee Schedule,35.42,Pays at 88% of Total Billed charges,4.75,Pays at 103% of GA Medicaid Fee Schedule,3.67,36.23,24.15
Outpatient Medical Services,LAB,84157,CSF PROTEIN,300,30,25.5,Pays at 85% of Billed charges for outpatient setting,4.61,Pays at 100% of GA Medicaid Fee Schedule,24.01,Pays at 80.03% of Total Billed charges,4.08,Pays at 102% of Medicare OPPS Rate,27,Pays at 90% of Total Billed charges,4.61,Pays at 100% of GA Medicaid Fee Schedule,4,Pays at 100% of Medicare OPPS Rate,4.61,Pays at 100% of GA Medicaid Fee Schedule,26.4,Pays at 88% of Total Billed charges,4.75,Pays at 103% of GA Medicaid Fee Schedule,4,27,18.00
Outpatient Medical Services,LAB,84157,"BODY FLUID, PROTEIN  (MAYO)",300,40,34,Pays at 85% of Billed charges for outpatient setting,4.61,Pays at 100% of GA Medicaid Fee Schedule,32.01,Pays at 80.03% of Total Billed charges,4.08,Pays at 102% of Medicare OPPS Rate,36,Pays at 90% of Total Billed charges,4.61,Pays at 100% of GA Medicaid Fee Schedule,4,Pays at 100% of Medicare OPPS Rate,4.61,Pays at 100% of GA Medicaid Fee Schedule,35.2,Pays at 88% of Total Billed charges,4.75,Pays at 103% of GA Medicaid Fee Schedule,4,36,24.00
Outpatient Medical Services,LAB,84157,"BODY FLUID, TOTAL PROTEIN  (MAYO)",300,44.5,37.83,Pays at 85% of Billed charges for outpatient setting,4.61,Pays at 100% of GA Medicaid Fee Schedule,35.61,Pays at 80.03% of Total Billed charges,4.08,Pays at 102% of Medicare OPPS Rate,40.05,Pays at 90% of Total Billed charges,4.61,Pays at 100% of GA Medicaid Fee Schedule,4,Pays at 100% of Medicare OPPS Rate,4.61,Pays at 100% of GA Medicaid Fee Schedule,39.16,Pays at 88% of Total Billed charges,4.75,Pays at 103% of GA Medicaid Fee Schedule,4,40.05,26.70
Outpatient Medical Services,LAB,84165,"ELECTRO, PROTEIN  SPEP (MAYO)",300,47.5,40.38,Pays at 85% of Billed charges for outpatient setting,13.51,Pays at 100% of GA Medicaid Fee Schedule,38.01,Pays at 80.03% of Total Billed charges,10.95,Pays at 102% of Medicare OPPS Rate,42.75,Pays at 90% of Total Billed charges,13.51,Pays at 100% of GA Medicaid Fee Schedule,10.74,Pays at 100% of Medicare OPPS Rate,13.51,Pays at 100% of GA Medicaid Fee Schedule,41.8,Pays at 88% of Total Billed charges,13.92,Pays at 103% of GA Medicaid Fee Schedule,10.74,42.75,28.50
Outpatient Medical Services,LAB,84165,"MONOCLONAL PROTEIN EXP, URINE  (MAYO)",300,224.25,190.61,Pays at 85% of Billed charges for outpatient setting,13.51,Pays at 100% of GA Medicaid Fee Schedule,179.47,Pays at 80.03% of Total Billed charges,10.95,Pays at 102% of Medicare OPPS Rate,201.83,Pays at 90% of Total Billed charges,13.51,Pays at 100% of GA Medicaid Fee Schedule,10.74,Pays at 100% of Medicare OPPS Rate,13.51,Pays at 100% of GA Medicaid Fee Schedule,197.34,Pays at 88% of Total Billed charges,13.92,Pays at 103% of GA Medicaid Fee Schedule,10.74,201.83,134.55
Outpatient Medical Services,LAB,84166,"ELECTROPHERESIS PROTEIN, URINE 24 (MAYO)",300,113.75,96.69,Pays at 85% of Billed charges for outpatient setting,22.43,Pays at 100% of GA Medicaid Fee Schedule,91.03,Pays at 80.03% of Total Billed charges,18.18,Pays at 102% of Medicare OPPS Rate,102.38,Pays at 90% of Total Billed charges,22.43,Pays at 100% of GA Medicaid Fee Schedule,17.82,Pays at 100% of Medicare OPPS Rate,22.43,Pays at 100% of GA Medicaid Fee Schedule,100.1,Pays at 88% of Total Billed charges,23.1,Pays at 103% of GA Medicaid Fee Schedule,17.82,102.38,68.25
Outpatient Medical Services,LAB,84166,"IMMUNOFIXATION, U  (MAYO)",300,113.75,96.69,Pays at 85% of Billed charges for outpatient setting,22.43,Pays at 100% of GA Medicaid Fee Schedule,91.03,Pays at 80.03% of Total Billed charges,18.18,Pays at 102% of Medicare OPPS Rate,102.38,Pays at 90% of Total Billed charges,22.43,Pays at 100% of GA Medicaid Fee Schedule,17.82,Pays at 100% of Medicare OPPS Rate,22.43,Pays at 100% of GA Medicaid Fee Schedule,100.1,Pays at 88% of Total Billed charges,23.1,Pays at 103% of GA Medicaid Fee Schedule,17.82,102.38,68.25
Outpatient Medical Services,LAB,84166,"ELECTRO PRO, BODY FLUID  (MAYO)",300,113.75,96.69,Pays at 85% of Billed charges for outpatient setting,22.43,Pays at 100% of GA Medicaid Fee Schedule,91.03,Pays at 80.03% of Total Billed charges,18.18,Pays at 102% of Medicare OPPS Rate,102.38,Pays at 90% of Total Billed charges,22.43,Pays at 100% of GA Medicaid Fee Schedule,17.82,Pays at 100% of Medicare OPPS Rate,22.43,Pays at 100% of GA Medicaid Fee Schedule,100.1,Pays at 88% of Total Billed charges,23.1,Pays at 103% of GA Medicaid Fee Schedule,17.82,102.38,68.25
Outpatient Medical Services,LAB,84206,PRO-INSULIN  (MAYO),300,117.75,100.09,Pays at 85% of Billed charges for outpatient setting,22.4,Pays at 100% of GA Medicaid Fee Schedule,94.24,Pays at 80.03% of Total Billed charges,27.22,Pays at 102% of Medicare OPPS Rate,105.98,Pays at 90% of Total Billed charges,22.4,Pays at 100% of GA Medicaid Fee Schedule,26.69,Pays at 100% of Medicare OPPS Rate,22.4,Pays at 100% of GA Medicaid Fee Schedule,103.62,Pays at 88% of Total Billed charges,23.07,Pays at 103% of GA Medicaid Fee Schedule,22.4,105.98,70.65
Outpatient Medical Services,LAB,84207,PYRIDOXAL 5-PHOSPHATE (PLP)  MAYO),300,161.5,137.28,Pays at 85% of Billed charges for outpatient setting,35.33,Pays at 100% of GA Medicaid Fee Schedule,129.25,Pays at 80.03% of Total Billed charges,28.66,Pays at 102% of Medicare OPPS Rate,145.35,Pays at 90% of Total Billed charges,35.33,Pays at 100% of GA Medicaid Fee Schedule,28.1,Pays at 100% of Medicare OPPS Rate,35.33,Pays at 100% of GA Medicaid Fee Schedule,142.12,Pays at 88% of Total Billed charges,36.39,Pays at 103% of GA Medicaid Fee Schedule,28.1,145.35,96.90
Outpatient Medical Services,LAB,84210,"PYRUVIC ACID, BLOOD  (MAYO)",300,41.25,35.06,Pays at 85% of Billed charges for outpatient setting,13.65,Pays at 100% of GA Medicaid Fee Schedule,33.01,Pays at 80.03% of Total Billed charges,14.76,Pays at 102% of Medicare OPPS Rate,37.13,Pays at 90% of Total Billed charges,13.65,Pays at 100% of GA Medicaid Fee Schedule,14.48,Pays at 100% of Medicare OPPS Rate,13.65,Pays at 100% of GA Medicaid Fee Schedule,36.3,Pays at 88% of Total Billed charges,14.06,Pays at 103% of GA Medicaid Fee Schedule,13.65,37.13,24.75
Outpatient Medical Services,LAB,84220,"PYRUVATE KINASE, RBC  (MAYO)",300,194,164.9,Pays at 85% of Billed charges for outpatient setting,11.86,Pays at 100% of GA Medicaid Fee Schedule,155.26,Pays at 80.03% of Total Billed charges,9.62,Pays at 102% of Medicare OPPS Rate,174.6,Pays at 90% of Total Billed charges,11.86,Pays at 100% of GA Medicaid Fee Schedule,9.44,Pays at 100% of Medicare OPPS Rate,11.86,Pays at 100% of GA Medicaid Fee Schedule,170.72,Pays at 88% of Total Billed charges,12.22,Pays at 103% of GA Medicaid Fee Schedule,9.44,174.6,116.40
Outpatient Medical Services,LAB,84233,..ERA,300,160,136,Pays at 85% of Billed charges for outpatient setting,80.99,Pays at 100% of GA Medicaid Fee Schedule,128.05,Pays at 80.03% of Total Billed charges,89.63,Pays at 102% of Medicare OPPS Rate,144,Pays at 90% of Total Billed charges,80.99,Pays at 100% of GA Medicaid Fee Schedule,87.88,Pays at 100% of Medicare OPPS Rate,80.99,Pays at 100% of GA Medicaid Fee Schedule,140.8,Pays at 88% of Total Billed charges,83.42,Pays at 103% of GA Medicaid Fee Schedule,80.99,144,96.00
Outpatient Medical Services,LAB,84244,RENIN  (MAYO),300,70.5,59.93,Pays at 85% of Billed charges for outpatient setting,27.66,Pays at 100% of GA Medicaid Fee Schedule,56.42,Pays at 80.03% of Total Billed charges,22.42,Pays at 102% of Medicare OPPS Rate,63.45,Pays at 90% of Total Billed charges,27.66,Pays at 100% of GA Medicaid Fee Schedule,21.99,Pays at 100% of Medicare OPPS Rate,27.66,Pays at 100% of GA Medicaid Fee Schedule,62.04,Pays at 88% of Total Billed charges,28.49,Pays at 103% of GA Medicaid Fee Schedule,21.99,63.45,42.30
Outpatient Medical Services,LAB,84252,"VITAMIN B2, RIBOFLAVIN  (MAYO)",300,67.25,57.16,Pays at 85% of Billed charges for outpatient setting,25.45,Pays at 100% of GA Medicaid Fee Schedule,53.82,Pays at 80.03% of Total Billed charges,20.64,Pays at 102% of Medicare OPPS Rate,60.53,Pays at 90% of Total Billed charges,25.45,Pays at 100% of GA Medicaid Fee Schedule,20.23,Pays at 100% of Medicare OPPS Rate,25.45,Pays at 100% of GA Medicaid Fee Schedule,59.18,Pays at 88% of Total Billed charges,26.21,Pays at 103% of GA Medicaid Fee Schedule,20.23,60.53,40.35
Outpatient Medical Services,LAB,84255,"SELENIUM, SERUM  (MAYO)",300,49.75,42.29,Pays at 85% of Billed charges for outpatient setting,32.1,Pays at 100% of GA Medicaid Fee Schedule,39.81,Pays at 80.03% of Total Billed charges,26.04,Pays at 102% of Medicare OPPS Rate,44.78,Pays at 90% of Total Billed charges,32.1,Pays at 100% of GA Medicaid Fee Schedule,25.53,Pays at 100% of Medicare OPPS Rate,32.1,Pays at 100% of GA Medicaid Fee Schedule,43.78,Pays at 88% of Total Billed charges,33.06,Pays at 103% of GA Medicaid Fee Schedule,25.53,44.78,29.85
Outpatient Medical Services,LAB,84260,SEROTONIN LEVEL  (MAYO),300,86.75,73.74,Pays at 85% of Billed charges for outpatient setting,38.95,Pays at 100% of GA Medicaid Fee Schedule,69.43,Pays at 80.03% of Total Billed charges,31.59,Pays at 102% of Medicare OPPS Rate,78.08,Pays at 90% of Total Billed charges,38.95,Pays at 100% of GA Medicaid Fee Schedule,30.98,Pays at 100% of Medicare OPPS Rate,38.95,Pays at 100% of GA Medicaid Fee Schedule,76.34,Pays at 88% of Total Billed charges,40.12,Pays at 103% of GA Medicaid Fee Schedule,30.98,78.08,52.05
Outpatient Medical Services,LAB,84270,SEX HORMONE BINDING GLOB  (MAYO),300,55.5,47.18,Pays at 85% of Billed charges for outpatient setting,27.32,Pays at 100% of GA Medicaid Fee Schedule,44.42,Pays at 80.03% of Total Billed charges,22.16,Pays at 102% of Medicare OPPS Rate,49.95,Pays at 90% of Total Billed charges,27.32,Pays at 100% of GA Medicaid Fee Schedule,21.73,Pays at 100% of Medicare OPPS Rate,27.32,Pays at 100% of GA Medicaid Fee Schedule,48.84,Pays at 88% of Total Billed charges,28.14,Pays at 103% of GA Medicaid Fee Schedule,21.73,49.95,33.30
Outpatient Medical Services,LAB,84270,SEX HORMONE BINDING GLOBULIN  (MAYO),300,119.75,101.79,Pays at 85% of Billed charges for outpatient setting,27.32,Pays at 100% of GA Medicaid Fee Schedule,95.84,Pays at 80.03% of Total Billed charges,22.16,Pays at 102% of Medicare OPPS Rate,107.78,Pays at 90% of Total Billed charges,27.32,Pays at 100% of GA Medicaid Fee Schedule,21.73,Pays at 100% of Medicare OPPS Rate,27.32,Pays at 100% of GA Medicaid Fee Schedule,105.38,Pays at 88% of Total Billed charges,28.14,Pays at 103% of GA Medicaid Fee Schedule,21.73,107.78,71.85
Outpatient Medical Services,LAB,84295,"SODIUM, BLOOD",300,15.38,13.07,Pays at 85% of Billed charges for outpatient setting,6.05,Pays at 100% of GA Medicaid Fee Schedule,12.31,Pays at 80.03% of Total Billed charges,4.9,Pays at 102% of Medicare OPPS Rate,13.84,Pays at 90% of Total Billed charges,6.05,Pays at 100% of GA Medicaid Fee Schedule,4.8,Pays at 100% of Medicare OPPS Rate,6.05,Pays at 100% of GA Medicaid Fee Schedule,13.53,Pays at 88% of Total Billed charges,6.23,Pays at 103% of GA Medicaid Fee Schedule,4.8,13.84,9.23
Outpatient Medical Services,LAB,84300,"URINE SODIUM, RANDOM",300,12.71,10.8,Pays at 85% of Billed charges for outpatient setting,4.35,Pays at 100% of GA Medicaid Fee Schedule,10.17,Pays at 80.03% of Total Billed charges,5.16,Pays at 102% of Medicare OPPS Rate,11.44,Pays at 90% of Total Billed charges,4.35,Pays at 100% of GA Medicaid Fee Schedule,5.05,Pays at 100% of Medicare OPPS Rate,4.35,Pays at 100% of GA Medicaid Fee Schedule,11.18,Pays at 88% of Total Billed charges,4.48,Pays at 103% of GA Medicaid Fee Schedule,4.35,11.44,7.63
Outpatient Medical Services,LAB,84300,"SODIUM, 24HR URINE  (MAYO)",300,25.2,21.42,Pays at 85% of Billed charges for outpatient setting,4.35,Pays at 100% of GA Medicaid Fee Schedule,20.17,Pays at 80.03% of Total Billed charges,5.16,Pays at 102% of Medicare OPPS Rate,22.68,Pays at 90% of Total Billed charges,4.35,Pays at 100% of GA Medicaid Fee Schedule,5.05,Pays at 100% of Medicare OPPS Rate,4.35,Pays at 100% of GA Medicaid Fee Schedule,22.18,Pays at 88% of Total Billed charges,4.48,Pays at 103% of GA Medicaid Fee Schedule,4.35,22.68,15.12
Outpatient Medical Services,LAB,84300,"SODIUM, 24HR URINE",300,33.5,28.48,Pays at 85% of Billed charges for outpatient setting,4.35,Pays at 100% of GA Medicaid Fee Schedule,26.81,Pays at 80.03% of Total Billed charges,5.16,Pays at 102% of Medicare OPPS Rate,30.15,Pays at 90% of Total Billed charges,4.35,Pays at 100% of GA Medicaid Fee Schedule,5.05,Pays at 100% of Medicare OPPS Rate,4.35,Pays at 100% of GA Medicaid Fee Schedule,29.48,Pays at 88% of Total Billed charges,4.48,Pays at 103% of GA Medicaid Fee Schedule,4.35,30.15,20.10
Outpatient Medical Services,LAB,84302,"SODIUM, FECES, QT  (MAYO)",300,31.5,26.78,Pays at 85% of Billed charges for outpatient setting,4.35,Pays at 100% of GA Medicaid Fee Schedule,25.21,Pays at 80.03% of Total Billed charges,4.95,Pays at 102% of Medicare OPPS Rate,28.35,Pays at 90% of Total Billed charges,4.35,Pays at 100% of GA Medicaid Fee Schedule,4.86,Pays at 100% of Medicare OPPS Rate,4.35,Pays at 100% of GA Medicaid Fee Schedule,27.72,Pays at 88% of Total Billed charges,4.48,Pays at 103% of GA Medicaid Fee Schedule,4.35,28.35,18.90
Outpatient Medical Services,LAB,84302,"SODIUM, BODY FLUID  (MAYO)",300,44.25,37.61,Pays at 85% of Billed charges for outpatient setting,4.35,Pays at 100% of GA Medicaid Fee Schedule,35.41,Pays at 80.03% of Total Billed charges,4.95,Pays at 102% of Medicare OPPS Rate,39.83,Pays at 90% of Total Billed charges,4.35,Pays at 100% of GA Medicaid Fee Schedule,4.86,Pays at 100% of Medicare OPPS Rate,4.35,Pays at 100% of GA Medicaid Fee Schedule,38.94,Pays at 88% of Total Billed charges,4.48,Pays at 103% of GA Medicaid Fee Schedule,4.35,39.83,26.55
Outpatient Medical Services,LAB,84305,INSULIN-LIKE GROWTH FACTOR (MAYO),300,68.25,58.01,Pays at 85% of Billed charges for outpatient setting,26.73,Pays at 100% of GA Medicaid Fee Schedule,54.62,Pays at 80.03% of Total Billed charges,21.68,Pays at 102% of Medicare OPPS Rate,61.43,Pays at 90% of Total Billed charges,26.73,Pays at 100% of GA Medicaid Fee Schedule,21.26,Pays at 100% of Medicare OPPS Rate,26.73,Pays at 100% of GA Medicaid Fee Schedule,60.06,Pays at 88% of Total Billed charges,27.53,Pays at 103% of GA Medicaid Fee Schedule,21.26,61.43,40.95
Outpatient Medical Services,LAB,84305,"SOMATOMEDIN-C, INSULIN-LIKE GROWTH PANEL",300,303.25,257.76,Pays at 85% of Billed charges for outpatient setting,26.73,Pays at 100% of GA Medicaid Fee Schedule,242.69,Pays at 80.03% of Total Billed charges,21.68,Pays at 102% of Medicare OPPS Rate,272.93,Pays at 90% of Total Billed charges,26.73,Pays at 100% of GA Medicaid Fee Schedule,21.26,Pays at 100% of Medicare OPPS Rate,26.73,Pays at 100% of GA Medicaid Fee Schedule,266.86,Pays at 88% of Total Billed charges,27.53,Pays at 103% of GA Medicaid Fee Schedule,21.26,272.93,181.95
Outpatient Medical Services,LAB,84311,"PORPHYRINS TOTAL, PLASMA  (MAYO)",300,82.75,70.34,Pays at 85% of Billed charges for outpatient setting,8.79,Pays at 100% of GA Medicaid Fee Schedule,66.22,Pays at 80.03% of Total Billed charges,8.26,Pays at 102% of Medicare OPPS Rate,74.48,Pays at 90% of Total Billed charges,8.79,Pays at 100% of GA Medicaid Fee Schedule,8.1,Pays at 100% of Medicare OPPS Rate,8.79,Pays at 100% of GA Medicaid Fee Schedule,72.82,Pays at 88% of Total Billed charges,9.05,Pays at 103% of GA Medicaid Fee Schedule,8.1,74.48,49.65
Outpatient Medical Services,LAB,84311,"CHOLESTEROL, BF  (MAYO)",300,281.5,239.28,Pays at 85% of Billed charges for outpatient setting,8.79,Pays at 100% of GA Medicaid Fee Schedule,225.28,Pays at 80.03% of Total Billed charges,8.26,Pays at 102% of Medicare OPPS Rate,253.35,Pays at 90% of Total Billed charges,8.79,Pays at 100% of GA Medicaid Fee Schedule,8.1,Pays at 100% of Medicare OPPS Rate,8.79,Pays at 100% of GA Medicaid Fee Schedule,247.72,Pays at 88% of Total Billed charges,9.05,Pays at 103% of GA Medicaid Fee Schedule,8.1,253.35,168.90
Outpatient Medical Services,LAB,84315,"SPECIFIC GRAVITY, BODY FLUID",300,29.25,24.86,Pays at 85% of Billed charges for outpatient setting,3.15,Pays at 100% of GA Medicaid Fee Schedule,23.41,Pays at 80.03% of Total Billed charges,3.34,Pays at 102% of Medicare OPPS Rate,26.33,Pays at 90% of Total Billed charges,3.15,Pays at 100% of GA Medicaid Fee Schedule,3.28,Pays at 100% of Medicare OPPS Rate,3.15,Pays at 100% of GA Medicaid Fee Schedule,25.74,Pays at 88% of Total Billed charges,3.24,Pays at 103% of GA Medicaid Fee Schedule,3.15,26.33,17.55
Outpatient Medical Services,LAB,84376,REDUCING SUBS/STOOL  (MAYO),300,81.75,69.49,Pays at 85% of Billed charges for outpatient setting,6.92,Pays at 100% of GA Medicaid Fee Schedule,65.42,Pays at 80.03% of Total Billed charges,5.61,Pays at 102% of Medicare OPPS Rate,73.58,Pays at 90% of Total Billed charges,6.92,Pays at 100% of GA Medicaid Fee Schedule,5.5,Pays at 100% of Medicare OPPS Rate,6.92,Pays at 100% of GA Medicaid Fee Schedule,71.94,Pays at 88% of Total Billed charges,7.13,Pays at 103% of GA Medicaid Fee Schedule,5.5,73.58,49.05
Outpatient Medical Services,LAB,84392,"SULFATE, 24HR URINE  (MAYO)",300,56,47.6,Pays at 85% of Billed charges for outpatient setting,5.98,Pays at 100% of GA Medicaid Fee Schedule,44.82,Pays at 80.03% of Total Billed charges,5.59,Pays at 102% of Medicare OPPS Rate,50.4,Pays at 90% of Total Billed charges,5.98,Pays at 100% of GA Medicaid Fee Schedule,5.49,Pays at 100% of Medicare OPPS Rate,5.98,Pays at 100% of GA Medicaid Fee Schedule,49.28,Pays at 88% of Total Billed charges,6.16,Pays at 103% of GA Medicaid Fee Schedule,5.49,50.4,33.60
Outpatient Medical Services,LAB,84402,TESTOSTERONE FREE  (MAYO),300,79,67.15,Pays at 85% of Billed charges for outpatient setting,32.01,Pays at 100% of GA Medicaid Fee Schedule,63.22,Pays at 80.03% of Total Billed charges,25.97,Pays at 102% of Medicare OPPS Rate,71.1,Pays at 90% of Total Billed charges,32.01,Pays at 100% of GA Medicaid Fee Schedule,25.47,Pays at 100% of Medicare OPPS Rate,32.01,Pays at 100% of GA Medicaid Fee Schedule,69.52,Pays at 88% of Total Billed charges,32.97,Pays at 103% of GA Medicaid Fee Schedule,25.47,71.1,47.40
Outpatient Medical Services,LAB,84403,TESTOSTERONE TOTAL  (MAYO),300,67.86,57.68,Pays at 85% of Billed charges for outpatient setting,32.47,Pays at 100% of GA Medicaid Fee Schedule,54.31,Pays at 80.03% of Total Billed charges,26.32,Pays at 102% of Medicare OPPS Rate,61.07,Pays at 90% of Total Billed charges,32.47,Pays at 100% of GA Medicaid Fee Schedule,25.81,Pays at 100% of Medicare OPPS Rate,32.47,Pays at 100% of GA Medicaid Fee Schedule,59.72,Pays at 88% of Total Billed charges,33.44,Pays at 103% of GA Medicaid Fee Schedule,25.81,61.07,40.72
Outpatient Medical Services,LAB,84425,"THIAMINE, B-1  (MAYO)",300,68.25,58.01,Pays at 85% of Billed charges for outpatient setting,26.7,Pays at 100% of GA Medicaid Fee Schedule,54.62,Pays at 80.03% of Total Billed charges,21.65,Pays at 102% of Medicare OPPS Rate,61.43,Pays at 90% of Total Billed charges,26.7,Pays at 100% of GA Medicaid Fee Schedule,21.23,Pays at 100% of Medicare OPPS Rate,26.7,Pays at 100% of GA Medicaid Fee Schedule,60.06,Pays at 88% of Total Billed charges,27.5,Pays at 103% of GA Medicaid Fee Schedule,21.23,61.43,40.95
Outpatient Medical Services,LAB,84432,"THYROGLOBULIN, TUMOR MARKER  (MAYO)",300,18.25,15.51,Pays at 85% of Billed charges for outpatient setting,20.2,Pays at 100% of GA Medicaid Fee Schedule,14.61,Pays at 80.03% of Total Billed charges,16.38,Pays at 102% of Medicare OPPS Rate,16.43,Pays at 90% of Total Billed charges,20.2,Pays at 100% of GA Medicaid Fee Schedule,16.05,Pays at 100% of Medicare OPPS Rate,20.2,Pays at 100% of GA Medicaid Fee Schedule,16.06,Pays at 88% of Total Billed charges,20.81,Pays at 103% of GA Medicaid Fee Schedule,14.61,20.81,10.95
Outpatient Medical Services,LAB,84432,THYROGLOBULIN MASS SPECTROMETRY  (MAYO),300,323.5,274.98,Pays at 85% of Billed charges for outpatient setting,20.2,Pays at 100% of GA Medicaid Fee Schedule,258.9,Pays at 80.03% of Total Billed charges,16.38,Pays at 102% of Medicare OPPS Rate,291.15,Pays at 90% of Total Billed charges,20.2,Pays at 100% of GA Medicaid Fee Schedule,16.05,Pays at 100% of Medicare OPPS Rate,20.2,Pays at 100% of GA Medicaid Fee Schedule,284.68,Pays at 88% of Total Billed charges,20.81,Pays at 103% of GA Medicaid Fee Schedule,16.05,291.15,194.10
Outpatient Medical Services,LAB,84436,Blood test to measure a type of thyroid hormone,300,45.92,39.03,Pays at 85% of Billed charges for outpatient setting,8.65,Pays at 100% of GA Medicaid Fee Schedule,36.75,Pays at 80.03% of Total Billed charges,7,Pays at 102% of Medicare OPPS Rate,41.33,Pays at 90% of Total Billed charges,8.65,Pays at 100% of GA Medicaid Fee Schedule,6.87,Pays at 100% of Medicare OPPS Rate,8.65,Pays at 100% of GA Medicaid Fee Schedule,40.41,Pays at 88% of Total Billed charges,8.91,Pays at 103% of GA Medicaid Fee Schedule,6.87,41.33,27.55
Outpatient Medical Services,LAB,84439,Blood test to evaluate thyroid function,300,45.92,39.03,Pays at 85% of Billed charges for outpatient setting,11.34,Pays at 100% of GA Medicaid Fee Schedule,36.75,Pays at 80.03% of Total Billed charges,9.2,Pays at 102% of Medicare OPPS Rate,41.33,Pays at 90% of Total Billed charges,11.34,Pays at 100% of GA Medicaid Fee Schedule,9.02,Pays at 100% of Medicare OPPS Rate,11.34,Pays at 100% of GA Medicaid Fee Schedule,40.41,Pays at 88% of Total Billed charges,11.68,Pays at 103% of GA Medicaid Fee Schedule,9.02,41.33,27.55
Outpatient Medical Services,LAB,84439,Blood test to evaluate thyroid function,300,88.36,75.11,Pays at 85% of Billed charges for outpatient setting,11.34,Pays at 100% of GA Medicaid Fee Schedule,70.71,Pays at 80.03% of Total Billed charges,9.2,Pays at 102% of Medicare OPPS Rate,79.52,Pays at 90% of Total Billed charges,11.34,Pays at 100% of GA Medicaid Fee Schedule,9.02,Pays at 100% of Medicare OPPS Rate,11.34,Pays at 100% of GA Medicaid Fee Schedule,77.76,Pays at 88% of Total Billed charges,11.68,Pays at 103% of GA Medicaid Fee Schedule,9.02,79.52,53.02
Outpatient Medical Services,LAB,84439,Blood test to evaluate thyroid function,300,235.5,200.18,Pays at 85% of Billed charges for outpatient setting,11.34,Pays at 100% of GA Medicaid Fee Schedule,188.47,Pays at 80.03% of Total Billed charges,9.2,Pays at 102% of Medicare OPPS Rate,211.95,Pays at 90% of Total Billed charges,11.34,Pays at 100% of GA Medicaid Fee Schedule,9.02,Pays at 100% of Medicare OPPS Rate,11.34,Pays at 100% of GA Medicaid Fee Schedule,207.24,Pays at 88% of Total Billed charges,11.68,Pays at 103% of GA Medicaid Fee Schedule,9.02,211.95,141.30
Outpatient Medical Services,LAB,84442,THYROID BINDING GLOBULIN  (MAYO),300,19.25,16.36,Pays at 85% of Billed charges for outpatient setting,14.63,Pays at 100% of GA Medicaid Fee Schedule,15.41,Pays at 80.03% of Total Billed charges,15.07,Pays at 102% of Medicare OPPS Rate,17.33,Pays at 90% of Total Billed charges,14.63,Pays at 100% of GA Medicaid Fee Schedule,14.78,Pays at 100% of Medicare OPPS Rate,14.63,Pays at 100% of GA Medicaid Fee Schedule,16.94,Pays at 88% of Total Billed charges,15.07,Pays at 103% of GA Medicaid Fee Schedule,14.63,17.33,11.55
Outpatient Medical Services,LAB,84443,"Blood test, thyroid stimulating hormone (TSH)",300,42.44,36.07,Pays at 85% of Billed charges for outpatient setting,21.12,Pays at 100% of GA Medicaid Fee Schedule,33.96,Pays at 80.03% of Total Billed charges,17.13,Pays at 102% of Medicare OPPS Rate,38.2,Pays at 90% of Total Billed charges,21.12,Pays at 100% of GA Medicaid Fee Schedule,16.8,Pays at 100% of Medicare OPPS Rate,21.12,Pays at 100% of GA Medicaid Fee Schedule,37.35,Pays at 88% of Total Billed charges,21.75,Pays at 103% of GA Medicaid Fee Schedule,16.8,38.2,25.46
Outpatient Medical Services,LAB,84443,"Blood test, thyroid stimulating hormone (TSH)",300,49.91,42.42,Pays at 85% of Billed charges for outpatient setting,21.12,Pays at 100% of GA Medicaid Fee Schedule,39.94,Pays at 80.03% of Total Billed charges,17.13,Pays at 102% of Medicare OPPS Rate,44.92,Pays at 90% of Total Billed charges,21.12,Pays at 100% of GA Medicaid Fee Schedule,16.8,Pays at 100% of Medicare OPPS Rate,21.12,Pays at 100% of GA Medicaid Fee Schedule,43.92,Pays at 88% of Total Billed charges,21.75,Pays at 103% of GA Medicaid Fee Schedule,16.8,44.92,29.95
Outpatient Medical Services,LAB,84443,"Blood test, thyroid stimulating hormone (TSH)",300,51.75,43.99,Pays at 85% of Billed charges for outpatient setting,21.12,Pays at 100% of GA Medicaid Fee Schedule,41.42,Pays at 80.03% of Total Billed charges,17.13,Pays at 102% of Medicare OPPS Rate,46.58,Pays at 90% of Total Billed charges,21.12,Pays at 100% of GA Medicaid Fee Schedule,16.8,Pays at 100% of Medicare OPPS Rate,21.12,Pays at 100% of GA Medicaid Fee Schedule,45.54,Pays at 88% of Total Billed charges,21.75,Pays at 103% of GA Medicaid Fee Schedule,16.8,46.58,31.05
Outpatient Medical Services,LAB,84445,THYRO-BINDING INHIB. IMMUNOGLOB (MAYO),300,162.5,138.13,Pays at 85% of Billed charges for outpatient setting,10.65,Pays at 100% of GA Medicaid Fee Schedule,130.05,Pays at 80.03% of Total Billed charges,51.87,Pays at 102% of Medicare OPPS Rate,146.25,Pays at 90% of Total Billed charges,10.65,Pays at 100% of GA Medicaid Fee Schedule,50.86,Pays at 100% of Medicare OPPS Rate,10.65,Pays at 100% of GA Medicaid Fee Schedule,143,Pays at 88% of Total Billed charges,10.97,Pays at 103% of GA Medicaid Fee Schedule,10.65,146.25,97.50
Outpatient Medical Services,LAB,84445,THYROID STIM IMMUNOGLOBUL  (MAYO),300,162.5,138.13,Pays at 85% of Billed charges for outpatient setting,10.65,Pays at 100% of GA Medicaid Fee Schedule,130.05,Pays at 80.03% of Total Billed charges,51.87,Pays at 102% of Medicare OPPS Rate,146.25,Pays at 90% of Total Billed charges,10.65,Pays at 100% of GA Medicaid Fee Schedule,50.86,Pays at 100% of Medicare OPPS Rate,10.65,Pays at 100% of GA Medicaid Fee Schedule,143,Pays at 88% of Total Billed charges,10.97,Pays at 103% of GA Medicaid Fee Schedule,10.65,146.25,97.50
Outpatient Medical Services,LAB,84446,VITAMIN E  (MAYO),300,45.5,38.68,Pays at 85% of Billed charges for outpatient setting,17.83,Pays at 100% of GA Medicaid Fee Schedule,36.41,Pays at 80.03% of Total Billed charges,14.46,Pays at 102% of Medicare OPPS Rate,40.95,Pays at 90% of Total Billed charges,17.83,Pays at 100% of GA Medicaid Fee Schedule,14.18,Pays at 100% of Medicare OPPS Rate,17.83,Pays at 100% of GA Medicaid Fee Schedule,40.04,Pays at 88% of Total Billed charges,18.36,Pays at 103% of GA Medicaid Fee Schedule,14.18,40.95,27.30
Outpatient Medical Services,LAB,84450,SGOT/AST,300,40.25,34.21,Pays at 85% of Billed charges for outpatient setting,6.35,Pays at 100% of GA Medicaid Fee Schedule,32.21,Pays at 80.03% of Total Billed charges,5.28,Pays at 102% of Medicare OPPS Rate,36.23,Pays at 90% of Total Billed charges,6.35,Pays at 100% of GA Medicaid Fee Schedule,5.18,Pays at 100% of Medicare OPPS Rate,6.35,Pays at 100% of GA Medicaid Fee Schedule,35.42,Pays at 88% of Total Billed charges,6.54,Pays at 103% of GA Medicaid Fee Schedule,5.18,36.23,24.15
Outpatient Medical Services,LAB,84460,Blood test to evaluate liver function,300,20.75,17.64,Pays at 85% of Billed charges for outpatient setting,6.35,Pays at 100% of GA Medicaid Fee Schedule,16.61,Pays at 80.03% of Total Billed charges,5.4,Pays at 102% of Medicare OPPS Rate,18.68,Pays at 90% of Total Billed charges,6.35,Pays at 100% of GA Medicaid Fee Schedule,5.3,Pays at 100% of Medicare OPPS Rate,6.35,Pays at 100% of GA Medicaid Fee Schedule,18.26,Pays at 88% of Total Billed charges,6.54,Pays at 103% of GA Medicaid Fee Schedule,5.3,18.68,12.45
Outpatient Medical Services,LAB,84460,Blood test to evaluate liver function,300,24.6,20.91,Pays at 85% of Billed charges for outpatient setting,6.35,Pays at 100% of GA Medicaid Fee Schedule,19.69,Pays at 80.03% of Total Billed charges,5.4,Pays at 102% of Medicare OPPS Rate,22.14,Pays at 90% of Total Billed charges,6.35,Pays at 100% of GA Medicaid Fee Schedule,5.3,Pays at 100% of Medicare OPPS Rate,6.35,Pays at 100% of GA Medicaid Fee Schedule,21.65,Pays at 88% of Total Billed charges,6.54,Pays at 103% of GA Medicaid Fee Schedule,5.3,22.14,14.76
Outpatient Medical Services,LAB,84466,TRANSFERRIN (TIBC),300,63.76,54.2,Pays at 85% of Billed charges for outpatient setting,16.06,Pays at 100% of GA Medicaid Fee Schedule,51.03,Pays at 80.03% of Total Billed charges,13.01,Pays at 102% of Medicare OPPS Rate,57.38,Pays at 90% of Total Billed charges,16.06,Pays at 100% of GA Medicaid Fee Schedule,12.76,Pays at 100% of Medicare OPPS Rate,16.06,Pays at 100% of GA Medicaid Fee Schedule,56.11,Pays at 88% of Total Billed charges,16.54,Pays at 103% of GA Medicaid Fee Schedule,12.76,57.38,38.26
Outpatient Medical Services,LAB,84478,"TRYGLYCERIDES, CDC  (MAYO)",300,13.25,11.26,Pays at 85% of Billed charges for outpatient setting,6.35,Pays at 100% of GA Medicaid Fee Schedule,10.6,Pays at 80.03% of Total Billed charges,5.85,Pays at 102% of Medicare OPPS Rate,11.93,Pays at 90% of Total Billed charges,6.35,Pays at 100% of GA Medicaid Fee Schedule,5.74,Pays at 100% of Medicare OPPS Rate,6.35,Pays at 100% of GA Medicaid Fee Schedule,11.66,Pays at 88% of Total Billed charges,6.54,Pays at 103% of GA Medicaid Fee Schedule,5.74,11.93,7.95
Outpatient Medical Services,LAB,84478,TRIGLYCERIDES,300,30,25.5,Pays at 85% of Billed charges for outpatient setting,6.35,Pays at 100% of GA Medicaid Fee Schedule,24.01,Pays at 80.03% of Total Billed charges,5.85,Pays at 102% of Medicare OPPS Rate,27,Pays at 90% of Total Billed charges,6.35,Pays at 100% of GA Medicaid Fee Schedule,5.74,Pays at 100% of Medicare OPPS Rate,6.35,Pays at 100% of GA Medicaid Fee Schedule,26.4,Pays at 88% of Total Billed charges,6.54,Pays at 103% of GA Medicaid Fee Schedule,5.74,27,18.00
Outpatient Medical Services,LAB,84479,T3 UPTAKE,300,45.92,39.03,Pays at 85% of Billed charges for outpatient setting,8.14,Pays at 100% of GA Medicaid Fee Schedule,36.75,Pays at 80.03% of Total Billed charges,6.59,Pays at 102% of Medicare OPPS Rate,41.33,Pays at 90% of Total Billed charges,8.14,Pays at 100% of GA Medicaid Fee Schedule,6.47,Pays at 100% of Medicare OPPS Rate,8.14,Pays at 100% of GA Medicaid Fee Schedule,40.41,Pays at 88% of Total Billed charges,8.38,Pays at 103% of GA Medicaid Fee Schedule,6.47,41.33,27.55
Outpatient Medical Services,LAB,84480,Blood test to evaluate thyroid function,300,35,29.75,Pays at 85% of Billed charges for outpatient setting,16.03,Pays at 100% of GA Medicaid Fee Schedule,28.01,Pays at 80.03% of Total Billed charges,14.46,Pays at 102% of Medicare OPPS Rate,31.5,Pays at 90% of Total Billed charges,16.03,Pays at 100% of GA Medicaid Fee Schedule,14.18,Pays at 100% of Medicare OPPS Rate,16.03,Pays at 100% of GA Medicaid Fee Schedule,30.8,Pays at 88% of Total Billed charges,16.51,Pays at 103% of GA Medicaid Fee Schedule,14.18,31.5,21.00
Outpatient Medical Services,LAB,84480,Blood test to evaluate thyroid function,300,45.5,38.68,Pays at 85% of Billed charges for outpatient setting,16.03,Pays at 100% of GA Medicaid Fee Schedule,36.41,Pays at 80.03% of Total Billed charges,14.46,Pays at 102% of Medicare OPPS Rate,40.95,Pays at 90% of Total Billed charges,16.03,Pays at 100% of GA Medicaid Fee Schedule,14.18,Pays at 100% of Medicare OPPS Rate,16.03,Pays at 100% of GA Medicaid Fee Schedule,40.04,Pays at 88% of Total Billed charges,16.51,Pays at 103% of GA Medicaid Fee Schedule,14.18,40.95,27.30
Outpatient Medical Services,LAB,84481,T3 FREE  (MAYO),300,53.75,45.69,Pays at 85% of Billed charges for outpatient setting,21.3,Pays at 100% of GA Medicaid Fee Schedule,43.02,Pays at 80.03% of Total Billed charges,17.27,Pays at 102% of Medicare OPPS Rate,48.38,Pays at 90% of Total Billed charges,21.3,Pays at 100% of GA Medicaid Fee Schedule,16.94,Pays at 100% of Medicare OPPS Rate,21.3,Pays at 100% of GA Medicaid Fee Schedule,47.3,Pays at 88% of Total Billed charges,21.94,Pays at 103% of GA Medicaid Fee Schedule,16.94,48.38,32.25
Outpatient Medical Services,LAB,84482,T3 REVERSE  (MAYO),300,51.25,43.56,Pays at 85% of Billed charges for outpatient setting,19.82,Pays at 100% of GA Medicaid Fee Schedule,41.02,Pays at 80.03% of Total Billed charges,16.07,Pays at 102% of Medicare OPPS Rate,46.13,Pays at 90% of Total Billed charges,19.82,Pays at 100% of GA Medicaid Fee Schedule,15.76,Pays at 100% of Medicare OPPS Rate,19.82,Pays at 100% of GA Medicaid Fee Schedule,45.1,Pays at 88% of Total Billed charges,20.41,Pays at 103% of GA Medicaid Fee Schedule,15.76,46.13,30.75
Outpatient Medical Services,LAB,84484,Blood test to measure a certain protein in the blood to determine heart muscle damage,300,66.22,56.29,Pays at 85% of Billed charges for outpatient setting,12.38,Pays at 100% of GA Medicaid Fee Schedule,53,Pays at 80.03% of Total Billed charges,12.71,Pays at 102% of Medicare OPPS Rate,59.6,Pays at 90% of Total Billed charges,12.38,Pays at 100% of GA Medicaid Fee Schedule,12.47,Pays at 100% of Medicare OPPS Rate,12.38,Pays at 100% of GA Medicaid Fee Schedule,58.27,Pays at 88% of Total Billed charges,12.75,Pays at 103% of GA Medicaid Fee Schedule,12.38,59.6,39.73
Outpatient Medical Services,LAB,84484,Blood test to measure a certain protein in the blood to determine heart muscle damage,300,74.9,63.67,Pays at 85% of Billed charges for outpatient setting,12.38,Pays at 100% of GA Medicaid Fee Schedule,59.94,Pays at 80.03% of Total Billed charges,12.71,Pays at 102% of Medicare OPPS Rate,67.41,Pays at 90% of Total Billed charges,12.38,Pays at 100% of GA Medicaid Fee Schedule,12.47,Pays at 100% of Medicare OPPS Rate,12.38,Pays at 100% of GA Medicaid Fee Schedule,65.91,Pays at 88% of Total Billed charges,12.75,Pays at 103% of GA Medicaid Fee Schedule,12.38,67.41,44.94
Outpatient Medical Services,LAB,84485,TRYPSIN  (MAYO),300,138,117.3,Pays at 85% of Billed charges for outpatient setting,9.44,Pays at 100% of GA Medicaid Fee Schedule,110.44,Pays at 80.03% of Total Billed charges,7.34,Pays at 102% of Medicare OPPS Rate,124.2,Pays at 90% of Total Billed charges,9.44,Pays at 100% of GA Medicaid Fee Schedule,7.2,Pays at 100% of Medicare OPPS Rate,9.44,Pays at 100% of GA Medicaid Fee Schedule,121.44,Pays at 88% of Total Billed charges,9.72,Pays at 103% of GA Medicaid Fee Schedule,7.2,124.2,82.80
Outpatient Medical Services,LAB,84520,BUN,300,30,25.5,Pays at 85% of Billed charges for outpatient setting,4.96,Pays at 100% of GA Medicaid Fee Schedule,24.01,Pays at 80.03% of Total Billed charges,4.02,Pays at 102% of Medicare OPPS Rate,27,Pays at 90% of Total Billed charges,4.96,Pays at 100% of GA Medicaid Fee Schedule,3.95,Pays at 100% of Medicare OPPS Rate,4.96,Pays at 100% of GA Medicaid Fee Schedule,26.4,Pays at 88% of Total Billed charges,5.11,Pays at 103% of GA Medicaid Fee Schedule,3.95,27,18.00
Outpatient Medical Services,LAB,84540,"UREA NITROGEN, 24HR URINE",300,35.75,30.39,Pays at 85% of Billed charges for outpatient setting,5.98,Pays at 100% of GA Medicaid Fee Schedule,28.61,Pays at 80.03% of Total Billed charges,5.67,Pays at 102% of Medicare OPPS Rate,32.18,Pays at 90% of Total Billed charges,5.98,Pays at 100% of GA Medicaid Fee Schedule,5.56,Pays at 100% of Medicare OPPS Rate,5.98,Pays at 100% of GA Medicaid Fee Schedule,31.46,Pays at 88% of Total Billed charges,6.16,Pays at 103% of GA Medicaid Fee Schedule,5.56,32.18,21.45
Outpatient Medical Services,LAB,84540,"UREA NITROGEN URINE,(MAYO)RANDOM",300,35.75,30.39,Pays at 85% of Billed charges for outpatient setting,5.98,Pays at 100% of GA Medicaid Fee Schedule,28.61,Pays at 80.03% of Total Billed charges,5.67,Pays at 102% of Medicare OPPS Rate,32.18,Pays at 90% of Total Billed charges,5.98,Pays at 100% of GA Medicaid Fee Schedule,5.56,Pays at 100% of Medicare OPPS Rate,5.98,Pays at 100% of GA Medicaid Fee Schedule,31.46,Pays at 88% of Total Billed charges,6.16,Pays at 103% of GA Medicaid Fee Schedule,5.56,32.18,21.45
Outpatient Medical Services,LAB,84545,..BUN CLEARANCE,300,84,71.4,Pays at 85% of Billed charges for outpatient setting,8.31,Pays at 100% of GA Medicaid Fee Schedule,67.23,Pays at 80.03% of Total Billed charges,7.34,Pays at 102% of Medicare OPPS Rate,75.6,Pays at 90% of Total Billed charges,8.31,Pays at 100% of GA Medicaid Fee Schedule,7.2,Pays at 100% of Medicare OPPS Rate,8.31,Pays at 100% of GA Medicaid Fee Schedule,73.92,Pays at 88% of Total Billed charges,8.56,Pays at 103% of GA Medicaid Fee Schedule,7.2,75.6,50.40
Outpatient Medical Services,LAB,84550,"URIC ACID, BLOOD",300,23.78,20.21,Pays at 85% of Billed charges for outpatient setting,5.68,Pays at 100% of GA Medicaid Fee Schedule,19.03,Pays at 80.03% of Total Billed charges,4.61,Pays at 102% of Medicare OPPS Rate,21.4,Pays at 90% of Total Billed charges,5.68,Pays at 100% of GA Medicaid Fee Schedule,4.51,Pays at 100% of Medicare OPPS Rate,5.68,Pays at 100% of GA Medicaid Fee Schedule,20.93,Pays at 88% of Total Billed charges,5.85,Pays at 103% of GA Medicaid Fee Schedule,4.51,21.4,14.27
Outpatient Medical Services,LAB,84560,"URIC ACID, 24HR URINE  (MAYO)",300,35.75,30.39,Pays at 85% of Billed charges for outpatient setting,5.98,Pays at 100% of GA Medicaid Fee Schedule,28.61,Pays at 80.03% of Total Billed charges,5.18,Pays at 102% of Medicare OPPS Rate,32.18,Pays at 90% of Total Billed charges,5.98,Pays at 100% of GA Medicaid Fee Schedule,5.08,Pays at 100% of Medicare OPPS Rate,5.98,Pays at 100% of GA Medicaid Fee Schedule,31.46,Pays at 88% of Total Billed charges,6.16,Pays at 103% of GA Medicaid Fee Schedule,5.08,32.18,21.45
Outpatient Medical Services,LAB,84560,"URIC ACID, 24HR URINE (MAYO)",300,72.5,61.63,Pays at 85% of Billed charges for outpatient setting,5.98,Pays at 100% of GA Medicaid Fee Schedule,58.02,Pays at 80.03% of Total Billed charges,5.18,Pays at 102% of Medicare OPPS Rate,65.25,Pays at 90% of Total Billed charges,5.98,Pays at 100% of GA Medicaid Fee Schedule,5.08,Pays at 100% of Medicare OPPS Rate,5.98,Pays at 100% of GA Medicaid Fee Schedule,63.8,Pays at 88% of Total Billed charges,6.16,Pays at 103% of GA Medicaid Fee Schedule,5.08,65.25,43.50
Outpatient Medical Services,LAB,84560,"URINE URIC ACID, RANDOM  (MAYO)",300,74.5,63.33,Pays at 85% of Billed charges for outpatient setting,5.98,Pays at 100% of GA Medicaid Fee Schedule,59.62,Pays at 80.03% of Total Billed charges,5.18,Pays at 102% of Medicare OPPS Rate,67.05,Pays at 90% of Total Billed charges,5.98,Pays at 100% of GA Medicaid Fee Schedule,5.08,Pays at 100% of Medicare OPPS Rate,5.98,Pays at 100% of GA Medicaid Fee Schedule,65.56,Pays at 88% of Total Billed charges,6.16,Pays at 103% of GA Medicaid Fee Schedule,5.08,67.05,44.70
Outpatient Medical Services,LAB,84577,"UROBILINOGEN, STOOL  (MAYO)",300,235.25,199.96,Pays at 85% of Billed charges for outpatient setting,8.79,Pays at 100% of GA Medicaid Fee Schedule,188.27,Pays at 80.03% of Total Billed charges,17.13,Pays at 102% of Medicare OPPS Rate,211.73,Pays at 90% of Total Billed charges,8.79,Pays at 100% of GA Medicaid Fee Schedule,16.8,Pays at 100% of Medicare OPPS Rate,8.79,Pays at 100% of GA Medicaid Fee Schedule,207.02,Pays at 88% of Total Billed charges,9.05,Pays at 103% of GA Medicaid Fee Schedule,8.79,211.73,141.15
Outpatient Medical Services,LAB,84580,"UROBILINOGEN, URINE  (MAYO)",300,143,121.55,Pays at 85% of Billed charges for outpatient setting,8.93,Pays at 100% of GA Medicaid Fee Schedule,114.44,Pays at 80.03% of Total Billed charges,9.74,Pays at 102% of Medicare OPPS Rate,128.7,Pays at 90% of Total Billed charges,8.93,Pays at 100% of GA Medicaid Fee Schedule,9.55,Pays at 100% of Medicare OPPS Rate,8.93,Pays at 100% of GA Medicaid Fee Schedule,125.84,Pays at 88% of Total Billed charges,9.2,Pays at 103% of GA Medicaid Fee Schedule,8.93,128.7,85.80
Outpatient Medical Services,LAB,84585,"VMA, 24HR URINE  (MAYO)",300,37.75,32.09,Pays at 85% of Billed charges for outpatient setting,19.49,Pays at 100% of GA Medicaid Fee Schedule,30.21,Pays at 80.03% of Total Billed charges,15.81,Pays at 102% of Medicare OPPS Rate,33.98,Pays at 90% of Total Billed charges,19.49,Pays at 100% of GA Medicaid Fee Schedule,15.5,Pays at 100% of Medicare OPPS Rate,19.49,Pays at 100% of GA Medicaid Fee Schedule,33.22,Pays at 88% of Total Billed charges,20.07,Pays at 103% of GA Medicaid Fee Schedule,15.5,33.98,22.65
Outpatient Medical Services,LAB,84586,VASOACTIVE INTEST. POLYPEPTIDE  (MAYO),300,95.75,81.39,Pays at 85% of Billed charges for outpatient setting,44.43,Pays at 100% of GA Medicaid Fee Schedule,76.63,Pays at 80.03% of Total Billed charges,36.03,Pays at 102% of Medicare OPPS Rate,86.18,Pays at 90% of Total Billed charges,44.43,Pays at 100% of GA Medicaid Fee Schedule,35.33,Pays at 100% of Medicare OPPS Rate,44.43,Pays at 100% of GA Medicaid Fee Schedule,84.26,Pays at 88% of Total Billed charges,45.76,Pays at 103% of GA Medicaid Fee Schedule,35.33,86.18,57.45
Outpatient Medical Services,LAB,84588,"ANTI-DIURETIC HORMONE, ADH  (MAYO)",300,108.75,92.44,Pays at 85% of Billed charges for outpatient setting,42.69,Pays at 100% of GA Medicaid Fee Schedule,87.03,Pays at 80.03% of Total Billed charges,34.61,Pays at 102% of Medicare OPPS Rate,97.88,Pays at 90% of Total Billed charges,42.69,Pays at 100% of GA Medicaid Fee Schedule,33.94,Pays at 100% of Medicare OPPS Rate,42.69,Pays at 100% of GA Medicaid Fee Schedule,95.7,Pays at 88% of Total Billed charges,43.97,Pays at 103% of GA Medicaid Fee Schedule,33.94,97.88,65.25
Outpatient Medical Services,LAB,84588,COPEPTIN proAVP (MAYO),300,366.38,311.42,Pays at 85% of Billed charges for outpatient setting,42.69,Pays at 100% of GA Medicaid Fee Schedule,293.21,Pays at 80.03% of Total Billed charges,34.61,Pays at 102% of Medicare OPPS Rate,329.74,Pays at 90% of Total Billed charges,42.69,Pays at 100% of GA Medicaid Fee Schedule,33.94,Pays at 100% of Medicare OPPS Rate,42.69,Pays at 100% of GA Medicaid Fee Schedule,322.41,Pays at 88% of Total Billed charges,43.97,Pays at 103% of GA Medicaid Fee Schedule,33.94,329.74,219.83
Outpatient Medical Services,LAB,84590,"VITAMIN A, SERUM  (MAYO)",300,37.25,31.66,Pays at 85% of Billed charges for outpatient setting,14.58,Pays at 100% of GA Medicaid Fee Schedule,29.81,Pays at 80.03% of Total Billed charges,11.84,Pays at 102% of Medicare OPPS Rate,33.53,Pays at 90% of Total Billed charges,14.58,Pays at 100% of GA Medicaid Fee Schedule,11.61,Pays at 100% of Medicare OPPS Rate,14.58,Pays at 100% of GA Medicaid Fee Schedule,32.78,Pays at 88% of Total Billed charges,15.02,Pays at 103% of GA Medicaid Fee Schedule,11.61,33.53,22.35
Outpatient Medical Services,LAB,84591,"VITAMIN B3, NIACIN  (MAYO)",300,124.75,106.04,Pays at 85% of Billed charges for outpatient setting,14.58,Pays at 100% of GA Medicaid Fee Schedule,99.84,Pays at 80.03% of Total Billed charges,17.4,Pays at 102% of Medicare OPPS Rate,112.28,Pays at 90% of Total Billed charges,14.58,Pays at 100% of GA Medicaid Fee Schedule,17.05,Pays at 100% of Medicare OPPS Rate,14.58,Pays at 100% of GA Medicaid Fee Schedule,109.78,Pays at 88% of Total Billed charges,15.02,Pays at 103% of GA Medicaid Fee Schedule,14.58,112.28,74.85
Outpatient Medical Services,LAB,84597,VITAMIN K  (MAYO),300,145.25,123.46,Pays at 85% of Billed charges for outpatient setting,17.24,Pays at 100% of GA Medicaid Fee Schedule,116.24,Pays at 80.03% of Total Billed charges,13.99,Pays at 102% of Medicare OPPS Rate,130.73,Pays at 90% of Total Billed charges,17.24,Pays at 100% of GA Medicaid Fee Schedule,13.72,Pays at 100% of Medicare OPPS Rate,17.24,Pays at 100% of GA Medicaid Fee Schedule,127.82,Pays at 88% of Total Billed charges,17.76,Pays at 103% of GA Medicaid Fee Schedule,13.72,130.73,87.15
Outpatient Medical Services,LAB,84630,"ZINC, SERUM  (MAYO)",300,24.25,20.61,Pays at 85% of Billed charges for outpatient setting,14.32,Pays at 100% of GA Medicaid Fee Schedule,19.41,Pays at 80.03% of Total Billed charges,11.61,Pays at 102% of Medicare OPPS Rate,21.83,Pays at 90% of Total Billed charges,14.32,Pays at 100% of GA Medicaid Fee Schedule,11.39,Pays at 100% of Medicare OPPS Rate,14.32,Pays at 100% of GA Medicaid Fee Schedule,21.34,Pays at 88% of Total Billed charges,14.75,Pays at 103% of GA Medicaid Fee Schedule,11.39,21.83,14.55
Outpatient Medical Services,LAB,84630,"ZINC, RBC  (MAYO)",300,68.5,58.23,Pays at 85% of Billed charges for outpatient setting,14.32,Pays at 100% of GA Medicaid Fee Schedule,54.82,Pays at 80.03% of Total Billed charges,11.61,Pays at 102% of Medicare OPPS Rate,61.65,Pays at 90% of Total Billed charges,14.32,Pays at 100% of GA Medicaid Fee Schedule,11.39,Pays at 100% of Medicare OPPS Rate,14.32,Pays at 100% of GA Medicaid Fee Schedule,60.28,Pays at 88% of Total Billed charges,14.75,Pays at 103% of GA Medicaid Fee Schedule,11.39,61.65,41.10
Outpatient Medical Services,LAB,84630,"ZINC, URINE  (MAYO)",300,68.75,58.44,Pays at 85% of Billed charges for outpatient setting,14.32,Pays at 100% of GA Medicaid Fee Schedule,55.02,Pays at 80.03% of Total Billed charges,11.61,Pays at 102% of Medicare OPPS Rate,61.88,Pays at 90% of Total Billed charges,14.32,Pays at 100% of GA Medicaid Fee Schedule,11.39,Pays at 100% of Medicare OPPS Rate,14.32,Pays at 100% of GA Medicaid Fee Schedule,60.5,Pays at 88% of Total Billed charges,14.75,Pays at 103% of GA Medicaid Fee Schedule,11.39,61.88,41.25
Outpatient Medical Services,LAB,84681,C-TELEPEPTIDE (MAYO),300,31.75,26.99,Pays at 85% of Billed charges for outpatient setting,19.98,Pays at 100% of GA Medicaid Fee Schedule,25.41,Pays at 80.03% of Total Billed charges,21.22,Pays at 102% of Medicare OPPS Rate,28.58,Pays at 90% of Total Billed charges,19.98,Pays at 100% of GA Medicaid Fee Schedule,20.81,Pays at 100% of Medicare OPPS Rate,19.98,Pays at 100% of GA Medicaid Fee Schedule,27.94,Pays at 88% of Total Billed charges,20.58,Pays at 103% of GA Medicaid Fee Schedule,19.98,28.58,19.05
Outpatient Medical Services,LAB,84681,C-PEPTIDE  (MAYO),300,66.25,56.31,Pays at 85% of Billed charges for outpatient setting,19.98,Pays at 100% of GA Medicaid Fee Schedule,53.02,Pays at 80.03% of Total Billed charges,21.22,Pays at 102% of Medicare OPPS Rate,59.63,Pays at 90% of Total Billed charges,19.98,Pays at 100% of GA Medicaid Fee Schedule,20.81,Pays at 100% of Medicare OPPS Rate,19.98,Pays at 100% of GA Medicaid Fee Schedule,58.3,Pays at 88% of Total Billed charges,20.58,Pays at 103% of GA Medicaid Fee Schedule,19.98,59.63,39.75
Outpatient Medical Services,LAB,84702,HCG QUANTITATIVE,300,54.38,46.22,Pays at 85% of Billed charges for outpatient setting,8.07,Pays at 100% of GA Medicaid Fee Schedule,43.52,Pays at 80.03% of Total Billed charges,15.35,Pays at 102% of Medicare OPPS Rate,48.94,Pays at 90% of Total Billed charges,8.07,Pays at 100% of GA Medicaid Fee Schedule,15.05,Pays at 100% of Medicare OPPS Rate,8.07,Pays at 100% of GA Medicaid Fee Schedule,47.85,Pays at 88% of Total Billed charges,8.31,Pays at 103% of GA Medicaid Fee Schedule,8.07,48.94,32.63
Outpatient Medical Services,LAB,84703,Blood test to assess for pregnancy,300,37.6,31.96,Pays at 85% of Billed charges for outpatient setting,8.07,Pays at 100% of GA Medicaid Fee Schedule,30.09,Pays at 80.03% of Total Billed charges,7.67,Pays at 102% of Medicare OPPS Rate,33.84,Pays at 90% of Total Billed charges,8.07,Pays at 100% of GA Medicaid Fee Schedule,7.52,Pays at 100% of Medicare OPPS Rate,8.07,Pays at 100% of GA Medicaid Fee Schedule,33.09,Pays at 88% of Total Billed charges,8.31,Pays at 103% of GA Medicaid Fee Schedule,7.52,33.84,22.56
Outpatient Medical Services,LAB,84999,"OSMOLALITY, STOOL  (MAYO)",300,31.5,26.78,Pays at 85% of Billed charges for outpatient setting,10.13,Pays at 32.15% of Total Billed charges,25.21,Pays at 80.03% of Total Billed charges,NA,Not Applicable,28.35,Pays at 90% of Total Billed charges,10.13,Pays at 32.15% of Total Billed charges,NA,Not Applicable,10.13,Pays at 32.15% of Total Billed charges,27.72,Pays at 88% of Total Billed charges,10.43,Pays at 33.11% of Total Billed charges,10.13,28.35,18.90
Outpatient Medical Services,LAB,84999,"POTASSIUM, FECES, QT  (MAYO)",300,31.5,26.78,Pays at 85% of Billed charges for outpatient setting,10.13,Pays at 32.15% of Total Billed charges,25.21,Pays at 80.03% of Total Billed charges,NA,Not Applicable,28.35,Pays at 90% of Total Billed charges,10.13,Pays at 32.15% of Total Billed charges,NA,Not Applicable,10.13,Pays at 32.15% of Total Billed charges,27.72,Pays at 88% of Total Billed charges,10.43,Pays at 33.11% of Total Billed charges,10.13,28.35,18.90
Outpatient Medical Services,LAB,84999,"POTASSIUM, BODY FLUID  (MAYO)",300,46,39.1,Pays at 85% of Billed charges for outpatient setting,14.79,Pays at 32.15% of Total Billed charges,36.81,Pays at 80.03% of Total Billed charges,NA,Not Applicable,41.4,Pays at 90% of Total Billed charges,14.79,Pays at 32.15% of Total Billed charges,NA,Not Applicable,14.79,Pays at 32.15% of Total Billed charges,40.48,Pays at 88% of Total Billed charges,15.23,Pays at 33.11% of Total Billed charges,14.79,41.4,27.60
Outpatient Medical Services,LAB,84999,CLINICAL CHEMISTRY TEST  (MAYO),300,140,119,Pays at 85% of Billed charges for outpatient setting,45.01,Pays at 32.15% of Total Billed charges,112.04,Pays at 80.03% of Total Billed charges,NA,Not Applicable,126,Pays at 90% of Total Billed charges,45.01,Pays at 32.15% of Total Billed charges,NA,Not Applicable,45.01,Pays at 32.15% of Total Billed charges,123.2,Pays at 88% of Total Billed charges,46.35,Pays at 33.11% of Total Billed charges,45.01,126,84.00
Outpatient Medical Services,LAB,84999,"DIPHENHYDRAMINE, QT SERUM/PLASMA  (MAYO)",300,214.25,182.11,Pays at 85% of Billed charges for outpatient setting,68.88,Pays at 32.15% of Total Billed charges,171.46,Pays at 80.03% of Total Billed charges,NA,Not Applicable,192.83,Pays at 90% of Total Billed charges,68.88,Pays at 32.15% of Total Billed charges,NA,Not Applicable,68.88,Pays at 32.15% of Total Billed charges,188.54,Pays at 88% of Total Billed charges,70.94,Pays at 33.11% of Total Billed charges,68.88,192.83,128.55
Outpatient Medical Services,LAB,84999,DRUG SCREEN: SEXUAL ASSAULT  (MAYO),300,546.75,464.74,Pays at 85% of Billed charges for outpatient setting,175.78,Pays at 32.15% of Total Billed charges,437.56,Pays at 80.03% of Total Billed charges,NA,Not Applicable,492.08,Pays at 90% of Total Billed charges,175.78,Pays at 32.15% of Total Billed charges,NA,Not Applicable,175.78,Pays at 32.15% of Total Billed charges,481.14,Pays at 88% of Total Billed charges,181.03,Pays at 33.11% of Total Billed charges,175.78,492.08,328.05
Outpatient Medical Services,LAB,85002,BLEEDING TIME,300,62,52.7,Pays at 85% of Billed charges for outpatient setting,5.66,Pays at 100% of GA Medicaid Fee Schedule,49.62,Pays at 80.03% of Total Billed charges,4.91,Pays at 102% of Medicare OPPS Rate,55.8,Pays at 90% of Total Billed charges,5.66,Pays at 100% of GA Medicaid Fee Schedule,4.82,Pays at 100% of Medicare OPPS Rate,5.66,Pays at 100% of GA Medicaid Fee Schedule,54.56,Pays at 88% of Total Billed charges,5.83,Pays at 103% of GA Medicaid Fee Schedule,4.82,55.8,37.20
Outpatient Medical Services,LAB,85007,Blood test to assess for infection,300,6,5.1,Pays at 85% of Billed charges for outpatient setting,4.33,Pays at 100% of GA Medicaid Fee Schedule,4.8,Pays at 80.03% of Total Billed charges,3.87,Pays at 102% of Medicare OPPS Rate,5.4,Pays at 90% of Total Billed charges,4.33,Pays at 100% of GA Medicaid Fee Schedule,3.8,Pays at 100% of Medicare OPPS Rate,4.33,Pays at 100% of GA Medicaid Fee Schedule,5.28,Pays at 88% of Total Billed charges,4.46,Pays at 103% of GA Medicaid Fee Schedule,3.8,5.4,3.60
Outpatient Medical Services,LAB,85014,HEMATOCRIT (HCT),300,14.5,12.33,Pays at 85% of Billed charges for outpatient setting,2.98,Pays at 100% of GA Medicaid Fee Schedule,11.6,Pays at 80.03% of Total Billed charges,2.41,Pays at 102% of Medicare OPPS Rate,13.05,Pays at 90% of Total Billed charges,2.98,Pays at 100% of GA Medicaid Fee Schedule,2.37,Pays at 100% of Medicare OPPS Rate,2.98,Pays at 100% of GA Medicaid Fee Schedule,12.76,Pays at 88% of Total Billed charges,3.07,Pays at 103% of GA Medicaid Fee Schedule,2.37,13.05,8.70
Outpatient Medical Services,LAB,85018,Blood test to measure levels of hemoglobin,300,14.5,12.33,Pays at 85% of Billed charges for outpatient setting,2.98,Pays at 100% of GA Medicaid Fee Schedule,11.6,Pays at 80.03% of Total Billed charges,2.41,Pays at 102% of Medicare OPPS Rate,13.05,Pays at 90% of Total Billed charges,2.98,Pays at 100% of GA Medicaid Fee Schedule,2.37,Pays at 100% of Medicare OPPS Rate,2.98,Pays at 100% of GA Medicaid Fee Schedule,12.76,Pays at 88% of Total Billed charges,3.07,Pays at 103% of GA Medicaid Fee Schedule,2.37,13.05,8.70
Outpatient Medical Services,LAB,85025,"Complete blood cell count, with differential white blood cells, automated",300,15.54,13.21,Pays at 85% of Billed charges for outpatient setting,9.77,Pays at 100% of GA Medicaid Fee Schedule,12.44,Pays at 80.03% of Total Billed charges,7.92,Pays at 102% of Medicare OPPS Rate,13.99,Pays at 90% of Total Billed charges,9.77,Pays at 100% of GA Medicaid Fee Schedule,7.77,Pays at 100% of Medicare OPPS Rate,9.77,Pays at 100% of GA Medicaid Fee Schedule,13.68,Pays at 88% of Total Billed charges,10.06,Pays at 103% of GA Medicaid Fee Schedule,7.77,13.99,9.32
Outpatient Medical Services,LAB,85025,"Complete blood cell count, with differential white blood cells, automated",300,53.75,45.69,Pays at 85% of Billed charges for outpatient setting,9.77,Pays at 100% of GA Medicaid Fee Schedule,43.02,Pays at 80.03% of Total Billed charges,7.92,Pays at 102% of Medicare OPPS Rate,48.38,Pays at 90% of Total Billed charges,9.77,Pays at 100% of GA Medicaid Fee Schedule,7.77,Pays at 100% of Medicare OPPS Rate,9.77,Pays at 100% of GA Medicaid Fee Schedule,47.3,Pays at 88% of Total Billed charges,10.06,Pays at 103% of GA Medicaid Fee Schedule,7.77,48.38,32.25
Outpatient Medical Services,LAB,85025,"Complete blood cell count, with differential white blood cells, automated",300,61.09,51.93,Pays at 85% of Billed charges for outpatient setting,9.77,Pays at 100% of GA Medicaid Fee Schedule,48.89,Pays at 80.03% of Total Billed charges,7.92,Pays at 102% of Medicare OPPS Rate,54.98,Pays at 90% of Total Billed charges,9.77,Pays at 100% of GA Medicaid Fee Schedule,7.77,Pays at 100% of Medicare OPPS Rate,9.77,Pays at 100% of GA Medicaid Fee Schedule,53.76,Pays at 88% of Total Billed charges,10.06,Pays at 103% of GA Medicaid Fee Schedule,7.77,54.98,36.65
Outpatient Medical Services,LAB,85025,"Complete blood cell count, with differential white blood cells, automated",300,75,63.75,Pays at 85% of Billed charges for outpatient setting,9.77,Pays at 100% of GA Medicaid Fee Schedule,60.02,Pays at 80.03% of Total Billed charges,7.92,Pays at 102% of Medicare OPPS Rate,67.5,Pays at 90% of Total Billed charges,9.77,Pays at 100% of GA Medicaid Fee Schedule,7.77,Pays at 100% of Medicare OPPS Rate,9.77,Pays at 100% of GA Medicaid Fee Schedule,66,Pays at 88% of Total Billed charges,10.06,Pays at 103% of GA Medicaid Fee Schedule,7.77,67.5,45.00
Outpatient Medical Services,LAB,85027,"Complete blood count, automated",300,37.31,31.71,Pays at 85% of Billed charges for outpatient setting,8.14,Pays at 100% of GA Medicaid Fee Schedule,29.86,Pays at 80.03% of Total Billed charges,6.59,Pays at 102% of Medicare OPPS Rate,33.58,Pays at 90% of Total Billed charges,8.14,Pays at 100% of GA Medicaid Fee Schedule,6.47,Pays at 100% of Medicare OPPS Rate,8.14,Pays at 100% of GA Medicaid Fee Schedule,32.83,Pays at 88% of Total Billed charges,8.38,Pays at 103% of GA Medicaid Fee Schedule,6.47,33.58,22.39
Outpatient Medical Services,LAB,85041,RBC COUNT,300,17.75,15.09,Pays at 85% of Billed charges for outpatient setting,3.78,Pays at 100% of GA Medicaid Fee Schedule,14.21,Pays at 80.03% of Total Billed charges,3.08,Pays at 102% of Medicare OPPS Rate,15.98,Pays at 90% of Total Billed charges,3.78,Pays at 100% of GA Medicaid Fee Schedule,3.02,Pays at 100% of Medicare OPPS Rate,3.78,Pays at 100% of GA Medicaid Fee Schedule,15.62,Pays at 88% of Total Billed charges,3.89,Pays at 103% of GA Medicaid Fee Schedule,3.02,15.98,10.65
Outpatient Medical Services,LAB,85045,RETICULOCYTE COUNT,300,34.85,29.62,Pays at 85% of Billed charges for outpatient setting,5.03,Pays at 100% of GA Medicaid Fee Schedule,27.89,Pays at 80.03% of Total Billed charges,4.06,Pays at 102% of Medicare OPPS Rate,31.37,Pays at 90% of Total Billed charges,5.03,Pays at 100% of GA Medicaid Fee Schedule,3.99,Pays at 100% of Medicare OPPS Rate,5.03,Pays at 100% of GA Medicaid Fee Schedule,30.67,Pays at 88% of Total Billed charges,5.18,Pays at 103% of GA Medicaid Fee Schedule,3.99,31.37,20.91
Outpatient Medical Services,LAB,85048,WBC,300,20.75,17.64,Pays at 85% of Billed charges for outpatient setting,3.2,Pays at 100% of GA Medicaid Fee Schedule,16.61,Pays at 80.03% of Total Billed charges,2.59,Pays at 102% of Medicare OPPS Rate,18.68,Pays at 90% of Total Billed charges,3.2,Pays at 100% of GA Medicaid Fee Schedule,2.54,Pays at 100% of Medicare OPPS Rate,3.2,Pays at 100% of GA Medicaid Fee Schedule,18.26,Pays at 88% of Total Billed charges,3.3,Pays at 103% of GA Medicaid Fee Schedule,2.54,18.68,12.45
Outpatient Medical Services,LAB,85048,EOSINOPHIL ABSOLUTE,300,40.75,34.64,Pays at 85% of Billed charges for outpatient setting,3.2,Pays at 100% of GA Medicaid Fee Schedule,32.61,Pays at 80.03% of Total Billed charges,2.59,Pays at 102% of Medicare OPPS Rate,36.68,Pays at 90% of Total Billed charges,3.2,Pays at 100% of GA Medicaid Fee Schedule,2.54,Pays at 100% of Medicare OPPS Rate,3.2,Pays at 100% of GA Medicaid Fee Schedule,35.86,Pays at 88% of Total Billed charges,3.3,Pays at 103% of GA Medicaid Fee Schedule,2.54,36.68,24.45
Outpatient Medical Services,LAB,85049,PLATELET COUNT,300,20.75,17.64,Pays at 85% of Billed charges for outpatient setting,5.63,Pays at 100% of GA Medicaid Fee Schedule,16.61,Pays at 80.03% of Total Billed charges,4.56,Pays at 102% of Medicare OPPS Rate,18.68,Pays at 90% of Total Billed charges,5.63,Pays at 100% of GA Medicaid Fee Schedule,4.48,Pays at 100% of Medicare OPPS Rate,5.63,Pays at 100% of GA Medicaid Fee Schedule,18.26,Pays at 88% of Total Billed charges,5.8,Pays at 103% of GA Medicaid Fee Schedule,4.48,18.68,12.45
Outpatient Medical Services,LAB,85060,PERIPHERAL REVIEW BY PATHOLOGIST,310,58,49.3,Pays at 85% of Billed charges for outpatient setting,25.97,Pays at 100% of GA Medicaid Fee Schedule,46.42,Pays at 80.03% of Total Billed charges,NA,Not Applicable,52.2,Pays at 90% of Total Billed charges,25.97,Pays at 100% of GA Medicaid Fee Schedule,NA,Not Applicable,25.97,Pays at 100% of GA Medicaid Fee Schedule,51.04,Pays at 88% of Total Billed charges,26.75,Pays at 103% of GA Medicaid Fee Schedule,25.97,52.2,34.80
Outpatient Medical Services,LAB,85097,BONE MARROW PREP & STAIN,310,269.75,229.29,Pays at 85% of Billed charges for outpatient setting,NA,Not Applicable.Service not offered,215.88,Pays at 80.03% of Total Billed charges,744.44,Pays at 102% of Medicare OPPS Rate,242.78,Pays at 90% of Total Billed charges,NA,Not Applicable.Service not offered,729.84,Pays at 100% of Medicare OPPS Rate,NA,Not Applicable.Service not offered,237.38,Pays at 88% of Total Billed charges,NA,Not Applicable.Service not offered,215.88,744.44,161.85
Outpatient Medical Services,LAB,85130,ARIXTRA (FONDAPARINUX)  (MAYO),300,183,155.55,Pays at 85% of Billed charges for outpatient setting,14.96,Pays at 100% of GA Medicaid Fee Schedule,146.45,Pays at 80.03% of Total Billed charges,12.12,Pays at 102% of Medicare OPPS Rate,164.7,Pays at 90% of Total Billed charges,14.96,Pays at 100% of GA Medicaid Fee Schedule,11.89,Pays at 100% of Medicare OPPS Rate,14.96,Pays at 100% of GA Medicaid Fee Schedule,161.04,Pays at 88% of Total Billed charges,15.41,Pays at 103% of GA Medicaid Fee Schedule,11.89,164.7,109.80
Outpatient Medical Services,LAB,85210,FACTOR II ASSAY  (MAYO),300,118.5,100.73,Pays at 85% of Billed charges for outpatient setting,16.33,Pays at 100% of GA Medicaid Fee Schedule,94.84,Pays at 80.03% of Total Billed charges,13.23,Pays at 102% of Medicare OPPS Rate,106.65,Pays at 90% of Total Billed charges,16.33,Pays at 100% of GA Medicaid Fee Schedule,12.98,Pays at 100% of Medicare OPPS Rate,16.33,Pays at 100% of GA Medicaid Fee Schedule,104.28,Pays at 88% of Total Billed charges,16.82,Pays at 103% of GA Medicaid Fee Schedule,12.98,106.65,71.10
Outpatient Medical Services,LAB,85220,FACTOR V ASSAY  (MAYO),300,260.5,221.43,Pays at 85% of Billed charges for outpatient setting,22.19,Pays at 100% of GA Medicaid Fee Schedule,208.48,Pays at 80.03% of Total Billed charges,18,Pays at 102% of Medicare OPPS Rate,234.45,Pays at 90% of Total Billed charges,22.19,Pays at 100% of GA Medicaid Fee Schedule,17.64,Pays at 100% of Medicare OPPS Rate,22.19,Pays at 100% of GA Medicaid Fee Schedule,229.24,Pays at 88% of Total Billed charges,22.86,Pays at 103% of GA Medicaid Fee Schedule,17.64,234.45,156.30
Outpatient Medical Services,LAB,85230,FACTOR VII ASSAY  (MAYO),300,118,100.3,Pays at 85% of Billed charges for outpatient setting,22.52,Pays at 100% of GA Medicaid Fee Schedule,94.44,Pays at 80.03% of Total Billed charges,18.25,Pays at 102% of Medicare OPPS Rate,106.2,Pays at 90% of Total Billed charges,22.52,Pays at 100% of GA Medicaid Fee Schedule,17.89,Pays at 100% of Medicare OPPS Rate,22.52,Pays at 100% of GA Medicaid Fee Schedule,103.84,Pays at 88% of Total Billed charges,23.2,Pays at 103% of GA Medicaid Fee Schedule,17.89,106.2,70.80
Outpatient Medical Services,LAB,85240,COAG FACTOR VIII ASSAY P (MAYO),300,184.25,156.61,Pays at 85% of Billed charges for outpatient setting,22.52,Pays at 100% of GA Medicaid Fee Schedule,147.46,Pays at 80.03% of Total Billed charges,18.25,Pays at 102% of Medicare OPPS Rate,165.83,Pays at 90% of Total Billed charges,22.52,Pays at 100% of GA Medicaid Fee Schedule,17.89,Pays at 100% of Medicare OPPS Rate,22.52,Pays at 100% of GA Medicaid Fee Schedule,162.14,Pays at 88% of Total Billed charges,23.2,Pays at 103% of GA Medicaid Fee Schedule,17.89,165.83,110.55
Outpatient Medical Services,LAB,85245,"RISTOCETIN CO FACTOR, PLASMA (MAYO)",300,239.33,203.43,Pays at 85% of Billed charges for outpatient setting,28.85,Pays at 100% of GA Medicaid Fee Schedule,191.54,Pays at 80.03% of Total Billed charges,23.39,Pays at 102% of Medicare OPPS Rate,215.4,Pays at 90% of Total Billed charges,28.85,Pays at 100% of GA Medicaid Fee Schedule,22.94,Pays at 100% of Medicare OPPS Rate,28.85,Pays at 100% of GA Medicaid Fee Schedule,210.61,Pays at 88% of Total Billed charges,29.72,Pays at 103% of GA Medicaid Fee Schedule,22.94,215.4,143.60
Outpatient Medical Services,LAB,85245,COAG. CONSULT. (VON WILLEBRAND) MAYO,300,694,589.9,Pays at 85% of Billed charges for outpatient setting,28.85,Pays at 100% of GA Medicaid Fee Schedule,555.41,Pays at 80.03% of Total Billed charges,23.39,Pays at 102% of Medicare OPPS Rate,624.6,Pays at 90% of Total Billed charges,28.85,Pays at 100% of GA Medicaid Fee Schedule,22.94,Pays at 100% of Medicare OPPS Rate,28.85,Pays at 100% of GA Medicaid Fee Schedule,610.72,Pays at 88% of Total Billed charges,29.72,Pays at 103% of GA Medicaid Fee Schedule,22.94,624.6,416.40
Outpatient Medical Services,LAB,85246,VON WILLEBRAND FACTOR AG  (MAYO),300,48.75,41.44,Pays at 85% of Billed charges for outpatient setting,28.85,Pays at 100% of GA Medicaid Fee Schedule,39.01,Pays at 80.03% of Total Billed charges,23.39,Pays at 102% of Medicare OPPS Rate,43.88,Pays at 90% of Total Billed charges,28.85,Pays at 100% of GA Medicaid Fee Schedule,22.94,Pays at 100% of Medicare OPPS Rate,28.85,Pays at 100% of GA Medicaid Fee Schedule,42.9,Pays at 88% of Total Billed charges,29.72,Pays at 103% of GA Medicaid Fee Schedule,22.94,43.88,29.25
Outpatient Medical Services,LAB,85246,VON WILLEBRAND PROFILE  (MAYO),300,927.88,788.7,Pays at 85% of Billed charges for outpatient setting,28.85,Pays at 100% of GA Medicaid Fee Schedule,742.58,Pays at 80.03% of Total Billed charges,23.39,Pays at 102% of Medicare OPPS Rate,835.09,Pays at 90% of Total Billed charges,28.85,Pays at 100% of GA Medicaid Fee Schedule,22.94,Pays at 100% of Medicare OPPS Rate,28.85,Pays at 100% of GA Medicaid Fee Schedule,816.53,Pays at 88% of Total Billed charges,29.72,Pays at 103% of GA Medicaid Fee Schedule,22.94,835.09,556.73
Outpatient Medical Services,LAB,85247,"VON WILLEBRAND FACTOR MULTIMER, P (MAYO)",300,166.35,141.4,Pays at 85% of Billed charges for outpatient setting,28.85,Pays at 100% of GA Medicaid Fee Schedule,133.13,Pays at 80.03% of Total Billed charges,23.39,Pays at 102% of Medicare OPPS Rate,149.72,Pays at 90% of Total Billed charges,28.85,Pays at 100% of GA Medicaid Fee Schedule,22.94,Pays at 100% of Medicare OPPS Rate,28.85,Pays at 100% of GA Medicaid Fee Schedule,146.39,Pays at 88% of Total Billed charges,29.72,Pays at 103% of GA Medicaid Fee Schedule,22.94,149.72,99.81
Outpatient Medical Services,LAB,85250,FACTOR IX  (MAYO),300,79.5,67.58,Pays at 85% of Billed charges for outpatient setting,23.94,Pays at 100% of GA Medicaid Fee Schedule,63.62,Pays at 80.03% of Total Billed charges,19.42,Pays at 102% of Medicare OPPS Rate,71.55,Pays at 90% of Total Billed charges,23.94,Pays at 100% of GA Medicaid Fee Schedule,19.04,Pays at 100% of Medicare OPPS Rate,23.94,Pays at 100% of GA Medicaid Fee Schedule,69.96,Pays at 88% of Total Billed charges,24.66,Pays at 103% of GA Medicaid Fee Schedule,19.04,71.55,47.70
Outpatient Medical Services,LAB,85250,FACTOR VIII  (MAYO),300,115.25,97.96,Pays at 85% of Billed charges for outpatient setting,23.94,Pays at 100% of GA Medicaid Fee Schedule,92.23,Pays at 80.03% of Total Billed charges,19.42,Pays at 102% of Medicare OPPS Rate,103.73,Pays at 90% of Total Billed charges,23.94,Pays at 100% of GA Medicaid Fee Schedule,19.04,Pays at 100% of Medicare OPPS Rate,23.94,Pays at 100% of GA Medicaid Fee Schedule,101.42,Pays at 88% of Total Billed charges,24.66,Pays at 103% of GA Medicaid Fee Schedule,19.04,103.73,69.15
Outpatient Medical Services,LAB,85250,FACTOR IX  ACTIVITY  (MAYO),300,115.25,97.96,Pays at 85% of Billed charges for outpatient setting,23.94,Pays at 100% of GA Medicaid Fee Schedule,92.23,Pays at 80.03% of Total Billed charges,19.42,Pays at 102% of Medicare OPPS Rate,103.73,Pays at 90% of Total Billed charges,23.94,Pays at 100% of GA Medicaid Fee Schedule,19.04,Pays at 100% of Medicare OPPS Rate,23.94,Pays at 100% of GA Medicaid Fee Schedule,101.42,Pays at 88% of Total Billed charges,24.66,Pays at 103% of GA Medicaid Fee Schedule,19.04,103.73,69.15
Outpatient Medical Services,LAB,85250,COAG FACTOR IX ASSAY P (MAYO),300,336.5,286.03,Pays at 85% of Billed charges for outpatient setting,23.94,Pays at 100% of GA Medicaid Fee Schedule,269.3,Pays at 80.03% of Total Billed charges,19.42,Pays at 102% of Medicare OPPS Rate,302.85,Pays at 90% of Total Billed charges,23.94,Pays at 100% of GA Medicaid Fee Schedule,19.04,Pays at 100% of Medicare OPPS Rate,23.94,Pays at 100% of GA Medicaid Fee Schedule,296.12,Pays at 88% of Total Billed charges,24.66,Pays at 103% of GA Medicaid Fee Schedule,19.04,302.85,201.90
Outpatient Medical Services,LAB,85260,FACTOR X ASSAY  (MAYO),300,101,85.85,Pays at 85% of Billed charges for outpatient setting,22.52,Pays at 100% of GA Medicaid Fee Schedule,80.83,Pays at 80.03% of Total Billed charges,18.25,Pays at 102% of Medicare OPPS Rate,90.9,Pays at 90% of Total Billed charges,22.52,Pays at 100% of GA Medicaid Fee Schedule,17.89,Pays at 100% of Medicare OPPS Rate,22.52,Pays at 100% of GA Medicaid Fee Schedule,88.88,Pays at 88% of Total Billed charges,23.2,Pays at 103% of GA Medicaid Fee Schedule,17.89,90.9,60.60
Outpatient Medical Services,LAB,85270,FACTOR XI  (MAYO),300,131,111.35,Pays at 85% of Billed charges for outpatient setting,22.52,Pays at 100% of GA Medicaid Fee Schedule,104.84,Pays at 80.03% of Total Billed charges,18.25,Pays at 102% of Medicare OPPS Rate,117.9,Pays at 90% of Total Billed charges,22.52,Pays at 100% of GA Medicaid Fee Schedule,17.89,Pays at 100% of Medicare OPPS Rate,22.52,Pays at 100% of GA Medicaid Fee Schedule,115.28,Pays at 88% of Total Billed charges,23.2,Pays at 103% of GA Medicaid Fee Schedule,17.89,117.9,78.60
Outpatient Medical Services,LAB,85270,COAG FACTOR XI ASSAY P (MAYO),300,358,304.3,Pays at 85% of Billed charges for outpatient setting,22.52,Pays at 100% of GA Medicaid Fee Schedule,286.51,Pays at 80.03% of Total Billed charges,18.25,Pays at 102% of Medicare OPPS Rate,322.2,Pays at 90% of Total Billed charges,22.52,Pays at 100% of GA Medicaid Fee Schedule,17.89,Pays at 100% of Medicare OPPS Rate,22.52,Pays at 100% of GA Medicaid Fee Schedule,315.04,Pays at 88% of Total Billed charges,23.2,Pays at 103% of GA Medicaid Fee Schedule,17.89,322.2,214.80
Outpatient Medical Services,LAB,85280,FACTOR XII  (MAYO),300,135.25,114.96,Pays at 85% of Billed charges for outpatient setting,24.34,Pays at 100% of GA Medicaid Fee Schedule,108.24,Pays at 80.03% of Total Billed charges,19.73,Pays at 102% of Medicare OPPS Rate,121.73,Pays at 90% of Total Billed charges,24.34,Pays at 100% of GA Medicaid Fee Schedule,19.35,Pays at 100% of Medicare OPPS Rate,24.34,Pays at 100% of GA Medicaid Fee Schedule,119.02,Pays at 88% of Total Billed charges,25.07,Pays at 103% of GA Medicaid Fee Schedule,19.35,121.73,81.15
Outpatient Medical Services,LAB,85280,COAG FACTOR XII ASSAY P (MAYO),300,220.5,187.43,Pays at 85% of Billed charges for outpatient setting,24.34,Pays at 100% of GA Medicaid Fee Schedule,176.47,Pays at 80.03% of Total Billed charges,19.73,Pays at 102% of Medicare OPPS Rate,198.45,Pays at 90% of Total Billed charges,24.34,Pays at 100% of GA Medicaid Fee Schedule,19.35,Pays at 100% of Medicare OPPS Rate,24.34,Pays at 100% of GA Medicaid Fee Schedule,194.04,Pays at 88% of Total Billed charges,25.07,Pays at 103% of GA Medicaid Fee Schedule,19.35,198.45,132.30
Outpatient Medical Services,LAB,85291,"FACTOR XIII, QL, REFLEX TO 1:1 MIX",300,100.5,85.43,Pays at 85% of Billed charges for outpatient setting,11.18,Pays at 100% of GA Medicaid Fee Schedule,80.43,Pays at 80.03% of Total Billed charges,9.29,Pays at 102% of Medicare OPPS Rate,90.45,Pays at 90% of Total Billed charges,11.18,Pays at 100% of GA Medicaid Fee Schedule,9.11,Pays at 100% of Medicare OPPS Rate,11.18,Pays at 100% of GA Medicaid Fee Schedule,88.44,Pays at 88% of Total Billed charges,11.52,Pays at 103% of GA Medicaid Fee Schedule,9.11,90.45,60.30
Outpatient Medical Services,LAB,85291,FACTOR XIII 1:1 MIX (MAYO),300,100.5,85.43,Pays at 85% of Billed charges for outpatient setting,11.18,Pays at 100% of GA Medicaid Fee Schedule,80.43,Pays at 80.03% of Total Billed charges,9.29,Pays at 102% of Medicare OPPS Rate,90.45,Pays at 90% of Total Billed charges,11.18,Pays at 100% of GA Medicaid Fee Schedule,9.11,Pays at 100% of Medicare OPPS Rate,11.18,Pays at 100% of GA Medicaid Fee Schedule,88.44,Pays at 88% of Total Billed charges,11.52,Pays at 103% of GA Medicaid Fee Schedule,9.11,90.45,60.30
Outpatient Medical Services,LAB,85300,ANTITHROMBIN III ACTIVITY  (MAYO),300,63.5,53.98,Pays at 85% of Billed charges for outpatient setting,14.9,Pays at 100% of GA Medicaid Fee Schedule,50.82,Pays at 80.03% of Total Billed charges,12.08,Pays at 102% of Medicare OPPS Rate,57.15,Pays at 90% of Total Billed charges,14.9,Pays at 100% of GA Medicaid Fee Schedule,11.85,Pays at 100% of Medicare OPPS Rate,14.9,Pays at 100% of GA Medicaid Fee Schedule,55.88,Pays at 88% of Total Billed charges,15.35,Pays at 103% of GA Medicaid Fee Schedule,11.85,57.15,38.10
Outpatient Medical Services,LAB,85300,"LUPUS PANEL, SLE  (MAYO)",300,209.75,178.29,Pays at 85% of Billed charges for outpatient setting,14.9,Pays at 100% of GA Medicaid Fee Schedule,167.86,Pays at 80.03% of Total Billed charges,12.08,Pays at 102% of Medicare OPPS Rate,188.78,Pays at 90% of Total Billed charges,14.9,Pays at 100% of GA Medicaid Fee Schedule,11.85,Pays at 100% of Medicare OPPS Rate,14.9,Pays at 100% of GA Medicaid Fee Schedule,184.58,Pays at 88% of Total Billed charges,15.35,Pays at 103% of GA Medicaid Fee Schedule,11.85,188.78,125.85
Outpatient Medical Services,LAB,85301,ANTITHROMBIN AG  (MAYO),300,61.75,52.49,Pays at 85% of Billed charges for outpatient setting,13.6,Pays at 100% of GA Medicaid Fee Schedule,49.42,Pays at 80.03% of Total Billed charges,11.02,Pays at 102% of Medicare OPPS Rate,55.58,Pays at 90% of Total Billed charges,13.6,Pays at 100% of GA Medicaid Fee Schedule,10.81,Pays at 100% of Medicare OPPS Rate,13.6,Pays at 100% of GA Medicaid Fee Schedule,54.34,Pays at 88% of Total Billed charges,14.01,Pays at 103% of GA Medicaid Fee Schedule,10.81,55.58,37.05
Outpatient Medical Services,LAB,85301,ANTITHROMBIN III  (MAYO),300,61.75,52.49,Pays at 85% of Billed charges for outpatient setting,13.6,Pays at 100% of GA Medicaid Fee Schedule,49.42,Pays at 80.03% of Total Billed charges,11.02,Pays at 102% of Medicare OPPS Rate,55.58,Pays at 90% of Total Billed charges,13.6,Pays at 100% of GA Medicaid Fee Schedule,10.81,Pays at 100% of Medicare OPPS Rate,13.6,Pays at 100% of GA Medicaid Fee Schedule,54.34,Pays at 88% of Total Billed charges,14.01,Pays at 103% of GA Medicaid Fee Schedule,10.81,55.58,37.05
Outpatient Medical Services,LAB,85302,PROTEIN C AG  (MAYO),300,56,47.6,Pays at 85% of Billed charges for outpatient setting,15.12,Pays at 100% of GA Medicaid Fee Schedule,44.82,Pays at 80.03% of Total Billed charges,12.25,Pays at 102% of Medicare OPPS Rate,50.4,Pays at 90% of Total Billed charges,15.12,Pays at 100% of GA Medicaid Fee Schedule,12.01,Pays at 100% of Medicare OPPS Rate,15.12,Pays at 100% of GA Medicaid Fee Schedule,49.28,Pays at 88% of Total Billed charges,15.57,Pays at 103% of GA Medicaid Fee Schedule,12.01,50.4,33.60
Outpatient Medical Services,LAB,85303,PROTEIN C ACTIVITY TOTAL & FREE (MAYO),300,59,50.15,Pays at 85% of Billed charges for outpatient setting,17.39,Pays at 100% of GA Medicaid Fee Schedule,47.22,Pays at 80.03% of Total Billed charges,14.11,Pays at 102% of Medicare OPPS Rate,53.1,Pays at 90% of Total Billed charges,17.39,Pays at 100% of GA Medicaid Fee Schedule,13.84,Pays at 100% of Medicare OPPS Rate,17.39,Pays at 100% of GA Medicaid Fee Schedule,51.92,Pays at 88% of Total Billed charges,17.91,Pays at 103% of GA Medicaid Fee Schedule,13.84,53.1,35.40
Outpatient Medical Services,LAB,85303,PROTEIN C-FUNC ACTIVITY  (MAYO),300,132.75,112.84,Pays at 85% of Billed charges for outpatient setting,17.39,Pays at 100% of GA Medicaid Fee Schedule,106.24,Pays at 80.03% of Total Billed charges,14.11,Pays at 102% of Medicare OPPS Rate,119.48,Pays at 90% of Total Billed charges,17.39,Pays at 100% of GA Medicaid Fee Schedule,13.84,Pays at 100% of Medicare OPPS Rate,17.39,Pays at 100% of GA Medicaid Fee Schedule,116.82,Pays at 88% of Total Billed charges,17.91,Pays at 103% of GA Medicaid Fee Schedule,13.84,119.48,79.65
Outpatient Medical Services,LAB,85305,PROTEIN S AG TOTAL (MAYO),300,167.25,142.16,Pays at 85% of Billed charges for outpatient setting,14.58,Pays at 100% of GA Medicaid Fee Schedule,133.85,Pays at 80.03% of Total Billed charges,11.84,Pays at 102% of Medicare OPPS Rate,150.53,Pays at 90% of Total Billed charges,14.58,Pays at 100% of GA Medicaid Fee Schedule,11.61,Pays at 100% of Medicare OPPS Rate,14.58,Pays at 100% of GA Medicaid Fee Schedule,147.18,Pays at 88% of Total Billed charges,15.02,Pays at 103% of GA Medicaid Fee Schedule,11.61,150.53,100.35
Outpatient Medical Services,LAB,85306,PROTEIN S AG FREE (MAYO),300,46,39.1,Pays at 85% of Billed charges for outpatient setting,19.27,Pays at 100% of GA Medicaid Fee Schedule,36.81,Pays at 80.03% of Total Billed charges,15.62,Pays at 102% of Medicare OPPS Rate,41.4,Pays at 90% of Total Billed charges,19.27,Pays at 100% of GA Medicaid Fee Schedule,15.32,Pays at 100% of Medicare OPPS Rate,19.27,Pays at 100% of GA Medicaid Fee Schedule,40.48,Pays at 88% of Total Billed charges,19.85,Pays at 103% of GA Medicaid Fee Schedule,15.32,41.4,27.60
Outpatient Medical Services,LAB,85306,PROTEIN S ACTIVITY  (MAYO),300,89,75.65,Pays at 85% of Billed charges for outpatient setting,19.27,Pays at 100% of GA Medicaid Fee Schedule,71.23,Pays at 80.03% of Total Billed charges,15.62,Pays at 102% of Medicare OPPS Rate,80.1,Pays at 90% of Total Billed charges,19.27,Pays at 100% of GA Medicaid Fee Schedule,15.32,Pays at 100% of Medicare OPPS Rate,19.27,Pays at 100% of GA Medicaid Fee Schedule,78.32,Pays at 88% of Total Billed charges,19.85,Pays at 103% of GA Medicaid Fee Schedule,15.32,80.1,53.40
Outpatient Medical Services,LAB,85307,"PROTEIN C RESISTANCE, APC-R  (MAYO)",300,99.5,84.58,Pays at 85% of Billed charges for outpatient setting,19.27,Pays at 100% of GA Medicaid Fee Schedule,79.63,Pays at 80.03% of Total Billed charges,15.62,Pays at 102% of Medicare OPPS Rate,89.55,Pays at 90% of Total Billed charges,19.27,Pays at 100% of GA Medicaid Fee Schedule,15.32,Pays at 100% of Medicare OPPS Rate,19.27,Pays at 100% of GA Medicaid Fee Schedule,87.56,Pays at 88% of Total Billed charges,19.85,Pays at 103% of GA Medicaid Fee Schedule,15.32,89.55,59.70
Outpatient Medical Services,LAB,85307,ACTIVATED PROTEIN-C RESISTANCE  (MAYO),300,109.5,93.08,Pays at 85% of Billed charges for outpatient setting,19.27,Pays at 100% of GA Medicaid Fee Schedule,87.63,Pays at 80.03% of Total Billed charges,15.62,Pays at 102% of Medicare OPPS Rate,98.55,Pays at 90% of Total Billed charges,19.27,Pays at 100% of GA Medicaid Fee Schedule,15.32,Pays at 100% of Medicare OPPS Rate,19.27,Pays at 100% of GA Medicaid Fee Schedule,96.36,Pays at 88% of Total Billed charges,19.85,Pays at 103% of GA Medicaid Fee Schedule,15.32,98.55,65.70
Outpatient Medical Services,LAB,85335,FACTOR V INHIBITOR SCREEN  (MAYO),300,189.95,161.46,Pays at 85% of Billed charges for outpatient setting,16.19,Pays at 100% of GA Medicaid Fee Schedule,152.02,Pays at 80.03% of Total Billed charges,13.12,Pays at 102% of Medicare OPPS Rate,170.96,Pays at 90% of Total Billed charges,16.19,Pays at 100% of GA Medicaid Fee Schedule,12.87,Pays at 100% of Medicare OPPS Rate,16.19,Pays at 100% of GA Medicaid Fee Schedule,167.16,Pays at 88% of Total Billed charges,16.68,Pays at 103% of GA Medicaid Fee Schedule,12.87,170.96,113.97
Outpatient Medical Services,LAB,85335,BETHESDA UNITS (MAYO),300,211.25,179.56,Pays at 85% of Billed charges for outpatient setting,16.19,Pays at 100% of GA Medicaid Fee Schedule,169.06,Pays at 80.03% of Total Billed charges,13.12,Pays at 102% of Medicare OPPS Rate,190.13,Pays at 90% of Total Billed charges,16.19,Pays at 100% of GA Medicaid Fee Schedule,12.87,Pays at 100% of Medicare OPPS Rate,16.19,Pays at 100% of GA Medicaid Fee Schedule,185.9,Pays at 88% of Total Billed charges,16.68,Pays at 103% of GA Medicaid Fee Schedule,12.87,190.13,126.75
Outpatient Medical Services,LAB,85335,COAG FACTOR VIII INHIB SC (MAYO),300,429.5,365.08,Pays at 85% of Billed charges for outpatient setting,16.19,Pays at 100% of GA Medicaid Fee Schedule,343.73,Pays at 80.03% of Total Billed charges,13.12,Pays at 102% of Medicare OPPS Rate,386.55,Pays at 90% of Total Billed charges,16.19,Pays at 100% of GA Medicaid Fee Schedule,12.87,Pays at 100% of Medicare OPPS Rate,16.19,Pays at 100% of GA Medicaid Fee Schedule,377.96,Pays at 88% of Total Billed charges,16.68,Pays at 103% of GA Medicaid Fee Schedule,12.87,386.55,257.70
Outpatient Medical Services,LAB,85347,"KAOLIN CLOTTING TIME, PTT-LA  (MAYO)",300,186.25,158.31,Pays at 85% of Billed charges for outpatient setting,5.36,Pays at 100% of GA Medicaid Fee Schedule,149.06,Pays at 80.03% of Total Billed charges,4.36,Pays at 102% of Medicare OPPS Rate,167.63,Pays at 90% of Total Billed charges,5.36,Pays at 100% of GA Medicaid Fee Schedule,4.28,Pays at 100% of Medicare OPPS Rate,5.36,Pays at 100% of GA Medicaid Fee Schedule,163.9,Pays at 88% of Total Billed charges,5.52,Pays at 103% of GA Medicaid Fee Schedule,4.28,167.63,111.75
Outpatient Medical Services,LAB,85362,FDP  (MAYO),300,153,130.05,Pays at 85% of Billed charges for outpatient setting,8.66,Pays at 100% of GA Medicaid Fee Schedule,122.45,Pays at 80.03% of Total Billed charges,7.02,Pays at 102% of Medicare OPPS Rate,137.7,Pays at 90% of Total Billed charges,8.66,Pays at 100% of GA Medicaid Fee Schedule,6.89,Pays at 100% of Medicare OPPS Rate,8.66,Pays at 100% of GA Medicaid Fee Schedule,134.64,Pays at 88% of Total Billed charges,8.92,Pays at 103% of GA Medicaid Fee Schedule,6.89,137.7,91.80
Outpatient Medical Services,LAB,85366,SOLUBLE FIBRIN MONOMER  (MAYO),300,63.5,53.98,Pays at 85% of Billed charges for outpatient setting,10.83,Pays at 100% of GA Medicaid Fee Schedule,50.82,Pays at 80.03% of Total Billed charges,82.06,Pays at 102% of Medicare OPPS Rate,57.15,Pays at 90% of Total Billed charges,10.83,Pays at 100% of GA Medicaid Fee Schedule,80.45,Pays at 100% of Medicare OPPS Rate,10.83,Pays at 100% of GA Medicaid Fee Schedule,55.88,Pays at 88% of Total Billed charges,11.15,Pays at 103% of GA Medicaid Fee Schedule,10.83,82.06,38.10
Outpatient Medical Services,LAB,85380,D-DIMER DO NOT USE YET!!!!!!,300,53,45.05,Pays at 85% of Billed charges for outpatient setting,12.8,Pays at 100% of GA Medicaid Fee Schedule,42.42,Pays at 80.03% of Total Billed charges,10.38,Pays at 102% of Medicare OPPS Rate,47.7,Pays at 90% of Total Billed charges,12.8,Pays at 100% of GA Medicaid Fee Schedule,10.18,Pays at 100% of Medicare OPPS Rate,12.8,Pays at 100% of GA Medicaid Fee Schedule,46.64,Pays at 88% of Total Billed charges,13.18,Pays at 103% of GA Medicaid Fee Schedule,10.18,47.7,31.80
Outpatient Medical Services,LAB,85380,D-DIMER,300,54.75,46.54,Pays at 85% of Billed charges for outpatient setting,12.8,Pays at 100% of GA Medicaid Fee Schedule,43.82,Pays at 80.03% of Total Billed charges,10.38,Pays at 102% of Medicare OPPS Rate,49.28,Pays at 90% of Total Billed charges,12.8,Pays at 100% of GA Medicaid Fee Schedule,10.18,Pays at 100% of Medicare OPPS Rate,12.8,Pays at 100% of GA Medicaid Fee Schedule,48.18,Pays at 88% of Total Billed charges,13.18,Pays at 103% of GA Medicaid Fee Schedule,10.18,49.28,32.85
Outpatient Medical Services,LAB,85384,FIBRINOGEN,300,65.75,55.89,Pays at 85% of Billed charges for outpatient setting,10.68,Pays at 100% of GA Medicaid Fee Schedule,52.62,Pays at 80.03% of Total Billed charges,9.91,Pays at 102% of Medicare OPPS Rate,59.18,Pays at 90% of Total Billed charges,10.68,Pays at 100% of GA Medicaid Fee Schedule,9.72,Pays at 100% of Medicare OPPS Rate,10.68,Pays at 100% of GA Medicaid Fee Schedule,57.86,Pays at 88% of Total Billed charges,11,Pays at 103% of GA Medicaid Fee Schedule,9.72,59.18,39.45
Outpatient Medical Services,LAB,85384,FIBRINOGEN  (MAYO),300,90.75,77.14,Pays at 85% of Billed charges for outpatient setting,10.68,Pays at 100% of GA Medicaid Fee Schedule,72.63,Pays at 80.03% of Total Billed charges,9.91,Pays at 102% of Medicare OPPS Rate,81.68,Pays at 90% of Total Billed charges,10.68,Pays at 100% of GA Medicaid Fee Schedule,9.72,Pays at 100% of Medicare OPPS Rate,10.68,Pays at 100% of GA Medicaid Fee Schedule,79.86,Pays at 88% of Total Billed charges,11,Pays at 103% of GA Medicaid Fee Schedule,9.72,81.68,54.45
Outpatient Medical Services,LAB,85390,SPECIAL COAG INTERPRETATION  (MAYO),300,53.75,45.69,Pays at 85% of Billed charges for outpatient setting,6.5,Pays at 100% of GA Medicaid Fee Schedule,43.02,Pays at 80.03% of Total Billed charges,15.78,Pays at 102% of Medicare OPPS Rate,48.38,Pays at 90% of Total Billed charges,6.5,Pays at 100% of GA Medicaid Fee Schedule,15.48,Pays at 100% of Medicare OPPS Rate,6.5,Pays at 100% of GA Medicaid Fee Schedule,47.3,Pays at 88% of Total Billed charges,6.7,Pays at 103% of GA Medicaid Fee Schedule,6.5,48.38,32.25
Outpatient Medical Services,LAB,85397,VON WILLEBRAND FACTOR ACTIVITY  (MAYO),300,274.12,233,Pays at 85% of Billed charges for outpatient setting,26.81,Pays at 100% of GA Medicaid Fee Schedule,219.38,Pays at 80.03% of Total Billed charges,31.47,Pays at 102% of Medicare OPPS Rate,246.71,Pays at 90% of Total Billed charges,26.81,Pays at 100% of GA Medicaid Fee Schedule,30.86,Pays at 100% of Medicare OPPS Rate,26.81,Pays at 100% of GA Medicaid Fee Schedule,241.23,Pays at 88% of Total Billed charges,27.61,Pays at 103% of GA Medicaid Fee Schedule,26.81,246.71,164.47
Outpatient Medical Services,LAB,85460,KLEIHAUER ACID ELUTION,300,131,111.35,Pays at 85% of Billed charges for outpatient setting,3.04,Pays at 100% of GA Medicaid Fee Schedule,104.84,Pays at 80.03% of Total Billed charges,7.88,Pays at 102% of Medicare OPPS Rate,117.9,Pays at 90% of Total Billed charges,3.04,Pays at 100% of GA Medicaid Fee Schedule,7.73,Pays at 100% of Medicare OPPS Rate,3.04,Pays at 100% of GA Medicaid Fee Schedule,115.28,Pays at 88% of Total Billed charges,3.13,Pays at 103% of GA Medicaid Fee Schedule,3.04,117.9,78.60
Outpatient Medical Services,LAB,85461,FETAL SCREEN,300,36.25,30.81,Pays at 85% of Billed charges for outpatient setting,8.33,Pays at 100% of GA Medicaid Fee Schedule,29.01,Pays at 80.03% of Total Billed charges,9.54,Pays at 102% of Medicare OPPS Rate,32.63,Pays at 90% of Total Billed charges,8.33,Pays at 100% of GA Medicaid Fee Schedule,9.36,Pays at 100% of Medicare OPPS Rate,8.33,Pays at 100% of GA Medicaid Fee Schedule,31.9,Pays at 88% of Total Billed charges,8.58,Pays at 103% of GA Medicaid Fee Schedule,8.33,32.63,21.75
Outpatient Medical Services,LAB,85475,"ACID HEMOLYSIN TEST, HAM'S  (MAYO)",300,95,80.75,Pays at 85% of Billed charges for outpatient setting,6.55,Pays at 100% of GA Medicaid Fee Schedule,76.03,Pays at 80.03% of Total Billed charges,9.04,Pays at 102% of Medicare OPPS Rate,85.5,Pays at 90% of Total Billed charges,6.55,Pays at 100% of GA Medicaid Fee Schedule,8.86,Pays at 100% of Medicare OPPS Rate,6.55,Pays at 100% of GA Medicaid Fee Schedule,83.6,Pays at 88% of Total Billed charges,6.75,Pays at 103% of GA Medicaid Fee Schedule,6.55,85.5,57.00
Outpatient Medical Services,LAB,85520,HEPARIN ANITI-XA  ASSAY  (MAYO),300,127.25,108.16,Pays at 85% of Billed charges for outpatient setting,16.46,Pays at 100% of GA Medicaid Fee Schedule,101.84,Pays at 80.03% of Total Billed charges,13.35,Pays at 102% of Medicare OPPS Rate,114.53,Pays at 90% of Total Billed charges,16.46,Pays at 100% of GA Medicaid Fee Schedule,13.09,Pays at 100% of Medicare OPPS Rate,16.46,Pays at 100% of GA Medicaid Fee Schedule,111.98,Pays at 88% of Total Billed charges,16.95,Pays at 103% of GA Medicaid Fee Schedule,13.09,114.53,76.35
Outpatient Medical Services,LAB,85540,LEUKOCYTE ALKALINE PHOSPH  (MAYO),300,67.55,57.42,Pays at 85% of Billed charges for outpatient setting,7.6,Pays at 100% of GA Medicaid Fee Schedule,54.06,Pays at 80.03% of Total Billed charges,8.77,Pays at 102% of Medicare OPPS Rate,60.8,Pays at 90% of Total Billed charges,7.6,Pays at 100% of GA Medicaid Fee Schedule,8.6,Pays at 100% of Medicare OPPS Rate,7.6,Pays at 100% of GA Medicaid Fee Schedule,59.44,Pays at 88% of Total Billed charges,7.83,Pays at 103% of GA Medicaid Fee Schedule,7.6,60.8,40.53
Outpatient Medical Services,LAB,85549,"LYSOZYME, PLASMA   (MAYO)",300,78.5,66.73,Pays at 85% of Billed charges for outpatient setting,23.59,Pays at 100% of GA Medicaid Fee Schedule,62.82,Pays at 80.03% of Total Billed charges,19.12,Pays at 102% of Medicare OPPS Rate,70.65,Pays at 90% of Total Billed charges,23.59,Pays at 100% of GA Medicaid Fee Schedule,18.75,Pays at 100% of Medicare OPPS Rate,23.59,Pays at 100% of GA Medicaid Fee Schedule,69.08,Pays at 88% of Total Billed charges,24.3,Pays at 103% of GA Medicaid Fee Schedule,18.75,70.65,47.10
Outpatient Medical Services,LAB,85549,"LYSOZYME, SERUM  (MAYO)",300,80.75,68.64,Pays at 85% of Billed charges for outpatient setting,23.59,Pays at 100% of GA Medicaid Fee Schedule,64.62,Pays at 80.03% of Total Billed charges,19.12,Pays at 102% of Medicare OPPS Rate,72.68,Pays at 90% of Total Billed charges,23.59,Pays at 100% of GA Medicaid Fee Schedule,18.75,Pays at 100% of Medicare OPPS Rate,23.59,Pays at 100% of GA Medicaid Fee Schedule,71.06,Pays at 88% of Total Billed charges,24.3,Pays at 103% of GA Medicaid Fee Schedule,18.75,72.68,48.45
Outpatient Medical Services,LAB,85557,OSMOTIC FRAGILITY  (MAYO),300,167.5,142.38,Pays at 85% of Billed charges for outpatient setting,16.79,Pays at 100% of GA Medicaid Fee Schedule,134.05,Pays at 80.03% of Total Billed charges,13.62,Pays at 102% of Medicare OPPS Rate,150.75,Pays at 90% of Total Billed charges,16.79,Pays at 100% of GA Medicaid Fee Schedule,13.36,Pays at 100% of Medicare OPPS Rate,16.79,Pays at 100% of GA Medicaid Fee Schedule,147.4,Pays at 88% of Total Billed charges,17.29,Pays at 103% of GA Medicaid Fee Schedule,13.36,150.75,100.50
Outpatient Medical Services,LAB,85597,"PLATELET NEUTRALIZATION, dRVVT  (MAYO)",300,113.5,96.48,Pays at 85% of Billed charges for outpatient setting,22.61,Pays at 100% of GA Medicaid Fee Schedule,90.83,Pays at 80.03% of Total Billed charges,18.33,Pays at 102% of Medicare OPPS Rate,102.15,Pays at 90% of Total Billed charges,22.61,Pays at 100% of GA Medicaid Fee Schedule,17.98,Pays at 100% of Medicare OPPS Rate,22.61,Pays at 100% of GA Medicaid Fee Schedule,99.88,Pays at 88% of Total Billed charges,23.29,Pays at 103% of GA Medicaid Fee Schedule,17.98,102.15,68.10
Outpatient Medical Services,LAB,85597,PTT-LA CONFIRMATION  (MAYO),300,272.25,231.41,Pays at 85% of Billed charges for outpatient setting,22.61,Pays at 100% of GA Medicaid Fee Schedule,217.88,Pays at 80.03% of Total Billed charges,18.33,Pays at 102% of Medicare OPPS Rate,245.03,Pays at 90% of Total Billed charges,22.61,Pays at 100% of GA Medicaid Fee Schedule,17.98,Pays at 100% of Medicare OPPS Rate,22.61,Pays at 100% of GA Medicaid Fee Schedule,239.58,Pays at 88% of Total Billed charges,23.29,Pays at 103% of GA Medicaid Fee Schedule,17.98,245.03,163.35
Outpatient Medical Services,LAB,85598,"PLATELET NEUTRALIZATION, HEX  (MAYO)",300,123.25,104.76,Pays at 85% of Billed charges for outpatient setting,20.24,Pays at 100% of GA Medicaid Fee Schedule,98.64,Pays at 80.03% of Total Billed charges,18.33,Pays at 102% of Medicare OPPS Rate,110.93,Pays at 90% of Total Billed charges,20.24,Pays at 100% of GA Medicaid Fee Schedule,17.98,Pays at 100% of Medicare OPPS Rate,20.24,Pays at 100% of GA Medicaid Fee Schedule,108.46,Pays at 88% of Total Billed charges,20.85,Pays at 103% of GA Medicaid Fee Schedule,17.98,110.93,73.95
Outpatient Medical Services,LAB,85598,"STACLOT LA, P (MAYO)",300,298,253.3,Pays at 85% of Billed charges for outpatient setting,20.24,Pays at 100% of GA Medicaid Fee Schedule,238.49,Pays at 80.03% of Total Billed charges,18.33,Pays at 102% of Medicare OPPS Rate,268.2,Pays at 90% of Total Billed charges,20.24,Pays at 100% of GA Medicaid Fee Schedule,17.98,Pays at 100% of Medicare OPPS Rate,20.24,Pays at 100% of GA Medicaid Fee Schedule,262.24,Pays at 88% of Total Billed charges,20.85,Pays at 103% of GA Medicaid Fee Schedule,17.98,268.2,178.80
Outpatient Medical Services,LAB,85610,"Blood test, clotting time",300,34.03,28.93,Pays at 85% of Billed charges for outpatient setting,4.94,Pays at 100% of GA Medicaid Fee Schedule,27.23,Pays at 80.03% of Total Billed charges,4.37,Pays at 102% of Medicare OPPS Rate,30.63,Pays at 90% of Total Billed charges,4.94,Pays at 100% of GA Medicaid Fee Schedule,4.29,Pays at 100% of Medicare OPPS Rate,4.94,Pays at 100% of GA Medicaid Fee Schedule,29.95,Pays at 88% of Total Billed charges,5.09,Pays at 103% of GA Medicaid Fee Schedule,4.29,30.63,20.42
Outpatient Medical Services,LAB,85610,"Blood test, clotting time",300,41.5,35.28,Pays at 85% of Billed charges for outpatient setting,4.94,Pays at 100% of GA Medicaid Fee Schedule,33.21,Pays at 80.03% of Total Billed charges,4.37,Pays at 102% of Medicare OPPS Rate,37.35,Pays at 90% of Total Billed charges,4.94,Pays at 100% of GA Medicaid Fee Schedule,4.29,Pays at 100% of Medicare OPPS Rate,4.94,Pays at 100% of GA Medicaid Fee Schedule,36.52,Pays at 88% of Total Billed charges,5.09,Pays at 103% of GA Medicaid Fee Schedule,4.29,37.35,24.90
Outpatient Medical Services,LAB,85610,"Blood test, clotting time",300,90,76.5,Pays at 85% of Billed charges for outpatient setting,4.94,Pays at 100% of GA Medicaid Fee Schedule,72.03,Pays at 80.03% of Total Billed charges,4.37,Pays at 102% of Medicare OPPS Rate,81,Pays at 90% of Total Billed charges,4.94,Pays at 100% of GA Medicaid Fee Schedule,4.29,Pays at 100% of Medicare OPPS Rate,4.94,Pays at 100% of GA Medicaid Fee Schedule,79.2,Pays at 88% of Total Billed charges,5.09,Pays at 103% of GA Medicaid Fee Schedule,4.29,81,54.00
Outpatient Medical Services,LAB,85611,PT MIXING STUDY  (MAYO),300,96.25,81.81,Pays at 85% of Billed charges for outpatient setting,4.96,Pays at 100% of GA Medicaid Fee Schedule,77.03,Pays at 80.03% of Total Billed charges,4.01,Pays at 102% of Medicare OPPS Rate,86.63,Pays at 90% of Total Billed charges,4.96,Pays at 100% of GA Medicaid Fee Schedule,3.94,Pays at 100% of Medicare OPPS Rate,4.96,Pays at 100% of GA Medicaid Fee Schedule,84.7,Pays at 88% of Total Billed charges,5.11,Pays at 103% of GA Medicaid Fee Schedule,3.94,86.63,57.75
Outpatient Medical Services,LAB,85613,DRVVT CONFIRMATION (MAYO),300,70.5,59.93,Pays at 85% of Billed charges for outpatient setting,12.03,Pays at 100% of GA Medicaid Fee Schedule,56.42,Pays at 80.03% of Total Billed charges,9.77,Pays at 102% of Medicare OPPS Rate,63.45,Pays at 90% of Total Billed charges,12.03,Pays at 100% of GA Medicaid Fee Schedule,9.58,Pays at 100% of Medicare OPPS Rate,12.03,Pays at 100% of GA Medicaid Fee Schedule,62.04,Pays at 88% of Total Billed charges,12.39,Pays at 103% of GA Medicaid Fee Schedule,9.58,63.45,42.30
Outpatient Medical Services,LAB,85613,DILUTE RUSSELL'S VIPER VENOM  (MAYO),300,74.5,63.33,Pays at 85% of Billed charges for outpatient setting,12.03,Pays at 100% of GA Medicaid Fee Schedule,59.62,Pays at 80.03% of Total Billed charges,9.77,Pays at 102% of Medicare OPPS Rate,67.05,Pays at 90% of Total Billed charges,12.03,Pays at 100% of GA Medicaid Fee Schedule,9.58,Pays at 100% of Medicare OPPS Rate,12.03,Pays at 100% of GA Medicaid Fee Schedule,65.56,Pays at 88% of Total Billed charges,12.39,Pays at 103% of GA Medicaid Fee Schedule,9.58,67.05,44.70
Outpatient Medical Services,LAB,85613,"DRVVT, MIX  LUPUS ANTICOAG PROFIL (MAYO)",300,147,124.95,Pays at 85% of Billed charges for outpatient setting,12.03,Pays at 100% of GA Medicaid Fee Schedule,117.64,Pays at 80.03% of Total Billed charges,9.77,Pays at 102% of Medicare OPPS Rate,132.3,Pays at 90% of Total Billed charges,12.03,Pays at 100% of GA Medicaid Fee Schedule,9.58,Pays at 100% of Medicare OPPS Rate,12.03,Pays at 100% of GA Medicaid Fee Schedule,129.36,Pays at 88% of Total Billed charges,12.39,Pays at 103% of GA Medicaid Fee Schedule,9.58,132.3,88.20
Outpatient Medical Services,LAB,85613,"DRVVT, MIX  (MAYO)",300,300,255,Pays at 85% of Billed charges for outpatient setting,12.03,Pays at 100% of GA Medicaid Fee Schedule,240.09,Pays at 80.03% of Total Billed charges,9.77,Pays at 102% of Medicare OPPS Rate,270,Pays at 90% of Total Billed charges,12.03,Pays at 100% of GA Medicaid Fee Schedule,9.58,Pays at 100% of Medicare OPPS Rate,12.03,Pays at 100% of GA Medicaid Fee Schedule,264,Pays at 88% of Total Billed charges,12.39,Pays at 103% of GA Medicaid Fee Schedule,9.58,270,180.00
Outpatient Medical Services,LAB,85635,"REPTILASE, PLASMA  (MAYO)",300,89.75,76.29,Pays at 85% of Billed charges for outpatient setting,12.38,Pays at 100% of GA Medicaid Fee Schedule,71.83,Pays at 80.03% of Total Billed charges,10.04,Pays at 102% of Medicare OPPS Rate,80.78,Pays at 90% of Total Billed charges,12.38,Pays at 100% of GA Medicaid Fee Schedule,9.85,Pays at 100% of Medicare OPPS Rate,12.38,Pays at 100% of GA Medicaid Fee Schedule,78.98,Pays at 88% of Total Billed charges,12.75,Pays at 103% of GA Medicaid Fee Schedule,9.85,80.78,53.85
Outpatient Medical Services,LAB,85651,"SED RATE, WESTERGREN",300,47.56,40.43,Pays at 85% of Billed charges for outpatient setting,4.46,Pays at 100% of GA Medicaid Fee Schedule,38.06,Pays at 80.03% of Total Billed charges,4.35,Pays at 102% of Medicare OPPS Rate,42.8,Pays at 90% of Total Billed charges,4.46,Pays at 100% of GA Medicaid Fee Schedule,4.26,Pays at 100% of Medicare OPPS Rate,4.46,Pays at 100% of GA Medicaid Fee Schedule,41.85,Pays at 88% of Total Billed charges,4.59,Pays at 103% of GA Medicaid Fee Schedule,4.26,42.8,28.54
Outpatient Medical Services,LAB,85660,SICKLE CELL TEST,300,34.5,29.33,Pays at 85% of Billed charges for outpatient setting,6.94,Pays at 100% of GA Medicaid Fee Schedule,27.61,Pays at 80.03% of Total Billed charges,5.62,Pays at 102% of Medicare OPPS Rate,31.05,Pays at 90% of Total Billed charges,6.94,Pays at 100% of GA Medicaid Fee Schedule,5.51,Pays at 100% of Medicare OPPS Rate,6.94,Pays at 100% of GA Medicaid Fee Schedule,30.36,Pays at 88% of Total Billed charges,7.15,Pays at 103% of GA Medicaid Fee Schedule,5.51,31.05,20.70
Outpatient Medical Services,LAB,85660,SICKLE CELL SCREEN  (MAYO),300,79.5,67.58,Pays at 85% of Billed charges for outpatient setting,6.94,Pays at 100% of GA Medicaid Fee Schedule,63.62,Pays at 80.03% of Total Billed charges,5.62,Pays at 102% of Medicare OPPS Rate,71.55,Pays at 90% of Total Billed charges,6.94,Pays at 100% of GA Medicaid Fee Schedule,5.51,Pays at 100% of Medicare OPPS Rate,6.94,Pays at 100% of GA Medicaid Fee Schedule,69.96,Pays at 88% of Total Billed charges,7.15,Pays at 103% of GA Medicaid Fee Schedule,5.51,71.55,47.70
Outpatient Medical Services,LAB,85660,"HEMOGLOBIN - S SCREEN, BLOOD  (MAYO)",300,79.5,67.58,Pays at 85% of Billed charges for outpatient setting,6.94,Pays at 100% of GA Medicaid Fee Schedule,63.62,Pays at 80.03% of Total Billed charges,5.62,Pays at 102% of Medicare OPPS Rate,71.55,Pays at 90% of Total Billed charges,6.94,Pays at 100% of GA Medicaid Fee Schedule,5.51,Pays at 100% of Medicare OPPS Rate,6.94,Pays at 100% of GA Medicaid Fee Schedule,69.96,Pays at 88% of Total Billed charges,7.15,Pays at 103% of GA Medicaid Fee Schedule,5.51,71.55,47.70
Outpatient Medical Services,LAB,85670,THROMBIN TIME  (MAYO),300,75.5,64.18,Pays at 85% of Billed charges for outpatient setting,7.26,Pays at 100% of GA Medicaid Fee Schedule,60.42,Pays at 80.03% of Total Billed charges,5.88,Pays at 102% of Medicare OPPS Rate,67.95,Pays at 90% of Total Billed charges,7.26,Pays at 100% of GA Medicaid Fee Schedule,5.77,Pays at 100% of Medicare OPPS Rate,7.26,Pays at 100% of GA Medicaid Fee Schedule,66.44,Pays at 88% of Total Billed charges,7.48,Pays at 103% of GA Medicaid Fee Schedule,5.77,67.95,45.30
Outpatient Medical Services,LAB,85705,LUPUS ANTICOAGULANT PROFILE  (MAYO),300,65.25,55.46,Pays at 85% of Billed charges for outpatient setting,12.11,Pays at 100% of GA Medicaid Fee Schedule,52.22,Pays at 80.03% of Total Billed charges,9.82,Pays at 102% of Medicare OPPS Rate,58.73,Pays at 90% of Total Billed charges,12.11,Pays at 100% of GA Medicaid Fee Schedule,9.63,Pays at 100% of Medicare OPPS Rate,12.11,Pays at 100% of GA Medicaid Fee Schedule,57.42,Pays at 88% of Total Billed charges,12.47,Pays at 103% of GA Medicaid Fee Schedule,9.63,58.73,39.15
Outpatient Medical Services,LAB,85730,Coagulation assessment blood test,300,34.03,28.93,Pays at 85% of Billed charges for outpatient setting,7.54,Pays at 100% of GA Medicaid Fee Schedule,27.23,Pays at 80.03% of Total Billed charges,6.13,Pays at 102% of Medicare OPPS Rate,30.63,Pays at 90% of Total Billed charges,7.54,Pays at 100% of GA Medicaid Fee Schedule,6.01,Pays at 100% of Medicare OPPS Rate,7.54,Pays at 100% of GA Medicaid Fee Schedule,29.95,Pays at 88% of Total Billed charges,7.77,Pays at 103% of GA Medicaid Fee Schedule,6.01,30.63,20.42
Outpatient Medical Services,LAB,85730,Coagulation assessment blood test,300,41.5,35.28,Pays at 85% of Billed charges for outpatient setting,7.54,Pays at 100% of GA Medicaid Fee Schedule,33.21,Pays at 80.03% of Total Billed charges,6.13,Pays at 102% of Medicare OPPS Rate,37.35,Pays at 90% of Total Billed charges,7.54,Pays at 100% of GA Medicaid Fee Schedule,6.01,Pays at 100% of Medicare OPPS Rate,7.54,Pays at 100% of GA Medicaid Fee Schedule,36.52,Pays at 88% of Total Billed charges,7.77,Pays at 103% of GA Medicaid Fee Schedule,6.01,37.35,24.90
Outpatient Medical Services,LAB,85730,Coagulation assessment blood test,300,62.25,52.91,Pays at 85% of Billed charges for outpatient setting,7.54,Pays at 100% of GA Medicaid Fee Schedule,49.82,Pays at 80.03% of Total Billed charges,6.13,Pays at 102% of Medicare OPPS Rate,56.03,Pays at 90% of Total Billed charges,7.54,Pays at 100% of GA Medicaid Fee Schedule,6.01,Pays at 100% of Medicare OPPS Rate,7.54,Pays at 100% of GA Medicaid Fee Schedule,54.78,Pays at 88% of Total Billed charges,7.77,Pays at 103% of GA Medicaid Fee Schedule,6.01,56.03,37.35
Outpatient Medical Services,LAB,85730,Coagulation assessment blood test,300,90,76.5,Pays at 85% of Billed charges for outpatient setting,7.54,Pays at 100% of GA Medicaid Fee Schedule,72.03,Pays at 80.03% of Total Billed charges,6.13,Pays at 102% of Medicare OPPS Rate,81,Pays at 90% of Total Billed charges,7.54,Pays at 100% of GA Medicaid Fee Schedule,6.01,Pays at 100% of Medicare OPPS Rate,7.54,Pays at 100% of GA Medicaid Fee Schedule,79.2,Pays at 88% of Total Billed charges,7.77,Pays at 103% of GA Medicaid Fee Schedule,6.01,81,54.00
Outpatient Medical Services,LAB,85730,Coagulation assessment blood test,300,111.5,94.78,Pays at 85% of Billed charges for outpatient setting,7.54,Pays at 100% of GA Medicaid Fee Schedule,89.23,Pays at 80.03% of Total Billed charges,6.13,Pays at 102% of Medicare OPPS Rate,100.35,Pays at 90% of Total Billed charges,7.54,Pays at 100% of GA Medicaid Fee Schedule,6.01,Pays at 100% of Medicare OPPS Rate,7.54,Pays at 100% of GA Medicaid Fee Schedule,98.12,Pays at 88% of Total Billed charges,7.77,Pays at 103% of GA Medicaid Fee Schedule,6.01,100.35,66.90
Outpatient Medical Services,LAB,85732,APTT MIX 1:1 (MAYO),300,101.5,86.28,Pays at 85% of Billed charges for outpatient setting,8.14,Pays at 100% of GA Medicaid Fee Schedule,81.23,Pays at 80.03% of Total Billed charges,6.59,Pays at 102% of Medicare OPPS Rate,91.35,Pays at 90% of Total Billed charges,8.14,Pays at 100% of GA Medicaid Fee Schedule,6.47,Pays at 100% of Medicare OPPS Rate,8.14,Pays at 100% of GA Medicaid Fee Schedule,89.32,Pays at 88% of Total Billed charges,8.38,Pays at 103% of GA Medicaid Fee Schedule,6.47,91.35,60.90
Outpatient Medical Services,LAB,85732,COAGULATION CONSULT PROLONG CLOT MAYO,300,131.5,111.78,Pays at 85% of Billed charges for outpatient setting,8.14,Pays at 100% of GA Medicaid Fee Schedule,105.24,Pays at 80.03% of Total Billed charges,6.59,Pays at 102% of Medicare OPPS Rate,118.35,Pays at 90% of Total Billed charges,8.14,Pays at 100% of GA Medicaid Fee Schedule,6.47,Pays at 100% of Medicare OPPS Rate,8.14,Pays at 100% of GA Medicaid Fee Schedule,115.72,Pays at 88% of Total Billed charges,8.38,Pays at 103% of GA Medicaid Fee Schedule,6.47,118.35,78.90
Outpatient Medical Services,LAB,85810,"VISCOSITY, SERUM  (MAYO)",300,99.75,84.79,Pays at 85% of Billed charges for outpatient setting,14.69,Pays at 100% of GA Medicaid Fee Schedule,79.83,Pays at 80.03% of Total Billed charges,11.9,Pays at 102% of Medicare OPPS Rate,89.78,Pays at 90% of Total Billed charges,14.69,Pays at 100% of GA Medicaid Fee Schedule,11.67,Pays at 100% of Medicare OPPS Rate,14.69,Pays at 100% of GA Medicaid Fee Schedule,87.78,Pays at 88% of Total Billed charges,15.13,Pays at 103% of GA Medicaid Fee Schedule,11.67,89.78,59.85
Outpatient Medical Services,LAB,85999,RBC SEPERATION (TBC),300,122,103.7,Pays at 85% of Billed charges for outpatient setting,39.22,Pays at 32.15% of Total Billed charges,97.64,Pays at 80.03% of Total Billed charges,NA,Not Applicable,109.8,Pays at 90% of Total Billed charges,39.22,Pays at 32.15% of Total Billed charges,NA,Not Applicable,39.22,Pays at 32.15% of Total Billed charges,107.36,Pays at 88% of Total Billed charges,40.39,Pays at 33.11% of Total Billed charges,39.22,109.8,73.20
Outpatient Medical Services,LAB,85999,"EOSINOPHILS, U EOSU1  (MAYO)",300,190.25,161.71,Pays at 85% of Billed charges for outpatient setting,61.17,Pays at 32.15% of Total Billed charges,152.26,Pays at 80.03% of Total Billed charges,NA,Not Applicable,171.23,Pays at 90% of Total Billed charges,61.17,Pays at 32.15% of Total Billed charges,NA,Not Applicable,61.17,Pays at 32.15% of Total Billed charges,167.42,Pays at 88% of Total Billed charges,62.99,Pays at 33.11% of Total Billed charges,61.17,171.23,114.15
Outpatient Medical Services,LAB,86000,"FRANCISELLA TULARENSIS AB, SERUM  (MAYO)",300,104.75,89.04,Pays at 85% of Billed charges for outpatient setting,8.78,Pays at 100% of GA Medicaid Fee Schedule,83.83,Pays at 80.03% of Total Billed charges,7.11,Pays at 102% of Medicare OPPS Rate,94.28,Pays at 90% of Total Billed charges,8.78,Pays at 100% of GA Medicaid Fee Schedule,6.98,Pays at 100% of Medicare OPPS Rate,8.78,Pays at 100% of GA Medicaid Fee Schedule,92.18,Pays at 88% of Total Billed charges,9.04,Pays at 103% of GA Medicaid Fee Schedule,6.98,94.28,62.85
Outpatient Medical Services,LAB,86003,"RAST, FIRE ANTS, IGE  (MAYO)",300,12.75,10.84,Pays at 85% of Billed charges for outpatient setting,6.57,Pays at 100% of GA Medicaid Fee Schedule,10.2,Pays at 80.03% of Total Billed charges,5.32,Pays at 102% of Medicare OPPS Rate,11.48,Pays at 90% of Total Billed charges,6.57,Pays at 100% of GA Medicaid Fee Schedule,5.22,Pays at 100% of Medicare OPPS Rate,6.57,Pays at 100% of GA Medicaid Fee Schedule,11.22,Pays at 88% of Total Billed charges,6.77,Pays at 103% of GA Medicaid Fee Schedule,5.22,11.48,7.65
Outpatient Medical Services,LAB,86003,ALTERNARIA TENUIS IGE (MAYO),300,15.5,13.18,Pays at 85% of Billed charges for outpatient setting,6.57,Pays at 100% of GA Medicaid Fee Schedule,12.4,Pays at 80.03% of Total Billed charges,5.32,Pays at 102% of Medicare OPPS Rate,13.95,Pays at 90% of Total Billed charges,6.57,Pays at 100% of GA Medicaid Fee Schedule,5.22,Pays at 100% of Medicare OPPS Rate,6.57,Pays at 100% of GA Medicaid Fee Schedule,13.64,Pays at 88% of Total Billed charges,6.77,Pays at 103% of GA Medicaid Fee Schedule,5.22,13.95,9.30
Outpatient Medical Services,LAB,86003,ASPERGILLUS FUMIGATUS IGE (MAYO),300,15.5,13.18,Pays at 85% of Billed charges for outpatient setting,6.57,Pays at 100% of GA Medicaid Fee Schedule,12.4,Pays at 80.03% of Total Billed charges,5.32,Pays at 102% of Medicare OPPS Rate,13.95,Pays at 90% of Total Billed charges,6.57,Pays at 100% of GA Medicaid Fee Schedule,5.22,Pays at 100% of Medicare OPPS Rate,6.57,Pays at 100% of GA Medicaid Fee Schedule,13.64,Pays at 88% of Total Billed charges,6.77,Pays at 103% of GA Medicaid Fee Schedule,5.22,13.95,9.30
Outpatient Medical Services,LAB,86003,CAT EPITHELIUM IGE (MAYO),300,15.5,13.18,Pays at 85% of Billed charges for outpatient setting,6.57,Pays at 100% of GA Medicaid Fee Schedule,12.4,Pays at 80.03% of Total Billed charges,5.32,Pays at 102% of Medicare OPPS Rate,13.95,Pays at 90% of Total Billed charges,6.57,Pays at 100% of GA Medicaid Fee Schedule,5.22,Pays at 100% of Medicare OPPS Rate,6.57,Pays at 100% of GA Medicaid Fee Schedule,13.64,Pays at 88% of Total Billed charges,6.77,Pays at 103% of GA Medicaid Fee Schedule,5.22,13.95,9.30
Outpatient Medical Services,LAB,86003,CLADOSPORIUM IGE (MAYO),300,15.5,13.18,Pays at 85% of Billed charges for outpatient setting,6.57,Pays at 100% of GA Medicaid Fee Schedule,12.4,Pays at 80.03% of Total Billed charges,5.32,Pays at 102% of Medicare OPPS Rate,13.95,Pays at 90% of Total Billed charges,6.57,Pays at 100% of GA Medicaid Fee Schedule,5.22,Pays at 100% of Medicare OPPS Rate,6.57,Pays at 100% of GA Medicaid Fee Schedule,13.64,Pays at 88% of Total Billed charges,6.77,Pays at 103% of GA Medicaid Fee Schedule,5.22,13.95,9.30
Outpatient Medical Services,LAB,86003,HOUSE DUST MITES D.F. IGE (MAYO),300,15.5,13.18,Pays at 85% of Billed charges for outpatient setting,6.57,Pays at 100% of GA Medicaid Fee Schedule,12.4,Pays at 80.03% of Total Billed charges,5.32,Pays at 102% of Medicare OPPS Rate,13.95,Pays at 90% of Total Billed charges,6.57,Pays at 100% of GA Medicaid Fee Schedule,5.22,Pays at 100% of Medicare OPPS Rate,6.57,Pays at 100% of GA Medicaid Fee Schedule,13.64,Pays at 88% of Total Billed charges,6.77,Pays at 103% of GA Medicaid Fee Schedule,5.22,13.95,9.30
Outpatient Medical Services,LAB,86003,DOG DANDER IGE (MAYO),300,15.5,13.18,Pays at 85% of Billed charges for outpatient setting,6.57,Pays at 100% of GA Medicaid Fee Schedule,12.4,Pays at 80.03% of Total Billed charges,5.32,Pays at 102% of Medicare OPPS Rate,13.95,Pays at 90% of Total Billed charges,6.57,Pays at 100% of GA Medicaid Fee Schedule,5.22,Pays at 100% of Medicare OPPS Rate,6.57,Pays at 100% of GA Medicaid Fee Schedule,13.64,Pays at 88% of Total Billed charges,6.77,Pays at 103% of GA Medicaid Fee Schedule,5.22,13.95,9.30
Outpatient Medical Services,LAB,86003,HOUSE DUST MITES D.P. IGE (MAYO),300,15.5,13.18,Pays at 85% of Billed charges for outpatient setting,6.57,Pays at 100% of GA Medicaid Fee Schedule,12.4,Pays at 80.03% of Total Billed charges,5.32,Pays at 102% of Medicare OPPS Rate,13.95,Pays at 90% of Total Billed charges,6.57,Pays at 100% of GA Medicaid Fee Schedule,5.22,Pays at 100% of Medicare OPPS Rate,6.57,Pays at 100% of GA Medicaid Fee Schedule,13.64,Pays at 88% of Total Billed charges,6.77,Pays at 103% of GA Medicaid Fee Schedule,5.22,13.95,9.30
Outpatient Medical Services,LAB,86003,HOUSE DUST GREER LAB IGE (MAYO),300,15.5,13.18,Pays at 85% of Billed charges for outpatient setting,6.57,Pays at 100% of GA Medicaid Fee Schedule,12.4,Pays at 80.03% of Total Billed charges,5.32,Pays at 102% of Medicare OPPS Rate,13.95,Pays at 90% of Total Billed charges,6.57,Pays at 100% of GA Medicaid Fee Schedule,5.22,Pays at 100% of Medicare OPPS Rate,6.57,Pays at 100% of GA Medicaid Fee Schedule,13.64,Pays at 88% of Total Billed charges,6.77,Pays at 103% of GA Medicaid Fee Schedule,5.22,13.95,9.30
Outpatient Medical Services,LAB,86003,HOUSE DUST H S LAB IGE (MAYO),300,15.5,13.18,Pays at 85% of Billed charges for outpatient setting,6.57,Pays at 100% of GA Medicaid Fee Schedule,12.4,Pays at 80.03% of Total Billed charges,5.32,Pays at 102% of Medicare OPPS Rate,13.95,Pays at 90% of Total Billed charges,6.57,Pays at 100% of GA Medicaid Fee Schedule,5.22,Pays at 100% of Medicare OPPS Rate,6.57,Pays at 100% of GA Medicaid Fee Schedule,13.64,Pays at 88% of Total Billed charges,6.77,Pays at 103% of GA Medicaid Fee Schedule,5.22,13.95,9.30
Outpatient Medical Services,LAB,86003,PENICILLIUM IGE (MAYO),300,15.5,13.18,Pays at 85% of Billed charges for outpatient setting,6.57,Pays at 100% of GA Medicaid Fee Schedule,12.4,Pays at 80.03% of Total Billed charges,5.32,Pays at 102% of Medicare OPPS Rate,13.95,Pays at 90% of Total Billed charges,6.57,Pays at 100% of GA Medicaid Fee Schedule,5.22,Pays at 100% of Medicare OPPS Rate,6.57,Pays at 100% of GA Medicaid Fee Schedule,13.64,Pays at 88% of Total Billed charges,6.77,Pays at 103% of GA Medicaid Fee Schedule,5.22,13.95,9.30
Outpatient Medical Services,LAB,86003,SILVER BIRCH IGE SILVER BIRCH IGE (MAYO),300,15.5,13.18,Pays at 85% of Billed charges for outpatient setting,6.57,Pays at 100% of GA Medicaid Fee Schedule,12.4,Pays at 80.03% of Total Billed charges,5.32,Pays at 102% of Medicare OPPS Rate,13.95,Pays at 90% of Total Billed charges,6.57,Pays at 100% of GA Medicaid Fee Schedule,5.22,Pays at 100% of Medicare OPPS Rate,6.57,Pays at 100% of GA Medicaid Fee Schedule,13.64,Pays at 88% of Total Billed charges,6.77,Pays at 103% of GA Medicaid Fee Schedule,5.22,13.95,9.30
Outpatient Medical Services,LAB,86003,"BOX ELD/MAPLE, S IGE (MAYO)",300,15.5,13.18,Pays at 85% of Billed charges for outpatient setting,6.57,Pays at 100% of GA Medicaid Fee Schedule,12.4,Pays at 80.03% of Total Billed charges,5.32,Pays at 102% of Medicare OPPS Rate,13.95,Pays at 90% of Total Billed charges,6.57,Pays at 100% of GA Medicaid Fee Schedule,5.22,Pays at 100% of Medicare OPPS Rate,6.57,Pays at 100% of GA Medicaid Fee Schedule,13.64,Pays at 88% of Total Billed charges,6.77,Pays at 103% of GA Medicaid Fee Schedule,5.22,13.95,9.30
Outpatient Medical Services,LAB,86003,ENGLISH PLANTAIN IGE (MAYO),300,15.5,13.18,Pays at 85% of Billed charges for outpatient setting,6.57,Pays at 100% of GA Medicaid Fee Schedule,12.4,Pays at 80.03% of Total Billed charges,5.32,Pays at 102% of Medicare OPPS Rate,13.95,Pays at 90% of Total Billed charges,6.57,Pays at 100% of GA Medicaid Fee Schedule,5.22,Pays at 100% of Medicare OPPS Rate,6.57,Pays at 100% of GA Medicaid Fee Schedule,13.64,Pays at 88% of Total Billed charges,6.77,Pays at 103% of GA Medicaid Fee Schedule,5.22,13.95,9.30
Outpatient Medical Services,LAB,86003,ELM IGE (MAYO),300,15.5,13.18,Pays at 85% of Billed charges for outpatient setting,6.57,Pays at 100% of GA Medicaid Fee Schedule,12.4,Pays at 80.03% of Total Billed charges,5.32,Pays at 102% of Medicare OPPS Rate,13.95,Pays at 90% of Total Billed charges,6.57,Pays at 100% of GA Medicaid Fee Schedule,5.22,Pays at 100% of Medicare OPPS Rate,6.57,Pays at 100% of GA Medicaid Fee Schedule,13.64,Pays at 88% of Total Billed charges,6.77,Pays at 103% of GA Medicaid Fee Schedule,5.22,13.95,9.30
Outpatient Medical Services,LAB,86003,JUNE GRASS IGE (MAYO),300,15.5,13.18,Pays at 85% of Billed charges for outpatient setting,6.57,Pays at 100% of GA Medicaid Fee Schedule,12.4,Pays at 80.03% of Total Billed charges,5.32,Pays at 102% of Medicare OPPS Rate,13.95,Pays at 90% of Total Billed charges,6.57,Pays at 100% of GA Medicaid Fee Schedule,5.22,Pays at 100% of Medicare OPPS Rate,6.57,Pays at 100% of GA Medicaid Fee Schedule,13.64,Pays at 88% of Total Billed charges,6.77,Pays at 103% of GA Medicaid Fee Schedule,5.22,13.95,9.30
Outpatient Medical Services,LAB,86003,LAMBS QUARTER IGE (MAYO),300,15.5,13.18,Pays at 85% of Billed charges for outpatient setting,6.57,Pays at 100% of GA Medicaid Fee Schedule,12.4,Pays at 80.03% of Total Billed charges,5.32,Pays at 102% of Medicare OPPS Rate,13.95,Pays at 90% of Total Billed charges,6.57,Pays at 100% of GA Medicaid Fee Schedule,5.22,Pays at 100% of Medicare OPPS Rate,6.57,Pays at 100% of GA Medicaid Fee Schedule,13.64,Pays at 88% of Total Billed charges,6.77,Pays at 103% of GA Medicaid Fee Schedule,5.22,13.95,9.30
Outpatient Medical Services,LAB,86003,OAK IGE (MAYO),300,15.5,13.18,Pays at 85% of Billed charges for outpatient setting,6.57,Pays at 100% of GA Medicaid Fee Schedule,12.4,Pays at 80.03% of Total Billed charges,5.32,Pays at 102% of Medicare OPPS Rate,13.95,Pays at 90% of Total Billed charges,6.57,Pays at 100% of GA Medicaid Fee Schedule,5.22,Pays at 100% of Medicare OPPS Rate,6.57,Pays at 100% of GA Medicaid Fee Schedule,13.64,Pays at 88% of Total Billed charges,6.77,Pays at 103% of GA Medicaid Fee Schedule,5.22,13.95,9.30
Outpatient Medical Services,LAB,86003,RYE GRASS (MAYO),300,15.5,13.18,Pays at 85% of Billed charges for outpatient setting,6.57,Pays at 100% of GA Medicaid Fee Schedule,12.4,Pays at 80.03% of Total Billed charges,5.32,Pays at 102% of Medicare OPPS Rate,13.95,Pays at 90% of Total Billed charges,6.57,Pays at 100% of GA Medicaid Fee Schedule,5.22,Pays at 100% of Medicare OPPS Rate,6.57,Pays at 100% of GA Medicaid Fee Schedule,13.64,Pays at 88% of Total Billed charges,6.77,Pays at 103% of GA Medicaid Fee Schedule,5.22,13.95,9.30
Outpatient Medical Services,LAB,86003,SHORT RAGWEED IGE (MAYO),300,15.5,13.18,Pays at 85% of Billed charges for outpatient setting,6.57,Pays at 100% of GA Medicaid Fee Schedule,12.4,Pays at 80.03% of Total Billed charges,5.32,Pays at 102% of Medicare OPPS Rate,13.95,Pays at 90% of Total Billed charges,6.57,Pays at 100% of GA Medicaid Fee Schedule,5.22,Pays at 100% of Medicare OPPS Rate,6.57,Pays at 100% of GA Medicaid Fee Schedule,13.64,Pays at 88% of Total Billed charges,6.77,Pays at 103% of GA Medicaid Fee Schedule,5.22,13.95,9.30
Outpatient Medical Services,LAB,86003,TIMOTHY GRASS IGE (MAYO),300,15.5,13.18,Pays at 85% of Billed charges for outpatient setting,6.57,Pays at 100% of GA Medicaid Fee Schedule,12.4,Pays at 80.03% of Total Billed charges,5.32,Pays at 102% of Medicare OPPS Rate,13.95,Pays at 90% of Total Billed charges,6.57,Pays at 100% of GA Medicaid Fee Schedule,5.22,Pays at 100% of Medicare OPPS Rate,6.57,Pays at 100% of GA Medicaid Fee Schedule,13.64,Pays at 88% of Total Billed charges,6.77,Pays at 103% of GA Medicaid Fee Schedule,5.22,13.95,9.30
Outpatient Medical Services,LAB,86003,"MOUNTAIN CEDAR, IGE (MAYO)",300,15.5,13.18,Pays at 85% of Billed charges for outpatient setting,6.57,Pays at 100% of GA Medicaid Fee Schedule,12.4,Pays at 80.03% of Total Billed charges,5.32,Pays at 102% of Medicare OPPS Rate,13.95,Pays at 90% of Total Billed charges,6.57,Pays at 100% of GA Medicaid Fee Schedule,5.22,Pays at 100% of Medicare OPPS Rate,6.57,Pays at 100% of GA Medicaid Fee Schedule,13.64,Pays at 88% of Total Billed charges,6.77,Pays at 103% of GA Medicaid Fee Schedule,5.22,13.95,9.30
Outpatient Medical Services,LAB,86003,"COCKROACH, IGE (MAYO)",300,15.5,13.18,Pays at 85% of Billed charges for outpatient setting,6.57,Pays at 100% of GA Medicaid Fee Schedule,12.4,Pays at 80.03% of Total Billed charges,5.32,Pays at 102% of Medicare OPPS Rate,13.95,Pays at 90% of Total Billed charges,6.57,Pays at 100% of GA Medicaid Fee Schedule,5.22,Pays at 100% of Medicare OPPS Rate,6.57,Pays at 100% of GA Medicaid Fee Schedule,13.64,Pays at 88% of Total Billed charges,6.77,Pays at 103% of GA Medicaid Fee Schedule,5.22,13.95,9.30
Outpatient Medical Services,LAB,86003,"BAHIA GRASS, IGE (MAYO)",300,15.5,13.18,Pays at 85% of Billed charges for outpatient setting,6.57,Pays at 100% of GA Medicaid Fee Schedule,12.4,Pays at 80.03% of Total Billed charges,5.32,Pays at 102% of Medicare OPPS Rate,13.95,Pays at 90% of Total Billed charges,6.57,Pays at 100% of GA Medicaid Fee Schedule,5.22,Pays at 100% of Medicare OPPS Rate,6.57,Pays at 100% of GA Medicaid Fee Schedule,13.64,Pays at 88% of Total Billed charges,6.77,Pays at 103% of GA Medicaid Fee Schedule,5.22,13.95,9.30
Outpatient Medical Services,LAB,86003,"ROUGH PIGWEED, IGE (MAYO)",300,15.5,13.18,Pays at 85% of Billed charges for outpatient setting,6.57,Pays at 100% of GA Medicaid Fee Schedule,12.4,Pays at 80.03% of Total Billed charges,5.32,Pays at 102% of Medicare OPPS Rate,13.95,Pays at 90% of Total Billed charges,6.57,Pays at 100% of GA Medicaid Fee Schedule,5.22,Pays at 100% of Medicare OPPS Rate,6.57,Pays at 100% of GA Medicaid Fee Schedule,13.64,Pays at 88% of Total Billed charges,6.77,Pays at 103% of GA Medicaid Fee Schedule,5.22,13.95,9.30
Outpatient Medical Services,LAB,86003,"NETTLE, IGE (MAYO)",300,15.5,13.18,Pays at 85% of Billed charges for outpatient setting,6.57,Pays at 100% of GA Medicaid Fee Schedule,12.4,Pays at 80.03% of Total Billed charges,5.32,Pays at 102% of Medicare OPPS Rate,13.95,Pays at 90% of Total Billed charges,6.57,Pays at 100% of GA Medicaid Fee Schedule,5.22,Pays at 100% of Medicare OPPS Rate,6.57,Pays at 100% of GA Medicaid Fee Schedule,13.64,Pays at 88% of Total Billed charges,6.77,Pays at 103% of GA Medicaid Fee Schedule,5.22,13.95,9.30
Outpatient Medical Services,LAB,86003,"RED SORREL, IGE (MAYO)",300,15.5,13.18,Pays at 85% of Billed charges for outpatient setting,6.57,Pays at 100% of GA Medicaid Fee Schedule,12.4,Pays at 80.03% of Total Billed charges,5.32,Pays at 102% of Medicare OPPS Rate,13.95,Pays at 90% of Total Billed charges,6.57,Pays at 100% of GA Medicaid Fee Schedule,5.22,Pays at 100% of Medicare OPPS Rate,6.57,Pays at 100% of GA Medicaid Fee Schedule,13.64,Pays at 88% of Total Billed charges,6.77,Pays at 103% of GA Medicaid Fee Schedule,5.22,13.95,9.30
Outpatient Medical Services,LAB,86003,"BERMUDA GRASS, IGE (MAYO)",300,15.5,13.18,Pays at 85% of Billed charges for outpatient setting,6.57,Pays at 100% of GA Medicaid Fee Schedule,12.4,Pays at 80.03% of Total Billed charges,5.32,Pays at 102% of Medicare OPPS Rate,13.95,Pays at 90% of Total Billed charges,6.57,Pays at 100% of GA Medicaid Fee Schedule,5.22,Pays at 100% of Medicare OPPS Rate,6.57,Pays at 100% of GA Medicaid Fee Schedule,13.64,Pays at 88% of Total Billed charges,6.77,Pays at 103% of GA Medicaid Fee Schedule,5.22,13.95,9.30
Outpatient Medical Services,LAB,86003,"PECAN HICKORY, IGE (MAYO)",300,15.5,13.18,Pays at 85% of Billed charges for outpatient setting,6.57,Pays at 100% of GA Medicaid Fee Schedule,12.4,Pays at 80.03% of Total Billed charges,5.32,Pays at 102% of Medicare OPPS Rate,13.95,Pays at 90% of Total Billed charges,6.57,Pays at 100% of GA Medicaid Fee Schedule,5.22,Pays at 100% of Medicare OPPS Rate,6.57,Pays at 100% of GA Medicaid Fee Schedule,13.64,Pays at 88% of Total Billed charges,6.77,Pays at 103% of GA Medicaid Fee Schedule,5.22,13.95,9.30
Outpatient Medical Services,LAB,86003,"EGG WHITE, IGE (MAYO)",300,16.5,14.03,Pays at 85% of Billed charges for outpatient setting,6.57,Pays at 100% of GA Medicaid Fee Schedule,13.2,Pays at 80.03% of Total Billed charges,5.32,Pays at 102% of Medicare OPPS Rate,14.85,Pays at 90% of Total Billed charges,6.57,Pays at 100% of GA Medicaid Fee Schedule,5.22,Pays at 100% of Medicare OPPS Rate,6.57,Pays at 100% of GA Medicaid Fee Schedule,14.52,Pays at 88% of Total Billed charges,6.77,Pays at 103% of GA Medicaid Fee Schedule,5.22,14.85,9.90
Outpatient Medical Services,LAB,86003,"MILK, IGE (MAYO)",300,16.5,14.03,Pays at 85% of Billed charges for outpatient setting,6.57,Pays at 100% of GA Medicaid Fee Schedule,13.2,Pays at 80.03% of Total Billed charges,5.32,Pays at 102% of Medicare OPPS Rate,14.85,Pays at 90% of Total Billed charges,6.57,Pays at 100% of GA Medicaid Fee Schedule,5.22,Pays at 100% of Medicare OPPS Rate,6.57,Pays at 100% of GA Medicaid Fee Schedule,14.52,Pays at 88% of Total Billed charges,6.77,Pays at 103% of GA Medicaid Fee Schedule,5.22,14.85,9.90
Outpatient Medical Services,LAB,86003,"OAT, IGE (MAYO)",300,16.5,14.03,Pays at 85% of Billed charges for outpatient setting,6.57,Pays at 100% of GA Medicaid Fee Schedule,13.2,Pays at 80.03% of Total Billed charges,5.32,Pays at 102% of Medicare OPPS Rate,14.85,Pays at 90% of Total Billed charges,6.57,Pays at 100% of GA Medicaid Fee Schedule,5.22,Pays at 100% of Medicare OPPS Rate,6.57,Pays at 100% of GA Medicaid Fee Schedule,14.52,Pays at 88% of Total Billed charges,6.77,Pays at 103% of GA Medicaid Fee Schedule,5.22,14.85,9.90
Outpatient Medical Services,LAB,86003,"SOYBEAN, IGE (MAYO)",300,16.5,14.03,Pays at 85% of Billed charges for outpatient setting,6.57,Pays at 100% of GA Medicaid Fee Schedule,13.2,Pays at 80.03% of Total Billed charges,5.32,Pays at 102% of Medicare OPPS Rate,14.85,Pays at 90% of Total Billed charges,6.57,Pays at 100% of GA Medicaid Fee Schedule,5.22,Pays at 100% of Medicare OPPS Rate,6.57,Pays at 100% of GA Medicaid Fee Schedule,14.52,Pays at 88% of Total Billed charges,6.77,Pays at 103% of GA Medicaid Fee Schedule,5.22,14.85,9.90
Outpatient Medical Services,LAB,86003,"WHEAT, IGE (MAYO)",300,16.5,14.03,Pays at 85% of Billed charges for outpatient setting,6.57,Pays at 100% of GA Medicaid Fee Schedule,13.2,Pays at 80.03% of Total Billed charges,5.32,Pays at 102% of Medicare OPPS Rate,14.85,Pays at 90% of Total Billed charges,6.57,Pays at 100% of GA Medicaid Fee Schedule,5.22,Pays at 100% of Medicare OPPS Rate,6.57,Pays at 100% of GA Medicaid Fee Schedule,14.52,Pays at 88% of Total Billed charges,6.77,Pays at 103% of GA Medicaid Fee Schedule,5.22,14.85,9.90
Outpatient Medical Services,LAB,86003,HONEY BEE ALLERGAN  (MAYO),300,17.25,14.66,Pays at 85% of Billed charges for outpatient setting,6.57,Pays at 100% of GA Medicaid Fee Schedule,13.81,Pays at 80.03% of Total Billed charges,5.32,Pays at 102% of Medicare OPPS Rate,15.53,Pays at 90% of Total Billed charges,6.57,Pays at 100% of GA Medicaid Fee Schedule,5.22,Pays at 100% of Medicare OPPS Rate,6.57,Pays at 100% of GA Medicaid Fee Schedule,15.18,Pays at 88% of Total Billed charges,6.77,Pays at 103% of GA Medicaid Fee Schedule,5.22,15.53,10.35
Outpatient Medical Services,LAB,86003,WHITE FACED HORNET ALLERGAN  (MAYO),300,17.25,14.66,Pays at 85% of Billed charges for outpatient setting,6.57,Pays at 100% of GA Medicaid Fee Schedule,13.81,Pays at 80.03% of Total Billed charges,5.32,Pays at 102% of Medicare OPPS Rate,15.53,Pays at 90% of Total Billed charges,6.57,Pays at 100% of GA Medicaid Fee Schedule,5.22,Pays at 100% of Medicare OPPS Rate,6.57,Pays at 100% of GA Medicaid Fee Schedule,15.18,Pays at 88% of Total Billed charges,6.77,Pays at 103% of GA Medicaid Fee Schedule,5.22,15.53,10.35
Outpatient Medical Services,LAB,86003,YELLOW HORNET ALLERGAN  (MAYO),300,17.25,14.66,Pays at 85% of Billed charges for outpatient setting,6.57,Pays at 100% of GA Medicaid Fee Schedule,13.81,Pays at 80.03% of Total Billed charges,5.32,Pays at 102% of Medicare OPPS Rate,15.53,Pays at 90% of Total Billed charges,6.57,Pays at 100% of GA Medicaid Fee Schedule,5.22,Pays at 100% of Medicare OPPS Rate,6.57,Pays at 100% of GA Medicaid Fee Schedule,15.18,Pays at 88% of Total Billed charges,6.77,Pays at 103% of GA Medicaid Fee Schedule,5.22,15.53,10.35
Outpatient Medical Services,LAB,86003,WASP ALLERGAN  (MAYO),300,17.25,14.66,Pays at 85% of Billed charges for outpatient setting,6.57,Pays at 100% of GA Medicaid Fee Schedule,13.81,Pays at 80.03% of Total Billed charges,5.32,Pays at 102% of Medicare OPPS Rate,15.53,Pays at 90% of Total Billed charges,6.57,Pays at 100% of GA Medicaid Fee Schedule,5.22,Pays at 100% of Medicare OPPS Rate,6.57,Pays at 100% of GA Medicaid Fee Schedule,15.18,Pays at 88% of Total Billed charges,6.77,Pays at 103% of GA Medicaid Fee Schedule,5.22,15.53,10.35
Outpatient Medical Services,LAB,86003,YELLOW JACKET ALLERGAN  (MAYO),300,17.25,14.66,Pays at 85% of Billed charges for outpatient setting,6.57,Pays at 100% of GA Medicaid Fee Schedule,13.81,Pays at 80.03% of Total Billed charges,5.32,Pays at 102% of Medicare OPPS Rate,15.53,Pays at 90% of Total Billed charges,6.57,Pays at 100% of GA Medicaid Fee Schedule,5.22,Pays at 100% of Medicare OPPS Rate,6.57,Pays at 100% of GA Medicaid Fee Schedule,15.18,Pays at 88% of Total Billed charges,6.77,Pays at 103% of GA Medicaid Fee Schedule,5.22,15.53,10.35
Outpatient Medical Services,LAB,86003,KIWI IGE ALLERGEN   (MAYO),300,17.75,15.09,Pays at 85% of Billed charges for outpatient setting,6.57,Pays at 100% of GA Medicaid Fee Schedule,14.21,Pays at 80.03% of Total Billed charges,5.32,Pays at 102% of Medicare OPPS Rate,15.98,Pays at 90% of Total Billed charges,6.57,Pays at 100% of GA Medicaid Fee Schedule,5.22,Pays at 100% of Medicare OPPS Rate,6.57,Pays at 100% of GA Medicaid Fee Schedule,15.62,Pays at 88% of Total Billed charges,6.77,Pays at 103% of GA Medicaid Fee Schedule,5.22,15.98,10.65
Outpatient Medical Services,LAB,86003,PINEAPPLE IGE ALLERGEN   (MAYO),300,18,15.3,Pays at 85% of Billed charges for outpatient setting,6.57,Pays at 100% of GA Medicaid Fee Schedule,14.41,Pays at 80.03% of Total Billed charges,5.32,Pays at 102% of Medicare OPPS Rate,16.2,Pays at 90% of Total Billed charges,6.57,Pays at 100% of GA Medicaid Fee Schedule,5.22,Pays at 100% of Medicare OPPS Rate,6.57,Pays at 100% of GA Medicaid Fee Schedule,15.84,Pays at 88% of Total Billed charges,6.77,Pays at 103% of GA Medicaid Fee Schedule,5.22,16.2,10.80
Outpatient Medical Services,LAB,86003,"PENICILLIN G, IGE  (MAYO)",300,21.5,18.28,Pays at 85% of Billed charges for outpatient setting,6.57,Pays at 100% of GA Medicaid Fee Schedule,17.21,Pays at 80.03% of Total Billed charges,5.32,Pays at 102% of Medicare OPPS Rate,19.35,Pays at 90% of Total Billed charges,6.57,Pays at 100% of GA Medicaid Fee Schedule,5.22,Pays at 100% of Medicare OPPS Rate,6.57,Pays at 100% of GA Medicaid Fee Schedule,18.92,Pays at 88% of Total Billed charges,6.77,Pays at 103% of GA Medicaid Fee Schedule,5.22,19.35,12.90
Outpatient Medical Services,LAB,86003,"WHEAT ALLERGAN, IGE  (MAYO)",300,21.5,18.28,Pays at 85% of Billed charges for outpatient setting,6.57,Pays at 100% of GA Medicaid Fee Schedule,17.21,Pays at 80.03% of Total Billed charges,5.32,Pays at 102% of Medicare OPPS Rate,19.35,Pays at 90% of Total Billed charges,6.57,Pays at 100% of GA Medicaid Fee Schedule,5.22,Pays at 100% of Medicare OPPS Rate,6.57,Pays at 100% of GA Medicaid Fee Schedule,18.92,Pays at 88% of Total Billed charges,6.77,Pays at 103% of GA Medicaid Fee Schedule,5.22,19.35,12.90
Outpatient Medical Services,LAB,86003,CHOCOLATE ALLERGAN IGE  (MAYO),300,21.5,18.28,Pays at 85% of Billed charges for outpatient setting,6.57,Pays at 100% of GA Medicaid Fee Schedule,17.21,Pays at 80.03% of Total Billed charges,5.32,Pays at 102% of Medicare OPPS Rate,19.35,Pays at 90% of Total Billed charges,6.57,Pays at 100% of GA Medicaid Fee Schedule,5.22,Pays at 100% of Medicare OPPS Rate,6.57,Pays at 100% of GA Medicaid Fee Schedule,18.92,Pays at 88% of Total Billed charges,6.77,Pays at 103% of GA Medicaid Fee Schedule,5.22,19.35,12.90
Outpatient Medical Services,LAB,86003,"RAST, INSULIN ALLERGY PORK,HUMAN, BOVINE",300,38.25,32.51,Pays at 85% of Billed charges for outpatient setting,6.57,Pays at 100% of GA Medicaid Fee Schedule,30.61,Pays at 80.03% of Total Billed charges,5.32,Pays at 102% of Medicare OPPS Rate,34.43,Pays at 90% of Total Billed charges,6.57,Pays at 100% of GA Medicaid Fee Schedule,5.22,Pays at 100% of Medicare OPPS Rate,6.57,Pays at 100% of GA Medicaid Fee Schedule,33.66,Pays at 88% of Total Billed charges,6.77,Pays at 103% of GA Medicaid Fee Schedule,5.22,34.43,22.95
Outpatient Medical Services,LAB,86003,GRASS #2 ALLERGANS IGE  (MAYO),300,56.5,48.03,Pays at 85% of Billed charges for outpatient setting,6.57,Pays at 100% of GA Medicaid Fee Schedule,45.22,Pays at 80.03% of Total Billed charges,5.32,Pays at 102% of Medicare OPPS Rate,50.85,Pays at 90% of Total Billed charges,6.57,Pays at 100% of GA Medicaid Fee Schedule,5.22,Pays at 100% of Medicare OPPS Rate,6.57,Pays at 100% of GA Medicaid Fee Schedule,49.72,Pays at 88% of Total Billed charges,6.77,Pays at 103% of GA Medicaid Fee Schedule,5.22,50.85,33.90
Outpatient Medical Services,LAB,86003,"FOOD ALLERGEN PANEL 6, (MAYO)",300,82.78,70.36,Pays at 85% of Billed charges for outpatient setting,6.57,Pays at 100% of GA Medicaid Fee Schedule,66.25,Pays at 80.03% of Total Billed charges,5.32,Pays at 102% of Medicare OPPS Rate,74.5,Pays at 90% of Total Billed charges,6.57,Pays at 100% of GA Medicaid Fee Schedule,5.22,Pays at 100% of Medicare OPPS Rate,6.57,Pays at 100% of GA Medicaid Fee Schedule,72.85,Pays at 88% of Total Billed charges,6.77,Pays at 103% of GA Medicaid Fee Schedule,5.22,74.5,49.67
Outpatient Medical Services,LAB,86003,FOOD NUT #1  (MAYO),300,178.28,151.54,Pays at 85% of Billed charges for outpatient setting,6.57,Pays at 100% of GA Medicaid Fee Schedule,142.68,Pays at 80.03% of Total Billed charges,5.32,Pays at 102% of Medicare OPPS Rate,160.45,Pays at 90% of Total Billed charges,6.57,Pays at 100% of GA Medicaid Fee Schedule,5.22,Pays at 100% of Medicare OPPS Rate,6.57,Pays at 100% of GA Medicaid Fee Schedule,156.89,Pays at 88% of Total Billed charges,6.77,Pays at 103% of GA Medicaid Fee Schedule,5.22,160.45,106.97
Outpatient Medical Services,LAB,86003,FOOD NUT #2  (MAYO),300,178.28,151.54,Pays at 85% of Billed charges for outpatient setting,6.57,Pays at 100% of GA Medicaid Fee Schedule,142.68,Pays at 80.03% of Total Billed charges,5.32,Pays at 102% of Medicare OPPS Rate,160.45,Pays at 90% of Total Billed charges,6.57,Pays at 100% of GA Medicaid Fee Schedule,5.22,Pays at 100% of Medicare OPPS Rate,6.57,Pays at 100% of GA Medicaid Fee Schedule,156.89,Pays at 88% of Total Billed charges,6.77,Pays at 103% of GA Medicaid Fee Schedule,5.22,160.45,106.97
Outpatient Medical Services,LAB,86003,"RAST, SHELLFISH & FISH  (MAYO)",300,192.5,163.63,Pays at 85% of Billed charges for outpatient setting,6.57,Pays at 100% of GA Medicaid Fee Schedule,154.06,Pays at 80.03% of Total Billed charges,5.32,Pays at 102% of Medicare OPPS Rate,173.25,Pays at 90% of Total Billed charges,6.57,Pays at 100% of GA Medicaid Fee Schedule,5.22,Pays at 100% of Medicare OPPS Rate,6.57,Pays at 100% of GA Medicaid Fee Schedule,169.4,Pays at 88% of Total Billed charges,6.77,Pays at 103% of GA Medicaid Fee Schedule,5.22,173.25,115.50
Outpatient Medical Services,LAB,86008,"GALACTOSE-ALPHA-1,3-GALACTOSE  (MAYO)",300,97,82.45,Pays at 85% of Billed charges for outpatient setting,17.71,Pays at 100% of GA Medicaid Fee Schedule,77.63,Pays at 80.03% of Total Billed charges,18.28,Pays at 102% of Medicare OPPS Rate,87.3,Pays at 90% of Total Billed charges,17.71,Pays at 100% of GA Medicaid Fee Schedule,17.93,Pays at 100% of Medicare OPPS Rate,17.71,Pays at 100% of GA Medicaid Fee Schedule,85.36,Pays at 88% of Total Billed charges,18.24,Pays at 103% of GA Medicaid Fee Schedule,17.71,87.3,58.20
Outpatient Medical Services,LAB,86021,"ANCA, IBD SCREEN WITH REFLEX  (MAYO)",300,215,182.75,Pays at 85% of Billed charges for outpatient setting,18.93,Pays at 100% of GA Medicaid Fee Schedule,172.06,Pays at 80.03% of Total Billed charges,15.35,Pays at 102% of Medicare OPPS Rate,193.5,Pays at 90% of Total Billed charges,18.93,Pays at 100% of GA Medicaid Fee Schedule,15.05,Pays at 100% of Medicare OPPS Rate,18.93,Pays at 100% of GA Medicaid Fee Schedule,189.2,Pays at 88% of Total Billed charges,19.5,Pays at 103% of GA Medicaid Fee Schedule,15.05,193.5,129.00
Outpatient Medical Services,LAB,86022,PLATELET CROSSMATCH,300,39,33.15,Pays at 85% of Billed charges for outpatient setting,23.09,Pays at 100% of GA Medicaid Fee Schedule,31.21,Pays at 80.03% of Total Billed charges,18.73,Pays at 102% of Medicare OPPS Rate,35.1,Pays at 90% of Total Billed charges,23.09,Pays at 100% of GA Medicaid Fee Schedule,18.37,Pays at 100% of Medicare OPPS Rate,23.09,Pays at 100% of GA Medicaid Fee Schedule,34.32,Pays at 88% of Total Billed charges,23.78,Pays at 103% of GA Medicaid Fee Schedule,18.37,35.1,23.40
Outpatient Medical Services,LAB,86022,HEPARIN INDUCED THROMBOCYTOPENIA  (MAYO),300,75,63.75,Pays at 85% of Billed charges for outpatient setting,23.09,Pays at 100% of GA Medicaid Fee Schedule,60.02,Pays at 80.03% of Total Billed charges,18.73,Pays at 102% of Medicare OPPS Rate,67.5,Pays at 90% of Total Billed charges,23.09,Pays at 100% of GA Medicaid Fee Schedule,18.37,Pays at 100% of Medicare OPPS Rate,23.09,Pays at 100% of GA Medicaid Fee Schedule,66,Pays at 88% of Total Billed charges,23.78,Pays at 103% of GA Medicaid Fee Schedule,18.37,67.5,45.00
Outpatient Medical Services,LAB,86022,PLATELET AB  (MAYO),300,277.25,235.66,Pays at 85% of Billed charges for outpatient setting,23.09,Pays at 100% of GA Medicaid Fee Schedule,221.88,Pays at 80.03% of Total Billed charges,18.73,Pays at 102% of Medicare OPPS Rate,249.53,Pays at 90% of Total Billed charges,23.09,Pays at 100% of GA Medicaid Fee Schedule,18.37,Pays at 100% of Medicare OPPS Rate,23.09,Pays at 100% of GA Medicaid Fee Schedule,243.98,Pays at 88% of Total Billed charges,23.78,Pays at 103% of GA Medicaid Fee Schedule,18.37,249.53,166.35
Outpatient Medical Services,LAB,86022,HEPARIN PF4 IGG AB (HIT)  (MAYO),300,401.25,341.06,Pays at 85% of Billed charges for outpatient setting,23.09,Pays at 100% of GA Medicaid Fee Schedule,321.12,Pays at 80.03% of Total Billed charges,18.73,Pays at 102% of Medicare OPPS Rate,361.13,Pays at 90% of Total Billed charges,23.09,Pays at 100% of GA Medicaid Fee Schedule,18.37,Pays at 100% of Medicare OPPS Rate,23.09,Pays at 100% of GA Medicaid Fee Schedule,353.1,Pays at 88% of Total Billed charges,23.78,Pays at 103% of GA Medicaid Fee Schedule,18.37,361.13,240.75
Outpatient Medical Services,LAB,86022,SEROTONIN RELEASE ASSAY  (MAYO),300,409.75,348.29,Pays at 85% of Billed charges for outpatient setting,23.09,Pays at 100% of GA Medicaid Fee Schedule,327.92,Pays at 80.03% of Total Billed charges,18.73,Pays at 102% of Medicare OPPS Rate,368.78,Pays at 90% of Total Billed charges,23.09,Pays at 100% of GA Medicaid Fee Schedule,18.37,Pays at 100% of Medicare OPPS Rate,23.09,Pays at 100% of GA Medicaid Fee Schedule,360.58,Pays at 88% of Total Billed charges,23.78,Pays at 103% of GA Medicaid Fee Schedule,18.37,368.78,245.85
Outpatient Medical Services,LAB,86038,ANA COMP PROFILE  (MAYO),300,25.9,22.02,Pays at 85% of Billed charges for outpatient setting,15.2,Pays at 100% of GA Medicaid Fee Schedule,20.73,Pays at 80.03% of Total Billed charges,12.33,Pays at 102% of Medicare OPPS Rate,23.31,Pays at 90% of Total Billed charges,15.2,Pays at 100% of GA Medicaid Fee Schedule,12.09,Pays at 100% of Medicare OPPS Rate,15.2,Pays at 100% of GA Medicaid Fee Schedule,22.79,Pays at 88% of Total Billed charges,15.66,Pays at 103% of GA Medicaid Fee Schedule,12.09,23.31,15.54
Outpatient Medical Services,LAB,86038,ANA  (MAYO),300,47.81,40.64,Pays at 85% of Billed charges for outpatient setting,15.2,Pays at 100% of GA Medicaid Fee Schedule,38.26,Pays at 80.03% of Total Billed charges,12.33,Pays at 102% of Medicare OPPS Rate,43.03,Pays at 90% of Total Billed charges,15.2,Pays at 100% of GA Medicaid Fee Schedule,12.09,Pays at 100% of Medicare OPPS Rate,15.2,Pays at 100% of GA Medicaid Fee Schedule,42.07,Pays at 88% of Total Billed charges,15.66,Pays at 103% of GA Medicaid Fee Schedule,12.09,43.03,28.69
Outpatient Medical Services,LAB,86038,"ANA, HEP-2  (MAYO)",300,72.5,61.63,Pays at 85% of Billed charges for outpatient setting,15.2,Pays at 100% of GA Medicaid Fee Schedule,58.02,Pays at 80.03% of Total Billed charges,12.33,Pays at 102% of Medicare OPPS Rate,65.25,Pays at 90% of Total Billed charges,15.2,Pays at 100% of GA Medicaid Fee Schedule,12.09,Pays at 100% of Medicare OPPS Rate,15.2,Pays at 100% of GA Medicaid Fee Schedule,63.8,Pays at 88% of Total Billed charges,15.66,Pays at 103% of GA Medicaid Fee Schedule,12.09,65.25,43.50
Outpatient Medical Services,LAB,86039,Blood test to determine autoimmune disorders,300,29.2,24.82,Pays at 85% of Billed charges for outpatient setting,14.04,Pays at 100% of GA Medicaid Fee Schedule,23.37,Pays at 80.03% of Total Billed charges,11.38,Pays at 102% of Medicare OPPS Rate,26.28,Pays at 90% of Total Billed charges,14.04,Pays at 100% of GA Medicaid Fee Schedule,11.16,Pays at 100% of Medicare OPPS Rate,14.04,Pays at 100% of GA Medicaid Fee Schedule,25.7,Pays at 88% of Total Billed charges,14.46,Pays at 103% of GA Medicaid Fee Schedule,11.16,26.28,17.52
Outpatient Medical Services,LAB,86060,"ASO TITER, STREPTOLYSIN O  (MAYO)",300,88.63,75.34,Pays at 85% of Billed charges for outpatient setting,8.79,Pays at 100% of GA Medicaid Fee Schedule,70.93,Pays at 80.03% of Total Billed charges,7.44,Pays at 102% of Medicare OPPS Rate,79.77,Pays at 90% of Total Billed charges,8.79,Pays at 100% of GA Medicaid Fee Schedule,7.3,Pays at 100% of Medicare OPPS Rate,8.79,Pays at 100% of GA Medicaid Fee Schedule,77.99,Pays at 88% of Total Billed charges,9.05,Pays at 103% of GA Medicaid Fee Schedule,7.3,79.77,53.18
Outpatient Medical Services,LAB,86140,CRP INFLAMMATION,300,68.25,58.01,Pays at 85% of Billed charges for outpatient setting,6.51,Pays at 100% of GA Medicaid Fee Schedule,54.62,Pays at 80.03% of Total Billed charges,5.28,Pays at 102% of Medicare OPPS Rate,61.43,Pays at 90% of Total Billed charges,6.51,Pays at 100% of GA Medicaid Fee Schedule,5.18,Pays at 100% of Medicare OPPS Rate,6.51,Pays at 100% of GA Medicaid Fee Schedule,60.06,Pays at 88% of Total Billed charges,6.71,Pays at 103% of GA Medicaid Fee Schedule,5.18,61.43,40.95
Outpatient Medical Services,LAB,86141,CRP HIGH SENSITIVITY (CARDIAC),300,68.25,58.01,Pays at 85% of Billed charges for outpatient setting,16.28,Pays at 100% of GA Medicaid Fee Schedule,54.62,Pays at 80.03% of Total Billed charges,13.2,Pays at 102% of Medicare OPPS Rate,61.43,Pays at 90% of Total Billed charges,16.28,Pays at 100% of GA Medicaid Fee Schedule,12.95,Pays at 100% of Medicare OPPS Rate,16.28,Pays at 100% of GA Medicaid Fee Schedule,60.06,Pays at 88% of Total Billed charges,16.77,Pays at 103% of GA Medicaid Fee Schedule,12.95,61.43,40.95
Outpatient Medical Services,LAB,86146,"BETA 2 GLYCOPROTEIN AB,IGA  (MAYO)",300,42.25,35.91,Pays at 85% of Billed charges for outpatient setting,31.99,Pays at 100% of GA Medicaid Fee Schedule,33.81,Pays at 80.03% of Total Billed charges,25.95,Pays at 102% of Medicare OPPS Rate,38.03,Pays at 90% of Total Billed charges,31.99,Pays at 100% of GA Medicaid Fee Schedule,25.45,Pays at 100% of Medicare OPPS Rate,31.99,Pays at 100% of GA Medicaid Fee Schedule,37.18,Pays at 88% of Total Billed charges,32.95,Pays at 103% of GA Medicaid Fee Schedule,25.45,38.03,25.35
Outpatient Medical Services,LAB,86146,"BETA 2 GLYCOPROTEIN AB, IGG  (MAYO)",300,88.77,75.45,Pays at 85% of Billed charges for outpatient setting,31.99,Pays at 100% of GA Medicaid Fee Schedule,71.04,Pays at 80.03% of Total Billed charges,25.95,Pays at 102% of Medicare OPPS Rate,79.89,Pays at 90% of Total Billed charges,31.99,Pays at 100% of GA Medicaid Fee Schedule,25.45,Pays at 100% of Medicare OPPS Rate,31.99,Pays at 100% of GA Medicaid Fee Schedule,78.12,Pays at 88% of Total Billed charges,32.95,Pays at 103% of GA Medicaid Fee Schedule,25.45,79.89,53.26
Outpatient Medical Services,LAB,86146,"BETA 2 GLYCOPROTEIN AB, IGM  (MAYO)",300,88.77,75.45,Pays at 85% of Billed charges for outpatient setting,31.99,Pays at 100% of GA Medicaid Fee Schedule,71.04,Pays at 80.03% of Total Billed charges,25.95,Pays at 102% of Medicare OPPS Rate,79.89,Pays at 90% of Total Billed charges,31.99,Pays at 100% of GA Medicaid Fee Schedule,25.45,Pays at 100% of Medicare OPPS Rate,31.99,Pays at 100% of GA Medicaid Fee Schedule,78.12,Pays at 88% of Total Billed charges,32.95,Pays at 103% of GA Medicaid Fee Schedule,25.45,79.89,53.26
Outpatient Medical Services,LAB,86147,Blood test to determine cause of inappropriate blood clot formation,300,40.5,34.43,Pays at 85% of Billed charges for outpatient setting,31.99,Pays at 100% of GA Medicaid Fee Schedule,32.41,Pays at 80.03% of Total Billed charges,25.95,Pays at 102% of Medicare OPPS Rate,36.45,Pays at 90% of Total Billed charges,31.99,Pays at 100% of GA Medicaid Fee Schedule,25.45,Pays at 100% of Medicare OPPS Rate,31.99,Pays at 100% of GA Medicaid Fee Schedule,35.64,Pays at 88% of Total Billed charges,32.95,Pays at 103% of GA Medicaid Fee Schedule,25.45,36.45,24.30
Outpatient Medical Services,LAB,86147,Blood test to determine cause of inappropriate blood clot formation,300,81.75,69.49,Pays at 85% of Billed charges for outpatient setting,31.99,Pays at 100% of GA Medicaid Fee Schedule,65.42,Pays at 80.03% of Total Billed charges,25.95,Pays at 102% of Medicare OPPS Rate,73.58,Pays at 90% of Total Billed charges,31.99,Pays at 100% of GA Medicaid Fee Schedule,25.45,Pays at 100% of Medicare OPPS Rate,31.99,Pays at 100% of GA Medicaid Fee Schedule,71.94,Pays at 88% of Total Billed charges,32.95,Pays at 103% of GA Medicaid Fee Schedule,25.45,73.58,49.05
Outpatient Medical Services,LAB,86147,Blood test to determine cause of inappropriate blood clot formation,300,81.75,69.49,Pays at 85% of Billed charges for outpatient setting,31.99,Pays at 100% of GA Medicaid Fee Schedule,65.42,Pays at 80.03% of Total Billed charges,25.95,Pays at 102% of Medicare OPPS Rate,73.58,Pays at 90% of Total Billed charges,31.99,Pays at 100% of GA Medicaid Fee Schedule,25.45,Pays at 100% of Medicare OPPS Rate,31.99,Pays at 100% of GA Medicaid Fee Schedule,71.94,Pays at 88% of Total Billed charges,32.95,Pays at 103% of GA Medicaid Fee Schedule,25.45,73.58,49.05
Outpatient Medical Services,LAB,86147,Blood test to determine cause of inappropriate blood clot formation,300,81.75,69.49,Pays at 85% of Billed charges for outpatient setting,31.99,Pays at 100% of GA Medicaid Fee Schedule,65.42,Pays at 80.03% of Total Billed charges,25.95,Pays at 102% of Medicare OPPS Rate,73.58,Pays at 90% of Total Billed charges,31.99,Pays at 100% of GA Medicaid Fee Schedule,25.45,Pays at 100% of Medicare OPPS Rate,31.99,Pays at 100% of GA Medicaid Fee Schedule,71.94,Pays at 88% of Total Billed charges,32.95,Pays at 103% of GA Medicaid Fee Schedule,25.45,73.58,49.05
Outpatient Medical Services,LAB,86148,PS/PT AB IGM SERUM  (MAYO),300,166.18,141.25,Pays at 85% of Billed charges for outpatient setting,20.2,Pays at 100% of GA Medicaid Fee Schedule,132.99,Pays at 80.03% of Total Billed charges,16.39,Pays at 102% of Medicare OPPS Rate,149.56,Pays at 90% of Total Billed charges,20.2,Pays at 100% of GA Medicaid Fee Schedule,16.07,Pays at 100% of Medicare OPPS Rate,20.2,Pays at 100% of GA Medicaid Fee Schedule,146.24,Pays at 88% of Total Billed charges,20.81,Pays at 103% of GA Medicaid Fee Schedule,16.07,149.56,99.71
Outpatient Medical Services,LAB,86148,PS/PT AB IGG SERUM  (MAYO),300,166.18,141.25,Pays at 85% of Billed charges for outpatient setting,20.2,Pays at 100% of GA Medicaid Fee Schedule,132.99,Pays at 80.03% of Total Billed charges,16.39,Pays at 102% of Medicare OPPS Rate,149.56,Pays at 90% of Total Billed charges,20.2,Pays at 100% of GA Medicaid Fee Schedule,16.07,Pays at 100% of Medicare OPPS Rate,20.2,Pays at 100% of GA Medicaid Fee Schedule,146.24,Pays at 88% of Total Billed charges,20.81,Pays at 103% of GA Medicaid Fee Schedule,16.07,149.56,99.71
Outpatient Medical Services,LAB,86157,COLD AGGLUTININ SCREEN  (MAYO),300,19.5,16.58,Pays at 85% of Billed charges for outpatient setting,10.14,Pays at 100% of GA Medicaid Fee Schedule,15.61,Pays at 80.03% of Total Billed charges,8.22,Pays at 102% of Medicare OPPS Rate,17.55,Pays at 90% of Total Billed charges,10.14,Pays at 100% of GA Medicaid Fee Schedule,8.06,Pays at 100% of Medicare OPPS Rate,10.14,Pays at 100% of GA Medicaid Fee Schedule,17.16,Pays at 88% of Total Billed charges,10.44,Pays at 103% of GA Medicaid Fee Schedule,8.06,17.55,11.70
Outpatient Medical Services,LAB,86160,"COMPLEMENT AG, EACH  (MAYO)",300,26,22.1,Pays at 85% of Billed charges for outpatient setting,15.1,Pays at 100% of GA Medicaid Fee Schedule,20.81,Pays at 80.03% of Total Billed charges,12.24,Pays at 102% of Medicare OPPS Rate,23.4,Pays at 90% of Total Billed charges,15.1,Pays at 100% of GA Medicaid Fee Schedule,12,Pays at 100% of Medicare OPPS Rate,15.1,Pays at 100% of GA Medicaid Fee Schedule,22.88,Pays at 88% of Total Billed charges,15.55,Pays at 103% of GA Medicaid Fee Schedule,12,23.4,15.60
Outpatient Medical Services,LAB,86160,C1-ESTERASE INIHIBTOR  (MAYO),300,27,22.95,Pays at 85% of Billed charges for outpatient setting,15.1,Pays at 100% of GA Medicaid Fee Schedule,21.61,Pays at 80.03% of Total Billed charges,12.24,Pays at 102% of Medicare OPPS Rate,24.3,Pays at 90% of Total Billed charges,15.1,Pays at 100% of GA Medicaid Fee Schedule,12,Pays at 100% of Medicare OPPS Rate,15.1,Pays at 100% of GA Medicaid Fee Schedule,23.76,Pays at 88% of Total Billed charges,15.55,Pays at 103% of GA Medicaid Fee Schedule,12,24.3,16.20
Outpatient Medical Services,LAB,86160,..C3 & C4 COMPLEMENT  (MAYO),300,31.75,26.99,Pays at 85% of Billed charges for outpatient setting,15.1,Pays at 100% of GA Medicaid Fee Schedule,25.41,Pays at 80.03% of Total Billed charges,12.24,Pays at 102% of Medicare OPPS Rate,28.58,Pays at 90% of Total Billed charges,15.1,Pays at 100% of GA Medicaid Fee Schedule,12,Pays at 100% of Medicare OPPS Rate,15.1,Pays at 100% of GA Medicaid Fee Schedule,27.94,Pays at 88% of Total Billed charges,15.55,Pays at 103% of GA Medicaid Fee Schedule,12,28.58,19.05
Outpatient Medical Services,LAB,86160,C4 COMPLEMENT SERUM  (MAYO),300,38.25,32.51,Pays at 85% of Billed charges for outpatient setting,15.1,Pays at 100% of GA Medicaid Fee Schedule,30.61,Pays at 80.03% of Total Billed charges,12.24,Pays at 102% of Medicare OPPS Rate,34.43,Pays at 90% of Total Billed charges,15.1,Pays at 100% of GA Medicaid Fee Schedule,12,Pays at 100% of Medicare OPPS Rate,15.1,Pays at 100% of GA Medicaid Fee Schedule,33.66,Pays at 88% of Total Billed charges,15.55,Pays at 103% of GA Medicaid Fee Schedule,12,34.43,22.95
Outpatient Medical Services,LAB,86160,C3 COMPLEMENT SERUM  (MAYO),300,38.25,32.51,Pays at 85% of Billed charges for outpatient setting,15.1,Pays at 100% of GA Medicaid Fee Schedule,30.61,Pays at 80.03% of Total Billed charges,12.24,Pays at 102% of Medicare OPPS Rate,34.43,Pays at 90% of Total Billed charges,15.1,Pays at 100% of GA Medicaid Fee Schedule,12,Pays at 100% of Medicare OPPS Rate,15.1,Pays at 100% of GA Medicaid Fee Schedule,33.66,Pays at 88% of Total Billed charges,15.55,Pays at 103% of GA Medicaid Fee Schedule,12,34.43,22.95
Outpatient Medical Services,LAB,86160,C1-ESTERASE INHIBITOR ASSAY  (MAYO),300,49.75,42.29,Pays at 85% of Billed charges for outpatient setting,15.1,Pays at 100% of GA Medicaid Fee Schedule,39.81,Pays at 80.03% of Total Billed charges,12.24,Pays at 102% of Medicare OPPS Rate,44.78,Pays at 90% of Total Billed charges,15.1,Pays at 100% of GA Medicaid Fee Schedule,12,Pays at 100% of Medicare OPPS Rate,15.1,Pays at 100% of GA Medicaid Fee Schedule,43.78,Pays at 88% of Total Billed charges,15.55,Pays at 103% of GA Medicaid Fee Schedule,12,44.78,29.85
Outpatient Medical Services,LAB,86160,C4a  (MAYO),300,79.25,67.36,Pays at 85% of Billed charges for outpatient setting,15.1,Pays at 100% of GA Medicaid Fee Schedule,63.42,Pays at 80.03% of Total Billed charges,12.24,Pays at 102% of Medicare OPPS Rate,71.33,Pays at 90% of Total Billed charges,15.1,Pays at 100% of GA Medicaid Fee Schedule,12,Pays at 100% of Medicare OPPS Rate,15.1,Pays at 100% of GA Medicaid Fee Schedule,69.74,Pays at 88% of Total Billed charges,15.55,Pays at 103% of GA Medicaid Fee Schedule,12,71.33,47.55
Outpatient Medical Services,LAB,86161,"COMPLEMENT, FUNCTIONAL EACH (MAYO)",300,100.5,85.43,Pays at 85% of Billed charges for outpatient setting,15.1,Pays at 100% of GA Medicaid Fee Schedule,80.43,Pays at 80.03% of Total Billed charges,12.24,Pays at 102% of Medicare OPPS Rate,90.45,Pays at 90% of Total Billed charges,15.1,Pays at 100% of GA Medicaid Fee Schedule,12,Pays at 100% of Medicare OPPS Rate,15.1,Pays at 100% of GA Medicaid Fee Schedule,88.44,Pays at 88% of Total Billed charges,15.55,Pays at 103% of GA Medicaid Fee Schedule,12,90.45,60.30
Outpatient Medical Services,LAB,86162,"COMPLEMENT TOTAL, CH-50  (MAYO)",300,65.25,55.46,Pays at 85% of Billed charges for outpatient setting,25.55,Pays at 100% of GA Medicaid Fee Schedule,52.22,Pays at 80.03% of Total Billed charges,20.72,Pays at 102% of Medicare OPPS Rate,58.73,Pays at 90% of Total Billed charges,25.55,Pays at 100% of GA Medicaid Fee Schedule,20.32,Pays at 100% of Medicare OPPS Rate,25.55,Pays at 100% of GA Medicaid Fee Schedule,57.42,Pays at 88% of Total Billed charges,26.32,Pays at 103% of GA Medicaid Fee Schedule,20.32,58.73,39.15
Outpatient Medical Services,LAB,86200,Blood test to diagnose rheumatoid arthritis,300,41.5,35.28,Pays at 85% of Billed charges for outpatient setting,16.28,Pays at 100% of GA Medicaid Fee Schedule,33.21,Pays at 80.03% of Total Billed charges,13.2,Pays at 102% of Medicare OPPS Rate,37.35,Pays at 90% of Total Billed charges,16.28,Pays at 100% of GA Medicaid Fee Schedule,12.95,Pays at 100% of Medicare OPPS Rate,16.28,Pays at 100% of GA Medicaid Fee Schedule,36.52,Pays at 88% of Total Billed charges,16.77,Pays at 103% of GA Medicaid Fee Schedule,12.95,37.35,24.90
Outpatient Medical Services,LAB,86200,Blood test to diagnose rheumatoid arthritis,300,96.45,81.98,Pays at 85% of Billed charges for outpatient setting,16.28,Pays at 100% of GA Medicaid Fee Schedule,77.19,Pays at 80.03% of Total Billed charges,13.2,Pays at 102% of Medicare OPPS Rate,86.81,Pays at 90% of Total Billed charges,16.28,Pays at 100% of GA Medicaid Fee Schedule,12.95,Pays at 100% of Medicare OPPS Rate,16.28,Pays at 100% of GA Medicaid Fee Schedule,84.88,Pays at 88% of Total Billed charges,16.77,Pays at 103% of GA Medicaid Fee Schedule,12.95,86.81,57.87
Outpatient Medical Services,LAB,86225,dsDNA AB REFLEX IGG (MAYO),300,21.67,18.42,Pays at 85% of Billed charges for outpatient setting,17.28,Pays at 100% of GA Medicaid Fee Schedule,17.34,Pays at 80.03% of Total Billed charges,14.01,Pays at 102% of Medicare OPPS Rate,19.5,Pays at 90% of Total Billed charges,17.28,Pays at 100% of GA Medicaid Fee Schedule,13.74,Pays at 100% of Medicare OPPS Rate,17.28,Pays at 100% of GA Medicaid Fee Schedule,19.07,Pays at 88% of Total Billed charges,17.8,Pays at 103% of GA Medicaid Fee Schedule,13.74,19.5,13.00
Outpatient Medical Services,LAB,86225,ANTI-dsDNA  (MAYO),300,43.5,36.98,Pays at 85% of Billed charges for outpatient setting,17.28,Pays at 100% of GA Medicaid Fee Schedule,34.81,Pays at 80.03% of Total Billed charges,14.01,Pays at 102% of Medicare OPPS Rate,39.15,Pays at 90% of Total Billed charges,17.28,Pays at 100% of GA Medicaid Fee Schedule,13.74,Pays at 100% of Medicare OPPS Rate,17.28,Pays at 100% of GA Medicaid Fee Schedule,38.28,Pays at 88% of Total Billed charges,17.8,Pays at 103% of GA Medicaid Fee Schedule,13.74,39.15,26.10
Outpatient Medical Services,LAB,86235,"ANTI-SCLERODERMA, SCI-70  (MAYO)",300,32.5,27.63,Pays at 85% of Billed charges for outpatient setting,22.55,Pays at 100% of GA Medicaid Fee Schedule,26.01,Pays at 80.03% of Total Billed charges,18.28,Pays at 102% of Medicare OPPS Rate,29.25,Pays at 90% of Total Billed charges,22.55,Pays at 100% of GA Medicaid Fee Schedule,17.93,Pays at 100% of Medicare OPPS Rate,22.55,Pays at 100% of GA Medicaid Fee Schedule,28.6,Pays at 88% of Total Billed charges,23.23,Pays at 103% of GA Medicaid Fee Schedule,17.93,29.25,19.50
Outpatient Medical Services,LAB,86235,SM ANTIBODIES (MAYO),300,41.5,35.28,Pays at 85% of Billed charges for outpatient setting,22.55,Pays at 100% of GA Medicaid Fee Schedule,33.21,Pays at 80.03% of Total Billed charges,18.28,Pays at 102% of Medicare OPPS Rate,37.35,Pays at 90% of Total Billed charges,22.55,Pays at 100% of GA Medicaid Fee Schedule,17.93,Pays at 100% of Medicare OPPS Rate,22.55,Pays at 100% of GA Medicaid Fee Schedule,36.52,Pays at 88% of Total Billed charges,23.23,Pays at 103% of GA Medicaid Fee Schedule,17.93,37.35,24.90
Outpatient Medical Services,LAB,86235,SMITH AUTOAB  (MAYO),300,57,48.45,Pays at 85% of Billed charges for outpatient setting,22.55,Pays at 100% of GA Medicaid Fee Schedule,45.62,Pays at 80.03% of Total Billed charges,18.28,Pays at 102% of Medicare OPPS Rate,51.3,Pays at 90% of Total Billed charges,22.55,Pays at 100% of GA Medicaid Fee Schedule,17.93,Pays at 100% of Medicare OPPS Rate,22.55,Pays at 100% of GA Medicaid Fee Schedule,50.16,Pays at 88% of Total Billed charges,23.23,Pays at 103% of GA Medicaid Fee Schedule,17.93,51.3,34.20
Outpatient Medical Services,LAB,86235,"ANTI-SSA, SJORGEN'S  (MAYO)",300,57,48.45,Pays at 85% of Billed charges for outpatient setting,22.55,Pays at 100% of GA Medicaid Fee Schedule,45.62,Pays at 80.03% of Total Billed charges,18.28,Pays at 102% of Medicare OPPS Rate,51.3,Pays at 90% of Total Billed charges,22.55,Pays at 100% of GA Medicaid Fee Schedule,17.93,Pays at 100% of Medicare OPPS Rate,22.55,Pays at 100% of GA Medicaid Fee Schedule,50.16,Pays at 88% of Total Billed charges,23.23,Pays at 103% of GA Medicaid Fee Schedule,17.93,51.3,34.20
Outpatient Medical Services,LAB,86235,"ANTI-SSB, SJORGEN'S  (MAYO)",300,57,48.45,Pays at 85% of Billed charges for outpatient setting,22.55,Pays at 100% of GA Medicaid Fee Schedule,45.62,Pays at 80.03% of Total Billed charges,18.28,Pays at 102% of Medicare OPPS Rate,51.3,Pays at 90% of Total Billed charges,22.55,Pays at 100% of GA Medicaid Fee Schedule,17.93,Pays at 100% of Medicare OPPS Rate,22.55,Pays at 100% of GA Medicaid Fee Schedule,50.16,Pays at 88% of Total Billed charges,23.23,Pays at 103% of GA Medicaid Fee Schedule,17.93,51.3,34.20
Outpatient Medical Services,LAB,86235,JO-1 AB  (MAYO),300,57,48.45,Pays at 85% of Billed charges for outpatient setting,22.55,Pays at 100% of GA Medicaid Fee Schedule,45.62,Pays at 80.03% of Total Billed charges,18.28,Pays at 102% of Medicare OPPS Rate,51.3,Pays at 90% of Total Billed charges,22.55,Pays at 100% of GA Medicaid Fee Schedule,17.93,Pays at 100% of Medicare OPPS Rate,22.55,Pays at 100% of GA Medicaid Fee Schedule,50.16,Pays at 88% of Total Billed charges,23.23,Pays at 103% of GA Medicaid Fee Schedule,17.93,51.3,34.20
Outpatient Medical Services,LAB,86235,"SCL-70 AB, IGG  (MAYO)",300,57,48.45,Pays at 85% of Billed charges for outpatient setting,22.55,Pays at 100% of GA Medicaid Fee Schedule,45.62,Pays at 80.03% of Total Billed charges,18.28,Pays at 102% of Medicare OPPS Rate,51.3,Pays at 90% of Total Billed charges,22.55,Pays at 100% of GA Medicaid Fee Schedule,17.93,Pays at 100% of Medicare OPPS Rate,22.55,Pays at 100% of GA Medicaid Fee Schedule,50.16,Pays at 88% of Total Billed charges,23.23,Pays at 103% of GA Medicaid Fee Schedule,17.93,51.3,34.20
Outpatient Medical Services,LAB,86235,RNP ANTIBODY  (MAYO),300,57,48.45,Pays at 85% of Billed charges for outpatient setting,22.55,Pays at 100% of GA Medicaid Fee Schedule,45.62,Pays at 80.03% of Total Billed charges,18.28,Pays at 102% of Medicare OPPS Rate,51.3,Pays at 90% of Total Billed charges,22.55,Pays at 100% of GA Medicaid Fee Schedule,17.93,Pays at 100% of Medicare OPPS Rate,22.55,Pays at 100% of GA Medicaid Fee Schedule,50.16,Pays at 88% of Total Billed charges,23.23,Pays at 103% of GA Medicaid Fee Schedule,17.93,51.3,34.20
Outpatient Medical Services,LAB,86235,PM-SCL AB  (MAYO),300,92.25,78.41,Pays at 85% of Billed charges for outpatient setting,22.55,Pays at 100% of GA Medicaid Fee Schedule,73.83,Pays at 80.03% of Total Billed charges,18.28,Pays at 102% of Medicare OPPS Rate,83.03,Pays at 90% of Total Billed charges,22.55,Pays at 100% of GA Medicaid Fee Schedule,17.93,Pays at 100% of Medicare OPPS Rate,22.55,Pays at 100% of GA Medicaid Fee Schedule,81.18,Pays at 88% of Total Billed charges,23.23,Pays at 103% of GA Medicaid Fee Schedule,17.93,83.03,55.35
Outpatient Medical Services,LAB,86235,CHROMATIN (NUCLEOSOMAL) AB  (MAYO),300,142.5,121.13,Pays at 85% of Billed charges for outpatient setting,22.55,Pays at 100% of GA Medicaid Fee Schedule,114.04,Pays at 80.03% of Total Billed charges,18.28,Pays at 102% of Medicare OPPS Rate,128.25,Pays at 90% of Total Billed charges,22.55,Pays at 100% of GA Medicaid Fee Schedule,17.93,Pays at 100% of Medicare OPPS Rate,22.55,Pays at 100% of GA Medicaid Fee Schedule,125.4,Pays at 88% of Total Billed charges,23.23,Pays at 103% of GA Medicaid Fee Schedule,17.93,128.25,85.50
Outpatient Medical Services,LAB,86255,ACTIN ANTIBODY  (MAYO),300,21.5,18.28,Pays at 85% of Billed charges for outpatient setting,15.16,Pays at 100% of GA Medicaid Fee Schedule,17.21,Pays at 80.03% of Total Billed charges,12.29,Pays at 102% of Medicare OPPS Rate,19.35,Pays at 90% of Total Billed charges,15.16,Pays at 100% of GA Medicaid Fee Schedule,12.05,Pays at 100% of Medicare OPPS Rate,15.16,Pays at 100% of GA Medicaid Fee Schedule,18.92,Pays at 88% of Total Billed charges,15.61,Pays at 103% of GA Medicaid Fee Schedule,12.05,19.35,12.90
Outpatient Medical Services,LAB,86255,"ENDOMYSIAL AB, IGA  (MAYO)",300,70.5,59.93,Pays at 85% of Billed charges for outpatient setting,15.16,Pays at 100% of GA Medicaid Fee Schedule,56.42,Pays at 80.03% of Total Billed charges,12.29,Pays at 102% of Medicare OPPS Rate,63.45,Pays at 90% of Total Billed charges,15.16,Pays at 100% of GA Medicaid Fee Schedule,12.05,Pays at 100% of Medicare OPPS Rate,15.16,Pays at 100% of GA Medicaid Fee Schedule,62.04,Pays at 88% of Total Billed charges,15.61,Pays at 103% of GA Medicaid Fee Schedule,12.05,63.45,42.30
Outpatient Medical Services,LAB,86255,PURKINJE CELL CYTOPLAS AB TYPE 1 (MAYO),300,141.63,120.39,Pays at 85% of Billed charges for outpatient setting,15.16,Pays at 100% of GA Medicaid Fee Schedule,113.35,Pays at 80.03% of Total Billed charges,12.29,Pays at 102% of Medicare OPPS Rate,127.47,Pays at 90% of Total Billed charges,15.16,Pays at 100% of GA Medicaid Fee Schedule,12.05,Pays at 100% of Medicare OPPS Rate,15.16,Pays at 100% of GA Medicaid Fee Schedule,124.63,Pays at 88% of Total Billed charges,15.61,Pays at 103% of GA Medicaid Fee Schedule,12.05,127.47,84.98
Outpatient Medical Services,LAB,86255,ANTI-NEURONAL NUCLEAR AB TYPE 3 (MAYO),300,141.63,120.39,Pays at 85% of Billed charges for outpatient setting,15.16,Pays at 100% of GA Medicaid Fee Schedule,113.35,Pays at 80.03% of Total Billed charges,12.29,Pays at 102% of Medicare OPPS Rate,127.47,Pays at 90% of Total Billed charges,15.16,Pays at 100% of GA Medicaid Fee Schedule,12.05,Pays at 100% of Medicare OPPS Rate,15.16,Pays at 100% of GA Medicaid Fee Schedule,124.63,Pays at 88% of Total Billed charges,15.61,Pays at 103% of GA Medicaid Fee Schedule,12.05,127.47,84.98
Outpatient Medical Services,LAB,86255,PURKINJE CELL CYTOPLAS AB TYPE 1 (MAYO),300,141.63,120.39,Pays at 85% of Billed charges for outpatient setting,15.16,Pays at 100% of GA Medicaid Fee Schedule,113.35,Pays at 80.03% of Total Billed charges,12.29,Pays at 102% of Medicare OPPS Rate,127.47,Pays at 90% of Total Billed charges,15.16,Pays at 100% of GA Medicaid Fee Schedule,12.05,Pays at 100% of Medicare OPPS Rate,15.16,Pays at 100% of GA Medicaid Fee Schedule,124.63,Pays at 88% of Total Billed charges,15.61,Pays at 103% of GA Medicaid Fee Schedule,12.05,127.47,84.98
Outpatient Medical Services,LAB,86255,ANTI-NEURONAL NUCLEAR AB TYPE 3 (MAYO),300,141.63,120.39,Pays at 85% of Billed charges for outpatient setting,15.16,Pays at 100% of GA Medicaid Fee Schedule,113.35,Pays at 80.03% of Total Billed charges,12.29,Pays at 102% of Medicare OPPS Rate,127.47,Pays at 90% of Total Billed charges,15.16,Pays at 100% of GA Medicaid Fee Schedule,12.05,Pays at 100% of Medicare OPPS Rate,15.16,Pays at 100% of GA Medicaid Fee Schedule,124.63,Pays at 88% of Total Billed charges,15.61,Pays at 103% of GA Medicaid Fee Schedule,12.05,127.47,84.98
Outpatient Medical Services,LAB,86255,ANTI-NEURONAL NUCLEAR AB TYPE 1 (MAYO),300,141.65,120.4,Pays at 85% of Billed charges for outpatient setting,15.16,Pays at 100% of GA Medicaid Fee Schedule,113.36,Pays at 80.03% of Total Billed charges,12.29,Pays at 102% of Medicare OPPS Rate,127.49,Pays at 90% of Total Billed charges,15.16,Pays at 100% of GA Medicaid Fee Schedule,12.05,Pays at 100% of Medicare OPPS Rate,15.16,Pays at 100% of GA Medicaid Fee Schedule,124.65,Pays at 88% of Total Billed charges,15.61,Pays at 103% of GA Medicaid Fee Schedule,12.05,127.49,84.99
Outpatient Medical Services,LAB,86255,PURKINJE CELL CYTOPLAS AB TYPE TR (MAYO),300,141.65,120.4,Pays at 85% of Billed charges for outpatient setting,15.16,Pays at 100% of GA Medicaid Fee Schedule,113.36,Pays at 80.03% of Total Billed charges,12.29,Pays at 102% of Medicare OPPS Rate,127.49,Pays at 90% of Total Billed charges,15.16,Pays at 100% of GA Medicaid Fee Schedule,12.05,Pays at 100% of Medicare OPPS Rate,15.16,Pays at 100% of GA Medicaid Fee Schedule,124.65,Pays at 88% of Total Billed charges,15.61,Pays at 103% of GA Medicaid Fee Schedule,12.05,127.49,84.99
Outpatient Medical Services,LAB,86255,PURKINJE CELL CYTOPLAS AB TYPE 2 (MAYO),300,141.65,120.4,Pays at 85% of Billed charges for outpatient setting,15.16,Pays at 100% of GA Medicaid Fee Schedule,113.36,Pays at 80.03% of Total Billed charges,12.29,Pays at 102% of Medicare OPPS Rate,127.49,Pays at 90% of Total Billed charges,15.16,Pays at 100% of GA Medicaid Fee Schedule,12.05,Pays at 100% of Medicare OPPS Rate,15.16,Pays at 100% of GA Medicaid Fee Schedule,124.65,Pays at 88% of Total Billed charges,15.61,Pays at 103% of GA Medicaid Fee Schedule,12.05,127.49,84.99
Outpatient Medical Services,LAB,86255,CRMP-5-IGG (MAYO),300,141.65,120.4,Pays at 85% of Billed charges for outpatient setting,15.16,Pays at 100% of GA Medicaid Fee Schedule,113.36,Pays at 80.03% of Total Billed charges,12.29,Pays at 102% of Medicare OPPS Rate,127.49,Pays at 90% of Total Billed charges,15.16,Pays at 100% of GA Medicaid Fee Schedule,12.05,Pays at 100% of Medicare OPPS Rate,15.16,Pays at 100% of GA Medicaid Fee Schedule,124.65,Pays at 88% of Total Billed charges,15.61,Pays at 103% of GA Medicaid Fee Schedule,12.05,127.49,84.99
Outpatient Medical Services,LAB,86255,ANTI-NEURONAL NUCLEAR AB TYPE 2 (MAYO),300,141.65,120.4,Pays at 85% of Billed charges for outpatient setting,15.16,Pays at 100% of GA Medicaid Fee Schedule,113.36,Pays at 80.03% of Total Billed charges,12.29,Pays at 102% of Medicare OPPS Rate,127.49,Pays at 90% of Total Billed charges,15.16,Pays at 100% of GA Medicaid Fee Schedule,12.05,Pays at 100% of Medicare OPPS Rate,15.16,Pays at 100% of GA Medicaid Fee Schedule,124.65,Pays at 88% of Total Billed charges,15.61,Pays at 103% of GA Medicaid Fee Schedule,12.05,127.49,84.99
Outpatient Medical Services,LAB,86255,AMPHYIPHYSIN AB (MAYO),300,141.65,120.4,Pays at 85% of Billed charges for outpatient setting,15.16,Pays at 100% of GA Medicaid Fee Schedule,113.36,Pays at 80.03% of Total Billed charges,12.29,Pays at 102% of Medicare OPPS Rate,127.49,Pays at 90% of Total Billed charges,15.16,Pays at 100% of GA Medicaid Fee Schedule,12.05,Pays at 100% of Medicare OPPS Rate,15.16,Pays at 100% of GA Medicaid Fee Schedule,124.65,Pays at 88% of Total Billed charges,15.61,Pays at 103% of GA Medicaid Fee Schedule,12.05,127.49,84.99
Outpatient Medical Services,LAB,86255,ANTI-GLIAL NUCLEAR AB TYPE 1 (MAYO),300,141.65,120.4,Pays at 85% of Billed charges for outpatient setting,15.16,Pays at 100% of GA Medicaid Fee Schedule,113.36,Pays at 80.03% of Total Billed charges,12.29,Pays at 102% of Medicare OPPS Rate,127.49,Pays at 90% of Total Billed charges,15.16,Pays at 100% of GA Medicaid Fee Schedule,12.05,Pays at 100% of Medicare OPPS Rate,15.16,Pays at 100% of GA Medicaid Fee Schedule,124.65,Pays at 88% of Total Billed charges,15.61,Pays at 103% of GA Medicaid Fee Schedule,12.05,127.49,84.99
Outpatient Medical Services,LAB,86255,ANTI-NEURONAL NUCLEAR AB TYPE 2 (MAYO),300,141.65,120.4,Pays at 85% of Billed charges for outpatient setting,15.16,Pays at 100% of GA Medicaid Fee Schedule,113.36,Pays at 80.03% of Total Billed charges,12.29,Pays at 102% of Medicare OPPS Rate,127.49,Pays at 90% of Total Billed charges,15.16,Pays at 100% of GA Medicaid Fee Schedule,12.05,Pays at 100% of Medicare OPPS Rate,15.16,Pays at 100% of GA Medicaid Fee Schedule,124.65,Pays at 88% of Total Billed charges,15.61,Pays at 103% of GA Medicaid Fee Schedule,12.05,127.49,84.99
Outpatient Medical Services,LAB,86255,ANTI-NEURONAL NUCLEAR AB TYPE 1 (MAYO),300,141.65,120.4,Pays at 85% of Billed charges for outpatient setting,15.16,Pays at 100% of GA Medicaid Fee Schedule,113.36,Pays at 80.03% of Total Billed charges,12.29,Pays at 102% of Medicare OPPS Rate,127.49,Pays at 90% of Total Billed charges,15.16,Pays at 100% of GA Medicaid Fee Schedule,12.05,Pays at 100% of Medicare OPPS Rate,15.16,Pays at 100% of GA Medicaid Fee Schedule,124.65,Pays at 88% of Total Billed charges,15.61,Pays at 103% of GA Medicaid Fee Schedule,12.05,127.49,84.99
Outpatient Medical Services,LAB,86255,AMPHYIPHYSIN AB CSF (MAYO),300,141.65,120.4,Pays at 85% of Billed charges for outpatient setting,15.16,Pays at 100% of GA Medicaid Fee Schedule,113.36,Pays at 80.03% of Total Billed charges,12.29,Pays at 102% of Medicare OPPS Rate,127.49,Pays at 90% of Total Billed charges,15.16,Pays at 100% of GA Medicaid Fee Schedule,12.05,Pays at 100% of Medicare OPPS Rate,15.16,Pays at 100% of GA Medicaid Fee Schedule,124.65,Pays at 88% of Total Billed charges,15.61,Pays at 103% of GA Medicaid Fee Schedule,12.05,127.49,84.99
Outpatient Medical Services,LAB,86255,PURKINJE CELL CYTOPLAS AB TYPE TR (MAYO),300,141.65,120.4,Pays at 85% of Billed charges for outpatient setting,15.16,Pays at 100% of GA Medicaid Fee Schedule,113.36,Pays at 80.03% of Total Billed charges,12.29,Pays at 102% of Medicare OPPS Rate,127.49,Pays at 90% of Total Billed charges,15.16,Pays at 100% of GA Medicaid Fee Schedule,12.05,Pays at 100% of Medicare OPPS Rate,15.16,Pays at 100% of GA Medicaid Fee Schedule,124.65,Pays at 88% of Total Billed charges,15.61,Pays at 103% of GA Medicaid Fee Schedule,12.05,127.49,84.99
Outpatient Medical Services,LAB,86255,PURKINJE CELL CYTOPLAS AB TYPE 2 (MAYO),300,141.65,120.4,Pays at 85% of Billed charges for outpatient setting,15.16,Pays at 100% of GA Medicaid Fee Schedule,113.36,Pays at 80.03% of Total Billed charges,12.29,Pays at 102% of Medicare OPPS Rate,127.49,Pays at 90% of Total Billed charges,15.16,Pays at 100% of GA Medicaid Fee Schedule,12.05,Pays at 100% of Medicare OPPS Rate,15.16,Pays at 100% of GA Medicaid Fee Schedule,124.65,Pays at 88% of Total Billed charges,15.61,Pays at 103% of GA Medicaid Fee Schedule,12.05,127.49,84.99
Outpatient Medical Services,LAB,86255,CRMP-5-IGG CSF (MAYO),300,141.65,120.4,Pays at 85% of Billed charges for outpatient setting,15.16,Pays at 100% of GA Medicaid Fee Schedule,113.36,Pays at 80.03% of Total Billed charges,12.29,Pays at 102% of Medicare OPPS Rate,127.49,Pays at 90% of Total Billed charges,15.16,Pays at 100% of GA Medicaid Fee Schedule,12.05,Pays at 100% of Medicare OPPS Rate,15.16,Pays at 100% of GA Medicaid Fee Schedule,124.65,Pays at 88% of Total Billed charges,15.61,Pays at 103% of GA Medicaid Fee Schedule,12.05,127.49,84.99
Outpatient Medical Services,LAB,86255,ANTI-GLIAL NUCLEAR AB TYPE 1 (MAYO),300,141.65,120.4,Pays at 85% of Billed charges for outpatient setting,15.16,Pays at 100% of GA Medicaid Fee Schedule,113.36,Pays at 80.03% of Total Billed charges,12.29,Pays at 102% of Medicare OPPS Rate,127.49,Pays at 90% of Total Billed charges,15.16,Pays at 100% of GA Medicaid Fee Schedule,12.05,Pays at 100% of Medicare OPPS Rate,15.16,Pays at 100% of GA Medicaid Fee Schedule,124.65,Pays at 88% of Total Billed charges,15.61,Pays at 103% of GA Medicaid Fee Schedule,12.05,127.49,84.99
Outpatient Medical Services,LAB,86255,ANTI-PANCREATIC ISLET CELL  (MAYO),300,183,155.55,Pays at 85% of Billed charges for outpatient setting,15.16,Pays at 100% of GA Medicaid Fee Schedule,146.45,Pays at 80.03% of Total Billed charges,12.29,Pays at 102% of Medicare OPPS Rate,164.7,Pays at 90% of Total Billed charges,15.16,Pays at 100% of GA Medicaid Fee Schedule,12.05,Pays at 100% of Medicare OPPS Rate,15.16,Pays at 100% of GA Medicaid Fee Schedule,161.04,Pays at 88% of Total Billed charges,15.61,Pays at 103% of GA Medicaid Fee Schedule,12.05,164.7,109.80
Outpatient Medical Services,LAB,86255,NEUTROPHIL SPECIFIC ABS  (MAYO),300,196.75,167.24,Pays at 85% of Billed charges for outpatient setting,15.16,Pays at 100% of GA Medicaid Fee Schedule,157.46,Pays at 80.03% of Total Billed charges,12.29,Pays at 102% of Medicare OPPS Rate,177.08,Pays at 90% of Total Billed charges,15.16,Pays at 100% of GA Medicaid Fee Schedule,12.05,Pays at 100% of Medicare OPPS Rate,15.16,Pays at 100% of GA Medicaid Fee Schedule,173.14,Pays at 88% of Total Billed charges,15.61,Pays at 103% of GA Medicaid Fee Schedule,12.05,177.08,118.05
Outpatient Medical Services,LAB,86255,"C-ANCA, ANTINEUT CYTOPLASMIC ABS  (MAYO)",300,270.58,229.99,Pays at 85% of Billed charges for outpatient setting,15.16,Pays at 100% of GA Medicaid Fee Schedule,216.55,Pays at 80.03% of Total Billed charges,12.29,Pays at 102% of Medicare OPPS Rate,243.52,Pays at 90% of Total Billed charges,15.16,Pays at 100% of GA Medicaid Fee Schedule,12.05,Pays at 100% of Medicare OPPS Rate,15.16,Pays at 100% of GA Medicaid Fee Schedule,238.11,Pays at 88% of Total Billed charges,15.61,Pays at 103% of GA Medicaid Fee Schedule,12.05,243.52,162.35
Outpatient Medical Services,LAB,86255,NEUROMYELITIS OPTICA/AQUAPORIN-4  (MAYO),300,760.75,646.64,Pays at 85% of Billed charges for outpatient setting,15.16,Pays at 100% of GA Medicaid Fee Schedule,608.83,Pays at 80.03% of Total Billed charges,12.29,Pays at 102% of Medicare OPPS Rate,684.68,Pays at 90% of Total Billed charges,15.16,Pays at 100% of GA Medicaid Fee Schedule,12.05,Pays at 100% of Medicare OPPS Rate,15.16,Pays at 100% of GA Medicaid Fee Schedule,669.46,Pays at 88% of Total Billed charges,15.61,Pays at 103% of GA Medicaid Fee Schedule,12.05,684.68,456.45
Outpatient Medical Services,LAB,86256,RETICULIN IGA TITER  (MAYO),300,112,95.2,Pays at 85% of Billed charges for outpatient setting,15.16,Pays at 100% of GA Medicaid Fee Schedule,89.63,Pays at 80.03% of Total Billed charges,12.29,Pays at 102% of Medicare OPPS Rate,100.8,Pays at 90% of Total Billed charges,15.16,Pays at 100% of GA Medicaid Fee Schedule,12.05,Pays at 100% of Medicare OPPS Rate,15.16,Pays at 100% of GA Medicaid Fee Schedule,98.56,Pays at 88% of Total Billed charges,15.61,Pays at 103% of GA Medicaid Fee Schedule,12.05,100.8,67.20
Outpatient Medical Services,LAB,86280,"E HISTOLYTICA AB, SERUM  (MAYO)",300,59.1,50.24,Pays at 85% of Billed charges for outpatient setting,10.3,Pays at 100% of GA Medicaid Fee Schedule,47.3,Pays at 80.03% of Total Billed charges,8.35,Pays at 102% of Medicare OPPS Rate,53.19,Pays at 90% of Total Billed charges,10.3,Pays at 100% of GA Medicaid Fee Schedule,8.19,Pays at 100% of Medicare OPPS Rate,10.3,Pays at 100% of GA Medicaid Fee Schedule,52.01,Pays at 88% of Total Billed charges,10.61,Pays at 103% of GA Medicaid Fee Schedule,8.19,53.19,35.46
Outpatient Medical Services,LAB,86300,Blood test to monitor breast cancer,300,47.5,40.38,Pays at 85% of Billed charges for outpatient setting,26.16,Pays at 100% of GA Medicaid Fee Schedule,38.01,Pays at 80.03% of Total Billed charges,21.22,Pays at 102% of Medicare OPPS Rate,42.75,Pays at 90% of Total Billed charges,26.16,Pays at 100% of GA Medicaid Fee Schedule,20.81,Pays at 100% of Medicare OPPS Rate,26.16,Pays at 100% of GA Medicaid Fee Schedule,41.8,Pays at 88% of Total Billed charges,26.94,Pays at 103% of GA Medicaid Fee Schedule,20.81,42.75,28.50
Outpatient Medical Services,LAB,86300,Blood test to monitor breast cancer,300,66.25,56.31,Pays at 85% of Billed charges for outpatient setting,26.16,Pays at 100% of GA Medicaid Fee Schedule,53.02,Pays at 80.03% of Total Billed charges,21.22,Pays at 102% of Medicare OPPS Rate,59.63,Pays at 90% of Total Billed charges,26.16,Pays at 100% of GA Medicaid Fee Schedule,20.81,Pays at 100% of Medicare OPPS Rate,26.16,Pays at 100% of GA Medicaid Fee Schedule,58.3,Pays at 88% of Total Billed charges,26.94,Pays at 103% of GA Medicaid Fee Schedule,20.81,59.63,39.75
Outpatient Medical Services,LAB,86301,CA 19-9  (MAYO),300,66.25,56.31,Pays at 85% of Billed charges for outpatient setting,26.16,Pays at 100% of GA Medicaid Fee Schedule,53.02,Pays at 80.03% of Total Billed charges,21.22,Pays at 102% of Medicare OPPS Rate,59.63,Pays at 90% of Total Billed charges,26.16,Pays at 100% of GA Medicaid Fee Schedule,20.81,Pays at 100% of Medicare OPPS Rate,26.16,Pays at 100% of GA Medicaid Fee Schedule,58.3,Pays at 88% of Total Billed charges,26.94,Pays at 103% of GA Medicaid Fee Schedule,20.81,59.63,39.75
Outpatient Medical Services,LAB,86304,Blood test to monitor for cancer,300,66.25,56.31,Pays at 85% of Billed charges for outpatient setting,26.16,Pays at 100% of GA Medicaid Fee Schedule,53.02,Pays at 80.03% of Total Billed charges,21.22,Pays at 102% of Medicare OPPS Rate,59.63,Pays at 90% of Total Billed charges,26.16,Pays at 100% of GA Medicaid Fee Schedule,20.81,Pays at 100% of Medicare OPPS Rate,26.16,Pays at 100% of GA Medicaid Fee Schedule,58.3,Pays at 88% of Total Billed charges,26.94,Pays at 103% of GA Medicaid Fee Schedule,20.81,59.63,39.75
Outpatient Medical Services,LAB,86308,MONO TEST QL,300,33,28.05,Pays at 85% of Billed charges for outpatient setting,6.51,Pays at 100% of GA Medicaid Fee Schedule,26.41,Pays at 80.03% of Total Billed charges,5.28,Pays at 102% of Medicare OPPS Rate,29.7,Pays at 90% of Total Billed charges,6.51,Pays at 100% of GA Medicaid Fee Schedule,5.18,Pays at 100% of Medicare OPPS Rate,6.51,Pays at 100% of GA Medicaid Fee Schedule,29.04,Pays at 88% of Total Billed charges,6.71,Pays at 103% of GA Medicaid Fee Schedule,5.18,29.7,19.80
Outpatient Medical Services,LAB,86308,"HETEROPHILE, AB  (MAYO)",300,63.75,54.19,Pays at 85% of Billed charges for outpatient setting,6.51,Pays at 100% of GA Medicaid Fee Schedule,51.02,Pays at 80.03% of Total Billed charges,5.28,Pays at 102% of Medicare OPPS Rate,57.38,Pays at 90% of Total Billed charges,6.51,Pays at 100% of GA Medicaid Fee Schedule,5.18,Pays at 100% of Medicare OPPS Rate,6.51,Pays at 100% of GA Medicaid Fee Schedule,56.1,Pays at 88% of Total Billed charges,6.71,Pays at 103% of GA Medicaid Fee Schedule,5.18,57.38,38.25
Outpatient Medical Services,LAB,86316,CHROMOGRANIN A  (MAYO),300,68.75,58.44,Pays at 85% of Billed charges for outpatient setting,26.16,Pays at 100% of GA Medicaid Fee Schedule,55.02,Pays at 80.03% of Total Billed charges,21.22,Pays at 102% of Medicare OPPS Rate,61.88,Pays at 90% of Total Billed charges,26.16,Pays at 100% of GA Medicaid Fee Schedule,20.81,Pays at 100% of Medicare OPPS Rate,26.16,Pays at 100% of GA Medicaid Fee Schedule,60.5,Pays at 88% of Total Billed charges,26.94,Pays at 103% of GA Medicaid Fee Schedule,20.81,61.88,41.25
Outpatient Medical Services,LAB,86316,"ALPHA FETOPROTEIN, PERITONEAL FL  (MAYO)",300,107.34,91.24,Pays at 85% of Billed charges for outpatient setting,26.16,Pays at 100% of GA Medicaid Fee Schedule,85.9,Pays at 80.03% of Total Billed charges,21.22,Pays at 102% of Medicare OPPS Rate,96.61,Pays at 90% of Total Billed charges,26.16,Pays at 100% of GA Medicaid Fee Schedule,20.81,Pays at 100% of Medicare OPPS Rate,26.16,Pays at 100% of GA Medicaid Fee Schedule,94.46,Pays at 88% of Total Billed charges,26.94,Pays at 103% of GA Medicaid Fee Schedule,20.81,96.61,64.40
Outpatient Medical Services,LAB,86316,HE4 OVARIAN CANCER MARKER  (MAYO),300,258.5,219.73,Pays at 85% of Billed charges for outpatient setting,26.16,Pays at 100% of GA Medicaid Fee Schedule,206.88,Pays at 80.03% of Total Billed charges,21.22,Pays at 102% of Medicare OPPS Rate,232.65,Pays at 90% of Total Billed charges,26.16,Pays at 100% of GA Medicaid Fee Schedule,20.81,Pays at 100% of Medicare OPPS Rate,26.16,Pays at 100% of GA Medicaid Fee Schedule,227.48,Pays at 88% of Total Billed charges,26.94,Pays at 103% of GA Medicaid Fee Schedule,20.81,232.65,155.10
Outpatient Medical Services,LAB,86317,S. PNEUMO INDIVIDUAL SEROTYPE IGG,300,10,8.5,Pays at 85% of Billed charges for outpatient setting,15.09,Pays at 100% of GA Medicaid Fee Schedule,8,Pays at 80.03% of Total Billed charges,15.28,Pays at 102% of Medicare OPPS Rate,9,Pays at 90% of Total Billed charges,15.09,Pays at 100% of GA Medicaid Fee Schedule,14.99,Pays at 100% of Medicare OPPS Rate,15.09,Pays at 100% of GA Medicaid Fee Schedule,8.8,Pays at 88% of Total Billed charges,15.54,Pays at 103% of GA Medicaid Fee Schedule,8,15.54,6.00
Outpatient Medical Services,LAB,86317,PNEUMO AB TYPE 1,300,23,19.55,Pays at 85% of Billed charges for outpatient setting,15.09,Pays at 100% of GA Medicaid Fee Schedule,18.41,Pays at 80.03% of Total Billed charges,15.28,Pays at 102% of Medicare OPPS Rate,20.7,Pays at 90% of Total Billed charges,15.09,Pays at 100% of GA Medicaid Fee Schedule,14.99,Pays at 100% of Medicare OPPS Rate,15.09,Pays at 100% of GA Medicaid Fee Schedule,20.24,Pays at 88% of Total Billed charges,15.54,Pays at 103% of GA Medicaid Fee Schedule,14.99,20.7,13.80
Outpatient Medical Services,LAB,86317,PNEUMO AB TYPE 3,300,23,19.55,Pays at 85% of Billed charges for outpatient setting,15.09,Pays at 100% of GA Medicaid Fee Schedule,18.41,Pays at 80.03% of Total Billed charges,15.28,Pays at 102% of Medicare OPPS Rate,20.7,Pays at 90% of Total Billed charges,15.09,Pays at 100% of GA Medicaid Fee Schedule,14.99,Pays at 100% of Medicare OPPS Rate,15.09,Pays at 100% of GA Medicaid Fee Schedule,20.24,Pays at 88% of Total Billed charges,15.54,Pays at 103% of GA Medicaid Fee Schedule,14.99,20.7,13.80
Outpatient Medical Services,LAB,86317,PNEUMO AB TYPE 4,300,23,19.55,Pays at 85% of Billed charges for outpatient setting,15.09,Pays at 100% of GA Medicaid Fee Schedule,18.41,Pays at 80.03% of Total Billed charges,15.28,Pays at 102% of Medicare OPPS Rate,20.7,Pays at 90% of Total Billed charges,15.09,Pays at 100% of GA Medicaid Fee Schedule,14.99,Pays at 100% of Medicare OPPS Rate,15.09,Pays at 100% of GA Medicaid Fee Schedule,20.24,Pays at 88% of Total Billed charges,15.54,Pays at 103% of GA Medicaid Fee Schedule,14.99,20.7,13.80
Outpatient Medical Services,LAB,86317,PNEUMO AB TYPE 8,300,23,19.55,Pays at 85% of Billed charges for outpatient setting,15.09,Pays at 100% of GA Medicaid Fee Schedule,18.41,Pays at 80.03% of Total Billed charges,15.28,Pays at 102% of Medicare OPPS Rate,20.7,Pays at 90% of Total Billed charges,15.09,Pays at 100% of GA Medicaid Fee Schedule,14.99,Pays at 100% of Medicare OPPS Rate,15.09,Pays at 100% of GA Medicaid Fee Schedule,20.24,Pays at 88% of Total Billed charges,15.54,Pays at 103% of GA Medicaid Fee Schedule,14.99,20.7,13.80
Outpatient Medical Services,LAB,86317,PNEUMO AB TYPE 9,300,23,19.55,Pays at 85% of Billed charges for outpatient setting,15.09,Pays at 100% of GA Medicaid Fee Schedule,18.41,Pays at 80.03% of Total Billed charges,15.28,Pays at 102% of Medicare OPPS Rate,20.7,Pays at 90% of Total Billed charges,15.09,Pays at 100% of GA Medicaid Fee Schedule,14.99,Pays at 100% of Medicare OPPS Rate,15.09,Pays at 100% of GA Medicaid Fee Schedule,20.24,Pays at 88% of Total Billed charges,15.54,Pays at 103% of GA Medicaid Fee Schedule,14.99,20.7,13.80
Outpatient Medical Services,LAB,86317,PNEUMO AB TYPE 12,300,23,19.55,Pays at 85% of Billed charges for outpatient setting,15.09,Pays at 100% of GA Medicaid Fee Schedule,18.41,Pays at 80.03% of Total Billed charges,15.28,Pays at 102% of Medicare OPPS Rate,20.7,Pays at 90% of Total Billed charges,15.09,Pays at 100% of GA Medicaid Fee Schedule,14.99,Pays at 100% of Medicare OPPS Rate,15.09,Pays at 100% of GA Medicaid Fee Schedule,20.24,Pays at 88% of Total Billed charges,15.54,Pays at 103% of GA Medicaid Fee Schedule,14.99,20.7,13.80
Outpatient Medical Services,LAB,86317,PNEUMO AB TYPE 14,300,23,19.55,Pays at 85% of Billed charges for outpatient setting,15.09,Pays at 100% of GA Medicaid Fee Schedule,18.41,Pays at 80.03% of Total Billed charges,15.28,Pays at 102% of Medicare OPPS Rate,20.7,Pays at 90% of Total Billed charges,15.09,Pays at 100% of GA Medicaid Fee Schedule,14.99,Pays at 100% of Medicare OPPS Rate,15.09,Pays at 100% of GA Medicaid Fee Schedule,20.24,Pays at 88% of Total Billed charges,15.54,Pays at 103% of GA Medicaid Fee Schedule,14.99,20.7,13.80
Outpatient Medical Services,LAB,86317,PNEUMO AB TYPE 19,300,23,19.55,Pays at 85% of Billed charges for outpatient setting,15.09,Pays at 100% of GA Medicaid Fee Schedule,18.41,Pays at 80.03% of Total Billed charges,15.28,Pays at 102% of Medicare OPPS Rate,20.7,Pays at 90% of Total Billed charges,15.09,Pays at 100% of GA Medicaid Fee Schedule,14.99,Pays at 100% of Medicare OPPS Rate,15.09,Pays at 100% of GA Medicaid Fee Schedule,20.24,Pays at 88% of Total Billed charges,15.54,Pays at 103% of GA Medicaid Fee Schedule,14.99,20.7,13.80
Outpatient Medical Services,LAB,86317,PNEUMO AB TYPE 23,300,23,19.55,Pays at 85% of Billed charges for outpatient setting,15.09,Pays at 100% of GA Medicaid Fee Schedule,18.41,Pays at 80.03% of Total Billed charges,15.28,Pays at 102% of Medicare OPPS Rate,20.7,Pays at 90% of Total Billed charges,15.09,Pays at 100% of GA Medicaid Fee Schedule,14.99,Pays at 100% of Medicare OPPS Rate,15.09,Pays at 100% of GA Medicaid Fee Schedule,20.24,Pays at 88% of Total Billed charges,15.54,Pays at 103% of GA Medicaid Fee Schedule,14.99,20.7,13.80
Outpatient Medical Services,LAB,86317,PNEUMO AB TYPE 26,300,23,19.55,Pays at 85% of Billed charges for outpatient setting,15.09,Pays at 100% of GA Medicaid Fee Schedule,18.41,Pays at 80.03% of Total Billed charges,15.28,Pays at 102% of Medicare OPPS Rate,20.7,Pays at 90% of Total Billed charges,15.09,Pays at 100% of GA Medicaid Fee Schedule,14.99,Pays at 100% of Medicare OPPS Rate,15.09,Pays at 100% of GA Medicaid Fee Schedule,20.24,Pays at 88% of Total Billed charges,15.54,Pays at 103% of GA Medicaid Fee Schedule,14.99,20.7,13.80
Outpatient Medical Services,LAB,86317,PNEUMO AB TYPE 51,300,23,19.55,Pays at 85% of Billed charges for outpatient setting,15.09,Pays at 100% of GA Medicaid Fee Schedule,18.41,Pays at 80.03% of Total Billed charges,15.28,Pays at 102% of Medicare OPPS Rate,20.7,Pays at 90% of Total Billed charges,15.09,Pays at 100% of GA Medicaid Fee Schedule,14.99,Pays at 100% of Medicare OPPS Rate,15.09,Pays at 100% of GA Medicaid Fee Schedule,20.24,Pays at 88% of Total Billed charges,15.54,Pays at 103% of GA Medicaid Fee Schedule,14.99,20.7,13.80
Outpatient Medical Services,LAB,86317,PNEUMO AB TYPE 56,300,23,19.55,Pays at 85% of Billed charges for outpatient setting,15.09,Pays at 100% of GA Medicaid Fee Schedule,18.41,Pays at 80.03% of Total Billed charges,15.28,Pays at 102% of Medicare OPPS Rate,20.7,Pays at 90% of Total Billed charges,15.09,Pays at 100% of GA Medicaid Fee Schedule,14.99,Pays at 100% of Medicare OPPS Rate,15.09,Pays at 100% of GA Medicaid Fee Schedule,20.24,Pays at 88% of Total Billed charges,15.54,Pays at 103% of GA Medicaid Fee Schedule,14.99,20.7,13.80
Outpatient Medical Services,LAB,86317,"TETANUS ANTITOXOID AB, IGG  (MAYO)",300,49,41.65,Pays at 85% of Billed charges for outpatient setting,15.09,Pays at 100% of GA Medicaid Fee Schedule,39.21,Pays at 80.03% of Total Billed charges,15.28,Pays at 102% of Medicare OPPS Rate,44.1,Pays at 90% of Total Billed charges,15.09,Pays at 100% of GA Medicaid Fee Schedule,14.99,Pays at 100% of Medicare OPPS Rate,15.09,Pays at 100% of GA Medicaid Fee Schedule,43.12,Pays at 88% of Total Billed charges,15.54,Pays at 103% of GA Medicaid Fee Schedule,14.99,44.1,29.40
Outpatient Medical Services,LAB,86320,IMMUNOFIXATION W LIGHT CHAINS SERUM MAYO,300,325,276.25,Pays at 85% of Billed charges for outpatient setting,28.19,Pays at 100% of GA Medicaid Fee Schedule,260.1,Pays at 80.03% of Total Billed charges,30.51,Pays at 102% of Medicare OPPS Rate,292.5,Pays at 90% of Total Billed charges,28.19,Pays at 100% of GA Medicaid Fee Schedule,29.92,Pays at 100% of Medicare OPPS Rate,28.19,Pays at 100% of GA Medicaid Fee Schedule,286,Pays at 88% of Total Billed charges,29.04,Pays at 103% of GA Medicaid Fee Schedule,28.19,292.5,195.00
Outpatient Medical Services,LAB,86325,IMMUNOFIXATION-OTHER FLDS  (MAYO),300,158.75,134.94,Pays at 85% of Billed charges for outpatient setting,28.12,Pays at 100% of GA Medicaid Fee Schedule,127.05,Pays at 80.03% of Total Billed charges,23.59,Pays at 102% of Medicare OPPS Rate,142.88,Pays at 90% of Total Billed charges,28.12,Pays at 100% of GA Medicaid Fee Schedule,23.13,Pays at 100% of Medicare OPPS Rate,28.12,Pays at 100% of GA Medicaid Fee Schedule,139.7,Pays at 88% of Total Billed charges,28.96,Pays at 103% of GA Medicaid Fee Schedule,23.13,142.88,95.25
Outpatient Medical Services,LAB,86332,IMMUNE COMPLEX CD3  (MAYO),300,198.75,168.94,Pays at 85% of Billed charges for outpatient setting,30.65,Pays at 100% of GA Medicaid Fee Schedule,159.06,Pays at 80.03% of Total Billed charges,24.85,Pays at 102% of Medicare OPPS Rate,178.88,Pays at 90% of Total Billed charges,30.65,Pays at 100% of GA Medicaid Fee Schedule,24.37,Pays at 100% of Medicare OPPS Rate,30.65,Pays at 100% of GA Medicaid Fee Schedule,174.9,Pays at 88% of Total Billed charges,31.57,Pays at 103% of GA Medicaid Fee Schedule,24.37,178.88,119.25
Outpatient Medical Services,LAB,86334,".IMMUNOFIXATION, SERUM  ONLY (MAYO)",300,220,187,Pays at 85% of Billed charges for outpatient setting,28.09,Pays at 100% of GA Medicaid Fee Schedule,176.07,Pays at 80.03% of Total Billed charges,22.78,Pays at 102% of Medicare OPPS Rate,198,Pays at 90% of Total Billed charges,28.09,Pays at 100% of GA Medicaid Fee Schedule,22.34,Pays at 100% of Medicare OPPS Rate,28.09,Pays at 100% of GA Medicaid Fee Schedule,193.6,Pays at 88% of Total Billed charges,28.93,Pays at 103% of GA Medicaid Fee Schedule,22.34,198,132.00
Outpatient Medical Services,LAB,86334,IMMUNOFIXATION SERUM ONLY  (MAYO),300,225.75,191.89,Pays at 85% of Billed charges for outpatient setting,28.09,Pays at 100% of GA Medicaid Fee Schedule,180.67,Pays at 80.03% of Total Billed charges,22.78,Pays at 102% of Medicare OPPS Rate,203.18,Pays at 90% of Total Billed charges,28.09,Pays at 100% of GA Medicaid Fee Schedule,22.34,Pays at 100% of Medicare OPPS Rate,28.09,Pays at 100% of GA Medicaid Fee Schedule,198.66,Pays at 88% of Total Billed charges,28.93,Pays at 103% of GA Medicaid Fee Schedule,22.34,203.18,135.45
Outpatient Medical Services,LAB,86335,BETA 2 TRANSFERRIN  (MAYO),300,150,127.5,Pays at 85% of Billed charges for outpatient setting,36.9,Pays at 100% of GA Medicaid Fee Schedule,120.05,Pays at 80.03% of Total Billed charges,29.93,Pays at 102% of Medicare OPPS Rate,135,Pays at 90% of Total Billed charges,36.9,Pays at 100% of GA Medicaid Fee Schedule,29.35,Pays at 100% of Medicare OPPS Rate,36.9,Pays at 100% of GA Medicaid Fee Schedule,132,Pays at 88% of Total Billed charges,38.01,Pays at 103% of GA Medicaid Fee Schedule,29.35,135,90.00
Outpatient Medical Services,LAB,86335,"IMMUNOFIX, ELECTRO W\CONC U  (MAYO)",300,220,187,Pays at 85% of Billed charges for outpatient setting,36.9,Pays at 100% of GA Medicaid Fee Schedule,176.07,Pays at 80.03% of Total Billed charges,29.93,Pays at 102% of Medicare OPPS Rate,198,Pays at 90% of Total Billed charges,36.9,Pays at 100% of GA Medicaid Fee Schedule,29.35,Pays at 100% of Medicare OPPS Rate,36.9,Pays at 100% of GA Medicaid Fee Schedule,193.6,Pays at 88% of Total Billed charges,38.01,Pays at 103% of GA Medicaid Fee Schedule,29.35,198,132.00
Outpatient Medical Services,LAB,86337,INSULIN AB  (MAYO),300,74.5,63.33,Pays at 85% of Billed charges for outpatient setting,26.93,Pays at 100% of GA Medicaid Fee Schedule,59.62,Pays at 80.03% of Total Billed charges,21.83,Pays at 102% of Medicare OPPS Rate,67.05,Pays at 90% of Total Billed charges,26.93,Pays at 100% of GA Medicaid Fee Schedule,21.41,Pays at 100% of Medicare OPPS Rate,26.93,Pays at 100% of GA Medicaid Fee Schedule,65.56,Pays at 88% of Total Billed charges,27.74,Pays at 103% of GA Medicaid Fee Schedule,21.41,67.05,44.70
Outpatient Medical Services,LAB,86340,"INTRINSIC FACTOR BLOCKING AB, S  (MAYO)",300,132.5,112.63,Pays at 85% of Billed charges for outpatient setting,18.95,Pays at 100% of GA Medicaid Fee Schedule,106.04,Pays at 80.03% of Total Billed charges,15.38,Pays at 102% of Medicare OPPS Rate,119.25,Pays at 90% of Total Billed charges,18.95,Pays at 100% of GA Medicaid Fee Schedule,15.08,Pays at 100% of Medicare OPPS Rate,18.95,Pays at 100% of GA Medicaid Fee Schedule,116.6,Pays at 88% of Total Billed charges,19.52,Pays at 103% of GA Medicaid Fee Schedule,15.08,119.25,79.50
Outpatient Medical Services,LAB,86341,ISLET CELL AB  (MAYO),300,88,74.8,Pays at 85% of Billed charges for outpatient setting,24.89,Pays at 100% of GA Medicaid Fee Schedule,70.43,Pays at 80.03% of Total Billed charges,24.04,Pays at 102% of Medicare OPPS Rate,79.2,Pays at 90% of Total Billed charges,24.89,Pays at 100% of GA Medicaid Fee Schedule,23.57,Pays at 100% of Medicare OPPS Rate,24.89,Pays at 100% of GA Medicaid Fee Schedule,77.44,Pays at 88% of Total Billed charges,25.64,Pays at 103% of GA Medicaid Fee Schedule,23.57,79.2,52.80
Outpatient Medical Services,LAB,86341,ANTI-GAD 65/INSULIN I125  (MAYO),300,278.75,236.94,Pays at 85% of Billed charges for outpatient setting,24.89,Pays at 100% of GA Medicaid Fee Schedule,223.08,Pays at 80.03% of Total Billed charges,24.04,Pays at 102% of Medicare OPPS Rate,250.88,Pays at 90% of Total Billed charges,24.89,Pays at 100% of GA Medicaid Fee Schedule,23.57,Pays at 100% of Medicare OPPS Rate,24.89,Pays at 100% of GA Medicaid Fee Schedule,245.3,Pays at 88% of Total Billed charges,25.64,Pays at 103% of GA Medicaid Fee Schedule,23.57,250.88,167.25
Outpatient Medical Services,LAB,86341,GLUTAMIC ACID  (MAYO),300,481,408.85,Pays at 85% of Billed charges for outpatient setting,24.89,Pays at 100% of GA Medicaid Fee Schedule,384.94,Pays at 80.03% of Total Billed charges,24.04,Pays at 102% of Medicare OPPS Rate,432.9,Pays at 90% of Total Billed charges,24.89,Pays at 100% of GA Medicaid Fee Schedule,23.57,Pays at 100% of Medicare OPPS Rate,24.89,Pays at 100% of GA Medicaid Fee Schedule,423.28,Pays at 88% of Total Billed charges,25.64,Pays at 103% of GA Medicaid Fee Schedule,23.57,432.9,288.60
Outpatient Medical Services,LAB,86353,LYMPHOCYTE PROLIFERATION TO AGS (MAYO),300,568.25,483.01,Pays at 85% of Billed charges for outpatient setting,61.64,Pays at 100% of GA Medicaid Fee Schedule,454.77,Pays at 80.03% of Total Billed charges,50.01,Pays at 102% of Medicare OPPS Rate,511.43,Pays at 90% of Total Billed charges,61.64,Pays at 100% of GA Medicaid Fee Schedule,49.03,Pays at 100% of Medicare OPPS Rate,61.64,Pays at 100% of GA Medicaid Fee Schedule,500.06,Pays at 88% of Total Billed charges,63.49,Pays at 103% of GA Medicaid Fee Schedule,49.03,511.43,340.95
Outpatient Medical Services,LAB,86355,"B CELLS, TOTAL COUNT  (MAYO)",310,50.25,42.71,Pays at 85% of Billed charges for outpatient setting,29.62,Pays at 100% of GA Medicaid Fee Schedule,40.22,Pays at 80.03% of Total Billed charges,38.48,Pays at 102% of Medicare OPPS Rate,45.23,Pays at 90% of Total Billed charges,29.62,Pays at 100% of GA Medicaid Fee Schedule,37.72,Pays at 100% of Medicare OPPS Rate,29.62,Pays at 100% of GA Medicaid Fee Schedule,44.22,Pays at 88% of Total Billed charges,30.51,Pays at 103% of GA Medicaid Fee Schedule,29.62,45.23,30.15
Outpatient Medical Services,LAB,86355,B CELLS TOTAL COUNT  (MAYO),300,305.5,259.68,Pays at 85% of Billed charges for outpatient setting,29.62,Pays at 100% of GA Medicaid Fee Schedule,244.49,Pays at 80.03% of Total Billed charges,38.48,Pays at 102% of Medicare OPPS Rate,274.95,Pays at 90% of Total Billed charges,29.62,Pays at 100% of GA Medicaid Fee Schedule,37.72,Pays at 100% of Medicare OPPS Rate,29.62,Pays at 100% of GA Medicaid Fee Schedule,268.84,Pays at 88% of Total Billed charges,30.51,Pays at 103% of GA Medicaid Fee Schedule,29.62,274.95,183.30
Outpatient Medical Services,LAB,86356,CD20 TOTAL COUNT  (MAYO),300,217,184.45,Pays at 85% of Billed charges for outpatient setting,32.83,Pays at 100% of GA Medicaid Fee Schedule,173.67,Pays at 80.03% of Total Billed charges,27.31,Pays at 102% of Medicare OPPS Rate,195.3,Pays at 90% of Total Billed charges,32.83,Pays at 100% of GA Medicaid Fee Schedule,26.78,Pays at 100% of Medicare OPPS Rate,32.83,Pays at 100% of GA Medicaid Fee Schedule,190.96,Pays at 88% of Total Billed charges,33.81,Pays at 103% of GA Medicaid Fee Schedule,26.78,195.3,130.20
Outpatient Medical Services,LAB,86357,"NATURAL KILLER CELL SUBSETS, QUAN (MAYO)",310,50.25,42.71,Pays at 85% of Billed charges for outpatient setting,29.62,Pays at 100% of GA Medicaid Fee Schedule,40.22,Pays at 80.03% of Total Billed charges,38.48,Pays at 102% of Medicare OPPS Rate,45.23,Pays at 90% of Total Billed charges,29.62,Pays at 100% of GA Medicaid Fee Schedule,37.72,Pays at 100% of Medicare OPPS Rate,29.62,Pays at 100% of GA Medicaid Fee Schedule,44.22,Pays at 88% of Total Billed charges,30.51,Pays at 103% of GA Medicaid Fee Schedule,29.62,45.23,30.15
Outpatient Medical Services,LAB,86359,"T CELLS, TOTAL COUNT  (MAYO)",300,120,102,Pays at 85% of Billed charges for outpatient setting,29.62,Pays at 100% of GA Medicaid Fee Schedule,96.04,Pays at 80.03% of Total Billed charges,38.48,Pays at 102% of Medicare OPPS Rate,108,Pays at 90% of Total Billed charges,29.62,Pays at 100% of GA Medicaid Fee Schedule,37.72,Pays at 100% of Medicare OPPS Rate,29.62,Pays at 100% of GA Medicaid Fee Schedule,105.6,Pays at 88% of Total Billed charges,30.51,Pays at 103% of GA Medicaid Fee Schedule,29.62,108,72.00
Outpatient Medical Services,LAB,86360,ABSOLUTE CD4 & CD8 COUNT  (MAYO),310,99.5,84.58,Pays at 85% of Billed charges for outpatient setting,59.09,Pays at 100% of GA Medicaid Fee Schedule,79.63,Pays at 80.03% of Total Billed charges,47.91,Pays at 102% of Medicare OPPS Rate,89.55,Pays at 90% of Total Billed charges,59.09,Pays at 100% of GA Medicaid Fee Schedule,46.98,Pays at 100% of Medicare OPPS Rate,59.09,Pays at 100% of GA Medicaid Fee Schedule,87.56,Pays at 88% of Total Billed charges,60.86,Pays at 103% of GA Medicaid Fee Schedule,46.98,89.55,59.70
Outpatient Medical Services,LAB,86376,"ANTI-MICROSOMAL, LIVER/KIDNEY  (MAYO)",300,36.5,31.03,Pays at 85% of Billed charges for outpatient setting,18.3,Pays at 100% of GA Medicaid Fee Schedule,29.21,Pays at 80.03% of Total Billed charges,14.84,Pays at 102% of Medicare OPPS Rate,32.85,Pays at 90% of Total Billed charges,18.3,Pays at 100% of GA Medicaid Fee Schedule,14.55,Pays at 100% of Medicare OPPS Rate,18.3,Pays at 100% of GA Medicaid Fee Schedule,32.12,Pays at 88% of Total Billed charges,18.85,Pays at 103% of GA Medicaid Fee Schedule,14.55,32.85,21.90
Outpatient Medical Services,LAB,86376,.THYROID MICROSOMAL - OBSOLETE,300,41.75,35.49,Pays at 85% of Billed charges for outpatient setting,18.3,Pays at 100% of GA Medicaid Fee Schedule,33.41,Pays at 80.03% of Total Billed charges,14.84,Pays at 102% of Medicare OPPS Rate,37.58,Pays at 90% of Total Billed charges,18.3,Pays at 100% of GA Medicaid Fee Schedule,14.55,Pays at 100% of Medicare OPPS Rate,18.3,Pays at 100% of GA Medicaid Fee Schedule,36.74,Pays at 88% of Total Billed charges,18.85,Pays at 103% of GA Medicaid Fee Schedule,14.55,37.58,25.05
Outpatient Medical Services,LAB,86376,THYROID PEROXIDASE AB  (MAYO),300,46.5,39.53,Pays at 85% of Billed charges for outpatient setting,18.3,Pays at 100% of GA Medicaid Fee Schedule,37.21,Pays at 80.03% of Total Billed charges,14.84,Pays at 102% of Medicare OPPS Rate,41.85,Pays at 90% of Total Billed charges,18.3,Pays at 100% of GA Medicaid Fee Schedule,14.55,Pays at 100% of Medicare OPPS Rate,18.3,Pays at 100% of GA Medicaid Fee Schedule,40.92,Pays at 88% of Total Billed charges,18.85,Pays at 103% of GA Medicaid Fee Schedule,14.55,41.85,27.90
Outpatient Medical Services,LAB,86382,RABIES TITER  (MAYO),300,271.83,231.06,Pays at 85% of Billed charges for outpatient setting,21.26,Pays at 100% of GA Medicaid Fee Schedule,217.55,Pays at 80.03% of Total Billed charges,17.24,Pays at 102% of Medicare OPPS Rate,244.65,Pays at 90% of Total Billed charges,21.26,Pays at 100% of GA Medicaid Fee Schedule,16.91,Pays at 100% of Medicare OPPS Rate,21.26,Pays at 100% of GA Medicaid Fee Schedule,239.21,Pays at 88% of Total Billed charges,21.9,Pays at 103% of GA Medicaid Fee Schedule,16.91,244.65,163.10
Outpatient Medical Services,LAB,86431,"RHEUMATOID FACTOR, SERUM (MAYO)",300,33,28.05,Pays at 85% of Billed charges for outpatient setting,7.14,Pays at 100% of GA Medicaid Fee Schedule,26.41,Pays at 80.03% of Total Billed charges,5.78,Pays at 102% of Medicare OPPS Rate,29.7,Pays at 90% of Total Billed charges,7.14,Pays at 100% of GA Medicaid Fee Schedule,5.67,Pays at 100% of Medicare OPPS Rate,7.14,Pays at 100% of GA Medicaid Fee Schedule,29.04,Pays at 88% of Total Billed charges,7.35,Pays at 103% of GA Medicaid Fee Schedule,5.67,29.7,19.80
Outpatient Medical Services,LAB,86480,QUANTIFERON (AFB) GOLD  (MAYO),300,224.5,190.83,Pays at 85% of Billed charges for outpatient setting,77.93,Pays at 100% of GA Medicaid Fee Schedule,179.67,Pays at 80.03% of Total Billed charges,63.21,Pays at 102% of Medicare OPPS Rate,202.05,Pays at 90% of Total Billed charges,77.93,Pays at 100% of GA Medicaid Fee Schedule,61.98,Pays at 100% of Medicare OPPS Rate,77.93,Pays at 100% of GA Medicaid Fee Schedule,197.56,Pays at 88% of Total Billed charges,80.27,Pays at 103% of GA Medicaid Fee Schedule,61.98,202.05,134.70
Outpatient Medical Services,LAB,86592,Blood test to screen for syphilis,300,13.35,11.35,Pays at 85% of Billed charges for outpatient setting,4.65,Pays at 100% of GA Medicaid Fee Schedule,10.68,Pays at 80.03% of Total Billed charges,4.35,Pays at 102% of Medicare OPPS Rate,12.02,Pays at 90% of Total Billed charges,4.65,Pays at 100% of GA Medicaid Fee Schedule,4.26,Pays at 100% of Medicare OPPS Rate,4.65,Pays at 100% of GA Medicaid Fee Schedule,11.75,Pays at 88% of Total Billed charges,4.79,Pays at 103% of GA Medicaid Fee Schedule,4.26,12.02,8.01
Outpatient Medical Services,LAB,86592,Blood test to screen for syphilis,300,28,23.8,Pays at 85% of Billed charges for outpatient setting,4.65,Pays at 100% of GA Medicaid Fee Schedule,22.41,Pays at 80.03% of Total Billed charges,4.35,Pays at 102% of Medicare OPPS Rate,25.2,Pays at 90% of Total Billed charges,4.65,Pays at 100% of GA Medicaid Fee Schedule,4.26,Pays at 100% of Medicare OPPS Rate,4.65,Pays at 100% of GA Medicaid Fee Schedule,24.64,Pays at 88% of Total Billed charges,4.79,Pays at 103% of GA Medicaid Fee Schedule,4.26,25.2,16.80
Outpatient Medical Services,LAB,86592,Blood test to screen for syphilis,300,33,28.05,Pays at 85% of Billed charges for outpatient setting,4.65,Pays at 100% of GA Medicaid Fee Schedule,26.41,Pays at 80.03% of Total Billed charges,4.35,Pays at 102% of Medicare OPPS Rate,29.7,Pays at 90% of Total Billed charges,4.65,Pays at 100% of GA Medicaid Fee Schedule,4.26,Pays at 100% of Medicare OPPS Rate,4.65,Pays at 100% of GA Medicaid Fee Schedule,29.04,Pays at 88% of Total Billed charges,4.79,Pays at 103% of GA Medicaid Fee Schedule,4.26,29.7,19.80
Outpatient Medical Services,LAB,86592,Blood test to screen for syphilis,300,91.5,77.78,Pays at 85% of Billed charges for outpatient setting,4.65,Pays at 100% of GA Medicaid Fee Schedule,73.23,Pays at 80.03% of Total Billed charges,4.35,Pays at 102% of Medicare OPPS Rate,82.35,Pays at 90% of Total Billed charges,4.65,Pays at 100% of GA Medicaid Fee Schedule,4.26,Pays at 100% of Medicare OPPS Rate,4.65,Pays at 100% of GA Medicaid Fee Schedule,80.52,Pays at 88% of Total Billed charges,4.79,Pays at 103% of GA Medicaid Fee Schedule,4.26,82.35,54.90
Outpatient Medical Services,LAB,86592,Blood test to screen for syphilis,300,117,99.45,Pays at 85% of Billed charges for outpatient setting,4.65,Pays at 100% of GA Medicaid Fee Schedule,93.64,Pays at 80.03% of Total Billed charges,4.35,Pays at 102% of Medicare OPPS Rate,105.3,Pays at 90% of Total Billed charges,4.65,Pays at 100% of GA Medicaid Fee Schedule,4.26,Pays at 100% of Medicare OPPS Rate,4.65,Pays at 100% of GA Medicaid Fee Schedule,102.96,Pays at 88% of Total Billed charges,4.79,Pays at 103% of GA Medicaid Fee Schedule,4.26,105.3,70.20
Outpatient Medical Services,LAB,86593,RPR TITER.S (MAYO),300,46.5,39.53,Pays at 85% of Billed charges for outpatient setting,14.95,Pays at 32.15% of Total Billed charges,37.21,Pays at 80.03% of Total Billed charges,4.48,Pays at 102% of Medicare OPPS Rate,41.85,Pays at 90% of Total Billed charges,14.95,Pays at 32.15% of Total Billed charges,4.4,Pays at 100% of Medicare OPPS Rate,14.95,Pays at 32.15% of Total Billed charges,40.92,Pays at 88% of Total Billed charges,15.4,Pays at 33.11% of Total Billed charges,4.4,41.85,27.90
Outpatient Medical Services,LAB,86603,ADENOVIRUS  (MAYO),300,127.75,108.59,Pays at 85% of Billed charges for outpatient setting,16.18,Pays at 100% of GA Medicaid Fee Schedule,102.24,Pays at 80.03% of Total Billed charges,13.12,Pays at 102% of Medicare OPPS Rate,114.98,Pays at 90% of Total Billed charges,16.18,Pays at 100% of GA Medicaid Fee Schedule,12.87,Pays at 100% of Medicare OPPS Rate,16.18,Pays at 100% of GA Medicaid Fee Schedule,112.42,Pays at 88% of Total Billed charges,16.67,Pays at 103% of GA Medicaid Fee Schedule,12.87,114.98,76.65
Outpatient Medical Services,LAB,86606,ASPERGILLAS AB  (MAYO),300,40.25,34.21,Pays at 85% of Billed charges for outpatient setting,18.93,Pays at 100% of GA Medicaid Fee Schedule,32.21,Pays at 80.03% of Total Billed charges,15.35,Pays at 102% of Medicare OPPS Rate,36.23,Pays at 90% of Total Billed charges,18.93,Pays at 100% of GA Medicaid Fee Schedule,15.05,Pays at 100% of Medicare OPPS Rate,18.93,Pays at 100% of GA Medicaid Fee Schedule,35.42,Pays at 88% of Total Billed charges,19.5,Pays at 103% of GA Medicaid Fee Schedule,15.05,36.23,24.15
Outpatient Medical Services,LAB,86606,HYPERSENSITIVE PNUEMONITIS IGG  (MAYO),300,97,82.45,Pays at 85% of Billed charges for outpatient setting,18.93,Pays at 100% of GA Medicaid Fee Schedule,77.63,Pays at 80.03% of Total Billed charges,15.35,Pays at 102% of Medicare OPPS Rate,87.3,Pays at 90% of Total Billed charges,18.93,Pays at 100% of GA Medicaid Fee Schedule,15.05,Pays at 100% of Medicare OPPS Rate,18.93,Pays at 100% of GA Medicaid Fee Schedule,85.36,Pays at 88% of Total Billed charges,19.5,Pays at 103% of GA Medicaid Fee Schedule,15.05,87.3,58.20
Outpatient Medical Services,LAB,86611,"BARTONELLA HENSELAE AB, IGG  (MAYO)",300,39.25,33.36,Pays at 85% of Billed charges for outpatient setting,12.8,Pays at 100% of GA Medicaid Fee Schedule,31.41,Pays at 80.03% of Total Billed charges,10.38,Pays at 102% of Medicare OPPS Rate,35.33,Pays at 90% of Total Billed charges,12.8,Pays at 100% of GA Medicaid Fee Schedule,10.18,Pays at 100% of Medicare OPPS Rate,12.8,Pays at 100% of GA Medicaid Fee Schedule,34.54,Pays at 88% of Total Billed charges,13.18,Pays at 103% of GA Medicaid Fee Schedule,10.18,35.33,23.55
Outpatient Medical Services,LAB,86611,"BARTONELLA HENSELAE AB, IGM  (MAYO)",300,39.25,33.36,Pays at 85% of Billed charges for outpatient setting,12.8,Pays at 100% of GA Medicaid Fee Schedule,31.41,Pays at 80.03% of Total Billed charges,10.38,Pays at 102% of Medicare OPPS Rate,35.33,Pays at 90% of Total Billed charges,12.8,Pays at 100% of GA Medicaid Fee Schedule,10.18,Pays at 100% of Medicare OPPS Rate,12.8,Pays at 100% of GA Medicaid Fee Schedule,34.54,Pays at 88% of Total Billed charges,13.18,Pays at 103% of GA Medicaid Fee Schedule,10.18,35.33,23.55
Outpatient Medical Services,LAB,86611,"BARTONELLA QUINTANA AB, IGG  (MAYO)",300,39.25,33.36,Pays at 85% of Billed charges for outpatient setting,12.8,Pays at 100% of GA Medicaid Fee Schedule,31.41,Pays at 80.03% of Total Billed charges,10.38,Pays at 102% of Medicare OPPS Rate,35.33,Pays at 90% of Total Billed charges,12.8,Pays at 100% of GA Medicaid Fee Schedule,10.18,Pays at 100% of Medicare OPPS Rate,12.8,Pays at 100% of GA Medicaid Fee Schedule,34.54,Pays at 88% of Total Billed charges,13.18,Pays at 103% of GA Medicaid Fee Schedule,10.18,35.33,23.55
Outpatient Medical Services,LAB,86611,"BARTONELLA QUINTANA AB, IGM  (MAYO)",300,39.25,33.36,Pays at 85% of Billed charges for outpatient setting,12.8,Pays at 100% of GA Medicaid Fee Schedule,31.41,Pays at 80.03% of Total Billed charges,10.38,Pays at 102% of Medicare OPPS Rate,35.33,Pays at 90% of Total Billed charges,12.8,Pays at 100% of GA Medicaid Fee Schedule,10.18,Pays at 100% of Medicare OPPS Rate,12.8,Pays at 100% of GA Medicaid Fee Schedule,34.54,Pays at 88% of Total Billed charges,13.18,Pays at 103% of GA Medicaid Fee Schedule,10.18,35.33,23.55
Outpatient Medical Services,LAB,86612,"BLASTOMYCES AB EIA, SERUM (MAYO)",300,120,102,Pays at 85% of Billed charges for outpatient setting,16.23,Pays at 100% of GA Medicaid Fee Schedule,96.04,Pays at 80.03% of Total Billed charges,13.15,Pays at 102% of Medicare OPPS Rate,108,Pays at 90% of Total Billed charges,16.23,Pays at 100% of GA Medicaid Fee Schedule,12.9,Pays at 100% of Medicare OPPS Rate,16.23,Pays at 100% of GA Medicaid Fee Schedule,105.6,Pays at 88% of Total Billed charges,16.72,Pays at 103% of GA Medicaid Fee Schedule,12.9,108,72.00
Outpatient Medical Services,LAB,86615,...BORDETELLA PERTUSSIS AB  (MAYO),300,69.75,59.29,Pays at 85% of Billed charges for outpatient setting,16.59,Pays at 100% of GA Medicaid Fee Schedule,55.82,Pays at 80.03% of Total Billed charges,13.45,Pays at 102% of Medicare OPPS Rate,62.78,Pays at 90% of Total Billed charges,16.59,Pays at 100% of GA Medicaid Fee Schedule,13.19,Pays at 100% of Medicare OPPS Rate,16.59,Pays at 100% of GA Medicaid Fee Schedule,61.38,Pays at 88% of Total Billed charges,17.09,Pays at 103% of GA Medicaid Fee Schedule,13.19,62.78,41.85
Outpatient Medical Services,LAB,86615,"BORDETELLA PERTUSSIS, IGG  (MAYO)",300,96.25,81.81,Pays at 85% of Billed charges for outpatient setting,16.59,Pays at 100% of GA Medicaid Fee Schedule,77.03,Pays at 80.03% of Total Billed charges,13.45,Pays at 102% of Medicare OPPS Rate,86.63,Pays at 90% of Total Billed charges,16.59,Pays at 100% of GA Medicaid Fee Schedule,13.19,Pays at 100% of Medicare OPPS Rate,16.59,Pays at 100% of GA Medicaid Fee Schedule,84.7,Pays at 88% of Total Billed charges,17.09,Pays at 103% of GA Medicaid Fee Schedule,13.19,86.63,57.75
Outpatient Medical Services,LAB,86617,".LYME DISEASE AB, SERUM, IGG  (MAYO)",300,49.75,42.29,Pays at 85% of Billed charges for outpatient setting,19.48,Pays at 100% of GA Medicaid Fee Schedule,39.81,Pays at 80.03% of Total Billed charges,15.79,Pays at 102% of Medicare OPPS Rate,44.78,Pays at 90% of Total Billed charges,19.48,Pays at 100% of GA Medicaid Fee Schedule,15.49,Pays at 100% of Medicare OPPS Rate,19.48,Pays at 100% of GA Medicaid Fee Schedule,43.78,Pays at 88% of Total Billed charges,20.06,Pays at 103% of GA Medicaid Fee Schedule,15.49,44.78,29.85
Outpatient Medical Services,LAB,86617,".LYME DISEASE AB, SERUM, IGM  (MAYO)",300,49.75,42.29,Pays at 85% of Billed charges for outpatient setting,19.48,Pays at 100% of GA Medicaid Fee Schedule,39.81,Pays at 80.03% of Total Billed charges,15.79,Pays at 102% of Medicare OPPS Rate,44.78,Pays at 90% of Total Billed charges,19.48,Pays at 100% of GA Medicaid Fee Schedule,15.49,Pays at 100% of Medicare OPPS Rate,19.48,Pays at 100% of GA Medicaid Fee Schedule,43.78,Pays at 88% of Total Billed charges,20.06,Pays at 103% of GA Medicaid Fee Schedule,15.49,44.78,29.85
Outpatient Medical Services,LAB,86618,LYME DISEASE SEROLOGY  (MAYO),300,54.75,46.54,Pays at 85% of Billed charges for outpatient setting,21.42,Pays at 100% of GA Medicaid Fee Schedule,43.82,Pays at 80.03% of Total Billed charges,17.37,Pays at 102% of Medicare OPPS Rate,49.28,Pays at 90% of Total Billed charges,21.42,Pays at 100% of GA Medicaid Fee Schedule,17.03,Pays at 100% of Medicare OPPS Rate,21.42,Pays at 100% of GA Medicaid Fee Schedule,48.18,Pays at 88% of Total Billed charges,22.06,Pays at 103% of GA Medicaid Fee Schedule,17.03,49.28,32.85
Outpatient Medical Services,LAB,86622,"Q FEVER AB TITERS, PHASE I & II  (MAYO)",300,33.75,28.69,Pays at 85% of Billed charges for outpatient setting,11.23,Pays at 100% of GA Medicaid Fee Schedule,27.01,Pays at 80.03% of Total Billed charges,9.1,Pays at 102% of Medicare OPPS Rate,30.38,Pays at 90% of Total Billed charges,11.23,Pays at 100% of GA Medicaid Fee Schedule,8.93,Pays at 100% of Medicare OPPS Rate,11.23,Pays at 100% of GA Medicaid Fee Schedule,29.7,Pays at 88% of Total Billed charges,11.57,Pays at 103% of GA Medicaid Fee Schedule,8.93,30.38,20.25
Outpatient Medical Services,LAB,86622,"BRUCELLA  AB, SERUM  (MAYO)",300,69.25,58.86,Pays at 85% of Billed charges for outpatient setting,11.23,Pays at 100% of GA Medicaid Fee Schedule,55.42,Pays at 80.03% of Total Billed charges,9.1,Pays at 102% of Medicare OPPS Rate,62.33,Pays at 90% of Total Billed charges,11.23,Pays at 100% of GA Medicaid Fee Schedule,8.93,Pays at 100% of Medicare OPPS Rate,11.23,Pays at 100% of GA Medicaid Fee Schedule,60.94,Pays at 88% of Total Billed charges,11.57,Pays at 103% of GA Medicaid Fee Schedule,8.93,62.33,41.55
Outpatient Medical Services,LAB,86628,"CANDIDA AB IgG,A & M  (MAYO)",300,146.5,124.53,Pays at 85% of Billed charges for outpatient setting,15.1,Pays at 100% of GA Medicaid Fee Schedule,117.24,Pays at 80.03% of Total Billed charges,12.25,Pays at 102% of Medicare OPPS Rate,131.85,Pays at 90% of Total Billed charges,15.1,Pays at 100% of GA Medicaid Fee Schedule,12.01,Pays at 100% of Medicare OPPS Rate,15.1,Pays at 100% of GA Medicaid Fee Schedule,128.92,Pays at 88% of Total Billed charges,15.55,Pays at 103% of GA Medicaid Fee Schedule,12.01,131.85,87.90
Outpatient Medical Services,LAB,86631,..CHLAMYDIA AG,300,116.25,98.81,Pays at 85% of Billed charges for outpatient setting,14.87,Pays at 100% of GA Medicaid Fee Schedule,93.03,Pays at 80.03% of Total Billed charges,12.05,Pays at 102% of Medicare OPPS Rate,104.63,Pays at 90% of Total Billed charges,14.87,Pays at 100% of GA Medicaid Fee Schedule,11.82,Pays at 100% of Medicare OPPS Rate,14.87,Pays at 100% of GA Medicaid Fee Schedule,102.3,Pays at 88% of Total Billed charges,15.32,Pays at 103% of GA Medicaid Fee Schedule,11.82,104.63,69.75
Outpatient Medical Services,LAB,86631,"CHLAMYDIA PANEL, SERUM (MAYO)",300,294.5,250.33,Pays at 85% of Billed charges for outpatient setting,14.87,Pays at 100% of GA Medicaid Fee Schedule,235.69,Pays at 80.03% of Total Billed charges,12.05,Pays at 102% of Medicare OPPS Rate,265.05,Pays at 90% of Total Billed charges,14.87,Pays at 100% of GA Medicaid Fee Schedule,11.82,Pays at 100% of Medicare OPPS Rate,14.87,Pays at 100% of GA Medicaid Fee Schedule,259.16,Pays at 88% of Total Billed charges,15.32,Pays at 103% of GA Medicaid Fee Schedule,11.82,265.05,176.70
Outpatient Medical Services,LAB,86635,COCCIDIOIDES AB IGG  (MAYO),300,78.13,66.41,Pays at 85% of Billed charges for outpatient setting,14.43,Pays at 100% of GA Medicaid Fee Schedule,62.53,Pays at 80.03% of Total Billed charges,11.69,Pays at 102% of Medicare OPPS Rate,70.32,Pays at 90% of Total Billed charges,14.43,Pays at 100% of GA Medicaid Fee Schedule,11.47,Pays at 100% of Medicare OPPS Rate,14.43,Pays at 100% of GA Medicaid Fee Schedule,68.75,Pays at 88% of Total Billed charges,14.86,Pays at 103% of GA Medicaid Fee Schedule,11.47,70.32,46.88
Outpatient Medical Services,LAB,86635,COCCIDIOIDES AB IGM  (MAYO),300,78.13,66.41,Pays at 85% of Billed charges for outpatient setting,14.43,Pays at 100% of GA Medicaid Fee Schedule,62.53,Pays at 80.03% of Total Billed charges,11.69,Pays at 102% of Medicare OPPS Rate,70.32,Pays at 90% of Total Billed charges,14.43,Pays at 100% of GA Medicaid Fee Schedule,11.47,Pays at 100% of Medicare OPPS Rate,14.43,Pays at 100% of GA Medicaid Fee Schedule,68.75,Pays at 88% of Total Billed charges,14.86,Pays at 103% of GA Medicaid Fee Schedule,11.47,70.32,46.88
Outpatient Medical Services,LAB,86635,COCCIDIOIDES COMPLEMENT F  (MAYO),300,78.13,66.41,Pays at 85% of Billed charges for outpatient setting,14.43,Pays at 100% of GA Medicaid Fee Schedule,62.53,Pays at 80.03% of Total Billed charges,11.69,Pays at 102% of Medicare OPPS Rate,70.32,Pays at 90% of Total Billed charges,14.43,Pays at 100% of GA Medicaid Fee Schedule,11.47,Pays at 100% of Medicare OPPS Rate,14.43,Pays at 100% of GA Medicaid Fee Schedule,68.75,Pays at 88% of Total Billed charges,14.86,Pays at 103% of GA Medicaid Fee Schedule,11.47,70.32,46.88
Outpatient Medical Services,LAB,86638,RESERVED (MAYO),300,25,21.25,Pays at 85% of Billed charges for outpatient setting,15.25,Pays at 100% of GA Medicaid Fee Schedule,20.01,Pays at 80.03% of Total Billed charges,12.36,Pays at 102% of Medicare OPPS Rate,22.5,Pays at 90% of Total Billed charges,15.25,Pays at 100% of GA Medicaid Fee Schedule,12.12,Pays at 100% of Medicare OPPS Rate,15.25,Pays at 100% of GA Medicaid Fee Schedule,22,Pays at 88% of Total Billed charges,15.71,Pays at 103% of GA Medicaid Fee Schedule,12.12,22.5,15.00
Outpatient Medical Services,LAB,86638,RESERVED (MAYO),300,25,21.25,Pays at 85% of Billed charges for outpatient setting,15.25,Pays at 100% of GA Medicaid Fee Schedule,20.01,Pays at 80.03% of Total Billed charges,12.36,Pays at 102% of Medicare OPPS Rate,22.5,Pays at 90% of Total Billed charges,15.25,Pays at 100% of GA Medicaid Fee Schedule,12.12,Pays at 100% of Medicare OPPS Rate,15.25,Pays at 100% of GA Medicaid Fee Schedule,22,Pays at 88% of Total Billed charges,15.71,Pays at 103% of GA Medicaid Fee Schedule,12.12,22.5,15.00
Outpatient Medical Services,LAB,86638,RESERVED (MAYO),300,25,21.25,Pays at 85% of Billed charges for outpatient setting,15.25,Pays at 100% of GA Medicaid Fee Schedule,20.01,Pays at 80.03% of Total Billed charges,12.36,Pays at 102% of Medicare OPPS Rate,22.5,Pays at 90% of Total Billed charges,15.25,Pays at 100% of GA Medicaid Fee Schedule,12.12,Pays at 100% of Medicare OPPS Rate,15.25,Pays at 100% of GA Medicaid Fee Schedule,22,Pays at 88% of Total Billed charges,15.71,Pays at 103% of GA Medicaid Fee Schedule,12.12,22.5,15.00
Outpatient Medical Services,LAB,86638,"Q FEVER AB, IGG (MAYO)",300,83,70.55,Pays at 85% of Billed charges for outpatient setting,15.25,Pays at 100% of GA Medicaid Fee Schedule,66.42,Pays at 80.03% of Total Billed charges,12.36,Pays at 102% of Medicare OPPS Rate,74.7,Pays at 90% of Total Billed charges,15.25,Pays at 100% of GA Medicaid Fee Schedule,12.12,Pays at 100% of Medicare OPPS Rate,15.25,Pays at 100% of GA Medicaid Fee Schedule,73.04,Pays at 88% of Total Billed charges,15.71,Pays at 103% of GA Medicaid Fee Schedule,12.12,74.7,49.80
Outpatient Medical Services,LAB,86638,"Q FEVER AB, IGM (MAYO)",300,83,70.55,Pays at 85% of Billed charges for outpatient setting,15.25,Pays at 100% of GA Medicaid Fee Schedule,66.42,Pays at 80.03% of Total Billed charges,12.36,Pays at 102% of Medicare OPPS Rate,74.7,Pays at 90% of Total Billed charges,15.25,Pays at 100% of GA Medicaid Fee Schedule,12.12,Pays at 100% of Medicare OPPS Rate,15.25,Pays at 100% of GA Medicaid Fee Schedule,73.04,Pays at 88% of Total Billed charges,15.71,Pays at 103% of GA Medicaid Fee Schedule,12.12,74.7,49.80
Outpatient Medical Services,LAB,86641,CRYPTOCOCCUS AG,300,29.53,25.1,Pays at 85% of Billed charges for outpatient setting,18.13,Pays at 100% of GA Medicaid Fee Schedule,23.63,Pays at 80.03% of Total Billed charges,14.69,Pays at 102% of Medicare OPPS Rate,26.58,Pays at 90% of Total Billed charges,18.13,Pays at 100% of GA Medicaid Fee Schedule,14.41,Pays at 100% of Medicare OPPS Rate,18.13,Pays at 100% of GA Medicaid Fee Schedule,25.99,Pays at 88% of Total Billed charges,18.67,Pays at 103% of GA Medicaid Fee Schedule,14.41,26.58,17.72
Outpatient Medical Services,LAB,86644,Blood test to monitor for cytomegalovirus,300,38.5,32.73,Pays at 85% of Billed charges for outpatient setting,14.63,Pays at 100% of GA Medicaid Fee Schedule,30.81,Pays at 80.03% of Total Billed charges,14.67,Pays at 102% of Medicare OPPS Rate,34.65,Pays at 90% of Total Billed charges,14.63,Pays at 100% of GA Medicaid Fee Schedule,14.39,Pays at 100% of Medicare OPPS Rate,14.63,Pays at 100% of GA Medicaid Fee Schedule,33.88,Pays at 88% of Total Billed charges,15.07,Pays at 103% of GA Medicaid Fee Schedule,14.39,34.65,23.10
Outpatient Medical Services,LAB,86644,Blood test to monitor for cytomegalovirus,300,40.5,34.43,Pays at 85% of Billed charges for outpatient setting,14.63,Pays at 100% of GA Medicaid Fee Schedule,32.41,Pays at 80.03% of Total Billed charges,14.67,Pays at 102% of Medicare OPPS Rate,36.45,Pays at 90% of Total Billed charges,14.63,Pays at 100% of GA Medicaid Fee Schedule,14.39,Pays at 100% of Medicare OPPS Rate,14.63,Pays at 100% of GA Medicaid Fee Schedule,35.64,Pays at 88% of Total Billed charges,15.07,Pays at 103% of GA Medicaid Fee Schedule,14.39,36.45,24.30
Outpatient Medical Services,LAB,86644,Blood test to monitor for cytomegalovirus,300,60,51,Pays at 85% of Billed charges for outpatient setting,14.63,Pays at 100% of GA Medicaid Fee Schedule,48.02,Pays at 80.03% of Total Billed charges,14.67,Pays at 102% of Medicare OPPS Rate,54,Pays at 90% of Total Billed charges,14.63,Pays at 100% of GA Medicaid Fee Schedule,14.39,Pays at 100% of Medicare OPPS Rate,14.63,Pays at 100% of GA Medicaid Fee Schedule,52.8,Pays at 88% of Total Billed charges,15.07,Pays at 103% of GA Medicaid Fee Schedule,14.39,54,36.00
Outpatient Medical Services,LAB,86644,Blood test to monitor for cytomegalovirus,300,220.5,187.43,Pays at 85% of Billed charges for outpatient setting,14.63,Pays at 100% of GA Medicaid Fee Schedule,176.47,Pays at 80.03% of Total Billed charges,14.67,Pays at 102% of Medicare OPPS Rate,198.45,Pays at 90% of Total Billed charges,14.63,Pays at 100% of GA Medicaid Fee Schedule,14.39,Pays at 100% of Medicare OPPS Rate,14.63,Pays at 100% of GA Medicaid Fee Schedule,194.04,Pays at 88% of Total Billed charges,15.07,Pays at 103% of GA Medicaid Fee Schedule,14.39,198.45,132.30
Outpatient Medical Services,LAB,86645,"CMV, IGM  (MAYO)",300,60,51,Pays at 85% of Billed charges for outpatient setting,21.19,Pays at 100% of GA Medicaid Fee Schedule,48.02,Pays at 80.03% of Total Billed charges,17.18,Pays at 102% of Medicare OPPS Rate,54,Pays at 90% of Total Billed charges,21.19,Pays at 100% of GA Medicaid Fee Schedule,16.85,Pays at 100% of Medicare OPPS Rate,21.19,Pays at 100% of GA Medicaid Fee Schedule,52.8,Pays at 88% of Total Billed charges,21.83,Pays at 103% of GA Medicaid Fee Schedule,16.85,54,36.00
Outpatient Medical Services,LAB,86648,DIPTHERIA/TETANUS ANTIBODY PANEL (MAYO),300,113.5,96.48,Pays at 85% of Billed charges for outpatient setting,19.13,Pays at 100% of GA Medicaid Fee Schedule,90.83,Pays at 80.03% of Total Billed charges,15.51,Pays at 102% of Medicare OPPS Rate,102.15,Pays at 90% of Total Billed charges,19.13,Pays at 100% of GA Medicaid Fee Schedule,15.21,Pays at 100% of Medicare OPPS Rate,19.13,Pays at 100% of GA Medicaid Fee Schedule,99.88,Pays at 88% of Total Billed charges,19.7,Pays at 103% of GA Medicaid Fee Schedule,15.21,102.15,68.10
Outpatient Medical Services,LAB,86652,EASTERN EQUINE ENCEPHALITIS AB  (MAYO),300,119,101.15,Pays at 85% of Billed charges for outpatient setting,16.59,Pays at 100% of GA Medicaid Fee Schedule,95.24,Pays at 80.03% of Total Billed charges,13.45,Pays at 102% of Medicare OPPS Rate,107.1,Pays at 90% of Total Billed charges,16.59,Pays at 100% of GA Medicaid Fee Schedule,13.19,Pays at 100% of Medicare OPPS Rate,16.59,Pays at 100% of GA Medicaid Fee Schedule,104.72,Pays at 88% of Total Billed charges,17.09,Pays at 103% of GA Medicaid Fee Schedule,13.19,107.1,71.40
Outpatient Medical Services,LAB,86658,Q FEVER IGG PHASE I SCREEN  (MAYO),300,27.75,23.59,Pays at 85% of Billed charges for outpatient setting,16.38,Pays at 100% of GA Medicaid Fee Schedule,22.21,Pays at 80.03% of Total Billed charges,13.29,Pays at 102% of Medicare OPPS Rate,24.98,Pays at 90% of Total Billed charges,16.38,Pays at 100% of GA Medicaid Fee Schedule,13.03,Pays at 100% of Medicare OPPS Rate,16.38,Pays at 100% of GA Medicaid Fee Schedule,24.42,Pays at 88% of Total Billed charges,16.87,Pays at 103% of GA Medicaid Fee Schedule,13.03,24.98,16.65
Outpatient Medical Services,LAB,86658,Q FEVER IGG PHASE II SCREEN  (MAYO),300,27.75,23.59,Pays at 85% of Billed charges for outpatient setting,16.38,Pays at 100% of GA Medicaid Fee Schedule,22.21,Pays at 80.03% of Total Billed charges,13.29,Pays at 102% of Medicare OPPS Rate,24.98,Pays at 90% of Total Billed charges,16.38,Pays at 100% of GA Medicaid Fee Schedule,13.03,Pays at 100% of Medicare OPPS Rate,16.38,Pays at 100% of GA Medicaid Fee Schedule,24.42,Pays at 88% of Total Billed charges,16.87,Pays at 103% of GA Medicaid Fee Schedule,13.03,24.98,16.65
Outpatient Medical Services,LAB,86658,Q FEVER IGM PHASE I SCREEN  (MAYO),300,27.75,23.59,Pays at 85% of Billed charges for outpatient setting,16.38,Pays at 100% of GA Medicaid Fee Schedule,22.21,Pays at 80.03% of Total Billed charges,13.29,Pays at 102% of Medicare OPPS Rate,24.98,Pays at 90% of Total Billed charges,16.38,Pays at 100% of GA Medicaid Fee Schedule,13.03,Pays at 100% of Medicare OPPS Rate,16.38,Pays at 100% of GA Medicaid Fee Schedule,24.42,Pays at 88% of Total Billed charges,16.87,Pays at 103% of GA Medicaid Fee Schedule,13.03,24.98,16.65
Outpatient Medical Services,LAB,86658,Q FEVER IGM PHASE II SCREEN  (MAYO),300,27.75,23.59,Pays at 85% of Billed charges for outpatient setting,16.38,Pays at 100% of GA Medicaid Fee Schedule,22.21,Pays at 80.03% of Total Billed charges,13.29,Pays at 102% of Medicare OPPS Rate,24.98,Pays at 90% of Total Billed charges,16.38,Pays at 100% of GA Medicaid Fee Schedule,13.03,Pays at 100% of Medicare OPPS Rate,16.38,Pays at 100% of GA Medicaid Fee Schedule,24.42,Pays at 88% of Total Billed charges,16.87,Pays at 103% of GA Medicaid Fee Schedule,13.03,24.98,16.65
Outpatient Medical Services,LAB,86658,COXSACKIE A  (MAYO),300,41.5,35.28,Pays at 85% of Billed charges for outpatient setting,16.38,Pays at 100% of GA Medicaid Fee Schedule,33.21,Pays at 80.03% of Total Billed charges,13.29,Pays at 102% of Medicare OPPS Rate,37.35,Pays at 90% of Total Billed charges,16.38,Pays at 100% of GA Medicaid Fee Schedule,13.03,Pays at 100% of Medicare OPPS Rate,16.38,Pays at 100% of GA Medicaid Fee Schedule,36.52,Pays at 88% of Total Billed charges,16.87,Pays at 103% of GA Medicaid Fee Schedule,13.03,37.35,24.90
Outpatient Medical Services,LAB,86658,COXSACKIE B  (MAYO),300,41.5,35.28,Pays at 85% of Billed charges for outpatient setting,16.38,Pays at 100% of GA Medicaid Fee Schedule,33.21,Pays at 80.03% of Total Billed charges,13.29,Pays at 102% of Medicare OPPS Rate,37.35,Pays at 90% of Total Billed charges,16.38,Pays at 100% of GA Medicaid Fee Schedule,13.03,Pays at 100% of Medicare OPPS Rate,16.38,Pays at 100% of GA Medicaid Fee Schedule,36.52,Pays at 88% of Total Billed charges,16.87,Pays at 103% of GA Medicaid Fee Schedule,13.03,37.35,24.90
Outpatient Medical Services,LAB,86663,"EBV IGG, AB EARLY AG  (MAYO)",300,47.5,40.38,Pays at 85% of Billed charges for outpatient setting,16.5,Pays at 100% of GA Medicaid Fee Schedule,38.01,Pays at 80.03% of Total Billed charges,13.38,Pays at 102% of Medicare OPPS Rate,42.75,Pays at 90% of Total Billed charges,16.5,Pays at 100% of GA Medicaid Fee Schedule,13.12,Pays at 100% of Medicare OPPS Rate,16.5,Pays at 100% of GA Medicaid Fee Schedule,41.8,Pays at 88% of Total Billed charges,17,Pays at 103% of GA Medicaid Fee Schedule,13.12,42.75,28.50
Outpatient Medical Services,LAB,86664,"EBNA AB, SERUM  (MAYO)",300,56,47.6,Pays at 85% of Billed charges for outpatient setting,19.24,Pays at 100% of GA Medicaid Fee Schedule,44.82,Pays at 80.03% of Total Billed charges,15.59,Pays at 102% of Medicare OPPS Rate,50.4,Pays at 90% of Total Billed charges,19.24,Pays at 100% of GA Medicaid Fee Schedule,15.29,Pays at 100% of Medicare OPPS Rate,19.24,Pays at 100% of GA Medicaid Fee Schedule,49.28,Pays at 88% of Total Billed charges,19.82,Pays at 103% of GA Medicaid Fee Schedule,15.29,50.4,33.60
Outpatient Medical Services,LAB,86665,Blood test to diagnose mononucleosis,300,53.6,45.56,Pays at 85% of Billed charges for outpatient setting,22.82,Pays at 100% of GA Medicaid Fee Schedule,42.9,Pays at 80.03% of Total Billed charges,18.5,Pays at 102% of Medicare OPPS Rate,48.24,Pays at 90% of Total Billed charges,22.82,Pays at 100% of GA Medicaid Fee Schedule,18.14,Pays at 100% of Medicare OPPS Rate,22.82,Pays at 100% of GA Medicaid Fee Schedule,47.17,Pays at 88% of Total Billed charges,23.5,Pays at 103% of GA Medicaid Fee Schedule,18.14,48.24,32.16
Outpatient Medical Services,LAB,86665,Blood test to diagnose mononucleosis,300,58,49.3,Pays at 85% of Billed charges for outpatient setting,22.82,Pays at 100% of GA Medicaid Fee Schedule,46.42,Pays at 80.03% of Total Billed charges,18.5,Pays at 102% of Medicare OPPS Rate,52.2,Pays at 90% of Total Billed charges,22.82,Pays at 100% of GA Medicaid Fee Schedule,18.14,Pays at 100% of Medicare OPPS Rate,22.82,Pays at 100% of GA Medicaid Fee Schedule,51.04,Pays at 88% of Total Billed charges,23.5,Pays at 103% of GA Medicaid Fee Schedule,18.14,52.2,34.80
Outpatient Medical Services,LAB,86665,Blood test to diagnose mononucleosis,300,58,49.3,Pays at 85% of Billed charges for outpatient setting,22.82,Pays at 100% of GA Medicaid Fee Schedule,46.42,Pays at 80.03% of Total Billed charges,18.5,Pays at 102% of Medicare OPPS Rate,52.2,Pays at 90% of Total Billed charges,22.82,Pays at 100% of GA Medicaid Fee Schedule,18.14,Pays at 100% of Medicare OPPS Rate,22.82,Pays at 100% of GA Medicaid Fee Schedule,51.04,Pays at 88% of Total Billed charges,23.5,Pays at 103% of GA Medicaid Fee Schedule,18.14,52.2,34.80
Outpatient Medical Services,LAB,86666,EHRLICHIA CHAFFIENSIS AB  (MAYO),300,158.5,134.73,Pays at 85% of Billed charges for outpatient setting,12.8,Pays at 100% of GA Medicaid Fee Schedule,126.85,Pays at 80.03% of Total Billed charges,10.38,Pays at 102% of Medicare OPPS Rate,142.65,Pays at 90% of Total Billed charges,12.8,Pays at 100% of GA Medicaid Fee Schedule,10.18,Pays at 100% of Medicare OPPS Rate,12.8,Pays at 100% of GA Medicaid Fee Schedule,139.48,Pays at 88% of Total Billed charges,13.18,Pays at 103% of GA Medicaid Fee Schedule,10.18,142.65,95.10
Outpatient Medical Services,LAB,86671,"FUNGUS, UNSPECIFIED, SERUM  (MAYO)",300,199,169.15,Pays at 85% of Billed charges for outpatient setting,15.42,Pays at 100% of GA Medicaid Fee Schedule,159.26,Pays at 80.03% of Total Billed charges,12.49,Pays at 102% of Medicare OPPS Rate,179.1,Pays at 90% of Total Billed charges,15.42,Pays at 100% of GA Medicaid Fee Schedule,12.25,Pays at 100% of Medicare OPPS Rate,15.42,Pays at 100% of GA Medicaid Fee Schedule,175.12,Pays at 88% of Total Billed charges,15.88,Pays at 103% of GA Medicaid Fee Schedule,12.25,179.1,119.40
Outpatient Medical Services,LAB,86674,GIARDIA LAMBIA  AB PANEL  (MAYO),300,84.75,72.04,Pays at 85% of Billed charges for outpatient setting,18.5,Pays at 100% of GA Medicaid Fee Schedule,67.83,Pays at 80.03% of Total Billed charges,15.01,Pays at 102% of Medicare OPPS Rate,76.28,Pays at 90% of Total Billed charges,18.5,Pays at 100% of GA Medicaid Fee Schedule,14.72,Pays at 100% of Medicare OPPS Rate,18.5,Pays at 100% of GA Medicaid Fee Schedule,74.58,Pays at 88% of Total Billed charges,19.06,Pays at 103% of GA Medicaid Fee Schedule,14.72,76.28,50.85
Outpatient Medical Services,LAB,86677,Blood test to if peptic ulcers are caused by a certain bacterium,300,49.75,42.29,Pays at 85% of Billed charges for outpatient setting,18.25,Pays at 100% of GA Medicaid Fee Schedule,39.81,Pays at 80.03% of Total Billed charges,17.18,Pays at 102% of Medicare OPPS Rate,44.78,Pays at 90% of Total Billed charges,18.25,Pays at 100% of GA Medicaid Fee Schedule,16.85,Pays at 100% of Medicare OPPS Rate,18.25,Pays at 100% of GA Medicaid Fee Schedule,43.78,Pays at 88% of Total Billed charges,18.8,Pays at 103% of GA Medicaid Fee Schedule,16.85,44.78,29.85
Outpatient Medical Services,LAB,86677,Blood test to if peptic ulcers are caused by a certain bacterium,300,52.75,44.84,Pays at 85% of Billed charges for outpatient setting,18.25,Pays at 100% of GA Medicaid Fee Schedule,42.22,Pays at 80.03% of Total Billed charges,17.18,Pays at 102% of Medicare OPPS Rate,47.48,Pays at 90% of Total Billed charges,18.25,Pays at 100% of GA Medicaid Fee Schedule,16.85,Pays at 100% of Medicare OPPS Rate,18.25,Pays at 100% of GA Medicaid Fee Schedule,46.42,Pays at 88% of Total Billed charges,18.8,Pays at 103% of GA Medicaid Fee Schedule,16.85,47.48,31.65
Outpatient Medical Services,LAB,86677,Blood test to if peptic ulcers are caused by a certain bacterium,300,71.25,60.56,Pays at 85% of Billed charges for outpatient setting,18.25,Pays at 100% of GA Medicaid Fee Schedule,57.02,Pays at 80.03% of Total Billed charges,17.18,Pays at 102% of Medicare OPPS Rate,64.13,Pays at 90% of Total Billed charges,18.25,Pays at 100% of GA Medicaid Fee Schedule,16.85,Pays at 100% of Medicare OPPS Rate,18.25,Pays at 100% of GA Medicaid Fee Schedule,62.7,Pays at 88% of Total Billed charges,18.8,Pays at 103% of GA Medicaid Fee Schedule,16.85,64.13,42.75
Outpatient Medical Services,LAB,86682,"TOXOCARA CANIS AB IGG, SERUM  (MAYO)",300,188.25,160.01,Pays at 85% of Billed charges for outpatient setting,16.35,Pays at 100% of GA Medicaid Fee Schedule,150.66,Pays at 80.03% of Total Billed charges,13.27,Pays at 102% of Medicare OPPS Rate,169.43,Pays at 90% of Total Billed charges,16.35,Pays at 100% of GA Medicaid Fee Schedule,13.01,Pays at 100% of Medicare OPPS Rate,16.35,Pays at 100% of GA Medicaid Fee Schedule,165.66,Pays at 88% of Total Billed charges,16.84,Pays at 103% of GA Medicaid Fee Schedule,13.01,169.43,112.95
Outpatient Medical Services,LAB,86684,"HAEMOPHILUS INFLUENZAE B, IGG  (MAYO)",300,99.25,84.36,Pays at 85% of Billed charges for outpatient setting,19.93,Pays at 100% of GA Medicaid Fee Schedule,79.43,Pays at 80.03% of Total Billed charges,16.15,Pays at 102% of Medicare OPPS Rate,89.33,Pays at 90% of Total Billed charges,19.93,Pays at 100% of GA Medicaid Fee Schedule,15.84,Pays at 100% of Medicare OPPS Rate,19.93,Pays at 100% of GA Medicaid Fee Schedule,87.34,Pays at 88% of Total Billed charges,20.53,Pays at 103% of GA Medicaid Fee Schedule,15.84,89.33,59.55
Outpatient Medical Services,LAB,86689,HIV-2 CONFIRMATION  (MAYO),300,94.5,80.33,Pays at 85% of Billed charges for outpatient setting,21.12,Pays at 100% of GA Medicaid Fee Schedule,75.63,Pays at 80.03% of Total Billed charges,19.73,Pays at 102% of Medicare OPPS Rate,85.05,Pays at 90% of Total Billed charges,21.12,Pays at 100% of GA Medicaid Fee Schedule,19.35,Pays at 100% of Medicare OPPS Rate,21.12,Pays at 100% of GA Medicaid Fee Schedule,83.16,Pays at 88% of Total Billed charges,21.75,Pays at 103% of GA Medicaid Fee Schedule,19.35,85.05,56.70
Outpatient Medical Services,LAB,86689,HIV-1 AB CONFIRM BY WESTERN BLOT  (MAYO),300,100.5,85.43,Pays at 85% of Billed charges for outpatient setting,21.12,Pays at 100% of GA Medicaid Fee Schedule,80.43,Pays at 80.03% of Total Billed charges,19.73,Pays at 102% of Medicare OPPS Rate,90.45,Pays at 90% of Total Billed charges,21.12,Pays at 100% of GA Medicaid Fee Schedule,19.35,Pays at 100% of Medicare OPPS Rate,21.12,Pays at 100% of GA Medicaid Fee Schedule,88.44,Pays at 88% of Total Billed charges,21.75,Pays at 103% of GA Medicaid Fee Schedule,19.35,90.45,60.30
Outpatient Medical Services,LAB,86692,"HEPATITIS DELTA AB, ANTI-HDV  (MAYO)",300,50,42.5,Pays at 85% of Billed charges for outpatient setting,21.58,Pays at 100% of GA Medicaid Fee Schedule,40.02,Pays at 80.03% of Total Billed charges,17.5,Pays at 102% of Medicare OPPS Rate,45,Pays at 90% of Total Billed charges,21.58,Pays at 100% of GA Medicaid Fee Schedule,17.16,Pays at 100% of Medicare OPPS Rate,21.58,Pays at 100% of GA Medicaid Fee Schedule,44,Pays at 88% of Total Billed charges,22.23,Pays at 103% of GA Medicaid Fee Schedule,17.16,45,30.00
Outpatient Medical Services,LAB,86694,HERPES SIMPLEX IGG TITER  (MAYO),300,33.5,28.48,Pays at 85% of Billed charges for outpatient setting,14.63,Pays at 100% of GA Medicaid Fee Schedule,26.81,Pays at 80.03% of Total Billed charges,14.67,Pays at 102% of Medicare OPPS Rate,30.15,Pays at 90% of Total Billed charges,14.63,Pays at 100% of GA Medicaid Fee Schedule,14.39,Pays at 100% of Medicare OPPS Rate,14.63,Pays at 100% of GA Medicaid Fee Schedule,29.48,Pays at 88% of Total Billed charges,15.07,Pays at 103% of GA Medicaid Fee Schedule,14.39,30.15,20.10
Outpatient Medical Services,LAB,86694,"HERPES SIMPLEX, IGM, EIA  (MAYO)",300,45.5,38.68,Pays at 85% of Billed charges for outpatient setting,14.63,Pays at 100% of GA Medicaid Fee Schedule,36.41,Pays at 80.03% of Total Billed charges,14.67,Pays at 102% of Medicare OPPS Rate,40.95,Pays at 90% of Total Billed charges,14.63,Pays at 100% of GA Medicaid Fee Schedule,14.39,Pays at 100% of Medicare OPPS Rate,14.63,Pays at 100% of GA Medicaid Fee Schedule,40.04,Pays at 88% of Total Billed charges,15.07,Pays at 103% of GA Medicaid Fee Schedule,14.39,40.95,27.30
Outpatient Medical Services,LAB,86695,HSV TYPE II AB IGG (MAYO),300,62,52.7,Pays at 85% of Billed charges for outpatient setting,16.59,Pays at 100% of GA Medicaid Fee Schedule,49.62,Pays at 80.03% of Total Billed charges,13.45,Pays at 102% of Medicare OPPS Rate,55.8,Pays at 90% of Total Billed charges,16.59,Pays at 100% of GA Medicaid Fee Schedule,13.19,Pays at 100% of Medicare OPPS Rate,16.59,Pays at 100% of GA Medicaid Fee Schedule,54.56,Pays at 88% of Total Billed charges,17.09,Pays at 103% of GA Medicaid Fee Schedule,13.19,55.8,37.20
Outpatient Medical Services,LAB,86696,HSV TYPE I  AB IGG (MAYO),300,42.5,36.13,Pays at 85% of Billed charges for outpatient setting,24.35,Pays at 100% of GA Medicaid Fee Schedule,34.01,Pays at 80.03% of Total Billed charges,19.73,Pays at 102% of Medicare OPPS Rate,38.25,Pays at 90% of Total Billed charges,24.35,Pays at 100% of GA Medicaid Fee Schedule,19.35,Pays at 100% of Medicare OPPS Rate,24.35,Pays at 100% of GA Medicaid Fee Schedule,37.4,Pays at 88% of Total Billed charges,25.08,Pays at 103% of GA Medicaid Fee Schedule,19.35,38.25,25.50
Outpatient Medical Services,LAB,86698,HISTOPLASMA AB SERUM  (MAYO),300,40.25,34.21,Pays at 85% of Billed charges for outpatient setting,15.71,Pays at 100% of GA Medicaid Fee Schedule,32.21,Pays at 80.03% of Total Billed charges,14.06,Pays at 102% of Medicare OPPS Rate,36.23,Pays at 90% of Total Billed charges,15.71,Pays at 100% of GA Medicaid Fee Schedule,13.79,Pays at 100% of Medicare OPPS Rate,15.71,Pays at 100% of GA Medicaid Fee Schedule,35.42,Pays at 88% of Total Billed charges,16.18,Pays at 103% of GA Medicaid Fee Schedule,13.79,36.23,24.15
Outpatient Medical Services,LAB,86701,HIV SCREEN  SCH,300,33,28.05,Pays at 85% of Billed charges for outpatient setting,9.7,Pays at 100% of GA Medicaid Fee Schedule,26.41,Pays at 80.03% of Total Billed charges,9.06,Pays at 102% of Medicare OPPS Rate,29.7,Pays at 90% of Total Billed charges,9.7,Pays at 100% of GA Medicaid Fee Schedule,8.89,Pays at 100% of Medicare OPPS Rate,9.7,Pays at 100% of GA Medicaid Fee Schedule,29.04,Pays at 88% of Total Billed charges,9.99,Pays at 103% of GA Medicaid Fee Schedule,8.89,29.7,19.80
Outpatient Medical Services,LAB,86701,HIV-1 AB (MAYO),300,110.75,94.14,Pays at 85% of Billed charges for outpatient setting,9.7,Pays at 100% of GA Medicaid Fee Schedule,88.63,Pays at 80.03% of Total Billed charges,9.06,Pays at 102% of Medicare OPPS Rate,99.68,Pays at 90% of Total Billed charges,9.7,Pays at 100% of GA Medicaid Fee Schedule,8.89,Pays at 100% of Medicare OPPS Rate,9.7,Pays at 100% of GA Medicaid Fee Schedule,97.46,Pays at 88% of Total Billed charges,9.99,Pays at 103% of GA Medicaid Fee Schedule,8.89,99.68,66.45
Outpatient Medical Services,LAB,86702,HIV-2  (MAYO),300,108.75,92.44,Pays at 85% of Billed charges for outpatient setting,14.75,Pays at 100% of GA Medicaid Fee Schedule,87.03,Pays at 80.03% of Total Billed charges,13.79,Pays at 102% of Medicare OPPS Rate,97.88,Pays at 90% of Total Billed charges,14.75,Pays at 100% of GA Medicaid Fee Schedule,13.52,Pays at 100% of Medicare OPPS Rate,14.75,Pays at 100% of GA Medicaid Fee Schedule,95.7,Pays at 88% of Total Billed charges,15.19,Pays at 103% of GA Medicaid Fee Schedule,13.52,97.88,65.25
Outpatient Medical Services,LAB,86702,HIV-2 AB  (MAYO),300,168.25,143.01,Pays at 85% of Billed charges for outpatient setting,14.75,Pays at 100% of GA Medicaid Fee Schedule,134.65,Pays at 80.03% of Total Billed charges,13.79,Pays at 102% of Medicare OPPS Rate,151.43,Pays at 90% of Total Billed charges,14.75,Pays at 100% of GA Medicaid Fee Schedule,13.52,Pays at 100% of Medicare OPPS Rate,14.75,Pays at 100% of GA Medicaid Fee Schedule,148.06,Pays at 88% of Total Billed charges,15.19,Pays at 103% of GA Medicaid Fee Schedule,13.52,151.43,100.95
Outpatient Medical Services,LAB,86703,Blood test to diagnose HIV,300,18.55,15.77,Pays at 85% of Billed charges for outpatient setting,14.96,Pays at 100% of GA Medicaid Fee Schedule,14.85,Pays at 80.03% of Total Billed charges,13.98,Pays at 102% of Medicare OPPS Rate,16.7,Pays at 90% of Total Billed charges,14.96,Pays at 100% of GA Medicaid Fee Schedule,13.71,Pays at 100% of Medicare OPPS Rate,14.96,Pays at 100% of GA Medicaid Fee Schedule,16.32,Pays at 88% of Total Billed charges,15.41,Pays at 103% of GA Medicaid Fee Schedule,13.71,16.7,11.13
Outpatient Medical Services,LAB,86704,Blood test indicating infection with Hepatitis B,300,28.12,23.9,Pays at 85% of Billed charges for outpatient setting,15.16,Pays at 100% of GA Medicaid Fee Schedule,22.5,Pays at 80.03% of Total Billed charges,12.29,Pays at 102% of Medicare OPPS Rate,25.31,Pays at 90% of Total Billed charges,15.16,Pays at 100% of GA Medicaid Fee Schedule,12.05,Pays at 100% of Medicare OPPS Rate,15.16,Pays at 100% of GA Medicaid Fee Schedule,24.75,Pays at 88% of Total Billed charges,15.61,Pays at 103% of GA Medicaid Fee Schedule,12.05,25.31,16.87
Outpatient Medical Services,LAB,86704,Blood test indicating infection with Hepatitis B,300,38.25,32.51,Pays at 85% of Billed charges for outpatient setting,15.16,Pays at 100% of GA Medicaid Fee Schedule,30.61,Pays at 80.03% of Total Billed charges,12.29,Pays at 102% of Medicare OPPS Rate,34.43,Pays at 90% of Total Billed charges,15.16,Pays at 100% of GA Medicaid Fee Schedule,12.05,Pays at 100% of Medicare OPPS Rate,15.16,Pays at 100% of GA Medicaid Fee Schedule,33.66,Pays at 88% of Total Billed charges,15.61,Pays at 103% of GA Medicaid Fee Schedule,12.05,34.43,22.95
Outpatient Medical Services,LAB,86704,Blood test indicating infection with Hepatitis B,300,38.25,32.51,Pays at 85% of Billed charges for outpatient setting,15.16,Pays at 100% of GA Medicaid Fee Schedule,30.61,Pays at 80.03% of Total Billed charges,12.29,Pays at 102% of Medicare OPPS Rate,34.43,Pays at 90% of Total Billed charges,15.16,Pays at 100% of GA Medicaid Fee Schedule,12.05,Pays at 100% of Medicare OPPS Rate,15.16,Pays at 100% of GA Medicaid Fee Schedule,33.66,Pays at 88% of Total Billed charges,15.61,Pays at 103% of GA Medicaid Fee Schedule,12.05,34.43,22.95
Outpatient Medical Services,LAB,86706,HEPATITIS B SURFACE ANTIBODY (MAYO),300,42.81,36.39,Pays at 85% of Billed charges for outpatient setting,13.51,Pays at 100% of GA Medicaid Fee Schedule,34.26,Pays at 80.03% of Total Billed charges,10.95,Pays at 102% of Medicare OPPS Rate,38.53,Pays at 90% of Total Billed charges,13.51,Pays at 100% of GA Medicaid Fee Schedule,10.74,Pays at 100% of Medicare OPPS Rate,13.51,Pays at 100% of GA Medicaid Fee Schedule,37.67,Pays at 88% of Total Billed charges,13.92,Pays at 103% of GA Medicaid Fee Schedule,10.74,38.53,25.69
Outpatient Medical Services,LAB,86707,HEPATITIS BE AB  (MAYO),300,37.25,31.66,Pays at 85% of Billed charges for outpatient setting,14.54,Pays at 100% of GA Medicaid Fee Schedule,29.81,Pays at 80.03% of Total Billed charges,11.8,Pays at 102% of Medicare OPPS Rate,33.53,Pays at 90% of Total Billed charges,14.54,Pays at 100% of GA Medicaid Fee Schedule,11.57,Pays at 100% of Medicare OPPS Rate,14.54,Pays at 100% of GA Medicaid Fee Schedule,32.78,Pays at 88% of Total Billed charges,14.98,Pays at 103% of GA Medicaid Fee Schedule,11.57,33.53,22.35
Outpatient Medical Services,LAB,86708,Blood test indicating infection with Hepatitis A,300,40,34,Pays at 85% of Billed charges for outpatient setting,15.58,Pays at 100% of GA Medicaid Fee Schedule,32.01,Pays at 80.03% of Total Billed charges,12.63,Pays at 102% of Medicare OPPS Rate,36,Pays at 90% of Total Billed charges,15.58,Pays at 100% of GA Medicaid Fee Schedule,12.39,Pays at 100% of Medicare OPPS Rate,15.58,Pays at 100% of GA Medicaid Fee Schedule,35.2,Pays at 88% of Total Billed charges,16.05,Pays at 103% of GA Medicaid Fee Schedule,12.39,36,24.00
Outpatient Medical Services,LAB,86708,Blood test indicating infection with Hepatitis A,300,41.5,35.28,Pays at 85% of Billed charges for outpatient setting,15.58,Pays at 100% of GA Medicaid Fee Schedule,33.21,Pays at 80.03% of Total Billed charges,12.63,Pays at 102% of Medicare OPPS Rate,37.35,Pays at 90% of Total Billed charges,15.58,Pays at 100% of GA Medicaid Fee Schedule,12.39,Pays at 100% of Medicare OPPS Rate,15.58,Pays at 100% of GA Medicaid Fee Schedule,36.52,Pays at 88% of Total Billed charges,16.05,Pays at 103% of GA Medicaid Fee Schedule,12.39,37.35,24.90
Outpatient Medical Services,LAB,86710,"INFLUENZA VIRUS A, IGG,IGM  (MAYO)",300,33.5,28.48,Pays at 85% of Billed charges for outpatient setting,17.05,Pays at 100% of GA Medicaid Fee Schedule,26.81,Pays at 80.03% of Total Billed charges,13.82,Pays at 102% of Medicare OPPS Rate,30.15,Pays at 90% of Total Billed charges,17.05,Pays at 100% of GA Medicaid Fee Schedule,13.55,Pays at 100% of Medicare OPPS Rate,17.05,Pays at 100% of GA Medicaid Fee Schedule,29.48,Pays at 88% of Total Billed charges,17.56,Pays at 103% of GA Medicaid Fee Schedule,13.55,30.15,20.10
Outpatient Medical Services,LAB,86710,"INFLUENZA VIRUS B, IGG,IGM  (MAYO)",300,33.5,28.48,Pays at 85% of Billed charges for outpatient setting,17.05,Pays at 100% of GA Medicaid Fee Schedule,26.81,Pays at 80.03% of Total Billed charges,13.82,Pays at 102% of Medicare OPPS Rate,30.15,Pays at 90% of Total Billed charges,17.05,Pays at 100% of GA Medicaid Fee Schedule,13.55,Pays at 100% of Medicare OPPS Rate,17.05,Pays at 100% of GA Medicaid Fee Schedule,29.48,Pays at 88% of Total Billed charges,17.56,Pays at 103% of GA Medicaid Fee Schedule,13.55,30.15,20.10
Outpatient Medical Services,LAB,86713,"LEGIONELLA PNEUMO AB, SERUM  (MAYO)",300,48.75,41.44,Pays at 85% of Billed charges for outpatient setting,19.25,Pays at 100% of GA Medicaid Fee Schedule,39.01,Pays at 80.03% of Total Billed charges,15.6,Pays at 102% of Medicare OPPS Rate,43.88,Pays at 90% of Total Billed charges,19.25,Pays at 100% of GA Medicaid Fee Schedule,15.3,Pays at 100% of Medicare OPPS Rate,19.25,Pays at 100% of GA Medicaid Fee Schedule,42.9,Pays at 88% of Total Billed charges,19.83,Pays at 103% of GA Medicaid Fee Schedule,15.3,43.88,29.25
Outpatient Medical Services,LAB,86720,LEPTOSPIRA IGM  (MAYO),300,157.08,133.52,Pays at 85% of Billed charges for outpatient setting,16.59,Pays at 100% of GA Medicaid Fee Schedule,125.71,Pays at 80.03% of Total Billed charges,16.52,Pays at 102% of Medicare OPPS Rate,141.37,Pays at 90% of Total Billed charges,16.59,Pays at 100% of GA Medicaid Fee Schedule,16.2,Pays at 100% of Medicare OPPS Rate,16.59,Pays at 100% of GA Medicaid Fee Schedule,138.23,Pays at 88% of Total Billed charges,17.09,Pays at 103% of GA Medicaid Fee Schedule,16.2,141.37,94.25
Outpatient Medical Services,LAB,86735,"MUMPS AB, IGM  (MAYO)",300,34,28.9,Pays at 85% of Billed charges for outpatient setting,16.41,Pays at 100% of GA Medicaid Fee Schedule,27.21,Pays at 80.03% of Total Billed charges,13.31,Pays at 102% of Medicare OPPS Rate,30.6,Pays at 90% of Total Billed charges,16.41,Pays at 100% of GA Medicaid Fee Schedule,13.05,Pays at 100% of Medicare OPPS Rate,16.41,Pays at 100% of GA Medicaid Fee Schedule,29.92,Pays at 88% of Total Billed charges,16.9,Pays at 103% of GA Medicaid Fee Schedule,13.05,30.6,20.40
Outpatient Medical Services,LAB,86735,"MUMPS AB, IGG  (MAYO)",300,41.5,35.28,Pays at 85% of Billed charges for outpatient setting,16.41,Pays at 100% of GA Medicaid Fee Schedule,33.21,Pays at 80.03% of Total Billed charges,13.31,Pays at 102% of Medicare OPPS Rate,37.35,Pays at 90% of Total Billed charges,16.41,Pays at 100% of GA Medicaid Fee Schedule,13.05,Pays at 100% of Medicare OPPS Rate,16.41,Pays at 100% of GA Medicaid Fee Schedule,36.52,Pays at 88% of Total Billed charges,16.9,Pays at 103% of GA Medicaid Fee Schedule,13.05,37.35,24.90
Outpatient Medical Services,LAB,86738,"M PNEUMONIAE AB, IGG&IGM (MAYO)",300,42.5,36.13,Pays at 85% of Billed charges for outpatient setting,16.66,Pays at 100% of GA Medicaid Fee Schedule,34.01,Pays at 80.03% of Total Billed charges,13.5,Pays at 102% of Medicare OPPS Rate,38.25,Pays at 90% of Total Billed charges,16.66,Pays at 100% of GA Medicaid Fee Schedule,13.24,Pays at 100% of Medicare OPPS Rate,16.66,Pays at 100% of GA Medicaid Fee Schedule,37.4,Pays at 88% of Total Billed charges,17.16,Pays at 103% of GA Medicaid Fee Schedule,13.24,38.25,25.50
Outpatient Medical Services,LAB,86738,"M PNEUMONIAE AB, IGM  (MAYO)",300,100,85,Pays at 85% of Billed charges for outpatient setting,16.66,Pays at 100% of GA Medicaid Fee Schedule,80.03,Pays at 80.03% of Total Billed charges,13.5,Pays at 102% of Medicare OPPS Rate,90,Pays at 90% of Total Billed charges,16.66,Pays at 100% of GA Medicaid Fee Schedule,13.24,Pays at 100% of Medicare OPPS Rate,16.66,Pays at 100% of GA Medicaid Fee Schedule,88,Pays at 88% of Total Billed charges,17.16,Pays at 103% of GA Medicaid Fee Schedule,13.24,90,60.00
Outpatient Medical Services,LAB,86738,MYCOPLASMA PNEUMONIAE IGA  (MAYO),300,133.25,113.26,Pays at 85% of Billed charges for outpatient setting,16.66,Pays at 100% of GA Medicaid Fee Schedule,106.64,Pays at 80.03% of Total Billed charges,13.5,Pays at 102% of Medicare OPPS Rate,119.93,Pays at 90% of Total Billed charges,16.66,Pays at 100% of GA Medicaid Fee Schedule,13.24,Pays at 100% of Medicare OPPS Rate,16.66,Pays at 100% of GA Medicaid Fee Schedule,117.26,Pays at 88% of Total Billed charges,17.16,Pays at 103% of GA Medicaid Fee Schedule,13.24,119.93,79.95
Outpatient Medical Services,LAB,86747,"PARVO-VIRUS, B-19, IGG/IGM   (MAYO)",300,74.5,63.33,Pays at 85% of Billed charges for outpatient setting,18.9,Pays at 100% of GA Medicaid Fee Schedule,59.62,Pays at 80.03% of Total Billed charges,15.33,Pays at 102% of Medicare OPPS Rate,67.05,Pays at 90% of Total Billed charges,18.9,Pays at 100% of GA Medicaid Fee Schedule,15.03,Pays at 100% of Medicare OPPS Rate,18.9,Pays at 100% of GA Medicaid Fee Schedule,65.56,Pays at 88% of Total Billed charges,19.47,Pays at 103% of GA Medicaid Fee Schedule,15.03,67.05,44.70
Outpatient Medical Services,LAB,86753,"ANTI-E HISTOLYTICA, AMOEBA TITER  (MAYO",300,61,51.85,Pays at 85% of Billed charges for outpatient setting,15.59,Pays at 100% of GA Medicaid Fee Schedule,48.82,Pays at 80.03% of Total Billed charges,12.63,Pays at 102% of Medicare OPPS Rate,54.9,Pays at 90% of Total Billed charges,15.59,Pays at 100% of GA Medicaid Fee Schedule,12.39,Pays at 100% of Medicare OPPS Rate,15.59,Pays at 100% of GA Medicaid Fee Schedule,53.68,Pays at 88% of Total Billed charges,16.06,Pays at 103% of GA Medicaid Fee Schedule,12.39,54.9,36.60
Outpatient Medical Services,LAB,86756,RSV,300,47.56,40.43,Pays at 85% of Billed charges for outpatient setting,16.21,Pays at 100% of GA Medicaid Fee Schedule,38.06,Pays at 80.03% of Total Billed charges,16.2,Pays at 102% of Medicare OPPS Rate,42.8,Pays at 90% of Total Billed charges,16.21,Pays at 100% of GA Medicaid Fee Schedule,15.89,Pays at 100% of Medicare OPPS Rate,16.21,Pays at 100% of GA Medicaid Fee Schedule,41.85,Pays at 88% of Total Billed charges,16.7,Pays at 103% of GA Medicaid Fee Schedule,15.89,42.8,28.54
Outpatient Medical Services,LAB,86757,RMSF IGM  (MAYO),300,42.75,36.34,Pays at 85% of Billed charges for outpatient setting,24.35,Pays at 100% of GA Medicaid Fee Schedule,34.21,Pays at 80.03% of Total Billed charges,19.73,Pays at 102% of Medicare OPPS Rate,38.48,Pays at 90% of Total Billed charges,24.35,Pays at 100% of GA Medicaid Fee Schedule,19.35,Pays at 100% of Medicare OPPS Rate,24.35,Pays at 100% of GA Medicaid Fee Schedule,37.62,Pays at 88% of Total Billed charges,25.08,Pays at 103% of GA Medicaid Fee Schedule,19.35,38.48,25.65
Outpatient Medical Services,LAB,86757,R TYPHI IGM  (MAYO),300,42.75,36.34,Pays at 85% of Billed charges for outpatient setting,24.35,Pays at 100% of GA Medicaid Fee Schedule,34.21,Pays at 80.03% of Total Billed charges,19.73,Pays at 102% of Medicare OPPS Rate,38.48,Pays at 90% of Total Billed charges,24.35,Pays at 100% of GA Medicaid Fee Schedule,19.35,Pays at 100% of Medicare OPPS Rate,24.35,Pays at 100% of GA Medicaid Fee Schedule,37.62,Pays at 88% of Total Billed charges,25.08,Pays at 103% of GA Medicaid Fee Schedule,19.35,38.48,25.65
Outpatient Medical Services,LAB,86757,SPOTTED FEVER GRP AB IGG  (MAYO),300,44,37.4,Pays at 85% of Billed charges for outpatient setting,24.35,Pays at 100% of GA Medicaid Fee Schedule,35.21,Pays at 80.03% of Total Billed charges,19.73,Pays at 102% of Medicare OPPS Rate,39.6,Pays at 90% of Total Billed charges,24.35,Pays at 100% of GA Medicaid Fee Schedule,19.35,Pays at 100% of Medicare OPPS Rate,24.35,Pays at 100% of GA Medicaid Fee Schedule,38.72,Pays at 88% of Total Billed charges,25.08,Pays at 103% of GA Medicaid Fee Schedule,19.35,39.6,26.40
Outpatient Medical Services,LAB,86757,SPOTTED FEVER GRP AB IGM  (MAYO),300,44,37.4,Pays at 85% of Billed charges for outpatient setting,24.35,Pays at 100% of GA Medicaid Fee Schedule,35.21,Pays at 80.03% of Total Billed charges,19.73,Pays at 102% of Medicare OPPS Rate,39.6,Pays at 90% of Total Billed charges,24.35,Pays at 100% of GA Medicaid Fee Schedule,19.35,Pays at 100% of Medicare OPPS Rate,24.35,Pays at 100% of GA Medicaid Fee Schedule,38.72,Pays at 88% of Total Billed charges,25.08,Pays at 103% of GA Medicaid Fee Schedule,19.35,39.6,26.40
Outpatient Medical Services,LAB,86757,RICKETTSIA SERUM ABS  (MAYO),300,55.5,47.18,Pays at 85% of Billed charges for outpatient setting,24.35,Pays at 100% of GA Medicaid Fee Schedule,44.42,Pays at 80.03% of Total Billed charges,19.73,Pays at 102% of Medicare OPPS Rate,49.95,Pays at 90% of Total Billed charges,24.35,Pays at 100% of GA Medicaid Fee Schedule,19.35,Pays at 100% of Medicare OPPS Rate,24.35,Pays at 100% of GA Medicaid Fee Schedule,48.84,Pays at 88% of Total Billed charges,25.08,Pays at 103% of GA Medicaid Fee Schedule,19.35,49.95,33.30
Outpatient Medical Services,LAB,86757,ROCKY MNT SPOTTED FEVER IGG  QUEST,300,75.05,63.79,Pays at 85% of Billed charges for outpatient setting,24.35,Pays at 100% of GA Medicaid Fee Schedule,60.06,Pays at 80.03% of Total Billed charges,19.73,Pays at 102% of Medicare OPPS Rate,67.55,Pays at 90% of Total Billed charges,24.35,Pays at 100% of GA Medicaid Fee Schedule,19.35,Pays at 100% of Medicare OPPS Rate,24.35,Pays at 100% of GA Medicaid Fee Schedule,66.04,Pays at 88% of Total Billed charges,25.08,Pays at 103% of GA Medicaid Fee Schedule,19.35,67.55,45.03
Outpatient Medical Services,LAB,86757,ETHYL (MAYO),300,80,68,Pays at 85% of Billed charges for outpatient setting,24.35,Pays at 100% of GA Medicaid Fee Schedule,64.02,Pays at 80.03% of Total Billed charges,19.73,Pays at 102% of Medicare OPPS Rate,72,Pays at 90% of Total Billed charges,24.35,Pays at 100% of GA Medicaid Fee Schedule,19.35,Pays at 100% of Medicare OPPS Rate,24.35,Pays at 100% of GA Medicaid Fee Schedule,70.4,Pays at 88% of Total Billed charges,25.08,Pays at 103% of GA Medicaid Fee Schedule,19.35,72,48.00
Outpatient Medical Services,LAB,86757,RMSF IGG  (MAYO),300,135.5,115.18,Pays at 85% of Billed charges for outpatient setting,24.35,Pays at 100% of GA Medicaid Fee Schedule,108.44,Pays at 80.03% of Total Billed charges,19.73,Pays at 102% of Medicare OPPS Rate,121.95,Pays at 90% of Total Billed charges,24.35,Pays at 100% of GA Medicaid Fee Schedule,19.35,Pays at 100% of Medicare OPPS Rate,24.35,Pays at 100% of GA Medicaid Fee Schedule,119.24,Pays at 88% of Total Billed charges,25.08,Pays at 103% of GA Medicaid Fee Schedule,19.35,121.95,81.30
Outpatient Medical Services,LAB,86757,R TYPHI IGG  (MAYO),300,142.75,121.34,Pays at 85% of Billed charges for outpatient setting,24.35,Pays at 100% of GA Medicaid Fee Schedule,114.24,Pays at 80.03% of Total Billed charges,19.73,Pays at 102% of Medicare OPPS Rate,128.48,Pays at 90% of Total Billed charges,24.35,Pays at 100% of GA Medicaid Fee Schedule,19.35,Pays at 100% of Medicare OPPS Rate,24.35,Pays at 100% of GA Medicaid Fee Schedule,125.62,Pays at 88% of Total Billed charges,25.08,Pays at 103% of GA Medicaid Fee Schedule,19.35,128.48,85.65
Outpatient Medical Services,LAB,86759,ROTAVIRUS AG,300,63.25,53.76,Pays at 85% of Billed charges for outpatient setting,16.59,Pays at 100% of GA Medicaid Fee Schedule,50.62,Pays at 80.03% of Total Billed charges,18.59,Pays at 102% of Medicare OPPS Rate,56.93,Pays at 90% of Total Billed charges,16.59,Pays at 100% of GA Medicaid Fee Schedule,18.23,Pays at 100% of Medicare OPPS Rate,16.59,Pays at 100% of GA Medicaid Fee Schedule,55.66,Pays at 88% of Total Billed charges,17.09,Pays at 103% of GA Medicaid Fee Schedule,16.59,56.93,37.95
Outpatient Medical Services,LAB,86762,Blood test to determine if antibodies exist for rubella,300,21,17.85,Pays at 85% of Billed charges for outpatient setting,14.63,Pays at 100% of GA Medicaid Fee Schedule,16.81,Pays at 80.03% of Total Billed charges,14.67,Pays at 102% of Medicare OPPS Rate,18.9,Pays at 90% of Total Billed charges,14.63,Pays at 100% of GA Medicaid Fee Schedule,14.39,Pays at 100% of Medicare OPPS Rate,14.63,Pays at 100% of GA Medicaid Fee Schedule,18.48,Pays at 88% of Total Billed charges,15.07,Pays at 103% of GA Medicaid Fee Schedule,14.39,18.9,12.60
Outpatient Medical Services,LAB,86762,Blood test to determine if antibodies exist for rubella,300,70.75,60.14,Pays at 85% of Billed charges for outpatient setting,14.63,Pays at 100% of GA Medicaid Fee Schedule,56.62,Pays at 80.03% of Total Billed charges,14.67,Pays at 102% of Medicare OPPS Rate,63.68,Pays at 90% of Total Billed charges,14.63,Pays at 100% of GA Medicaid Fee Schedule,14.39,Pays at 100% of Medicare OPPS Rate,14.63,Pays at 100% of GA Medicaid Fee Schedule,62.26,Pays at 88% of Total Billed charges,15.07,Pays at 103% of GA Medicaid Fee Schedule,14.39,63.68,42.45
Outpatient Medical Services,LAB,86765,Blood test to determine if antibodies exist for measles,300,39,33.15,Pays at 85% of Billed charges for outpatient setting,16.2,Pays at 100% of GA Medicaid Fee Schedule,31.21,Pays at 80.03% of Total Billed charges,13.13,Pays at 102% of Medicare OPPS Rate,35.1,Pays at 90% of Total Billed charges,16.2,Pays at 100% of GA Medicaid Fee Schedule,12.88,Pays at 100% of Medicare OPPS Rate,16.2,Pays at 100% of GA Medicaid Fee Schedule,34.32,Pays at 88% of Total Billed charges,16.69,Pays at 103% of GA Medicaid Fee Schedule,12.88,35.1,23.40
Outpatient Medical Services,LAB,86765,Blood test to determine if antibodies exist for measles,300,39,33.15,Pays at 85% of Billed charges for outpatient setting,16.2,Pays at 100% of GA Medicaid Fee Schedule,31.21,Pays at 80.03% of Total Billed charges,13.13,Pays at 102% of Medicare OPPS Rate,35.1,Pays at 90% of Total Billed charges,16.2,Pays at 100% of GA Medicaid Fee Schedule,12.88,Pays at 100% of Medicare OPPS Rate,16.2,Pays at 100% of GA Medicaid Fee Schedule,34.32,Pays at 88% of Total Billed charges,16.69,Pays at 103% of GA Medicaid Fee Schedule,12.88,35.1,23.40
Outpatient Medical Services,LAB,86765,Blood test to determine if antibodies exist for measles,300,51.88,44.1,Pays at 85% of Billed charges for outpatient setting,16.2,Pays at 100% of GA Medicaid Fee Schedule,41.52,Pays at 80.03% of Total Billed charges,13.13,Pays at 102% of Medicare OPPS Rate,46.69,Pays at 90% of Total Billed charges,16.2,Pays at 100% of GA Medicaid Fee Schedule,12.88,Pays at 100% of Medicare OPPS Rate,16.2,Pays at 100% of GA Medicaid Fee Schedule,45.65,Pays at 88% of Total Billed charges,16.69,Pays at 103% of GA Medicaid Fee Schedule,12.88,46.69,31.13
Outpatient Medical Services,LAB,86768,"..SALMONELLA ABS, SERUM  (MAYO)",300,32,27.2,Pays at 85% of Billed charges for outpatient setting,16.59,Pays at 100% of GA Medicaid Fee Schedule,25.61,Pays at 80.03% of Total Billed charges,13.45,Pays at 102% of Medicare OPPS Rate,28.8,Pays at 90% of Total Billed charges,16.59,Pays at 100% of GA Medicaid Fee Schedule,13.19,Pays at 100% of Medicare OPPS Rate,16.59,Pays at 100% of GA Medicaid Fee Schedule,28.16,Pays at 88% of Total Billed charges,17.09,Pays at 103% of GA Medicaid Fee Schedule,13.19,28.8,19.20
Outpatient Medical Services,LAB,86769,SARS-CoV-2 IGG AB SERUM  (MAYO),300,139.78,118.81,Pays at 85% of Billed charges for outpatient setting,51.31,Pays at 100% of GA Medicaid Fee Schedule,111.87,Pays at 80.03% of Total Billed charges,42.97,Pays at 102% of Medicare OPPS Rate,125.8,Pays at 90% of Total Billed charges,51.31,Pays at 100% of GA Medicaid Fee Schedule,42.13,Pays at 100% of Medicare OPPS Rate,51.31,Pays at 100% of GA Medicaid Fee Schedule,123.01,Pays at 88% of Total Billed charges,52.85,Pays at 103% of GA Medicaid Fee Schedule,42.13,125.8,83.87
Outpatient Medical Services,LAB,86774,TETANUS TOXIN AB POST-IMM  (MAYO),300,43.25,36.76,Pays at 85% of Billed charges for outpatient setting,18.61,Pays at 100% of GA Medicaid Fee Schedule,34.61,Pays at 80.03% of Total Billed charges,15.09,Pays at 102% of Medicare OPPS Rate,38.93,Pays at 90% of Total Billed charges,18.61,Pays at 100% of GA Medicaid Fee Schedule,14.8,Pays at 100% of Medicare OPPS Rate,18.61,Pays at 100% of GA Medicaid Fee Schedule,38.06,Pays at 88% of Total Billed charges,19.17,Pays at 103% of GA Medicaid Fee Schedule,14.8,38.93,25.95
Outpatient Medical Services,LAB,86774,TETANUS TOXIN AB PREIMMUNIZATION  (MAYO),300,43.5,36.98,Pays at 85% of Billed charges for outpatient setting,18.61,Pays at 100% of GA Medicaid Fee Schedule,34.81,Pays at 80.03% of Total Billed charges,15.09,Pays at 102% of Medicare OPPS Rate,39.15,Pays at 90% of Total Billed charges,18.61,Pays at 100% of GA Medicaid Fee Schedule,14.8,Pays at 100% of Medicare OPPS Rate,18.61,Pays at 100% of GA Medicaid Fee Schedule,38.28,Pays at 88% of Total Billed charges,19.17,Pays at 103% of GA Medicaid Fee Schedule,14.8,39.15,26.10
Outpatient Medical Services,LAB,86777,TOXOPLASMA  AB SCREEN  (MAYO),300,36.75,31.24,Pays at 85% of Billed charges for outpatient setting,14.63,Pays at 100% of GA Medicaid Fee Schedule,29.41,Pays at 80.03% of Total Billed charges,14.67,Pays at 102% of Medicare OPPS Rate,33.08,Pays at 90% of Total Billed charges,14.63,Pays at 100% of GA Medicaid Fee Schedule,14.39,Pays at 100% of Medicare OPPS Rate,14.63,Pays at 100% of GA Medicaid Fee Schedule,32.34,Pays at 88% of Total Billed charges,15.07,Pays at 103% of GA Medicaid Fee Schedule,14.39,33.08,22.05
Outpatient Medical Services,LAB,86777,"TOXOPLASMOSIS, IGG  (MAYO)",300,110.5,93.93,Pays at 85% of Billed charges for outpatient setting,14.63,Pays at 100% of GA Medicaid Fee Schedule,88.43,Pays at 80.03% of Total Billed charges,14.67,Pays at 102% of Medicare OPPS Rate,99.45,Pays at 90% of Total Billed charges,14.63,Pays at 100% of GA Medicaid Fee Schedule,14.39,Pays at 100% of Medicare OPPS Rate,14.63,Pays at 100% of GA Medicaid Fee Schedule,97.24,Pays at 88% of Total Billed charges,15.07,Pays at 103% of GA Medicaid Fee Schedule,14.39,99.45,66.30
Outpatient Medical Services,LAB,86778,"TOXOPLASMOSIS, IGM   (MAYO)",300,110.5,93.93,Pays at 85% of Billed charges for outpatient setting,18.11,Pays at 100% of GA Medicaid Fee Schedule,88.43,Pays at 80.03% of Total Billed charges,14.69,Pays at 102% of Medicare OPPS Rate,99.45,Pays at 90% of Total Billed charges,18.11,Pays at 100% of GA Medicaid Fee Schedule,14.41,Pays at 100% of Medicare OPPS Rate,18.11,Pays at 100% of GA Medicaid Fee Schedule,97.24,Pays at 88% of Total Billed charges,18.65,Pays at 103% of GA Medicaid Fee Schedule,14.41,99.45,66.30
Outpatient Medical Services,LAB,86780,Blood test to determine existence of certain bacterium that causes syphilis,300,32.5,27.63,Pays at 85% of Billed charges for outpatient setting,10.45,Pays at 32.15% of Total Billed charges,26.01,Pays at 80.03% of Total Billed charges,13.5,Pays at 102% of Medicare OPPS Rate,29.25,Pays at 90% of Total Billed charges,10.45,Pays at 32.15% of Total Billed charges,13.24,Pays at 100% of Medicare OPPS Rate,10.45,Pays at 32.15% of Total Billed charges,28.6,Pays at 88% of Total Billed charges,10.76,Pays at 33.11% of Total Billed charges,10.45,29.25,19.50
Outpatient Medical Services,LAB,86780,Blood test to determine existence of certain bacterium that causes syphilis,300,65,55.25,Pays at 85% of Billed charges for outpatient setting,20.9,Pays at 32.15% of Total Billed charges,52.02,Pays at 80.03% of Total Billed charges,13.5,Pays at 102% of Medicare OPPS Rate,58.5,Pays at 90% of Total Billed charges,20.9,Pays at 32.15% of Total Billed charges,13.24,Pays at 100% of Medicare OPPS Rate,20.9,Pays at 32.15% of Total Billed charges,57.2,Pays at 88% of Total Billed charges,21.52,Pays at 33.11% of Total Billed charges,13.24,58.5,39.00
Outpatient Medical Services,LAB,86780,Blood test to determine existence of certain bacterium that causes syphilis,300,135.5,115.18,Pays at 85% of Billed charges for outpatient setting,43.56,Pays at 32.15% of Total Billed charges,108.44,Pays at 80.03% of Total Billed charges,13.5,Pays at 102% of Medicare OPPS Rate,121.95,Pays at 90% of Total Billed charges,43.56,Pays at 32.15% of Total Billed charges,13.24,Pays at 100% of Medicare OPPS Rate,43.56,Pays at 32.15% of Total Billed charges,119.24,Pays at 88% of Total Billed charges,44.86,Pays at 33.11% of Total Billed charges,13.24,121.95,81.30
Outpatient Medical Services,LAB,86780,Blood test to determine existence of certain bacterium that causes syphilis,300,135.5,115.18,Pays at 85% of Billed charges for outpatient setting,43.56,Pays at 32.15% of Total Billed charges,108.44,Pays at 80.03% of Total Billed charges,13.5,Pays at 102% of Medicare OPPS Rate,121.95,Pays at 90% of Total Billed charges,43.56,Pays at 32.15% of Total Billed charges,13.24,Pays at 100% of Medicare OPPS Rate,43.56,Pays at 32.15% of Total Billed charges,119.24,Pays at 88% of Total Billed charges,44.86,Pays at 33.11% of Total Billed charges,13.24,121.95,81.30
Outpatient Medical Services,LAB,86784,TRICHINELLA  AB  (MAYO),300,60.25,51.21,Pays at 85% of Billed charges for outpatient setting,15.8,Pays at 100% of GA Medicaid Fee Schedule,48.22,Pays at 80.03% of Total Billed charges,12.81,Pays at 102% of Medicare OPPS Rate,54.23,Pays at 90% of Total Billed charges,15.8,Pays at 100% of GA Medicaid Fee Schedule,12.56,Pays at 100% of Medicare OPPS Rate,15.8,Pays at 100% of GA Medicaid Fee Schedule,53.02,Pays at 88% of Total Billed charges,16.27,Pays at 103% of GA Medicaid Fee Schedule,12.56,54.23,36.15
Outpatient Medical Services,LAB,86787,VARICELLA ZOSTER IGG  (MAYO),300,41.5,35.28,Pays at 85% of Billed charges for outpatient setting,16.2,Pays at 100% of GA Medicaid Fee Schedule,33.21,Pays at 80.03% of Total Billed charges,13.13,Pays at 102% of Medicare OPPS Rate,37.35,Pays at 90% of Total Billed charges,16.2,Pays at 100% of GA Medicaid Fee Schedule,12.88,Pays at 100% of Medicare OPPS Rate,16.2,Pays at 100% of GA Medicaid Fee Schedule,36.52,Pays at 88% of Total Billed charges,16.69,Pays at 103% of GA Medicaid Fee Schedule,12.88,37.35,24.90
Outpatient Medical Services,LAB,86787,VARICELLA ZOSTER IGM  (MAYO),300,41.5,35.28,Pays at 85% of Billed charges for outpatient setting,16.2,Pays at 100% of GA Medicaid Fee Schedule,33.21,Pays at 80.03% of Total Billed charges,13.13,Pays at 102% of Medicare OPPS Rate,37.35,Pays at 90% of Total Billed charges,16.2,Pays at 100% of GA Medicaid Fee Schedule,12.88,Pays at 100% of Medicare OPPS Rate,16.2,Pays at 100% of GA Medicaid Fee Schedule,36.52,Pays at 88% of Total Billed charges,16.69,Pays at 103% of GA Medicaid Fee Schedule,12.88,37.35,24.90
Outpatient Medical Services,LAB,86788,".WEST NILE VIRUS, IGM  (MAYO)",300,53.75,45.69,Pays at 85% of Billed charges for outpatient setting,21.19,Pays at 100% of GA Medicaid Fee Schedule,43.02,Pays at 80.03% of Total Billed charges,17.18,Pays at 102% of Medicare OPPS Rate,48.38,Pays at 90% of Total Billed charges,21.19,Pays at 100% of GA Medicaid Fee Schedule,16.85,Pays at 100% of Medicare OPPS Rate,21.19,Pays at 100% of GA Medicaid Fee Schedule,47.3,Pays at 88% of Total Billed charges,21.83,Pays at 103% of GA Medicaid Fee Schedule,16.85,48.38,32.25
Outpatient Medical Services,LAB,86789,".WEST NILE VIRUS, IGG  (MAYO)",300,45.5,38.68,Pays at 85% of Billed charges for outpatient setting,14.63,Pays at 100% of GA Medicaid Fee Schedule,36.41,Pays at 80.03% of Total Billed charges,14.67,Pays at 102% of Medicare OPPS Rate,40.95,Pays at 90% of Total Billed charges,14.63,Pays at 100% of GA Medicaid Fee Schedule,14.39,Pays at 100% of Medicare OPPS Rate,14.63,Pays at 100% of GA Medicaid Fee Schedule,40.04,Pays at 88% of Total Billed charges,15.07,Pays at 103% of GA Medicaid Fee Schedule,14.39,40.95,27.30
Outpatient Medical Services,LAB,86790,"HANTAVIRUS, IGG  (MAYO)",300,98.75,83.94,Pays at 85% of Billed charges for outpatient setting,16.2,Pays at 100% of GA Medicaid Fee Schedule,79.03,Pays at 80.03% of Total Billed charges,13.13,Pays at 102% of Medicare OPPS Rate,88.88,Pays at 90% of Total Billed charges,16.2,Pays at 100% of GA Medicaid Fee Schedule,12.88,Pays at 100% of Medicare OPPS Rate,16.2,Pays at 100% of GA Medicaid Fee Schedule,86.9,Pays at 88% of Total Billed charges,16.69,Pays at 103% of GA Medicaid Fee Schedule,12.88,88.88,59.25
Outpatient Medical Services,LAB,86790,"HANTAVIRUS, IGM  (MAYO)",300,98.75,83.94,Pays at 85% of Billed charges for outpatient setting,16.2,Pays at 100% of GA Medicaid Fee Schedule,79.03,Pays at 80.03% of Total Billed charges,13.13,Pays at 102% of Medicare OPPS Rate,88.88,Pays at 90% of Total Billed charges,16.2,Pays at 100% of GA Medicaid Fee Schedule,12.88,Pays at 100% of Medicare OPPS Rate,16.2,Pays at 100% of GA Medicaid Fee Schedule,86.9,Pays at 88% of Total Billed charges,16.69,Pays at 103% of GA Medicaid Fee Schedule,12.88,88.88,59.25
Outpatient Medical Services,LAB,86790,HUMAN T-CELL TYPE I & II (MAYO),300,151,128.35,Pays at 85% of Billed charges for outpatient setting,16.2,Pays at 100% of GA Medicaid Fee Schedule,120.85,Pays at 80.03% of Total Billed charges,13.13,Pays at 102% of Medicare OPPS Rate,135.9,Pays at 90% of Total Billed charges,16.2,Pays at 100% of GA Medicaid Fee Schedule,12.88,Pays at 100% of Medicare OPPS Rate,16.2,Pays at 100% of GA Medicaid Fee Schedule,132.88,Pays at 88% of Total Billed charges,16.69,Pays at 103% of GA Medicaid Fee Schedule,12.88,135.9,90.60
Outpatient Medical Services,LAB,86790,CHIKUNGUNYA AB IGG  (MAYO),300,174.75,148.54,Pays at 85% of Billed charges for outpatient setting,16.2,Pays at 100% of GA Medicaid Fee Schedule,139.85,Pays at 80.03% of Total Billed charges,13.13,Pays at 102% of Medicare OPPS Rate,157.28,Pays at 90% of Total Billed charges,16.2,Pays at 100% of GA Medicaid Fee Schedule,12.88,Pays at 100% of Medicare OPPS Rate,16.2,Pays at 100% of GA Medicaid Fee Schedule,153.78,Pays at 88% of Total Billed charges,16.69,Pays at 103% of GA Medicaid Fee Schedule,12.88,157.28,104.85
Outpatient Medical Services,LAB,86790,CHIKUNGUNYA AB IGM  (MAYO),300,174.75,148.54,Pays at 85% of Billed charges for outpatient setting,16.2,Pays at 100% of GA Medicaid Fee Schedule,139.85,Pays at 80.03% of Total Billed charges,13.13,Pays at 102% of Medicare OPPS Rate,157.28,Pays at 90% of Total Billed charges,16.2,Pays at 100% of GA Medicaid Fee Schedule,12.88,Pays at 100% of Medicare OPPS Rate,16.2,Pays at 100% of GA Medicaid Fee Schedule,153.78,Pays at 88% of Total Billed charges,16.69,Pays at 103% of GA Medicaid Fee Schedule,12.88,157.28,104.85
Outpatient Medical Services,LAB,86800,ANTI THYROID AB  (MAYO),300,49.86,42.38,Pays at 85% of Billed charges for outpatient setting,20,Pays at 100% of GA Medicaid Fee Schedule,39.9,Pays at 80.03% of Total Billed charges,16.22,Pays at 102% of Medicare OPPS Rate,44.87,Pays at 90% of Total Billed charges,20,Pays at 100% of GA Medicaid Fee Schedule,15.91,Pays at 100% of Medicare OPPS Rate,20,Pays at 100% of GA Medicaid Fee Schedule,43.88,Pays at 88% of Total Billed charges,20.6,Pays at 103% of GA Medicaid Fee Schedule,15.91,44.87,29.92
Outpatient Medical Services,LAB,86800,"THYROGLOBULIN AB, QT  (MAYO)",300,50.75,43.14,Pays at 85% of Billed charges for outpatient setting,20,Pays at 100% of GA Medicaid Fee Schedule,40.62,Pays at 80.03% of Total Billed charges,16.22,Pays at 102% of Medicare OPPS Rate,45.68,Pays at 90% of Total Billed charges,20,Pays at 100% of GA Medicaid Fee Schedule,15.91,Pays at 100% of Medicare OPPS Rate,20,Pays at 100% of GA Medicaid Fee Schedule,44.66,Pays at 88% of Total Billed charges,20.6,Pays at 103% of GA Medicaid Fee Schedule,15.91,45.68,30.45
Outpatient Medical Services,LAB,86800,THYROGLOBULIN TUMOR REFLEX TO MS OR IA,300,50.75,43.14,Pays at 85% of Billed charges for outpatient setting,20,Pays at 100% of GA Medicaid Fee Schedule,40.62,Pays at 80.03% of Total Billed charges,16.22,Pays at 102% of Medicare OPPS Rate,45.68,Pays at 90% of Total Billed charges,20,Pays at 100% of GA Medicaid Fee Schedule,15.91,Pays at 100% of Medicare OPPS Rate,20,Pays at 100% of GA Medicaid Fee Schedule,44.66,Pays at 88% of Total Billed charges,20.6,Pays at 103% of GA Medicaid Fee Schedule,15.91,45.68,30.45
Outpatient Medical Services,LAB,86803,Blood test to determine infection with Hepatitis C,300,56.88,48.35,Pays at 85% of Billed charges for outpatient setting,10,Pays at 100% of GA Medicaid Fee Schedule,45.52,Pays at 80.03% of Total Billed charges,14.55,Pays at 102% of Medicare OPPS Rate,51.19,Pays at 90% of Total Billed charges,10,Pays at 100% of GA Medicaid Fee Schedule,14.27,Pays at 100% of Medicare OPPS Rate,10,Pays at 100% of GA Medicaid Fee Schedule,50.05,Pays at 88% of Total Billed charges,10.3,Pays at 103% of GA Medicaid Fee Schedule,10,51.19,34.13
Outpatient Medical Services,LAB,86803,Blood test to determine infection with Hepatitis C,300,134.25,114.11,Pays at 85% of Billed charges for outpatient setting,10,Pays at 100% of GA Medicaid Fee Schedule,107.44,Pays at 80.03% of Total Billed charges,14.55,Pays at 102% of Medicare OPPS Rate,120.83,Pays at 90% of Total Billed charges,10,Pays at 100% of GA Medicaid Fee Schedule,14.27,Pays at 100% of Medicare OPPS Rate,10,Pays at 100% of GA Medicaid Fee Schedule,118.14,Pays at 88% of Total Billed charges,10.3,Pays at 103% of GA Medicaid Fee Schedule,10,120.83,80.55
Outpatient Medical Services,LAB,86812,HLA B27 BLOOD  (MAYO),300,82.75,70.34,Pays at 85% of Billed charges for outpatient setting,32.45,Pays at 100% of GA Medicaid Fee Schedule,66.22,Pays at 80.03% of Total Billed charges,26.32,Pays at 102% of Medicare OPPS Rate,74.48,Pays at 90% of Total Billed charges,32.45,Pays at 100% of GA Medicaid Fee Schedule,25.81,Pays at 100% of Medicare OPPS Rate,32.45,Pays at 100% of GA Medicaid Fee Schedule,72.82,Pays at 88% of Total Billed charges,33.42,Pays at 103% of GA Medicaid Fee Schedule,25.81,74.48,49.65
Outpatient Medical Services,LAB,86813,HLA  A & B CLASS I DNA TYPING  (MAYO),300,280.25,238.21,Pays at 85% of Billed charges for outpatient setting,72.92,Pays at 100% of GA Medicaid Fee Schedule,224.28,Pays at 80.03% of Total Billed charges,59.16,Pays at 102% of Medicare OPPS Rate,252.23,Pays at 90% of Total Billed charges,72.92,Pays at 100% of GA Medicaid Fee Schedule,58,Pays at 100% of Medicare OPPS Rate,72.92,Pays at 100% of GA Medicaid Fee Schedule,246.62,Pays at 88% of Total Billed charges,75.11,Pays at 103% of GA Medicaid Fee Schedule,58,252.23,168.15
Outpatient Medical Services,LAB,86850,Blood test to screen for antibodies that could harm red blood cells,300,20,17,Pays at 85% of Billed charges for outpatient setting,15.23,Pays at 100% of GA Medicaid Fee Schedule,16.01,Pays at 80.03% of Total Billed charges,48.06,Pays at 102% of Medicare OPPS Rate,18,Pays at 90% of Total Billed charges,15.23,Pays at 100% of GA Medicaid Fee Schedule,47.12,Pays at 100% of Medicare OPPS Rate,15.23,Pays at 100% of GA Medicaid Fee Schedule,17.6,Pays at 88% of Total Billed charges,15.69,Pays at 103% of GA Medicaid Fee Schedule,15.23,48.06,12.00
Outpatient Medical Services,LAB,86850,Blood test to screen for antibodies that could harm red blood cells,300,116,98.6,Pays at 85% of Billed charges for outpatient setting,15.23,Pays at 100% of GA Medicaid Fee Schedule,92.83,Pays at 80.03% of Total Billed charges,48.06,Pays at 102% of Medicare OPPS Rate,104.4,Pays at 90% of Total Billed charges,15.23,Pays at 100% of GA Medicaid Fee Schedule,47.12,Pays at 100% of Medicare OPPS Rate,15.23,Pays at 100% of GA Medicaid Fee Schedule,102.08,Pays at 88% of Total Billed charges,15.69,Pays at 103% of GA Medicaid Fee Schedule,15.23,104.4,69.60
Outpatient Medical Services,LAB,86860,ANTIBODY ELUTION (EACH),300,88.75,75.44,Pays at 85% of Billed charges for outpatient setting,6.12,Pays at 100% of GA Medicaid Fee Schedule,71.03,Pays at 80.03% of Total Billed charges,150.75,Pays at 102% of Medicare OPPS Rate,79.88,Pays at 90% of Total Billed charges,6.12,Pays at 100% of GA Medicaid Fee Schedule,147.8,Pays at 100% of Medicare OPPS Rate,6.12,Pays at 100% of GA Medicaid Fee Schedule,78.1,Pays at 88% of Total Billed charges,6.3,Pays at 103% of GA Medicaid Fee Schedule,6.12,150.75,53.25
Outpatient Medical Services,LAB,86870,ANTIBODY PANEL (TBC),300,97,82.45,Pays at 85% of Billed charges for outpatient setting,6.12,Pays at 100% of GA Medicaid Fee Schedule,77.63,Pays at 80.03% of Total Billed charges,310.72,Pays at 102% of Medicare OPPS Rate,87.3,Pays at 90% of Total Billed charges,6.12,Pays at 100% of GA Medicaid Fee Schedule,304.63,Pays at 100% of Medicare OPPS Rate,6.12,Pays at 100% of GA Medicaid Fee Schedule,85.36,Pays at 88% of Total Billed charges,6.3,Pays at 103% of GA Medicaid Fee Schedule,6.12,310.72,58.20
Outpatient Medical Services,LAB,86870,TBC IMMUNO WORKUP,300,197.75,168.09,Pays at 85% of Billed charges for outpatient setting,6.12,Pays at 100% of GA Medicaid Fee Schedule,158.26,Pays at 80.03% of Total Billed charges,310.72,Pays at 102% of Medicare OPPS Rate,177.98,Pays at 90% of Total Billed charges,6.12,Pays at 100% of GA Medicaid Fee Schedule,304.63,Pays at 100% of Medicare OPPS Rate,6.12,Pays at 100% of GA Medicaid Fee Schedule,174.02,Pays at 88% of Total Billed charges,6.3,Pays at 103% of GA Medicaid Fee Schedule,6.12,310.72,118.65
Outpatient Medical Services,LAB,86870,ANTIBODY IDENTIFICATION,300,557.75,474.09,Pays at 85% of Billed charges for outpatient setting,6.12,Pays at 100% of GA Medicaid Fee Schedule,446.37,Pays at 80.03% of Total Billed charges,310.72,Pays at 102% of Medicare OPPS Rate,501.98,Pays at 90% of Total Billed charges,6.12,Pays at 100% of GA Medicaid Fee Schedule,304.63,Pays at 100% of Medicare OPPS Rate,6.12,Pays at 100% of GA Medicaid Fee Schedule,490.82,Pays at 88% of Total Billed charges,6.3,Pays at 103% of GA Medicaid Fee Schedule,6.12,501.98,334.65
Outpatient Medical Services,LAB,86880,DIRECT COOMBS,300,42.25,35.91,Pays at 85% of Billed charges for outpatient setting,6.75,Pays at 100% of GA Medicaid Fee Schedule,33.81,Pays at 80.03% of Total Billed charges,55.1,Pays at 102% of Medicare OPPS Rate,38.03,Pays at 90% of Total Billed charges,6.75,Pays at 100% of GA Medicaid Fee Schedule,54.02,Pays at 100% of Medicare OPPS Rate,6.75,Pays at 100% of GA Medicaid Fee Schedule,37.18,Pays at 88% of Total Billed charges,6.95,Pays at 103% of GA Medicaid Fee Schedule,6.75,55.1,25.35
Outpatient Medical Services,LAB,86880,"COOMBS, DIRECT",300,67.86,57.68,Pays at 85% of Billed charges for outpatient setting,6.75,Pays at 100% of GA Medicaid Fee Schedule,54.31,Pays at 80.03% of Total Billed charges,55.1,Pays at 102% of Medicare OPPS Rate,61.07,Pays at 90% of Total Billed charges,6.75,Pays at 100% of GA Medicaid Fee Schedule,54.02,Pays at 100% of Medicare OPPS Rate,6.75,Pays at 100% of GA Medicaid Fee Schedule,59.72,Pays at 88% of Total Billed charges,6.95,Pays at 103% of GA Medicaid Fee Schedule,6.75,61.07,40.72
Outpatient Medical Services,LAB,86885,SELECTED CELL PANEL,300,40.5,34.43,Pays at 85% of Billed charges for outpatient setting,7.19,Pays at 100% of GA Medicaid Fee Schedule,32.41,Pays at 80.03% of Total Billed charges,150.75,Pays at 102% of Medicare OPPS Rate,36.45,Pays at 90% of Total Billed charges,7.19,Pays at 100% of GA Medicaid Fee Schedule,147.8,Pays at 100% of Medicare OPPS Rate,7.19,Pays at 100% of GA Medicaid Fee Schedule,35.64,Pays at 88% of Total Billed charges,7.41,Pays at 103% of GA Medicaid Fee Schedule,7.19,150.75,24.30
Outpatient Medical Services,LAB,86886,ANTIBODY TITER,300,334.25,284.11,Pays at 85% of Billed charges for outpatient setting,5.85,Pays at 100% of GA Medicaid Fee Schedule,267.5,Pays at 80.03% of Total Billed charges,150.75,Pays at 102% of Medicare OPPS Rate,300.83,Pays at 90% of Total Billed charges,5.85,Pays at 100% of GA Medicaid Fee Schedule,147.8,Pays at 100% of Medicare OPPS Rate,5.85,Pays at 100% of GA Medicaid Fee Schedule,294.14,Pays at 88% of Total Billed charges,6.03,Pays at 103% of GA Medicaid Fee Schedule,5.85,300.83,200.55
Outpatient Medical Services,LAB,86890,AUTOLOGOUS DONATION,300,192.5,163.63,Pays at 85% of Billed charges for outpatient setting,61.89,Pays at 32.15% of Total Billed charges,154.06,Pays at 80.03% of Total Billed charges,150.75,Pays at 102% of Medicare OPPS Rate,173.25,Pays at 90% of Total Billed charges,61.89,Pays at 32.15% of Total Billed charges,147.8,Pays at 100% of Medicare OPPS Rate,61.89,Pays at 32.15% of Total Billed charges,169.4,Pays at 88% of Total Billed charges,63.74,Pays at 33.11% of Total Billed charges,61.89,173.25,115.50
Outpatient Medical Services,LAB,86891,CELL SAVER AUTOTRANSFUSION,300,734.75,624.54,Pays at 85% of Billed charges for outpatient setting,236.22,Pays at 32.15% of Total Billed charges,588.02,Pays at 80.03% of Total Billed charges,744.44,Pays at 102% of Medicare OPPS Rate,661.28,Pays at 90% of Total Billed charges,236.22,Pays at 32.15% of Total Billed charges,729.84,Pays at 100% of Medicare OPPS Rate,236.22,Pays at 32.15% of Total Billed charges,646.58,Pays at 88% of Total Billed charges,243.28,Pays at 33.11% of Total Billed charges,236.22,744.44,440.85
Outpatient Medical Services,LAB,86900,ABO BLOOD TYPING,300,272.25,231.41,Pays at 85% of Billed charges for outpatient setting,3.75,Pays at 100% of GA Medicaid Fee Schedule,217.88,Pays at 80.03% of Total Billed charges,111.31,Pays at 102% of Medicare OPPS Rate,245.03,Pays at 90% of Total Billed charges,3.75,Pays at 100% of GA Medicaid Fee Schedule,109.13,Pays at 100% of Medicare OPPS Rate,3.75,Pays at 100% of GA Medicaid Fee Schedule,239.58,Pays at 88% of Total Billed charges,3.86,Pays at 103% of GA Medicaid Fee Schedule,3.75,245.03,163.35
Outpatient Medical Services,LAB,86901,.RH,300,38.5,32.73,Pays at 85% of Billed charges for outpatient setting,14.51,Pays at 100% of GA Medicaid Fee Schedule,30.81,Pays at 80.03% of Total Billed charges,32.54,Pays at 102% of Medicare OPPS Rate,34.65,Pays at 90% of Total Billed charges,14.51,Pays at 100% of GA Medicaid Fee Schedule,31.91,Pays at 100% of Medicare OPPS Rate,14.51,Pays at 100% of GA Medicaid Fee Schedule,33.88,Pays at 88% of Total Billed charges,14.95,Pays at 103% of GA Medicaid Fee Schedule,14.51,34.65,23.10
Outpatient Medical Services,LAB,86901,RH TYPE,300,82.75,70.34,Pays at 85% of Billed charges for outpatient setting,14.51,Pays at 100% of GA Medicaid Fee Schedule,66.22,Pays at 80.03% of Total Billed charges,32.54,Pays at 102% of Medicare OPPS Rate,74.48,Pays at 90% of Total Billed charges,14.51,Pays at 100% of GA Medicaid Fee Schedule,31.91,Pays at 100% of Medicare OPPS Rate,14.51,Pays at 100% of GA Medicaid Fee Schedule,72.82,Pays at 88% of Total Billed charges,14.95,Pays at 103% of GA Medicaid Fee Schedule,14.51,74.48,49.65
Outpatient Medical Services,LAB,86902,RHOGAM,300,457.36,388.76,Pays at 85% of Billed charges for outpatient setting,4.3,Pays at 100% of GA Medicaid Fee Schedule,366.03,Pays at 80.03% of Total Billed charges,310.72,Pays at 102% of Medicare OPPS Rate,411.62,Pays at 90% of Total Billed charges,4.3,Pays at 100% of GA Medicaid Fee Schedule,304.63,Pays at 100% of Medicare OPPS Rate,4.3,Pays at 100% of GA Medicaid Fee Schedule,402.48,Pays at 88% of Total Billed charges,4.43,Pays at 103% of GA Medicaid Fee Schedule,4.3,411.62,274.42
Outpatient Medical Services,LAB,86904,CROSSMATCH,300,183.27,155.78,Pays at 85% of Billed charges for outpatient setting,11.95,Pays at 100% of GA Medicaid Fee Schedule,146.67,Pays at 80.03% of Total Billed charges,32.54,Pays at 102% of Medicare OPPS Rate,164.94,Pays at 90% of Total Billed charges,11.95,Pays at 100% of GA Medicaid Fee Schedule,31.91,Pays at 100% of Medicare OPPS Rate,11.95,Pays at 100% of GA Medicaid Fee Schedule,161.28,Pays at 88% of Total Billed charges,12.31,Pays at 103% of GA Medicaid Fee Schedule,11.95,164.94,109.96
Outpatient Medical Services,LAB,86905,RBC PHENOTYPE PANEL (13 ANTIGENS) (TBC),300,233,198.05,Pays at 85% of Billed charges for outpatient setting,4.81,Pays at 100% of GA Medicaid Fee Schedule,186.47,Pays at 80.03% of Total Billed charges,310.72,Pays at 102% of Medicare OPPS Rate,209.7,Pays at 90% of Total Billed charges,4.81,Pays at 100% of GA Medicaid Fee Schedule,304.63,Pays at 100% of Medicare OPPS Rate,4.81,Pays at 100% of GA Medicaid Fee Schedule,205.04,Pays at 88% of Total Billed charges,4.95,Pays at 103% of GA Medicaid Fee Schedule,4.81,310.72,139.80
Outpatient Medical Services,LAB,86905,RBC ANTIGEN TYPING (EACH),300,557.75,474.09,Pays at 85% of Billed charges for outpatient setting,4.81,Pays at 100% of GA Medicaid Fee Schedule,446.37,Pays at 80.03% of Total Billed charges,310.72,Pays at 102% of Medicare OPPS Rate,501.98,Pays at 90% of Total Billed charges,4.81,Pays at 100% of GA Medicaid Fee Schedule,304.63,Pays at 100% of Medicare OPPS Rate,4.81,Pays at 100% of GA Medicaid Fee Schedule,490.82,Pays at 88% of Total Billed charges,4.95,Pays at 103% of GA Medicaid Fee Schedule,4.81,501.98,334.65
Outpatient Medical Services,LAB,86922,AHG CROSSMATCH (PER UNIT),300,24.5,20.83,Pays at 85% of Billed charges for outpatient setting,7.88,Pays at 32.15% of Total Billed charges,19.61,Pays at 80.03% of Total Billed charges,150.75,Pays at 102% of Medicare OPPS Rate,22.05,Pays at 90% of Total Billed charges,7.88,Pays at 32.15% of Total Billed charges,147.8,Pays at 100% of Medicare OPPS Rate,7.88,Pays at 32.15% of Total Billed charges,21.56,Pays at 88% of Total Billed charges,8.11,Pays at 33.11% of Total Billed charges,7.88,150.75,14.70
Outpatient Medical Services,LAB,86945,IRRADIATION,300,33.25,28.26,Pays at 85% of Billed charges for outpatient setting,36.05,Pays at 100% of GA Medicaid Fee Schedule,26.61,Pays at 80.03% of Total Billed charges,32.54,Pays at 102% of Medicare OPPS Rate,29.93,Pays at 90% of Total Billed charges,36.05,Pays at 100% of GA Medicaid Fee Schedule,31.91,Pays at 100% of Medicare OPPS Rate,36.05,Pays at 100% of GA Medicaid Fee Schedule,29.26,Pays at 88% of Total Billed charges,37.13,Pays at 103% of GA Medicaid Fee Schedule,26.61,37.13,19.95
Outpatient Medical Services,LAB,86970,RBC TREATMENT (TBC),300,92.75,78.84,Pays at 85% of Billed charges for outpatient setting,29.82,Pays at 32.15% of Total Billed charges,74.23,Pays at 80.03% of Total Billed charges,32.54,Pays at 102% of Medicare OPPS Rate,83.48,Pays at 90% of Total Billed charges,29.82,Pays at 32.15% of Total Billed charges,31.91,Pays at 100% of Medicare OPPS Rate,29.82,Pays at 32.15% of Total Billed charges,81.62,Pays at 88% of Total Billed charges,30.71,Pays at 33.11% of Total Billed charges,29.82,83.48,55.65
Outpatient Medical Services,LAB,86977,ANTIBODY NEUTRALIZATION,300,88.75,75.44,Pays at 85% of Billed charges for outpatient setting,28.53,Pays at 32.15% of Total Billed charges,71.03,Pays at 80.03% of Total Billed charges,150.75,Pays at 102% of Medicare OPPS Rate,79.88,Pays at 90% of Total Billed charges,28.53,Pays at 32.15% of Total Billed charges,147.8,Pays at 100% of Medicare OPPS Rate,28.53,Pays at 32.15% of Total Billed charges,78.1,Pays at 88% of Total Billed charges,29.39,Pays at 33.11% of Total Billed charges,28.53,150.75,53.25
Outpatient Medical Services,LAB,86978,ANTIBODY ABSORPTION,300,82.75,70.34,Pays at 85% of Billed charges for outpatient setting,26.6,Pays at 32.15% of Total Billed charges,66.22,Pays at 80.03% of Total Billed charges,32.54,Pays at 102% of Medicare OPPS Rate,74.48,Pays at 90% of Total Billed charges,26.6,Pays at 32.15% of Total Billed charges,31.91,Pays at 100% of Medicare OPPS Rate,26.6,Pays at 32.15% of Total Billed charges,72.82,Pays at 88% of Total Billed charges,27.4,Pays at 33.11% of Total Billed charges,26.6,74.48,49.65
Outpatient Medical Services,LAB,87015,MICROSPORIDIAN DETECTION STAIN  (MAYO),300,62,52.7,Pays at 85% of Billed charges for outpatient setting,8.4,Pays at 100% of GA Medicaid Fee Schedule,49.62,Pays at 80.03% of Total Billed charges,6.81,Pays at 102% of Medicare OPPS Rate,55.8,Pays at 90% of Total Billed charges,8.4,Pays at 100% of GA Medicaid Fee Schedule,6.68,Pays at 100% of Medicare OPPS Rate,8.4,Pays at 100% of GA Medicaid Fee Schedule,54.56,Pays at 88% of Total Billed charges,8.65,Pays at 103% of GA Medicaid Fee Schedule,6.68,55.8,37.20
Outpatient Medical Services,LAB,87015,"..MYCOBACTERIA CULTURE, CONC  (MAYO)",300,69.75,59.29,Pays at 85% of Billed charges for outpatient setting,8.4,Pays at 100% of GA Medicaid Fee Schedule,55.82,Pays at 80.03% of Total Billed charges,6.81,Pays at 102% of Medicare OPPS Rate,62.78,Pays at 90% of Total Billed charges,8.4,Pays at 100% of GA Medicaid Fee Schedule,6.68,Pays at 100% of Medicare OPPS Rate,8.4,Pays at 100% of GA Medicaid Fee Schedule,61.38,Pays at 88% of Total Billed charges,8.65,Pays at 103% of GA Medicaid Fee Schedule,6.68,62.78,41.85
Outpatient Medical Services,LAB,87015,"MYCOBACTERIA CULTURE, CONC  (MAYO)",300,80.75,68.64,Pays at 85% of Billed charges for outpatient setting,8.4,Pays at 100% of GA Medicaid Fee Schedule,64.62,Pays at 80.03% of Total Billed charges,6.81,Pays at 102% of Medicare OPPS Rate,72.68,Pays at 90% of Total Billed charges,8.4,Pays at 100% of GA Medicaid Fee Schedule,6.68,Pays at 100% of Medicare OPPS Rate,8.4,Pays at 100% of GA Medicaid Fee Schedule,71.06,Pays at 88% of Total Billed charges,8.65,Pays at 103% of GA Medicaid Fee Schedule,6.68,72.68,48.45
Outpatient Medical Services,LAB,87015,CRYPTOSPORIDIUM SMEAR  (MAYO),300,99.25,84.36,Pays at 85% of Billed charges for outpatient setting,8.4,Pays at 100% of GA Medicaid Fee Schedule,79.43,Pays at 80.03% of Total Billed charges,6.81,Pays at 102% of Medicare OPPS Rate,89.33,Pays at 90% of Total Billed charges,8.4,Pays at 100% of GA Medicaid Fee Schedule,6.68,Pays at 100% of Medicare OPPS Rate,8.4,Pays at 100% of GA Medicaid Fee Schedule,87.34,Pays at 88% of Total Billed charges,8.65,Pays at 103% of GA Medicaid Fee Schedule,6.68,89.33,59.55
Outpatient Medical Services,LAB,87040,Blood test to screen for bacteria in the blood,300,51.66,43.91,Pays at 85% of Billed charges for outpatient setting,12.98,Pays at 100% of GA Medicaid Fee Schedule,41.34,Pays at 80.03% of Total Billed charges,10.52,Pays at 102% of Medicare OPPS Rate,46.49,Pays at 90% of Total Billed charges,12.98,Pays at 100% of GA Medicaid Fee Schedule,10.32,Pays at 100% of Medicare OPPS Rate,12.98,Pays at 100% of GA Medicaid Fee Schedule,45.46,Pays at 88% of Total Billed charges,13.37,Pays at 103% of GA Medicaid Fee Schedule,10.32,46.49,31.00
Outpatient Medical Services,LAB,87040,Blood test to screen for bacteria in the blood,300,51.66,43.91,Pays at 85% of Billed charges for outpatient setting,12.98,Pays at 100% of GA Medicaid Fee Schedule,41.34,Pays at 80.03% of Total Billed charges,10.52,Pays at 102% of Medicare OPPS Rate,46.49,Pays at 90% of Total Billed charges,12.98,Pays at 100% of GA Medicaid Fee Schedule,10.32,Pays at 100% of Medicare OPPS Rate,12.98,Pays at 100% of GA Medicaid Fee Schedule,45.46,Pays at 88% of Total Billed charges,13.37,Pays at 103% of GA Medicaid Fee Schedule,10.32,46.49,31.00
Outpatient Medical Services,LAB,87040,Blood test to screen for bacteria in the blood,300,53.51,45.48,Pays at 85% of Billed charges for outpatient setting,12.98,Pays at 100% of GA Medicaid Fee Schedule,42.82,Pays at 80.03% of Total Billed charges,10.52,Pays at 102% of Medicare OPPS Rate,48.16,Pays at 90% of Total Billed charges,12.98,Pays at 100% of GA Medicaid Fee Schedule,10.32,Pays at 100% of Medicare OPPS Rate,12.98,Pays at 100% of GA Medicaid Fee Schedule,47.09,Pays at 88% of Total Billed charges,13.37,Pays at 103% of GA Medicaid Fee Schedule,10.32,48.16,32.11
Outpatient Medical Services,LAB,87045,"CULTURE, STOOL",300,94.3,80.16,Pays at 85% of Billed charges for outpatient setting,30.32,Pays at 32.15% of Total Billed charges,75.47,Pays at 80.03% of Total Billed charges,9.62,Pays at 102% of Medicare OPPS Rate,84.87,Pays at 90% of Total Billed charges,30.32,Pays at 32.15% of Total Billed charges,9.44,Pays at 100% of Medicare OPPS Rate,30.32,Pays at 32.15% of Total Billed charges,82.98,Pays at 88% of Total Billed charges,31.22,Pays at 33.11% of Total Billed charges,9.44,84.87,56.58
Outpatient Medical Services,LAB,87046,Blood test to identify bacteria that may be contributing to symptoms in the gastrointestinal tract,300,24.6,20.91,Pays at 85% of Billed charges for outpatient setting,2.97,Pays at 100% of GA Medicaid Fee Schedule,19.69,Pays at 80.03% of Total Billed charges,9.62,Pays at 102% of Medicare OPPS Rate,22.14,Pays at 90% of Total Billed charges,2.97,Pays at 100% of GA Medicaid Fee Schedule,9.44,Pays at 100% of Medicare OPPS Rate,2.97,Pays at 100% of GA Medicaid Fee Schedule,21.65,Pays at 88% of Total Billed charges,3.06,Pays at 103% of GA Medicaid Fee Schedule,2.97,22.14,14.76
Outpatient Medical Services,LAB,87046,Blood test to identify bacteria that may be contributing to symptoms in the gastrointestinal tract,300,37.25,31.66,Pays at 85% of Billed charges for outpatient setting,2.97,Pays at 100% of GA Medicaid Fee Schedule,29.81,Pays at 80.03% of Total Billed charges,9.62,Pays at 102% of Medicare OPPS Rate,33.53,Pays at 90% of Total Billed charges,2.97,Pays at 100% of GA Medicaid Fee Schedule,9.44,Pays at 100% of Medicare OPPS Rate,2.97,Pays at 100% of GA Medicaid Fee Schedule,32.78,Pays at 88% of Total Billed charges,3.06,Pays at 103% of GA Medicaid Fee Schedule,2.97,33.53,22.35
Outpatient Medical Services,LAB,87070,Test of body fluid other than blood to assess for bacteria,300,21.55,18.32,Pays at 85% of Billed charges for outpatient setting,10.83,Pays at 100% of GA Medicaid Fee Schedule,17.25,Pays at 80.03% of Total Billed charges,8.79,Pays at 102% of Medicare OPPS Rate,19.4,Pays at 90% of Total Billed charges,10.83,Pays at 100% of GA Medicaid Fee Schedule,8.61,Pays at 100% of Medicare OPPS Rate,10.83,Pays at 100% of GA Medicaid Fee Schedule,18.96,Pays at 88% of Total Billed charges,11.15,Pays at 103% of GA Medicaid Fee Schedule,8.61,19.4,12.93
Outpatient Medical Services,LAB,87070,Test of body fluid other than blood to assess for bacteria,300,47.56,40.43,Pays at 85% of Billed charges for outpatient setting,10.83,Pays at 100% of GA Medicaid Fee Schedule,38.06,Pays at 80.03% of Total Billed charges,8.79,Pays at 102% of Medicare OPPS Rate,42.8,Pays at 90% of Total Billed charges,10.83,Pays at 100% of GA Medicaid Fee Schedule,8.61,Pays at 100% of Medicare OPPS Rate,10.83,Pays at 100% of GA Medicaid Fee Schedule,41.85,Pays at 88% of Total Billed charges,11.15,Pays at 103% of GA Medicaid Fee Schedule,8.61,42.8,28.54
Outpatient Medical Services,LAB,87070,Test of body fluid other than blood to assess for bacteria,300,50.75,43.14,Pays at 85% of Billed charges for outpatient setting,10.83,Pays at 100% of GA Medicaid Fee Schedule,40.62,Pays at 80.03% of Total Billed charges,8.79,Pays at 102% of Medicare OPPS Rate,45.68,Pays at 90% of Total Billed charges,10.83,Pays at 100% of GA Medicaid Fee Schedule,8.61,Pays at 100% of Medicare OPPS Rate,10.83,Pays at 100% of GA Medicaid Fee Schedule,44.66,Pays at 88% of Total Billed charges,11.15,Pays at 103% of GA Medicaid Fee Schedule,8.61,45.68,30.45
Outpatient Medical Services,LAB,87070,Test of body fluid other than blood to assess for bacteria,300,50.75,43.14,Pays at 85% of Billed charges for outpatient setting,10.83,Pays at 100% of GA Medicaid Fee Schedule,40.62,Pays at 80.03% of Total Billed charges,8.79,Pays at 102% of Medicare OPPS Rate,45.68,Pays at 90% of Total Billed charges,10.83,Pays at 100% of GA Medicaid Fee Schedule,8.61,Pays at 100% of Medicare OPPS Rate,10.83,Pays at 100% of GA Medicaid Fee Schedule,44.66,Pays at 88% of Total Billed charges,11.15,Pays at 103% of GA Medicaid Fee Schedule,8.61,45.68,30.45
Outpatient Medical Services,LAB,87070,Test of body fluid other than blood to assess for bacteria,300,50.75,43.14,Pays at 85% of Billed charges for outpatient setting,10.83,Pays at 100% of GA Medicaid Fee Schedule,40.62,Pays at 80.03% of Total Billed charges,8.79,Pays at 102% of Medicare OPPS Rate,45.68,Pays at 90% of Total Billed charges,10.83,Pays at 100% of GA Medicaid Fee Schedule,8.61,Pays at 100% of Medicare OPPS Rate,10.83,Pays at 100% of GA Medicaid Fee Schedule,44.66,Pays at 88% of Total Billed charges,11.15,Pays at 103% of GA Medicaid Fee Schedule,8.61,45.68,30.45
Outpatient Medical Services,LAB,87070,Test of body fluid other than blood to assess for bacteria,300,58,49.3,Pays at 85% of Billed charges for outpatient setting,10.83,Pays at 100% of GA Medicaid Fee Schedule,46.42,Pays at 80.03% of Total Billed charges,8.79,Pays at 102% of Medicare OPPS Rate,52.2,Pays at 90% of Total Billed charges,10.83,Pays at 100% of GA Medicaid Fee Schedule,8.61,Pays at 100% of Medicare OPPS Rate,10.83,Pays at 100% of GA Medicaid Fee Schedule,51.04,Pays at 88% of Total Billed charges,11.15,Pays at 103% of GA Medicaid Fee Schedule,8.61,52.2,34.80
Outpatient Medical Services,LAB,87075,CULTURE ANAEROBIC,300,71.5,60.78,Pays at 85% of Billed charges for outpatient setting,11.9,Pays at 100% of GA Medicaid Fee Schedule,57.22,Pays at 80.03% of Total Billed charges,9.65,Pays at 102% of Medicare OPPS Rate,64.35,Pays at 90% of Total Billed charges,11.9,Pays at 100% of GA Medicaid Fee Schedule,9.47,Pays at 100% of Medicare OPPS Rate,11.9,Pays at 100% of GA Medicaid Fee Schedule,62.92,Pays at 88% of Total Billed charges,12.26,Pays at 103% of GA Medicaid Fee Schedule,9.47,64.35,42.90
Outpatient Medical Services,LAB,87076,"ID MALDI-TOF, ANAEROBE  (MAYO)",300,94.25,80.11,Pays at 85% of Billed charges for outpatient setting,10.16,Pays at 100% of GA Medicaid Fee Schedule,75.43,Pays at 80.03% of Total Billed charges,8.24,Pays at 102% of Medicare OPPS Rate,84.83,Pays at 90% of Total Billed charges,10.16,Pays at 100% of GA Medicaid Fee Schedule,8.08,Pays at 100% of Medicare OPPS Rate,10.16,Pays at 100% of GA Medicaid Fee Schedule,82.94,Pays at 88% of Total Billed charges,10.46,Pays at 103% of GA Medicaid Fee Schedule,8.08,84.83,56.55
Outpatient Medical Services,LAB,87076,ANA ID PANEL  (MAYO),300,307.4,261.29,Pays at 85% of Billed charges for outpatient setting,10.16,Pays at 100% of GA Medicaid Fee Schedule,246.01,Pays at 80.03% of Total Billed charges,8.24,Pays at 102% of Medicare OPPS Rate,276.66,Pays at 90% of Total Billed charges,10.16,Pays at 100% of GA Medicaid Fee Schedule,8.08,Pays at 100% of Medicare OPPS Rate,10.16,Pays at 100% of GA Medicaid Fee Schedule,270.51,Pays at 88% of Total Billed charges,10.46,Pays at 103% of GA Medicaid Fee Schedule,8.08,276.66,184.44
Outpatient Medical Services,LAB,87077,Test of a wound for type of bacterial infection,300,31,26.35,Pays at 85% of Billed charges for outpatient setting,10.16,Pays at 100% of GA Medicaid Fee Schedule,24.81,Pays at 80.03% of Total Billed charges,8.24,Pays at 102% of Medicare OPPS Rate,27.9,Pays at 90% of Total Billed charges,10.16,Pays at 100% of GA Medicaid Fee Schedule,8.08,Pays at 100% of Medicare OPPS Rate,10.16,Pays at 100% of GA Medicaid Fee Schedule,27.28,Pays at 88% of Total Billed charges,10.46,Pays at 103% of GA Medicaid Fee Schedule,8.08,27.9,18.60
Outpatient Medical Services,LAB,87077,Test of a wound for type of bacterial infection,300,63.25,53.76,Pays at 85% of Billed charges for outpatient setting,10.16,Pays at 100% of GA Medicaid Fee Schedule,50.62,Pays at 80.03% of Total Billed charges,8.24,Pays at 102% of Medicare OPPS Rate,56.93,Pays at 90% of Total Billed charges,10.16,Pays at 100% of GA Medicaid Fee Schedule,8.08,Pays at 100% of Medicare OPPS Rate,10.16,Pays at 100% of GA Medicaid Fee Schedule,55.66,Pays at 88% of Total Billed charges,10.46,Pays at 103% of GA Medicaid Fee Schedule,8.08,56.93,37.95
Outpatient Medical Services,LAB,87077,Test of a wound for type of bacterial infection,300,149,126.65,Pays at 85% of Billed charges for outpatient setting,10.16,Pays at 100% of GA Medicaid Fee Schedule,119.24,Pays at 80.03% of Total Billed charges,8.24,Pays at 102% of Medicare OPPS Rate,134.1,Pays at 90% of Total Billed charges,10.16,Pays at 100% of GA Medicaid Fee Schedule,8.08,Pays at 100% of Medicare OPPS Rate,10.16,Pays at 100% of GA Medicaid Fee Schedule,131.12,Pays at 88% of Total Billed charges,10.46,Pays at 103% of GA Medicaid Fee Schedule,8.08,134.1,89.40
Outpatient Medical Services,LAB,87077,Test of a wound for type of bacterial infection,300,201.5,171.28,Pays at 85% of Billed charges for outpatient setting,10.16,Pays at 100% of GA Medicaid Fee Schedule,161.26,Pays at 80.03% of Total Billed charges,8.24,Pays at 102% of Medicare OPPS Rate,181.35,Pays at 90% of Total Billed charges,10.16,Pays at 100% of GA Medicaid Fee Schedule,8.08,Pays at 100% of Medicare OPPS Rate,10.16,Pays at 100% of GA Medicaid Fee Schedule,177.32,Pays at 88% of Total Billed charges,10.46,Pays at 103% of GA Medicaid Fee Schedule,8.08,181.35,120.90
Outpatient Medical Services,LAB,87081,Medical test to find an infection,300,52.75,44.84,Pays at 85% of Billed charges for outpatient setting,8.33,Pays at 100% of GA Medicaid Fee Schedule,42.22,Pays at 80.03% of Total Billed charges,6.76,Pays at 102% of Medicare OPPS Rate,47.48,Pays at 90% of Total Billed charges,8.33,Pays at 100% of GA Medicaid Fee Schedule,6.63,Pays at 100% of Medicare OPPS Rate,8.33,Pays at 100% of GA Medicaid Fee Schedule,46.42,Pays at 88% of Total Billed charges,8.58,Pays at 103% of GA Medicaid Fee Schedule,6.63,47.48,31.65
Outpatient Medical Services,LAB,87088,Culture of the urine to determine bacterial infection,300,41.62,35.38,Pays at 85% of Billed charges for outpatient setting,10.18,Pays at 100% of GA Medicaid Fee Schedule,33.31,Pays at 80.03% of Total Billed charges,8.25,Pays at 102% of Medicare OPPS Rate,37.46,Pays at 90% of Total Billed charges,10.18,Pays at 100% of GA Medicaid Fee Schedule,8.09,Pays at 100% of Medicare OPPS Rate,10.18,Pays at 100% of GA Medicaid Fee Schedule,36.63,Pays at 88% of Total Billed charges,10.49,Pays at 103% of GA Medicaid Fee Schedule,8.09,37.46,24.97
Outpatient Medical Services,LAB,87101,A procedure used to determine if fungi are present in an area of the body,300,87.25,74.16,Pays at 85% of Billed charges for outpatient setting,9.69,Pays at 100% of GA Medicaid Fee Schedule,69.83,Pays at 80.03% of Total Billed charges,7.86,Pays at 102% of Medicare OPPS Rate,78.53,Pays at 90% of Total Billed charges,9.69,Pays at 100% of GA Medicaid Fee Schedule,7.71,Pays at 100% of Medicare OPPS Rate,9.69,Pays at 100% of GA Medicaid Fee Schedule,76.78,Pays at 88% of Total Billed charges,9.98,Pays at 103% of GA Medicaid Fee Schedule,7.71,78.53,52.35
Outpatient Medical Services,LAB,87101,A procedure used to determine if fungi are present in an area of the body,300,96.25,81.81,Pays at 85% of Billed charges for outpatient setting,9.69,Pays at 100% of GA Medicaid Fee Schedule,77.03,Pays at 80.03% of Total Billed charges,7.86,Pays at 102% of Medicare OPPS Rate,86.63,Pays at 90% of Total Billed charges,9.69,Pays at 100% of GA Medicaid Fee Schedule,7.71,Pays at 100% of Medicare OPPS Rate,9.69,Pays at 100% of GA Medicaid Fee Schedule,84.7,Pays at 88% of Total Billed charges,9.98,Pays at 103% of GA Medicaid Fee Schedule,7.71,86.63,57.75
Outpatient Medical Services,LAB,87102,"CULTURE FUNGI OTHER, NOT BLOOD  (MAYO)",300,90,76.5,Pays at 85% of Billed charges for outpatient setting,10.57,Pays at 100% of GA Medicaid Fee Schedule,72.03,Pays at 80.03% of Total Billed charges,8.57,Pays at 102% of Medicare OPPS Rate,81,Pays at 90% of Total Billed charges,10.57,Pays at 100% of GA Medicaid Fee Schedule,8.41,Pays at 100% of Medicare OPPS Rate,10.57,Pays at 100% of GA Medicaid Fee Schedule,79.2,Pays at 88% of Total Billed charges,10.89,Pays at 103% of GA Medicaid Fee Schedule,8.41,81,54.00
Outpatient Medical Services,LAB,87103,CULTURE FUNGI BLOOD  (MAYO),300,98.75,83.94,Pays at 85% of Billed charges for outpatient setting,11.34,Pays at 100% of GA Medicaid Fee Schedule,79.03,Pays at 80.03% of Total Billed charges,20.86,Pays at 102% of Medicare OPPS Rate,88.88,Pays at 90% of Total Billed charges,11.34,Pays at 100% of GA Medicaid Fee Schedule,20.46,Pays at 100% of Medicare OPPS Rate,11.34,Pays at 100% of GA Medicaid Fee Schedule,86.9,Pays at 88% of Total Billed charges,11.68,Pays at 103% of GA Medicaid Fee Schedule,11.34,88.88,59.25
Outpatient Medical Services,LAB,87106,YEAST/FUNGUS ID  (MAYO),300,91.25,77.56,Pays at 85% of Billed charges for outpatient setting,12.98,Pays at 100% of GA Medicaid Fee Schedule,73.03,Pays at 80.03% of Total Billed charges,10.52,Pays at 102% of Medicare OPPS Rate,82.13,Pays at 90% of Total Billed charges,12.98,Pays at 100% of GA Medicaid Fee Schedule,10.32,Pays at 100% of Medicare OPPS Rate,12.98,Pays at 100% of GA Medicaid Fee Schedule,80.3,Pays at 88% of Total Billed charges,13.37,Pays at 103% of GA Medicaid Fee Schedule,10.32,82.13,54.75
Outpatient Medical Services,LAB,87106,"ID MALDI-TOF MS, YEAST  (MAYO)",300,141.6,120.36,Pays at 85% of Billed charges for outpatient setting,12.98,Pays at 100% of GA Medicaid Fee Schedule,113.32,Pays at 80.03% of Total Billed charges,10.52,Pays at 102% of Medicare OPPS Rate,127.44,Pays at 90% of Total Billed charges,12.98,Pays at 100% of GA Medicaid Fee Schedule,10.32,Pays at 100% of Medicare OPPS Rate,12.98,Pays at 100% of GA Medicaid Fee Schedule,124.61,Pays at 88% of Total Billed charges,13.37,Pays at 103% of GA Medicaid Fee Schedule,10.32,127.44,84.96
Outpatient Medical Services,LAB,87107,"FUNGAL ID, PANEL B  (MAYO)",300,78.54,66.76,Pays at 85% of Billed charges for outpatient setting,12.98,Pays at 100% of GA Medicaid Fee Schedule,62.86,Pays at 80.03% of Total Billed charges,10.52,Pays at 102% of Medicare OPPS Rate,70.69,Pays at 90% of Total Billed charges,12.98,Pays at 100% of GA Medicaid Fee Schedule,10.32,Pays at 100% of Medicare OPPS Rate,12.98,Pays at 100% of GA Medicaid Fee Schedule,69.12,Pays at 88% of Total Billed charges,13.37,Pays at 103% of GA Medicaid Fee Schedule,10.32,70.69,47.12
Outpatient Medical Services,LAB,87107,FUNGUS ID PANEL A  (MAYO),300,80.75,68.64,Pays at 85% of Billed charges for outpatient setting,12.98,Pays at 100% of GA Medicaid Fee Schedule,64.62,Pays at 80.03% of Total Billed charges,10.52,Pays at 102% of Medicare OPPS Rate,72.68,Pays at 90% of Total Billed charges,12.98,Pays at 100% of GA Medicaid Fee Schedule,10.32,Pays at 100% of Medicare OPPS Rate,12.98,Pays at 100% of GA Medicaid Fee Schedule,71.06,Pays at 88% of Total Billed charges,13.37,Pays at 103% of GA Medicaid Fee Schedule,10.32,72.68,48.45
Outpatient Medical Services,LAB,87107,"ID MALDI-TOF MS, FUNGI  (MAYO)",300,124.25,105.61,Pays at 85% of Billed charges for outpatient setting,12.98,Pays at 100% of GA Medicaid Fee Schedule,99.44,Pays at 80.03% of Total Billed charges,10.52,Pays at 102% of Medicare OPPS Rate,111.83,Pays at 90% of Total Billed charges,12.98,Pays at 100% of GA Medicaid Fee Schedule,10.32,Pays at 100% of Medicare OPPS Rate,12.98,Pays at 100% of GA Medicaid Fee Schedule,109.34,Pays at 88% of Total Billed charges,13.37,Pays at 103% of GA Medicaid Fee Schedule,10.32,111.83,74.55
Outpatient Medical Services,LAB,87107,"FUNGI ID, MALDI-TOF  (MAYO)",300,133,113.05,Pays at 85% of Billed charges for outpatient setting,12.98,Pays at 100% of GA Medicaid Fee Schedule,106.44,Pays at 80.03% of Total Billed charges,10.52,Pays at 102% of Medicare OPPS Rate,119.7,Pays at 90% of Total Billed charges,12.98,Pays at 100% of GA Medicaid Fee Schedule,10.32,Pays at 100% of Medicare OPPS Rate,12.98,Pays at 100% of GA Medicaid Fee Schedule,117.04,Pays at 88% of Total Billed charges,13.37,Pays at 103% of GA Medicaid Fee Schedule,10.32,119.7,79.80
Outpatient Medical Services,LAB,87110,"..CULTURE, CHLAMYDIA TRACH AMP  (MAYO)",300,55.19,46.91,Pays at 85% of Billed charges for outpatient setting,24.63,Pays at 100% of GA Medicaid Fee Schedule,44.17,Pays at 80.03% of Total Billed charges,19.99,Pays at 102% of Medicare OPPS Rate,49.67,Pays at 90% of Total Billed charges,24.63,Pays at 100% of GA Medicaid Fee Schedule,19.6,Pays at 100% of Medicare OPPS Rate,24.63,Pays at 100% of GA Medicaid Fee Schedule,48.57,Pays at 88% of Total Billed charges,25.37,Pays at 103% of GA Medicaid Fee Schedule,19.6,49.67,33.11
Outpatient Medical Services,LAB,87116,CULTURE AFB  (MAYO),300,96.25,81.81,Pays at 85% of Billed charges for outpatient setting,30.94,Pays at 32.15% of Total Billed charges,77.03,Pays at 80.03% of Total Billed charges,11.01,Pays at 102% of Medicare OPPS Rate,86.63,Pays at 90% of Total Billed charges,30.94,Pays at 32.15% of Total Billed charges,10.8,Pays at 100% of Medicare OPPS Rate,30.94,Pays at 32.15% of Total Billed charges,84.7,Pays at 88% of Total Billed charges,31.87,Pays at 33.11% of Total Billed charges,10.8,86.63,57.75
Outpatient Medical Services,LAB,87116,CULTURE AFB BLOOD  (MAYO),300,99.25,84.36,Pays at 85% of Billed charges for outpatient setting,31.91,Pays at 32.15% of Total Billed charges,79.43,Pays at 80.03% of Total Billed charges,11.01,Pays at 102% of Medicare OPPS Rate,89.33,Pays at 90% of Total Billed charges,31.91,Pays at 32.15% of Total Billed charges,10.8,Pays at 100% of Medicare OPPS Rate,31.91,Pays at 32.15% of Total Billed charges,87.34,Pays at 88% of Total Billed charges,32.86,Pays at 33.11% of Total Billed charges,10.8,89.33,59.55
Outpatient Medical Services,LAB,87116,CULTURE AFB TISSUE (MAYO),300,296,251.6,Pays at 85% of Billed charges for outpatient setting,95.16,Pays at 32.15% of Total Billed charges,236.89,Pays at 80.03% of Total Billed charges,11.01,Pays at 102% of Medicare OPPS Rate,266.4,Pays at 90% of Total Billed charges,95.16,Pays at 32.15% of Total Billed charges,10.8,Pays at 100% of Medicare OPPS Rate,95.16,Pays at 32.15% of Total Billed charges,260.48,Pays at 88% of Total Billed charges,98.01,Pays at 33.11% of Total Billed charges,10.8,266.4,177.60
Outpatient Medical Services,LAB,87118,"ID MALDI-TOF MS, AFB  (MAYO)",300,108.5,92.23,Pays at 85% of Billed charges for outpatient setting,34.88,Pays at 32.15% of Total Billed charges,86.83,Pays at 80.03% of Total Billed charges,14.9,Pays at 102% of Medicare OPPS Rate,97.65,Pays at 90% of Total Billed charges,34.88,Pays at 32.15% of Total Billed charges,14.61,Pays at 100% of Medicare OPPS Rate,34.88,Pays at 32.15% of Total Billed charges,95.48,Pays at 88% of Total Billed charges,35.92,Pays at 33.11% of Total Billed charges,14.61,97.65,65.10
Outpatient Medical Services,LAB,87118,CULTURE REF ID MYCOBACTERIA/NOCAR (MAYO),300,273.5,232.48,Pays at 85% of Billed charges for outpatient setting,87.93,Pays at 32.15% of Total Billed charges,218.88,Pays at 80.03% of Total Billed charges,14.9,Pays at 102% of Medicare OPPS Rate,246.15,Pays at 90% of Total Billed charges,87.93,Pays at 32.15% of Total Billed charges,14.61,Pays at 100% of Medicare OPPS Rate,87.93,Pays at 32.15% of Total Billed charges,240.68,Pays at 88% of Total Billed charges,90.56,Pays at 33.11% of Total Billed charges,14.61,246.15,164.10
Outpatient Medical Services,LAB,87147,SEROLOGIC AGG METHOD ID EC1  (MAYO),300,44.5,37.83,Pays at 85% of Billed charges for outpatient setting,5.61,Pays at 100% of GA Medicaid Fee Schedule,35.61,Pays at 80.03% of Total Billed charges,5.28,Pays at 102% of Medicare OPPS Rate,40.05,Pays at 90% of Total Billed charges,5.61,Pays at 100% of GA Medicaid Fee Schedule,5.18,Pays at 100% of Medicare OPPS Rate,5.61,Pays at 100% of GA Medicaid Fee Schedule,39.16,Pays at 88% of Total Billed charges,5.78,Pays at 103% of GA Medicaid Fee Schedule,5.18,40.05,26.70
Outpatient Medical Services,LAB,87150,MYCOBACTERIA ID PROBE  (MAYO),300,192.5,163.63,Pays at 85% of Billed charges for outpatient setting,61.89,Pays at 32.15% of Total Billed charges,154.06,Pays at 80.03% of Total Billed charges,35.79,Pays at 102% of Medicare OPPS Rate,173.25,Pays at 90% of Total Billed charges,61.89,Pays at 32.15% of Total Billed charges,35.09,Pays at 100% of Medicare OPPS Rate,61.89,Pays at 32.15% of Total Billed charges,169.4,Pays at 88% of Total Billed charges,63.74,Pays at 33.11% of Total Billed charges,35.09,173.25,115.50
Outpatient Medical Services,LAB,87153,MYCOBACTERIA  SEQUENCING ID  (MAYO),300,113.25,96.26,Pays at 85% of Billed charges for outpatient setting,36.41,Pays at 32.15% of Total Billed charges,90.63,Pays at 80.03% of Total Billed charges,117.66,Pays at 102% of Medicare OPPS Rate,101.93,Pays at 90% of Total Billed charges,36.41,Pays at 32.15% of Total Billed charges,115.36,Pays at 100% of Medicare OPPS Rate,36.41,Pays at 32.15% of Total Billed charges,99.66,Pays at 88% of Total Billed charges,37.5,Pays at 33.11% of Total Billed charges,36.41,117.66,67.95
Outpatient Medical Services,LAB,87153,MYCOBACTERIUM ID REFLEX  (MAYO),300,117,99.45,Pays at 85% of Billed charges for outpatient setting,37.62,Pays at 32.15% of Total Billed charges,93.64,Pays at 80.03% of Total Billed charges,117.66,Pays at 102% of Medicare OPPS Rate,105.3,Pays at 90% of Total Billed charges,37.62,Pays at 32.15% of Total Billed charges,115.36,Pays at 100% of Medicare OPPS Rate,37.62,Pays at 32.15% of Total Billed charges,102.96,Pays at 88% of Total Billed charges,38.74,Pays at 33.11% of Total Billed charges,37.62,117.66,70.20
Outpatient Medical Services,LAB,87153,"FUNGAL ID, D2F1  (MAYO)",300,316.4,268.94,Pays at 85% of Billed charges for outpatient setting,101.72,Pays at 32.15% of Total Billed charges,253.21,Pays at 80.03% of Total Billed charges,117.66,Pays at 102% of Medicare OPPS Rate,284.76,Pays at 90% of Total Billed charges,101.72,Pays at 32.15% of Total Billed charges,115.36,Pays at 100% of Medicare OPPS Rate,101.72,Pays at 32.15% of Total Billed charges,278.43,Pays at 88% of Total Billed charges,104.76,Pays at 33.11% of Total Billed charges,101.72,284.76,189.84
Outpatient Medical Services,LAB,87169,PARASITE IDENTIFICATION  (MAYO),300,75.5,64.18,Pays at 85% of Billed charges for outpatient setting,5.36,Pays at 100% of GA Medicaid Fee Schedule,60.42,Pays at 80.03% of Total Billed charges,4.39,Pays at 102% of Medicare OPPS Rate,67.95,Pays at 90% of Total Billed charges,5.36,Pays at 100% of GA Medicaid Fee Schedule,4.3,Pays at 100% of Medicare OPPS Rate,5.36,Pays at 100% of GA Medicaid Fee Schedule,66.44,Pays at 88% of Total Billed charges,5.52,Pays at 103% of GA Medicaid Fee Schedule,4.3,67.95,45.30
Outpatient Medical Services,LAB,87172,..PIN WORM PREP,300,35,29.75,Pays at 85% of Billed charges for outpatient setting,5.36,Pays at 100% of GA Medicaid Fee Schedule,28.01,Pays at 80.03% of Total Billed charges,4.35,Pays at 102% of Medicare OPPS Rate,31.5,Pays at 90% of Total Billed charges,5.36,Pays at 100% of GA Medicaid Fee Schedule,4.26,Pays at 100% of Medicare OPPS Rate,5.36,Pays at 100% of GA Medicaid Fee Schedule,30.8,Pays at 88% of Total Billed charges,5.52,Pays at 103% of GA Medicaid Fee Schedule,4.26,31.5,21.00
Outpatient Medical Services,LAB,87172,PINWORM ANALYSIS,300,39.75,33.79,Pays at 85% of Billed charges for outpatient setting,5.36,Pays at 100% of GA Medicaid Fee Schedule,31.81,Pays at 80.03% of Total Billed charges,4.35,Pays at 102% of Medicare OPPS Rate,35.78,Pays at 90% of Total Billed charges,5.36,Pays at 100% of GA Medicaid Fee Schedule,4.26,Pays at 100% of Medicare OPPS Rate,5.36,Pays at 100% of GA Medicaid Fee Schedule,34.98,Pays at 88% of Total Billed charges,5.52,Pays at 103% of GA Medicaid Fee Schedule,4.26,35.78,23.85
Outpatient Medical Services,LAB,87176,TISSUE PROCESSING  (MAYO),300,32,27.2,Pays at 85% of Billed charges for outpatient setting,7.4,Pays at 100% of GA Medicaid Fee Schedule,25.61,Pays at 80.03% of Total Billed charges,5.99,Pays at 102% of Medicare OPPS Rate,28.8,Pays at 90% of Total Billed charges,7.4,Pays at 100% of GA Medicaid Fee Schedule,5.88,Pays at 100% of Medicare OPPS Rate,7.4,Pays at 100% of GA Medicaid Fee Schedule,28.16,Pays at 88% of Total Billed charges,7.62,Pays at 103% of GA Medicaid Fee Schedule,5.88,28.8,19.20
Outpatient Medical Services,LAB,87177,"O&P DIRECT SMEARS, CONC&ID  (MAYO)",300,35,29.75,Pays at 85% of Billed charges for outpatient setting,11.19,Pays at 100% of GA Medicaid Fee Schedule,28.01,Pays at 80.03% of Total Billed charges,9.07,Pays at 102% of Medicare OPPS Rate,31.5,Pays at 90% of Total Billed charges,11.19,Pays at 100% of GA Medicaid Fee Schedule,8.9,Pays at 100% of Medicare OPPS Rate,11.19,Pays at 100% of GA Medicaid Fee Schedule,30.8,Pays at 88% of Total Billed charges,11.53,Pays at 103% of GA Medicaid Fee Schedule,8.9,31.5,21.00
Outpatient Medical Services,LAB,87181,E-TEST GRADIENT STRIP,300,19.38,16.47,Pays at 85% of Billed charges for outpatient setting,5.98,Pays at 100% of GA Medicaid Fee Schedule,15.51,Pays at 80.03% of Total Billed charges,4.84,Pays at 102% of Medicare OPPS Rate,17.44,Pays at 90% of Total Billed charges,5.98,Pays at 100% of GA Medicaid Fee Schedule,4.75,Pays at 100% of Medicare OPPS Rate,5.98,Pays at 100% of GA Medicaid Fee Schedule,17.05,Pays at 88% of Total Billed charges,6.16,Pays at 103% of GA Medicaid Fee Schedule,4.75,17.44,11.63
Outpatient Medical Services,LAB,87181,ANAEROBIC SUSC PER AGENT (MAYO),300,64.75,55.04,Pays at 85% of Billed charges for outpatient setting,5.98,Pays at 100% of GA Medicaid Fee Schedule,51.82,Pays at 80.03% of Total Billed charges,4.84,Pays at 102% of Medicare OPPS Rate,58.28,Pays at 90% of Total Billed charges,5.98,Pays at 100% of GA Medicaid Fee Schedule,4.75,Pays at 100% of Medicare OPPS Rate,5.98,Pays at 100% of GA Medicaid Fee Schedule,56.98,Pays at 88% of Total Billed charges,6.16,Pays at 103% of GA Medicaid Fee Schedule,4.75,58.28,38.85
Outpatient Medical Services,LAB,87181,ANAEROBIC ANTIMICROBIAL SENSITIVITY,300,112,95.2,Pays at 85% of Billed charges for outpatient setting,5.98,Pays at 100% of GA Medicaid Fee Schedule,89.63,Pays at 80.03% of Total Billed charges,4.84,Pays at 102% of Medicare OPPS Rate,100.8,Pays at 90% of Total Billed charges,5.98,Pays at 100% of GA Medicaid Fee Schedule,4.75,Pays at 100% of Medicare OPPS Rate,5.98,Pays at 100% of GA Medicaid Fee Schedule,98.56,Pays at 88% of Total Billed charges,6.16,Pays at 103% of GA Medicaid Fee Schedule,4.75,100.8,67.20
Outpatient Medical Services,LAB,87181,ANAEROBIC SENSITIVITY BATTERY (MAYO),300,148.25,126.01,Pays at 85% of Billed charges for outpatient setting,5.98,Pays at 100% of GA Medicaid Fee Schedule,118.64,Pays at 80.03% of Total Billed charges,4.84,Pays at 102% of Medicare OPPS Rate,133.43,Pays at 90% of Total Billed charges,5.98,Pays at 100% of GA Medicaid Fee Schedule,4.75,Pays at 100% of Medicare OPPS Rate,5.98,Pays at 100% of GA Medicaid Fee Schedule,130.46,Pays at 88% of Total Billed charges,6.16,Pays at 103% of GA Medicaid Fee Schedule,4.75,133.43,88.95
Outpatient Medical Services,LAB,87184,KIRBY BAUER SENSITIVITY,300,26.5,22.53,Pays at 85% of Billed charges for outpatient setting,8.67,Pays at 100% of GA Medicaid Fee Schedule,21.21,Pays at 80.03% of Total Billed charges,7.62,Pays at 102% of Medicare OPPS Rate,23.85,Pays at 90% of Total Billed charges,8.67,Pays at 100% of GA Medicaid Fee Schedule,7.48,Pays at 100% of Medicare OPPS Rate,8.67,Pays at 100% of GA Medicaid Fee Schedule,23.32,Pays at 88% of Total Billed charges,8.93,Pays at 103% of GA Medicaid Fee Schedule,7.48,23.85,15.90
Outpatient Medical Services,LAB,87185,BETA LACTAMASE,300,37.25,31.66,Pays at 85% of Billed charges for outpatient setting,5.98,Pays at 100% of GA Medicaid Fee Schedule,29.81,Pays at 80.03% of Total Billed charges,4.84,Pays at 102% of Medicare OPPS Rate,33.53,Pays at 90% of Total Billed charges,5.98,Pays at 100% of GA Medicaid Fee Schedule,4.75,Pays at 100% of Medicare OPPS Rate,5.98,Pays at 100% of GA Medicaid Fee Schedule,32.78,Pays at 88% of Total Billed charges,6.16,Pays at 103% of GA Medicaid Fee Schedule,4.75,33.53,22.35
Outpatient Medical Services,LAB,87185,CARBAPENEMASE-CARBA NP TEST  (MAYO),300,302.25,256.91,Pays at 85% of Billed charges for outpatient setting,5.98,Pays at 100% of GA Medicaid Fee Schedule,241.89,Pays at 80.03% of Total Billed charges,4.84,Pays at 102% of Medicare OPPS Rate,272.03,Pays at 90% of Total Billed charges,5.98,Pays at 100% of GA Medicaid Fee Schedule,4.75,Pays at 100% of Medicare OPPS Rate,5.98,Pays at 100% of GA Medicaid Fee Schedule,265.98,Pays at 88% of Total Billed charges,6.16,Pays at 103% of GA Medicaid Fee Schedule,4.75,272.03,181.35
Outpatient Medical Services,LAB,87186,A test used to determine which medications work on bacteria for fungi,300,66.25,56.31,Pays at 85% of Billed charges for outpatient setting,10.87,Pays at 100% of GA Medicaid Fee Schedule,53.02,Pays at 80.03% of Total Billed charges,8.82,Pays at 102% of Medicare OPPS Rate,59.63,Pays at 90% of Total Billed charges,10.87,Pays at 100% of GA Medicaid Fee Schedule,8.65,Pays at 100% of Medicare OPPS Rate,10.87,Pays at 100% of GA Medicaid Fee Schedule,58.3,Pays at 88% of Total Billed charges,11.2,Pays at 103% of GA Medicaid Fee Schedule,8.65,59.63,39.75
Outpatient Medical Services,LAB,87186,A test used to determine which medications work on bacteria for fungi,300,77.75,66.09,Pays at 85% of Billed charges for outpatient setting,10.87,Pays at 100% of GA Medicaid Fee Schedule,62.22,Pays at 80.03% of Total Billed charges,8.82,Pays at 102% of Medicare OPPS Rate,69.98,Pays at 90% of Total Billed charges,10.87,Pays at 100% of GA Medicaid Fee Schedule,8.65,Pays at 100% of Medicare OPPS Rate,10.87,Pays at 100% of GA Medicaid Fee Schedule,68.42,Pays at 88% of Total Billed charges,11.2,Pays at 103% of GA Medicaid Fee Schedule,8.65,69.98,46.65
Outpatient Medical Services,LAB,87186,A test used to determine which medications work on bacteria for fungi,300,134.5,114.33,Pays at 85% of Billed charges for outpatient setting,10.87,Pays at 100% of GA Medicaid Fee Schedule,107.64,Pays at 80.03% of Total Billed charges,8.82,Pays at 102% of Medicare OPPS Rate,121.05,Pays at 90% of Total Billed charges,10.87,Pays at 100% of GA Medicaid Fee Schedule,8.65,Pays at 100% of Medicare OPPS Rate,10.87,Pays at 100% of GA Medicaid Fee Schedule,118.36,Pays at 88% of Total Billed charges,11.2,Pays at 103% of GA Medicaid Fee Schedule,8.65,121.05,80.70
Outpatient Medical Services,LAB,87186,A test used to determine which medications work on bacteria for fungi,300,331.75,281.99,Pays at 85% of Billed charges for outpatient setting,10.87,Pays at 100% of GA Medicaid Fee Schedule,265.5,Pays at 80.03% of Total Billed charges,8.82,Pays at 102% of Medicare OPPS Rate,298.58,Pays at 90% of Total Billed charges,10.87,Pays at 100% of GA Medicaid Fee Schedule,8.65,Pays at 100% of Medicare OPPS Rate,10.87,Pays at 100% of GA Medicaid Fee Schedule,291.94,Pays at 88% of Total Billed charges,11.2,Pays at 103% of GA Medicaid Fee Schedule,8.65,298.58,199.05
Outpatient Medical Services,LAB,87186,A test used to determine which medications work on bacteria for fungi,300,398.44,338.67,Pays at 85% of Billed charges for outpatient setting,10.87,Pays at 100% of GA Medicaid Fee Schedule,318.87,Pays at 80.03% of Total Billed charges,8.82,Pays at 102% of Medicare OPPS Rate,358.6,Pays at 90% of Total Billed charges,10.87,Pays at 100% of GA Medicaid Fee Schedule,8.65,Pays at 100% of Medicare OPPS Rate,10.87,Pays at 100% of GA Medicaid Fee Schedule,350.63,Pays at 88% of Total Billed charges,11.2,Pays at 103% of GA Medicaid Fee Schedule,8.65,358.6,239.06
Outpatient Medical Services,LAB,87188,MOLD SENSITIVITY  (MAYO),300,134.5,114.33,Pays at 85% of Billed charges for outpatient setting,8.34,Pays at 100% of GA Medicaid Fee Schedule,107.64,Pays at 80.03% of Total Billed charges,6.77,Pays at 102% of Medicare OPPS Rate,121.05,Pays at 90% of Total Billed charges,8.34,Pays at 100% of GA Medicaid Fee Schedule,6.64,Pays at 100% of Medicare OPPS Rate,8.34,Pays at 100% of GA Medicaid Fee Schedule,118.36,Pays at 88% of Total Billed charges,8.59,Pays at 103% of GA Medicaid Fee Schedule,6.64,121.05,80.70
Outpatient Medical Services,LAB,87190,TB SENSITIVITY  (MAYO),300,195.5,166.18,Pays at 85% of Billed charges for outpatient setting,7.11,Pays at 100% of GA Medicaid Fee Schedule,156.46,Pays at 80.03% of Total Billed charges,7.45,Pays at 102% of Medicare OPPS Rate,175.95,Pays at 90% of Total Billed charges,7.11,Pays at 100% of GA Medicaid Fee Schedule,7.31,Pays at 100% of Medicare OPPS Rate,7.11,Pays at 100% of GA Medicaid Fee Schedule,172.04,Pays at 88% of Total Billed charges,7.32,Pays at 103% of GA Medicaid Fee Schedule,7.11,175.95,117.30
Outpatient Medical Services,LAB,87205,A lab test used to detect bacteria or fungi in a sample taken from the site of a suspected infection,300,23.78,20.21,Pays at 85% of Billed charges for outpatient setting,2.95,Pays at 100% of GA Medicaid Fee Schedule,19.03,Pays at 80.03% of Total Billed charges,4.35,Pays at 102% of Medicare OPPS Rate,21.4,Pays at 90% of Total Billed charges,2.95,Pays at 100% of GA Medicaid Fee Schedule,4.26,Pays at 100% of Medicare OPPS Rate,2.95,Pays at 100% of GA Medicaid Fee Schedule,20.93,Pays at 88% of Total Billed charges,3.04,Pays at 103% of GA Medicaid Fee Schedule,2.95,21.4,14.27
Outpatient Medical Services,LAB,87205,A lab test used to detect bacteria or fungi in a sample taken from the site of a suspected infection,300,38.25,32.51,Pays at 85% of Billed charges for outpatient setting,2.95,Pays at 100% of GA Medicaid Fee Schedule,30.61,Pays at 80.03% of Total Billed charges,4.35,Pays at 102% of Medicare OPPS Rate,34.43,Pays at 90% of Total Billed charges,2.95,Pays at 100% of GA Medicaid Fee Schedule,4.26,Pays at 100% of Medicare OPPS Rate,2.95,Pays at 100% of GA Medicaid Fee Schedule,33.66,Pays at 88% of Total Billed charges,3.04,Pays at 103% of GA Medicaid Fee Schedule,2.95,34.43,22.95
Outpatient Medical Services,LAB,87205,A lab test used to detect bacteria or fungi in a sample taken from the site of a suspected infection,300,45,38.25,Pays at 85% of Billed charges for outpatient setting,2.95,Pays at 100% of GA Medicaid Fee Schedule,36.01,Pays at 80.03% of Total Billed charges,4.35,Pays at 102% of Medicare OPPS Rate,40.5,Pays at 90% of Total Billed charges,2.95,Pays at 100% of GA Medicaid Fee Schedule,4.26,Pays at 100% of Medicare OPPS Rate,2.95,Pays at 100% of GA Medicaid Fee Schedule,39.6,Pays at 88% of Total Billed charges,3.04,Pays at 103% of GA Medicaid Fee Schedule,2.95,40.5,27.00
Outpatient Medical Services,LAB,87205,A lab test used to detect bacteria or fungi in a sample taken from the site of a suspected infection,300,191.5,162.78,Pays at 85% of Billed charges for outpatient setting,2.95,Pays at 100% of GA Medicaid Fee Schedule,153.26,Pays at 80.03% of Total Billed charges,4.35,Pays at 102% of Medicare OPPS Rate,172.35,Pays at 90% of Total Billed charges,2.95,Pays at 100% of GA Medicaid Fee Schedule,4.26,Pays at 100% of Medicare OPPS Rate,2.95,Pays at 100% of GA Medicaid Fee Schedule,168.52,Pays at 88% of Total Billed charges,3.04,Pays at 103% of GA Medicaid Fee Schedule,2.95,172.35,114.90
Outpatient Medical Services,LAB,87206,AFB SMEAR (MYCOBACT),300,30,25.5,Pays at 85% of Billed charges for outpatient setting,6.75,Pays at 100% of GA Medicaid Fee Schedule,24.01,Pays at 80.03% of Total Billed charges,5.49,Pays at 102% of Medicare OPPS Rate,27,Pays at 90% of Total Billed charges,6.75,Pays at 100% of GA Medicaid Fee Schedule,5.39,Pays at 100% of Medicare OPPS Rate,6.75,Pays at 100% of GA Medicaid Fee Schedule,26.4,Pays at 88% of Total Billed charges,6.95,Pays at 103% of GA Medicaid Fee Schedule,5.39,27,18.00
Outpatient Medical Services,LAB,87206,..FUNGAL SMEAR (MAYO),300,36.75,31.24,Pays at 85% of Billed charges for outpatient setting,6.75,Pays at 100% of GA Medicaid Fee Schedule,29.41,Pays at 80.03% of Total Billed charges,5.49,Pays at 102% of Medicare OPPS Rate,33.08,Pays at 90% of Total Billed charges,6.75,Pays at 100% of GA Medicaid Fee Schedule,5.39,Pays at 100% of Medicare OPPS Rate,6.75,Pays at 100% of GA Medicaid Fee Schedule,32.34,Pays at 88% of Total Billed charges,6.95,Pays at 103% of GA Medicaid Fee Schedule,5.39,33.08,22.05
Outpatient Medical Services,LAB,87206,ACID FAST SMEAR (MAYO),300,40.25,34.21,Pays at 85% of Billed charges for outpatient setting,6.75,Pays at 100% of GA Medicaid Fee Schedule,32.21,Pays at 80.03% of Total Billed charges,5.49,Pays at 102% of Medicare OPPS Rate,36.23,Pays at 90% of Total Billed charges,6.75,Pays at 100% of GA Medicaid Fee Schedule,5.39,Pays at 100% of Medicare OPPS Rate,6.75,Pays at 100% of GA Medicaid Fee Schedule,35.42,Pays at 88% of Total Billed charges,6.95,Pays at 103% of GA Medicaid Fee Schedule,5.39,36.23,24.15
Outpatient Medical Services,LAB,87207,SPECIAL STAIN,300,43.75,37.19,Pays at 85% of Billed charges for outpatient setting,7.53,Pays at 100% of GA Medicaid Fee Schedule,35.01,Pays at 80.03% of Total Billed charges,6.1,Pays at 102% of Medicare OPPS Rate,39.38,Pays at 90% of Total Billed charges,7.53,Pays at 100% of GA Medicaid Fee Schedule,5.99,Pays at 100% of Medicare OPPS Rate,7.53,Pays at 100% of GA Medicaid Fee Schedule,38.5,Pays at 88% of Total Billed charges,7.76,Pays at 103% of GA Medicaid Fee Schedule,5.99,39.38,26.25
Outpatient Medical Services,LAB,87207,MALARIA SMEAR  (MAYO),300,50.75,43.14,Pays at 85% of Billed charges for outpatient setting,7.53,Pays at 100% of GA Medicaid Fee Schedule,40.62,Pays at 80.03% of Total Billed charges,6.1,Pays at 102% of Medicare OPPS Rate,45.68,Pays at 90% of Total Billed charges,7.53,Pays at 100% of GA Medicaid Fee Schedule,5.99,Pays at 100% of Medicare OPPS Rate,7.53,Pays at 100% of GA Medicaid Fee Schedule,44.66,Pays at 88% of Total Billed charges,7.76,Pays at 103% of GA Medicaid Fee Schedule,5.99,45.68,30.45
Outpatient Medical Services,LAB,87209,O&P COMPLEX SPECIAL STAIN  (MAYO),300,71.25,60.56,Pays at 85% of Billed charges for outpatient setting,22.6,Pays at 100% of GA Medicaid Fee Schedule,57.02,Pays at 80.03% of Total Billed charges,18.33,Pays at 102% of Medicare OPPS Rate,64.13,Pays at 90% of Total Billed charges,22.6,Pays at 100% of GA Medicaid Fee Schedule,17.98,Pays at 100% of Medicare OPPS Rate,22.6,Pays at 100% of GA Medicaid Fee Schedule,62.7,Pays at 88% of Total Billed charges,23.28,Pays at 103% of GA Medicaid Fee Schedule,17.98,64.13,42.75
Outpatient Medical Services,LAB,87210,A lab test to screen for evidence of vaginal infection,300,10,8.5,Pays at 85% of Billed charges for outpatient setting,5.36,Pays at 100% of GA Medicaid Fee Schedule,8,Pays at 80.03% of Total Billed charges,5.93,Pays at 102% of Medicare OPPS Rate,9,Pays at 90% of Total Billed charges,5.36,Pays at 100% of GA Medicaid Fee Schedule,5.82,Pays at 100% of Medicare OPPS Rate,5.36,Pays at 100% of GA Medicaid Fee Schedule,8.8,Pays at 88% of Total Billed charges,5.52,Pays at 103% of GA Medicaid Fee Schedule,5.36,9,6.00
Outpatient Medical Services,LAB,87210,A lab test to screen for evidence of vaginal infection,300,40.25,34.21,Pays at 85% of Billed charges for outpatient setting,5.36,Pays at 100% of GA Medicaid Fee Schedule,32.21,Pays at 80.03% of Total Billed charges,5.93,Pays at 102% of Medicare OPPS Rate,36.23,Pays at 90% of Total Billed charges,5.36,Pays at 100% of GA Medicaid Fee Schedule,5.82,Pays at 100% of Medicare OPPS Rate,5.36,Pays at 100% of GA Medicaid Fee Schedule,35.42,Pays at 88% of Total Billed charges,5.52,Pays at 103% of GA Medicaid Fee Schedule,5.36,36.23,24.15
Outpatient Medical Services,LAB,87220,"KOH PREP, FUNGUS  (MAYO)",300,39.25,33.36,Pays at 85% of Billed charges for outpatient setting,5.36,Pays at 100% of GA Medicaid Fee Schedule,31.41,Pays at 80.03% of Total Billed charges,4.35,Pays at 102% of Medicare OPPS Rate,35.33,Pays at 90% of Total Billed charges,5.36,Pays at 100% of GA Medicaid Fee Schedule,4.26,Pays at 100% of Medicare OPPS Rate,5.36,Pays at 100% of GA Medicaid Fee Schedule,34.54,Pays at 88% of Total Billed charges,5.52,Pays at 103% of GA Medicaid Fee Schedule,4.26,35.33,23.55
Outpatient Medical Services,LAB,87230,"CYTOTOXIN, C. DIFFICLE AB  (MAYO)",300,168.75,143.44,Pays at 85% of Billed charges for outpatient setting,24.83,Pays at 100% of GA Medicaid Fee Schedule,135.05,Pays at 80.03% of Total Billed charges,20.13,Pays at 102% of Medicare OPPS Rate,151.88,Pays at 90% of Total Billed charges,24.83,Pays at 100% of GA Medicaid Fee Schedule,19.73,Pays at 100% of Medicare OPPS Rate,24.83,Pays at 100% of GA Medicaid Fee Schedule,148.5,Pays at 88% of Total Billed charges,25.57,Pays at 103% of GA Medicaid Fee Schedule,19.73,151.88,101.25
Outpatient Medical Services,LAB,87252,"CULTURE VIRUS, NON RESPIRATORY  (MAYO)",300,79.25,67.36,Pays at 85% of Billed charges for outpatient setting,27.8,Pays at 100% of GA Medicaid Fee Schedule,63.42,Pays at 80.03% of Total Billed charges,26.59,Pays at 102% of Medicare OPPS Rate,71.33,Pays at 90% of Total Billed charges,27.8,Pays at 100% of GA Medicaid Fee Schedule,26.07,Pays at 100% of Medicare OPPS Rate,27.8,Pays at 100% of GA Medicaid Fee Schedule,69.74,Pays at 88% of Total Billed charges,28.63,Pays at 103% of GA Medicaid Fee Schedule,26.07,71.33,47.55
Outpatient Medical Services,LAB,87252,"VIRAL SMEAR, SHELL VIAL  (MAYO)",300,79.25,67.36,Pays at 85% of Billed charges for outpatient setting,27.8,Pays at 100% of GA Medicaid Fee Schedule,63.42,Pays at 80.03% of Total Billed charges,26.59,Pays at 102% of Medicare OPPS Rate,71.33,Pays at 90% of Total Billed charges,27.8,Pays at 100% of GA Medicaid Fee Schedule,26.07,Pays at 100% of Medicare OPPS Rate,27.8,Pays at 100% of GA Medicaid Fee Schedule,69.74,Pays at 88% of Total Billed charges,28.63,Pays at 103% of GA Medicaid Fee Schedule,26.07,71.33,47.55
Outpatient Medical Services,LAB,87252,CULTURE VIRUS  (MAYO),300,82.75,70.34,Pays at 85% of Billed charges for outpatient setting,27.8,Pays at 100% of GA Medicaid Fee Schedule,66.22,Pays at 80.03% of Total Billed charges,26.59,Pays at 102% of Medicare OPPS Rate,74.48,Pays at 90% of Total Billed charges,27.8,Pays at 100% of GA Medicaid Fee Schedule,26.07,Pays at 100% of Medicare OPPS Rate,27.8,Pays at 100% of GA Medicaid Fee Schedule,72.82,Pays at 88% of Total Billed charges,28.63,Pays at 103% of GA Medicaid Fee Schedule,26.07,74.48,49.65
Outpatient Medical Services,LAB,87253,ECHOVIRUS  (MAYO),300,70.25,59.71,Pays at 85% of Billed charges for outpatient setting,20.48,Pays at 100% of GA Medicaid Fee Schedule,56.22,Pays at 80.03% of Total Billed charges,20.6,Pays at 102% of Medicare OPPS Rate,63.23,Pays at 90% of Total Billed charges,20.48,Pays at 100% of GA Medicaid Fee Schedule,20.2,Pays at 100% of Medicare OPPS Rate,20.48,Pays at 100% of GA Medicaid Fee Schedule,61.82,Pays at 88% of Total Billed charges,21.09,Pays at 103% of GA Medicaid Fee Schedule,20.2,63.23,42.15
Outpatient Medical Services,LAB,87253,VIRUS IDENTIFICATION  (MAYO),300,80.75,68.64,Pays at 85% of Billed charges for outpatient setting,20.48,Pays at 100% of GA Medicaid Fee Schedule,64.62,Pays at 80.03% of Total Billed charges,20.6,Pays at 102% of Medicare OPPS Rate,72.68,Pays at 90% of Total Billed charges,20.48,Pays at 100% of GA Medicaid Fee Schedule,20.2,Pays at 100% of Medicare OPPS Rate,20.48,Pays at 100% of GA Medicaid Fee Schedule,71.06,Pays at 88% of Total Billed charges,21.09,Pays at 103% of GA Medicaid Fee Schedule,20.2,72.68,48.45
Outpatient Medical Services,LAB,87265,BORDETELLA PERTUSSIS SMEAR  (MAYO),300,44.75,38.04,Pays at 85% of Billed charges for outpatient setting,15.08,Pays at 100% of GA Medicaid Fee Schedule,35.81,Pays at 80.03% of Total Billed charges,12.21,Pays at 102% of Medicare OPPS Rate,40.28,Pays at 90% of Total Billed charges,15.08,Pays at 100% of GA Medicaid Fee Schedule,11.98,Pays at 100% of Medicare OPPS Rate,15.08,Pays at 100% of GA Medicaid Fee Schedule,39.38,Pays at 88% of Total Billed charges,15.53,Pays at 103% of GA Medicaid Fee Schedule,11.98,40.28,26.85
Outpatient Medical Services,LAB,87305,ASPERGILLAS AG GALACTOMANNAN  (MAYO),300,170.75,145.14,Pays at 85% of Billed charges for outpatient setting,15.08,Pays at 100% of GA Medicaid Fee Schedule,136.65,Pays at 80.03% of Total Billed charges,12.21,Pays at 102% of Medicare OPPS Rate,153.68,Pays at 90% of Total Billed charges,15.08,Pays at 100% of GA Medicaid Fee Schedule,11.98,Pays at 100% of Medicare OPPS Rate,15.08,Pays at 100% of GA Medicaid Fee Schedule,150.26,Pays at 88% of Total Billed charges,15.53,Pays at 103% of GA Medicaid Fee Schedule,11.98,153.68,102.45
Outpatient Medical Services,LAB,87328,CRYPTOSPORIDIUM AG,300,63.25,53.76,Pays at 85% of Billed charges for outpatient setting,15.08,Pays at 100% of GA Medicaid Fee Schedule,50.62,Pays at 80.03% of Total Billed charges,14.09,Pays at 102% of Medicare OPPS Rate,56.93,Pays at 90% of Total Billed charges,15.08,Pays at 100% of GA Medicaid Fee Schedule,13.82,Pays at 100% of Medicare OPPS Rate,15.08,Pays at 100% of GA Medicaid Fee Schedule,55.66,Pays at 88% of Total Billed charges,15.53,Pays at 103% of GA Medicaid Fee Schedule,13.82,56.93,37.95
Outpatient Medical Services,LAB,87329,GIARDIA AG,300,63.25,53.76,Pays at 85% of Billed charges for outpatient setting,15.08,Pays at 100% of GA Medicaid Fee Schedule,50.62,Pays at 80.03% of Total Billed charges,12.21,Pays at 102% of Medicare OPPS Rate,56.93,Pays at 90% of Total Billed charges,15.08,Pays at 100% of GA Medicaid Fee Schedule,11.98,Pays at 100% of Medicare OPPS Rate,15.08,Pays at 100% of GA Medicaid Fee Schedule,55.66,Pays at 88% of Total Billed charges,15.53,Pays at 103% of GA Medicaid Fee Schedule,11.98,56.93,37.95
Outpatient Medical Services,LAB,87338,"H. PYLORI, FECES AG, EIA (MAYO)",300,257.25,218.66,Pays at 85% of Billed charges for outpatient setting,18.09,Pays at 100% of GA Medicaid Fee Schedule,205.88,Pays at 80.03% of Total Billed charges,14.66,Pays at 102% of Medicare OPPS Rate,231.53,Pays at 90% of Total Billed charges,18.09,Pays at 100% of GA Medicaid Fee Schedule,14.38,Pays at 100% of Medicare OPPS Rate,18.09,Pays at 100% of GA Medicaid Fee Schedule,226.38,Pays at 88% of Total Billed charges,18.63,Pays at 103% of GA Medicaid Fee Schedule,14.38,231.53,154.35
Outpatient Medical Services,LAB,87340,HEPATITIS B SURFACE AG (HBsAG)  (MAYO),300,41.25,35.06,Pays at 85% of Billed charges for outpatient setting,12.99,Pays at 100% of GA Medicaid Fee Schedule,33.01,Pays at 80.03% of Total Billed charges,10.53,Pays at 102% of Medicare OPPS Rate,37.13,Pays at 90% of Total Billed charges,12.99,Pays at 100% of GA Medicaid Fee Schedule,10.33,Pays at 100% of Medicare OPPS Rate,12.99,Pays at 100% of GA Medicaid Fee Schedule,36.3,Pays at 88% of Total Billed charges,13.38,Pays at 103% of GA Medicaid Fee Schedule,10.33,37.13,24.75
Outpatient Medical Services,LAB,87350,HEPATITIS BE AG  (MAYO),300,37.25,31.66,Pays at 85% of Billed charges for outpatient setting,14.49,Pays at 100% of GA Medicaid Fee Schedule,29.81,Pays at 80.03% of Total Billed charges,11.76,Pays at 102% of Medicare OPPS Rate,33.53,Pays at 90% of Total Billed charges,14.49,Pays at 100% of GA Medicaid Fee Schedule,11.53,Pays at 100% of Medicare OPPS Rate,14.49,Pays at 100% of GA Medicaid Fee Schedule,32.78,Pays at 88% of Total Billed charges,14.92,Pays at 103% of GA Medicaid Fee Schedule,11.53,33.53,22.35
Outpatient Medical Services,LAB,87385,"HISTOPLASMA  AG, URINE  (MAYO)",300,223.5,189.98,Pays at 85% of Billed charges for outpatient setting,15.08,Pays at 100% of GA Medicaid Fee Schedule,178.87,Pays at 80.03% of Total Billed charges,13.51,Pays at 102% of Medicare OPPS Rate,201.15,Pays at 90% of Total Billed charges,15.08,Pays at 100% of GA Medicaid Fee Schedule,13.25,Pays at 100% of Medicare OPPS Rate,15.08,Pays at 100% of GA Medicaid Fee Schedule,196.68,Pays at 88% of Total Billed charges,15.53,Pays at 103% of GA Medicaid Fee Schedule,13.25,201.15,134.10
Outpatient Medical Services,LAB,87389,Test for HIV,300,121.75,103.49,Pays at 85% of Billed charges for outpatient setting,27.3,Pays at 100% of GA Medicaid Fee Schedule,97.44,Pays at 80.03% of Total Billed charges,24.56,Pays at 102% of Medicare OPPS Rate,109.58,Pays at 90% of Total Billed charges,27.3,Pays at 100% of GA Medicaid Fee Schedule,24.08,Pays at 100% of Medicare OPPS Rate,27.3,Pays at 100% of GA Medicaid Fee Schedule,107.14,Pays at 88% of Total Billed charges,28.12,Pays at 103% of GA Medicaid Fee Schedule,24.08,109.58,73.05
Outpatient Medical Services,LAB,87389,Test for HIV,300,625,531.25,Pays at 85% of Billed charges for outpatient setting,27.3,Pays at 100% of GA Medicaid Fee Schedule,500.19,Pays at 80.03% of Total Billed charges,24.56,Pays at 102% of Medicare OPPS Rate,562.5,Pays at 90% of Total Billed charges,27.3,Pays at 100% of GA Medicaid Fee Schedule,24.08,Pays at 100% of Medicare OPPS Rate,27.3,Pays at 100% of GA Medicaid Fee Schedule,550,Pays at 88% of Total Billed charges,28.12,Pays at 103% of GA Medicaid Fee Schedule,24.08,562.5,375.00
Outpatient Medical Services,LAB,87400,".FLU - A, RAPID TEST",300,28.91,24.57,Pays at 85% of Billed charges for outpatient setting,15.08,Pays at 100% of GA Medicaid Fee Schedule,23.14,Pays at 80.03% of Total Billed charges,14.41,Pays at 102% of Medicare OPPS Rate,26.02,Pays at 90% of Total Billed charges,15.08,Pays at 100% of GA Medicaid Fee Schedule,14.13,Pays at 100% of Medicare OPPS Rate,15.08,Pays at 100% of GA Medicaid Fee Schedule,25.44,Pays at 88% of Total Billed charges,15.53,Pays at 103% of GA Medicaid Fee Schedule,14.13,26.02,17.35
Outpatient Medical Services,LAB,87400,".FLU - B, RAPID TEST",300,28.91,24.57,Pays at 85% of Billed charges for outpatient setting,15.08,Pays at 100% of GA Medicaid Fee Schedule,23.14,Pays at 80.03% of Total Billed charges,14.41,Pays at 102% of Medicare OPPS Rate,26.02,Pays at 90% of Total Billed charges,15.08,Pays at 100% of GA Medicaid Fee Schedule,14.13,Pays at 100% of Medicare OPPS Rate,15.08,Pays at 100% of GA Medicaid Fee Schedule,25.44,Pays at 88% of Total Billed charges,15.53,Pays at 103% of GA Medicaid Fee Schedule,14.13,26.02,17.35
Outpatient Medical Services,LAB,87426,COVID ANTIGEN,300,187.5,159.38,Pays at 85% of Billed charges for outpatient setting,36.18,Pays at 100% of GA Medicaid Fee Schedule,150.06,Pays at 80.03% of Total Billed charges,36.03,Pays at 102% of Medicare OPPS Rate,168.75,Pays at 90% of Total Billed charges,36.18,Pays at 100% of GA Medicaid Fee Schedule,35.33,Pays at 100% of Medicare OPPS Rate,36.18,Pays at 100% of GA Medicaid Fee Schedule,165,Pays at 88% of Total Billed charges,37.27,Pays at 103% of GA Medicaid Fee Schedule,35.33,168.75,112.50
Outpatient Medical Services,LAB,87427,"TOXIGENIC E. COLI  AG, FECES  (MAYO)",300,117.75,100.09,Pays at 85% of Billed charges for outpatient setting,15.08,Pays at 100% of GA Medicaid Fee Schedule,94.24,Pays at 80.03% of Total Billed charges,12.21,Pays at 102% of Medicare OPPS Rate,105.98,Pays at 90% of Total Billed charges,15.08,Pays at 100% of GA Medicaid Fee Schedule,11.98,Pays at 100% of Medicare OPPS Rate,15.08,Pays at 100% of GA Medicaid Fee Schedule,103.62,Pays at 88% of Total Billed charges,15.53,Pays at 103% of GA Medicaid Fee Schedule,11.98,105.98,70.65
Outpatient Medical Services,LAB,87449,"FUNGITELL, SERUM  (MAYO)",300,188.25,160.01,Pays at 85% of Billed charges for outpatient setting,15.08,Pays at 100% of GA Medicaid Fee Schedule,150.66,Pays at 80.03% of Total Billed charges,12.21,Pays at 102% of Medicare OPPS Rate,169.43,Pays at 90% of Total Billed charges,15.08,Pays at 100% of GA Medicaid Fee Schedule,11.98,Pays at 100% of Medicare OPPS Rate,15.08,Pays at 100% of GA Medicaid Fee Schedule,165.66,Pays at 88% of Total Billed charges,15.53,Pays at 103% of GA Medicaid Fee Schedule,11.98,169.43,112.95
Outpatient Medical Services,LAB,87476,"LYME DISEASE, PCR,   (MAYO)",300,158,134.3,Pays at 85% of Billed charges for outpatient setting,24.67,Pays at 100% of GA Medicaid Fee Schedule,126.45,Pays at 80.03% of Total Billed charges,35.79,Pays at 102% of Medicare OPPS Rate,142.2,Pays at 90% of Total Billed charges,24.67,Pays at 100% of GA Medicaid Fee Schedule,35.09,Pays at 100% of Medicare OPPS Rate,24.67,Pays at 100% of GA Medicaid Fee Schedule,139.04,Pays at 88% of Total Billed charges,25.41,Pays at 103% of GA Medicaid Fee Schedule,24.67,142.2,94.80
Outpatient Medical Services,LAB,87486,CHLAMYDIA PNEUMONIAE DNA-PCR  (MAYO),300,320.75,272.64,Pays at 85% of Billed charges for outpatient setting,24.67,Pays at 100% of GA Medicaid Fee Schedule,256.7,Pays at 80.03% of Total Billed charges,35.79,Pays at 102% of Medicare OPPS Rate,288.68,Pays at 90% of Total Billed charges,24.67,Pays at 100% of GA Medicaid Fee Schedule,35.09,Pays at 100% of Medicare OPPS Rate,24.67,Pays at 100% of GA Medicaid Fee Schedule,282.26,Pays at 88% of Total Billed charges,25.41,Pays at 103% of GA Medicaid Fee Schedule,24.67,288.68,192.45
Outpatient Medical Services,LAB,87491,Test that detects Chlamydia,300,60.25,51.21,Pays at 85% of Billed charges for outpatient setting,24.67,Pays at 100% of GA Medicaid Fee Schedule,48.22,Pays at 80.03% of Total Billed charges,35.79,Pays at 102% of Medicare OPPS Rate,54.23,Pays at 90% of Total Billed charges,24.67,Pays at 100% of GA Medicaid Fee Schedule,35.09,Pays at 100% of Medicare OPPS Rate,24.67,Pays at 100% of GA Medicaid Fee Schedule,53.02,Pays at 88% of Total Billed charges,25.41,Pays at 103% of GA Medicaid Fee Schedule,24.67,54.23,36.15
Outpatient Medical Services,LAB,87491,Test that detects Chlamydia,300,120.53,102.45,Pays at 85% of Billed charges for outpatient setting,24.67,Pays at 100% of GA Medicaid Fee Schedule,96.46,Pays at 80.03% of Total Billed charges,35.79,Pays at 102% of Medicare OPPS Rate,108.48,Pays at 90% of Total Billed charges,24.67,Pays at 100% of GA Medicaid Fee Schedule,35.09,Pays at 100% of Medicare OPPS Rate,24.67,Pays at 100% of GA Medicaid Fee Schedule,106.07,Pays at 88% of Total Billed charges,25.41,Pays at 103% of GA Medicaid Fee Schedule,24.67,108.48,72.32
Outpatient Medical Services,LAB,87491,Test that detects Chlamydia,300,139.69,118.74,Pays at 85% of Billed charges for outpatient setting,24.67,Pays at 100% of GA Medicaid Fee Schedule,111.79,Pays at 80.03% of Total Billed charges,35.79,Pays at 102% of Medicare OPPS Rate,125.72,Pays at 90% of Total Billed charges,24.67,Pays at 100% of GA Medicaid Fee Schedule,35.09,Pays at 100% of Medicare OPPS Rate,24.67,Pays at 100% of GA Medicaid Fee Schedule,122.93,Pays at 88% of Total Billed charges,25.41,Pays at 103% of GA Medicaid Fee Schedule,24.67,125.72,83.81
Outpatient Medical Services,LAB,87493,C. DIFF TOXIN A,300,43.25,36.76,Pays at 85% of Billed charges for outpatient setting,13.9,Pays at 32.15% of Total Billed charges,34.61,Pays at 80.03% of Total Billed charges,38.01,Pays at 102% of Medicare OPPS Rate,38.93,Pays at 90% of Total Billed charges,13.9,Pays at 32.15% of Total Billed charges,37.27,Pays at 100% of Medicare OPPS Rate,13.9,Pays at 32.15% of Total Billed charges,38.06,Pays at 88% of Total Billed charges,14.32,Pays at 33.11% of Total Billed charges,13.9,38.93,25.95
Outpatient Medical Services,LAB,87493,C. DIFF TOXIN B,300,43.25,36.76,Pays at 85% of Billed charges for outpatient setting,13.9,Pays at 32.15% of Total Billed charges,34.61,Pays at 80.03% of Total Billed charges,38.01,Pays at 102% of Medicare OPPS Rate,38.93,Pays at 90% of Total Billed charges,13.9,Pays at 32.15% of Total Billed charges,37.27,Pays at 100% of Medicare OPPS Rate,13.9,Pays at 32.15% of Total Billed charges,38.06,Pays at 88% of Total Billed charges,14.32,Pays at 33.11% of Total Billed charges,13.9,38.93,25.95
Outpatient Medical Services,LAB,87493,C. DIFF BY PCR,300,91.64,77.89,Pays at 85% of Billed charges for outpatient setting,29.46,Pays at 32.15% of Total Billed charges,73.34,Pays at 80.03% of Total Billed charges,38.01,Pays at 102% of Medicare OPPS Rate,82.48,Pays at 90% of Total Billed charges,29.46,Pays at 32.15% of Total Billed charges,37.27,Pays at 100% of Medicare OPPS Rate,29.46,Pays at 32.15% of Total Billed charges,80.64,Pays at 88% of Total Billed charges,30.34,Pays at 33.11% of Total Billed charges,29.46,82.48,54.98
Outpatient Medical Services,LAB,87496,"CMV, CSF (OTHER BODY FLUID)  (MAYO)",300,122.25,103.91,Pays at 85% of Billed charges for outpatient setting,24.67,Pays at 100% of GA Medicaid Fee Schedule,97.84,Pays at 80.03% of Total Billed charges,35.79,Pays at 102% of Medicare OPPS Rate,110.03,Pays at 90% of Total Billed charges,24.67,Pays at 100% of GA Medicaid Fee Schedule,35.09,Pays at 100% of Medicare OPPS Rate,24.67,Pays at 100% of GA Medicaid Fee Schedule,107.58,Pays at 88% of Total Billed charges,25.41,Pays at 103% of GA Medicaid Fee Schedule,24.67,110.03,73.35
Outpatient Medical Services,LAB,87497,CMV PCR PLASMA  (MAYO),300,136.5,116.03,Pays at 85% of Billed charges for outpatient setting,53.87,Pays at 100% of GA Medicaid Fee Schedule,109.24,Pays at 80.03% of Total Billed charges,43.69,Pays at 102% of Medicare OPPS Rate,122.85,Pays at 90% of Total Billed charges,53.87,Pays at 100% of GA Medicaid Fee Schedule,42.84,Pays at 100% of Medicare OPPS Rate,53.87,Pays at 100% of GA Medicaid Fee Schedule,120.12,Pays at 88% of Total Billed charges,55.49,Pays at 103% of GA Medicaid Fee Schedule,42.84,122.85,81.90
Outpatient Medical Services,LAB,87498,"ENTEROVIRUS, VARIOUS SOURCE  PCR  (MAYO)",300,120,102,Pays at 85% of Billed charges for outpatient setting,24.67,Pays at 100% of GA Medicaid Fee Schedule,96.04,Pays at 80.03% of Total Billed charges,35.79,Pays at 102% of Medicare OPPS Rate,108,Pays at 90% of Total Billed charges,24.67,Pays at 100% of GA Medicaid Fee Schedule,35.09,Pays at 100% of Medicare OPPS Rate,24.67,Pays at 100% of GA Medicaid Fee Schedule,105.6,Pays at 88% of Total Billed charges,25.41,Pays at 103% of GA Medicaid Fee Schedule,24.67,108,72.00
Outpatient Medical Services,LAB,87498,"ENTEROVIRUS, PLASMA  (MAYO)",300,120,102,Pays at 85% of Billed charges for outpatient setting,24.67,Pays at 100% of GA Medicaid Fee Schedule,96.04,Pays at 80.03% of Total Billed charges,35.79,Pays at 102% of Medicare OPPS Rate,108,Pays at 90% of Total Billed charges,24.67,Pays at 100% of GA Medicaid Fee Schedule,35.09,Pays at 100% of Medicare OPPS Rate,24.67,Pays at 100% of GA Medicaid Fee Schedule,105.6,Pays at 88% of Total Billed charges,25.41,Pays at 103% of GA Medicaid Fee Schedule,24.67,108,72.00
Outpatient Medical Services,LAB,87502,INFLUENZA A H1N1 PCR  (MAYO),300,324.25,275.61,Pays at 85% of Billed charges for outpatient setting,58.43,Pays at 100% of GA Medicaid Fee Schedule,259.5,Pays at 80.03% of Total Billed charges,97.71,Pays at 102% of Medicare OPPS Rate,291.83,Pays at 90% of Total Billed charges,58.43,Pays at 100% of GA Medicaid Fee Schedule,95.8,Pays at 100% of Medicare OPPS Rate,58.43,Pays at 100% of GA Medicaid Fee Schedule,285.34,Pays at 88% of Total Billed charges,60.18,Pays at 103% of GA Medicaid Fee Schedule,58.43,291.83,194.55
Outpatient Medical Services,LAB,87517,HEPATITIS B VIRAL DNA (HBV-DNA)   (MAYO),300,309.75,263.29,Pays at 85% of Billed charges for outpatient setting,53.87,Pays at 100% of GA Medicaid Fee Schedule,247.89,Pays at 80.03% of Total Billed charges,43.69,Pays at 102% of Medicare OPPS Rate,278.78,Pays at 90% of Total Billed charges,53.87,Pays at 100% of GA Medicaid Fee Schedule,42.84,Pays at 100% of Medicare OPPS Rate,53.87,Pays at 100% of GA Medicaid Fee Schedule,272.58,Pays at 88% of Total Billed charges,55.49,Pays at 103% of GA Medicaid Fee Schedule,42.84,278.78,185.85
Outpatient Medical Services,LAB,87522,HEPATITIS C VIRUS (HCV-RNA)  (MAYO),300,279,237.15,Pays at 85% of Billed charges for outpatient setting,53.87,Pays at 100% of GA Medicaid Fee Schedule,223.28,Pays at 80.03% of Total Billed charges,43.69,Pays at 102% of Medicare OPPS Rate,251.1,Pays at 90% of Total Billed charges,53.87,Pays at 100% of GA Medicaid Fee Schedule,42.84,Pays at 100% of Medicare OPPS Rate,53.87,Pays at 100% of GA Medicaid Fee Schedule,245.52,Pays at 88% of Total Billed charges,55.49,Pays at 103% of GA Medicaid Fee Schedule,42.84,251.1,167.40
Outpatient Medical Services,LAB,87529,"HSV-1 & HSV-2, PCR (VARIOUS)  (MAYO)",300,74.25,63.11,Pays at 85% of Billed charges for outpatient setting,24.67,Pays at 100% of GA Medicaid Fee Schedule,59.42,Pays at 80.03% of Total Billed charges,35.79,Pays at 102% of Medicare OPPS Rate,66.83,Pays at 90% of Total Billed charges,24.67,Pays at 100% of GA Medicaid Fee Schedule,35.09,Pays at 100% of Medicare OPPS Rate,24.67,Pays at 100% of GA Medicaid Fee Schedule,65.34,Pays at 88% of Total Billed charges,25.41,Pays at 103% of GA Medicaid Fee Schedule,24.67,66.83,44.55
Outpatient Medical Services,LAB,87529,HERPES SIMPLEX (PCR)  CSF (MAYO),300,79.5,67.58,Pays at 85% of Billed charges for outpatient setting,24.67,Pays at 100% of GA Medicaid Fee Schedule,63.62,Pays at 80.03% of Total Billed charges,35.79,Pays at 102% of Medicare OPPS Rate,71.55,Pays at 90% of Total Billed charges,24.67,Pays at 100% of GA Medicaid Fee Schedule,35.09,Pays at 100% of Medicare OPPS Rate,24.67,Pays at 100% of GA Medicaid Fee Schedule,69.96,Pays at 88% of Total Billed charges,25.41,Pays at 103% of GA Medicaid Fee Schedule,24.67,71.55,47.70
Outpatient Medical Services,LAB,87529,HERPES SIMPLEX (PCR)  (MAYO),300,79.5,67.58,Pays at 85% of Billed charges for outpatient setting,24.67,Pays at 100% of GA Medicaid Fee Schedule,63.62,Pays at 80.03% of Total Billed charges,35.79,Pays at 102% of Medicare OPPS Rate,71.55,Pays at 90% of Total Billed charges,24.67,Pays at 100% of GA Medicaid Fee Schedule,35.09,Pays at 100% of Medicare OPPS Rate,24.67,Pays at 100% of GA Medicaid Fee Schedule,69.96,Pays at 88% of Total Billed charges,25.41,Pays at 103% of GA Medicaid Fee Schedule,24.67,71.55,47.70
Outpatient Medical Services,LAB,87529,HERPES SIMPLEX (PCR) GYN  (MAYO),300,82.5,70.13,Pays at 85% of Billed charges for outpatient setting,24.67,Pays at 100% of GA Medicaid Fee Schedule,66.02,Pays at 80.03% of Total Billed charges,35.79,Pays at 102% of Medicare OPPS Rate,74.25,Pays at 90% of Total Billed charges,24.67,Pays at 100% of GA Medicaid Fee Schedule,35.09,Pays at 100% of Medicare OPPS Rate,24.67,Pays at 100% of GA Medicaid Fee Schedule,72.6,Pays at 88% of Total Billed charges,25.41,Pays at 103% of GA Medicaid Fee Schedule,24.67,74.25,49.50
Outpatient Medical Services,LAB,87529,HSV MOLECULAR DETECTION PCR  (MAYO),300,102.5,87.13,Pays at 85% of Billed charges for outpatient setting,24.67,Pays at 100% of GA Medicaid Fee Schedule,82.03,Pays at 80.03% of Total Billed charges,35.79,Pays at 102% of Medicare OPPS Rate,92.25,Pays at 90% of Total Billed charges,24.67,Pays at 100% of GA Medicaid Fee Schedule,35.09,Pays at 100% of Medicare OPPS Rate,24.67,Pays at 100% of GA Medicaid Fee Schedule,90.2,Pays at 88% of Total Billed charges,25.41,Pays at 103% of GA Medicaid Fee Schedule,24.67,92.25,61.50
Outpatient Medical Services,LAB,87529,"HSV, CSF & OTHER BODY FLUID, PCR  (MAYO)",300,111.75,94.99,Pays at 85% of Billed charges for outpatient setting,24.67,Pays at 100% of GA Medicaid Fee Schedule,89.43,Pays at 80.03% of Total Billed charges,35.79,Pays at 102% of Medicare OPPS Rate,100.58,Pays at 90% of Total Billed charges,24.67,Pays at 100% of GA Medicaid Fee Schedule,35.09,Pays at 100% of Medicare OPPS Rate,24.67,Pays at 100% of GA Medicaid Fee Schedule,98.34,Pays at 88% of Total Billed charges,25.41,Pays at 103% of GA Medicaid Fee Schedule,24.67,100.58,67.05
Outpatient Medical Services,LAB,87529,HSV 1 & 2 QUALITATIVE PCR BLOOD  (MAYO),300,343.25,291.76,Pays at 85% of Billed charges for outpatient setting,24.67,Pays at 100% of GA Medicaid Fee Schedule,274.7,Pays at 80.03% of Total Billed charges,35.79,Pays at 102% of Medicare OPPS Rate,308.93,Pays at 90% of Total Billed charges,24.67,Pays at 100% of GA Medicaid Fee Schedule,35.09,Pays at 100% of Medicare OPPS Rate,24.67,Pays at 100% of GA Medicaid Fee Schedule,302.06,Pays at 88% of Total Billed charges,25.41,Pays at 103% of GA Medicaid Fee Schedule,24.67,308.93,205.95
Outpatient Medical Services,LAB,87535,"HIV-1 DNA, QL, PCR  (MAYO)",300,123.25,104.76,Pays at 85% of Billed charges for outpatient setting,24.67,Pays at 100% of GA Medicaid Fee Schedule,98.64,Pays at 80.03% of Total Billed charges,35.79,Pays at 102% of Medicare OPPS Rate,110.93,Pays at 90% of Total Billed charges,24.67,Pays at 100% of GA Medicaid Fee Schedule,35.09,Pays at 100% of Medicare OPPS Rate,24.67,Pays at 100% of GA Medicaid Fee Schedule,108.46,Pays at 88% of Total Billed charges,25.41,Pays at 103% of GA Medicaid Fee Schedule,24.67,110.93,73.95
Outpatient Medical Services,LAB,87535,HIV-1 DNA & RNA QL PCR  (MAYO),300,479.25,407.36,Pays at 85% of Billed charges for outpatient setting,24.67,Pays at 100% of GA Medicaid Fee Schedule,383.54,Pays at 80.03% of Total Billed charges,35.79,Pays at 102% of Medicare OPPS Rate,431.33,Pays at 90% of Total Billed charges,24.67,Pays at 100% of GA Medicaid Fee Schedule,35.09,Pays at 100% of Medicare OPPS Rate,24.67,Pays at 100% of GA Medicaid Fee Schedule,421.74,Pays at 88% of Total Billed charges,25.41,Pays at 103% of GA Medicaid Fee Schedule,24.67,431.33,287.55
Outpatient Medical Services,LAB,87536,"HIV-1 DNA, QUANT, PLASMA (MAYO)",300,134.86,114.63,Pays at 85% of Billed charges for outpatient setting,56.5,Pays at 100% of GA Medicaid Fee Schedule,107.93,Pays at 80.03% of Total Billed charges,86.8,Pays at 102% of Medicare OPPS Rate,121.37,Pays at 90% of Total Billed charges,56.5,Pays at 100% of GA Medicaid Fee Schedule,85.1,Pays at 100% of Medicare OPPS Rate,56.5,Pays at 100% of GA Medicaid Fee Schedule,118.68,Pays at 88% of Total Billed charges,58.2,Pays at 103% of GA Medicaid Fee Schedule,56.5,121.37,80.92
Outpatient Medical Services,LAB,87536,HIV-1 RNA/PCR  (MAYO),300,272.25,231.41,Pays at 85% of Billed charges for outpatient setting,56.5,Pays at 100% of GA Medicaid Fee Schedule,217.88,Pays at 80.03% of Total Billed charges,86.8,Pays at 102% of Medicare OPPS Rate,245.03,Pays at 90% of Total Billed charges,56.5,Pays at 100% of GA Medicaid Fee Schedule,85.1,Pays at 100% of Medicare OPPS Rate,56.5,Pays at 100% of GA Medicaid Fee Schedule,239.58,Pays at 88% of Total Billed charges,58.2,Pays at 103% of GA Medicaid Fee Schedule,56.5,245.03,163.35
Outpatient Medical Services,LAB,87536,VIRAL LOAD HIV 1 (MAYO),300,551.75,468.99,Pays at 85% of Billed charges for outpatient setting,56.5,Pays at 100% of GA Medicaid Fee Schedule,441.57,Pays at 80.03% of Total Billed charges,86.8,Pays at 102% of Medicare OPPS Rate,496.58,Pays at 90% of Total Billed charges,56.5,Pays at 100% of GA Medicaid Fee Schedule,85.1,Pays at 100% of Medicare OPPS Rate,56.5,Pays at 100% of GA Medicaid Fee Schedule,485.54,Pays at 88% of Total Billed charges,58.2,Pays at 103% of GA Medicaid Fee Schedule,56.5,496.58,331.05
Outpatient Medical Services,LAB,87556,AMPLIFIED M.TUBERCULOSIS  (MAYO),300,419.25,356.36,Pays at 85% of Billed charges for outpatient setting,134.79,Pays at 32.15% of Total Billed charges,335.53,Pays at 80.03% of Total Billed charges,42.51,Pays at 102% of Medicare OPPS Rate,377.33,Pays at 90% of Total Billed charges,134.79,Pays at 32.15% of Total Billed charges,41.68,Pays at 100% of Medicare OPPS Rate,134.79,Pays at 32.15% of Total Billed charges,368.94,Pays at 88% of Total Billed charges,138.81,Pays at 33.11% of Total Billed charges,41.68,377.33,251.55
Outpatient Medical Services,LAB,87581,MYCOPLASMA PNEUMO PCR (MAYO),300,642.75,546.34,Pays at 85% of Billed charges for outpatient setting,24.67,Pays at 100% of GA Medicaid Fee Schedule,514.39,Pays at 80.03% of Total Billed charges,35.79,Pays at 102% of Medicare OPPS Rate,578.48,Pays at 90% of Total Billed charges,24.67,Pays at 100% of GA Medicaid Fee Schedule,35.09,Pays at 100% of Medicare OPPS Rate,24.67,Pays at 100% of GA Medicaid Fee Schedule,565.62,Pays at 88% of Total Billed charges,25.41,Pays at 103% of GA Medicaid Fee Schedule,24.67,578.48,385.65
Outpatient Medical Services,LAB,87591,Blood test for an STD,300,60.28,51.24,Pays at 85% of Billed charges for outpatient setting,21.42,Pays at 100% of GA Medicaid Fee Schedule,48.24,Pays at 80.03% of Total Billed charges,35.79,Pays at 102% of Medicare OPPS Rate,54.25,Pays at 90% of Total Billed charges,21.42,Pays at 100% of GA Medicaid Fee Schedule,35.09,Pays at 100% of Medicare OPPS Rate,21.42,Pays at 100% of GA Medicaid Fee Schedule,53.05,Pays at 88% of Total Billed charges,22.06,Pays at 103% of GA Medicaid Fee Schedule,21.42,54.25,36.17
Outpatient Medical Services,LAB,87591,Blood test for an STD,300,109.65,93.2,Pays at 85% of Billed charges for outpatient setting,21.42,Pays at 100% of GA Medicaid Fee Schedule,87.75,Pays at 80.03% of Total Billed charges,35.79,Pays at 102% of Medicare OPPS Rate,98.69,Pays at 90% of Total Billed charges,21.42,Pays at 100% of GA Medicaid Fee Schedule,35.09,Pays at 100% of Medicare OPPS Rate,21.42,Pays at 100% of GA Medicaid Fee Schedule,96.49,Pays at 88% of Total Billed charges,22.06,Pays at 103% of GA Medicaid Fee Schedule,21.42,98.69,65.79
Outpatient Medical Services,LAB,87591,Blood test for an STD,300,139.69,118.74,Pays at 85% of Billed charges for outpatient setting,21.42,Pays at 100% of GA Medicaid Fee Schedule,111.79,Pays at 80.03% of Total Billed charges,35.79,Pays at 102% of Medicare OPPS Rate,125.72,Pays at 90% of Total Billed charges,21.42,Pays at 100% of GA Medicaid Fee Schedule,35.09,Pays at 100% of Medicare OPPS Rate,21.42,Pays at 100% of GA Medicaid Fee Schedule,122.93,Pays at 88% of Total Billed charges,22.06,Pays at 103% of GA Medicaid Fee Schedule,21.42,125.72,83.81
Outpatient Medical Services,LAB,87623,ANMED HPV,300,146.88,124.85,Pays at 85% of Billed charges for outpatient setting,18.25,Pays at 100% of GA Medicaid Fee Schedule,117.55,Pays at 80.03% of Total Billed charges,35.79,Pays at 102% of Medicare OPPS Rate,132.19,Pays at 90% of Total Billed charges,18.25,Pays at 100% of GA Medicaid Fee Schedule,35.09,Pays at 100% of Medicare OPPS Rate,18.25,Pays at 100% of GA Medicaid Fee Schedule,129.25,Pays at 88% of Total Billed charges,18.8,Pays at 103% of GA Medicaid Fee Schedule,18.25,132.19,88.13
Outpatient Medical Services,LAB,87624,Detection test for human papillomavirus (hpv),300,97.5,82.88,Pays at 85% of Billed charges for outpatient setting,18.25,Pays at 100% of GA Medicaid Fee Schedule,78.03,Pays at 80.03% of Total Billed charges,35.79,Pays at 102% of Medicare OPPS Rate,87.75,Pays at 90% of Total Billed charges,18.25,Pays at 100% of GA Medicaid Fee Schedule,35.09,Pays at 100% of Medicare OPPS Rate,18.25,Pays at 100% of GA Medicaid Fee Schedule,85.8,Pays at 88% of Total Billed charges,18.8,Pays at 103% of GA Medicaid Fee Schedule,18.25,87.75,58.50
Outpatient Medical Services,LAB,87635,CORONAVIRUS COVID-19 PCR (DSL),300,170.69,145.09,Pays at 85% of Billed charges for outpatient setting,51.31,Pays at 100% of GA Medicaid Fee Schedule,136.6,Pays at 80.03% of Total Billed charges,52.33,Pays at 102% of Medicare OPPS Rate,153.62,Pays at 90% of Total Billed charges,51.31,Pays at 100% of GA Medicaid Fee Schedule,51.31,Pays at 100% of Medicare OPPS Rate,51.31,Pays at 100% of GA Medicaid Fee Schedule,150.21,Pays at 88% of Total Billed charges,52.85,Pays at 103% of GA Medicaid Fee Schedule,51.31,153.62,102.41
Outpatient Medical Services,LAB,87635,CORONAVIRUS COVID-19 PCR (QUEST),300,172.5,146.63,Pays at 85% of Billed charges for outpatient setting,51.31,Pays at 100% of GA Medicaid Fee Schedule,138.05,Pays at 80.03% of Total Billed charges,52.33,Pays at 102% of Medicare OPPS Rate,155.25,Pays at 90% of Total Billed charges,51.31,Pays at 100% of GA Medicaid Fee Schedule,51.31,Pays at 100% of Medicare OPPS Rate,51.31,Pays at 100% of GA Medicaid Fee Schedule,151.8,Pays at 88% of Total Billed charges,52.85,Pays at 103% of GA Medicaid Fee Schedule,51.31,155.25,103.50
Outpatient Medical Services,LAB,87635,CORONAVIRUS COVID-19 PCR (SCH),300,187.5,159.38,Pays at 85% of Billed charges for outpatient setting,51.31,Pays at 100% of GA Medicaid Fee Schedule,150.06,Pays at 80.03% of Total Billed charges,52.33,Pays at 102% of Medicare OPPS Rate,168.75,Pays at 90% of Total Billed charges,51.31,Pays at 100% of GA Medicaid Fee Schedule,51.31,Pays at 100% of Medicare OPPS Rate,51.31,Pays at 100% of GA Medicaid Fee Schedule,165,Pays at 88% of Total Billed charges,52.85,Pays at 103% of GA Medicaid Fee Schedule,51.31,168.75,112.50
Outpatient Medical Services,LAB,87641,MRSA SCREEN (PCR),300,139.69,118.74,Pays at 85% of Billed charges for outpatient setting,24.67,Pays at 100% of GA Medicaid Fee Schedule,111.79,Pays at 80.03% of Total Billed charges,35.79,Pays at 102% of Medicare OPPS Rate,125.72,Pays at 90% of Total Billed charges,24.67,Pays at 100% of GA Medicaid Fee Schedule,35.09,Pays at 100% of Medicare OPPS Rate,24.67,Pays at 100% of GA Medicaid Fee Schedule,122.93,Pays at 88% of Total Billed charges,25.41,Pays at 103% of GA Medicaid Fee Schedule,24.67,125.72,83.81
Outpatient Medical Services,LAB,87641,MRSA SCREEN (PCR) - OPS,300,139.69,118.74,Pays at 85% of Billed charges for outpatient setting,24.67,Pays at 100% of GA Medicaid Fee Schedule,111.79,Pays at 80.03% of Total Billed charges,35.79,Pays at 102% of Medicare OPPS Rate,125.72,Pays at 90% of Total Billed charges,24.67,Pays at 100% of GA Medicaid Fee Schedule,35.09,Pays at 100% of Medicare OPPS Rate,24.67,Pays at 100% of GA Medicaid Fee Schedule,122.93,Pays at 88% of Total Billed charges,25.41,Pays at 103% of GA Medicaid Fee Schedule,24.67,125.72,83.81
Outpatient Medical Services,LAB,87661,Blood test for an STD,300,146.65,124.65,Pays at 85% of Billed charges for outpatient setting,21.42,Pays at 100% of GA Medicaid Fee Schedule,117.36,Pays at 80.03% of Total Billed charges,35.79,Pays at 102% of Medicare OPPS Rate,131.99,Pays at 90% of Total Billed charges,21.42,Pays at 100% of GA Medicaid Fee Schedule,35.09,Pays at 100% of Medicare OPPS Rate,21.42,Pays at 100% of GA Medicaid Fee Schedule,129.05,Pays at 88% of Total Billed charges,22.06,Pays at 103% of GA Medicaid Fee Schedule,21.42,131.99,87.99
Outpatient Medical Services,LAB,87661,Blood test for an STD,300,204.25,173.61,Pays at 85% of Billed charges for outpatient setting,21.42,Pays at 100% of GA Medicaid Fee Schedule,163.46,Pays at 80.03% of Total Billed charges,35.79,Pays at 102% of Medicare OPPS Rate,183.83,Pays at 90% of Total Billed charges,21.42,Pays at 100% of GA Medicaid Fee Schedule,35.09,Pays at 100% of Medicare OPPS Rate,21.42,Pays at 100% of GA Medicaid Fee Schedule,179.74,Pays at 88% of Total Billed charges,22.06,Pays at 103% of GA Medicaid Fee Schedule,21.42,183.83,122.55
Outpatient Medical Services,LAB,87798,"WEST NILE RNA-PCR, CSF  (MAYO)",300,90.75,77.14,Pays at 85% of Billed charges for outpatient setting,24.67,Pays at 100% of GA Medicaid Fee Schedule,72.63,Pays at 80.03% of Total Billed charges,35.79,Pays at 102% of Medicare OPPS Rate,81.68,Pays at 90% of Total Billed charges,24.67,Pays at 100% of GA Medicaid Fee Schedule,35.09,Pays at 100% of Medicare OPPS Rate,24.67,Pays at 100% of GA Medicaid Fee Schedule,79.86,Pays at 88% of Total Billed charges,25.41,Pays at 103% of GA Medicaid Fee Schedule,24.67,81.68,54.45
Outpatient Medical Services,LAB,87798,VARICELLA ZOSTER (PCR)  (MAYO),300,93.25,79.26,Pays at 85% of Billed charges for outpatient setting,24.67,Pays at 100% of GA Medicaid Fee Schedule,74.63,Pays at 80.03% of Total Billed charges,35.79,Pays at 102% of Medicare OPPS Rate,83.93,Pays at 90% of Total Billed charges,24.67,Pays at 100% of GA Medicaid Fee Schedule,35.09,Pays at 100% of Medicare OPPS Rate,24.67,Pays at 100% of GA Medicaid Fee Schedule,82.06,Pays at 88% of Total Billed charges,25.41,Pays at 103% of GA Medicaid Fee Schedule,24.67,83.93,55.95
Outpatient Medical Services,LAB,87798,"BORDETELLA PERTUSSIS, PCR  (MAYO)",300,111.75,94.99,Pays at 85% of Billed charges for outpatient setting,24.67,Pays at 100% of GA Medicaid Fee Schedule,89.43,Pays at 80.03% of Total Billed charges,35.79,Pays at 102% of Medicare OPPS Rate,100.58,Pays at 90% of Total Billed charges,24.67,Pays at 100% of GA Medicaid Fee Schedule,35.09,Pays at 100% of Medicare OPPS Rate,24.67,Pays at 100% of GA Medicaid Fee Schedule,98.34,Pays at 88% of Total Billed charges,25.41,Pays at 103% of GA Medicaid Fee Schedule,24.67,100.58,67.05
Outpatient Medical Services,LAB,87798,"BORDETELLA PARAPERTUSSIS, PCR  (MAYO)",300,111.75,94.99,Pays at 85% of Billed charges for outpatient setting,24.67,Pays at 100% of GA Medicaid Fee Schedule,89.43,Pays at 80.03% of Total Billed charges,35.79,Pays at 102% of Medicare OPPS Rate,100.58,Pays at 90% of Total Billed charges,24.67,Pays at 100% of GA Medicaid Fee Schedule,35.09,Pays at 100% of Medicare OPPS Rate,24.67,Pays at 100% of GA Medicaid Fee Schedule,98.34,Pays at 88% of Total Billed charges,25.41,Pays at 103% of GA Medicaid Fee Schedule,24.67,100.58,67.05
Outpatient Medical Services,LAB,87798,"..ENTEROVIRUS, CSF PCR  (MAYO)",300,124.2,105.57,Pays at 85% of Billed charges for outpatient setting,24.67,Pays at 100% of GA Medicaid Fee Schedule,99.4,Pays at 80.03% of Total Billed charges,35.79,Pays at 102% of Medicare OPPS Rate,111.78,Pays at 90% of Total Billed charges,24.67,Pays at 100% of GA Medicaid Fee Schedule,35.09,Pays at 100% of Medicare OPPS Rate,24.67,Pays at 100% of GA Medicaid Fee Schedule,109.3,Pays at 88% of Total Billed charges,25.41,Pays at 103% of GA Medicaid Fee Schedule,24.67,111.78,74.52
Outpatient Medical Services,LAB,87798,"WEST NILE VIRUS, CSF PCR  (MAYO)",300,127,107.95,Pays at 85% of Billed charges for outpatient setting,24.67,Pays at 100% of GA Medicaid Fee Schedule,101.64,Pays at 80.03% of Total Billed charges,35.79,Pays at 102% of Medicare OPPS Rate,114.3,Pays at 90% of Total Billed charges,24.67,Pays at 100% of GA Medicaid Fee Schedule,35.09,Pays at 100% of Medicare OPPS Rate,24.67,Pays at 100% of GA Medicaid Fee Schedule,111.76,Pays at 88% of Total Billed charges,25.41,Pays at 103% of GA Medicaid Fee Schedule,24.67,114.3,76.20
Outpatient Medical Services,LAB,87798,"ADENOVIRUS, DNA-PCR EACH  (MAYO)",300,143.5,121.98,Pays at 85% of Billed charges for outpatient setting,24.67,Pays at 100% of GA Medicaid Fee Schedule,114.84,Pays at 80.03% of Total Billed charges,35.79,Pays at 102% of Medicare OPPS Rate,129.15,Pays at 90% of Total Billed charges,24.67,Pays at 100% of GA Medicaid Fee Schedule,35.09,Pays at 100% of Medicare OPPS Rate,24.67,Pays at 100% of GA Medicaid Fee Schedule,126.28,Pays at 88% of Total Billed charges,25.41,Pays at 103% of GA Medicaid Fee Schedule,24.67,129.15,86.10
Outpatient Medical Services,LAB,87798,"ADENOVIRUS, CSF  (MAYO)",300,143.5,121.98,Pays at 85% of Billed charges for outpatient setting,24.67,Pays at 100% of GA Medicaid Fee Schedule,114.84,Pays at 80.03% of Total Billed charges,35.79,Pays at 102% of Medicare OPPS Rate,129.15,Pays at 90% of Total Billed charges,24.67,Pays at 100% of GA Medicaid Fee Schedule,35.09,Pays at 100% of Medicare OPPS Rate,24.67,Pays at 100% of GA Medicaid Fee Schedule,126.28,Pays at 88% of Total Billed charges,25.41,Pays at 103% of GA Medicaid Fee Schedule,24.67,129.15,86.10
Outpatient Medical Services,LAB,87798,"PARVOVIRUS, PCR, IGM  (MAYO)",300,186.25,158.31,Pays at 85% of Billed charges for outpatient setting,24.67,Pays at 100% of GA Medicaid Fee Schedule,149.06,Pays at 80.03% of Total Billed charges,35.79,Pays at 102% of Medicare OPPS Rate,167.63,Pays at 90% of Total Billed charges,24.67,Pays at 100% of GA Medicaid Fee Schedule,35.09,Pays at 100% of Medicare OPPS Rate,24.67,Pays at 100% of GA Medicaid Fee Schedule,163.9,Pays at 88% of Total Billed charges,25.41,Pays at 103% of GA Medicaid Fee Schedule,24.67,167.63,111.75
Outpatient Medical Services,LAB,87798,PNEUMOCYSTIS JIROVECKI (CARINII) PCR,300,249,211.65,Pays at 85% of Billed charges for outpatient setting,24.67,Pays at 100% of GA Medicaid Fee Schedule,199.27,Pays at 80.03% of Total Billed charges,35.79,Pays at 102% of Medicare OPPS Rate,224.1,Pays at 90% of Total Billed charges,24.67,Pays at 100% of GA Medicaid Fee Schedule,35.09,Pays at 100% of Medicare OPPS Rate,24.67,Pays at 100% of GA Medicaid Fee Schedule,219.12,Pays at 88% of Total Billed charges,25.41,Pays at 103% of GA Medicaid Fee Schedule,24.67,224.1,149.40
Outpatient Medical Services,LAB,87798,KPC - PCR  (MAYO).,300,308.25,262.01,Pays at 85% of Billed charges for outpatient setting,24.67,Pays at 100% of GA Medicaid Fee Schedule,246.69,Pays at 80.03% of Total Billed charges,35.79,Pays at 102% of Medicare OPPS Rate,277.43,Pays at 90% of Total Billed charges,24.67,Pays at 100% of GA Medicaid Fee Schedule,35.09,Pays at 100% of Medicare OPPS Rate,24.67,Pays at 100% of GA Medicaid Fee Schedule,271.26,Pays at 88% of Total Billed charges,25.41,Pays at 103% of GA Medicaid Fee Schedule,24.67,277.43,184.95
Outpatient Medical Services,LAB,87798,NDM - PCR  (MAYO).,300,308.25,262.01,Pays at 85% of Billed charges for outpatient setting,24.67,Pays at 100% of GA Medicaid Fee Schedule,246.69,Pays at 80.03% of Total Billed charges,35.79,Pays at 102% of Medicare OPPS Rate,277.43,Pays at 90% of Total Billed charges,24.67,Pays at 100% of GA Medicaid Fee Schedule,35.09,Pays at 100% of Medicare OPPS Rate,24.67,Pays at 100% of GA Medicaid Fee Schedule,271.26,Pays at 88% of Total Billed charges,25.41,Pays at 103% of GA Medicaid Fee Schedule,24.67,277.43,184.95
Outpatient Medical Services,LAB,87798,"MALARIA DETECTION, PCR  (MAYO)",300,333.33,283.33,Pays at 85% of Billed charges for outpatient setting,24.67,Pays at 100% of GA Medicaid Fee Schedule,266.76,Pays at 80.03% of Total Billed charges,35.79,Pays at 102% of Medicare OPPS Rate,300,Pays at 90% of Total Billed charges,24.67,Pays at 100% of GA Medicaid Fee Schedule,35.09,Pays at 100% of Medicare OPPS Rate,24.67,Pays at 100% of GA Medicaid Fee Schedule,293.33,Pays at 88% of Total Billed charges,25.41,Pays at 103% of GA Medicaid Fee Schedule,24.67,300,200.00
Outpatient Medical Services,LAB,87798,NORWALK LIKE VIRUS PCR (MAYO),300,381,323.85,Pays at 85% of Billed charges for outpatient setting,24.67,Pays at 100% of GA Medicaid Fee Schedule,304.91,Pays at 80.03% of Total Billed charges,35.79,Pays at 102% of Medicare OPPS Rate,342.9,Pays at 90% of Total Billed charges,24.67,Pays at 100% of GA Medicaid Fee Schedule,35.09,Pays at 100% of Medicare OPPS Rate,24.67,Pays at 100% of GA Medicaid Fee Schedule,335.28,Pays at 88% of Total Billed charges,25.41,Pays at 103% of GA Medicaid Fee Schedule,24.67,342.9,228.60
Outpatient Medical Services,LAB,87798,VARICELLA ZOSTER DNA QT PCR  (MAYO),300,391.5,332.78,Pays at 85% of Billed charges for outpatient setting,24.67,Pays at 100% of GA Medicaid Fee Schedule,313.32,Pays at 80.03% of Total Billed charges,35.79,Pays at 102% of Medicare OPPS Rate,352.35,Pays at 90% of Total Billed charges,24.67,Pays at 100% of GA Medicaid Fee Schedule,35.09,Pays at 100% of Medicare OPPS Rate,24.67,Pays at 100% of GA Medicaid Fee Schedule,344.52,Pays at 88% of Total Billed charges,25.41,Pays at 103% of GA Medicaid Fee Schedule,24.67,352.35,234.90
Outpatient Medical Services,LAB,87798,"EBV, PCR QT EACH  (MAYO)",300,471.25,400.56,Pays at 85% of Billed charges for outpatient setting,24.67,Pays at 100% of GA Medicaid Fee Schedule,377.14,Pays at 80.03% of Total Billed charges,35.79,Pays at 102% of Medicare OPPS Rate,424.13,Pays at 90% of Total Billed charges,24.67,Pays at 100% of GA Medicaid Fee Schedule,35.09,Pays at 100% of Medicare OPPS Rate,24.67,Pays at 100% of GA Medicaid Fee Schedule,414.7,Pays at 88% of Total Billed charges,25.41,Pays at 103% of GA Medicaid Fee Schedule,24.67,424.13,282.75
Outpatient Medical Services,LAB,87798,CHIKUNGUNYA RNA QL PCR  (MAYO),300,555.5,472.18,Pays at 85% of Billed charges for outpatient setting,24.67,Pays at 100% of GA Medicaid Fee Schedule,444.57,Pays at 80.03% of Total Billed charges,35.79,Pays at 102% of Medicare OPPS Rate,499.95,Pays at 90% of Total Billed charges,24.67,Pays at 100% of GA Medicaid Fee Schedule,35.09,Pays at 100% of Medicare OPPS Rate,24.67,Pays at 100% of GA Medicaid Fee Schedule,488.84,Pays at 88% of Total Billed charges,25.41,Pays at 103% of GA Medicaid Fee Schedule,24.67,499.95,333.30
Outpatient Medical Services,LAB,87799,"BK VIRUS, PCR  (MAYO)",300,164.25,139.61,Pays at 85% of Billed charges for outpatient setting,52.81,Pays at 32.15% of Total Billed charges,131.45,Pays at 80.03% of Total Billed charges,43.69,Pays at 102% of Medicare OPPS Rate,147.83,Pays at 90% of Total Billed charges,52.81,Pays at 32.15% of Total Billed charges,42.84,Pays at 100% of Medicare OPPS Rate,52.81,Pays at 32.15% of Total Billed charges,144.54,Pays at 88% of Total Billed charges,54.38,Pays at 33.11% of Total Billed charges,42.84,147.83,98.55
Outpatient Medical Services,LAB,87799,BK VIRUS URINE (PCR)  (MAYO),300,219.25,186.36,Pays at 85% of Billed charges for outpatient setting,70.49,Pays at 32.15% of Total Billed charges,175.47,Pays at 80.03% of Total Billed charges,43.69,Pays at 102% of Medicare OPPS Rate,197.33,Pays at 90% of Total Billed charges,70.49,Pays at 32.15% of Total Billed charges,42.84,Pays at 100% of Medicare OPPS Rate,70.49,Pays at 32.15% of Total Billed charges,192.94,Pays at 88% of Total Billed charges,72.59,Pays at 33.11% of Total Billed charges,42.84,197.33,131.55
Outpatient Medical Services,LAB,87799,"EBV, MOLECULAR DETECTION QT PCR  (MAYO)",300,354.63,301.44,Pays at 85% of Billed charges for outpatient setting,114.01,Pays at 32.15% of Total Billed charges,283.81,Pays at 80.03% of Total Billed charges,43.69,Pays at 102% of Medicare OPPS Rate,319.17,Pays at 90% of Total Billed charges,114.01,Pays at 32.15% of Total Billed charges,42.84,Pays at 100% of Medicare OPPS Rate,114.01,Pays at 32.15% of Total Billed charges,312.07,Pays at 88% of Total Billed charges,117.42,Pays at 33.11% of Total Billed charges,42.84,319.17,212.78
Outpatient Medical Services,LAB,87799,"JC VIRUS DNA, QT PCR  (MAYO)",300,468,397.8,Pays at 85% of Billed charges for outpatient setting,150.46,Pays at 32.15% of Total Billed charges,374.54,Pays at 80.03% of Total Billed charges,43.69,Pays at 102% of Medicare OPPS Rate,421.2,Pays at 90% of Total Billed charges,150.46,Pays at 32.15% of Total Billed charges,42.84,Pays at 100% of Medicare OPPS Rate,150.46,Pays at 32.15% of Total Billed charges,411.84,Pays at 88% of Total Billed charges,154.95,Pays at 33.11% of Total Billed charges,42.84,421.2,280.80
Outpatient Medical Services,LAB,87801,Blood test to determine genetic material of certain infectious agents,300,459.5,390.58,Pays at 85% of Billed charges for outpatient setting,49.34,Pays at 100% of GA Medicaid Fee Schedule,367.74,Pays at 80.03% of Total Billed charges,71.6,Pays at 102% of Medicare OPPS Rate,413.55,Pays at 90% of Total Billed charges,49.34,Pays at 100% of GA Medicaid Fee Schedule,70.2,Pays at 100% of Medicare OPPS Rate,49.34,Pays at 100% of GA Medicaid Fee Schedule,404.36,Pays at 88% of Total Billed charges,50.82,Pays at 103% of GA Medicaid Fee Schedule,49.34,413.55,275.70
Outpatient Medical Services,LAB,87880,Test for strep A,300,40.8,34.68,Pays at 85% of Billed charges for outpatient setting,15.08,Pays at 100% of GA Medicaid Fee Schedule,32.65,Pays at 80.03% of Total Billed charges,16.86,Pays at 102% of Medicare OPPS Rate,36.72,Pays at 90% of Total Billed charges,15.08,Pays at 100% of GA Medicaid Fee Schedule,16.53,Pays at 100% of Medicare OPPS Rate,15.08,Pays at 100% of GA Medicaid Fee Schedule,35.9,Pays at 88% of Total Billed charges,15.53,Pays at 103% of GA Medicaid Fee Schedule,15.08,36.72,24.48
Outpatient Medical Services,LAB,87899,SHIGA TOXIN,300,34.03,28.93,Pays at 85% of Billed charges for outpatient setting,15.08,Pays at 100% of GA Medicaid Fee Schedule,27.23,Pays at 80.03% of Total Billed charges,16.39,Pays at 102% of Medicare OPPS Rate,30.63,Pays at 90% of Total Billed charges,15.08,Pays at 100% of GA Medicaid Fee Schedule,16.07,Pays at 100% of Medicare OPPS Rate,15.08,Pays at 100% of GA Medicaid Fee Schedule,29.95,Pays at 88% of Total Billed charges,15.53,Pays at 103% of GA Medicaid Fee Schedule,15.08,30.63,20.42
Outpatient Medical Services,LAB,87899,"LEGIONELLA  AG, URINE  (MAYO)",300,65.25,55.46,Pays at 85% of Billed charges for outpatient setting,15.08,Pays at 100% of GA Medicaid Fee Schedule,52.22,Pays at 80.03% of Total Billed charges,16.39,Pays at 102% of Medicare OPPS Rate,58.73,Pays at 90% of Total Billed charges,15.08,Pays at 100% of GA Medicaid Fee Schedule,16.07,Pays at 100% of Medicare OPPS Rate,15.08,Pays at 100% of GA Medicaid Fee Schedule,57.42,Pays at 88% of Total Billed charges,15.53,Pays at 103% of GA Medicaid Fee Schedule,15.08,58.73,39.15
Outpatient Medical Services,LAB,87899,"CRYPTOCOCCUS AG, CSF  (MAYO)",300,69.25,58.86,Pays at 85% of Billed charges for outpatient setting,15.08,Pays at 100% of GA Medicaid Fee Schedule,55.42,Pays at 80.03% of Total Billed charges,16.39,Pays at 102% of Medicare OPPS Rate,62.33,Pays at 90% of Total Billed charges,15.08,Pays at 100% of GA Medicaid Fee Schedule,16.07,Pays at 100% of Medicare OPPS Rate,15.08,Pays at 100% of GA Medicaid Fee Schedule,60.94,Pays at 88% of Total Billed charges,15.53,Pays at 103% of GA Medicaid Fee Schedule,15.08,62.33,41.55
Outpatient Medical Services,LAB,87899,STREPTOCOCCUS PNEUMONIAE AG URIN  (MAYO),300,96.25,81.81,Pays at 85% of Billed charges for outpatient setting,15.08,Pays at 100% of GA Medicaid Fee Schedule,77.03,Pays at 80.03% of Total Billed charges,16.39,Pays at 102% of Medicare OPPS Rate,86.63,Pays at 90% of Total Billed charges,15.08,Pays at 100% of GA Medicaid Fee Schedule,16.07,Pays at 100% of Medicare OPPS Rate,15.08,Pays at 100% of GA Medicaid Fee Schedule,84.7,Pays at 88% of Total Billed charges,15.53,Pays at 103% of GA Medicaid Fee Schedule,15.08,86.63,57.75
Outpatient Medical Services,LAB,87899,"CRYPTOCOCCUS AG, SERUM  (MAYO)",300,128.25,109.01,Pays at 85% of Billed charges for outpatient setting,15.08,Pays at 100% of GA Medicaid Fee Schedule,102.64,Pays at 80.03% of Total Billed charges,16.39,Pays at 102% of Medicare OPPS Rate,115.43,Pays at 90% of Total Billed charges,15.08,Pays at 100% of GA Medicaid Fee Schedule,16.07,Pays at 100% of Medicare OPPS Rate,15.08,Pays at 100% of GA Medicaid Fee Schedule,112.86,Pays at 88% of Total Billed charges,15.53,Pays at 103% of GA Medicaid Fee Schedule,15.08,115.43,76.95
Outpatient Medical Services,LAB,87899,"CRYPTOCOCCUS AG TITER, LFA SERUM  (MAYO)",300,339.5,288.58,Pays at 85% of Billed charges for outpatient setting,15.08,Pays at 100% of GA Medicaid Fee Schedule,271.7,Pays at 80.03% of Total Billed charges,16.39,Pays at 102% of Medicare OPPS Rate,305.55,Pays at 90% of Total Billed charges,15.08,Pays at 100% of GA Medicaid Fee Schedule,16.07,Pays at 100% of Medicare OPPS Rate,15.08,Pays at 100% of GA Medicaid Fee Schedule,298.76,Pays at 88% of Total Billed charges,15.53,Pays at 103% of GA Medicaid Fee Schedule,15.08,305.55,203.70
Outpatient Medical Services,LAB,87901,HIV GENOTYPE  (MAYO),300,1005,854.25,Pays at 85% of Billed charges for outpatient setting,109.67,Pays at 100% of GA Medicaid Fee Schedule,804.3,Pays at 80.03% of Total Billed charges,262.59,Pays at 102% of Medicare OPPS Rate,904.5,Pays at 90% of Total Billed charges,109.67,Pays at 100% of GA Medicaid Fee Schedule,257.45,Pays at 100% of Medicare OPPS Rate,109.67,Pays at 100% of GA Medicaid Fee Schedule,884.4,Pays at 88% of Total Billed charges,112.96,Pays at 103% of GA Medicaid Fee Schedule,109.67,904.5,603.00
Outpatient Medical Services,LAB,87902,HEPATITIS C VIRUS GENOTYPING  (MAYO),300,822.75,699.34,Pays at 85% of Billed charges for outpatient setting,109.67,Pays at 100% of GA Medicaid Fee Schedule,658.45,Pays at 80.03% of Total Billed charges,262.59,Pays at 102% of Medicare OPPS Rate,740.48,Pays at 90% of Total Billed charges,109.67,Pays at 100% of GA Medicaid Fee Schedule,257.45,Pays at 100% of Medicare OPPS Rate,109.67,Pays at 100% of GA Medicaid Fee Schedule,724.02,Pays at 88% of Total Billed charges,112.96,Pays at 103% of GA Medicaid Fee Schedule,109.67,740.48,493.65
Outpatient Medical Services,LAB,88104,"EXTRAGENITAL CYTOLOGY( FLUIDS,BRUSHINGS)",310,138.75,117.94,Pays at 85% of Billed charges for outpatient setting,42.68,Pays at 100% of GA Medicaid Fee Schedule,111.04,Pays at 80.03% of Total Billed charges,32.54,Pays at 102% of Medicare OPPS Rate,124.88,Pays at 90% of Total Billed charges,42.68,Pays at 100% of GA Medicaid Fee Schedule,31.91,Pays at 100% of Medicare OPPS Rate,42.68,Pays at 100% of GA Medicaid Fee Schedule,122.1,Pays at 88% of Total Billed charges,43.96,Pays at 103% of GA Medicaid Fee Schedule,31.91,124.88,83.25
Outpatient Medical Services,LAB,88104,NON-GYN PREP TECHNICAL FEE,310,156.25,132.81,Pays at 85% of Billed charges for outpatient setting,42.68,Pays at 100% of GA Medicaid Fee Schedule,125.05,Pays at 80.03% of Total Billed charges,32.54,Pays at 102% of Medicare OPPS Rate,140.63,Pays at 90% of Total Billed charges,42.68,Pays at 100% of GA Medicaid Fee Schedule,31.91,Pays at 100% of Medicare OPPS Rate,42.68,Pays at 100% of GA Medicaid Fee Schedule,137.5,Pays at 88% of Total Billed charges,43.96,Pays at 103% of GA Medicaid Fee Schedule,31.91,140.63,93.75
Outpatient Medical Services,LAB,88108,CYTO-SPIN SLIDES,310,82.75,70.34,Pays at 85% of Billed charges for outpatient setting,45.74,Pays at 100% of GA Medicaid Fee Schedule,66.22,Pays at 80.03% of Total Billed charges,32.54,Pays at 102% of Medicare OPPS Rate,74.48,Pays at 90% of Total Billed charges,45.74,Pays at 100% of GA Medicaid Fee Schedule,31.91,Pays at 100% of Medicare OPPS Rate,45.74,Pays at 100% of GA Medicaid Fee Schedule,72.82,Pays at 88% of Total Billed charges,47.11,Pays at 103% of GA Medicaid Fee Schedule,31.91,74.48,49.65
Outpatient Medical Services,LAB,88112,Urine test,310,258.5,219.73,Pays at 85% of Billed charges for outpatient setting,106.19,Pays at 100% of GA Medicaid Fee Schedule,206.88,Pays at 80.03% of Total Billed charges,48.06,Pays at 102% of Medicare OPPS Rate,232.65,Pays at 90% of Total Billed charges,106.19,Pays at 100% of GA Medicaid Fee Schedule,47.12,Pays at 100% of Medicare OPPS Rate,106.19,Pays at 100% of GA Medicaid Fee Schedule,227.48,Pays at 88% of Total Billed charges,109.38,Pays at 103% of GA Medicaid Fee Schedule,47.12,232.65,155.10
Outpatient Medical Services,LAB,88141,Cervical cancer screening test with interpretation,300,144.25,122.61,Pays at 85% of Billed charges for outpatient setting,23.78,Pays at 100% of GA Medicaid Fee Schedule,115.44,Pays at 80.03% of Total Billed charges,NA,Not Applicable,129.83,Pays at 90% of Total Billed charges,23.78,Pays at 100% of GA Medicaid Fee Schedule,NA,Not Applicable,23.78,Pays at 100% of GA Medicaid Fee Schedule,126.94,Pays at 88% of Total Billed charges,24.49,Pays at 103% of GA Medicaid Fee Schedule,23.78,129.83,86.55
Outpatient Medical Services,LAB,88141,Cervical cancer screening test with interpretation,300,144.25,122.61,Pays at 85% of Billed charges for outpatient setting,23.78,Pays at 100% of GA Medicaid Fee Schedule,115.44,Pays at 80.03% of Total Billed charges,NA,Not Applicable,129.83,Pays at 90% of Total Billed charges,23.78,Pays at 100% of GA Medicaid Fee Schedule,NA,Not Applicable,23.78,Pays at 100% of GA Medicaid Fee Schedule,126.94,Pays at 88% of Total Billed charges,24.49,Pays at 103% of GA Medicaid Fee Schedule,23.78,129.83,86.55
Outpatient Medical Services,LAB,88142,PAP smear,300,85.94,73.05,Pays at 85% of Billed charges for outpatient setting,25.48,Pays at 100% of GA Medicaid Fee Schedule,68.78,Pays at 80.03% of Total Billed charges,20.66,Pays at 102% of Medicare OPPS Rate,77.35,Pays at 90% of Total Billed charges,25.48,Pays at 100% of GA Medicaid Fee Schedule,20.26,Pays at 100% of Medicare OPPS Rate,25.48,Pays at 100% of GA Medicaid Fee Schedule,75.63,Pays at 88% of Total Billed charges,26.24,Pays at 103% of GA Medicaid Fee Schedule,20.26,77.35,51.56
Outpatient Medical Services,LAB,88142,PAP smear,300,117.5,99.88,Pays at 85% of Billed charges for outpatient setting,25.48,Pays at 100% of GA Medicaid Fee Schedule,94.04,Pays at 80.03% of Total Billed charges,20.66,Pays at 102% of Medicare OPPS Rate,105.75,Pays at 90% of Total Billed charges,25.48,Pays at 100% of GA Medicaid Fee Schedule,20.26,Pays at 100% of Medicare OPPS Rate,25.48,Pays at 100% of GA Medicaid Fee Schedule,103.4,Pays at 88% of Total Billed charges,26.24,Pays at 103% of GA Medicaid Fee Schedule,20.26,105.75,70.50
Outpatient Medical Services,LAB,88160,BUCCAL SMEAR (MAYO),310,702.25,596.91,Pays at 85% of Billed charges for outpatient setting,46.13,Pays at 100% of GA Medicaid Fee Schedule,562.01,Pays at 80.03% of Total Billed charges,23.92,Pays at 102% of Medicare OPPS Rate,632.03,Pays at 90% of Total Billed charges,46.13,Pays at 100% of GA Medicaid Fee Schedule,23.46,Pays at 100% of Medicare OPPS Rate,46.13,Pays at 100% of GA Medicaid Fee Schedule,617.98,Pays at 88% of Total Billed charges,47.51,Pays at 103% of GA Medicaid Fee Schedule,23.46,632.03,421.35
Outpatient Medical Services,LAB,88164,PAP SMEAR ROUTINE,311,41.75,35.49,Pays at 85% of Billed charges for outpatient setting,13.28,Pays at 100% of GA Medicaid Fee Schedule,33.41,Pays at 80.03% of Total Billed charges,17.65,Pays at 102% of Medicare OPPS Rate,37.58,Pays at 90% of Total Billed charges,13.28,Pays at 100% of GA Medicaid Fee Schedule,17.3,Pays at 100% of Medicare OPPS Rate,13.28,Pays at 100% of GA Medicaid Fee Schedule,36.74,Pays at 88% of Total Billed charges,13.68,Pays at 103% of GA Medicaid Fee Schedule,13.28,37.58,25.05
Outpatient Medical Services,LAB,88172,FINE NEEDLE ASPIRATION TECH FEE,310,334.25,284.11,Pays at 85% of Billed charges for outpatient setting,56.58,Pays at 100% of GA Medicaid Fee Schedule,267.5,Pays at 80.03% of Total Billed charges,150.75,Pays at 102% of Medicare OPPS Rate,300.83,Pays at 90% of Total Billed charges,56.58,Pays at 100% of GA Medicaid Fee Schedule,147.8,Pays at 100% of Medicare OPPS Rate,56.58,Pays at 100% of GA Medicaid Fee Schedule,294.14,Pays at 88% of Total Billed charges,58.28,Pays at 103% of GA Medicaid Fee Schedule,56.58,300.83,200.55
Outpatient Medical Services,LAB,88173,FINE NEEDLE ASPIRATION,310,99.25,84.36,Pays at 85% of Billed charges for outpatient setting,91.58,Pays at 100% of GA Medicaid Fee Schedule,79.43,Pays at 80.03% of Total Billed charges,48.06,Pays at 102% of Medicare OPPS Rate,89.33,Pays at 90% of Total Billed charges,91.58,Pays at 100% of GA Medicaid Fee Schedule,47.12,Pays at 100% of Medicare OPPS Rate,91.58,Pays at 100% of GA Medicaid Fee Schedule,87.34,Pays at 88% of Total Billed charges,94.33,Pays at 103% of GA Medicaid Fee Schedule,47.12,94.33,59.55
Outpatient Medical Services,LAB,88184,LEUKO ADHESION DEFICIENCY PANEL  (MAYO),300,112.75,95.84,Pays at 85% of Billed charges for outpatient setting,46.1,Pays at 100% of GA Medicaid Fee Schedule,90.23,Pays at 80.03% of Total Billed charges,310.72,Pays at 102% of Medicare OPPS Rate,101.48,Pays at 90% of Total Billed charges,46.1,Pays at 100% of GA Medicaid Fee Schedule,304.63,Pays at 100% of Medicare OPPS Rate,46.1,Pays at 100% of GA Medicaid Fee Schedule,99.22,Pays at 88% of Total Billed charges,47.48,Pays at 103% of GA Medicaid Fee Schedule,46.1,310.72,67.65
Outpatient Medical Services,LAB,88184,"FLOW CYTO CELL SURFACE, TC",311,557.75,474.09,Pays at 85% of Billed charges for outpatient setting,46.1,Pays at 100% of GA Medicaid Fee Schedule,446.37,Pays at 80.03% of Total Billed charges,310.72,Pays at 102% of Medicare OPPS Rate,501.98,Pays at 90% of Total Billed charges,46.1,Pays at 100% of GA Medicaid Fee Schedule,304.63,Pays at 100% of Medicare OPPS Rate,46.1,Pays at 100% of GA Medicaid Fee Schedule,490.82,Pays at 88% of Total Billed charges,47.48,Pays at 103% of GA Medicaid Fee Schedule,46.1,501.98,334.65
Outpatient Medical Services,LAB,88185,"FLOW CYTO, EACH ADDL MARKER, TC",311,28.5,24.23,Pays at 85% of Billed charges for outpatient setting,22.67,Pays at 100% of GA Medicaid Fee Schedule,22.81,Pays at 80.03% of Total Billed charges,NA,Not Applicable,25.65,Pays at 90% of Total Billed charges,22.67,Pays at 100% of GA Medicaid Fee Schedule,NA,Not Applicable,22.67,Pays at 100% of GA Medicaid Fee Schedule,25.08,Pays at 88% of Total Billed charges,23.35,Pays at 103% of GA Medicaid Fee Schedule,22.67,25.65,17.10
Outpatient Medical Services,LAB,88187,"FLOW CYTO, 2-8 MARKERS INTERP",300,117.75,100.09,Pays at 85% of Billed charges for outpatient setting,59.78,Pays at 100% of GA Medicaid Fee Schedule,94.24,Pays at 80.03% of Total Billed charges,NA,Not Applicable,105.98,Pays at 90% of Total Billed charges,59.78,Pays at 100% of GA Medicaid Fee Schedule,NA,Not Applicable,59.78,Pays at 100% of GA Medicaid Fee Schedule,103.62,Pays at 88% of Total Billed charges,61.57,Pays at 103% of GA Medicaid Fee Schedule,59.78,105.98,70.65
Outpatient Medical Services,LAB,88187,FLOW CYTOMETRY,310,206.25,175.31,Pays at 85% of Billed charges for outpatient setting,59.78,Pays at 100% of GA Medicaid Fee Schedule,165.06,Pays at 80.03% of Total Billed charges,NA,Not Applicable,185.63,Pays at 90% of Total Billed charges,59.78,Pays at 100% of GA Medicaid Fee Schedule,NA,Not Applicable,59.78,Pays at 100% of GA Medicaid Fee Schedule,181.5,Pays at 88% of Total Billed charges,61.57,Pays at 103% of GA Medicaid Fee Schedule,59.78,185.63,123.75
Outpatient Medical Services,LAB,88188,"FLOW CYTO, 9-15 ADDL MARKERS INTERP",310,160.75,136.64,Pays at 85% of Billed charges for outpatient setting,74.6,Pays at 100% of GA Medicaid Fee Schedule,128.65,Pays at 80.03% of Total Billed charges,NA,Not Applicable,144.68,Pays at 90% of Total Billed charges,74.6,Pays at 100% of GA Medicaid Fee Schedule,NA,Not Applicable,74.6,Pays at 100% of GA Medicaid Fee Schedule,141.46,Pays at 88% of Total Billed charges,76.84,Pays at 103% of GA Medicaid Fee Schedule,74.6,144.68,96.45
Outpatient Medical Services,LAB,88189,"FLOW CYTO, 16 OR MORE MARKERS  INTERP",300,187.5,159.38,Pays at 85% of Billed charges for outpatient setting,98.26,Pays at 100% of GA Medicaid Fee Schedule,150.06,Pays at 80.03% of Total Billed charges,NA,Not Applicable,168.75,Pays at 90% of Total Billed charges,98.26,Pays at 100% of GA Medicaid Fee Schedule,NA,Not Applicable,98.26,Pays at 100% of GA Medicaid Fee Schedule,165,Pays at 88% of Total Billed charges,101.21,Pays at 103% of GA Medicaid Fee Schedule,98.26,168.75,112.50
Outpatient Medical Services,LAB,88237,TISSUE CULTURE FOR NEOPLASTIC DISORDERS,310,67.5,57.38,Pays at 85% of Billed charges for outpatient setting,111.02,Pays at 100% of GA Medicaid Fee Schedule,54.02,Pays at 80.03% of Total Billed charges,146.62,Pays at 102% of Medicare OPPS Rate,60.75,Pays at 90% of Total Billed charges,111.02,Pays at 100% of GA Medicaid Fee Schedule,143.75,Pays at 100% of Medicare OPPS Rate,111.02,Pays at 100% of GA Medicaid Fee Schedule,59.4,Pays at 88% of Total Billed charges,114.35,Pays at 103% of GA Medicaid Fee Schedule,54.02,146.62,40.50
Outpatient Medical Services,LAB,88237,TISSUE CULTURE NEOPLASTIC DISORDERS,300,187,158.95,Pays at 85% of Billed charges for outpatient setting,111.02,Pays at 100% of GA Medicaid Fee Schedule,149.66,Pays at 80.03% of Total Billed charges,146.62,Pays at 102% of Medicare OPPS Rate,168.3,Pays at 90% of Total Billed charges,111.02,Pays at 100% of GA Medicaid Fee Schedule,143.75,Pays at 100% of Medicare OPPS Rate,111.02,Pays at 100% of GA Medicaid Fee Schedule,164.56,Pays at 88% of Total Billed charges,114.35,Pays at 103% of GA Medicaid Fee Schedule,111.02,168.3,112.20
Outpatient Medical Services,LAB,88237,TISSUE CULTURE BONE MARROW   (CSI),310,187.25,159.16,Pays at 85% of Billed charges for outpatient setting,111.02,Pays at 100% of GA Medicaid Fee Schedule,149.86,Pays at 80.03% of Total Billed charges,146.62,Pays at 102% of Medicare OPPS Rate,168.53,Pays at 90% of Total Billed charges,111.02,Pays at 100% of GA Medicaid Fee Schedule,143.75,Pays at 100% of Medicare OPPS Rate,111.02,Pays at 100% of GA Medicaid Fee Schedule,164.78,Pays at 88% of Total Billed charges,114.35,Pays at 103% of GA Medicaid Fee Schedule,111.02,168.53,112.35
Outpatient Medical Services,LAB,88239,TISSUE CULTURE  (I.O),300,721.75,613.49,Pays at 85% of Billed charges for outpatient setting,185.51,Pays at 100% of GA Medicaid Fee Schedule,577.62,Pays at 80.03% of Total Billed charges,150.47,Pays at 102% of Medicare OPPS Rate,649.58,Pays at 90% of Total Billed charges,185.51,Pays at 100% of GA Medicaid Fee Schedule,147.52,Pays at 100% of Medicare OPPS Rate,185.51,Pays at 100% of GA Medicaid Fee Schedule,635.14,Pays at 88% of Total Billed charges,191.08,Pays at 103% of GA Medicaid Fee Schedule,147.52,649.58,433.05
Outpatient Medical Services,LAB,88248,CHROMOSOME FRAGILE X SYNDROME  (MAYO),310,370.5,314.93,Pays at 85% of Billed charges for outpatient setting,217.76,Pays at 100% of GA Medicaid Fee Schedule,296.51,Pays at 80.03% of Total Billed charges,176.63,Pays at 102% of Medicare OPPS Rate,333.45,Pays at 90% of Total Billed charges,217.76,Pays at 100% of GA Medicaid Fee Schedule,173.17,Pays at 100% of Medicare OPPS Rate,217.76,Pays at 100% of GA Medicaid Fee Schedule,326.04,Pays at 88% of Total Billed charges,224.29,Pays at 103% of GA Medicaid Fee Schedule,173.17,333.45,222.30
Outpatient Medical Services,LAB,88261,"CHROMO ANALYSIS; 5 CELLS, 1 KARO W BAND",300,374.5,318.33,Pays at 85% of Billed charges for outpatient setting,222.24,Pays at 100% of GA Medicaid Fee Schedule,299.71,Pays at 80.03% of Total Billed charges,269.62,Pays at 102% of Medicare OPPS Rate,337.05,Pays at 90% of Total Billed charges,222.24,Pays at 100% of GA Medicaid Fee Schedule,264.33,Pays at 100% of Medicare OPPS Rate,222.24,Pays at 100% of GA Medicaid Fee Schedule,329.56,Pays at 88% of Total Billed charges,228.91,Pays at 103% of GA Medicaid Fee Schedule,222.24,337.05,224.70
Outpatient Medical Services,LAB,88262,CHROMOSOME ANALYSIS-CONGENITAL DISORDERS,310,539.75,458.79,Pays at 85% of Billed charges for outpatient setting,156.73,Pays at 100% of GA Medicaid Fee Schedule,431.96,Pays at 80.03% of Total Billed charges,127.99,Pays at 102% of Medicare OPPS Rate,485.78,Pays at 90% of Total Billed charges,156.73,Pays at 100% of GA Medicaid Fee Schedule,125.49,Pays at 100% of Medicare OPPS Rate,156.73,Pays at 100% of GA Medicaid Fee Schedule,474.98,Pays at 88% of Total Billed charges,161.43,Pays at 103% of GA Medicaid Fee Schedule,125.49,485.78,323.85
Outpatient Medical Services,LAB,88262,CHROMASOME ANALYSIS 15-20 CELLS  (MAYO),310,613.25,521.26,Pays at 85% of Billed charges for outpatient setting,156.73,Pays at 100% of GA Medicaid Fee Schedule,490.78,Pays at 80.03% of Total Billed charges,127.99,Pays at 102% of Medicare OPPS Rate,551.93,Pays at 90% of Total Billed charges,156.73,Pays at 100% of GA Medicaid Fee Schedule,125.49,Pays at 100% of Medicare OPPS Rate,156.73,Pays at 100% of GA Medicaid Fee Schedule,539.66,Pays at 88% of Total Billed charges,161.43,Pays at 103% of GA Medicaid Fee Schedule,125.49,551.93,367.95
Outpatient Medical Services,LAB,88262,"CHROMOSOME ANALYSIS, AUTOPSY  (MAYO)",310,979,832.15,Pays at 85% of Billed charges for outpatient setting,156.73,Pays at 100% of GA Medicaid Fee Schedule,783.49,Pays at 80.03% of Total Billed charges,127.99,Pays at 102% of Medicare OPPS Rate,881.1,Pays at 90% of Total Billed charges,156.73,Pays at 100% of GA Medicaid Fee Schedule,125.49,Pays at 100% of Medicare OPPS Rate,156.73,Pays at 100% of GA Medicaid Fee Schedule,861.52,Pays at 88% of Total Billed charges,161.43,Pays at 103% of GA Medicaid Fee Schedule,125.49,881.1,587.40
Outpatient Medical Services,LAB,88264,CHROMASOME ANALYSIS 20-25 CELLS  (LABCOR,310,1032.75,877.84,Pays at 85% of Billed charges for outpatient setting,156.73,Pays at 100% of GA Medicaid Fee Schedule,826.51,Pays at 80.03% of Total Billed charges,147.5,Pays at 102% of Medicare OPPS Rate,929.48,Pays at 90% of Total Billed charges,156.73,Pays at 100% of GA Medicaid Fee Schedule,144.61,Pays at 100% of Medicare OPPS Rate,156.73,Pays at 100% of GA Medicaid Fee Schedule,908.82,Pays at 88% of Total Billed charges,161.43,Pays at 103% of GA Medicaid Fee Schedule,144.61,929.48,619.65
Outpatient Medical Services,LAB,88264,CYTOGENIC STUDIES: BONE MARROW ASPIRATE,310,2295,1950.75,Pays at 85% of Billed charges for outpatient setting,156.73,Pays at 100% of GA Medicaid Fee Schedule,1836.69,Pays at 80.03% of Total Billed charges,147.5,Pays at 102% of Medicare OPPS Rate,2065.5,Pays at 90% of Total Billed charges,156.73,Pays at 100% of GA Medicaid Fee Schedule,144.61,Pays at 100% of Medicare OPPS Rate,156.73,Pays at 100% of GA Medicaid Fee Schedule,2019.6,Pays at 88% of Total Billed charges,161.43,Pays at 103% of GA Medicaid Fee Schedule,144.61,2065.5,1377.00
Outpatient Medical Services,LAB,88267,CHROMOSOME ANAL AMNIO FL  (MAYO),310,944.75,803.04,Pays at 85% of Billed charges for outpatient setting,226.05,Pays at 100% of GA Medicaid Fee Schedule,756.08,Pays at 80.03% of Total Billed charges,192.34,Pays at 102% of Medicare OPPS Rate,850.28,Pays at 90% of Total Billed charges,226.05,Pays at 100% of GA Medicaid Fee Schedule,188.57,Pays at 100% of Medicare OPPS Rate,226.05,Pays at 100% of GA Medicaid Fee Schedule,831.38,Pays at 88% of Total Billed charges,232.83,Pays at 103% of GA Medicaid Fee Schedule,188.57,850.28,566.85
Outpatient Medical Services,LAB,88280,CHROMASOME KAROTYPE,300,53.25,45.26,Pays at 85% of Billed charges for outpatient setting,31.56,Pays at 100% of GA Medicaid Fee Schedule,42.62,Pays at 80.03% of Total Billed charges,34.13,Pays at 102% of Medicare OPPS Rate,47.93,Pays at 90% of Total Billed charges,31.56,Pays at 100% of GA Medicaid Fee Schedule,33.47,Pays at 100% of Medicare OPPS Rate,31.56,Pays at 100% of GA Medicaid Fee Schedule,46.86,Pays at 88% of Total Billed charges,32.51,Pays at 103% of GA Medicaid Fee Schedule,31.56,47.93,31.95
Outpatient Medical Services,LAB,88280,"CYTOGENETICS KAROTYPE, ADDL   (CSI)",300,53.25,45.26,Pays at 85% of Billed charges for outpatient setting,31.56,Pays at 100% of GA Medicaid Fee Schedule,42.62,Pays at 80.03% of Total Billed charges,34.13,Pays at 102% of Medicare OPPS Rate,47.93,Pays at 90% of Total Billed charges,31.56,Pays at 100% of GA Medicaid Fee Schedule,33.47,Pays at 100% of Medicare OPPS Rate,31.56,Pays at 100% of GA Medicaid Fee Schedule,46.86,Pays at 88% of Total Billed charges,32.51,Pays at 103% of GA Medicaid Fee Schedule,31.56,47.93,31.95
Outpatient Medical Services,LAB,88285,"CHROMO ANALYSIS; ADD'L CELLS COUNTED, EA",300,40.25,34.21,Pays at 85% of Billed charges for outpatient setting,23.89,Pays at 100% of GA Medicaid Fee Schedule,32.21,Pays at 80.03% of Total Billed charges,27.44,Pays at 102% of Medicare OPPS Rate,36.23,Pays at 90% of Total Billed charges,23.89,Pays at 100% of GA Medicaid Fee Schedule,26.91,Pays at 100% of Medicare OPPS Rate,23.89,Pays at 100% of GA Medicaid Fee Schedule,35.42,Pays at 88% of Total Billed charges,24.61,Pays at 103% of GA Medicaid Fee Schedule,23.89,36.23,24.15
Outpatient Medical Services,LAB,88304,..DERMA-PATH(TISSUE),310,65,55.25,Pays at 85% of Billed charges for outpatient setting,30.18,Pays at 100% of GA Medicaid Fee Schedule,52.02,Pays at 80.03% of Total Billed charges,48.06,Pays at 102% of Medicare OPPS Rate,58.5,Pays at 90% of Total Billed charges,30.18,Pays at 100% of GA Medicaid Fee Schedule,47.12,Pays at 100% of Medicare OPPS Rate,30.18,Pays at 100% of GA Medicaid Fee Schedule,57.2,Pays at 88% of Total Billed charges,31.09,Pays at 103% of GA Medicaid Fee Schedule,30.18,58.5,39.00
Outpatient Medical Services,LAB,88305,Test of tissues for diagnosis of abnormalities,310,189.25,160.86,Pays at 85% of Billed charges for outpatient setting,65.88,Pays at 100% of GA Medicaid Fee Schedule,151.46,Pays at 80.03% of Total Billed charges,48.06,Pays at 102% of Medicare OPPS Rate,170.33,Pays at 90% of Total Billed charges,65.88,Pays at 100% of GA Medicaid Fee Schedule,47.12,Pays at 100% of Medicare OPPS Rate,65.88,Pays at 100% of GA Medicaid Fee Schedule,166.54,Pays at 88% of Total Billed charges,67.86,Pays at 103% of GA Medicaid Fee Schedule,47.12,170.33,113.55
Outpatient Medical Services,LAB,88305,Test of tissues for diagnosis of abnormalities,310,363.75,309.19,Pays at 85% of Billed charges for outpatient setting,65.88,Pays at 100% of GA Medicaid Fee Schedule,291.11,Pays at 80.03% of Total Billed charges,48.06,Pays at 102% of Medicare OPPS Rate,327.38,Pays at 90% of Total Billed charges,65.88,Pays at 100% of GA Medicaid Fee Schedule,47.12,Pays at 100% of Medicare OPPS Rate,65.88,Pays at 100% of GA Medicaid Fee Schedule,320.1,Pays at 88% of Total Billed charges,67.86,Pays at 103% of GA Medicaid Fee Schedule,47.12,327.38,218.25
Outpatient Medical Services,LAB,88305,Test of tissues for diagnosis of abnormalities,310,459.5,390.58,Pays at 85% of Billed charges for outpatient setting,65.88,Pays at 100% of GA Medicaid Fee Schedule,367.74,Pays at 80.03% of Total Billed charges,48.06,Pays at 102% of Medicare OPPS Rate,413.55,Pays at 90% of Total Billed charges,65.88,Pays at 100% of GA Medicaid Fee Schedule,47.12,Pays at 100% of Medicare OPPS Rate,65.88,Pays at 100% of GA Medicaid Fee Schedule,404.36,Pays at 88% of Total Billed charges,67.86,Pays at 103% of GA Medicaid Fee Schedule,47.12,413.55,275.70
Outpatient Medical Services,LAB,88305,Test of tissues for diagnosis of abnormalities,300,491.75,417.99,Pays at 85% of Billed charges for outpatient setting,65.88,Pays at 100% of GA Medicaid Fee Schedule,393.55,Pays at 80.03% of Total Billed charges,48.06,Pays at 102% of Medicare OPPS Rate,442.58,Pays at 90% of Total Billed charges,65.88,Pays at 100% of GA Medicaid Fee Schedule,47.12,Pays at 100% of Medicare OPPS Rate,65.88,Pays at 100% of GA Medicaid Fee Schedule,432.74,Pays at 88% of Total Billed charges,67.86,Pays at 103% of GA Medicaid Fee Schedule,47.12,442.58,295.05
Outpatient Medical Services,LAB,88305,Test of tissues for diagnosis of abnormalities,310,491.75,417.99,Pays at 85% of Billed charges for outpatient setting,65.88,Pays at 100% of GA Medicaid Fee Schedule,393.55,Pays at 80.03% of Total Billed charges,48.06,Pays at 102% of Medicare OPPS Rate,442.58,Pays at 90% of Total Billed charges,65.88,Pays at 100% of GA Medicaid Fee Schedule,47.12,Pays at 100% of Medicare OPPS Rate,65.88,Pays at 100% of GA Medicaid Fee Schedule,432.74,Pays at 88% of Total Billed charges,67.86,Pays at 103% of GA Medicaid Fee Schedule,47.12,442.58,295.05
Outpatient Medical Services,LAB,88307,PATH EXAM LGE/MUL SM TECH  (CSI),310,364.75,310.04,Pays at 85% of Billed charges for outpatient setting,133.3,Pays at 100% of GA Medicaid Fee Schedule,291.91,Pays at 80.03% of Total Billed charges,310.72,Pays at 102% of Medicare OPPS Rate,328.28,Pays at 90% of Total Billed charges,133.3,Pays at 100% of GA Medicaid Fee Schedule,304.63,Pays at 100% of Medicare OPPS Rate,133.3,Pays at 100% of GA Medicaid Fee Schedule,320.98,Pays at 88% of Total Billed charges,137.3,Pays at 103% of GA Medicaid Fee Schedule,133.3,328.28,218.85
Outpatient Medical Services,LAB,88311,..DECALCIFICATION,310,60,51,Pays at 85% of Billed charges for outpatient setting,15.45,Pays at 100% of GA Medicaid Fee Schedule,48.02,Pays at 80.03% of Total Billed charges,NA,Not Applicable,54,Pays at 90% of Total Billed charges,15.45,Pays at 100% of GA Medicaid Fee Schedule,NA,Not Applicable,15.45,Pays at 100% of GA Medicaid Fee Schedule,52.8,Pays at 88% of Total Billed charges,15.91,Pays at 103% of GA Medicaid Fee Schedule,15.45,54,36.00
Outpatient Medical Services,LAB,88312,Blood test to assist with diagnosis,310,109.75,93.29,Pays at 85% of Billed charges for outpatient setting,43.39,Pays at 100% of GA Medicaid Fee Schedule,87.83,Pays at 80.03% of Total Billed charges,48.06,Pays at 102% of Medicare OPPS Rate,98.78,Pays at 90% of Total Billed charges,43.39,Pays at 100% of GA Medicaid Fee Schedule,47.12,Pays at 100% of Medicare OPPS Rate,43.39,Pays at 100% of GA Medicaid Fee Schedule,96.58,Pays at 88% of Total Billed charges,44.69,Pays at 103% of GA Medicaid Fee Schedule,43.39,98.78,65.85
Outpatient Medical Services,LAB,88313,Blood test to assist with diagnosis,300,119.5,101.58,Pays at 85% of Billed charges for outpatient setting,44.91,Pays at 100% of GA Medicaid Fee Schedule,95.64,Pays at 80.03% of Total Billed charges,32.54,Pays at 102% of Medicare OPPS Rate,107.55,Pays at 90% of Total Billed charges,44.91,Pays at 100% of GA Medicaid Fee Schedule,31.91,Pays at 100% of Medicare OPPS Rate,44.91,Pays at 100% of GA Medicaid Fee Schedule,105.16,Pays at 88% of Total Billed charges,46.26,Pays at 103% of GA Medicaid Fee Schedule,31.91,107.55,71.70
Outpatient Medical Services,LAB,88313,Blood test to assist with diagnosis,310,164.5,139.83,Pays at 85% of Billed charges for outpatient setting,44.91,Pays at 100% of GA Medicaid Fee Schedule,131.65,Pays at 80.03% of Total Billed charges,32.54,Pays at 102% of Medicare OPPS Rate,148.05,Pays at 90% of Total Billed charges,44.91,Pays at 100% of GA Medicaid Fee Schedule,31.91,Pays at 100% of Medicare OPPS Rate,44.91,Pays at 100% of GA Medicaid Fee Schedule,144.76,Pays at 88% of Total Billed charges,46.26,Pays at 103% of GA Medicaid Fee Schedule,31.91,148.05,98.70
Outpatient Medical Services,LAB,88313,Blood test to assist with diagnosis,310,164.5,139.83,Pays at 85% of Billed charges for outpatient setting,44.91,Pays at 100% of GA Medicaid Fee Schedule,131.65,Pays at 80.03% of Total Billed charges,32.54,Pays at 102% of Medicare OPPS Rate,148.05,Pays at 90% of Total Billed charges,44.91,Pays at 100% of GA Medicaid Fee Schedule,31.91,Pays at 100% of Medicare OPPS Rate,44.91,Pays at 100% of GA Medicaid Fee Schedule,144.76,Pays at 88% of Total Billed charges,46.26,Pays at 103% of GA Medicaid Fee Schedule,31.91,148.05,98.70
Outpatient Medical Services,LAB,88313,Blood test to assist with diagnosis,310,164.5,139.83,Pays at 85% of Billed charges for outpatient setting,44.91,Pays at 100% of GA Medicaid Fee Schedule,131.65,Pays at 80.03% of Total Billed charges,32.54,Pays at 102% of Medicare OPPS Rate,148.05,Pays at 90% of Total Billed charges,44.91,Pays at 100% of GA Medicaid Fee Schedule,31.91,Pays at 100% of Medicare OPPS Rate,44.91,Pays at 100% of GA Medicaid Fee Schedule,144.76,Pays at 88% of Total Billed charges,46.26,Pays at 103% of GA Medicaid Fee Schedule,31.91,148.05,98.70
Outpatient Medical Services,LAB,88313,Blood test to assist with diagnosis,310,177.75,151.09,Pays at 85% of Billed charges for outpatient setting,44.91,Pays at 100% of GA Medicaid Fee Schedule,142.25,Pays at 80.03% of Total Billed charges,32.54,Pays at 102% of Medicare OPPS Rate,159.98,Pays at 90% of Total Billed charges,44.91,Pays at 100% of GA Medicaid Fee Schedule,31.91,Pays at 100% of Medicare OPPS Rate,44.91,Pays at 100% of GA Medicaid Fee Schedule,156.42,Pays at 88% of Total Billed charges,46.26,Pays at 103% of GA Medicaid Fee Schedule,31.91,159.98,106.65
Outpatient Medical Services,LAB,88313,Blood test to assist with diagnosis,310,207,175.95,Pays at 85% of Billed charges for outpatient setting,44.91,Pays at 100% of GA Medicaid Fee Schedule,165.66,Pays at 80.03% of Total Billed charges,32.54,Pays at 102% of Medicare OPPS Rate,186.3,Pays at 90% of Total Billed charges,44.91,Pays at 100% of GA Medicaid Fee Schedule,31.91,Pays at 100% of Medicare OPPS Rate,44.91,Pays at 100% of GA Medicaid Fee Schedule,182.16,Pays at 88% of Total Billed charges,46.26,Pays at 103% of GA Medicaid Fee Schedule,31.91,186.3,124.20
Outpatient Medical Services,LAB,88313,Blood test to assist with diagnosis,310,365.25,310.46,Pays at 85% of Billed charges for outpatient setting,44.91,Pays at 100% of GA Medicaid Fee Schedule,292.31,Pays at 80.03% of Total Billed charges,32.54,Pays at 102% of Medicare OPPS Rate,328.73,Pays at 90% of Total Billed charges,44.91,Pays at 100% of GA Medicaid Fee Schedule,31.91,Pays at 100% of Medicare OPPS Rate,44.91,Pays at 100% of GA Medicaid Fee Schedule,321.42,Pays at 88% of Total Billed charges,46.26,Pays at 103% of GA Medicaid Fee Schedule,31.91,328.73,219.15
Outpatient Medical Services,LAB,88313,Blood test to assist with diagnosis,310,473,402.05,Pays at 85% of Billed charges for outpatient setting,44.91,Pays at 100% of GA Medicaid Fee Schedule,378.54,Pays at 80.03% of Total Billed charges,32.54,Pays at 102% of Medicare OPPS Rate,425.7,Pays at 90% of Total Billed charges,44.91,Pays at 100% of GA Medicaid Fee Schedule,31.91,Pays at 100% of Medicare OPPS Rate,44.91,Pays at 100% of GA Medicaid Fee Schedule,416.24,Pays at 88% of Total Billed charges,46.26,Pays at 103% of GA Medicaid Fee Schedule,31.91,425.7,283.80
Outpatient Medical Services,LAB,88314,MUSCLE ATPASE ACID ALK STAIN (MAYO),300,176,149.6,Pays at 85% of Billed charges for outpatient setting,88.62,Pays at 100% of GA Medicaid Fee Schedule,140.85,Pays at 80.03% of Total Billed charges,NA,Not Applicable,158.4,Pays at 90% of Total Billed charges,88.62,Pays at 100% of GA Medicaid Fee Schedule,NA,Not Applicable,88.62,Pays at 100% of GA Medicaid Fee Schedule,154.88,Pays at 88% of Total Billed charges,91.28,Pays at 103% of GA Medicaid Fee Schedule,88.62,158.4,105.60
Outpatient Medical Services,LAB,88314,MUSCLE PERIODIC ACID-SCHIFF STAIN (MAYO),300,176,149.6,Pays at 85% of Billed charges for outpatient setting,88.62,Pays at 100% of GA Medicaid Fee Schedule,140.85,Pays at 80.03% of Total Billed charges,NA,Not Applicable,158.4,Pays at 90% of Total Billed charges,88.62,Pays at 100% of GA Medicaid Fee Schedule,NA,Not Applicable,88.62,Pays at 100% of GA Medicaid Fee Schedule,154.88,Pays at 88% of Total Billed charges,91.28,Pays at 103% of GA Medicaid Fee Schedule,88.62,158.4,105.60
Outpatient Medical Services,LAB,88314,MUSCLE TRICH WATER SOLUBLE STAIN (MAYO),300,176,149.6,Pays at 85% of Billed charges for outpatient setting,88.62,Pays at 100% of GA Medicaid Fee Schedule,140.85,Pays at 80.03% of Total Billed charges,NA,Not Applicable,158.4,Pays at 90% of Total Billed charges,88.62,Pays at 100% of GA Medicaid Fee Schedule,NA,Not Applicable,88.62,Pays at 100% of GA Medicaid Fee Schedule,154.88,Pays at 88% of Total Billed charges,91.28,Pays at 103% of GA Medicaid Fee Schedule,88.62,158.4,105.60
Outpatient Medical Services,LAB,88314,MUSCLE CONGO RED STAIN (MAYO),300,176,149.6,Pays at 85% of Billed charges for outpatient setting,88.62,Pays at 100% of GA Medicaid Fee Schedule,140.85,Pays at 80.03% of Total Billed charges,NA,Not Applicable,158.4,Pays at 90% of Total Billed charges,88.62,Pays at 100% of GA Medicaid Fee Schedule,NA,Not Applicable,88.62,Pays at 100% of GA Medicaid Fee Schedule,154.88,Pays at 88% of Total Billed charges,91.28,Pays at 103% of GA Medicaid Fee Schedule,88.62,158.4,105.60
Outpatient Medical Services,LAB,88314,MUSCLE OIL RED O STAIN (MAYO),300,176,149.6,Pays at 85% of Billed charges for outpatient setting,88.62,Pays at 100% of GA Medicaid Fee Schedule,140.85,Pays at 80.03% of Total Billed charges,NA,Not Applicable,158.4,Pays at 90% of Total Billed charges,88.62,Pays at 100% of GA Medicaid Fee Schedule,NA,Not Applicable,88.62,Pays at 100% of GA Medicaid Fee Schedule,154.88,Pays at 88% of Total Billed charges,91.28,Pays at 103% of GA Medicaid Fee Schedule,88.62,158.4,105.60
Outpatient Medical Services,LAB,88314,MUSCLE TB ATPASE STAIN (MAYO),300,176,149.6,Pays at 85% of Billed charges for outpatient setting,88.62,Pays at 100% of GA Medicaid Fee Schedule,140.85,Pays at 80.03% of Total Billed charges,NA,Not Applicable,158.4,Pays at 90% of Total Billed charges,88.62,Pays at 100% of GA Medicaid Fee Schedule,NA,Not Applicable,88.62,Pays at 100% of GA Medicaid Fee Schedule,154.88,Pays at 88% of Total Billed charges,91.28,Pays at 103% of GA Medicaid Fee Schedule,88.62,158.4,105.60
Outpatient Medical Services,LAB,88314,HISTOCHEM MUSCEL PANEL  (MAYO),310,3403.75,2893.19,Pays at 85% of Billed charges for outpatient setting,88.62,Pays at 100% of GA Medicaid Fee Schedule,2724.02,Pays at 80.03% of Total Billed charges,NA,Not Applicable,3063.38,Pays at 90% of Total Billed charges,88.62,Pays at 100% of GA Medicaid Fee Schedule,NA,Not Applicable,88.62,Pays at 100% of GA Medicaid Fee Schedule,2995.3,Pays at 88% of Total Billed charges,91.28,Pays at 103% of GA Medicaid Fee Schedule,88.62,3063.38,2042.25
Outpatient Medical Services,LAB,88319,MUSCLE CYTOCHROME OXIDASE STAIN (MAYO),300,269,228.65,Pays at 85% of Billed charges for outpatient setting,86.63,Pays at 100% of GA Medicaid Fee Schedule,215.28,Pays at 80.03% of Total Billed charges,744.44,Pays at 102% of Medicare OPPS Rate,242.1,Pays at 90% of Total Billed charges,86.63,Pays at 100% of GA Medicaid Fee Schedule,729.84,Pays at 100% of Medicare OPPS Rate,86.63,Pays at 100% of GA Medicaid Fee Schedule,236.72,Pays at 88% of Total Billed charges,89.23,Pays at 103% of GA Medicaid Fee Schedule,86.63,744.44,161.40
Outpatient Medical Services,LAB,88319,MUSCLE SUCCINIC DEHYDRO STAIN (MAYO),300,269,228.65,Pays at 85% of Billed charges for outpatient setting,86.63,Pays at 100% of GA Medicaid Fee Schedule,215.28,Pays at 80.03% of Total Billed charges,744.44,Pays at 102% of Medicare OPPS Rate,242.1,Pays at 90% of Total Billed charges,86.63,Pays at 100% of GA Medicaid Fee Schedule,729.84,Pays at 100% of Medicare OPPS Rate,86.63,Pays at 100% of GA Medicaid Fee Schedule,236.72,Pays at 88% of Total Billed charges,89.23,Pays at 103% of GA Medicaid Fee Schedule,86.63,744.44,161.40
Outpatient Medical Services,LAB,88319,MUSCLE ACETATE NON-SPEC EST STAIN (MAYO),300,269,228.65,Pays at 85% of Billed charges for outpatient setting,86.63,Pays at 100% of GA Medicaid Fee Schedule,215.28,Pays at 80.03% of Total Billed charges,744.44,Pays at 102% of Medicare OPPS Rate,242.1,Pays at 90% of Total Billed charges,86.63,Pays at 100% of GA Medicaid Fee Schedule,729.84,Pays at 100% of Medicare OPPS Rate,86.63,Pays at 100% of GA Medicaid Fee Schedule,236.72,Pays at 88% of Total Billed charges,89.23,Pays at 103% of GA Medicaid Fee Schedule,86.63,744.44,161.40
Outpatient Medical Services,LAB,88319,MUSCLE NADH DEHYDRO STAIN (MAYO),300,269,228.65,Pays at 85% of Billed charges for outpatient setting,86.63,Pays at 100% of GA Medicaid Fee Schedule,215.28,Pays at 80.03% of Total Billed charges,744.44,Pays at 102% of Medicare OPPS Rate,242.1,Pays at 90% of Total Billed charges,86.63,Pays at 100% of GA Medicaid Fee Schedule,729.84,Pays at 100% of Medicare OPPS Rate,86.63,Pays at 100% of GA Medicaid Fee Schedule,236.72,Pays at 88% of Total Billed charges,89.23,Pays at 103% of GA Medicaid Fee Schedule,86.63,744.44,161.40
Outpatient Medical Services,LAB,88319,MUSCLE ACID PHOSPHATASE STAIN (MAYO),300,269,228.65,Pays at 85% of Billed charges for outpatient setting,86.63,Pays at 100% of GA Medicaid Fee Schedule,215.28,Pays at 80.03% of Total Billed charges,744.44,Pays at 102% of Medicare OPPS Rate,242.1,Pays at 90% of Total Billed charges,86.63,Pays at 100% of GA Medicaid Fee Schedule,729.84,Pays at 100% of Medicare OPPS Rate,86.63,Pays at 100% of GA Medicaid Fee Schedule,236.72,Pays at 88% of Total Billed charges,89.23,Pays at 103% of GA Medicaid Fee Schedule,86.63,744.44,161.40
Outpatient Medical Services,LAB,88319,MUSCLE PHOSPHORYLASE STAIN (MAYO),300,269,228.65,Pays at 85% of Billed charges for outpatient setting,86.63,Pays at 100% of GA Medicaid Fee Schedule,215.28,Pays at 80.03% of Total Billed charges,744.44,Pays at 102% of Medicare OPPS Rate,242.1,Pays at 90% of Total Billed charges,86.63,Pays at 100% of GA Medicaid Fee Schedule,729.84,Pays at 100% of Medicare OPPS Rate,86.63,Pays at 100% of GA Medicaid Fee Schedule,236.72,Pays at 88% of Total Billed charges,89.23,Pays at 103% of GA Medicaid Fee Schedule,86.63,744.44,161.40
Outpatient Medical Services,LAB,88321,"PATHOLOGY, CONSULT ON REFERRED SLIDES",310,267.75,227.59,Pays at 85% of Billed charges for outpatient setting,59.02,Pays at 100% of GA Medicaid Fee Schedule,214.28,Pays at 80.03% of Total Billed charges,32.54,Pays at 102% of Medicare OPPS Rate,240.98,Pays at 90% of Total Billed charges,59.02,Pays at 100% of GA Medicaid Fee Schedule,31.91,Pays at 100% of Medicare OPPS Rate,59.02,Pays at 100% of GA Medicaid Fee Schedule,235.62,Pays at 88% of Total Billed charges,60.79,Pays at 103% of GA Medicaid Fee Schedule,31.91,240.98,160.65
Outpatient Medical Services,LAB,88321,PATHOLOGY -OUTSIDE SLIDE INTERPRETATION,310,388.25,330.01,Pays at 85% of Billed charges for outpatient setting,59.02,Pays at 100% of GA Medicaid Fee Schedule,310.72,Pays at 80.03% of Total Billed charges,32.54,Pays at 102% of Medicare OPPS Rate,349.43,Pays at 90% of Total Billed charges,59.02,Pays at 100% of GA Medicaid Fee Schedule,31.91,Pays at 100% of Medicare OPPS Rate,59.02,Pays at 100% of GA Medicaid Fee Schedule,341.66,Pays at 88% of Total Billed charges,60.79,Pays at 103% of GA Medicaid Fee Schedule,31.91,349.43,232.95
Outpatient Medical Services,LAB,88323,PATHOLOGY CONSULT (CSI),310,82.75,70.34,Pays at 85% of Billed charges for outpatient setting,93.21,Pays at 100% of GA Medicaid Fee Schedule,66.22,Pays at 80.03% of Total Billed charges,48.06,Pays at 102% of Medicare OPPS Rate,74.48,Pays at 90% of Total Billed charges,93.21,Pays at 100% of GA Medicaid Fee Schedule,47.12,Pays at 100% of Medicare OPPS Rate,93.21,Pays at 100% of GA Medicaid Fee Schedule,72.82,Pays at 88% of Total Billed charges,96.01,Pays at 103% of GA Medicaid Fee Schedule,47.12,96.01,49.65
Outpatient Medical Services,LAB,88323,"DIAGNOSTIC, OUTSIDE MATRL  (JOHN HOPKIN)",310,543.25,461.76,Pays at 85% of Billed charges for outpatient setting,93.21,Pays at 100% of GA Medicaid Fee Schedule,434.76,Pays at 80.03% of Total Billed charges,48.06,Pays at 102% of Medicare OPPS Rate,488.93,Pays at 90% of Total Billed charges,93.21,Pays at 100% of GA Medicaid Fee Schedule,47.12,Pays at 100% of Medicare OPPS Rate,93.21,Pays at 100% of GA Medicaid Fee Schedule,478.06,Pays at 88% of Total Billed charges,96.01,Pays at 103% of GA Medicaid Fee Schedule,47.12,488.93,325.95
Outpatient Medical Services,LAB,88325,RENAL PATHOLOGY CONSULT  (MAYO),310,249.5,212.08,Pays at 85% of Billed charges for outpatient setting,95.02,Pays at 100% of GA Medicaid Fee Schedule,199.67,Pays at 80.03% of Total Billed charges,150.75,Pays at 102% of Medicare OPPS Rate,224.55,Pays at 90% of Total Billed charges,95.02,Pays at 100% of GA Medicaid Fee Schedule,147.8,Pays at 100% of Medicare OPPS Rate,95.02,Pays at 100% of GA Medicaid Fee Schedule,219.56,Pays at 88% of Total Billed charges,97.87,Pays at 103% of GA Medicaid Fee Schedule,95.02,224.55,149.70
Outpatient Medical Services,LAB,88329,CONSULT DURING SURGERY,310,258.5,219.73,Pays at 85% of Billed charges for outpatient setting,36.87,Pays at 100% of GA Medicaid Fee Schedule,206.88,Pays at 80.03% of Total Billed charges,32.54,Pays at 102% of Medicare OPPS Rate,232.65,Pays at 90% of Total Billed charges,36.87,Pays at 100% of GA Medicaid Fee Schedule,31.91,Pays at 100% of Medicare OPPS Rate,36.87,Pays at 100% of GA Medicaid Fee Schedule,227.48,Pays at 88% of Total Billed charges,37.98,Pays at 103% of GA Medicaid Fee Schedule,31.91,232.65,155.10
Outpatient Medical Services,LAB,88331,PATHOLOGY FROZEN SECTION CONSULT,310,508.25,432.01,Pays at 85% of Billed charges for outpatient setting,74.76,Pays at 100% of GA Medicaid Fee Schedule,406.75,Pays at 80.03% of Total Billed charges,150.75,Pays at 102% of Medicare OPPS Rate,457.43,Pays at 90% of Total Billed charges,74.76,Pays at 100% of GA Medicaid Fee Schedule,147.8,Pays at 100% of Medicare OPPS Rate,74.76,Pays at 100% of GA Medicaid Fee Schedule,447.26,Pays at 88% of Total Billed charges,77,Pays at 103% of GA Medicaid Fee Schedule,74.76,457.43,304.95
Outpatient Medical Services,LAB,88332,ADDITION FROZEN SECTION,310,169.5,144.08,Pays at 85% of Billed charges for outpatient setting,37.53,Pays at 100% of GA Medicaid Fee Schedule,135.65,Pays at 80.03% of Total Billed charges,NA,Not Applicable,152.55,Pays at 90% of Total Billed charges,37.53,Pays at 100% of GA Medicaid Fee Schedule,NA,Not Applicable,37.53,Pays at 100% of GA Medicaid Fee Schedule,149.16,Pays at 88% of Total Billed charges,38.66,Pays at 103% of GA Medicaid Fee Schedule,37.53,152.55,101.70
Outpatient Medical Services,LAB,88333,TOUCH PREP ADDITIONAL,310,34.5,29.33,Pays at 85% of Billed charges for outpatient setting,75.49,Pays at 100% of GA Medicaid Fee Schedule,27.61,Pays at 80.03% of Total Billed charges,744.44,Pays at 102% of Medicare OPPS Rate,31.05,Pays at 90% of Total Billed charges,75.49,Pays at 100% of GA Medicaid Fee Schedule,729.84,Pays at 100% of Medicare OPPS Rate,75.49,Pays at 100% of GA Medicaid Fee Schedule,30.36,Pays at 88% of Total Billed charges,77.75,Pays at 103% of GA Medicaid Fee Schedule,27.61,744.44,20.70
Outpatient Medical Services,LAB,88333,CYTOPATHOLOGY SMEAR PREP,310,50,42.5,Pays at 85% of Billed charges for outpatient setting,75.49,Pays at 100% of GA Medicaid Fee Schedule,40.02,Pays at 80.03% of Total Billed charges,744.44,Pays at 102% of Medicare OPPS Rate,45,Pays at 90% of Total Billed charges,75.49,Pays at 100% of GA Medicaid Fee Schedule,729.84,Pays at 100% of Medicare OPPS Rate,75.49,Pays at 100% of GA Medicaid Fee Schedule,44,Pays at 88% of Total Billed charges,77.75,Pays at 103% of GA Medicaid Fee Schedule,40.02,744.44,30.00
Outpatient Medical Services,LAB,88333,TOUCH PREP,310,1399.25,1189.36,Pays at 85% of Billed charges for outpatient setting,75.49,Pays at 100% of GA Medicaid Fee Schedule,1119.82,Pays at 80.03% of Total Billed charges,744.44,Pays at 102% of Medicare OPPS Rate,1259.33,Pays at 90% of Total Billed charges,75.49,Pays at 100% of GA Medicaid Fee Schedule,729.84,Pays at 100% of Medicare OPPS Rate,75.49,Pays at 100% of GA Medicaid Fee Schedule,1231.34,Pays at 88% of Total Billed charges,77.75,Pays at 103% of GA Medicaid Fee Schedule,75.49,1259.33,839.55
Outpatient Medical Services,LAB,88341,"IMMUNHISTOCHEM STAIN, TC  (CSI)",310,74,62.9,Pays at 85% of Billed charges for outpatient setting,57.38,Pays at 100% of GA Medicaid Fee Schedule,59.22,Pays at 80.03% of Total Billed charges,NA,Not Applicable,66.6,Pays at 90% of Total Billed charges,57.38,Pays at 100% of GA Medicaid Fee Schedule,NA,Not Applicable,57.38,Pays at 100% of GA Medicaid Fee Schedule,65.12,Pays at 88% of Total Billed charges,59.1,Pays at 103% of GA Medicaid Fee Schedule,57.38,66.6,44.40
Outpatient Medical Services,LAB,88341,"IMMUNHISTOCHEM STAIN, ADDL  (CSI)",310,97.25,82.66,Pays at 85% of Billed charges for outpatient setting,57.38,Pays at 100% of GA Medicaid Fee Schedule,77.83,Pays at 80.03% of Total Billed charges,NA,Not Applicable,87.53,Pays at 90% of Total Billed charges,57.38,Pays at 100% of GA Medicaid Fee Schedule,NA,Not Applicable,57.38,Pays at 100% of GA Medicaid Fee Schedule,85.58,Pays at 88% of Total Billed charges,59.1,Pays at 103% of GA Medicaid Fee Schedule,57.38,87.53,58.35
Outpatient Medical Services,LAB,88341,"IMMUNHISTOCHEM STAIN, ADDL  (IGO)",310,97.25,82.66,Pays at 85% of Billed charges for outpatient setting,57.38,Pays at 100% of GA Medicaid Fee Schedule,77.83,Pays at 80.03% of Total Billed charges,NA,Not Applicable,87.53,Pays at 90% of Total Billed charges,57.38,Pays at 100% of GA Medicaid Fee Schedule,NA,Not Applicable,57.38,Pays at 100% of GA Medicaid Fee Schedule,85.58,Pays at 88% of Total Billed charges,59.1,Pays at 103% of GA Medicaid Fee Schedule,57.38,87.53,58.35
Outpatient Medical Services,LAB,88342,Pathology test,310,85.5,72.68,Pays at 85% of Billed charges for outpatient setting,71.58,Pays at 100% of GA Medicaid Fee Schedule,68.43,Pays at 80.03% of Total Billed charges,150.75,Pays at 102% of Medicare OPPS Rate,76.95,Pays at 90% of Total Billed charges,71.58,Pays at 100% of GA Medicaid Fee Schedule,147.8,Pays at 100% of Medicare OPPS Rate,71.58,Pays at 100% of GA Medicaid Fee Schedule,75.24,Pays at 88% of Total Billed charges,73.73,Pays at 103% of GA Medicaid Fee Schedule,68.43,150.75,51.30
Outpatient Medical Services,LAB,88342,Pathology test,310,104.5,88.83,Pays at 85% of Billed charges for outpatient setting,71.58,Pays at 100% of GA Medicaid Fee Schedule,83.63,Pays at 80.03% of Total Billed charges,150.75,Pays at 102% of Medicare OPPS Rate,94.05,Pays at 90% of Total Billed charges,71.58,Pays at 100% of GA Medicaid Fee Schedule,147.8,Pays at 100% of Medicare OPPS Rate,71.58,Pays at 100% of GA Medicaid Fee Schedule,91.96,Pays at 88% of Total Billed charges,73.73,Pays at 103% of GA Medicaid Fee Schedule,71.58,150.75,62.70
Outpatient Medical Services,LAB,88342,Pathology test,310,168.25,143.01,Pays at 85% of Billed charges for outpatient setting,71.58,Pays at 100% of GA Medicaid Fee Schedule,134.65,Pays at 80.03% of Total Billed charges,150.75,Pays at 102% of Medicare OPPS Rate,151.43,Pays at 90% of Total Billed charges,71.58,Pays at 100% of GA Medicaid Fee Schedule,147.8,Pays at 100% of Medicare OPPS Rate,71.58,Pays at 100% of GA Medicaid Fee Schedule,148.06,Pays at 88% of Total Billed charges,73.73,Pays at 103% of GA Medicaid Fee Schedule,71.58,151.43,100.95
Outpatient Medical Services,LAB,88342,Pathology test,310,209.5,178.08,Pays at 85% of Billed charges for outpatient setting,71.58,Pays at 100% of GA Medicaid Fee Schedule,167.66,Pays at 80.03% of Total Billed charges,150.75,Pays at 102% of Medicare OPPS Rate,188.55,Pays at 90% of Total Billed charges,71.58,Pays at 100% of GA Medicaid Fee Schedule,147.8,Pays at 100% of Medicare OPPS Rate,71.58,Pays at 100% of GA Medicaid Fee Schedule,184.36,Pays at 88% of Total Billed charges,73.73,Pays at 103% of GA Medicaid Fee Schedule,71.58,188.55,125.70
Outpatient Medical Services,LAB,88344,"PROSTATE TRIPLE VIEW, TC  (IO)",310,218.5,185.73,Pays at 85% of Billed charges for outpatient setting,99.31,Pays at 100% of GA Medicaid Fee Schedule,174.87,Pays at 80.03% of Total Billed charges,310.72,Pays at 102% of Medicare OPPS Rate,196.65,Pays at 90% of Total Billed charges,99.31,Pays at 100% of GA Medicaid Fee Schedule,304.63,Pays at 100% of Medicare OPPS Rate,99.31,Pays at 100% of GA Medicaid Fee Schedule,192.28,Pays at 88% of Total Billed charges,102.29,Pays at 103% of GA Medicaid Fee Schedule,99.31,310.72,131.10
Outpatient Medical Services,LAB,88344,IMMUNOHISTO MULTIPLEX STAIN TC,310,557.75,474.09,Pays at 85% of Billed charges for outpatient setting,99.31,Pays at 100% of GA Medicaid Fee Schedule,446.37,Pays at 80.03% of Total Billed charges,310.72,Pays at 102% of Medicare OPPS Rate,501.98,Pays at 90% of Total Billed charges,99.31,Pays at 100% of GA Medicaid Fee Schedule,304.63,Pays at 100% of Medicare OPPS Rate,99.31,Pays at 100% of GA Medicaid Fee Schedule,490.82,Pays at 88% of Total Billed charges,102.29,Pays at 103% of GA Medicaid Fee Schedule,99.31,501.98,334.65
Outpatient Medical Services,LAB,88346,IF INITIAL (MAYO),310,43.5,36.98,Pays at 85% of Billed charges for outpatient setting,70.93,Pays at 100% of GA Medicaid Fee Schedule,34.81,Pays at 80.03% of Total Billed charges,310.72,Pays at 102% of Medicare OPPS Rate,39.15,Pays at 90% of Total Billed charges,70.93,Pays at 100% of GA Medicaid Fee Schedule,304.63,Pays at 100% of Medicare OPPS Rate,70.93,Pays at 100% of GA Medicaid Fee Schedule,38.28,Pays at 88% of Total Billed charges,73.06,Pays at 103% of GA Medicaid Fee Schedule,34.81,310.72,26.10
Outpatient Medical Services,LAB,88346,"C3 IF, RENAL  (MAYO)",310,46.75,39.74,Pays at 85% of Billed charges for outpatient setting,70.93,Pays at 100% of GA Medicaid Fee Schedule,37.41,Pays at 80.03% of Total Billed charges,310.72,Pays at 102% of Medicare OPPS Rate,42.08,Pays at 90% of Total Billed charges,70.93,Pays at 100% of GA Medicaid Fee Schedule,304.63,Pays at 100% of Medicare OPPS Rate,70.93,Pays at 100% of GA Medicaid Fee Schedule,41.14,Pays at 88% of Total Billed charges,73.06,Pays at 103% of GA Medicaid Fee Schedule,37.41,310.72,28.05
Outpatient Medical Services,LAB,88346,"FIBRINOGEN IF, RENAL   (MAYO)",310,46.75,39.74,Pays at 85% of Billed charges for outpatient setting,70.93,Pays at 100% of GA Medicaid Fee Schedule,37.41,Pays at 80.03% of Total Billed charges,310.72,Pays at 102% of Medicare OPPS Rate,42.08,Pays at 90% of Total Billed charges,70.93,Pays at 100% of GA Medicaid Fee Schedule,304.63,Pays at 100% of Medicare OPPS Rate,70.93,Pays at 100% of GA Medicaid Fee Schedule,41.14,Pays at 88% of Total Billed charges,73.06,Pays at 103% of GA Medicaid Fee Schedule,37.41,310.72,28.05
Outpatient Medical Services,LAB,88346,"IGA IF, RENAL   (MAYO)",310,46.75,39.74,Pays at 85% of Billed charges for outpatient setting,70.93,Pays at 100% of GA Medicaid Fee Schedule,37.41,Pays at 80.03% of Total Billed charges,310.72,Pays at 102% of Medicare OPPS Rate,42.08,Pays at 90% of Total Billed charges,70.93,Pays at 100% of GA Medicaid Fee Schedule,304.63,Pays at 100% of Medicare OPPS Rate,70.93,Pays at 100% of GA Medicaid Fee Schedule,41.14,Pays at 88% of Total Billed charges,73.06,Pays at 103% of GA Medicaid Fee Schedule,37.41,310.72,28.05
Outpatient Medical Services,LAB,88346,"IGM IF, RENAL   (MAYO)",310,46.75,39.74,Pays at 85% of Billed charges for outpatient setting,70.93,Pays at 100% of GA Medicaid Fee Schedule,37.41,Pays at 80.03% of Total Billed charges,310.72,Pays at 102% of Medicare OPPS Rate,42.08,Pays at 90% of Total Billed charges,70.93,Pays at 100% of GA Medicaid Fee Schedule,304.63,Pays at 100% of Medicare OPPS Rate,70.93,Pays at 100% of GA Medicaid Fee Schedule,41.14,Pays at 88% of Total Billed charges,73.06,Pays at 103% of GA Medicaid Fee Schedule,37.41,310.72,28.05
Outpatient Medical Services,LAB,88346,"LAMBDA IF, RENAL   (MAYO)",310,46.75,39.74,Pays at 85% of Billed charges for outpatient setting,70.93,Pays at 100% of GA Medicaid Fee Schedule,37.41,Pays at 80.03% of Total Billed charges,310.72,Pays at 102% of Medicare OPPS Rate,42.08,Pays at 90% of Total Billed charges,70.93,Pays at 100% of GA Medicaid Fee Schedule,304.63,Pays at 100% of Medicare OPPS Rate,70.93,Pays at 100% of GA Medicaid Fee Schedule,41.14,Pays at 88% of Total Billed charges,73.06,Pays at 103% of GA Medicaid Fee Schedule,37.41,310.72,28.05
Outpatient Medical Services,LAB,88346,"IGG IF, RENAL   (MAYO)",310,46.75,39.74,Pays at 85% of Billed charges for outpatient setting,70.93,Pays at 100% of GA Medicaid Fee Schedule,37.41,Pays at 80.03% of Total Billed charges,310.72,Pays at 102% of Medicare OPPS Rate,42.08,Pays at 90% of Total Billed charges,70.93,Pays at 100% of GA Medicaid Fee Schedule,304.63,Pays at 100% of Medicare OPPS Rate,70.93,Pays at 100% of GA Medicaid Fee Schedule,41.14,Pays at 88% of Total Billed charges,73.06,Pays at 103% of GA Medicaid Fee Schedule,37.41,310.72,28.05
Outpatient Medical Services,LAB,88346,"KAPPA IF, RENAL   (MAYO)",310,46.75,39.74,Pays at 85% of Billed charges for outpatient setting,70.93,Pays at 100% of GA Medicaid Fee Schedule,37.41,Pays at 80.03% of Total Billed charges,310.72,Pays at 102% of Medicare OPPS Rate,42.08,Pays at 90% of Total Billed charges,70.93,Pays at 100% of GA Medicaid Fee Schedule,304.63,Pays at 100% of Medicare OPPS Rate,70.93,Pays at 100% of GA Medicaid Fee Schedule,41.14,Pays at 88% of Total Billed charges,73.06,Pays at 103% of GA Medicaid Fee Schedule,37.41,310.72,28.05
Outpatient Medical Services,LAB,88346,"C1Q IF, RENAL   (MAYO)",310,46.75,39.74,Pays at 85% of Billed charges for outpatient setting,70.93,Pays at 100% of GA Medicaid Fee Schedule,37.41,Pays at 80.03% of Total Billed charges,310.72,Pays at 102% of Medicare OPPS Rate,42.08,Pays at 90% of Total Billed charges,70.93,Pays at 100% of GA Medicaid Fee Schedule,304.63,Pays at 100% of Medicare OPPS Rate,70.93,Pays at 100% of GA Medicaid Fee Schedule,41.14,Pays at 88% of Total Billed charges,73.06,Pays at 103% of GA Medicaid Fee Schedule,37.41,310.72,28.05
Outpatient Medical Services,LAB,88346,"ALBUMIN IF, RENAL   (MAYO)",310,46.75,39.74,Pays at 85% of Billed charges for outpatient setting,70.93,Pays at 100% of GA Medicaid Fee Schedule,37.41,Pays at 80.03% of Total Billed charges,310.72,Pays at 102% of Medicare OPPS Rate,42.08,Pays at 90% of Total Billed charges,70.93,Pays at 100% of GA Medicaid Fee Schedule,304.63,Pays at 100% of Medicare OPPS Rate,70.93,Pays at 100% of GA Medicaid Fee Schedule,41.14,Pays at 88% of Total Billed charges,73.06,Pays at 103% of GA Medicaid Fee Schedule,37.41,310.72,28.05
Outpatient Medical Services,LAB,88346,IF INITIAL ANTIBODY STAIN RENAL (MAYO),310,557.75,474.09,Pays at 85% of Billed charges for outpatient setting,70.93,Pays at 100% of GA Medicaid Fee Schedule,446.37,Pays at 80.03% of Total Billed charges,310.72,Pays at 102% of Medicare OPPS Rate,501.98,Pays at 90% of Total Billed charges,70.93,Pays at 100% of GA Medicaid Fee Schedule,304.63,Pays at 100% of Medicare OPPS Rate,70.93,Pays at 100% of GA Medicaid Fee Schedule,490.82,Pays at 88% of Total Billed charges,73.06,Pays at 103% of GA Medicaid Fee Schedule,70.93,501.98,334.65
Outpatient Medical Services,LAB,88347,"IF, EACH AB, IND; C4D TRANSPLANTS (MAYO)",310,46.75,39.74,Pays at 85% of Billed charges for outpatient setting,15.03,Pays at 32.15% of Total Billed charges,37.41,Pays at 80.03% of Total Billed charges,NA,Not Applicable,42.08,Pays at 90% of Total Billed charges,15.03,Pays at 32.15% of Total Billed charges,NA,Not Applicable,15.03,Pays at 32.15% of Total Billed charges,41.14,Pays at 88% of Total Billed charges,15.48,Pays at 33.11% of Total Billed charges,15.03,42.08,28.05
Outpatient Medical Services,LAB,88347,"PLA2R PARAFFIN IF, RENAL  (MAYO)",310,248.75,211.44,Pays at 85% of Billed charges for outpatient setting,79.97,Pays at 32.15% of Total Billed charges,199.07,Pays at 80.03% of Total Billed charges,NA,Not Applicable,223.88,Pays at 90% of Total Billed charges,79.97,Pays at 32.15% of Total Billed charges,NA,Not Applicable,79.97,Pays at 32.15% of Total Billed charges,218.9,Pays at 88% of Total Billed charges,82.36,Pays at 33.11% of Total Billed charges,79.97,223.88,149.25
Outpatient Medical Services,LAB,88348,RENAL BIOPSY ELECTRON MIC  (MAYO),310,818.75,695.94,Pays at 85% of Billed charges for outpatient setting,279.47,Pays at 100% of GA Medicaid Fee Schedule,655.25,Pays at 80.03% of Total Billed charges,744.44,Pays at 102% of Medicare OPPS Rate,736.88,Pays at 90% of Total Billed charges,279.47,Pays at 100% of GA Medicaid Fee Schedule,729.84,Pays at 100% of Medicare OPPS Rate,279.47,Pays at 100% of GA Medicaid Fee Schedule,720.5,Pays at 88% of Total Billed charges,287.85,Pays at 103% of GA Medicaid Fee Schedule,279.47,744.44,491.25
Outpatient Medical Services,LAB,88350,RENAL BIOPSY IMMUNOHISTOL/IF (MAYO),310,43.5,36.98,Pays at 85% of Billed charges for outpatient setting,61.42,Pays at 100% of GA Medicaid Fee Schedule,34.81,Pays at 80.03% of Total Billed charges,NA,Not Applicable,39.15,Pays at 90% of Total Billed charges,61.42,Pays at 100% of GA Medicaid Fee Schedule,NA,Not Applicable,61.42,Pays at 100% of GA Medicaid Fee Schedule,38.28,Pays at 88% of Total Billed charges,63.26,Pays at 103% of GA Medicaid Fee Schedule,34.81,63.26,26.10
Outpatient Medical Services,LAB,88350,IF ADDITIONAL (MAYO),310,358,304.3,Pays at 85% of Billed charges for outpatient setting,61.42,Pays at 100% of GA Medicaid Fee Schedule,286.51,Pays at 80.03% of Total Billed charges,NA,Not Applicable,322.2,Pays at 90% of Total Billed charges,61.42,Pays at 100% of GA Medicaid Fee Schedule,NA,Not Applicable,61.42,Pays at 100% of GA Medicaid Fee Schedule,315.04,Pays at 88% of Total Billed charges,63.26,Pays at 103% of GA Medicaid Fee Schedule,61.42,322.2,214.80
Outpatient Medical Services,LAB,88361,KRAS MUTATION PANEL,300,477.25,405.66,Pays at 85% of Billed charges for outpatient setting,122.28,Pays at 100% of GA Medicaid Fee Schedule,381.94,Pays at 80.03% of Total Billed charges,310.72,Pays at 102% of Medicare OPPS Rate,429.53,Pays at 90% of Total Billed charges,122.28,Pays at 100% of GA Medicaid Fee Schedule,304.63,Pays at 100% of Medicare OPPS Rate,122.28,Pays at 100% of GA Medicaid Fee Schedule,419.98,Pays at 88% of Total Billed charges,125.95,Pays at 103% of GA Medicaid Fee Schedule,122.28,429.53,286.35
Outpatient Medical Services,LAB,88363,EXAM/SELECTION OF RETRIEVED ARCHIVAL,300,27.75,23.59,Pays at 85% of Billed charges for outpatient setting,22.94,Pays at 100% of GA Medicaid Fee Schedule,22.21,Pays at 80.03% of Total Billed charges,23.92,Pays at 102% of Medicare OPPS Rate,24.98,Pays at 90% of Total Billed charges,22.94,Pays at 100% of GA Medicaid Fee Schedule,23.46,Pays at 100% of Medicare OPPS Rate,22.94,Pays at 100% of GA Medicaid Fee Schedule,24.42,Pays at 88% of Total Billed charges,23.63,Pays at 103% of GA Medicaid Fee Schedule,22.21,24.98,16.65
Outpatient Medical Services,LAB,88368,"MORPHO ANALYSIS, IN SITU EACH  (CSI)",310,233,198.05,Pays at 85% of Billed charges for outpatient setting,169.57,Pays at 100% of GA Medicaid Fee Schedule,186.47,Pays at 80.03% of Total Billed charges,310.72,Pays at 102% of Medicare OPPS Rate,209.7,Pays at 90% of Total Billed charges,169.57,Pays at 100% of GA Medicaid Fee Schedule,304.63,Pays at 100% of Medicare OPPS Rate,169.57,Pays at 100% of GA Medicaid Fee Schedule,205.04,Pays at 88% of Total Billed charges,174.66,Pays at 103% of GA Medicaid Fee Schedule,169.57,310.72,139.80
Outpatient Medical Services,LAB,88368,UROVYSION FOR BLADDER CANCER  (MAYO),310,706.25,600.31,Pays at 85% of Billed charges for outpatient setting,169.57,Pays at 100% of GA Medicaid Fee Schedule,565.21,Pays at 80.03% of Total Billed charges,310.72,Pays at 102% of Medicare OPPS Rate,635.63,Pays at 90% of Total Billed charges,169.57,Pays at 100% of GA Medicaid Fee Schedule,304.63,Pays at 100% of Medicare OPPS Rate,169.57,Pays at 100% of GA Medicaid Fee Schedule,621.5,Pays at 88% of Total Billed charges,174.66,Pays at 103% of GA Medicaid Fee Schedule,169.57,635.63,423.75
Outpatient Medical Services,LAB,88377,FISH EA MULTIPLEX STAIN   (CSI),310,465.75,395.89,Pays at 85% of Billed charges for outpatient setting,181.64,Pays at 100% of GA Medicaid Fee Schedule,372.74,Pays at 80.03% of Total Billed charges,150.75,Pays at 102% of Medicare OPPS Rate,419.18,Pays at 90% of Total Billed charges,181.64,Pays at 100% of GA Medicaid Fee Schedule,147.8,Pays at 100% of Medicare OPPS Rate,181.64,Pays at 100% of GA Medicaid Fee Schedule,409.86,Pays at 88% of Total Billed charges,187.09,Pays at 103% of GA Medicaid Fee Schedule,147.8,419.18,279.45
Outpatient Medical Services,LAB,88720,"BILIRUBIN, TRANSCUT",301,12.71,10.8,Pays at 85% of Billed charges for outpatient setting,4.09,Pays at 32.15% of Total Billed charges,10.17,Pays at 80.03% of Total Billed charges,5.12,Pays at 102% of Medicare OPPS Rate,11.44,Pays at 90% of Total Billed charges,4.09,Pays at 32.15% of Total Billed charges,5.01,Pays at 100% of Medicare OPPS Rate,4.09,Pays at 32.15% of Total Billed charges,11.18,Pays at 88% of Total Billed charges,4.21,Pays at 33.11% of Total Billed charges,4.09,11.44,7.63
Outpatient Medical Services,LAB,89051,BODY FLUID CELL COUNT AND DIFF (NEGMC),300,45,38.25,Pays at 85% of Billed charges for outpatient setting,2.21,Pays at 100% of GA Medicaid Fee Schedule,36.01,Pays at 80.03% of Total Billed charges,5.71,Pays at 102% of Medicare OPPS Rate,40.5,Pays at 90% of Total Billed charges,2.21,Pays at 100% of GA Medicaid Fee Schedule,5.6,Pays at 100% of Medicare OPPS Rate,2.21,Pays at 100% of GA Medicaid Fee Schedule,39.6,Pays at 88% of Total Billed charges,2.28,Pays at 103% of GA Medicaid Fee Schedule,2.21,40.5,27.00
Outpatient Medical Services,LAB,89051,FLUID CELL COUNT/DIFF,300,62,52.7,Pays at 85% of Billed charges for outpatient setting,2.21,Pays at 100% of GA Medicaid Fee Schedule,49.62,Pays at 80.03% of Total Billed charges,5.71,Pays at 102% of Medicare OPPS Rate,55.8,Pays at 90% of Total Billed charges,2.21,Pays at 100% of GA Medicaid Fee Schedule,5.6,Pays at 100% of Medicare OPPS Rate,2.21,Pays at 100% of GA Medicaid Fee Schedule,54.56,Pays at 88% of Total Billed charges,2.28,Pays at 103% of GA Medicaid Fee Schedule,2.21,55.8,37.20
Outpatient Medical Services,LAB,89055,"SMEAR FOR WBC, STOOL",300,39.25,33.36,Pays at 85% of Billed charges for outpatient setting,2.95,Pays at 100% of GA Medicaid Fee Schedule,31.41,Pays at 80.03% of Total Billed charges,4.35,Pays at 102% of Medicare OPPS Rate,35.33,Pays at 90% of Total Billed charges,2.95,Pays at 100% of GA Medicaid Fee Schedule,4.26,Pays at 100% of Medicare OPPS Rate,2.95,Pays at 100% of GA Medicaid Fee Schedule,34.54,Pays at 88% of Total Billed charges,3.04,Pays at 103% of GA Medicaid Fee Schedule,2.95,35.33,23.55
Outpatient Medical Services,LAB,89060,CRYSTAL ANALYSIS,300,38.5,32.73,Pays at 85% of Billed charges for outpatient setting,8.99,Pays at 100% of GA Medicaid Fee Schedule,30.81,Pays at 80.03% of Total Billed charges,7.47,Pays at 102% of Medicare OPPS Rate,34.65,Pays at 90% of Total Billed charges,8.99,Pays at 100% of GA Medicaid Fee Schedule,7.33,Pays at 100% of Medicare OPPS Rate,8.99,Pays at 100% of GA Medicaid Fee Schedule,33.88,Pays at 88% of Total Billed charges,9.26,Pays at 103% of GA Medicaid Fee Schedule,7.33,34.65,23.10
Outpatient Medical Services,LAB,89060,CRYSTAL ANALYSIS (ANMED),300,45,38.25,Pays at 85% of Billed charges for outpatient setting,8.99,Pays at 100% of GA Medicaid Fee Schedule,36.01,Pays at 80.03% of Total Billed charges,7.47,Pays at 102% of Medicare OPPS Rate,40.5,Pays at 90% of Total Billed charges,8.99,Pays at 100% of GA Medicaid Fee Schedule,7.33,Pays at 100% of Medicare OPPS Rate,8.99,Pays at 100% of GA Medicaid Fee Schedule,39.6,Pays at 88% of Total Billed charges,9.26,Pays at 103% of GA Medicaid Fee Schedule,7.33,40.5,27.00
Outpatient Medical Services,LAB,89060,URIC ACID CRYSTALS,300,49.75,42.29,Pays at 85% of Billed charges for outpatient setting,8.99,Pays at 100% of GA Medicaid Fee Schedule,39.81,Pays at 80.03% of Total Billed charges,7.47,Pays at 102% of Medicare OPPS Rate,44.78,Pays at 90% of Total Billed charges,8.99,Pays at 100% of GA Medicaid Fee Schedule,7.33,Pays at 100% of Medicare OPPS Rate,8.99,Pays at 100% of GA Medicaid Fee Schedule,43.78,Pays at 88% of Total Billed charges,9.26,Pays at 103% of GA Medicaid Fee Schedule,7.33,44.78,29.85
Outpatient Medical Services,LAB,89125,"..FECAL FAT STAIN, QL",300,45,38.25,Pays at 85% of Billed charges for outpatient setting,5.43,Pays at 100% of GA Medicaid Fee Schedule,36.01,Pays at 80.03% of Total Billed charges,5.99,Pays at 102% of Medicare OPPS Rate,40.5,Pays at 90% of Total Billed charges,5.43,Pays at 100% of GA Medicaid Fee Schedule,5.88,Pays at 100% of Medicare OPPS Rate,5.43,Pays at 100% of GA Medicaid Fee Schedule,39.6,Pays at 88% of Total Billed charges,5.59,Pays at 103% of GA Medicaid Fee Schedule,5.43,40.5,27.00
Outpatient Medical Services,LAB,89125,"FECAL FAT STAIN, QL OIL RED",300,49.75,42.29,Pays at 85% of Billed charges for outpatient setting,5.43,Pays at 100% of GA Medicaid Fee Schedule,39.81,Pays at 80.03% of Total Billed charges,5.99,Pays at 102% of Medicare OPPS Rate,44.78,Pays at 90% of Total Billed charges,5.43,Pays at 100% of GA Medicaid Fee Schedule,5.88,Pays at 100% of Medicare OPPS Rate,5.43,Pays at 100% of GA Medicaid Fee Schedule,43.78,Pays at 88% of Total Billed charges,5.59,Pays at 103% of GA Medicaid Fee Schedule,5.43,44.78,29.85
Outpatient Medical Services,LAB,89300,..SEMEN MORPHOLOGY (SMEAR),300,66.9,56.87,Pays at 85% of Billed charges for outpatient setting,11.21,Pays at 100% of GA Medicaid Fee Schedule,53.54,Pays at 80.03% of Total Billed charges,10.03,Pays at 102% of Medicare OPPS Rate,60.21,Pays at 90% of Total Billed charges,11.21,Pays at 100% of GA Medicaid Fee Schedule,9.84,Pays at 100% of Medicare OPPS Rate,11.21,Pays at 100% of GA Medicaid Fee Schedule,58.87,Pays at 88% of Total Billed charges,11.55,Pays at 103% of GA Medicaid Fee Schedule,9.84,60.21,40.14
Outpatient Medical Services,LAB,89321,SEMEN ANALYSIS (POST VASEC),300,66.9,56.87,Pays at 85% of Billed charges for outpatient setting,7.25,Pays at 100% of GA Medicaid Fee Schedule,53.54,Pays at 80.03% of Total Billed charges,12.29,Pays at 102% of Medicare OPPS Rate,60.21,Pays at 90% of Total Billed charges,7.25,Pays at 100% of GA Medicaid Fee Schedule,12.05,Pays at 100% of Medicare OPPS Rate,7.25,Pays at 100% of GA Medicaid Fee Schedule,58.87,Pays at 88% of Total Billed charges,7.47,Pays at 103% of GA Medicaid Fee Schedule,7.25,60.21,40.14
Outpatient Medical Services,LAB,89322,SEMEN ANALYSIS (TOTAL),300,115,97.75,Pays at 85% of Billed charges for outpatient setting,14.51,Pays at 100% of GA Medicaid Fee Schedule,92.03,Pays at 80.03% of Total Billed charges,15.81,Pays at 102% of Medicare OPPS Rate,103.5,Pays at 90% of Total Billed charges,14.51,Pays at 100% of GA Medicaid Fee Schedule,15.5,Pays at 100% of Medicare OPPS Rate,14.51,Pays at 100% of GA Medicaid Fee Schedule,101.2,Pays at 88% of Total Billed charges,14.95,Pays at 103% of GA Medicaid Fee Schedule,14.51,103.5,69.00
Outpatient Medical Services,LAB,81003,Automated urinalysis test,300,4.62,3.93,Pays at 85% of Billed charges for outpatient setting,2.83,Pays at 100% of GA Medicaid Fee Schedule,3.7,Pays at 80.03% of Total Billed charges,2.29,Pays at 102% of Medicare OPPS Rate,4.16,Pays at 90% of Total Billed charges,2.83,Pays at 100% of GA Medicaid Fee Schedule,2.25,Pays at 100% of Medicare OPPS Rate,2.83,Pays at 100% of GA Medicaid Fee Schedule,4.07,Pays at 88% of Total Billed charges,2.91,Pays at 103% of GA Medicaid Fee Schedule,2.25,4.16,2.77
Outpatient Medical Services,LAB,81003,Automated urinalysis test,300,24.75,21.04,Pays at 85% of Billed charges for outpatient setting,2.83,Pays at 100% of GA Medicaid Fee Schedule,19.81,Pays at 80.03% of Total Billed charges,2.29,Pays at 102% of Medicare OPPS Rate,22.28,Pays at 90% of Total Billed charges,2.83,Pays at 100% of GA Medicaid Fee Schedule,2.25,Pays at 100% of Medicare OPPS Rate,2.83,Pays at 100% of GA Medicaid Fee Schedule,21.78,Pays at 88% of Total Billed charges,2.91,Pays at 103% of GA Medicaid Fee Schedule,2.25,22.28,14.85
Outpatient Medical Services,LAB,88104,CYTOPATHOLOGY FLUID,310,194,164.9,Pays at 85% of Billed charges for outpatient setting,42.68,Pays at 100% of GA Medicaid Fee Schedule,155.26,Pays at 80.03% of Total Billed charges,32.54,Pays at 102% of Medicare OPPS Rate,174.6,Pays at 90% of Total Billed charges,42.68,Pays at 100% of GA Medicaid Fee Schedule,31.91,Pays at 100% of Medicare OPPS Rate,42.68,Pays at 100% of GA Medicaid Fee Schedule,170.72,Pays at 88% of Total Billed charges,43.96,Pays at 103% of GA Medicaid Fee Schedule,31.91,174.6,116.40
Outpatient Medical Services,LAB,0027U,JAK2 EXON 12 MUTATION DETECTION (MAYO),300,577.75,491.09,Pays at 85% of Billed charges for outpatient setting,185.75,Pays at 32.15% of Total Billed charges,462.37,Pays at 80.03% of Total Billed charges,124.34,Pays at 102% of Medicare OPPS Rate,519.98,Pays at 90% of Total Billed charges,185.75,Pays at 32.15% of Total Billed charges,121.91,Pays at 100% of Medicare OPPS Rate,185.75,Pays at 32.15% of Total Billed charges,508.42,Pays at 88% of Total Billed charges,191.29,Pays at 33.11% of Total Billed charges,121.91,519.98,346.65
Outpatient Medical Services,LAB,0097U,GI PANEL PATHOGEN PCR (MAYO),300,1361.4,1157.19,Pays at 85% of Billed charges for outpatient setting,437.69,Pays at 32.15% of Total Billed charges,1089.53,Pays at 80.03% of Total Billed charges,1361.4,Not Applicable,1225.26,Pays at 90% of Total Billed charges,437.69,Pays at 32.15% of Total Billed charges,1361.4,Not Applicable,437.69,Pays at 32.15% of Total Billed charges,1198.03,Pays at 88% of Total Billed charges,450.76,Pays at 33.11% of Total Billed charges,437.69,1361.4,816.84
Outpatient Medical Services,LAB,0099U,VIRAL RESPIRATORY PANEL PCR (MAYO),300,1318.75,1120.94,Pays at 85% of Billed charges for outpatient setting,423.98,Pays at 32.15% of Total Billed charges,1055.4,Pays at 80.03% of Total Billed charges,1318.75,Not Applicable,1186.88,Pays at 90% of Total Billed charges,423.98,Pays at 32.15% of Total Billed charges,1318.75,Not Applicable,423.98,Pays at 32.15% of Total Billed charges,1160.5,Pays at 88% of Total Billed charges,436.64,Pays at 33.11% of Total Billed charges,423.98,1318.75,791.25
Outpatient Medical Services,LAB,0241U,COVID 4 PLEX PCR,300,425,361.25,Pays at 85% of Billed charges for outpatient setting,142.63,Pays at 100% of GA Medicaid Fee Schedule,340.13,Pays at 80.03% of Total Billed charges,145.48,Pays at 102% of Medicare OPPS Rate,382.5,Pays at 90% of Total Billed charges,142.63,Pays at 100% of GA Medicaid Fee Schedule,142.63,Pays at 100% of Medicare OPPS Rate,142.63,Pays at 100% of GA Medicaid Fee Schedule,374,Pays at 88% of Total Billed charges,146.91,Pays at 103% of GA Medicaid Fee Schedule,142.63,382.5,255.00
Outpatient Medical Services,LAB,82575,ISTAT (CREATININE-CLEARANCE),300,68,57.8,Pays at 85% of Billed charges for outpatient setting,11.88,Pays at 100% of GA Medicaid Fee Schedule,54.42,Pays at 80.03% of Total Billed charges,9.64,Pays at 102% of Medicare OPPS Rate,61.2,Pays at 90% of Total Billed charges,11.88,Pays at 100% of GA Medicaid Fee Schedule,9.46,Pays at 100% of Medicare OPPS Rate,11.88,Pays at 100% of GA Medicaid Fee Schedule,59.84,Pays at 88% of Total Billed charges,12.24,Pays at 103% of GA Medicaid Fee Schedule,9.46,61.2,40.80
Outpatient Medical Services,LAB,82575,ISTAT (CREATININE),300,81.75,69.49,Pays at 85% of Billed charges for outpatient setting,11.88,Pays at 100% of GA Medicaid Fee Schedule,65.42,Pays at 80.03% of Total Billed charges,9.64,Pays at 102% of Medicare OPPS Rate,73.58,Pays at 90% of Total Billed charges,11.88,Pays at 100% of GA Medicaid Fee Schedule,9.46,Pays at 100% of Medicare OPPS Rate,11.88,Pays at 100% of GA Medicaid Fee Schedule,71.94,Pays at 88% of Total Billed charges,12.24,Pays at 103% of GA Medicaid Fee Schedule,9.46,73.58,49.05
Outpatient Medical Services,LAB,82947,Quantitative measure of glucose build up in the blood over time,300,7.5,6.38,Pays at 85% of Billed charges for outpatient setting,4.93,Pays at 100% of GA Medicaid Fee Schedule,6,Pays at 80.03% of Total Billed charges,4,Pays at 102% of Medicare OPPS Rate,6.75,Pays at 90% of Total Billed charges,4.93,Pays at 100% of GA Medicaid Fee Schedule,3.93,Pays at 100% of Medicare OPPS Rate,4.93,Pays at 100% of GA Medicaid Fee Schedule,6.6,Pays at 88% of Total Billed charges,5.08,Pays at 103% of GA Medicaid Fee Schedule,3.93,6.75,4.50
Outpatient Medical Services,LAB,82947,Quantitative measure of glucose build up in the blood over time,300,9.02,7.67,Pays at 85% of Billed charges for outpatient setting,4.93,Pays at 100% of GA Medicaid Fee Schedule,7.22,Pays at 80.03% of Total Billed charges,4,Pays at 102% of Medicare OPPS Rate,8.12,Pays at 90% of Total Billed charges,4.93,Pays at 100% of GA Medicaid Fee Schedule,3.93,Pays at 100% of Medicare OPPS Rate,4.93,Pays at 100% of GA Medicaid Fee Schedule,7.94,Pays at 88% of Total Billed charges,5.08,Pays at 103% of GA Medicaid Fee Schedule,3.93,8.12,5.41
Outpatient Medical Services,LAB,82947,Quantitative measure of glucose build up in the blood over time,300,31.37,26.66,Pays at 85% of Billed charges for outpatient setting,4.93,Pays at 100% of GA Medicaid Fee Schedule,25.11,Pays at 80.03% of Total Billed charges,4,Pays at 102% of Medicare OPPS Rate,28.23,Pays at 90% of Total Billed charges,4.93,Pays at 100% of GA Medicaid Fee Schedule,3.93,Pays at 100% of Medicare OPPS Rate,4.93,Pays at 100% of GA Medicaid Fee Schedule,27.61,Pays at 88% of Total Billed charges,5.08,Pays at 103% of GA Medicaid Fee Schedule,3.93,28.23,18.82
Outpatient Medical Services,LAB,82947,Quantitative measure of glucose build up in the blood over time,300,31.37,26.66,Pays at 85% of Billed charges for outpatient setting,4.93,Pays at 100% of GA Medicaid Fee Schedule,25.11,Pays at 80.03% of Total Billed charges,4,Pays at 102% of Medicare OPPS Rate,28.23,Pays at 90% of Total Billed charges,4.93,Pays at 100% of GA Medicaid Fee Schedule,3.93,Pays at 100% of Medicare OPPS Rate,4.93,Pays at 100% of GA Medicaid Fee Schedule,27.61,Pays at 88% of Total Billed charges,5.08,Pays at 103% of GA Medicaid Fee Schedule,3.93,28.23,18.82
Outpatient Medical Services,LAB,82947,Quantitative measure of glucose build up in the blood over time,300,33.01,28.06,Pays at 85% of Billed charges for outpatient setting,4.93,Pays at 100% of GA Medicaid Fee Schedule,26.42,Pays at 80.03% of Total Billed charges,4,Pays at 102% of Medicare OPPS Rate,29.71,Pays at 90% of Total Billed charges,4.93,Pays at 100% of GA Medicaid Fee Schedule,3.93,Pays at 100% of Medicare OPPS Rate,4.93,Pays at 100% of GA Medicaid Fee Schedule,29.05,Pays at 88% of Total Billed charges,5.08,Pays at 103% of GA Medicaid Fee Schedule,3.93,29.71,19.81
Outpatient Medical Services,LAB,82947,Quantitative measure of glucose build up in the blood over time,300,33.01,28.06,Pays at 85% of Billed charges for outpatient setting,4.93,Pays at 100% of GA Medicaid Fee Schedule,26.42,Pays at 80.03% of Total Billed charges,4,Pays at 102% of Medicare OPPS Rate,29.71,Pays at 90% of Total Billed charges,4.93,Pays at 100% of GA Medicaid Fee Schedule,3.93,Pays at 100% of Medicare OPPS Rate,4.93,Pays at 100% of GA Medicaid Fee Schedule,29.05,Pays at 88% of Total Billed charges,5.08,Pays at 103% of GA Medicaid Fee Schedule,3.93,29.71,19.81
Outpatient Medical Services,LAB,82947,Quantitative measure of glucose build up in the blood over time,300,40,34,Pays at 85% of Billed charges for outpatient setting,4.93,Pays at 100% of GA Medicaid Fee Schedule,32.01,Pays at 80.03% of Total Billed charges,4,Pays at 102% of Medicare OPPS Rate,36,Pays at 90% of Total Billed charges,4.93,Pays at 100% of GA Medicaid Fee Schedule,3.93,Pays at 100% of Medicare OPPS Rate,4.93,Pays at 100% of GA Medicaid Fee Schedule,35.2,Pays at 88% of Total Billed charges,5.08,Pays at 103% of GA Medicaid Fee Schedule,3.93,36,24.00
Outpatient Medical Services,LAB,82947,Quantitative measure of glucose build up in the blood over time,300,40.25,34.21,Pays at 85% of Billed charges for outpatient setting,4.93,Pays at 100% of GA Medicaid Fee Schedule,32.21,Pays at 80.03% of Total Billed charges,4,Pays at 102% of Medicare OPPS Rate,36.23,Pays at 90% of Total Billed charges,4.93,Pays at 100% of GA Medicaid Fee Schedule,3.93,Pays at 100% of Medicare OPPS Rate,4.93,Pays at 100% of GA Medicaid Fee Schedule,35.42,Pays at 88% of Total Billed charges,5.08,Pays at 103% of GA Medicaid Fee Schedule,3.93,36.23,24.15
Outpatient Medical Services,LAB,82947,Quantitative measure of glucose build up in the blood over time,300,40.25,34.21,Pays at 85% of Billed charges for outpatient setting,4.93,Pays at 100% of GA Medicaid Fee Schedule,32.21,Pays at 80.03% of Total Billed charges,4,Pays at 102% of Medicare OPPS Rate,36.23,Pays at 90% of Total Billed charges,4.93,Pays at 100% of GA Medicaid Fee Schedule,3.93,Pays at 100% of Medicare OPPS Rate,4.93,Pays at 100% of GA Medicaid Fee Schedule,35.42,Pays at 88% of Total Billed charges,5.08,Pays at 103% of GA Medicaid Fee Schedule,3.93,36.23,24.15
Outpatient Medical Services,LAB,82947,Quantitative measure of glucose build up in the blood over time,300,40.25,34.21,Pays at 85% of Billed charges for outpatient setting,4.93,Pays at 100% of GA Medicaid Fee Schedule,32.21,Pays at 80.03% of Total Billed charges,4,Pays at 102% of Medicare OPPS Rate,36.23,Pays at 90% of Total Billed charges,4.93,Pays at 100% of GA Medicaid Fee Schedule,3.93,Pays at 100% of Medicare OPPS Rate,4.93,Pays at 100% of GA Medicaid Fee Schedule,35.42,Pays at 88% of Total Billed charges,5.08,Pays at 103% of GA Medicaid Fee Schedule,3.93,36.23,24.15
Outpatient Medical Services,LAB,87798,"H PYLORI + CLARI RESIST, PCR, F (MAYO)",300,387.55,329.42,Pays at 85% of Billed charges for outpatient setting,24.67,Pays at 100% of GA Medicaid Fee Schedule,310.16,Pays at 80.03% of Total Billed charges,35.79,Pays at 102% of Medicare OPPS Rate,348.8,Pays at 90% of Total Billed charges,24.67,Pays at 100% of GA Medicaid Fee Schedule,35.09,Pays at 100% of Medicare OPPS Rate,24.67,Pays at 100% of GA Medicaid Fee Schedule,341.04,Pays at 88% of Total Billed charges,25.41,Pays at 103% of GA Medicaid Fee Schedule,24.67,348.8,232.53
Outpatient Medical Services,LAB,88160,NON-GYN INTERPRETATION ONLY,310,138.75,117.94,Pays at 85% of Billed charges for outpatient setting,46.13,Pays at 100% of GA Medicaid Fee Schedule,111.04,Pays at 80.03% of Total Billed charges,23.92,Pays at 102% of Medicare OPPS Rate,124.88,Pays at 90% of Total Billed charges,46.13,Pays at 100% of GA Medicaid Fee Schedule,23.46,Pays at 100% of Medicare OPPS Rate,46.13,Pays at 100% of GA Medicaid Fee Schedule,122.1,Pays at 88% of Total Billed charges,47.51,Pays at 103% of GA Medicaid Fee Schedule,23.46,124.88,83.25
Outpatient Medical Services,LAB,88300,TISSUE GROSS ONLY,310,79.75,67.79,Pays at 85% of Billed charges for outpatient setting,14.3,Pays at 100% of GA Medicaid Fee Schedule,63.82,Pays at 80.03% of Total Billed charges,23.92,Pays at 102% of Medicare OPPS Rate,71.78,Pays at 90% of Total Billed charges,14.3,Pays at 100% of GA Medicaid Fee Schedule,23.46,Pays at 100% of Medicare OPPS Rate,14.3,Pays at 100% of GA Medicaid Fee Schedule,70.18,Pays at 88% of Total Billed charges,14.73,Pays at 103% of GA Medicaid Fee Schedule,14.3,71.78,47.85
Outpatient Medical Services,LAB,88302,GROUP I FOR ID PURPOSES,310,82.75,70.34,Pays at 85% of Billed charges for outpatient setting,35.06,Pays at 100% of GA Medicaid Fee Schedule,66.22,Pays at 80.03% of Total Billed charges,23.92,Pays at 102% of Medicare OPPS Rate,74.48,Pays at 90% of Total Billed charges,35.06,Pays at 100% of GA Medicaid Fee Schedule,23.46,Pays at 100% of Medicare OPPS Rate,35.06,Pays at 100% of GA Medicaid Fee Schedule,72.82,Pays at 88% of Total Billed charges,36.11,Pays at 103% of GA Medicaid Fee Schedule,23.46,74.48,49.65
Outpatient Medical Services,LAB,88304,SMALL UNCOMPLICATED SPECIMEN,310,173.44,147.42,Pays at 85% of Billed charges for outpatient setting,30.18,Pays at 100% of GA Medicaid Fee Schedule,138.8,Pays at 80.03% of Total Billed charges,48.06,Pays at 102% of Medicare OPPS Rate,156.1,Pays at 90% of Total Billed charges,30.18,Pays at 100% of GA Medicaid Fee Schedule,47.12,Pays at 100% of Medicare OPPS Rate,30.18,Pays at 100% of GA Medicaid Fee Schedule,152.63,Pays at 88% of Total Billed charges,31.09,Pays at 103% of GA Medicaid Fee Schedule,30.18,156.1,104.06
Outpatient Medical Services,LAB,88305,Test of tissues for diagnosis of abnormalities,310,189.25,160.86,Pays at 85% of Billed charges for outpatient setting,65.88,Pays at 100% of GA Medicaid Fee Schedule,151.46,Pays at 80.03% of Total Billed charges,48.06,Pays at 102% of Medicare OPPS Rate,170.33,Pays at 90% of Total Billed charges,65.88,Pays at 100% of GA Medicaid Fee Schedule,47.12,Pays at 100% of Medicare OPPS Rate,65.88,Pays at 100% of GA Medicaid Fee Schedule,166.54,Pays at 88% of Total Billed charges,67.86,Pays at 103% of GA Medicaid Fee Schedule,47.12,170.33,113.55
Outpatient Medical Services,LAB,88307,LARGER COMPLEX SPECIMEN,310,337.19,286.61,Pays at 85% of Billed charges for outpatient setting,133.3,Pays at 100% of GA Medicaid Fee Schedule,269.85,Pays at 80.03% of Total Billed charges,310.72,Pays at 102% of Medicare OPPS Rate,303.47,Pays at 90% of Total Billed charges,133.3,Pays at 100% of GA Medicaid Fee Schedule,304.63,Pays at 100% of Medicare OPPS Rate,133.3,Pays at 100% of GA Medicaid Fee Schedule,296.73,Pays at 88% of Total Billed charges,137.3,Pays at 103% of GA Medicaid Fee Schedule,133.3,310.72,202.31
Outpatient Medical Services,LAB,88309,COMPREHENSIVE EXAM,310,1399.25,1189.36,Pays at 85% of Billed charges for outpatient setting,187.78,Pays at 100% of GA Medicaid Fee Schedule,1119.82,Pays at 80.03% of Total Billed charges,744.44,Pays at 102% of Medicare OPPS Rate,1259.33,Pays at 90% of Total Billed charges,187.78,Pays at 100% of GA Medicaid Fee Schedule,729.84,Pays at 100% of Medicare OPPS Rate,187.78,Pays at 100% of GA Medicaid Fee Schedule,1231.34,Pays at 88% of Total Billed charges,193.41,Pays at 103% of GA Medicaid Fee Schedule,187.78,1259.33,839.55
Outpatient Medical Services,LAB,88311,DECALCIFICATION,310,119.5,101.58,Pays at 85% of Billed charges for outpatient setting,15.45,Pays at 100% of GA Medicaid Fee Schedule,95.64,Pays at 80.03% of Total Billed charges,NA,Not Applicable,107.55,Pays at 90% of Total Billed charges,15.45,Pays at 100% of GA Medicaid Fee Schedule,NA,Not Applicable,15.45,Pays at 100% of GA Medicaid Fee Schedule,105.16,Pays at 88% of Total Billed charges,15.91,Pays at 103% of GA Medicaid Fee Schedule,15.45,107.55,71.70
Outpatient Medical Services,LAB,88313,Blood test to assist with diagnosis,310,245.25,208.46,Pays at 85% of Billed charges for outpatient setting,44.91,Pays at 100% of GA Medicaid Fee Schedule,196.27,Pays at 80.03% of Total Billed charges,32.54,Pays at 102% of Medicare OPPS Rate,220.73,Pays at 90% of Total Billed charges,44.91,Pays at 100% of GA Medicaid Fee Schedule,31.91,Pays at 100% of Medicare OPPS Rate,44.91,Pays at 100% of GA Medicaid Fee Schedule,215.82,Pays at 88% of Total Billed charges,46.26,Pays at 103% of GA Medicaid Fee Schedule,31.91,220.73,147.15
Outpatient Medical Services,LAB,88342,Pathology test,310,557.75,474.09,Pays at 85% of Billed charges for outpatient setting,71.58,Pays at 100% of GA Medicaid Fee Schedule,446.37,Pays at 80.03% of Total Billed charges,150.75,Pays at 102% of Medicare OPPS Rate,501.98,Pays at 90% of Total Billed charges,71.58,Pays at 100% of GA Medicaid Fee Schedule,147.8,Pays at 100% of Medicare OPPS Rate,71.58,Pays at 100% of GA Medicaid Fee Schedule,490.82,Pays at 88% of Total Billed charges,73.73,Pays at 103% of GA Medicaid Fee Schedule,71.58,501.98,334.65
Outpatient Medical Services,LAB,88344,"IMMUNHISTOCHEM STAIN, TC  (CSI)",310,219.25,186.36,Pays at 85% of Billed charges for outpatient setting,99.31,Pays at 100% of GA Medicaid Fee Schedule,175.47,Pays at 80.03% of Total Billed charges,310.72,Pays at 102% of Medicare OPPS Rate,197.33,Pays at 90% of Total Billed charges,99.31,Pays at 100% of GA Medicaid Fee Schedule,304.63,Pays at 100% of Medicare OPPS Rate,99.31,Pays at 100% of GA Medicaid Fee Schedule,192.94,Pays at 88% of Total Billed charges,102.29,Pays at 103% of GA Medicaid Fee Schedule,99.31,310.72,131.55
Outpatient Medical Services,LAB,88360,TUMOR IHC ER/PR/HER2,310,557.75,474.09,Pays at 85% of Billed charges for outpatient setting,97.65,Pays at 100% of GA Medicaid Fee Schedule,446.37,Pays at 80.03% of Total Billed charges,150.75,Pays at 102% of Medicare OPPS Rate,501.98,Pays at 90% of Total Billed charges,97.65,Pays at 100% of GA Medicaid Fee Schedule,147.8,Pays at 100% of Medicare OPPS Rate,97.65,Pays at 100% of GA Medicaid Fee Schedule,490.82,Pays at 88% of Total Billed charges,100.58,Pays at 103% of GA Medicaid Fee Schedule,97.65,501.98,334.65
Outpatient Medical Services,LAB,88365,EBER (FISH PROBE)  (CSI),310,250.25,212.71,Pays at 85% of Billed charges for outpatient setting,88.18,Pays at 100% of GA Medicaid Fee Schedule,200.28,Pays at 80.03% of Total Billed charges,150.75,Pays at 102% of Medicare OPPS Rate,225.23,Pays at 90% of Total Billed charges,88.18,Pays at 100% of GA Medicaid Fee Schedule,147.8,Pays at 100% of Medicare OPPS Rate,88.18,Pays at 100% of GA Medicaid Fee Schedule,220.22,Pays at 88% of Total Billed charges,90.83,Pays at 103% of GA Medicaid Fee Schedule,88.18,225.23,150.15
Outpatient Medical Services,LAB,88367,HER2/NEU FISH-TC   (CSI),310,543.25,461.76,Pays at 85% of Billed charges for outpatient setting,187.35,Pays at 100% of GA Medicaid Fee Schedule,434.76,Pays at 80.03% of Total Billed charges,310.72,Pays at 102% of Medicare OPPS Rate,488.93,Pays at 90% of Total Billed charges,187.35,Pays at 100% of GA Medicaid Fee Schedule,304.63,Pays at 100% of Medicare OPPS Rate,187.35,Pays at 100% of GA Medicaid Fee Schedule,478.06,Pays at 88% of Total Billed charges,192.97,Pays at 103% of GA Medicaid Fee Schedule,187.35,488.93,325.95
Outpatient Medical Services,LAB,C9803,SPEC. COLLECTION FEE-LAB (COVID),300,75,63.75,Pays at 85% of Billed charges for outpatient setting,24.11,Pays at 32.15% of Total Billed charges,60.02,Pays at 80.03% of Total Billed charges,23.92,Pays at 102% of Medicare OPPS Rate,67.5,Pays at 90% of Total Billed charges,24.11,Pays at 32.15% of Total Billed charges,23.46,Pays at 100% of Medicare OPPS Rate,24.11,Pays at 32.15% of Total Billed charges,66,Pays at 88% of Total Billed charges,24.83,Pays at 33.11% of Total Billed charges,23.46,67.5,45.00
Outpatient Medical Services,LAB,G0001,ARTERIAL SPECIMEN COLLECT,300,10,8.5,Pays at 85% of Billed charges for outpatient setting,3.22,Pays at 32.15% of Total Billed charges,8,Pays at 80.03% of Total Billed charges,NA,Not Applicable,9,Pays at 90% of Total Billed charges,3.22,Pays at 32.15% of Total Billed charges,NA,Not Applicable,3.22,Pays at 32.15% of Total Billed charges,8.8,Pays at 88% of Total Billed charges,3.31,Pays at 33.11% of Total Billed charges,3.22,9,6.00
Outpatient Medical Services,LAB,G0103,Prostate cancer screening; prostate specific antigen test (psa),300,53.51,45.48,Pays at 85% of Billed charges for outpatient setting,25.7,Pays at 100% of GA Medicaid Fee Schedule,42.82,Pays at 80.03% of Total Billed charges,19.69,Pays at 102% of Medicare OPPS Rate,48.16,Pays at 90% of Total Billed charges,25.7,Pays at 100% of GA Medicaid Fee Schedule,19.3,Pays at 100% of Medicare OPPS Rate,25.7,Pays at 100% of GA Medicaid Fee Schedule,47.09,Pays at 88% of Total Billed charges,26.47,Pays at 103% of GA Medicaid Fee Schedule,19.3,48.16,32.11
Outpatient Medical Services,LAB,G0431,"QL, MULTIPLE DRUG CLASS PER ENCOUNTER",300,155.25,131.96,Pays at 85% of Billed charges for outpatient setting,49.91,Pays at 32.15% of Total Billed charges,124.25,Pays at 80.03% of Total Billed charges,NA,Not Applicable,139.73,Pays at 90% of Total Billed charges,49.91,Pays at 32.15% of Total Billed charges,NA,Not Applicable,49.91,Pays at 32.15% of Total Billed charges,136.62,Pays at 88% of Total Billed charges,51.4,Pays at 33.11% of Total Billed charges,49.91,139.73,93.15
Outpatient Medical Services,LAB,S3620,STATE LAB/SCREENING NEWBORN,300,115.83,98.46,Pays at 85% of Billed charges for outpatient setting,37.24,Pays at 32.15% of Total Billed charges,92.7,Pays at 80.03% of Total Billed charges,NA,Not Applicable,104.25,Pays at 90% of Total Billed charges,37.24,Pays at 32.15% of Total Billed charges,NA,Not Applicable,37.24,Pays at 32.15% of Total Billed charges,101.93,Pays at 88% of Total Billed charges,38.35,Pays at 33.11% of Total Billed charges,37.24,104.25,69.50
Outpatient Medical Services,Visit Charges 2,99201,VISIT - NEW PATIENT - LEVEL 1,510,188,159.8,Pays at 85% of Billed charges for outpatient setting,60.44,Pays at 32.15% of Total Billed charges,150.46,Pays at 80.03% of Total Billed charges,NA,Not Applicable,169.2,Pays at 90% of Total Billed charges,60.44,Pays at 32.15% of Total Billed charges,NA,Not Applicable,60.44,Pays at 32.15% of Total Billed charges,165.44,Pays at 88% of Total Billed charges,62.25,Pays at 33.11% of Total Billed charges,60.44,169.2,112.80
Outpatient Medical Services,Visit Charges 2,99202,"New patient office or other outpatient visit, typically 10 minutes",510,235,199.75,Pays at 85% of Billed charges for outpatient setting,75.55,Pays at 32.15% of Total Billed charges,188.07,Pays at 80.03% of Total Billed charges,NA,Not Applicable,211.5,Pays at 90% of Total Billed charges,75.55,Pays at 32.15% of Total Billed charges,NA,Not Applicable,75.55,Pays at 32.15% of Total Billed charges,206.8,Pays at 88% of Total Billed charges,77.81,Pays at 33.11% of Total Billed charges,75.55,211.5,141.00
Outpatient Medical Services,Visit Charges 2,99203,"New patient office or other outpatient visit, typically 30 min",510,400.63,340.54,Pays at 85% of Billed charges for outpatient setting,128.8,Pays at 32.15% of Total Billed charges,320.62,Pays at 80.03% of Total Billed charges,NA,Not Applicable,360.57,Pays at 90% of Total Billed charges,128.8,Pays at 32.15% of Total Billed charges,NA,Not Applicable,128.8,Pays at 32.15% of Total Billed charges,352.55,Pays at 88% of Total Billed charges,132.65,Pays at 33.11% of Total Billed charges,128.8,360.57,240.38
Outpatient Medical Services,Visit Charges 2,99204,"New patient office of other outpatient visit, typically 45 min",510,408.75,347.44,Pays at 85% of Billed charges for outpatient setting,131.41,Pays at 32.15% of Total Billed charges,327.12,Pays at 80.03% of Total Billed charges,NA,Not Applicable,367.88,Pays at 90% of Total Billed charges,131.41,Pays at 32.15% of Total Billed charges,NA,Not Applicable,131.41,Pays at 32.15% of Total Billed charges,359.7,Pays at 88% of Total Billed charges,135.34,Pays at 33.11% of Total Billed charges,131.41,367.88,245.25
Outpatient Medical Services,Visit Charges 2,99205,"New patient office of other outpatient visit, typically 60 min",510,561,476.85,Pays at 85% of Billed charges for outpatient setting,180.36,Pays at 32.15% of Total Billed charges,448.97,Pays at 80.03% of Total Billed charges,NA,Not Applicable,504.9,Pays at 90% of Total Billed charges,180.36,Pays at 32.15% of Total Billed charges,NA,Not Applicable,180.36,Pays at 32.15% of Total Billed charges,493.68,Pays at 88% of Total Billed charges,185.75,Pays at 33.11% of Total Billed charges,180.36,504.9,336.60
Outpatient Medical Services,Visit Charges 2,99211,Outpatient visit of established patient not requiring a physician,760,93,79.05,Pays at 85% of Billed charges for outpatient setting,29.9,Pays at 32.15% of Total Billed charges,74.43,Pays at 80.03% of Total Billed charges,NA,Not Applicable,83.7,Pays at 90% of Total Billed charges,29.9,Pays at 32.15% of Total Billed charges,NA,Not Applicable,29.9,Pays at 32.15% of Total Billed charges,81.84,Pays at 88% of Total Billed charges,30.79,Pays at 33.11% of Total Billed charges,29.9,83.7,55.80
Outpatient Medical Services,Visit Charges 2,99211,Outpatient visit of established patient not requiring a physician,760,93,79.05,Pays at 85% of Billed charges for outpatient setting,29.9,Pays at 32.15% of Total Billed charges,74.43,Pays at 80.03% of Total Billed charges,NA,Not Applicable,83.7,Pays at 90% of Total Billed charges,29.9,Pays at 32.15% of Total Billed charges,NA,Not Applicable,29.9,Pays at 32.15% of Total Billed charges,81.84,Pays at 88% of Total Billed charges,30.79,Pays at 33.11% of Total Billed charges,29.9,83.7,55.80
Outpatient Medical Services,Visit Charges 2,99211,Outpatient visit of established patient not requiring a physician,760,93,79.05,Pays at 85% of Billed charges for outpatient setting,29.9,Pays at 32.15% of Total Billed charges,74.43,Pays at 80.03% of Total Billed charges,NA,Not Applicable,83.7,Pays at 90% of Total Billed charges,29.9,Pays at 32.15% of Total Billed charges,NA,Not Applicable,29.9,Pays at 32.15% of Total Billed charges,81.84,Pays at 88% of Total Billed charges,30.79,Pays at 33.11% of Total Billed charges,29.9,83.7,55.80
Outpatient Medical Services,Visit Charges 2,99211,Outpatient visit of established patient not requiring a physician,760,93,79.05,Pays at 85% of Billed charges for outpatient setting,29.9,Pays at 32.15% of Total Billed charges,74.43,Pays at 80.03% of Total Billed charges,NA,Not Applicable,83.7,Pays at 90% of Total Billed charges,29.9,Pays at 32.15% of Total Billed charges,NA,Not Applicable,29.9,Pays at 32.15% of Total Billed charges,81.84,Pays at 88% of Total Billed charges,30.79,Pays at 33.11% of Total Billed charges,29.9,83.7,55.80
Outpatient Medical Services,Visit Charges 2,99211,Outpatient visit of established patient not requiring a physician,762,93,79.05,Pays at 85% of Billed charges for outpatient setting,29.9,Pays at 32.15% of Total Billed charges,74.43,Pays at 80.03% of Total Billed charges,NA,Not Applicable,83.7,Pays at 90% of Total Billed charges,29.9,Pays at 32.15% of Total Billed charges,NA,Not Applicable,29.9,Pays at 32.15% of Total Billed charges,81.84,Pays at 88% of Total Billed charges,30.79,Pays at 33.11% of Total Billed charges,29.9,83.7,55.80
Outpatient Medical Services,Visit Charges 2,99211,Outpatient visit of established patient not requiring a physician,510,294,249.9,Pays at 85% of Billed charges for outpatient setting,94.52,Pays at 32.15% of Total Billed charges,235.29,Pays at 80.03% of Total Billed charges,NA,Not Applicable,264.6,Pays at 90% of Total Billed charges,94.52,Pays at 32.15% of Total Billed charges,NA,Not Applicable,94.52,Pays at 32.15% of Total Billed charges,258.72,Pays at 88% of Total Billed charges,97.34,Pays at 33.11% of Total Billed charges,94.52,264.6,176.40
Outpatient Medical Services,Visit Charges 2,99212,Outpatient visit of established patient requiring a physician,510,199.06,169.2,Pays at 85% of Billed charges for outpatient setting,64,Pays at 32.15% of Total Billed charges,159.31,Pays at 80.03% of Total Billed charges,NA,Not Applicable,179.15,Pays at 90% of Total Billed charges,64,Pays at 32.15% of Total Billed charges,NA,Not Applicable,64,Pays at 32.15% of Total Billed charges,175.17,Pays at 88% of Total Billed charges,65.91,Pays at 33.11% of Total Billed charges,64,179.15,119.44
Outpatient Medical Services,Visit Charges 2,99213,"Established patient office or other outpatient visit, typically 15 minutes",510,295,250.75,Pays at 85% of Billed charges for outpatient setting,94.84,Pays at 32.15% of Total Billed charges,236.09,Pays at 80.03% of Total Billed charges,NA,Not Applicable,265.5,Pays at 90% of Total Billed charges,94.84,Pays at 32.15% of Total Billed charges,NA,Not Applicable,94.84,Pays at 32.15% of Total Billed charges,259.6,Pays at 88% of Total Billed charges,97.67,Pays at 33.11% of Total Billed charges,94.84,265.5,177.00
Outpatient Medical Services,Visit Charges 2,99214,"Established patient office or other outpatient visit, typically 25 minutes",510,320.5,272.43,Pays at 85% of Billed charges for outpatient setting,103.04,Pays at 32.15% of Total Billed charges,256.5,Pays at 80.03% of Total Billed charges,NA,Not Applicable,288.45,Pays at 90% of Total Billed charges,103.04,Pays at 32.15% of Total Billed charges,NA,Not Applicable,103.04,Pays at 32.15% of Total Billed charges,282.04,Pays at 88% of Total Billed charges,106.12,Pays at 33.11% of Total Billed charges,103.04,288.45,192.30
Outpatient Medical Services,Visit Charges 2,99215,"Established patient office or other outpatient, visit typically 40 minutes",510,411,349.35,Pays at 85% of Billed charges for outpatient setting,132.14,Pays at 32.15% of Total Billed charges,328.92,Pays at 80.03% of Total Billed charges,NA,Not Applicable,369.9,Pays at 90% of Total Billed charges,132.14,Pays at 32.15% of Total Billed charges,NA,Not Applicable,132.14,Pays at 32.15% of Total Billed charges,361.68,Pays at 88% of Total Billed charges,136.08,Pays at 33.11% of Total Billed charges,132.14,369.9,246.60
Outpatient Medical Services,Visit Charges 2,99218,OP OBSERVATION SURG,762,29.25,24.86,Pays at 85% of Billed charges for outpatient setting,9.4,Pays at 32.15% of Total Billed charges,23.41,Pays at 80.03% of Total Billed charges,NA,Not Applicable,26.33,Pays at 90% of Total Billed charges,9.4,Pays at 32.15% of Total Billed charges,NA,Not Applicable,9.4,Pays at 32.15% of Total Billed charges,25.74,Pays at 88% of Total Billed charges,9.68,Pays at 33.11% of Total Billed charges,9.4,26.33,17.55
Outpatient Medical Services,Visit Charges 2,99218,OP OBSERVATION PED,762,29.25,24.86,Pays at 85% of Billed charges for outpatient setting,9.4,Pays at 32.15% of Total Billed charges,23.41,Pays at 80.03% of Total Billed charges,NA,Not Applicable,26.33,Pays at 90% of Total Billed charges,9.4,Pays at 32.15% of Total Billed charges,NA,Not Applicable,9.4,Pays at 32.15% of Total Billed charges,25.74,Pays at 88% of Total Billed charges,9.68,Pays at 33.11% of Total Billed charges,9.4,26.33,17.55
Outpatient Medical Services,Visit Charges 2,99218,OP OBSERVATION OB,762,30.5,25.93,Pays at 85% of Billed charges for outpatient setting,9.81,Pays at 32.15% of Total Billed charges,24.41,Pays at 80.03% of Total Billed charges,NA,Not Applicable,27.45,Pays at 90% of Total Billed charges,9.81,Pays at 32.15% of Total Billed charges,NA,Not Applicable,9.81,Pays at 32.15% of Total Billed charges,26.84,Pays at 88% of Total Billed charges,10.1,Pays at 33.11% of Total Billed charges,9.81,27.45,18.30
Outpatient Medical Services,Visit Charges 2,99218,OP OBSERVATION STEP-DOWN,762,53,45.05,Pays at 85% of Billed charges for outpatient setting,17.04,Pays at 32.15% of Total Billed charges,42.42,Pays at 80.03% of Total Billed charges,NA,Not Applicable,47.7,Pays at 90% of Total Billed charges,17.04,Pays at 32.15% of Total Billed charges,NA,Not Applicable,17.04,Pays at 32.15% of Total Billed charges,46.64,Pays at 88% of Total Billed charges,17.55,Pays at 33.11% of Total Billed charges,17.04,47.7,31.80
Outpatient Medical Services,Visit Charges 2,99218,OP OBSERVATION,762,94.71,80.5,Pays at 85% of Billed charges for outpatient setting,30.45,Pays at 32.15% of Total Billed charges,75.8,Pays at 80.03% of Total Billed charges,NA,Not Applicable,85.24,Pays at 90% of Total Billed charges,30.45,Pays at 32.15% of Total Billed charges,NA,Not Applicable,30.45,Pays at 32.15% of Total Billed charges,83.34,Pays at 88% of Total Billed charges,31.36,Pays at 33.11% of Total Billed charges,30.45,85.24,56.83
Outpatient Medical Services,Visit Charges 2,99218,OP OBSERVATION ICU,762,117.19,99.61,Pays at 85% of Billed charges for outpatient setting,37.68,Pays at 32.15% of Total Billed charges,93.79,Pays at 80.03% of Total Billed charges,NA,Not Applicable,105.47,Pays at 90% of Total Billed charges,37.68,Pays at 32.15% of Total Billed charges,NA,Not Applicable,37.68,Pays at 32.15% of Total Billed charges,103.13,Pays at 88% of Total Billed charges,38.8,Pays at 33.11% of Total Billed charges,37.68,105.47,70.31
Outpatient Medical Services,Visit Charges 2,G0244,OP OBSERVATION,762,29.25,24.86,Pays at 85% of Billed charges for outpatient setting,9.4,Pays at 32.15% of Total Billed charges,23.41,Pays at 80.03% of Total Billed charges,NA,Not Applicable,26.33,Pays at 90% of Total Billed charges,9.4,Pays at 32.15% of Total Billed charges,NA,Not Applicable,9.4,Pays at 32.15% of Total Billed charges,25.74,Pays at 88% of Total Billed charges,9.68,Pays at 33.11% of Total Billed charges,9.4,26.33,17.55
Outpatient Medical Services,Visit Charges 2,G0263,OP OBSERVATION,762,29.25,24.86,Pays at 85% of Billed charges for outpatient setting,9.4,Pays at 32.15% of Total Billed charges,23.41,Pays at 80.03% of Total Billed charges,NA,Not Applicable,26.33,Pays at 90% of Total Billed charges,9.4,Pays at 32.15% of Total Billed charges,NA,Not Applicable,9.4,Pays at 32.15% of Total Billed charges,25.74,Pays at 88% of Total Billed charges,9.68,Pays at 33.11% of Total Billed charges,9.4,26.33,17.55
Outpatient Medical Services,Visit Charges 2,G0264,ICU OBSERVATION,762,87.25,74.16,Pays at 85% of Billed charges for outpatient setting,28.05,Pays at 32.15% of Total Billed charges,69.83,Pays at 80.03% of Total Billed charges,NA,Not Applicable,78.53,Pays at 90% of Total Billed charges,28.05,Pays at 32.15% of Total Billed charges,NA,Not Applicable,28.05,Pays at 32.15% of Total Billed charges,76.78,Pays at 88% of Total Billed charges,28.89,Pays at 33.11% of Total Billed charges,28.05,78.53,52.35
Outpatient Medical Services,Visit Charges 2,G0264,OP OBSERVATION,762,29.25,24.86,Pays at 85% of Billed charges for outpatient setting,9.4,Pays at 32.15% of Total Billed charges,23.41,Pays at 80.03% of Total Billed charges,NA,Not Applicable,26.33,Pays at 90% of Total Billed charges,9.4,Pays at 32.15% of Total Billed charges,NA,Not Applicable,9.4,Pays at 32.15% of Total Billed charges,25.74,Pays at 88% of Total Billed charges,9.68,Pays at 33.11% of Total Billed charges,9.4,26.33,17.55
Outpatient Medical Services,Visit Charges 2,G0463,VISIT - ESTABLISHED PATIENT - LEVEL 1,510,294,249.9,Pays at 85% of Billed charges for outpatient setting,94.52,Pays at 32.15% of Total Billed charges,235.29,Pays at 80.03% of Total Billed charges,115.86,Pays at 102% of Medicare OPPS Rate,264.6,Pays at 90% of Total Billed charges,94.52,Pays at 32.15% of Total Billed charges,113.59,Pays at 100% of Medicare OPPS Rate,94.52,Pays at 32.15% of Total Billed charges,258.72,Pays at 88% of Total Billed charges,97.34,Pays at 33.11% of Total Billed charges,94.52,264.6,176.40
Outpatient Medical Services,RADIOLOGY,19282,MM DIGITAL  MAMMO NEEDLE LOC 2ND LESION,320,477.25,405.66,Pays at 85% of Billed charges for outpatient setting,153.44,Pays at 32.15% of Total Billed charges,381.94,Pays at 80.03% of Total Billed charges,NA,Not Applicable,429.53,Pays at 90% of Total Billed charges,153.44,Pays at 32.15% of Total Billed charges,NA,Not Applicable,153.44,Pays at 32.15% of Total Billed charges,419.98,Pays at 88% of Total Billed charges,158.02,Pays at 33.11% of Total Billed charges,153.44,429.53,286.35
Outpatient Medical Services,RADIOLOGY,19285,"US BRST BX W/WO CLIP, SPECM IMG, INC 1ST",320,1775,1508.75,Pays at 85% of Billed charges for outpatient setting,570.66,Pays at 32.15% of Total Billed charges,1420.53,Pays at 80.03% of Total Billed charges,622.16,Pays at 102% of Medicare OPPS Rate,1597.5,Pays at 90% of Total Billed charges,570.66,Pays at 32.15% of Total Billed charges,609.97,Pays at 100% of Medicare OPPS Rate,570.66,Pays at 32.15% of Total Billed charges,1562,Pays at 88% of Total Billed charges,587.7,Pays at 33.11% of Total Billed charges,570.66,1597.5,1065.00
Outpatient Medical Services,RADIOLOGY,19286,US BREAST LOCALIZATION PLACEMENT 2ND LES,320,719.25,611.36,Pays at 85% of Billed charges for outpatient setting,231.24,Pays at 32.15% of Total Billed charges,575.62,Pays at 80.03% of Total Billed charges,NA,Not Applicable,647.33,Pays at 90% of Total Billed charges,231.24,Pays at 32.15% of Total Billed charges,NA,Not Applicable,231.24,Pays at 32.15% of Total Billed charges,632.94,Pays at 88% of Total Billed charges,238.14,Pays at 33.11% of Total Billed charges,231.24,647.33,431.55
Outpatient Medical Services,RADIOLOGY,19287,MRI TISSUE MARKER PLACEMENT,320,65.75,55.89,Pays at 85% of Billed charges for outpatient setting,21.14,Pays at 32.15% of Total Billed charges,52.62,Pays at 80.03% of Total Billed charges,622.16,Pays at 102% of Medicare OPPS Rate,59.18,Pays at 90% of Total Billed charges,21.14,Pays at 32.15% of Total Billed charges,609.97,Pays at 100% of Medicare OPPS Rate,21.14,Pays at 32.15% of Total Billed charges,57.86,Pays at 88% of Total Billed charges,21.77,Pays at 33.11% of Total Billed charges,21.14,622.16,39.45
Outpatient Medical Services,RADIOLOGY,20220,BONE BIOSPY,320,825,701.25,Pays at 85% of Billed charges for outpatient setting,265.24,Pays at 32.15% of Total Billed charges,660.25,Pays at 80.03% of Total Billed charges,1437.62,Pays at 102% of Medicare OPPS Rate,742.5,Pays at 90% of Total Billed charges,265.24,Pays at 32.15% of Total Billed charges,1409.43,Pays at 100% of Medicare OPPS Rate,265.24,Pays at 32.15% of Total Billed charges,726,Pays at 88% of Total Billed charges,273.16,Pays at 33.11% of Total Billed charges,265.24,1437.62,495.00
Outpatient Medical Services,RADIOLOGY,20225,BONE BIOSPY DEEP,320,825,701.25,Pays at 85% of Billed charges for outpatient setting,265.24,Pays at 32.15% of Total Billed charges,660.25,Pays at 80.03% of Total Billed charges,1437.62,Pays at 102% of Medicare OPPS Rate,742.5,Pays at 90% of Total Billed charges,265.24,Pays at 32.15% of Total Billed charges,1409.43,Pays at 100% of Medicare OPPS Rate,265.24,Pays at 32.15% of Total Billed charges,726,Pays at 88% of Total Billed charges,273.16,Pays at 33.11% of Total Billed charges,265.24,1437.62,495.00
Outpatient Medical Services,RADIOLOGY,23350,INJECT SHOULDER ARTROGRAM,320,63.25,53.76,Pays at 85% of Billed charges for outpatient setting,20.33,Pays at 32.15% of Total Billed charges,50.62,Pays at 80.03% of Total Billed charges,NA,Not Applicable,56.93,Pays at 90% of Total Billed charges,20.33,Pays at 32.15% of Total Billed charges,NA,Not Applicable,20.33,Pays at 32.15% of Total Billed charges,55.66,Pays at 88% of Total Billed charges,20.94,Pays at 33.11% of Total Billed charges,20.33,56.93,37.95
Outpatient Medical Services,RADIOLOGY,36904,MECHANICAL THROMBECTOMY,320,242,205.7,Pays at 85% of Billed charges for outpatient setting,77.8,Pays at 32.15% of Total Billed charges,193.67,Pays at 80.03% of Total Billed charges,5000.02,Pays at 102% of Medicare OPPS Rate,217.8,Pays at 90% of Total Billed charges,77.8,Pays at 32.15% of Total Billed charges,4901.97,Pays at 100% of Medicare OPPS Rate,77.8,Pays at 32.15% of Total Billed charges,212.96,Pays at 88% of Total Billed charges,80.13,Pays at 33.11% of Total Billed charges,77.8,5000.02,145.20
Outpatient Medical Services,RADIOLOGY,62322,Injection of substance into spinal canal of lower back or sacrum using imaging guidance,320,674.75,573.54,Pays at 85% of Billed charges for outpatient setting,216.93,Pays at 32.15% of Total Billed charges,540,Pays at 80.03% of Total Billed charges,816.98,Pays at 102% of Medicare OPPS Rate,607.28,Pays at 90% of Total Billed charges,216.93,Pays at 32.15% of Total Billed charges,800.96,Pays at 100% of Medicare OPPS Rate,216.93,Pays at 32.15% of Total Billed charges,593.78,Pays at 88% of Total Billed charges,223.41,Pays at 33.11% of Total Billed charges,216.93,816.98,404.85
Outpatient Medical Services,RADIOLOGY,62322,Injection of substance into spinal canal of lower back or sacrum using imaging guidance,320,541,459.85,Pays at 85% of Billed charges for outpatient setting,173.93,Pays at 32.15% of Total Billed charges,432.96,Pays at 80.03% of Total Billed charges,816.98,Pays at 102% of Medicare OPPS Rate,486.9,Pays at 90% of Total Billed charges,173.93,Pays at 32.15% of Total Billed charges,800.96,Pays at 100% of Medicare OPPS Rate,173.93,Pays at 32.15% of Total Billed charges,476.08,Pays at 88% of Total Billed charges,179.13,Pays at 33.11% of Total Billed charges,173.93,816.98,324.60
Outpatient Medical Services,RADIOLOGY,62322,Injection of substance into spinal canal of lower back or sacrum using imaging guidance,320,983.5,835.98,Pays at 85% of Billed charges for outpatient setting,316.2,Pays at 32.15% of Total Billed charges,787.1,Pays at 80.03% of Total Billed charges,816.98,Pays at 102% of Medicare OPPS Rate,885.15,Pays at 90% of Total Billed charges,316.2,Pays at 32.15% of Total Billed charges,800.96,Pays at 100% of Medicare OPPS Rate,316.2,Pays at 32.15% of Total Billed charges,865.48,Pays at 88% of Total Billed charges,325.64,Pays at 33.11% of Total Billed charges,316.2,885.15,590.10
Outpatient Medical Services,RADIOLOGY,70100,MANDIBLE <4V,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,70110,MANDIBLE,320,296,251.6,Pays at 85% of Billed charges for outpatient setting,95.16,Pays at 32.15% of Total Billed charges,236.89,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,266.4,Pays at 90% of Total Billed charges,95.16,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,95.16,Pays at 32.15% of Total Billed charges,260.48,Pays at 88% of Total Billed charges,98.01,Pays at 33.11% of Total Billed charges,95.16,266.4,177.60
Outpatient Medical Services,RADIOLOGY,70140,ZYGOMA <3V,320,163.5,138.98,Pays at 85% of Billed charges for outpatient setting,52.57,Pays at 32.15% of Total Billed charges,130.85,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,147.15,Pays at 90% of Total Billed charges,52.57,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,52.57,Pays at 32.15% of Total Billed charges,143.88,Pays at 88% of Total Billed charges,54.13,Pays at 33.11% of Total Billed charges,52.57,147.15,98.10
Outpatient Medical Services,RADIOLOGY,70160,NASAL BONES,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,70200,ORBITS 4V,320,296,251.6,Pays at 85% of Billed charges for outpatient setting,95.16,Pays at 32.15% of Total Billed charges,236.89,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,266.4,Pays at 90% of Total Billed charges,95.16,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,95.16,Pays at 32.15% of Total Billed charges,260.48,Pays at 88% of Total Billed charges,98.01,Pays at 33.11% of Total Billed charges,95.16,266.4,177.60
Outpatient Medical Services,RADIOLOGY,70260,SKULL COMPLETE 4V,320,296,251.6,Pays at 85% of Billed charges for outpatient setting,95.16,Pays at 32.15% of Total Billed charges,236.89,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,266.4,Pays at 90% of Total Billed charges,95.16,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,95.16,Pays at 32.15% of Total Billed charges,260.48,Pays at 88% of Total Billed charges,98.01,Pays at 33.11% of Total Billed charges,95.16,266.4,177.60
Outpatient Medical Services,RADIOLOGY,70360,NECK SOFT TISSUE,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,70360,PORT NECK SOFT TISSUE,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,70380,SALIVARY GLAND CALCULUS,320,194,164.9,Pays at 85% of Billed charges for outpatient setting,62.37,Pays at 32.15% of Total Billed charges,155.26,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,174.6,Pays at 90% of Total Billed charges,62.37,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,62.37,Pays at 32.15% of Total Billed charges,170.72,Pays at 88% of Total Billed charges,64.23,Pays at 33.11% of Total Billed charges,62.37,174.6,116.40
Outpatient Medical Services,RADIOLOGY,70544,MRA HEAD WITHOUT CONTRAST,320,961.5,817.28,Pays at 85% of Billed charges for outpatient setting,309.12,Pays at 32.15% of Total Billed charges,769.49,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,865.35,Pays at 90% of Total Billed charges,309.12,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,309.12,Pays at 32.15% of Total Billed charges,846.12,Pays at 88% of Total Billed charges,318.35,Pays at 33.11% of Total Billed charges,219.48,865.35,576.90
Outpatient Medical Services,RADIOLOGY,71045,Single view,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.28,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,71045,Single view,320,169.5,144.08,Pays at 85% of Billed charges for outpatient setting,54.49,Pays at 32.15% of Total Billed charges,135.65,Pays at 80.03% of Total Billed charges,83.28,Pays at 102% of Medicare OPPS Rate,152.55,Pays at 90% of Total Billed charges,54.49,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,54.49,Pays at 32.15% of Total Billed charges,149.16,Pays at 88% of Total Billed charges,56.12,Pays at 33.11% of Total Billed charges,54.49,152.55,101.70
Outpatient Medical Services,RADIOLOGY,71046,"2 views, front and back",320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.28,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,71047,3 views,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,71100,RIBS UNILAT 2V,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,71110,RIBS BILAT 3V,320,296,251.6,Pays at 85% of Billed charges for outpatient setting,95.16,Pays at 32.15% of Total Billed charges,236.89,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,266.4,Pays at 90% of Total Billed charges,95.16,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,95.16,Pays at 32.15% of Total Billed charges,260.48,Pays at 88% of Total Billed charges,98.01,Pays at 33.11% of Total Billed charges,95.16,266.4,177.60
Outpatient Medical Services,RADIOLOGY,71111,RIBS BILAT 4V,320,296,251.6,Pays at 85% of Billed charges for outpatient setting,95.16,Pays at 32.15% of Total Billed charges,236.89,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,266.4,Pays at 90% of Total Billed charges,95.16,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,95.16,Pays at 32.15% of Total Billed charges,260.48,Pays at 88% of Total Billed charges,98.01,Pays at 33.11% of Total Billed charges,95.16,266.4,177.60
Outpatient Medical Services,RADIOLOGY,71120,STERNUM 2V,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,72040,"Radiologic examination of the neck/spine, 2-3 views",320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,72050,"Radiologic examination of the neck/spine, 4-5 views",320,153.75,130.69,Pays at 85% of Billed charges for outpatient setting,49.43,Pays at 32.15% of Total Billed charges,123.05,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,138.38,Pays at 90% of Total Billed charges,49.43,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,49.43,Pays at 32.15% of Total Billed charges,135.3,Pays at 88% of Total Billed charges,50.91,Pays at 33.11% of Total Billed charges,49.43,138.38,92.25
Outpatient Medical Services,RADIOLOGY,72050,"Radiologic examination of the neck/spine, 4-5 views",320,111,94.35,Pays at 85% of Billed charges for outpatient setting,35.69,Pays at 32.15% of Total Billed charges,88.83,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,99.9,Pays at 90% of Total Billed charges,35.69,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,35.69,Pays at 32.15% of Total Billed charges,97.68,Pays at 88% of Total Billed charges,36.75,Pays at 33.11% of Total Billed charges,35.69,102.46,66.60
Outpatient Medical Services,RADIOLOGY,72080,SPINE THORACOLUMBAR AP/LAT 2 VIEWS,320,141.45,120.23,Pays at 85% of Billed charges for outpatient setting,45.48,Pays at 32.15% of Total Billed charges,113.2,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,127.31,Pays at 90% of Total Billed charges,45.48,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,45.48,Pays at 32.15% of Total Billed charges,124.48,Pays at 88% of Total Billed charges,46.83,Pays at 33.11% of Total Billed charges,45.48,127.31,84.87
Outpatient Medical Services,RADIOLOGY,72170,Radiologic examination of the pelvis,320,115,97.75,Pays at 85% of Billed charges for outpatient setting,36.97,Pays at 32.15% of Total Billed charges,92.03,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,103.5,Pays at 90% of Total Billed charges,36.97,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,36.97,Pays at 32.15% of Total Billed charges,101.2,Pays at 88% of Total Billed charges,38.08,Pays at 33.11% of Total Billed charges,36.97,103.5,69.00
Outpatient Medical Services,RADIOLOGY,72170,Radiologic examination of the pelvis,320,1005.31,854.51,Pays at 85% of Billed charges for outpatient setting,323.21,Pays at 32.15% of Total Billed charges,804.55,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,904.78,Pays at 90% of Total Billed charges,323.21,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,323.21,Pays at 32.15% of Total Billed charges,884.67,Pays at 88% of Total Billed charges,332.86,Pays at 33.11% of Total Billed charges,100.45,904.78,603.19
Outpatient Medical Services,RADIOLOGY,72170,Radiologic examination of the pelvis,320,150,127.5,Pays at 85% of Billed charges for outpatient setting,48.23,Pays at 32.15% of Total Billed charges,120.05,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,135,Pays at 90% of Total Billed charges,48.23,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,48.23,Pays at 32.15% of Total Billed charges,132,Pays at 88% of Total Billed charges,49.67,Pays at 33.11% of Total Billed charges,48.23,135,90.00
Outpatient Medical Services,RADIOLOGY,72170,Radiologic examination of the pelvis,320,296,251.6,Pays at 85% of Billed charges for outpatient setting,95.16,Pays at 32.15% of Total Billed charges,236.89,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,266.4,Pays at 90% of Total Billed charges,95.16,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,95.16,Pays at 32.15% of Total Billed charges,260.48,Pays at 88% of Total Billed charges,98.01,Pays at 33.11% of Total Billed charges,95.16,266.4,177.60
Outpatient Medical Services,RADIOLOGY,72220,SACRUM AND COCCYX 2V,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73000,Radiologic examination of the collar bone,320,199.38,169.47,Pays at 85% of Billed charges for outpatient setting,64.1,Pays at 32.15% of Total Billed charges,159.56,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,179.44,Pays at 90% of Total Billed charges,64.1,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,64.1,Pays at 32.15% of Total Billed charges,175.45,Pays at 88% of Total Billed charges,66.01,Pays at 33.11% of Total Billed charges,64.1,179.44,119.63
Outpatient Medical Services,RADIOLOGY,73000,Radiologic examination of the collar bone,320,159.5,135.58,Pays at 85% of Billed charges for outpatient setting,51.28,Pays at 32.15% of Total Billed charges,127.65,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,143.55,Pays at 90% of Total Billed charges,51.28,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.28,Pays at 32.15% of Total Billed charges,140.36,Pays at 88% of Total Billed charges,52.81,Pays at 33.11% of Total Billed charges,51.28,143.55,95.70
Outpatient Medical Services,RADIOLOGY,73010,SCAPULA,320,296,251.6,Pays at 85% of Billed charges for outpatient setting,95.16,Pays at 32.15% of Total Billed charges,236.89,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,266.4,Pays at 90% of Total Billed charges,95.16,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,95.16,Pays at 32.15% of Total Billed charges,260.48,Pays at 88% of Total Billed charges,98.01,Pays at 33.11% of Total Billed charges,95.16,266.4,177.60
Outpatient Medical Services,RADIOLOGY,73020,OR SHOULDER AP 1V,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73020,SHOULDER AP 1V LT,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73110,Up to 3 views,320,100,85,Pays at 85% of Billed charges for outpatient setting,32.15,Pays at 32.15% of Total Billed charges,80.03,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,90,Pays at 90% of Total Billed charges,32.15,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,32.15,Pays at 32.15% of Total Billed charges,88,Pays at 88% of Total Billed charges,33.11,Pays at 33.11% of Total Billed charges,32.15,90,60.00
Outpatient Medical Services,RADIOLOGY,73502,PELVIS /HIPS PEDS 2V,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73502,OR HIP OPERATIVE,320,578.5,491.73,Pays at 85% of Billed charges for outpatient setting,185.99,Pays at 32.15% of Total Billed charges,462.97,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,520.65,Pays at 90% of Total Billed charges,185.99,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,185.99,Pays at 32.15% of Total Billed charges,509.08,Pays at 88% of Total Billed charges,191.54,Pays at 33.11% of Total Billed charges,81.65,520.65,347.10
Outpatient Medical Services,RADIOLOGY,73503,PELVIS 4 VIEWS,320,388.25,330.01,Pays at 85% of Billed charges for outpatient setting,124.82,Pays at 32.15% of Total Billed charges,310.72,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,349.43,Pays at 90% of Total Billed charges,124.82,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,124.82,Pays at 32.15% of Total Billed charges,341.66,Pays at 88% of Total Billed charges,128.55,Pays at 33.11% of Total Billed charges,100.45,349.43,232.95
Outpatient Medical Services,RADIOLOGY,73525,HIP ARTHRO INJ,320,548,465.8,Pays at 85% of Billed charges for outpatient setting,176.18,Pays at 32.15% of Total Billed charges,438.56,Pays at 80.03% of Total Billed charges,353.21,Pays at 102% of Medicare OPPS Rate,493.2,Pays at 90% of Total Billed charges,176.18,Pays at 32.15% of Total Billed charges,346.29,Pays at 100% of Medicare OPPS Rate,176.18,Pays at 32.15% of Total Billed charges,482.24,Pays at 88% of Total Billed charges,181.44,Pays at 33.11% of Total Billed charges,176.18,493.2,328.80
Outpatient Medical Services,RADIOLOGY,73590,Radiologic examination of the lower leg,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73610,Radiologic examination of the ankle with 3 views,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73660,Radiologic examination of the toe(s),320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,74018,OR ABDOMEN,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,74021,PORT ABDOMEN FLAT/UPRIGHT,320,296,251.6,Pays at 85% of Billed charges for outpatient setting,95.16,Pays at 32.15% of Total Billed charges,236.89,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,266.4,Pays at 90% of Total Billed charges,95.16,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,95.16,Pays at 32.15% of Total Billed charges,260.48,Pays at 88% of Total Billed charges,98.01,Pays at 33.11% of Total Billed charges,95.16,266.4,177.60
Outpatient Medical Services,RADIOLOGY,74022,Serial radiologic examination of the abdomen,320,221.25,188.06,Pays at 85% of Billed charges for outpatient setting,71.13,Pays at 32.15% of Total Billed charges,177.07,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,199.13,Pays at 90% of Total Billed charges,71.13,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,71.13,Pays at 32.15% of Total Billed charges,194.7,Pays at 88% of Total Billed charges,73.26,Pays at 33.11% of Total Billed charges,71.13,199.13,132.75
Outpatient Medical Services,RADIOLOGY,74022,Serial radiologic examination of the abdomen,320,355,301.75,Pays at 85% of Billed charges for outpatient setting,114.13,Pays at 32.15% of Total Billed charges,284.11,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,319.5,Pays at 90% of Total Billed charges,114.13,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,114.13,Pays at 32.15% of Total Billed charges,312.4,Pays at 88% of Total Billed charges,117.54,Pays at 33.11% of Total Billed charges,100.45,319.5,213.00
Outpatient Medical Services,RADIOLOGY,74220,ESOPHAGUS,320,654,555.9,Pays at 85% of Billed charges for outpatient setting,210.26,Pays at 32.15% of Total Billed charges,523.4,Pays at 80.03% of Total Billed charges,172.89,Pays at 102% of Medicare OPPS Rate,588.6,Pays at 90% of Total Billed charges,210.26,Pays at 32.15% of Total Billed charges,169.5,Pays at 100% of Medicare OPPS Rate,210.26,Pays at 32.15% of Total Billed charges,575.52,Pays at 88% of Total Billed charges,216.54,Pays at 33.11% of Total Billed charges,169.5,588.6,392.40
Outpatient Medical Services,RADIOLOGY,74230,ESOPHAGRAM,320,239.45,203.53,Pays at 85% of Billed charges for outpatient setting,76.98,Pays at 32.15% of Total Billed charges,191.63,Pays at 80.03% of Total Billed charges,172.89,Pays at 102% of Medicare OPPS Rate,215.51,Pays at 90% of Total Billed charges,76.98,Pays at 32.15% of Total Billed charges,169.5,Pays at 100% of Medicare OPPS Rate,76.98,Pays at 32.15% of Total Billed charges,210.72,Pays at 88% of Total Billed charges,79.28,Pays at 33.11% of Total Billed charges,76.98,215.51,143.67
Outpatient Medical Services,RADIOLOGY,74230,MODIFIED BARIUM SWALLOW W VIDEO,320,296,251.6,Pays at 85% of Billed charges for outpatient setting,95.16,Pays at 32.15% of Total Billed charges,236.89,Pays at 80.03% of Total Billed charges,172.89,Pays at 102% of Medicare OPPS Rate,266.4,Pays at 90% of Total Billed charges,95.16,Pays at 32.15% of Total Billed charges,169.5,Pays at 100% of Medicare OPPS Rate,95.16,Pays at 32.15% of Total Billed charges,260.48,Pays at 88% of Total Billed charges,98.01,Pays at 33.11% of Total Billed charges,95.16,266.4,177.60
Outpatient Medical Services,RADIOLOGY,74240,GI SERIES,320,784.5,666.83,Pays at 85% of Billed charges for outpatient setting,252.22,Pays at 32.15% of Total Billed charges,627.84,Pays at 80.03% of Total Billed charges,172.89,Pays at 102% of Medicare OPPS Rate,706.05,Pays at 90% of Total Billed charges,252.22,Pays at 32.15% of Total Billed charges,169.5,Pays at 100% of Medicare OPPS Rate,252.22,Pays at 32.15% of Total Billed charges,690.36,Pays at 88% of Total Billed charges,259.75,Pays at 33.11% of Total Billed charges,169.5,706.05,470.70
Outpatient Medical Services,RADIOLOGY,74240,GI W SMALL BOWEL,320,601.25,511.06,Pays at 85% of Billed charges for outpatient setting,193.3,Pays at 32.15% of Total Billed charges,481.18,Pays at 80.03% of Total Billed charges,172.89,Pays at 102% of Medicare OPPS Rate,541.13,Pays at 90% of Total Billed charges,193.3,Pays at 32.15% of Total Billed charges,169.5,Pays at 100% of Medicare OPPS Rate,193.3,Pays at 32.15% of Total Billed charges,529.1,Pays at 88% of Total Billed charges,199.07,Pays at 33.11% of Total Billed charges,169.5,541.13,360.75
Outpatient Medical Services,RADIOLOGY,74250,SMALL BOWEL SERIES,320,296,251.6,Pays at 85% of Billed charges for outpatient setting,95.16,Pays at 32.15% of Total Billed charges,236.89,Pays at 80.03% of Total Billed charges,172.89,Pays at 102% of Medicare OPPS Rate,266.4,Pays at 90% of Total Billed charges,95.16,Pays at 32.15% of Total Billed charges,169.5,Pays at 100% of Medicare OPPS Rate,95.16,Pays at 32.15% of Total Billed charges,260.48,Pays at 88% of Total Billed charges,98.01,Pays at 33.11% of Total Billed charges,95.16,266.4,177.60
Outpatient Medical Services,RADIOLOGY,74270,BARIUM ENEMA,320,654,555.9,Pays at 85% of Billed charges for outpatient setting,210.26,Pays at 32.15% of Total Billed charges,523.4,Pays at 80.03% of Total Billed charges,172.89,Pays at 102% of Medicare OPPS Rate,588.6,Pays at 90% of Total Billed charges,210.26,Pays at 32.15% of Total Billed charges,169.5,Pays at 100% of Medicare OPPS Rate,210.26,Pays at 32.15% of Total Billed charges,575.52,Pays at 88% of Total Billed charges,216.54,Pays at 33.11% of Total Billed charges,169.5,588.6,392.40
Outpatient Medical Services,RADIOLOGY,74270,BARIUM ENEMA DIAGNOSTIC,320,654,555.9,Pays at 85% of Billed charges for outpatient setting,210.26,Pays at 32.15% of Total Billed charges,523.4,Pays at 80.03% of Total Billed charges,172.89,Pays at 102% of Medicare OPPS Rate,588.6,Pays at 90% of Total Billed charges,210.26,Pays at 32.15% of Total Billed charges,169.5,Pays at 100% of Medicare OPPS Rate,210.26,Pays at 32.15% of Total Billed charges,575.52,Pays at 88% of Total Billed charges,216.54,Pays at 33.11% of Total Billed charges,169.5,588.6,392.40
Outpatient Medical Services,RADIOLOGY,74300,OR CHOLANGIOGRAM OPERATIVE,320,308.75,262.44,Pays at 85% of Billed charges for outpatient setting,99.26,Pays at 32.15% of Total Billed charges,247.09,Pays at 80.03% of Total Billed charges,NA,Not Applicable,277.88,Pays at 90% of Total Billed charges,99.26,Pays at 32.15% of Total Billed charges,NA,Not Applicable,99.26,Pays at 32.15% of Total Billed charges,271.7,Pays at 88% of Total Billed charges,102.23,Pays at 33.11% of Total Billed charges,99.26,277.88,185.25
Outpatient Medical Services,RADIOLOGY,74328,ERCP,320,290.5,246.93,Pays at 85% of Billed charges for outpatient setting,93.4,Pays at 32.15% of Total Billed charges,232.49,Pays at 80.03% of Total Billed charges,NA,Not Applicable,261.45,Pays at 90% of Total Billed charges,93.4,Pays at 32.15% of Total Billed charges,NA,Not Applicable,93.4,Pays at 32.15% of Total Billed charges,255.64,Pays at 88% of Total Billed charges,96.18,Pays at 33.11% of Total Billed charges,93.4,261.45,174.30
Outpatient Medical Services,RADIOLOGY,74330,ERCP S & I ONLY,320,806.5,685.53,Pays at 85% of Billed charges for outpatient setting,259.29,Pays at 32.15% of Total Billed charges,645.44,Pays at 80.03% of Total Billed charges,NA,Not Applicable,725.85,Pays at 90% of Total Billed charges,259.29,Pays at 32.15% of Total Billed charges,NA,Not Applicable,259.29,Pays at 32.15% of Total Billed charges,709.72,Pays at 88% of Total Billed charges,267.03,Pays at 33.11% of Total Billed charges,259.29,725.85,483.90
Outpatient Medical Services,RADIOLOGY,74400,IVP,320,290,246.5,Pays at 85% of Billed charges for outpatient setting,93.24,Pays at 32.15% of Total Billed charges,232.09,Pays at 80.03% of Total Billed charges,172.88,Pays at 102% of Medicare OPPS Rate,261,Pays at 90% of Total Billed charges,93.24,Pays at 32.15% of Total Billed charges,169.49,Pays at 100% of Medicare OPPS Rate,93.24,Pays at 32.15% of Total Billed charges,255.2,Pays at 88% of Total Billed charges,96.02,Pays at 33.11% of Total Billed charges,93.24,261,174.00
Outpatient Medical Services,RADIOLOGY,74400,IVP,320,654,555.9,Pays at 85% of Billed charges for outpatient setting,210.26,Pays at 32.15% of Total Billed charges,523.4,Pays at 80.03% of Total Billed charges,172.88,Pays at 102% of Medicare OPPS Rate,588.6,Pays at 90% of Total Billed charges,210.26,Pays at 32.15% of Total Billed charges,169.49,Pays at 100% of Medicare OPPS Rate,210.26,Pays at 32.15% of Total Billed charges,575.52,Pays at 88% of Total Billed charges,216.54,Pays at 33.11% of Total Billed charges,169.49,588.6,392.40
Outpatient Medical Services,RADIOLOGY,74410,IVP INFUSION DRIP,320,290,246.5,Pays at 85% of Billed charges for outpatient setting,93.24,Pays at 32.15% of Total Billed charges,232.09,Pays at 80.03% of Total Billed charges,172.88,Pays at 102% of Medicare OPPS Rate,261,Pays at 90% of Total Billed charges,93.24,Pays at 32.15% of Total Billed charges,169.49,Pays at 100% of Medicare OPPS Rate,93.24,Pays at 32.15% of Total Billed charges,255.2,Pays at 88% of Total Billed charges,96.02,Pays at 33.11% of Total Billed charges,93.24,261,174.00
Outpatient Medical Services,RADIOLOGY,74415,IVP NEPHROTOMOGRAPHY,320,435.25,369.96,Pays at 85% of Billed charges for outpatient setting,139.93,Pays at 32.15% of Total Billed charges,348.33,Pays at 80.03% of Total Billed charges,172.88,Pays at 102% of Medicare OPPS Rate,391.73,Pays at 90% of Total Billed charges,139.93,Pays at 32.15% of Total Billed charges,169.49,Pays at 100% of Medicare OPPS Rate,139.93,Pays at 32.15% of Total Billed charges,383.02,Pays at 88% of Total Billed charges,144.11,Pays at 33.11% of Total Billed charges,139.93,391.73,261.15
Outpatient Medical Services,RADIOLOGY,74420,UROGRAPHY RETROGRADE WWO KUB,320,221.07,187.91,Pays at 85% of Billed charges for outpatient setting,71.07,Pays at 32.15% of Total Billed charges,176.92,Pays at 80.03% of Total Billed charges,353.2,Pays at 102% of Medicare OPPS Rate,198.96,Pays at 90% of Total Billed charges,71.07,Pays at 32.15% of Total Billed charges,346.28,Pays at 100% of Medicare OPPS Rate,71.07,Pays at 32.15% of Total Billed charges,194.54,Pays at 88% of Total Billed charges,73.2,Pays at 33.11% of Total Billed charges,71.07,353.2,132.64
Outpatient Medical Services,RADIOLOGY,74420,OR PYELOGRAM RETRO,320,358,304.3,Pays at 85% of Billed charges for outpatient setting,115.1,Pays at 32.15% of Total Billed charges,286.51,Pays at 80.03% of Total Billed charges,353.2,Pays at 102% of Medicare OPPS Rate,322.2,Pays at 90% of Total Billed charges,115.1,Pays at 32.15% of Total Billed charges,346.28,Pays at 100% of Medicare OPPS Rate,115.1,Pays at 32.15% of Total Billed charges,315.04,Pays at 88% of Total Billed charges,118.53,Pays at 33.11% of Total Billed charges,115.1,353.2,214.80
Outpatient Medical Services,RADIOLOGY,74425,FLUORO NEPHROSTOGRAM,320,269.75,229.29,Pays at 85% of Billed charges for outpatient setting,86.72,Pays at 32.15% of Total Billed charges,215.88,Pays at 80.03% of Total Billed charges,353.21,Pays at 102% of Medicare OPPS Rate,242.78,Pays at 90% of Total Billed charges,86.72,Pays at 32.15% of Total Billed charges,346.29,Pays at 100% of Medicare OPPS Rate,86.72,Pays at 32.15% of Total Billed charges,237.38,Pays at 88% of Total Billed charges,89.31,Pays at 33.11% of Total Billed charges,86.72,353.21,161.85
Outpatient Medical Services,RADIOLOGY,74430,CYSTOGRAM NON-VOIDING,320,654,555.9,Pays at 85% of Billed charges for outpatient setting,210.26,Pays at 32.15% of Total Billed charges,523.4,Pays at 80.03% of Total Billed charges,353.21,Pays at 102% of Medicare OPPS Rate,588.6,Pays at 90% of Total Billed charges,210.26,Pays at 32.15% of Total Billed charges,346.29,Pays at 100% of Medicare OPPS Rate,210.26,Pays at 32.15% of Total Billed charges,575.52,Pays at 88% of Total Billed charges,216.54,Pays at 33.11% of Total Billed charges,210.26,588.6,392.40
Outpatient Medical Services,RADIOLOGY,74430,OR CYSTOGRAM NON-VOIDING,320,654,555.9,Pays at 85% of Billed charges for outpatient setting,210.26,Pays at 32.15% of Total Billed charges,523.4,Pays at 80.03% of Total Billed charges,353.21,Pays at 102% of Medicare OPPS Rate,588.6,Pays at 90% of Total Billed charges,210.26,Pays at 32.15% of Total Billed charges,346.29,Pays at 100% of Medicare OPPS Rate,210.26,Pays at 32.15% of Total Billed charges,575.52,Pays at 88% of Total Billed charges,216.54,Pays at 33.11% of Total Billed charges,210.26,588.6,392.40
Outpatient Medical Services,RADIOLOGY,74450,URETHROGRAM RETRO OPERATIVE,320,187.5,159.38,Pays at 85% of Billed charges for outpatient setting,60.28,Pays at 32.15% of Total Billed charges,150.06,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,168.75,Pays at 90% of Total Billed charges,60.28,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,60.28,Pays at 32.15% of Total Billed charges,165,Pays at 88% of Total Billed charges,62.08,Pays at 33.11% of Total Billed charges,60.28,223.87,112.50
Outpatient Medical Services,RADIOLOGY,74450,OR URETHROGRAM,320,358,304.3,Pays at 85% of Billed charges for outpatient setting,115.1,Pays at 32.15% of Total Billed charges,286.51,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,322.2,Pays at 90% of Total Billed charges,115.1,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,115.1,Pays at 32.15% of Total Billed charges,315.04,Pays at 88% of Total Billed charges,118.53,Pays at 33.11% of Total Billed charges,115.1,322.2,214.80
Outpatient Medical Services,RADIOLOGY,76000,"Flouroscopy, or x-ray ""movie"" that takes less than an hour",320,601.25,511.06,Pays at 85% of Billed charges for outpatient setting,193.3,Pays at 32.15% of Total Billed charges,481.18,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,541.13,Pays at 90% of Total Billed charges,193.3,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,193.3,Pays at 32.15% of Total Billed charges,529.1,Pays at 88% of Total Billed charges,199.07,Pays at 33.11% of Total Billed charges,193.3,541.13,360.75
Outpatient Medical Services,RADIOLOGY,76000,"Flouroscopy, or x-ray ""movie"" that takes less than an hour",320,457.25,388.66,Pays at 85% of Billed charges for outpatient setting,147.01,Pays at 32.15% of Total Billed charges,365.94,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,411.53,Pays at 90% of Total Billed charges,147.01,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,147.01,Pays at 32.15% of Total Billed charges,402.38,Pays at 88% of Total Billed charges,151.4,Pays at 33.11% of Total Billed charges,147.01,411.53,274.35
Outpatient Medical Services,RADIOLOGY,76000,"Flouroscopy, or x-ray ""movie"" that takes less than an hour",320,357.75,304.09,Pays at 85% of Billed charges for outpatient setting,115.02,Pays at 32.15% of Total Billed charges,286.31,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,321.98,Pays at 90% of Total Billed charges,115.02,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,115.02,Pays at 32.15% of Total Billed charges,314.82,Pays at 88% of Total Billed charges,118.45,Pays at 33.11% of Total Billed charges,115.02,321.98,214.65
Outpatient Medical Services,RADIOLOGY,76001,OR IMAGE INTENSIFER > 1 HR,320,936,795.6,Pays at 85% of Billed charges for outpatient setting,300.92,Pays at 32.15% of Total Billed charges,749.08,Pays at 80.03% of Total Billed charges,NA,Not Applicable,842.4,Pays at 90% of Total Billed charges,300.92,Pays at 32.15% of Total Billed charges,NA,Not Applicable,300.92,Pays at 32.15% of Total Billed charges,823.68,Pays at 88% of Total Billed charges,309.91,Pays at 33.11% of Total Billed charges,300.92,842.4,561.60
Outpatient Medical Services,RADIOLOGY,76001,OR FLUOR > 1 HOUR,320,994.75,845.54,Pays at 85% of Billed charges for outpatient setting,319.81,Pays at 32.15% of Total Billed charges,796.1,Pays at 80.03% of Total Billed charges,NA,Not Applicable,895.28,Pays at 90% of Total Billed charges,319.81,Pays at 32.15% of Total Billed charges,NA,Not Applicable,319.81,Pays at 32.15% of Total Billed charges,875.38,Pays at 88% of Total Billed charges,329.36,Pays at 33.11% of Total Billed charges,319.81,895.28,596.85
Outpatient Medical Services,RADIOLOGY,76095,MM STEREOTACTIC LOC DIAG,320,207,175.95,Pays at 85% of Billed charges for outpatient setting,66.55,Pays at 32.15% of Total Billed charges,165.66,Pays at 80.03% of Total Billed charges,NA,Not Applicable,186.3,Pays at 90% of Total Billed charges,66.55,Pays at 32.15% of Total Billed charges,NA,Not Applicable,66.55,Pays at 32.15% of Total Billed charges,182.16,Pays at 88% of Total Billed charges,68.54,Pays at 33.11% of Total Billed charges,66.55,186.3,124.20
Outpatient Medical Services,RADIOLOGY,76098,BREAST SURGICAL SPECIMEN,320,55,46.75,Pays at 85% of Billed charges for outpatient setting,17.68,Pays at 32.15% of Total Billed charges,44.02,Pays at 80.03% of Total Billed charges,482.35,Pays at 102% of Medicare OPPS Rate,49.5,Pays at 90% of Total Billed charges,17.68,Pays at 32.15% of Total Billed charges,472.89,Pays at 100% of Medicare OPPS Rate,17.68,Pays at 32.15% of Total Billed charges,48.4,Pays at 88% of Total Billed charges,18.21,Pays at 33.11% of Total Billed charges,17.68,482.35,33.00
Outpatient Medical Services,RADIOLOGY,76098,MM BREAST SPECIMEN DIAG,320,176,149.6,Pays at 85% of Billed charges for outpatient setting,56.58,Pays at 32.15% of Total Billed charges,140.85,Pays at 80.03% of Total Billed charges,482.35,Pays at 102% of Medicare OPPS Rate,158.4,Pays at 90% of Total Billed charges,56.58,Pays at 32.15% of Total Billed charges,472.89,Pays at 100% of Medicare OPPS Rate,56.58,Pays at 32.15% of Total Billed charges,154.88,Pays at 88% of Total Billed charges,58.27,Pays at 33.11% of Total Billed charges,56.58,482.35,105.60
Outpatient Medical Services,RADIOLOGY,76942,US GUIDANCE PROCEDURES,320,298.5,253.73,Pays at 85% of Billed charges for outpatient setting,95.97,Pays at 32.15% of Total Billed charges,238.89,Pays at 80.03% of Total Billed charges,NA,Not Applicable,268.65,Pays at 90% of Total Billed charges,95.97,Pays at 32.15% of Total Billed charges,NA,Not Applicable,95.97,Pays at 32.15% of Total Billed charges,262.68,Pays at 88% of Total Billed charges,98.83,Pays at 33.11% of Total Billed charges,95.97,268.65,179.10
Outpatient Medical Services,RADIOLOGY,77003,FLUORO GUIDE NEEDLE PLACEMENT,320,217.25,184.66,Pays at 85% of Billed charges for outpatient setting,69.85,Pays at 32.15% of Total Billed charges,173.87,Pays at 80.03% of Total Billed charges,NA,Not Applicable,195.53,Pays at 90% of Total Billed charges,69.85,Pays at 32.15% of Total Billed charges,NA,Not Applicable,69.85,Pays at 32.15% of Total Billed charges,191.18,Pays at 88% of Total Billed charges,71.93,Pays at 33.11% of Total Billed charges,69.85,195.53,130.35
Outpatient Medical Services,RADIOLOGY,77073,BONE LENGTH STUDY,320,314.75,267.54,Pays at 85% of Billed charges for outpatient setting,101.19,Pays at 32.15% of Total Billed charges,251.89,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,283.28,Pays at 90% of Total Billed charges,101.19,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,101.19,Pays at 32.15% of Total Billed charges,276.98,Pays at 88% of Total Billed charges,104.21,Pays at 33.11% of Total Billed charges,100.45,283.28,188.85
Outpatient Medical Services,RADIOLOGY,77075,SKELETAL SURVEY FOR METASTASES,320,296,251.6,Pays at 85% of Billed charges for outpatient setting,95.16,Pays at 32.15% of Total Billed charges,236.89,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,266.4,Pays at 90% of Total Billed charges,95.16,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,95.16,Pays at 32.15% of Total Billed charges,260.48,Pays at 88% of Total Billed charges,98.01,Pays at 33.11% of Total Billed charges,95.16,266.4,177.60
Outpatient Medical Services,RADIOLOGY,77075,SKELETAL SURVEY,320,474,402.9,Pays at 85% of Billed charges for outpatient setting,152.39,Pays at 32.15% of Total Billed charges,379.34,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,426.6,Pays at 90% of Total Billed charges,152.39,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,152.39,Pays at 32.15% of Total Billed charges,417.12,Pays at 88% of Total Billed charges,156.94,Pays at 33.11% of Total Billed charges,100.45,426.6,284.40
Outpatient Medical Services,RADIOLOGY,77078,CT BONE DENSITY STUDY,320,357.75,304.09,Pays at 85% of Billed charges for outpatient setting,115.02,Pays at 32.15% of Total Billed charges,286.31,Pays at 80.03% of Total Billed charges,83.28,Pays at 102% of Medicare OPPS Rate,321.98,Pays at 90% of Total Billed charges,115.02,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,115.02,Pays at 32.15% of Total Billed charges,314.82,Pays at 88% of Total Billed charges,118.45,Pays at 33.11% of Total Billed charges,81.65,321.98,214.65
Outpatient Medical Services,RADIOLOGY,73030,Radiologic examination of the shoulder,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73090,Radiologic examination of the forearm,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73110,Up to 3 views,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73552,FEMUR BILAT 2V,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73562,Radiologic examination of the knee with 3 views,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73562,Radiologic examination of the knee with 3 views,320,386,328.1,Pays at 85% of Billed charges for outpatient setting,124.1,Pays at 32.15% of Total Billed charges,308.92,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,347.4,Pays at 90% of Total Billed charges,124.1,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,124.1,Pays at 32.15% of Total Billed charges,339.68,Pays at 88% of Total Billed charges,127.8,Pays at 33.11% of Total Billed charges,81.65,347.4,231.60
Outpatient Medical Services,RADIOLOGY,73564,Radiologic examination of the knee with 4 or more views,320,296,251.6,Pays at 85% of Billed charges for outpatient setting,95.16,Pays at 32.15% of Total Billed charges,236.89,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,266.4,Pays at 90% of Total Billed charges,95.16,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,95.16,Pays at 32.15% of Total Billed charges,260.48,Pays at 88% of Total Billed charges,98.01,Pays at 33.11% of Total Billed charges,95.16,266.4,177.60
Outpatient Medical Services,RADIOLOGY,73590,Radiologic examination of the lower leg,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73590,Radiologic examination of the lower leg,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73650,Radiologic examination of the heel,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,10007,"FLUORO, FINE NEEDLE ASPIRATION,1ST LES",320,1482,1259.7,Pays at 85% of Billed charges for outpatient setting,476.46,Pays at 32.15% of Total Billed charges,1186.04,Pays at 80.03% of Total Billed charges,622.15,Pays at 102% of Medicare OPPS Rate,1333.8,Pays at 90% of Total Billed charges,476.46,Pays at 32.15% of Total Billed charges,609.96,Pays at 100% of Medicare OPPS Rate,476.46,Pays at 32.15% of Total Billed charges,1304.16,Pays at 88% of Total Billed charges,490.69,Pays at 33.11% of Total Billed charges,476.46,1333.8,889.20
Outpatient Medical Services,RADIOLOGY,10008,"FLUORO,FINE NEEDLE ASPIRATION,EA ADD LES",320,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,NA,Not Applicable,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,NA,Not Applicable,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,RADIOLOGY,19085,MRI AUTOMATED VACUUM ASSISTED BIOPSY,320,2633.5,2238.48,Pays at 85% of Billed charges for outpatient setting,846.67,Pays at 32.15% of Total Billed charges,2107.59,Pays at 80.03% of Total Billed charges,1437.62,Pays at 102% of Medicare OPPS Rate,2370.15,Pays at 90% of Total Billed charges,846.67,Pays at 32.15% of Total Billed charges,1409.43,Pays at 100% of Medicare OPPS Rate,846.67,Pays at 32.15% of Total Billed charges,2317.48,Pays at 88% of Total Billed charges,871.95,Pays at 33.11% of Total Billed charges,846.67,2370.15,1580.10
Outpatient Medical Services,RADIOLOGY,19125,US BREAST BIOPSY,320,1438.75,1222.94,Pays at 85% of Billed charges for outpatient setting,462.56,Pays at 32.15% of Total Billed charges,1151.43,Pays at 80.03% of Total Billed charges,3295.83,Pays at 102% of Medicare OPPS Rate,1294.88,Pays at 90% of Total Billed charges,462.56,Pays at 32.15% of Total Billed charges,3231.21,Pays at 100% of Medicare OPPS Rate,462.56,Pays at 32.15% of Total Billed charges,1266.1,Pays at 88% of Total Billed charges,476.37,Pays at 33.11% of Total Billed charges,462.56,3295.83,863.25
Outpatient Medical Services,RADIOLOGY,20206,BIOPSY OF MUSCLE,320,216.75,184.24,Pays at 85% of Billed charges for outpatient setting,69.69,Pays at 32.15% of Total Billed charges,173.47,Pays at 80.03% of Total Billed charges,1437.62,Pays at 102% of Medicare OPPS Rate,195.08,Pays at 90% of Total Billed charges,69.69,Pays at 32.15% of Total Billed charges,1409.43,Pays at 100% of Medicare OPPS Rate,69.69,Pays at 32.15% of Total Billed charges,190.74,Pays at 88% of Total Billed charges,71.77,Pays at 33.11% of Total Billed charges,69.69,1437.62,130.05
Outpatient Medical Services,RADIOLOGY,20605,Draining or injecting medication into a large joint/bursa without ultrasound,320,222.25,188.91,Pays at 85% of Billed charges for outpatient setting,71.45,Pays at 32.15% of Total Billed charges,177.87,Pays at 80.03% of Total Billed charges,260.64,Pays at 102% of Medicare OPPS Rate,200.03,Pays at 90% of Total Billed charges,71.45,Pays at 32.15% of Total Billed charges,255.55,Pays at 100% of Medicare OPPS Rate,71.45,Pays at 32.15% of Total Billed charges,195.58,Pays at 88% of Total Billed charges,73.59,Pays at 33.11% of Total Billed charges,71.45,260.64,133.35
Outpatient Medical Services,RADIOLOGY,20610,Draining or injecting medication into a major joint/bursa without ultrasound,320,444.25,377.61,Pays at 85% of Billed charges for outpatient setting,142.83,Pays at 32.15% of Total Billed charges,355.53,Pays at 80.03% of Total Billed charges,260.64,Pays at 102% of Medicare OPPS Rate,399.83,Pays at 90% of Total Billed charges,142.83,Pays at 32.15% of Total Billed charges,255.55,Pays at 100% of Medicare OPPS Rate,142.83,Pays at 32.15% of Total Billed charges,390.94,Pays at 88% of Total Billed charges,147.09,Pays at 33.11% of Total Billed charges,142.83,399.83,266.55
Outpatient Medical Services,RADIOLOGY,20610,Draining or injecting medication into a major joint/bursa without ultrasound,320,431.25,366.56,Pays at 85% of Billed charges for outpatient setting,138.65,Pays at 32.15% of Total Billed charges,345.13,Pays at 80.03% of Total Billed charges,260.64,Pays at 102% of Medicare OPPS Rate,388.13,Pays at 90% of Total Billed charges,138.65,Pays at 32.15% of Total Billed charges,255.55,Pays at 100% of Medicare OPPS Rate,138.65,Pays at 32.15% of Total Billed charges,379.5,Pays at 88% of Total Billed charges,142.79,Pays at 33.11% of Total Billed charges,138.65,388.13,258.75
Outpatient Medical Services,RADIOLOGY,27093,INJECTION FOR HIP ARTHROGRAM,320,63.25,53.76,Pays at 85% of Billed charges for outpatient setting,20.33,Pays at 32.15% of Total Billed charges,50.62,Pays at 80.03% of Total Billed charges,NA,Not Applicable,56.93,Pays at 90% of Total Billed charges,20.33,Pays at 32.15% of Total Billed charges,NA,Not Applicable,20.33,Pays at 32.15% of Total Billed charges,55.66,Pays at 88% of Total Billed charges,20.94,Pays at 33.11% of Total Billed charges,20.33,56.93,37.95
Outpatient Medical Services,RADIOLOGY,27370,INJECT KNEE ARTROGRAM,320,63.25,53.76,Pays at 85% of Billed charges for outpatient setting,20.33,Pays at 32.15% of Total Billed charges,50.62,Pays at 80.03% of Total Billed charges,NA,Not Applicable,56.93,Pays at 90% of Total Billed charges,20.33,Pays at 32.15% of Total Billed charges,NA,Not Applicable,20.33,Pays at 32.15% of Total Billed charges,55.66,Pays at 88% of Total Billed charges,20.94,Pays at 33.11% of Total Billed charges,20.33,56.93,37.95
Outpatient Medical Services,RADIOLOGY,32555,THORACENTESIS CHEST,320,432.75,367.84,Pays at 85% of Billed charges for outpatient setting,139.13,Pays at 32.15% of Total Billed charges,346.33,Pays at 80.03% of Total Billed charges,554.6,Pays at 102% of Medicare OPPS Rate,389.48,Pays at 90% of Total Billed charges,139.13,Pays at 32.15% of Total Billed charges,543.73,Pays at 100% of Medicare OPPS Rate,139.13,Pays at 32.15% of Total Billed charges,380.82,Pays at 88% of Total Billed charges,143.28,Pays at 33.11% of Total Billed charges,139.13,554.6,259.65
Outpatient Medical Services,RADIOLOGY,36005,INJECTION FOR VENOGRAM,320,63.25,53.76,Pays at 85% of Billed charges for outpatient setting,20.33,Pays at 32.15% of Total Billed charges,50.62,Pays at 80.03% of Total Billed charges,NA,Not Applicable,56.93,Pays at 90% of Total Billed charges,20.33,Pays at 32.15% of Total Billed charges,NA,Not Applicable,20.33,Pays at 32.15% of Total Billed charges,55.66,Pays at 88% of Total Billed charges,20.94,Pays at 33.11% of Total Billed charges,20.33,56.93,37.95
Outpatient Medical Services,RADIOLOGY,47000,CT BIOPSY OF LIVER (CT GUIDED),320,3838,3262.3,Pays at 85% of Billed charges for outpatient setting,1233.92,Pays at 32.15% of Total Billed charges,3071.55,Pays at 80.03% of Total Billed charges,1437.62,Pays at 102% of Medicare OPPS Rate,3454.2,Pays at 90% of Total Billed charges,1233.92,Pays at 32.15% of Total Billed charges,1409.43,Pays at 100% of Medicare OPPS Rate,1233.92,Pays at 32.15% of Total Billed charges,3377.44,Pays at 88% of Total Billed charges,1270.76,Pays at 33.11% of Total Billed charges,1233.92,3454.2,2302.80
Outpatient Medical Services,RADIOLOGY,47531,CHOLANGIOGRAM T-TUBE,320,308.75,262.44,Pays at 85% of Billed charges for outpatient setting,99.26,Pays at 32.15% of Total Billed charges,247.09,Pays at 80.03% of Total Billed charges,3395.67,Pays at 102% of Medicare OPPS Rate,277.88,Pays at 90% of Total Billed charges,99.26,Pays at 32.15% of Total Billed charges,3329.09,Pays at 100% of Medicare OPPS Rate,99.26,Pays at 32.15% of Total Billed charges,271.7,Pays at 88% of Total Billed charges,102.23,Pays at 33.11% of Total Billed charges,99.26,3395.67,185.25
Outpatient Medical Services,RADIOLOGY,49082,PARACENTESIS ABDOMEN WITHOUT,320,688.55,585.27,Pays at 85% of Billed charges for outpatient setting,221.37,Pays at 32.15% of Total Billed charges,551.05,Pays at 80.03% of Total Billed charges,791.41,Pays at 102% of Medicare OPPS Rate,619.7,Pays at 90% of Total Billed charges,221.37,Pays at 32.15% of Total Billed charges,775.89,Pays at 100% of Medicare OPPS Rate,221.37,Pays at 32.15% of Total Billed charges,605.92,Pays at 88% of Total Billed charges,227.98,Pays at 33.11% of Total Billed charges,221.37,791.41,413.13
Outpatient Medical Services,RADIOLOGY,49083,PARACENTESIS ABDOMEN WITH AND WITHOUT,320,1032.7,877.8,Pays at 85% of Billed charges for outpatient setting,332.01,Pays at 32.15% of Total Billed charges,826.47,Pays at 80.03% of Total Billed charges,791.41,Pays at 102% of Medicare OPPS Rate,929.43,Pays at 90% of Total Billed charges,332.01,Pays at 32.15% of Total Billed charges,775.89,Pays at 100% of Medicare OPPS Rate,332.01,Pays at 32.15% of Total Billed charges,908.78,Pays at 88% of Total Billed charges,341.93,Pays at 33.11% of Total Billed charges,332.01,929.43,619.62
Outpatient Medical Services,RADIOLOGY,64470,FACET INJ CERV/THORACIC BIL,320,1320,1122,Pays at 85% of Billed charges for outpatient setting,424.38,Pays at 32.15% of Total Billed charges,1056.4,Pays at 80.03% of Total Billed charges,NA,Not Applicable,1188,Pays at 90% of Total Billed charges,424.38,Pays at 32.15% of Total Billed charges,NA,Not Applicable,424.38,Pays at 32.15% of Total Billed charges,1161.6,Pays at 88% of Total Billed charges,437.05,Pays at 33.11% of Total Billed charges,424.38,1188,792.00
Outpatient Medical Services,RADIOLOGY,64470,FACET INJ CERV/THORACIC UNIL,320,660,561,Pays at 85% of Billed charges for outpatient setting,212.19,Pays at 32.15% of Total Billed charges,528.2,Pays at 80.03% of Total Billed charges,NA,Not Applicable,594,Pays at 90% of Total Billed charges,212.19,Pays at 32.15% of Total Billed charges,NA,Not Applicable,212.19,Pays at 32.15% of Total Billed charges,580.8,Pays at 88% of Total Billed charges,218.53,Pays at 33.11% of Total Billed charges,212.19,594,396.00
Outpatient Medical Services,RADIOLOGY,64472,FACET INJ CERV/THORACIC EA ADD BIL,320,1320,1122,Pays at 85% of Billed charges for outpatient setting,424.38,Pays at 32.15% of Total Billed charges,1056.4,Pays at 80.03% of Total Billed charges,NA,Not Applicable,1188,Pays at 90% of Total Billed charges,424.38,Pays at 32.15% of Total Billed charges,NA,Not Applicable,424.38,Pays at 32.15% of Total Billed charges,1161.6,Pays at 88% of Total Billed charges,437.05,Pays at 33.11% of Total Billed charges,424.38,1188,792.00
Outpatient Medical Services,RADIOLOGY,64472,FACET INJ CERV/THORACIC EA ADD UNIL,320,660,561,Pays at 85% of Billed charges for outpatient setting,212.19,Pays at 32.15% of Total Billed charges,528.2,Pays at 80.03% of Total Billed charges,NA,Not Applicable,594,Pays at 90% of Total Billed charges,212.19,Pays at 32.15% of Total Billed charges,NA,Not Applicable,212.19,Pays at 32.15% of Total Billed charges,580.8,Pays at 88% of Total Billed charges,218.53,Pays at 33.11% of Total Billed charges,212.19,594,396.00
Outpatient Medical Services,RADIOLOGY,64475,FACET INJ LUMB/SACR BIL,320,1320,1122,Pays at 85% of Billed charges for outpatient setting,424.38,Pays at 32.15% of Total Billed charges,1056.4,Pays at 80.03% of Total Billed charges,NA,Not Applicable,1188,Pays at 90% of Total Billed charges,424.38,Pays at 32.15% of Total Billed charges,NA,Not Applicable,424.38,Pays at 32.15% of Total Billed charges,1161.6,Pays at 88% of Total Billed charges,437.05,Pays at 33.11% of Total Billed charges,424.38,1188,792.00
Outpatient Medical Services,RADIOLOGY,64476,FACET INJ LUMB/SACR EA ADD BIL,320,1320,1122,Pays at 85% of Billed charges for outpatient setting,424.38,Pays at 32.15% of Total Billed charges,1056.4,Pays at 80.03% of Total Billed charges,NA,Not Applicable,1188,Pays at 90% of Total Billed charges,424.38,Pays at 32.15% of Total Billed charges,NA,Not Applicable,424.38,Pays at 32.15% of Total Billed charges,1161.6,Pays at 88% of Total Billed charges,437.05,Pays at 33.11% of Total Billed charges,424.38,1188,792.00
Outpatient Medical Services,RADIOLOGY,64476,FACET INJ LUMB/SACR EA ADD UNIL,320,660,561,Pays at 85% of Billed charges for outpatient setting,212.19,Pays at 32.15% of Total Billed charges,528.2,Pays at 80.03% of Total Billed charges,NA,Not Applicable,594,Pays at 90% of Total Billed charges,212.19,Pays at 32.15% of Total Billed charges,NA,Not Applicable,212.19,Pays at 32.15% of Total Billed charges,580.8,Pays at 88% of Total Billed charges,218.53,Pays at 33.11% of Total Billed charges,212.19,594,396.00
Outpatient Medical Services,RADIOLOGY,64483,Injections of anesthetic and/or steroid drug into lower or sacral spine nerve root using imaging guidance,320,1320,1122,Pays at 85% of Billed charges for outpatient setting,424.38,Pays at 32.15% of Total Billed charges,1056.4,Pays at 80.03% of Total Billed charges,816.98,Pays at 102% of Medicare OPPS Rate,1188,Pays at 90% of Total Billed charges,424.38,Pays at 32.15% of Total Billed charges,800.96,Pays at 100% of Medicare OPPS Rate,424.38,Pays at 32.15% of Total Billed charges,1161.6,Pays at 88% of Total Billed charges,437.05,Pays at 33.11% of Total Billed charges,424.38,1188,792.00
Outpatient Medical Services,RADIOLOGY,64483,Injections of anesthetic and/or steroid drug into lower or sacral spine nerve root using imaging guidance,320,660,561,Pays at 85% of Billed charges for outpatient setting,212.19,Pays at 32.15% of Total Billed charges,528.2,Pays at 80.03% of Total Billed charges,816.98,Pays at 102% of Medicare OPPS Rate,594,Pays at 90% of Total Billed charges,212.19,Pays at 32.15% of Total Billed charges,800.96,Pays at 100% of Medicare OPPS Rate,212.19,Pays at 32.15% of Total Billed charges,580.8,Pays at 88% of Total Billed charges,218.53,Pays at 33.11% of Total Billed charges,212.19,816.98,396.00
Outpatient Medical Services,RADIOLOGY,64484,NERVE ROOT BLOCK LUMBAR EA ADDITIONAL,320,1320,1122,Pays at 85% of Billed charges for outpatient setting,424.38,Pays at 32.15% of Total Billed charges,1056.4,Pays at 80.03% of Total Billed charges,NA,Not Applicable,1188,Pays at 90% of Total Billed charges,424.38,Pays at 32.15% of Total Billed charges,NA,Not Applicable,424.38,Pays at 32.15% of Total Billed charges,1161.6,Pays at 88% of Total Billed charges,437.05,Pays at 33.11% of Total Billed charges,424.38,1188,792.00
Outpatient Medical Services,RADIOLOGY,64484,NERVE ROOT BLOCK LUMBAR EA ADD,320,660,561,Pays at 85% of Billed charges for outpatient setting,212.19,Pays at 32.15% of Total Billed charges,528.2,Pays at 80.03% of Total Billed charges,NA,Not Applicable,594,Pays at 90% of Total Billed charges,212.19,Pays at 32.15% of Total Billed charges,NA,Not Applicable,212.19,Pays at 32.15% of Total Billed charges,580.8,Pays at 88% of Total Billed charges,218.53,Pays at 33.11% of Total Billed charges,212.19,594,396.00
Outpatient Medical Services,RADIOLOGY,64493,Injection into lower back of nerve block using imaging guidance,320,983.5,835.98,Pays at 85% of Billed charges for outpatient setting,316.2,Pays at 32.15% of Total Billed charges,787.1,Pays at 80.03% of Total Billed charges,816.98,Pays at 102% of Medicare OPPS Rate,885.15,Pays at 90% of Total Billed charges,316.2,Pays at 32.15% of Total Billed charges,800.96,Pays at 100% of Medicare OPPS Rate,316.2,Pays at 32.15% of Total Billed charges,865.48,Pays at 88% of Total Billed charges,325.64,Pays at 33.11% of Total Billed charges,316.2,885.15,590.10
Outpatient Medical Services,RADIOLOGY,70110,PORT MANDIBLE 4V,320,289,245.65,Pays at 85% of Billed charges for outpatient setting,92.91,Pays at 32.15% of Total Billed charges,231.29,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,260.1,Pays at 90% of Total Billed charges,92.91,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,92.91,Pays at 32.15% of Total Billed charges,254.32,Pays at 88% of Total Billed charges,95.69,Pays at 33.11% of Total Billed charges,92.91,260.1,173.40
Outpatient Medical Services,RADIOLOGY,70130,MASTOIDS 3V PER SIDE,320,221.5,188.28,Pays at 85% of Billed charges for outpatient setting,71.21,Pays at 32.15% of Total Billed charges,177.27,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,199.35,Pays at 90% of Total Billed charges,71.21,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,71.21,Pays at 32.15% of Total Billed charges,194.92,Pays at 88% of Total Billed charges,73.34,Pays at 33.11% of Total Billed charges,71.21,199.35,132.90
Outpatient Medical Services,RADIOLOGY,70130,PORT MASTOIDS 3V EA SIDE,320,289,245.65,Pays at 85% of Billed charges for outpatient setting,92.91,Pays at 32.15% of Total Billed charges,231.29,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,260.1,Pays at 90% of Total Billed charges,92.91,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,92.91,Pays at 32.15% of Total Billed charges,254.32,Pays at 88% of Total Billed charges,95.69,Pays at 33.11% of Total Billed charges,92.91,260.1,173.40
Outpatient Medical Services,RADIOLOGY,70134,INT AUDITORY MEATIUS,320,288.75,245.44,Pays at 85% of Billed charges for outpatient setting,92.83,Pays at 32.15% of Total Billed charges,231.09,Pays at 80.03% of Total Billed charges,482.35,Pays at 102% of Medicare OPPS Rate,259.88,Pays at 90% of Total Billed charges,92.83,Pays at 32.15% of Total Billed charges,472.89,Pays at 100% of Medicare OPPS Rate,92.83,Pays at 32.15% of Total Billed charges,254.1,Pays at 88% of Total Billed charges,95.61,Pays at 33.11% of Total Billed charges,92.83,482.35,173.25
Outpatient Medical Services,RADIOLOGY,70140,FACIAL BONES LESS THAN 3V,320,239,203.15,Pays at 85% of Billed charges for outpatient setting,76.84,Pays at 32.15% of Total Billed charges,191.27,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,215.1,Pays at 90% of Total Billed charges,76.84,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,76.84,Pays at 32.15% of Total Billed charges,210.32,Pays at 88% of Total Billed charges,79.13,Pays at 33.11% of Total Billed charges,76.84,215.1,143.40
Outpatient Medical Services,RADIOLOGY,70150,FACIAL BONES 3V,320,296,251.6,Pays at 85% of Billed charges for outpatient setting,95.16,Pays at 32.15% of Total Billed charges,236.89,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,266.4,Pays at 90% of Total Billed charges,95.16,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,95.16,Pays at 32.15% of Total Billed charges,260.48,Pays at 88% of Total Billed charges,98.01,Pays at 33.11% of Total Billed charges,95.16,266.4,177.60
Outpatient Medical Services,RADIOLOGY,70150,PORT FACIAL BONES 3V,320,298.75,253.94,Pays at 85% of Billed charges for outpatient setting,96.05,Pays at 32.15% of Total Billed charges,239.09,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,268.88,Pays at 90% of Total Billed charges,96.05,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,96.05,Pays at 32.15% of Total Billed charges,262.9,Pays at 88% of Total Billed charges,98.92,Pays at 33.11% of Total Billed charges,96.05,268.88,179.25
Outpatient Medical Services,RADIOLOGY,70160,PORT NASAL BONES 3V,320,219.75,186.79,Pays at 85% of Billed charges for outpatient setting,70.65,Pays at 32.15% of Total Billed charges,175.87,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,197.78,Pays at 90% of Total Billed charges,70.65,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,70.65,Pays at 32.15% of Total Billed charges,193.38,Pays at 88% of Total Billed charges,72.76,Pays at 33.11% of Total Billed charges,70.65,197.78,131.85
Outpatient Medical Services,RADIOLOGY,70190,OPTIC FORAMINA,320,221.5,188.28,Pays at 85% of Billed charges for outpatient setting,71.21,Pays at 32.15% of Total Billed charges,177.27,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,199.35,Pays at 90% of Total Billed charges,71.21,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,71.21,Pays at 32.15% of Total Billed charges,194.92,Pays at 88% of Total Billed charges,73.34,Pays at 33.11% of Total Billed charges,71.21,199.35,132.90
Outpatient Medical Services,RADIOLOGY,70200,PORT ORBITS 4V,320,289,245.65,Pays at 85% of Billed charges for outpatient setting,92.91,Pays at 32.15% of Total Billed charges,231.29,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,260.1,Pays at 90% of Total Billed charges,92.91,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,92.91,Pays at 32.15% of Total Billed charges,254.32,Pays at 88% of Total Billed charges,95.69,Pays at 33.11% of Total Billed charges,92.91,260.1,173.40
Outpatient Medical Services,RADIOLOGY,70210,SINUSES <3V,320,135,114.75,Pays at 85% of Billed charges for outpatient setting,43.4,Pays at 32.15% of Total Billed charges,108.04,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,121.5,Pays at 90% of Total Billed charges,43.4,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,43.4,Pays at 32.15% of Total Billed charges,118.8,Pays at 88% of Total Billed charges,44.7,Pays at 33.11% of Total Billed charges,43.4,121.5,81.00
Outpatient Medical Services,RADIOLOGY,70210,PORT SINUSES <3V,320,209.75,178.29,Pays at 85% of Billed charges for outpatient setting,67.43,Pays at 32.15% of Total Billed charges,167.86,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,188.78,Pays at 90% of Total Billed charges,67.43,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,67.43,Pays at 32.15% of Total Billed charges,184.58,Pays at 88% of Total Billed charges,69.45,Pays at 33.11% of Total Billed charges,67.43,188.78,125.85
Outpatient Medical Services,RADIOLOGY,70220,SINUSES PARANASAL 3V,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,70240,SELLA TURCICA,320,168.75,143.44,Pays at 85% of Billed charges for outpatient setting,54.25,Pays at 32.15% of Total Billed charges,135.05,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,151.88,Pays at 90% of Total Billed charges,54.25,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,54.25,Pays at 32.15% of Total Billed charges,148.5,Pays at 88% of Total Billed charges,55.87,Pays at 33.11% of Total Billed charges,54.25,151.88,101.25
Outpatient Medical Services,RADIOLOGY,70250,SKULL LIMITED <4V,320,296,251.6,Pays at 85% of Billed charges for outpatient setting,95.16,Pays at 32.15% of Total Billed charges,236.89,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,266.4,Pays at 90% of Total Billed charges,95.16,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,95.16,Pays at 32.15% of Total Billed charges,260.48,Pays at 88% of Total Billed charges,98.01,Pays at 33.11% of Total Billed charges,95.16,266.4,177.60
Outpatient Medical Services,RADIOLOGY,70250,PORT SKULL LTD <4V,320,202.5,172.13,Pays at 85% of Billed charges for outpatient setting,65.1,Pays at 32.15% of Total Billed charges,162.06,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,182.25,Pays at 90% of Total Billed charges,65.1,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,65.1,Pays at 32.15% of Total Billed charges,178.2,Pays at 88% of Total Billed charges,67.05,Pays at 33.11% of Total Billed charges,65.1,182.25,121.50
Outpatient Medical Services,RADIOLOGY,70330,TM JOINTS BILAT,320,442,375.7,Pays at 85% of Billed charges for outpatient setting,142.1,Pays at 32.15% of Total Billed charges,353.73,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,397.8,Pays at 90% of Total Billed charges,142.1,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,142.1,Pays at 32.15% of Total Billed charges,388.96,Pays at 88% of Total Billed charges,146.35,Pays at 33.11% of Total Billed charges,81.65,397.8,265.20
Outpatient Medical Services,RADIOLOGY,70330,TM JOINTS BILAT,320,456.75,388.24,Pays at 85% of Billed charges for outpatient setting,146.85,Pays at 32.15% of Total Billed charges,365.54,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,411.08,Pays at 90% of Total Billed charges,146.85,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,146.85,Pays at 32.15% of Total Billed charges,401.94,Pays at 88% of Total Billed charges,151.23,Pays at 33.11% of Total Billed charges,81.65,411.08,274.05
Outpatient Medical Services,RADIOLOGY,70390,SIALOGRAM,320,279,237.15,Pays at 85% of Billed charges for outpatient setting,89.7,Pays at 32.15% of Total Billed charges,223.28,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,251.1,Pays at 90% of Total Billed charges,89.7,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,89.7,Pays at 32.15% of Total Billed charges,245.52,Pays at 88% of Total Billed charges,92.38,Pays at 33.11% of Total Billed charges,89.7,251.1,167.40
Outpatient Medical Services,RADIOLOGY,70546,MRA HEAD WWO CONTRAST,320,2138,1817.3,Pays at 85% of Billed charges for outpatient setting,687.37,Pays at 32.15% of Total Billed charges,1711.04,Pays at 80.03% of Total Billed charges,353.2,Pays at 102% of Medicare OPPS Rate,1924.2,Pays at 90% of Total Billed charges,687.37,Pays at 32.15% of Total Billed charges,346.28,Pays at 100% of Medicare OPPS Rate,687.37,Pays at 32.15% of Total Billed charges,1881.44,Pays at 88% of Total Billed charges,707.89,Pays at 33.11% of Total Billed charges,346.28,1924.2,1282.80
Outpatient Medical Services,RADIOLOGY,71022,CHEST OBLIQUE PROJ,320,169.5,144.08,Pays at 85% of Billed charges for outpatient setting,54.49,Pays at 32.15% of Total Billed charges,135.65,Pays at 80.03% of Total Billed charges,169.5,Not Applicable,152.55,Pays at 90% of Total Billed charges,54.49,Pays at 32.15% of Total Billed charges,169.5,Not Applicable,54.49,Pays at 32.15% of Total Billed charges,149.16,Pays at 88% of Total Billed charges,56.12,Pays at 33.11% of Total Billed charges,54.49,169.5,101.70
Outpatient Medical Services,RADIOLOGY,71045,Single view,320,49.35,41.95,Pays at 85% of Billed charges for outpatient setting,15.87,Pays at 32.15% of Total Billed charges,39.49,Pays at 80.03% of Total Billed charges,83.28,Pays at 102% of Medicare OPPS Rate,44.42,Pays at 90% of Total Billed charges,15.87,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,15.87,Pays at 32.15% of Total Billed charges,43.43,Pays at 88% of Total Billed charges,16.34,Pays at 33.11% of Total Billed charges,15.87,83.28,29.61
Outpatient Medical Services,RADIOLOGY,71045,Single view,320,200.63,170.54,Pays at 85% of Billed charges for outpatient setting,64.5,Pays at 32.15% of Total Billed charges,160.56,Pays at 80.03% of Total Billed charges,83.28,Pays at 102% of Medicare OPPS Rate,180.57,Pays at 90% of Total Billed charges,64.5,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,64.5,Pays at 32.15% of Total Billed charges,176.55,Pays at 88% of Total Billed charges,66.43,Pays at 33.11% of Total Billed charges,64.5,180.57,120.38
Outpatient Medical Services,RADIOLOGY,71045,Single view,320,131.61,111.87,Pays at 85% of Billed charges for outpatient setting,42.31,Pays at 32.15% of Total Billed charges,105.33,Pays at 80.03% of Total Billed charges,83.28,Pays at 102% of Medicare OPPS Rate,118.45,Pays at 90% of Total Billed charges,42.31,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,42.31,Pays at 32.15% of Total Billed charges,115.82,Pays at 88% of Total Billed charges,43.58,Pays at 33.11% of Total Billed charges,42.31,118.45,78.97
Outpatient Medical Services,RADIOLOGY,71046,"2 views, front and back",320,192.5,163.63,Pays at 85% of Billed charges for outpatient setting,61.89,Pays at 32.15% of Total Billed charges,154.06,Pays at 80.03% of Total Billed charges,83.28,Pays at 102% of Medicare OPPS Rate,173.25,Pays at 90% of Total Billed charges,61.89,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,61.89,Pays at 32.15% of Total Billed charges,169.4,Pays at 88% of Total Billed charges,63.74,Pays at 33.11% of Total Billed charges,61.89,173.25,115.50
Outpatient Medical Services,RADIOLOGY,71046,"2 views, front and back",320,121,102.85,Pays at 85% of Billed charges for outpatient setting,38.9,Pays at 32.15% of Total Billed charges,96.84,Pays at 80.03% of Total Billed charges,83.28,Pays at 102% of Medicare OPPS Rate,108.9,Pays at 90% of Total Billed charges,38.9,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,38.9,Pays at 32.15% of Total Billed charges,106.48,Pays at 88% of Total Billed charges,40.06,Pays at 33.11% of Total Billed charges,38.9,108.9,72.60
Outpatient Medical Services,RADIOLOGY,71046,"2 views, front and back",320,200.63,170.54,Pays at 85% of Billed charges for outpatient setting,64.5,Pays at 32.15% of Total Billed charges,160.56,Pays at 80.03% of Total Billed charges,83.28,Pays at 102% of Medicare OPPS Rate,180.57,Pays at 90% of Total Billed charges,64.5,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,64.5,Pays at 32.15% of Total Billed charges,176.55,Pays at 88% of Total Billed charges,66.43,Pays at 33.11% of Total Billed charges,64.5,180.57,120.38
Outpatient Medical Services,RADIOLOGY,71048,4 or more views,320,323,274.55,Pays at 85% of Billed charges for outpatient setting,103.84,Pays at 32.15% of Total Billed charges,258.5,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,290.7,Pays at 90% of Total Billed charges,103.84,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,103.84,Pays at 32.15% of Total Billed charges,284.24,Pays at 88% of Total Billed charges,106.95,Pays at 33.11% of Total Billed charges,100.45,290.7,193.80
Outpatient Medical Services,RADIOLOGY,71048,4 or more views,320,371.8,316.03,Pays at 85% of Billed charges for outpatient setting,119.53,Pays at 32.15% of Total Billed charges,297.55,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,334.62,Pays at 90% of Total Billed charges,119.53,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,119.53,Pays at 32.15% of Total Billed charges,327.18,Pays at 88% of Total Billed charges,123.1,Pays at 33.11% of Total Billed charges,100.45,334.62,223.08
Outpatient Medical Services,RADIOLOGY,71090,PACEMAKER W/FLUORO,320,988,839.8,Pays at 85% of Billed charges for outpatient setting,317.64,Pays at 32.15% of Total Billed charges,790.7,Pays at 80.03% of Total Billed charges,988,Not Applicable,889.2,Pays at 90% of Total Billed charges,317.64,Pays at 32.15% of Total Billed charges,988,Not Applicable,317.64,Pays at 32.15% of Total Billed charges,869.44,Pays at 88% of Total Billed charges,327.13,Pays at 33.11% of Total Billed charges,317.64,988,592.80
Outpatient Medical Services,RADIOLOGY,71090,OR PACEMAKER W/FLUORO,320,988,839.8,Pays at 85% of Billed charges for outpatient setting,317.64,Pays at 32.15% of Total Billed charges,790.7,Pays at 80.03% of Total Billed charges,988,Not Applicable,889.2,Pays at 90% of Total Billed charges,317.64,Pays at 32.15% of Total Billed charges,988,Not Applicable,317.64,Pays at 32.15% of Total Billed charges,869.44,Pays at 88% of Total Billed charges,327.13,Pays at 33.11% of Total Billed charges,317.64,988,592.80
Outpatient Medical Services,RADIOLOGY,71101,Radiologic examination of one side of the chest/ribs,320,242.72,206.31,Pays at 85% of Billed charges for outpatient setting,78.03,Pays at 32.15% of Total Billed charges,194.25,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,218.45,Pays at 90% of Total Billed charges,78.03,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,78.03,Pays at 32.15% of Total Billed charges,213.59,Pays at 88% of Total Billed charges,80.36,Pays at 33.11% of Total Billed charges,78.03,218.45,145.63
Outpatient Medical Services,RADIOLOGY,71101,Radiologic examination of one side of the chest/ribs,320,229,194.65,Pays at 85% of Billed charges for outpatient setting,73.62,Pays at 32.15% of Total Billed charges,183.27,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,206.1,Pays at 90% of Total Billed charges,73.62,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,73.62,Pays at 32.15% of Total Billed charges,201.52,Pays at 88% of Total Billed charges,75.82,Pays at 33.11% of Total Billed charges,73.62,206.1,137.40
Outpatient Medical Services,RADIOLOGY,71111,PORT RIBS BILAT 4V,320,308.75,262.44,Pays at 85% of Billed charges for outpatient setting,99.26,Pays at 32.15% of Total Billed charges,247.09,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,277.88,Pays at 90% of Total Billed charges,99.26,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,99.26,Pays at 32.15% of Total Billed charges,271.7,Pays at 88% of Total Billed charges,102.23,Pays at 33.11% of Total Billed charges,99.26,277.88,185.25
Outpatient Medical Services,RADIOLOGY,71120,PORT STERNUM 2V,320,209.75,178.29,Pays at 85% of Billed charges for outpatient setting,67.43,Pays at 32.15% of Total Billed charges,167.86,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,188.78,Pays at 90% of Total Billed charges,67.43,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,67.43,Pays at 32.15% of Total Billed charges,184.58,Pays at 88% of Total Billed charges,69.45,Pays at 33.11% of Total Billed charges,67.43,188.78,125.85
Outpatient Medical Services,RADIOLOGY,71130,STERNOCLAVICULAR JOINTS 3V,320,192.5,163.63,Pays at 85% of Billed charges for outpatient setting,61.89,Pays at 32.15% of Total Billed charges,154.06,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,173.25,Pays at 90% of Total Billed charges,61.89,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,61.89,Pays at 32.15% of Total Billed charges,169.4,Pays at 88% of Total Billed charges,63.74,Pays at 33.11% of Total Billed charges,61.89,173.25,115.50
Outpatient Medical Services,RADIOLOGY,71130,PORT STERNOCLAVICULAR JOINTS 3V,320,258.5,219.73,Pays at 85% of Billed charges for outpatient setting,83.11,Pays at 32.15% of Total Billed charges,206.88,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,232.65,Pays at 90% of Total Billed charges,83.11,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,83.11,Pays at 32.15% of Total Billed charges,227.48,Pays at 88% of Total Billed charges,85.59,Pays at 33.11% of Total Billed charges,81.65,232.65,155.10
Outpatient Medical Services,RADIOLOGY,72020,CERVICAL LIMITED 1 VIEW,320,149.25,126.86,Pays at 85% of Billed charges for outpatient setting,47.98,Pays at 32.15% of Total Billed charges,119.44,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,134.33,Pays at 90% of Total Billed charges,47.98,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,47.98,Pays at 32.15% of Total Billed charges,131.34,Pays at 88% of Total Billed charges,49.42,Pays at 33.11% of Total Billed charges,47.98,134.33,89.55
Outpatient Medical Services,RADIOLOGY,72020,SCOLIOSIS STUDY LIMITED,320,207,175.95,Pays at 85% of Billed charges for outpatient setting,66.55,Pays at 32.15% of Total Billed charges,165.66,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,186.3,Pays at 90% of Total Billed charges,66.55,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,66.55,Pays at 32.15% of Total Billed charges,182.16,Pays at 88% of Total Billed charges,68.54,Pays at 33.11% of Total Billed charges,66.55,186.3,124.20
Outpatient Medical Services,RADIOLOGY,72020,PORT X-TABLE CERVICAL 1V,320,149.25,126.86,Pays at 85% of Billed charges for outpatient setting,47.98,Pays at 32.15% of Total Billed charges,119.44,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,134.33,Pays at 90% of Total Billed charges,47.98,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,47.98,Pays at 32.15% of Total Billed charges,131.34,Pays at 88% of Total Billed charges,49.42,Pays at 33.11% of Total Billed charges,47.98,134.33,89.55
Outpatient Medical Services,RADIOLOGY,72040,"Radiologic examination of the neck/spine, 2-3 views",320,131.61,111.87,Pays at 85% of Billed charges for outpatient setting,42.31,Pays at 32.15% of Total Billed charges,105.33,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,118.45,Pays at 90% of Total Billed charges,42.31,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,42.31,Pays at 32.15% of Total Billed charges,115.82,Pays at 88% of Total Billed charges,43.58,Pays at 33.11% of Total Billed charges,42.31,118.45,78.97
Outpatient Medical Services,RADIOLOGY,72040,"Radiologic examination of the neck/spine, 2-3 views",320,209.75,178.29,Pays at 85% of Billed charges for outpatient setting,67.43,Pays at 32.15% of Total Billed charges,167.86,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,188.78,Pays at 90% of Total Billed charges,67.43,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,67.43,Pays at 32.15% of Total Billed charges,184.58,Pays at 88% of Total Billed charges,69.45,Pays at 33.11% of Total Billed charges,67.43,188.78,125.85
Outpatient Medical Services,RADIOLOGY,72040,"Radiologic examination of the neck/spine, 2-3 views",320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,72050,"Radiologic examination of the neck/spine, 4-5 views",320,296,251.6,Pays at 85% of Billed charges for outpatient setting,95.16,Pays at 32.15% of Total Billed charges,236.89,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,266.4,Pays at 90% of Total Billed charges,95.16,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,95.16,Pays at 32.15% of Total Billed charges,260.48,Pays at 88% of Total Billed charges,98.01,Pays at 33.11% of Total Billed charges,95.16,266.4,177.60
Outpatient Medical Services,RADIOLOGY,72050,"Radiologic examination of the neck/spine, 4-5 views",320,310.5,263.93,Pays at 85% of Billed charges for outpatient setting,99.83,Pays at 32.15% of Total Billed charges,248.49,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,279.45,Pays at 90% of Total Billed charges,99.83,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,99.83,Pays at 32.15% of Total Billed charges,273.24,Pays at 88% of Total Billed charges,102.81,Pays at 33.11% of Total Billed charges,99.83,279.45,186.30
Outpatient Medical Services,RADIOLOGY,72052,CERVICAL COMPLETE,320,195.98,166.58,Pays at 85% of Billed charges for outpatient setting,63.01,Pays at 32.15% of Total Billed charges,156.84,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,176.38,Pays at 90% of Total Billed charges,63.01,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,63.01,Pays at 32.15% of Total Billed charges,172.46,Pays at 88% of Total Billed charges,64.89,Pays at 33.11% of Total Billed charges,63.01,176.38,117.59
Outpatient Medical Services,RADIOLOGY,72070,"Radiologic examination of the middle spine, 2 views",320,296,251.6,Pays at 85% of Billed charges for outpatient setting,95.16,Pays at 32.15% of Total Billed charges,236.89,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,266.4,Pays at 90% of Total Billed charges,95.16,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,95.16,Pays at 32.15% of Total Billed charges,260.48,Pays at 88% of Total Billed charges,98.01,Pays at 33.11% of Total Billed charges,95.16,266.4,177.60
Outpatient Medical Services,RADIOLOGY,72070,"Radiologic examination of the middle spine, 2 views",320,289,245.65,Pays at 85% of Billed charges for outpatient setting,92.91,Pays at 32.15% of Total Billed charges,231.29,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,260.1,Pays at 90% of Total Billed charges,92.91,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,92.91,Pays at 32.15% of Total Billed charges,254.32,Pays at 88% of Total Billed charges,95.69,Pays at 33.11% of Total Billed charges,92.91,260.1,173.40
Outpatient Medical Services,RADIOLOGY,72072,"Radiologic examination of the middle spine, 3 views",320,254.75,216.54,Pays at 85% of Billed charges for outpatient setting,81.9,Pays at 32.15% of Total Billed charges,203.88,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,229.28,Pays at 90% of Total Billed charges,81.9,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,81.9,Pays at 32.15% of Total Billed charges,224.18,Pays at 88% of Total Billed charges,84.35,Pays at 33.11% of Total Billed charges,81.9,229.28,152.85
Outpatient Medical Services,RADIOLOGY,72072,"Radiologic examination of the middle spine, 3 views",320,242.72,206.31,Pays at 85% of Billed charges for outpatient setting,78.03,Pays at 32.15% of Total Billed charges,194.25,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,218.45,Pays at 90% of Total Billed charges,78.03,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,78.03,Pays at 32.15% of Total Billed charges,213.59,Pays at 88% of Total Billed charges,80.36,Pays at 33.11% of Total Billed charges,78.03,218.45,145.63
Outpatient Medical Services,RADIOLOGY,72074,THORACIC 4V,320,296,251.6,Pays at 85% of Billed charges for outpatient setting,95.16,Pays at 32.15% of Total Billed charges,236.89,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,266.4,Pays at 90% of Total Billed charges,95.16,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,95.16,Pays at 32.15% of Total Billed charges,260.48,Pays at 88% of Total Billed charges,98.01,Pays at 33.11% of Total Billed charges,95.16,266.4,177.60
Outpatient Medical Services,RADIOLOGY,72080,PORT THORACOLUMBAR AP/LAT 2V,320,289,245.65,Pays at 85% of Billed charges for outpatient setting,92.91,Pays at 32.15% of Total Billed charges,231.29,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,260.1,Pays at 90% of Total Billed charges,92.91,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,92.91,Pays at 32.15% of Total Billed charges,254.32,Pays at 88% of Total Billed charges,95.69,Pays at 33.11% of Total Billed charges,81.65,260.1,173.40
Outpatient Medical Services,RADIOLOGY,72082,SCOLIOSIS STUDY 2 VIEW,320,368,312.8,Pays at 85% of Billed charges for outpatient setting,118.31,Pays at 32.15% of Total Billed charges,294.51,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,331.2,Pays at 90% of Total Billed charges,118.31,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,118.31,Pays at 32.15% of Total Billed charges,323.84,Pays at 88% of Total Billed charges,121.84,Pays at 33.11% of Total Billed charges,100.45,331.2,220.80
Outpatient Medical Services,RADIOLOGY,72083,SCOLIOSIS STUDY COMPLETE,320,381,323.85,Pays at 85% of Billed charges for outpatient setting,122.49,Pays at 32.15% of Total Billed charges,304.91,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,342.9,Pays at 90% of Total Billed charges,122.49,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,122.49,Pays at 32.15% of Total Billed charges,335.28,Pays at 88% of Total Billed charges,126.15,Pays at 33.11% of Total Billed charges,100.44,342.9,228.60
Outpatient Medical Services,RADIOLOGY,72100,X-ray of the lower spine 2-3 views,320,203.77,173.2,Pays at 85% of Billed charges for outpatient setting,65.51,Pays at 32.15% of Total Billed charges,163.08,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,183.39,Pays at 90% of Total Billed charges,65.51,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,65.51,Pays at 32.15% of Total Billed charges,179.32,Pays at 88% of Total Billed charges,67.47,Pays at 33.11% of Total Billed charges,65.51,183.39,122.26
Outpatient Medical Services,RADIOLOGY,72100,X-ray of the lower spine 2-3 views,320,296,251.6,Pays at 85% of Billed charges for outpatient setting,95.16,Pays at 32.15% of Total Billed charges,236.89,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,266.4,Pays at 90% of Total Billed charges,95.16,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,95.16,Pays at 32.15% of Total Billed charges,260.48,Pays at 88% of Total Billed charges,98.01,Pays at 33.11% of Total Billed charges,95.16,266.4,177.60
Outpatient Medical Services,RADIOLOGY,72110,"X-ray of lower and sacral spine, minimum of 4 views",320,617.5,524.88,Pays at 85% of Billed charges for outpatient setting,198.53,Pays at 32.15% of Total Billed charges,494.19,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,555.75,Pays at 90% of Total Billed charges,198.53,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,198.53,Pays at 32.15% of Total Billed charges,543.4,Pays at 88% of Total Billed charges,204.45,Pays at 33.11% of Total Billed charges,100.45,555.75,370.50
Outpatient Medical Services,RADIOLOGY,72114,LUMBAR FLEX & EXT,320,296,251.6,Pays at 85% of Billed charges for outpatient setting,95.16,Pays at 32.15% of Total Billed charges,236.89,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,266.4,Pays at 90% of Total Billed charges,95.16,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,95.16,Pays at 32.15% of Total Billed charges,260.48,Pays at 88% of Total Billed charges,98.01,Pays at 33.11% of Total Billed charges,95.16,266.4,177.60
Outpatient Medical Services,RADIOLOGY,72170,Radiologic examination of the pelvis,320,159.5,135.58,Pays at 85% of Billed charges for outpatient setting,51.28,Pays at 32.15% of Total Billed charges,127.65,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,143.55,Pays at 90% of Total Billed charges,51.28,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,51.28,Pays at 32.15% of Total Billed charges,140.36,Pays at 88% of Total Billed charges,52.81,Pays at 33.11% of Total Billed charges,51.28,143.55,95.70
Outpatient Medical Services,RADIOLOGY,72190,PELVIS 5 OR MORE VIEWS,320,491.75,417.99,Pays at 85% of Billed charges for outpatient setting,158.1,Pays at 32.15% of Total Billed charges,393.55,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,442.58,Pays at 90% of Total Billed charges,158.1,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,158.1,Pays at 32.15% of Total Billed charges,432.74,Pays at 88% of Total Billed charges,162.82,Pays at 33.11% of Total Billed charges,100.45,442.58,295.05
Outpatient Medical Services,RADIOLOGY,72200,SACROILIAC JOINTS <3V,320,296,251.6,Pays at 85% of Billed charges for outpatient setting,95.16,Pays at 32.15% of Total Billed charges,236.89,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,266.4,Pays at 90% of Total Billed charges,95.16,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,95.16,Pays at 32.15% of Total Billed charges,260.48,Pays at 88% of Total Billed charges,98.01,Pays at 33.11% of Total Billed charges,95.16,266.4,177.60
Outpatient Medical Services,RADIOLOGY,72200,PORT SACROILIAC JOINTS <3V,320,248.5,211.23,Pays at 85% of Billed charges for outpatient setting,79.89,Pays at 32.15% of Total Billed charges,198.87,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,223.65,Pays at 90% of Total Billed charges,79.89,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,79.89,Pays at 32.15% of Total Billed charges,218.68,Pays at 88% of Total Billed charges,82.28,Pays at 33.11% of Total Billed charges,79.89,223.65,149.10
Outpatient Medical Services,RADIOLOGY,72202,SACROILIAC JOINTS 3V,320,296,251.6,Pays at 85% of Billed charges for outpatient setting,95.16,Pays at 32.15% of Total Billed charges,236.89,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,266.4,Pays at 90% of Total Billed charges,95.16,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,95.16,Pays at 32.15% of Total Billed charges,260.48,Pays at 88% of Total Billed charges,98.01,Pays at 33.11% of Total Billed charges,95.16,266.4,177.60
Outpatient Medical Services,RADIOLOGY,72220,PORT SACRUM/COCCYX 2V,320,248.5,211.23,Pays at 85% of Billed charges for outpatient setting,79.89,Pays at 32.15% of Total Billed charges,198.87,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,223.65,Pays at 90% of Total Billed charges,79.89,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,79.89,Pays at 32.15% of Total Billed charges,218.68,Pays at 88% of Total Billed charges,82.28,Pays at 33.11% of Total Billed charges,79.89,223.65,149.10
Outpatient Medical Services,RADIOLOGY,73000,Radiologic examination of the collar bone,320,219.75,186.79,Pays at 85% of Billed charges for outpatient setting,70.65,Pays at 32.15% of Total Billed charges,175.87,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,197.78,Pays at 90% of Total Billed charges,70.65,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,70.65,Pays at 32.15% of Total Billed charges,193.38,Pays at 88% of Total Billed charges,72.76,Pays at 33.11% of Total Billed charges,70.65,197.78,131.85
Outpatient Medical Services,RADIOLOGY,73010,PORT SCAPULA,320,248.5,211.23,Pays at 85% of Billed charges for outpatient setting,79.89,Pays at 32.15% of Total Billed charges,198.87,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,223.65,Pays at 90% of Total Billed charges,79.89,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,79.89,Pays at 32.15% of Total Billed charges,218.68,Pays at 88% of Total Billed charges,82.28,Pays at 33.11% of Total Billed charges,79.89,223.65,149.10
Outpatient Medical Services,RADIOLOGY,73020,PORT SHOULDER AP 1V LT,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73020,PORT SHOULDER AP 1V RT,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73020,SHOULDER AP 1V RT,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73030,Radiologic examination of the shoulder,320,514.5,437.33,Pays at 85% of Billed charges for outpatient setting,165.41,Pays at 32.15% of Total Billed charges,411.75,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,463.05,Pays at 90% of Total Billed charges,165.41,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,165.41,Pays at 32.15% of Total Billed charges,452.76,Pays at 88% of Total Billed charges,170.35,Pays at 33.11% of Total Billed charges,81.65,463.05,308.70
Outpatient Medical Services,RADIOLOGY,73030,Radiologic examination of the shoulder,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73030,Radiologic examination of the shoulder,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73030,Radiologic examination of the shoulder,320,298.75,253.94,Pays at 85% of Billed charges for outpatient setting,96.05,Pays at 32.15% of Total Billed charges,239.09,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,268.88,Pays at 90% of Total Billed charges,96.05,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,96.05,Pays at 32.15% of Total Billed charges,262.9,Pays at 88% of Total Billed charges,98.92,Pays at 33.11% of Total Billed charges,81.65,268.88,179.25
Outpatient Medical Services,RADIOLOGY,73030,Radiologic examination of the shoulder,320,236.78,201.26,Pays at 85% of Billed charges for outpatient setting,76.12,Pays at 32.15% of Total Billed charges,189.5,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,213.1,Pays at 90% of Total Billed charges,76.12,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,76.12,Pays at 32.15% of Total Billed charges,208.37,Pays at 88% of Total Billed charges,78.4,Pays at 33.11% of Total Billed charges,76.12,213.1,142.07
Outpatient Medical Services,RADIOLOGY,73030,Radiologic examination of the shoulder,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73030,Radiologic examination of the shoulder,320,373.44,317.42,Pays at 85% of Billed charges for outpatient setting,120.06,Pays at 32.15% of Total Billed charges,298.86,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,336.1,Pays at 90% of Total Billed charges,120.06,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,120.06,Pays at 32.15% of Total Billed charges,328.63,Pays at 88% of Total Billed charges,123.65,Pays at 33.11% of Total Billed charges,81.65,336.1,224.06
Outpatient Medical Services,RADIOLOGY,73030,Radiologic examination of the shoulder,320,298.75,253.94,Pays at 85% of Billed charges for outpatient setting,96.05,Pays at 32.15% of Total Billed charges,239.09,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,268.88,Pays at 90% of Total Billed charges,96.05,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,96.05,Pays at 32.15% of Total Billed charges,262.9,Pays at 88% of Total Billed charges,98.92,Pays at 33.11% of Total Billed charges,81.65,268.88,179.25
Outpatient Medical Services,RADIOLOGY,73030,Radiologic examination of the shoulder,320,360.94,306.8,Pays at 85% of Billed charges for outpatient setting,116.04,Pays at 32.15% of Total Billed charges,288.86,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,324.85,Pays at 90% of Total Billed charges,116.04,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,116.04,Pays at 32.15% of Total Billed charges,317.63,Pays at 88% of Total Billed charges,119.51,Pays at 33.11% of Total Billed charges,81.65,324.85,216.56
Outpatient Medical Services,RADIOLOGY,73040,ARTHROGRAM SHOULDER LT,320,465.75,395.89,Pays at 85% of Billed charges for outpatient setting,149.74,Pays at 32.15% of Total Billed charges,372.74,Pays at 80.03% of Total Billed charges,353.21,Pays at 102% of Medicare OPPS Rate,419.18,Pays at 90% of Total Billed charges,149.74,Pays at 32.15% of Total Billed charges,346.29,Pays at 100% of Medicare OPPS Rate,149.74,Pays at 32.15% of Total Billed charges,409.86,Pays at 88% of Total Billed charges,154.21,Pays at 33.11% of Total Billed charges,149.74,419.18,279.45
Outpatient Medical Services,RADIOLOGY,73040,ARTHROGRAM SHOULDER RT,320,465.75,395.89,Pays at 85% of Billed charges for outpatient setting,149.74,Pays at 32.15% of Total Billed charges,372.74,Pays at 80.03% of Total Billed charges,353.21,Pays at 102% of Medicare OPPS Rate,419.18,Pays at 90% of Total Billed charges,149.74,Pays at 32.15% of Total Billed charges,346.29,Pays at 100% of Medicare OPPS Rate,149.74,Pays at 32.15% of Total Billed charges,409.86,Pays at 88% of Total Billed charges,154.21,Pays at 33.11% of Total Billed charges,149.74,419.18,279.45
Outpatient Medical Services,RADIOLOGY,73050,AC JOINTS,320,219.75,186.79,Pays at 85% of Billed charges for outpatient setting,70.65,Pays at 32.15% of Total Billed charges,175.87,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,197.78,Pays at 90% of Total Billed charges,70.65,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,70.65,Pays at 32.15% of Total Billed charges,193.38,Pays at 88% of Total Billed charges,72.76,Pays at 33.11% of Total Billed charges,70.65,197.78,131.85
Outpatient Medical Services,RADIOLOGY,73050,PORT A-C JOINTS,320,279.25,237.36,Pays at 85% of Billed charges for outpatient setting,89.78,Pays at 32.15% of Total Billed charges,223.48,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,251.33,Pays at 90% of Total Billed charges,89.78,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,89.78,Pays at 32.15% of Total Billed charges,245.74,Pays at 88% of Total Billed charges,92.46,Pays at 33.11% of Total Billed charges,81.65,251.33,167.55
Outpatient Medical Services,RADIOLOGY,73060,HUMERUS BILATERAL 2 VIEWS,320,256.75,218.24,Pays at 85% of Billed charges for outpatient setting,82.55,Pays at 32.15% of Total Billed charges,205.48,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,231.08,Pays at 90% of Total Billed charges,82.55,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,82.55,Pays at 32.15% of Total Billed charges,225.94,Pays at 88% of Total Billed charges,85.01,Pays at 33.11% of Total Billed charges,81.65,231.08,154.05
Outpatient Medical Services,RADIOLOGY,73060,OR HUMERUS 2V LT,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73060,HUMERUS 2V LT,320,200.63,170.54,Pays at 85% of Billed charges for outpatient setting,64.5,Pays at 32.15% of Total Billed charges,160.56,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,180.57,Pays at 90% of Total Billed charges,64.5,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,64.5,Pays at 32.15% of Total Billed charges,176.55,Pays at 88% of Total Billed charges,66.43,Pays at 33.11% of Total Billed charges,64.5,180.57,120.38
Outpatient Medical Services,RADIOLOGY,73060,PORT HUMERUS 2V LT,320,219.75,186.79,Pays at 85% of Billed charges for outpatient setting,70.65,Pays at 32.15% of Total Billed charges,175.87,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,197.78,Pays at 90% of Total Billed charges,70.65,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,70.65,Pays at 32.15% of Total Billed charges,193.38,Pays at 88% of Total Billed charges,72.76,Pays at 33.11% of Total Billed charges,70.65,197.78,131.85
Outpatient Medical Services,RADIOLOGY,73060,OR HUMERUS 2V RT,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73060,HUMERUS 2V RT,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73060,PORT HUMERUS 2V RT,320,219.75,186.79,Pays at 85% of Billed charges for outpatient setting,70.65,Pays at 32.15% of Total Billed charges,175.87,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,197.78,Pays at 90% of Total Billed charges,70.65,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,70.65,Pays at 32.15% of Total Billed charges,193.38,Pays at 88% of Total Billed charges,72.76,Pays at 33.11% of Total Billed charges,70.65,197.78,131.85
Outpatient Medical Services,RADIOLOGY,73070,"Radiologic examination, elbow; 2 views",320,318.75,270.94,Pays at 85% of Billed charges for outpatient setting,102.48,Pays at 32.15% of Total Billed charges,255.1,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,286.88,Pays at 90% of Total Billed charges,102.48,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,102.48,Pays at 32.15% of Total Billed charges,280.5,Pays at 88% of Total Billed charges,105.54,Pays at 33.11% of Total Billed charges,81.65,286.88,191.25
Outpatient Medical Services,RADIOLOGY,73070,"Radiologic examination, elbow; 2 views",320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73070,"Radiologic examination, elbow; 2 views",320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73070,"Radiologic examination, elbow; 2 views",320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73070,"Radiologic examination, elbow; 2 views",320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73070,"Radiologic examination, elbow; 2 views",320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73070,"Radiologic examination, elbow; 2 views",320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73080,"Radiologic examination, elbow; 3 or more views",320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73080,"Radiologic examination, elbow; 3 or more views",320,199.25,169.36,Pays at 85% of Billed charges for outpatient setting,64.06,Pays at 32.15% of Total Billed charges,159.46,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,179.33,Pays at 90% of Total Billed charges,64.06,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,64.06,Pays at 32.15% of Total Billed charges,175.34,Pays at 88% of Total Billed charges,65.97,Pays at 33.11% of Total Billed charges,64.06,179.33,119.55
Outpatient Medical Services,RADIOLOGY,73080,"Radiologic examination, elbow; 3 or more views",320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73080,"Radiologic examination, elbow; 3 or more views",320,131.25,111.56,Pays at 85% of Billed charges for outpatient setting,42.2,Pays at 32.15% of Total Billed charges,105.04,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,118.13,Pays at 90% of Total Billed charges,42.2,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,42.2,Pays at 32.15% of Total Billed charges,115.5,Pays at 88% of Total Billed charges,43.46,Pays at 33.11% of Total Billed charges,42.2,118.13,78.75
Outpatient Medical Services,RADIOLOGY,73080,"Radiologic examination, elbow; 3 or more views",320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73090,Radiologic examination of the forearm,320,159.5,135.58,Pays at 85% of Billed charges for outpatient setting,51.28,Pays at 32.15% of Total Billed charges,127.65,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,143.55,Pays at 90% of Total Billed charges,51.28,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.28,Pays at 32.15% of Total Billed charges,140.36,Pays at 88% of Total Billed charges,52.81,Pays at 33.11% of Total Billed charges,51.28,143.55,95.70
Outpatient Medical Services,RADIOLOGY,73090,Radiologic examination of the forearm,320,219.75,186.79,Pays at 85% of Billed charges for outpatient setting,70.65,Pays at 32.15% of Total Billed charges,175.87,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,197.78,Pays at 90% of Total Billed charges,70.65,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,70.65,Pays at 32.15% of Total Billed charges,193.38,Pays at 88% of Total Billed charges,72.76,Pays at 33.11% of Total Billed charges,70.65,197.78,131.85
Outpatient Medical Services,RADIOLOGY,73090,Radiologic examination of the forearm,320,159.5,135.58,Pays at 85% of Billed charges for outpatient setting,51.28,Pays at 32.15% of Total Billed charges,127.65,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,143.55,Pays at 90% of Total Billed charges,51.28,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.28,Pays at 32.15% of Total Billed charges,140.36,Pays at 88% of Total Billed charges,52.81,Pays at 33.11% of Total Billed charges,51.28,143.55,95.70
Outpatient Medical Services,RADIOLOGY,73090,Radiologic examination of the forearm,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73090,Radiologic examination of the forearm,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73090,Radiologic examination of the forearm,320,199.38,169.47,Pays at 85% of Billed charges for outpatient setting,64.1,Pays at 32.15% of Total Billed charges,159.56,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,179.44,Pays at 90% of Total Billed charges,64.1,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,64.1,Pays at 32.15% of Total Billed charges,175.45,Pays at 88% of Total Billed charges,66.01,Pays at 33.11% of Total Billed charges,64.1,179.44,119.63
Outpatient Medical Services,RADIOLOGY,73100,3 or more views,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73100,3 or more views,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73100,3 or more views,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73100,3 or more views,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73100,3 or more views,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73100,3 or more views,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73110,Up to 3 views,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73110,Up to 3 views,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73110,Up to 3 views,320,200.63,170.54,Pays at 85% of Billed charges for outpatient setting,64.5,Pays at 32.15% of Total Billed charges,160.56,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,180.57,Pays at 90% of Total Billed charges,64.5,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,64.5,Pays at 32.15% of Total Billed charges,176.55,Pays at 88% of Total Billed charges,66.43,Pays at 33.11% of Total Billed charges,64.5,180.57,120.38
Outpatient Medical Services,RADIOLOGY,73110,Up to 3 views,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73110,Up to 3 views,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73110,Up to 3 views,320,131.61,111.87,Pays at 85% of Billed charges for outpatient setting,42.31,Pays at 32.15% of Total Billed charges,105.33,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,118.45,Pays at 90% of Total Billed charges,42.31,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,42.31,Pays at 32.15% of Total Billed charges,115.82,Pays at 88% of Total Billed charges,43.58,Pays at 33.11% of Total Billed charges,42.31,118.45,78.97
Outpatient Medical Services,RADIOLOGY,73110,Up to 3 views,320,133.95,113.86,Pays at 85% of Billed charges for outpatient setting,43.06,Pays at 32.15% of Total Billed charges,107.2,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,120.56,Pays at 90% of Total Billed charges,43.06,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,43.06,Pays at 32.15% of Total Billed charges,117.88,Pays at 88% of Total Billed charges,44.35,Pays at 33.11% of Total Billed charges,43.06,120.56,80.37
Outpatient Medical Services,RADIOLOGY,73115,ARTHROGRAM WRIST RT,320,517.5,439.88,Pays at 85% of Billed charges for outpatient setting,166.38,Pays at 32.15% of Total Billed charges,414.16,Pays at 80.03% of Total Billed charges,353.21,Pays at 102% of Medicare OPPS Rate,465.75,Pays at 90% of Total Billed charges,166.38,Pays at 32.15% of Total Billed charges,346.29,Pays at 100% of Medicare OPPS Rate,166.38,Pays at 32.15% of Total Billed charges,455.4,Pays at 88% of Total Billed charges,171.34,Pays at 33.11% of Total Billed charges,166.38,465.75,310.50
Outpatient Medical Services,RADIOLOGY,73115,ARTHROGRAM WRIST RT,320,332.5,282.63,Pays at 85% of Billed charges for outpatient setting,106.9,Pays at 32.15% of Total Billed charges,266.1,Pays at 80.03% of Total Billed charges,353.21,Pays at 102% of Medicare OPPS Rate,299.25,Pays at 90% of Total Billed charges,106.9,Pays at 32.15% of Total Billed charges,346.29,Pays at 100% of Medicare OPPS Rate,106.9,Pays at 32.15% of Total Billed charges,292.6,Pays at 88% of Total Billed charges,110.09,Pays at 33.11% of Total Billed charges,106.9,353.21,199.50
Outpatient Medical Services,RADIOLOGY,73120,X-ray of the hand with 2 views,320,296,251.6,Pays at 85% of Billed charges for outpatient setting,95.16,Pays at 32.15% of Total Billed charges,236.89,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,266.4,Pays at 90% of Total Billed charges,95.16,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,95.16,Pays at 32.15% of Total Billed charges,260.48,Pays at 88% of Total Billed charges,98.01,Pays at 33.11% of Total Billed charges,95.16,266.4,177.60
Outpatient Medical Services,RADIOLOGY,73120,X-ray of the hand with 2 views,320,125.25,106.46,Pays at 85% of Billed charges for outpatient setting,40.27,Pays at 32.15% of Total Billed charges,100.24,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,112.73,Pays at 90% of Total Billed charges,40.27,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,40.27,Pays at 32.15% of Total Billed charges,110.22,Pays at 88% of Total Billed charges,41.47,Pays at 33.11% of Total Billed charges,40.27,112.73,75.15
Outpatient Medical Services,RADIOLOGY,73120,X-ray of the hand with 2 views,320,296,251.6,Pays at 85% of Billed charges for outpatient setting,95.16,Pays at 32.15% of Total Billed charges,236.89,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,266.4,Pays at 90% of Total Billed charges,95.16,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,95.16,Pays at 32.15% of Total Billed charges,260.48,Pays at 88% of Total Billed charges,98.01,Pays at 33.11% of Total Billed charges,95.16,266.4,177.60
Outpatient Medical Services,RADIOLOGY,73120,X-ray of the hand with 2 views,320,125.25,106.46,Pays at 85% of Billed charges for outpatient setting,40.27,Pays at 32.15% of Total Billed charges,100.24,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,112.73,Pays at 90% of Total Billed charges,40.27,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,40.27,Pays at 32.15% of Total Billed charges,110.22,Pays at 88% of Total Billed charges,41.47,Pays at 33.11% of Total Billed charges,40.27,112.73,75.15
Outpatient Medical Services,RADIOLOGY,73130,X-ray of the hand with 3 or more views,320,192.5,163.63,Pays at 85% of Billed charges for outpatient setting,61.89,Pays at 32.15% of Total Billed charges,154.06,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,173.25,Pays at 90% of Total Billed charges,61.89,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,61.89,Pays at 32.15% of Total Billed charges,169.4,Pays at 88% of Total Billed charges,63.74,Pays at 33.11% of Total Billed charges,61.89,173.25,115.50
Outpatient Medical Services,RADIOLOGY,73130,X-ray of the hand with 3 or more views,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73130,X-ray of the hand with 3 or more views,320,200.63,170.54,Pays at 85% of Billed charges for outpatient setting,64.5,Pays at 32.15% of Total Billed charges,160.56,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,180.57,Pays at 90% of Total Billed charges,64.5,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,64.5,Pays at 32.15% of Total Billed charges,176.55,Pays at 88% of Total Billed charges,66.43,Pays at 33.11% of Total Billed charges,64.5,180.57,120.38
Outpatient Medical Services,RADIOLOGY,73130,X-ray of the hand with 3 or more views,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73130,X-ray of the hand with 3 or more views,320,200.63,170.54,Pays at 85% of Billed charges for outpatient setting,64.5,Pays at 32.15% of Total Billed charges,160.56,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,180.57,Pays at 90% of Total Billed charges,64.5,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,64.5,Pays at 32.15% of Total Billed charges,176.55,Pays at 88% of Total Billed charges,66.43,Pays at 33.11% of Total Billed charges,64.5,180.57,120.38
Outpatient Medical Services,RADIOLOGY,73140,Radiologic examination of the finger(s),320,149.25,126.86,Pays at 85% of Billed charges for outpatient setting,47.98,Pays at 32.15% of Total Billed charges,119.44,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,134.33,Pays at 90% of Total Billed charges,47.98,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,47.98,Pays at 32.15% of Total Billed charges,131.34,Pays at 88% of Total Billed charges,49.42,Pays at 33.11% of Total Billed charges,47.98,134.33,89.55
Outpatient Medical Services,RADIOLOGY,73140,Radiologic examination of the finger(s),320,200.63,170.54,Pays at 85% of Billed charges for outpatient setting,64.5,Pays at 32.15% of Total Billed charges,160.56,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,180.57,Pays at 90% of Total Billed charges,64.5,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,64.5,Pays at 32.15% of Total Billed charges,176.55,Pays at 88% of Total Billed charges,66.43,Pays at 33.11% of Total Billed charges,64.5,180.57,120.38
Outpatient Medical Services,RADIOLOGY,73140,Radiologic examination of the finger(s),320,117.25,99.66,Pays at 85% of Billed charges for outpatient setting,37.7,Pays at 32.15% of Total Billed charges,93.84,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,105.53,Pays at 90% of Total Billed charges,37.7,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,37.7,Pays at 32.15% of Total Billed charges,103.18,Pays at 88% of Total Billed charges,38.82,Pays at 33.11% of Total Billed charges,37.7,105.53,70.35
Outpatient Medical Services,RADIOLOGY,73140,Radiologic examination of the finger(s),320,149.25,126.86,Pays at 85% of Billed charges for outpatient setting,47.98,Pays at 32.15% of Total Billed charges,119.44,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,134.33,Pays at 90% of Total Billed charges,47.98,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,47.98,Pays at 32.15% of Total Billed charges,131.34,Pays at 88% of Total Billed charges,49.42,Pays at 33.11% of Total Billed charges,47.98,134.33,89.55
Outpatient Medical Services,RADIOLOGY,73140,Radiologic examination of the finger(s),320,155.25,131.96,Pays at 85% of Billed charges for outpatient setting,49.91,Pays at 32.15% of Total Billed charges,124.25,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,139.73,Pays at 90% of Total Billed charges,49.91,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,49.91,Pays at 32.15% of Total Billed charges,136.62,Pays at 88% of Total Billed charges,51.4,Pays at 33.11% of Total Billed charges,49.91,139.73,93.15
Outpatient Medical Services,RADIOLOGY,73140,Radiologic examination of the finger(s),320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73140,Radiologic examination of the finger(s),320,209.75,178.29,Pays at 85% of Billed charges for outpatient setting,67.43,Pays at 32.15% of Total Billed charges,167.86,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,188.78,Pays at 90% of Total Billed charges,67.43,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,67.43,Pays at 32.15% of Total Billed charges,184.58,Pays at 88% of Total Billed charges,69.45,Pays at 33.11% of Total Billed charges,67.43,188.78,125.85
Outpatient Medical Services,RADIOLOGY,73501,HIP 1V LT,320,149.25,126.86,Pays at 85% of Billed charges for outpatient setting,47.98,Pays at 32.15% of Total Billed charges,119.44,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,134.33,Pays at 90% of Total Billed charges,47.98,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,47.98,Pays at 32.15% of Total Billed charges,131.34,Pays at 88% of Total Billed charges,49.42,Pays at 33.11% of Total Billed charges,47.98,134.33,89.55
Outpatient Medical Services,RADIOLOGY,73501,PORT HIP UNILAT 1V LT,320,209.75,178.29,Pays at 85% of Billed charges for outpatient setting,67.43,Pays at 32.15% of Total Billed charges,167.86,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,188.78,Pays at 90% of Total Billed charges,67.43,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,67.43,Pays at 32.15% of Total Billed charges,184.58,Pays at 88% of Total Billed charges,69.45,Pays at 33.11% of Total Billed charges,67.43,188.78,125.85
Outpatient Medical Services,RADIOLOGY,73501,HIP 1V RT,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73501,PORT HIP UNILAT 1V RT,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73501,HIP OPERATIVE,320,873.85,742.77,Pays at 85% of Billed charges for outpatient setting,280.94,Pays at 32.15% of Total Billed charges,699.34,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,786.47,Pays at 90% of Total Billed charges,280.94,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,280.94,Pays at 32.15% of Total Billed charges,768.99,Pays at 88% of Total Billed charges,289.33,Pays at 33.11% of Total Billed charges,81.65,786.47,524.31
Outpatient Medical Services,RADIOLOGY,73502,PORT HIP AP/LAT 2V LT,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73502,HIP AP/LAT 2V LT,320,155.19,131.91,Pays at 85% of Billed charges for outpatient setting,49.89,Pays at 32.15% of Total Billed charges,124.2,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,139.67,Pays at 90% of Total Billed charges,49.89,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,49.89,Pays at 32.15% of Total Billed charges,136.57,Pays at 88% of Total Billed charges,51.38,Pays at 33.11% of Total Billed charges,49.89,139.67,93.11
Outpatient Medical Services,RADIOLOGY,73502,PORT HIP AP/LAT 2V RT,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73502,HIP AP/LAT 2V RT,320,155.19,131.91,Pays at 85% of Billed charges for outpatient setting,49.89,Pays at 32.15% of Total Billed charges,124.2,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,139.67,Pays at 90% of Total Billed charges,49.89,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,49.89,Pays at 32.15% of Total Billed charges,136.57,Pays at 88% of Total Billed charges,51.38,Pays at 33.11% of Total Billed charges,49.89,139.67,93.11
Outpatient Medical Services,RADIOLOGY,73502,PORT HIP OPERATIVE,320,994.75,845.54,Pays at 85% of Billed charges for outpatient setting,319.81,Pays at 32.15% of Total Billed charges,796.1,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,895.28,Pays at 90% of Total Billed charges,319.81,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,319.81,Pays at 32.15% of Total Billed charges,875.38,Pays at 88% of Total Billed charges,329.36,Pays at 33.11% of Total Billed charges,81.65,895.28,596.85
Outpatient Medical Services,RADIOLOGY,73521,PORT HIP BILAT 2V EA HIP,320,287.25,244.16,Pays at 85% of Billed charges for outpatient setting,92.35,Pays at 32.15% of Total Billed charges,229.89,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,258.53,Pays at 90% of Total Billed charges,92.35,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,92.35,Pays at 32.15% of Total Billed charges,252.78,Pays at 88% of Total Billed charges,95.11,Pays at 33.11% of Total Billed charges,92.35,258.53,172.35
Outpatient Medical Services,RADIOLOGY,73521,HIP BILAT 2V EA HIP,320,296,251.6,Pays at 85% of Billed charges for outpatient setting,95.16,Pays at 32.15% of Total Billed charges,236.89,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,266.4,Pays at 90% of Total Billed charges,95.16,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,95.16,Pays at 32.15% of Total Billed charges,260.48,Pays at 88% of Total Billed charges,98.01,Pays at 33.11% of Total Billed charges,95.16,266.4,177.60
Outpatient Medical Services,RADIOLOGY,73525,ARTHROGRAM HIP BILAT,320,1035,879.75,Pays at 85% of Billed charges for outpatient setting,332.75,Pays at 32.15% of Total Billed charges,828.31,Pays at 80.03% of Total Billed charges,353.21,Pays at 102% of Medicare OPPS Rate,931.5,Pays at 90% of Total Billed charges,332.75,Pays at 32.15% of Total Billed charges,346.29,Pays at 100% of Medicare OPPS Rate,332.75,Pays at 32.15% of Total Billed charges,910.8,Pays at 88% of Total Billed charges,342.69,Pays at 33.11% of Total Billed charges,332.75,931.5,621.00
Outpatient Medical Services,RADIOLOGY,73525,ARTHROGRAM HIP LT,320,517.5,439.88,Pays at 85% of Billed charges for outpatient setting,166.38,Pays at 32.15% of Total Billed charges,414.16,Pays at 80.03% of Total Billed charges,353.21,Pays at 102% of Medicare OPPS Rate,465.75,Pays at 90% of Total Billed charges,166.38,Pays at 32.15% of Total Billed charges,346.29,Pays at 100% of Medicare OPPS Rate,166.38,Pays at 32.15% of Total Billed charges,455.4,Pays at 88% of Total Billed charges,171.34,Pays at 33.11% of Total Billed charges,166.38,465.75,310.50
Outpatient Medical Services,RADIOLOGY,73525,ARTHROGRAM HIP RIGHT,320,500,425,Pays at 85% of Billed charges for outpatient setting,160.75,Pays at 32.15% of Total Billed charges,400.15,Pays at 80.03% of Total Billed charges,353.21,Pays at 102% of Medicare OPPS Rate,450,Pays at 90% of Total Billed charges,160.75,Pays at 32.15% of Total Billed charges,346.29,Pays at 100% of Medicare OPPS Rate,160.75,Pays at 32.15% of Total Billed charges,440,Pays at 88% of Total Billed charges,165.55,Pays at 33.11% of Total Billed charges,160.75,450,300.00
Outpatient Medical Services,RADIOLOGY,73552,FEMUR 2V LT,320,200.63,170.54,Pays at 85% of Billed charges for outpatient setting,64.5,Pays at 32.15% of Total Billed charges,160.56,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,180.57,Pays at 90% of Total Billed charges,64.5,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,64.5,Pays at 32.15% of Total Billed charges,176.55,Pays at 88% of Total Billed charges,66.43,Pays at 33.11% of Total Billed charges,64.5,180.57,120.38
Outpatient Medical Services,RADIOLOGY,73552,PORT FEMUR 2V LT,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73552,OR FEMUR 2V LT,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73552,OR FEMUR 2V RT,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73552,FEMUR 2V RT,320,200.63,170.54,Pays at 85% of Billed charges for outpatient setting,64.5,Pays at 32.15% of Total Billed charges,160.56,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,180.57,Pays at 90% of Total Billed charges,64.5,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,64.5,Pays at 32.15% of Total Billed charges,176.55,Pays at 88% of Total Billed charges,66.43,Pays at 33.11% of Total Billed charges,64.5,180.57,120.38
Outpatient Medical Services,RADIOLOGY,73552,PORT FEMUR 2V RT,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73560,Radiologic examination of the knee with 1 or 2 views,320,378.2,321.47,Pays at 85% of Billed charges for outpatient setting,121.59,Pays at 32.15% of Total Billed charges,302.67,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,340.38,Pays at 90% of Total Billed charges,121.59,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,121.59,Pays at 32.15% of Total Billed charges,332.82,Pays at 88% of Total Billed charges,125.22,Pays at 33.11% of Total Billed charges,81.65,340.38,226.92
Outpatient Medical Services,RADIOLOGY,73560,Radiologic examination of the knee with 1 or 2 views,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73560,Radiologic examination of the knee with 1 or 2 views,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73560,Radiologic examination of the knee with 1 or 2 views,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73560,Radiologic examination of the knee with 1 or 2 views,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73560,Radiologic examination of the knee with 1 or 2 views,320,202.5,172.13,Pays at 85% of Billed charges for outpatient setting,65.1,Pays at 32.15% of Total Billed charges,162.06,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,182.25,Pays at 90% of Total Billed charges,65.1,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,65.1,Pays at 32.15% of Total Billed charges,178.2,Pays at 88% of Total Billed charges,67.05,Pays at 33.11% of Total Billed charges,65.1,182.25,121.50
Outpatient Medical Services,RADIOLOGY,73560,Radiologic examination of the knee with 1 or 2 views,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73560,Radiologic examination of the knee with 1 or 2 views,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73560,Radiologic examination of the knee with 1 or 2 views,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73560,Radiologic examination of the knee with 1 or 2 views,320,202.5,172.13,Pays at 85% of Billed charges for outpatient setting,65.1,Pays at 32.15% of Total Billed charges,162.06,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,182.25,Pays at 90% of Total Billed charges,65.1,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,65.1,Pays at 32.15% of Total Billed charges,178.2,Pays at 88% of Total Billed charges,67.05,Pays at 33.11% of Total Billed charges,65.1,182.25,121.50
Outpatient Medical Services,RADIOLOGY,73560,Radiologic examination of the knee with 1 or 2 views,320,159.5,135.58,Pays at 85% of Billed charges for outpatient setting,51.28,Pays at 32.15% of Total Billed charges,127.65,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,143.55,Pays at 90% of Total Billed charges,51.28,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.28,Pays at 32.15% of Total Billed charges,140.36,Pays at 88% of Total Billed charges,52.81,Pays at 33.11% of Total Billed charges,51.28,143.55,95.70
Outpatient Medical Services,RADIOLOGY,73560,Radiologic examination of the knee with 1 or 2 views,320,149.25,126.86,Pays at 85% of Billed charges for outpatient setting,47.98,Pays at 32.15% of Total Billed charges,119.44,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,134.33,Pays at 90% of Total Billed charges,47.98,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,47.98,Pays at 32.15% of Total Billed charges,131.34,Pays at 88% of Total Billed charges,49.42,Pays at 33.11% of Total Billed charges,47.98,134.33,89.55
Outpatient Medical Services,RADIOLOGY,73562,Radiologic examination of the knee with 3 views,320,200.63,170.54,Pays at 85% of Billed charges for outpatient setting,64.5,Pays at 32.15% of Total Billed charges,160.56,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,180.57,Pays at 90% of Total Billed charges,64.5,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,64.5,Pays at 32.15% of Total Billed charges,176.55,Pays at 88% of Total Billed charges,66.43,Pays at 33.11% of Total Billed charges,64.5,180.57,120.38
Outpatient Medical Services,RADIOLOGY,73562,Radiologic examination of the knee with 3 views,320,199.25,169.36,Pays at 85% of Billed charges for outpatient setting,64.06,Pays at 32.15% of Total Billed charges,159.46,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,179.33,Pays at 90% of Total Billed charges,64.06,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,64.06,Pays at 32.15% of Total Billed charges,175.34,Pays at 88% of Total Billed charges,65.97,Pays at 33.11% of Total Billed charges,64.06,179.33,119.55
Outpatient Medical Services,RADIOLOGY,73562,Radiologic examination of the knee with 3 views,320,192.5,163.63,Pays at 85% of Billed charges for outpatient setting,61.89,Pays at 32.15% of Total Billed charges,154.06,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,173.25,Pays at 90% of Total Billed charges,61.89,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,61.89,Pays at 32.15% of Total Billed charges,169.4,Pays at 88% of Total Billed charges,63.74,Pays at 33.11% of Total Billed charges,61.89,173.25,115.50
Outpatient Medical Services,RADIOLOGY,73562,Radiologic examination of the knee with 3 views,320,131.61,111.87,Pays at 85% of Billed charges for outpatient setting,42.31,Pays at 32.15% of Total Billed charges,105.33,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,118.45,Pays at 90% of Total Billed charges,42.31,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,42.31,Pays at 32.15% of Total Billed charges,115.82,Pays at 88% of Total Billed charges,43.58,Pays at 33.11% of Total Billed charges,42.31,118.45,78.97
Outpatient Medical Services,RADIOLOGY,73562,Radiologic examination of the knee with 3 views,320,200.63,170.54,Pays at 85% of Billed charges for outpatient setting,64.5,Pays at 32.15% of Total Billed charges,160.56,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,180.57,Pays at 90% of Total Billed charges,64.5,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,64.5,Pays at 32.15% of Total Billed charges,176.55,Pays at 88% of Total Billed charges,66.43,Pays at 33.11% of Total Billed charges,64.5,180.57,120.38
Outpatient Medical Services,RADIOLOGY,73562,Radiologic examination of the knee with 3 views,320,199.25,169.36,Pays at 85% of Billed charges for outpatient setting,64.06,Pays at 32.15% of Total Billed charges,159.46,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,179.33,Pays at 90% of Total Billed charges,64.06,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,64.06,Pays at 32.15% of Total Billed charges,175.34,Pays at 88% of Total Billed charges,65.97,Pays at 33.11% of Total Billed charges,64.06,179.33,119.55
Outpatient Medical Services,RADIOLOGY,73562,Radiologic examination of the knee with 3 views,320,192.5,163.63,Pays at 85% of Billed charges for outpatient setting,61.89,Pays at 32.15% of Total Billed charges,154.06,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,173.25,Pays at 90% of Total Billed charges,61.89,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,61.89,Pays at 32.15% of Total Billed charges,169.4,Pays at 88% of Total Billed charges,63.74,Pays at 33.11% of Total Billed charges,61.89,173.25,115.50
Outpatient Medical Services,RADIOLOGY,73564,Radiologic examination of the knee with 4 or more views,320,296,251.6,Pays at 85% of Billed charges for outpatient setting,95.16,Pays at 32.15% of Total Billed charges,236.89,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,266.4,Pays at 90% of Total Billed charges,95.16,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,95.16,Pays at 32.15% of Total Billed charges,260.48,Pays at 88% of Total Billed charges,98.01,Pays at 33.11% of Total Billed charges,95.16,266.4,177.60
Outpatient Medical Services,RADIOLOGY,73564,Radiologic examination of the knee with 4 or more views,320,296,251.6,Pays at 85% of Billed charges for outpatient setting,95.16,Pays at 32.15% of Total Billed charges,236.89,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,266.4,Pays at 90% of Total Billed charges,95.16,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,95.16,Pays at 32.15% of Total Billed charges,260.48,Pays at 88% of Total Billed charges,98.01,Pays at 33.11% of Total Billed charges,95.16,266.4,177.60
Outpatient Medical Services,RADIOLOGY,73564,Radiologic examination of the knee with 4 or more views,320,296,251.6,Pays at 85% of Billed charges for outpatient setting,95.16,Pays at 32.15% of Total Billed charges,236.89,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,266.4,Pays at 90% of Total Billed charges,95.16,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,95.16,Pays at 32.15% of Total Billed charges,260.48,Pays at 88% of Total Billed charges,98.01,Pays at 33.11% of Total Billed charges,95.16,266.4,177.60
Outpatient Medical Services,RADIOLOGY,73564,Radiologic examination of the knee with 4 or more views,320,296,251.6,Pays at 85% of Billed charges for outpatient setting,95.16,Pays at 32.15% of Total Billed charges,236.89,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,266.4,Pays at 90% of Total Billed charges,95.16,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,95.16,Pays at 32.15% of Total Billed charges,260.48,Pays at 88% of Total Billed charges,98.01,Pays at 33.11% of Total Billed charges,95.16,266.4,177.60
Outpatient Medical Services,RADIOLOGY,73580,ARTHROGRAM KNEE LT,320,621,527.85,Pays at 85% of Billed charges for outpatient setting,199.65,Pays at 32.15% of Total Billed charges,496.99,Pays at 80.03% of Total Billed charges,353.21,Pays at 102% of Medicare OPPS Rate,558.9,Pays at 90% of Total Billed charges,199.65,Pays at 32.15% of Total Billed charges,346.29,Pays at 100% of Medicare OPPS Rate,199.65,Pays at 32.15% of Total Billed charges,546.48,Pays at 88% of Total Billed charges,205.61,Pays at 33.11% of Total Billed charges,199.65,558.9,372.60
Outpatient Medical Services,RADIOLOGY,73580,ARTHROGRAM KNEE RT,320,600,510,Pays at 85% of Billed charges for outpatient setting,192.9,Pays at 32.15% of Total Billed charges,480.18,Pays at 80.03% of Total Billed charges,353.21,Pays at 102% of Medicare OPPS Rate,540,Pays at 90% of Total Billed charges,192.9,Pays at 32.15% of Total Billed charges,346.29,Pays at 100% of Medicare OPPS Rate,192.9,Pays at 32.15% of Total Billed charges,528,Pays at 88% of Total Billed charges,198.66,Pays at 33.11% of Total Billed charges,192.9,540,360.00
Outpatient Medical Services,RADIOLOGY,73590,Radiologic examination of the lower leg,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73590,Radiologic examination of the lower leg,320,130.79,111.17,Pays at 85% of Billed charges for outpatient setting,42.05,Pays at 32.15% of Total Billed charges,104.67,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,117.71,Pays at 90% of Total Billed charges,42.05,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,42.05,Pays at 32.15% of Total Billed charges,115.1,Pays at 88% of Total Billed charges,43.3,Pays at 33.11% of Total Billed charges,42.05,117.71,78.47
Outpatient Medical Services,RADIOLOGY,73590,Radiologic examination of the lower leg,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73590,Radiologic examination of the lower leg,320,131.61,111.87,Pays at 85% of Billed charges for outpatient setting,42.31,Pays at 32.15% of Total Billed charges,105.33,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,118.45,Pays at 90% of Total Billed charges,42.31,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,42.31,Pays at 32.15% of Total Billed charges,115.82,Pays at 88% of Total Billed charges,43.58,Pays at 33.11% of Total Billed charges,42.31,118.45,78.97
Outpatient Medical Services,RADIOLOGY,73600,Radiologic examination of the ankle with 2 views,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73600,Radiologic examination of the ankle with 2 views,320,159.5,135.58,Pays at 85% of Billed charges for outpatient setting,51.28,Pays at 32.15% of Total Billed charges,127.65,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,143.55,Pays at 90% of Total Billed charges,51.28,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.28,Pays at 32.15% of Total Billed charges,140.36,Pays at 88% of Total Billed charges,52.81,Pays at 33.11% of Total Billed charges,51.28,143.55,95.70
Outpatient Medical Services,RADIOLOGY,73600,Radiologic examination of the ankle with 2 views,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73600,Radiologic examination of the ankle with 2 views,320,159.5,135.58,Pays at 85% of Billed charges for outpatient setting,51.28,Pays at 32.15% of Total Billed charges,127.65,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,143.55,Pays at 90% of Total Billed charges,51.28,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.28,Pays at 32.15% of Total Billed charges,140.36,Pays at 88% of Total Billed charges,52.81,Pays at 33.11% of Total Billed charges,51.28,143.55,95.70
Outpatient Medical Services,RADIOLOGY,73610,Radiologic examination of the ankle with 3 views,320,192.5,163.63,Pays at 85% of Billed charges for outpatient setting,61.89,Pays at 32.15% of Total Billed charges,154.06,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,173.25,Pays at 90% of Total Billed charges,61.89,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,61.89,Pays at 32.15% of Total Billed charges,169.4,Pays at 88% of Total Billed charges,63.74,Pays at 33.11% of Total Billed charges,61.89,173.25,115.50
Outpatient Medical Services,RADIOLOGY,73610,Radiologic examination of the ankle with 3 views,320,200.63,170.54,Pays at 85% of Billed charges for outpatient setting,64.5,Pays at 32.15% of Total Billed charges,160.56,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,180.57,Pays at 90% of Total Billed charges,64.5,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,64.5,Pays at 32.15% of Total Billed charges,176.55,Pays at 88% of Total Billed charges,66.43,Pays at 33.11% of Total Billed charges,64.5,180.57,120.38
Outpatient Medical Services,RADIOLOGY,73610,Radiologic examination of the ankle with 3 views,320,200.63,170.54,Pays at 85% of Billed charges for outpatient setting,64.5,Pays at 32.15% of Total Billed charges,160.56,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,180.57,Pays at 90% of Total Billed charges,64.5,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,64.5,Pays at 32.15% of Total Billed charges,176.55,Pays at 88% of Total Billed charges,66.43,Pays at 33.11% of Total Billed charges,64.5,180.57,120.38
Outpatient Medical Services,RADIOLOGY,73610,Radiologic examination of the ankle with 3 views,320,219.75,186.79,Pays at 85% of Billed charges for outpatient setting,70.65,Pays at 32.15% of Total Billed charges,175.87,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,197.78,Pays at 90% of Total Billed charges,70.65,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,70.65,Pays at 32.15% of Total Billed charges,193.38,Pays at 88% of Total Billed charges,72.76,Pays at 33.11% of Total Billed charges,70.65,197.78,131.85
Outpatient Medical Services,RADIOLOGY,73620,"Radiologic examination, foot; 2 views",320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73620,"Radiologic examination, foot; 2 views",320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73620,"Radiologic examination, foot; 2 views",320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73620,"Radiologic examination, foot; 2 views",320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73630,Radiologic examination of the foot with 3 or more views,320,192.5,163.63,Pays at 85% of Billed charges for outpatient setting,61.89,Pays at 32.15% of Total Billed charges,154.06,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,173.25,Pays at 90% of Total Billed charges,61.89,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,61.89,Pays at 32.15% of Total Billed charges,169.4,Pays at 88% of Total Billed charges,63.74,Pays at 33.11% of Total Billed charges,61.89,173.25,115.50
Outpatient Medical Services,RADIOLOGY,73630,Radiologic examination of the foot with 3 or more views,320,318.75,270.94,Pays at 85% of Billed charges for outpatient setting,102.48,Pays at 32.15% of Total Billed charges,255.1,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,286.88,Pays at 90% of Total Billed charges,102.48,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,102.48,Pays at 32.15% of Total Billed charges,280.5,Pays at 88% of Total Billed charges,105.54,Pays at 33.11% of Total Billed charges,81.65,286.88,191.25
Outpatient Medical Services,RADIOLOGY,73630,Radiologic examination of the foot with 3 or more views,320,200.63,170.54,Pays at 85% of Billed charges for outpatient setting,64.5,Pays at 32.15% of Total Billed charges,160.56,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,180.57,Pays at 90% of Total Billed charges,64.5,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,64.5,Pays at 32.15% of Total Billed charges,176.55,Pays at 88% of Total Billed charges,66.43,Pays at 33.11% of Total Billed charges,64.5,180.57,120.38
Outpatient Medical Services,RADIOLOGY,73630,Radiologic examination of the foot with 3 or more views,320,219.75,186.79,Pays at 85% of Billed charges for outpatient setting,70.65,Pays at 32.15% of Total Billed charges,175.87,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,197.78,Pays at 90% of Total Billed charges,70.65,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,70.65,Pays at 32.15% of Total Billed charges,193.38,Pays at 88% of Total Billed charges,72.76,Pays at 33.11% of Total Billed charges,70.65,197.78,131.85
Outpatient Medical Services,RADIOLOGY,73630,Radiologic examination of the foot with 3 or more views,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73630,Radiologic examination of the foot with 3 or more views,320,131.61,111.87,Pays at 85% of Billed charges for outpatient setting,42.31,Pays at 32.15% of Total Billed charges,105.33,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,118.45,Pays at 90% of Total Billed charges,42.31,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,42.31,Pays at 32.15% of Total Billed charges,115.82,Pays at 88% of Total Billed charges,43.58,Pays at 33.11% of Total Billed charges,42.31,118.45,78.97
Outpatient Medical Services,RADIOLOGY,73650,Radiologic examination of the heel,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73650,Radiologic examination of the heel,320,202.5,172.13,Pays at 85% of Billed charges for outpatient setting,65.1,Pays at 32.15% of Total Billed charges,162.06,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,182.25,Pays at 90% of Total Billed charges,65.1,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,65.1,Pays at 32.15% of Total Billed charges,178.2,Pays at 88% of Total Billed charges,67.05,Pays at 33.11% of Total Billed charges,65.1,182.25,121.50
Outpatient Medical Services,RADIOLOGY,73650,Radiologic examination of the heel,320,149.25,126.86,Pays at 85% of Billed charges for outpatient setting,47.98,Pays at 32.15% of Total Billed charges,119.44,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,134.33,Pays at 90% of Total Billed charges,47.98,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,47.98,Pays at 32.15% of Total Billed charges,131.34,Pays at 88% of Total Billed charges,49.42,Pays at 33.11% of Total Billed charges,47.98,134.33,89.55
Outpatient Medical Services,RADIOLOGY,73650,Radiologic examination of the heel,320,378.2,321.47,Pays at 85% of Billed charges for outpatient setting,121.59,Pays at 32.15% of Total Billed charges,302.67,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,340.38,Pays at 90% of Total Billed charges,121.59,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,121.59,Pays at 32.15% of Total Billed charges,332.82,Pays at 88% of Total Billed charges,125.22,Pays at 33.11% of Total Billed charges,81.65,340.38,226.92
Outpatient Medical Services,RADIOLOGY,73650,Radiologic examination of the heel,320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73650,Radiologic examination of the heel,320,202.5,172.13,Pays at 85% of Billed charges for outpatient setting,65.1,Pays at 32.15% of Total Billed charges,162.06,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,182.25,Pays at 90% of Total Billed charges,65.1,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,65.1,Pays at 32.15% of Total Billed charges,178.2,Pays at 88% of Total Billed charges,67.05,Pays at 33.11% of Total Billed charges,65.1,182.25,121.50
Outpatient Medical Services,RADIOLOGY,73650,Radiologic examination of the heel,320,149.25,126.86,Pays at 85% of Billed charges for outpatient setting,47.98,Pays at 32.15% of Total Billed charges,119.44,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,134.33,Pays at 90% of Total Billed charges,47.98,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,47.98,Pays at 32.15% of Total Billed charges,131.34,Pays at 88% of Total Billed charges,49.42,Pays at 33.11% of Total Billed charges,47.98,134.33,89.55
Outpatient Medical Services,RADIOLOGY,73660,Radiologic examination of the toe(s),320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73660,Radiologic examination of the toe(s),320,149.25,126.86,Pays at 85% of Billed charges for outpatient setting,47.98,Pays at 32.15% of Total Billed charges,119.44,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,134.33,Pays at 90% of Total Billed charges,47.98,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,47.98,Pays at 32.15% of Total Billed charges,131.34,Pays at 88% of Total Billed charges,49.42,Pays at 33.11% of Total Billed charges,47.98,134.33,89.55
Outpatient Medical Services,RADIOLOGY,73660,Radiologic examination of the toe(s),320,209.75,178.29,Pays at 85% of Billed charges for outpatient setting,67.43,Pays at 32.15% of Total Billed charges,167.86,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,188.78,Pays at 90% of Total Billed charges,67.43,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,67.43,Pays at 32.15% of Total Billed charges,184.58,Pays at 88% of Total Billed charges,69.45,Pays at 33.11% of Total Billed charges,67.43,188.78,125.85
Outpatient Medical Services,RADIOLOGY,73660,Radiologic examination of the toe(s),320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73660,Radiologic examination of the toe(s),320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73660,Radiologic examination of the toe(s),320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73660,Radiologic examination of the toe(s),320,160.5,136.43,Pays at 85% of Billed charges for outpatient setting,51.6,Pays at 32.15% of Total Billed charges,128.45,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,144.45,Pays at 90% of Total Billed charges,51.6,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,51.6,Pays at 32.15% of Total Billed charges,141.24,Pays at 88% of Total Billed charges,53.14,Pays at 33.11% of Total Billed charges,51.6,144.45,96.30
Outpatient Medical Services,RADIOLOGY,73660,Radiologic examination of the toe(s),320,209.75,178.29,Pays at 85% of Billed charges for outpatient setting,67.43,Pays at 32.15% of Total Billed charges,167.86,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,188.78,Pays at 90% of Total Billed charges,67.43,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,67.43,Pays at 32.15% of Total Billed charges,184.58,Pays at 88% of Total Billed charges,69.45,Pays at 33.11% of Total Billed charges,67.43,188.78,125.85
Outpatient Medical Services,RADIOLOGY,74018,ABDOMEN,320,179.75,152.79,Pays at 85% of Billed charges for outpatient setting,57.79,Pays at 32.15% of Total Billed charges,143.85,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,161.78,Pays at 90% of Total Billed charges,57.79,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,57.79,Pays at 32.15% of Total Billed charges,158.18,Pays at 88% of Total Billed charges,59.52,Pays at 33.11% of Total Billed charges,57.79,161.78,107.85
Outpatient Medical Services,RADIOLOGY,74018,PORT ABDOMEN SINGLE AP,320,157.85,134.17,Pays at 85% of Billed charges for outpatient setting,50.75,Pays at 32.15% of Total Billed charges,126.33,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,142.07,Pays at 90% of Total Billed charges,50.75,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,50.75,Pays at 32.15% of Total Billed charges,138.91,Pays at 88% of Total Billed charges,52.26,Pays at 33.11% of Total Billed charges,50.75,142.07,94.71
Outpatient Medical Services,RADIOLOGY,74021,ABDOMEN FLAT/UPRIGHT,320,204.69,173.99,Pays at 85% of Billed charges for outpatient setting,65.81,Pays at 32.15% of Total Billed charges,163.81,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,184.22,Pays at 90% of Total Billed charges,65.81,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,65.81,Pays at 32.15% of Total Billed charges,180.13,Pays at 88% of Total Billed charges,67.77,Pays at 33.11% of Total Billed charges,65.81,184.22,122.81
Outpatient Medical Services,RADIOLOGY,74022,Serial radiologic examination of the abdomen,320,409,347.65,Pays at 85% of Billed charges for outpatient setting,131.49,Pays at 32.15% of Total Billed charges,327.32,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,368.1,Pays at 90% of Total Billed charges,131.49,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,131.49,Pays at 32.15% of Total Billed charges,359.92,Pays at 88% of Total Billed charges,135.42,Pays at 33.11% of Total Billed charges,100.45,368.1,245.40
Outpatient Medical Services,RADIOLOGY,74220,PORT ESOPHAGUS,320,577.5,490.88,Pays at 85% of Billed charges for outpatient setting,185.67,Pays at 32.15% of Total Billed charges,462.17,Pays at 80.03% of Total Billed charges,172.89,Pays at 102% of Medicare OPPS Rate,519.75,Pays at 90% of Total Billed charges,185.67,Pays at 32.15% of Total Billed charges,169.5,Pays at 100% of Medicare OPPS Rate,185.67,Pays at 32.15% of Total Billed charges,508.2,Pays at 88% of Total Billed charges,191.21,Pays at 33.11% of Total Billed charges,169.5,519.75,346.50
Outpatient Medical Services,RADIOLOGY,74250,PORT SMALL BOWEL SERIES,320,328.75,279.44,Pays at 85% of Billed charges for outpatient setting,105.69,Pays at 32.15% of Total Billed charges,263.1,Pays at 80.03% of Total Billed charges,172.89,Pays at 102% of Medicare OPPS Rate,295.88,Pays at 90% of Total Billed charges,105.69,Pays at 32.15% of Total Billed charges,169.5,Pays at 100% of Medicare OPPS Rate,105.69,Pays at 32.15% of Total Billed charges,289.3,Pays at 88% of Total Billed charges,108.85,Pays at 33.11% of Total Billed charges,105.69,295.88,197.25
Outpatient Medical Services,RADIOLOGY,74280,BARIUM ENEMA W AIR CONTRAST,320,994.75,845.54,Pays at 85% of Billed charges for outpatient setting,319.81,Pays at 32.15% of Total Billed charges,796.1,Pays at 80.03% of Total Billed charges,172.89,Pays at 102% of Medicare OPPS Rate,895.28,Pays at 90% of Total Billed charges,319.81,Pays at 32.15% of Total Billed charges,169.5,Pays at 100% of Medicare OPPS Rate,319.81,Pays at 32.15% of Total Billed charges,875.38,Pays at 88% of Total Billed charges,329.36,Pays at 33.11% of Total Billed charges,169.5,895.28,596.85
Outpatient Medical Services,RADIOLOGY,74290,GALLBLADDER,320,399.05,339.19,Pays at 85% of Billed charges for outpatient setting,128.29,Pays at 32.15% of Total Billed charges,319.36,Pays at 80.03% of Total Billed charges,172.89,Pays at 102% of Medicare OPPS Rate,359.15,Pays at 90% of Total Billed charges,128.29,Pays at 32.15% of Total Billed charges,169.5,Pays at 100% of Medicare OPPS Rate,128.29,Pays at 32.15% of Total Billed charges,351.16,Pays at 88% of Total Billed charges,132.13,Pays at 33.11% of Total Billed charges,128.29,359.15,239.43
Outpatient Medical Services,RADIOLOGY,74290,GALLBLADDER REPEAT,320,213.75,181.69,Pays at 85% of Billed charges for outpatient setting,68.72,Pays at 32.15% of Total Billed charges,171.06,Pays at 80.03% of Total Billed charges,172.89,Pays at 102% of Medicare OPPS Rate,192.38,Pays at 90% of Total Billed charges,68.72,Pays at 32.15% of Total Billed charges,169.5,Pays at 100% of Medicare OPPS Rate,68.72,Pays at 32.15% of Total Billed charges,188.1,Pays at 88% of Total Billed charges,70.77,Pays at 33.11% of Total Billed charges,68.72,192.38,128.25
Outpatient Medical Services,RADIOLOGY,74290,PORT GALLBLADDER ORAL CONTRAST,320,464.95,395.21,Pays at 85% of Billed charges for outpatient setting,149.48,Pays at 32.15% of Total Billed charges,372.1,Pays at 80.03% of Total Billed charges,172.89,Pays at 102% of Medicare OPPS Rate,418.46,Pays at 90% of Total Billed charges,149.48,Pays at 32.15% of Total Billed charges,169.5,Pays at 100% of Medicare OPPS Rate,149.48,Pays at 32.15% of Total Billed charges,409.16,Pays at 88% of Total Billed charges,153.94,Pays at 33.11% of Total Billed charges,149.48,418.46,278.97
Outpatient Medical Services,RADIOLOGY,74300,CHOLANGIOGRAM OPERATIVE,320,288.2,244.97,Pays at 85% of Billed charges for outpatient setting,92.66,Pays at 32.15% of Total Billed charges,230.65,Pays at 80.03% of Total Billed charges,288.2,Not Applicable,259.38,Pays at 90% of Total Billed charges,92.66,Pays at 32.15% of Total Billed charges,288.2,Not Applicable,92.66,Pays at 32.15% of Total Billed charges,253.62,Pays at 88% of Total Billed charges,95.42,Pays at 33.11% of Total Billed charges,92.66,288.2,172.92
Outpatient Medical Services,RADIOLOGY,74400,OR IVP,320,716.5,609.03,Pays at 85% of Billed charges for outpatient setting,230.35,Pays at 32.15% of Total Billed charges,573.41,Pays at 80.03% of Total Billed charges,172.88,Pays at 102% of Medicare OPPS Rate,644.85,Pays at 90% of Total Billed charges,230.35,Pays at 32.15% of Total Billed charges,169.49,Pays at 100% of Medicare OPPS Rate,230.35,Pays at 32.15% of Total Billed charges,630.52,Pays at 88% of Total Billed charges,237.23,Pays at 33.11% of Total Billed charges,169.49,644.85,429.90
Outpatient Medical Services,RADIOLOGY,74400,PORT IVP WWO KUB,320,594.6,505.41,Pays at 85% of Billed charges for outpatient setting,191.16,Pays at 32.15% of Total Billed charges,475.86,Pays at 80.03% of Total Billed charges,172.88,Pays at 102% of Medicare OPPS Rate,535.14,Pays at 90% of Total Billed charges,191.16,Pays at 32.15% of Total Billed charges,169.49,Pays at 100% of Medicare OPPS Rate,191.16,Pays at 32.15% of Total Billed charges,523.25,Pays at 88% of Total Billed charges,196.87,Pays at 33.11% of Total Billed charges,169.49,535.14,356.76
Outpatient Medical Services,RADIOLOGY,74415,IVP W/NEPHRO,320,716.5,609.03,Pays at 85% of Billed charges for outpatient setting,230.35,Pays at 32.15% of Total Billed charges,573.41,Pays at 80.03% of Total Billed charges,172.88,Pays at 102% of Medicare OPPS Rate,644.85,Pays at 90% of Total Billed charges,230.35,Pays at 32.15% of Total Billed charges,169.49,Pays at 100% of Medicare OPPS Rate,230.35,Pays at 32.15% of Total Billed charges,630.52,Pays at 88% of Total Billed charges,237.23,Pays at 33.11% of Total Billed charges,169.49,644.85,429.90
Outpatient Medical Services,RADIOLOGY,74420,OR  PYELOGRAM RETRO,320,270.15,229.63,Pays at 85% of Billed charges for outpatient setting,86.85,Pays at 32.15% of Total Billed charges,216.2,Pays at 80.03% of Total Billed charges,353.2,Pays at 102% of Medicare OPPS Rate,243.14,Pays at 90% of Total Billed charges,86.85,Pays at 32.15% of Total Billed charges,346.28,Pays at 100% of Medicare OPPS Rate,86.85,Pays at 32.15% of Total Billed charges,237.73,Pays at 88% of Total Billed charges,89.45,Pays at 33.11% of Total Billed charges,86.85,353.2,162.09
Outpatient Medical Services,RADIOLOGY,74420,PORT PYELOGRAM RETO,320,365.5,310.68,Pays at 85% of Billed charges for outpatient setting,117.51,Pays at 32.15% of Total Billed charges,292.51,Pays at 80.03% of Total Billed charges,353.2,Pays at 102% of Medicare OPPS Rate,328.95,Pays at 90% of Total Billed charges,117.51,Pays at 32.15% of Total Billed charges,346.28,Pays at 100% of Medicare OPPS Rate,117.51,Pays at 32.15% of Total Billed charges,321.64,Pays at 88% of Total Billed charges,121.02,Pays at 33.11% of Total Billed charges,117.51,353.2,219.30
Outpatient Medical Services,RADIOLOGY,74425,NEPHROSTOGRAM,320,318.75,270.94,Pays at 85% of Billed charges for outpatient setting,102.48,Pays at 32.15% of Total Billed charges,255.1,Pays at 80.03% of Total Billed charges,353.21,Pays at 102% of Medicare OPPS Rate,286.88,Pays at 90% of Total Billed charges,102.48,Pays at 32.15% of Total Billed charges,346.29,Pays at 100% of Medicare OPPS Rate,102.48,Pays at 32.15% of Total Billed charges,280.5,Pays at 88% of Total Billed charges,105.54,Pays at 33.11% of Total Billed charges,102.48,353.21,191.25
Outpatient Medical Services,RADIOLOGY,74430,PORT CYSTOGRAM 3V,320,353.25,300.26,Pays at 85% of Billed charges for outpatient setting,113.57,Pays at 32.15% of Total Billed charges,282.71,Pays at 80.03% of Total Billed charges,353.21,Pays at 102% of Medicare OPPS Rate,317.93,Pays at 90% of Total Billed charges,113.57,Pays at 32.15% of Total Billed charges,346.29,Pays at 100% of Medicare OPPS Rate,113.57,Pays at 32.15% of Total Billed charges,310.86,Pays at 88% of Total Billed charges,116.96,Pays at 33.11% of Total Billed charges,113.57,353.21,211.95
Outpatient Medical Services,RADIOLOGY,74455,VCUG,320,465.75,395.89,Pays at 85% of Billed charges for outpatient setting,149.74,Pays at 32.15% of Total Billed charges,372.74,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,419.18,Pays at 90% of Total Billed charges,149.74,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,149.74,Pays at 32.15% of Total Billed charges,409.86,Pays at 88% of Total Billed charges,154.21,Pays at 33.11% of Total Billed charges,149.74,419.18,279.45
Outpatient Medical Services,RADIOLOGY,74455,CYSTOGRAM VOIDING,320,288.2,244.97,Pays at 85% of Billed charges for outpatient setting,92.66,Pays at 32.15% of Total Billed charges,230.65,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,259.38,Pays at 90% of Total Billed charges,92.66,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,92.66,Pays at 32.15% of Total Billed charges,253.62,Pays at 88% of Total Billed charges,95.42,Pays at 33.11% of Total Billed charges,92.66,259.38,172.92
Outpatient Medical Services,RADIOLOGY,74710,PELVIMETRY,320,204.5,173.83,Pays at 85% of Billed charges for outpatient setting,65.75,Pays at 32.15% of Total Billed charges,163.66,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,184.05,Pays at 90% of Total Billed charges,65.75,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,65.75,Pays at 32.15% of Total Billed charges,179.96,Pays at 88% of Total Billed charges,67.71,Pays at 33.11% of Total Billed charges,65.75,184.05,122.70
Outpatient Medical Services,RADIOLOGY,74740,HYSTEROSALPINGOGRAM,320,596.25,506.81,Pays at 85% of Billed charges for outpatient setting,191.69,Pays at 32.15% of Total Billed charges,477.18,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,536.63,Pays at 90% of Total Billed charges,191.69,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,191.69,Pays at 32.15% of Total Billed charges,524.7,Pays at 88% of Total Billed charges,197.42,Pays at 33.11% of Total Billed charges,191.69,536.63,357.75
Outpatient Medical Services,RADIOLOGY,75820,VENOGRAM EXTREMITY UNILAT LT,320,647.75,550.59,Pays at 85% of Billed charges for outpatient setting,208.25,Pays at 32.15% of Total Billed charges,518.39,Pays at 80.03% of Total Billed charges,1426.41,Pays at 102% of Medicare OPPS Rate,582.98,Pays at 90% of Total Billed charges,208.25,Pays at 32.15% of Total Billed charges,1398.44,Pays at 100% of Medicare OPPS Rate,208.25,Pays at 32.15% of Total Billed charges,570.02,Pays at 88% of Total Billed charges,214.47,Pays at 33.11% of Total Billed charges,208.25,1426.41,388.65
Outpatient Medical Services,RADIOLOGY,75820,VENOGRAM EXTREMITY UNILAT RT,320,647.75,550.59,Pays at 85% of Billed charges for outpatient setting,208.25,Pays at 32.15% of Total Billed charges,518.39,Pays at 80.03% of Total Billed charges,1426.41,Pays at 102% of Medicare OPPS Rate,582.98,Pays at 90% of Total Billed charges,208.25,Pays at 32.15% of Total Billed charges,1398.44,Pays at 100% of Medicare OPPS Rate,208.25,Pays at 32.15% of Total Billed charges,570.02,Pays at 88% of Total Billed charges,214.47,Pays at 33.11% of Total Billed charges,208.25,1426.41,388.65
Outpatient Medical Services,RADIOLOGY,75822,VENOGRAM EXTREMITY BILAT,320,1294.25,1100.11,Pays at 85% of Billed charges for outpatient setting,416.1,Pays at 32.15% of Total Billed charges,1035.79,Pays at 80.03% of Total Billed charges,1426.4,Pays at 102% of Medicare OPPS Rate,1164.83,Pays at 90% of Total Billed charges,416.1,Pays at 32.15% of Total Billed charges,1398.43,Pays at 100% of Medicare OPPS Rate,416.1,Pays at 32.15% of Total Billed charges,1138.94,Pays at 88% of Total Billed charges,428.53,Pays at 33.11% of Total Billed charges,416.1,1426.4,776.55
Outpatient Medical Services,RADIOLOGY,76000,"Flouroscopy, or x-ray ""movie"" that takes less than an hour",320,478.75,406.94,Pays at 85% of Billed charges for outpatient setting,153.92,Pays at 32.15% of Total Billed charges,383.14,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,430.88,Pays at 90% of Total Billed charges,153.92,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,153.92,Pays at 32.15% of Total Billed charges,421.3,Pays at 88% of Total Billed charges,158.51,Pays at 33.11% of Total Billed charges,153.92,430.88,287.25
Outpatient Medical Services,RADIOLOGY,76001,FLUORO GREATER THAN 1 HR,320,994.75,845.54,Pays at 85% of Billed charges for outpatient setting,319.81,Pays at 32.15% of Total Billed charges,796.1,Pays at 80.03% of Total Billed charges,994.75,Not Applicable,895.28,Pays at 90% of Total Billed charges,319.81,Pays at 32.15% of Total Billed charges,994.75,Not Applicable,319.81,Pays at 32.15% of Total Billed charges,875.38,Pays at 88% of Total Billed charges,329.36,Pays at 33.11% of Total Billed charges,319.81,994.75,596.85
Outpatient Medical Services,RADIOLOGY,76003,FLUORO LOC NEEDLE BX,320,291,247.35,Pays at 85% of Billed charges for outpatient setting,93.56,Pays at 32.15% of Total Billed charges,232.89,Pays at 80.03% of Total Billed charges,291,Not Applicable,261.9,Pays at 90% of Total Billed charges,93.56,Pays at 32.15% of Total Billed charges,291,Not Applicable,93.56,Pays at 32.15% of Total Billed charges,256.08,Pays at 88% of Total Billed charges,96.35,Pays at 33.11% of Total Billed charges,93.56,291,174.60
Outpatient Medical Services,RADIOLOGY,76080,FISTULA/ABCESS,320,601.25,511.06,Pays at 85% of Billed charges for outpatient setting,193.3,Pays at 32.15% of Total Billed charges,481.18,Pays at 80.03% of Total Billed charges,482.35,Pays at 102% of Medicare OPPS Rate,541.13,Pays at 90% of Total Billed charges,193.3,Pays at 32.15% of Total Billed charges,472.89,Pays at 100% of Medicare OPPS Rate,193.3,Pays at 32.15% of Total Billed charges,529.1,Pays at 88% of Total Billed charges,199.07,Pays at 33.11% of Total Billed charges,193.3,541.13,360.75
Outpatient Medical Services,RADIOLOGY,76100,TOMOGRAPHY,320,409,347.65,Pays at 85% of Billed charges for outpatient setting,131.49,Pays at 32.15% of Total Billed charges,327.32,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,368.1,Pays at 90% of Total Billed charges,131.49,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,131.49,Pays at 32.15% of Total Billed charges,359.92,Pays at 88% of Total Billed charges,135.42,Pays at 33.11% of Total Billed charges,100.45,368.1,245.40
Outpatient Medical Services,RADIOLOGY,77001,FLUORO FOR CENTRAL VENOUS ACCESS,320,357.75,304.09,Pays at 85% of Billed charges for outpatient setting,115.02,Pays at 32.15% of Total Billed charges,286.31,Pays at 80.03% of Total Billed charges,357.75,Not Applicable,321.98,Pays at 90% of Total Billed charges,115.02,Pays at 32.15% of Total Billed charges,357.75,Not Applicable,115.02,Pays at 32.15% of Total Billed charges,314.82,Pays at 88% of Total Billed charges,118.45,Pays at 33.11% of Total Billed charges,115.02,357.75,214.65
Outpatient Medical Services,RADIOLOGY,77002,FLUORO GUIDE W NEEDLE PLACEMENT,320,357.75,304.09,Pays at 85% of Billed charges for outpatient setting,115.02,Pays at 32.15% of Total Billed charges,286.31,Pays at 80.03% of Total Billed charges,357.75,Not Applicable,321.98,Pays at 90% of Total Billed charges,115.02,Pays at 32.15% of Total Billed charges,357.75,Not Applicable,115.02,Pays at 32.15% of Total Billed charges,314.82,Pays at 88% of Total Billed charges,118.45,Pays at 33.11% of Total Billed charges,115.02,357.75,214.65
Outpatient Medical Services,RADIOLOGY,77002,OR FLUORO LOC NEEDLE BX,320,357.75,304.09,Pays at 85% of Billed charges for outpatient setting,115.02,Pays at 32.15% of Total Billed charges,286.31,Pays at 80.03% of Total Billed charges,357.75,Not Applicable,321.98,Pays at 90% of Total Billed charges,115.02,Pays at 32.15% of Total Billed charges,357.75,Not Applicable,115.02,Pays at 32.15% of Total Billed charges,314.82,Pays at 88% of Total Billed charges,118.45,Pays at 33.11% of Total Billed charges,115.02,357.75,214.65
Outpatient Medical Services,RADIOLOGY,77003,FACET FLUORO GUIDE W NEEDLE PLCMT,320,271.75,230.99,Pays at 85% of Billed charges for outpatient setting,87.37,Pays at 32.15% of Total Billed charges,217.48,Pays at 80.03% of Total Billed charges,271.75,Not Applicable,244.58,Pays at 90% of Total Billed charges,87.37,Pays at 32.15% of Total Billed charges,271.75,Not Applicable,87.37,Pays at 32.15% of Total Billed charges,239.14,Pays at 88% of Total Billed charges,89.98,Pays at 33.11% of Total Billed charges,87.37,271.75,163.05
Outpatient Medical Services,RADIOLOGY,77072,BONE AGE HAND AP,320,269.75,229.29,Pays at 85% of Billed charges for outpatient setting,86.72,Pays at 32.15% of Total Billed charges,215.88,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,242.78,Pays at 90% of Total Billed charges,86.72,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,86.72,Pays at 32.15% of Total Billed charges,237.38,Pays at 88% of Total Billed charges,89.31,Pays at 33.11% of Total Billed charges,86.72,242.78,161.85
Outpatient Medical Services,RADIOLOGY,77076,SKELETAL SURVEY INFANT,320,856.5,728.03,Pays at 85% of Billed charges for outpatient setting,275.36,Pays at 32.15% of Total Billed charges,685.46,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,770.85,Pays at 90% of Total Billed charges,275.36,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,275.36,Pays at 32.15% of Total Billed charges,753.72,Pays at 88% of Total Billed charges,283.59,Pays at 33.11% of Total Billed charges,100.45,770.85,513.90
Outpatient Medical Services,RADIOLOGY,77076,INJECTION IM MUSCLE,320,107.5,91.38,Pays at 85% of Billed charges for outpatient setting,34.56,Pays at 32.15% of Total Billed charges,86.03,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,96.75,Pays at 90% of Total Billed charges,34.56,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,34.56,Pays at 32.15% of Total Billed charges,94.6,Pays at 88% of Total Billed charges,35.59,Pays at 33.11% of Total Billed charges,34.56,102.46,64.50
Outpatient Medical Services,RADIOLOGY,77078,CT BONE DENSITY SPINE,320,415.75,353.39,Pays at 85% of Billed charges for outpatient setting,133.66,Pays at 32.15% of Total Billed charges,332.72,Pays at 80.03% of Total Billed charges,83.28,Pays at 102% of Medicare OPPS Rate,374.18,Pays at 90% of Total Billed charges,133.66,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,133.66,Pays at 32.15% of Total Billed charges,365.86,Pays at 88% of Total Billed charges,137.65,Pays at 33.11% of Total Billed charges,81.65,374.18,249.45
Outpatient Medical Services,RADIOLOGY,320,EMERGENCY CHARGE,320,SERVICE NOT OFFERED,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,0,0,#VALUE!
Outpatient Medical Services,RADIOLOGY,320,PORTABLE,320,SERVICE NOT OFFERED,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,0,0,#VALUE!
Outpatient Medical Services,RADIOLOGY,320,STAT CHARGE,320,SERVICE NOT OFFERED,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,0,0,#VALUE!
Outpatient Medical Services,RADIOLOGY,320,=> XRAY ORDER            <=,320,SERVICE NOT OFFERED,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,0,0,#VALUE!
Outpatient Medical Services,RADIOLOGY,320,FLUOROSCOPY,320,109.86,93.38,Pays at 85% of Billed charges for outpatient setting,35.32,Pays at 32.15% of Total Billed charges,87.92,Pays at 80.03% of Total Billed charges,109.86,Not Applicable,98.87,Pays at 90% of Total Billed charges,35.32,Pays at 32.15% of Total Billed charges,109.86,Not Applicable,35.32,Pays at 32.15% of Total Billed charges,96.68,Pays at 88% of Total Billed charges,36.37,Pays at 33.11% of Total Billed charges,35.32,109.86,65.92
Outpatient Medical Services,RADIOLOGY,96413,IV ADMIN - BIOLOGIC/CHEMO INITIAL HOUR,335,770,654.5,Pays at 85% of Billed charges for outpatient setting,247.56,Pays at 32.15% of Total Billed charges,616.23,Pays at 80.03% of Total Billed charges,318.87,Pays at 102% of Medicare OPPS Rate,693,Pays at 90% of Total Billed charges,247.56,Pays at 32.15% of Total Billed charges,312.62,Pays at 100% of Medicare OPPS Rate,247.56,Pays at 32.15% of Total Billed charges,677.6,Pays at 88% of Total Billed charges,254.95,Pays at 33.11% of Total Billed charges,247.56,693,462.00
Outpatient Medical Services,RADIOLOGY,96413,IV CHEMO 1 HOUR,335,225,191.25,Pays at 85% of Billed charges for outpatient setting,72.34,Pays at 32.15% of Total Billed charges,180.07,Pays at 80.03% of Total Billed charges,318.87,Pays at 102% of Medicare OPPS Rate,202.5,Pays at 90% of Total Billed charges,72.34,Pays at 32.15% of Total Billed charges,312.62,Pays at 100% of Medicare OPPS Rate,72.34,Pays at 32.15% of Total Billed charges,198,Pays at 88% of Total Billed charges,74.5,Pays at 33.11% of Total Billed charges,72.34,318.87,135.00
Outpatient Medical Services,RADIOLOGY,96415,Chemotherapy infusion-each additional hour,335,150,127.5,Pays at 85% of Billed charges for outpatient setting,48.23,Pays at 32.15% of Total Billed charges,120.05,Pays at 80.03% of Total Billed charges,64.66,Pays at 102% of Medicare OPPS Rate,135,Pays at 90% of Total Billed charges,48.23,Pays at 32.15% of Total Billed charges,63.41,Pays at 100% of Medicare OPPS Rate,48.23,Pays at 32.15% of Total Billed charges,132,Pays at 88% of Total Billed charges,49.67,Pays at 33.11% of Total Billed charges,48.23,135,90.00
Outpatient Medical Services,RADIOLOGY,96415,Chemotherapy infusion-each additional hour,335,38,32.3,Pays at 85% of Billed charges for outpatient setting,12.22,Pays at 32.15% of Total Billed charges,30.41,Pays at 80.03% of Total Billed charges,64.66,Pays at 102% of Medicare OPPS Rate,34.2,Pays at 90% of Total Billed charges,12.22,Pays at 32.15% of Total Billed charges,63.41,Pays at 100% of Medicare OPPS Rate,12.22,Pays at 32.15% of Total Billed charges,33.44,Pays at 88% of Total Billed charges,12.58,Pays at 33.11% of Total Billed charges,12.22,64.66,22.80
Outpatient Medical Services,RADIOLOGY,78806,NM WHOLE BODY WHITE CELL,340,1791.25,1522.56,Pays at 85% of Billed charges for outpatient setting,575.89,Pays at 32.15% of Total Billed charges,1433.54,Pays at 80.03% of Total Billed charges,1791.25,Not Applicable,1612.13,Pays at 90% of Total Billed charges,575.89,Pays at 32.15% of Total Billed charges,1791.25,Not Applicable,575.89,Pays at 32.15% of Total Billed charges,1576.3,Pays at 88% of Total Billed charges,593.08,Pays at 33.11% of Total Billed charges,575.89,1791.25,1074.75
Outpatient Medical Services,RADIOLOGY,340,=> NUCLEAR MED ORDER     <=,340,SERVICE NOT OFFERED,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,0,0,#VALUE!
Outpatient Medical Services,RADIOLOGY,78012,THYROID UPTAKE,341,SERVICE NOT OFFERED,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,372.62,Pays at 102% of Medicare OPPS Rate,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,365.31,Pays at 100% of Medicare OPPS Rate,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,365.31,372.62,#VALUE!
Outpatient Medical Services,RADIOLOGY,78013,NM THYROID IMAGING WITH VASCULAR FLOW,341,1144.5,972.83,Pays at 85% of Billed charges for outpatient setting,367.96,Pays at 32.15% of Total Billed charges,915.94,Pays at 80.03% of Total Billed charges,372.62,Pays at 102% of Medicare OPPS Rate,1030.05,Pays at 90% of Total Billed charges,367.96,Pays at 32.15% of Total Billed charges,365.31,Pays at 100% of Medicare OPPS Rate,367.96,Pays at 32.15% of Total Billed charges,1007.16,Pays at 88% of Total Billed charges,378.94,Pays at 33.11% of Total Billed charges,365.31,1030.05,686.70
Outpatient Medical Services,RADIOLOGY,78014,Scan using a radioactive medication (radiopharmaceutical) to take pictures or images of the thyroid gland.,341,1102.75,937.34,Pays at 85% of Billed charges for outpatient setting,354.53,Pays at 32.15% of Total Billed charges,882.53,Pays at 80.03% of Total Billed charges,372.62,Pays at 102% of Medicare OPPS Rate,992.48,Pays at 90% of Total Billed charges,354.53,Pays at 32.15% of Total Billed charges,365.31,Pays at 100% of Medicare OPPS Rate,354.53,Pays at 32.15% of Total Billed charges,970.42,Pays at 88% of Total Billed charges,365.12,Pays at 33.11% of Total Billed charges,354.53,992.48,661.65
Outpatient Medical Services,RADIOLOGY,78070,NM PARATHYROID(MIBI SCAN),341,1005,854.25,Pays at 85% of Billed charges for outpatient setting,323.11,Pays at 32.15% of Total Billed charges,804.3,Pays at 80.03% of Total Billed charges,372.62,Pays at 102% of Medicare OPPS Rate,904.5,Pays at 90% of Total Billed charges,323.11,Pays at 32.15% of Total Billed charges,365.31,Pays at 100% of Medicare OPPS Rate,323.11,Pays at 32.15% of Total Billed charges,884.4,Pays at 88% of Total Billed charges,332.76,Pays at 33.11% of Total Billed charges,323.11,904.5,603.00
Outpatient Medical Services,RADIOLOGY,78185,NM SPLEEN SCAN,341,856.5,728.03,Pays at 85% of Billed charges for outpatient setting,275.36,Pays at 32.15% of Total Billed charges,685.46,Pays at 80.03% of Total Billed charges,372.62,Pays at 102% of Medicare OPPS Rate,770.85,Pays at 90% of Total Billed charges,275.36,Pays at 32.15% of Total Billed charges,365.31,Pays at 100% of Medicare OPPS Rate,275.36,Pays at 32.15% of Total Billed charges,753.72,Pays at 88% of Total Billed charges,283.59,Pays at 33.11% of Total Billed charges,275.36,770.85,513.90
Outpatient Medical Services,RADIOLOGY,78215,(E) LIVER AND SPLEEN IMAGING,341,1691.75,1437.99,Pays at 85% of Billed charges for outpatient setting,543.9,Pays at 32.15% of Total Billed charges,1353.91,Pays at 80.03% of Total Billed charges,372.62,Pays at 102% of Medicare OPPS Rate,1522.58,Pays at 90% of Total Billed charges,543.9,Pays at 32.15% of Total Billed charges,365.31,Pays at 100% of Medicare OPPS Rate,543.9,Pays at 32.15% of Total Billed charges,1488.74,Pays at 88% of Total Billed charges,560.14,Pays at 33.11% of Total Billed charges,365.31,1522.58,1015.05
Outpatient Medical Services,RADIOLOGY,78215,LIVER AND SPLEEN IMAGING,341,1314.5,1117.33,Pays at 85% of Billed charges for outpatient setting,422.61,Pays at 32.15% of Total Billed charges,1051.99,Pays at 80.03% of Total Billed charges,372.62,Pays at 102% of Medicare OPPS Rate,1183.05,Pays at 90% of Total Billed charges,422.61,Pays at 32.15% of Total Billed charges,365.31,Pays at 100% of Medicare OPPS Rate,422.61,Pays at 32.15% of Total Billed charges,1156.76,Pays at 88% of Total Billed charges,435.23,Pays at 33.11% of Total Billed charges,365.31,1183.05,788.70
Outpatient Medical Services,RADIOLOGY,78216,NM LIVER/SPLEEN IMAGING W/VASCULAR FLOW,341,1443.5,1226.98,Pays at 85% of Billed charges for outpatient setting,464.09,Pays at 32.15% of Total Billed charges,1155.23,Pays at 80.03% of Total Billed charges,372.62,Pays at 102% of Medicare OPPS Rate,1299.15,Pays at 90% of Total Billed charges,464.09,Pays at 32.15% of Total Billed charges,365.31,Pays at 100% of Medicare OPPS Rate,464.09,Pays at 32.15% of Total Billed charges,1270.28,Pays at 88% of Total Billed charges,477.94,Pays at 33.11% of Total Billed charges,365.31,1299.15,866.10
Outpatient Medical Services,RADIOLOGY,78226,NM BILIARY SCAN (GB),341,1423.5,1209.98,Pays at 85% of Billed charges for outpatient setting,457.66,Pays at 32.15% of Total Billed charges,1139.23,Pays at 80.03% of Total Billed charges,372.62,Pays at 102% of Medicare OPPS Rate,1281.15,Pays at 90% of Total Billed charges,457.66,Pays at 32.15% of Total Billed charges,365.31,Pays at 100% of Medicare OPPS Rate,457.66,Pays at 32.15% of Total Billed charges,1252.68,Pays at 88% of Total Billed charges,471.32,Pays at 33.11% of Total Billed charges,365.31,1281.15,854.10
Outpatient Medical Services,RADIOLOGY,78226,(E) HEPATOBILIARY DUCTAL SYSTEM IMAGING,341,1753,1490.05,Pays at 85% of Billed charges for outpatient setting,563.59,Pays at 32.15% of Total Billed charges,1402.93,Pays at 80.03% of Total Billed charges,372.62,Pays at 102% of Medicare OPPS Rate,1577.7,Pays at 90% of Total Billed charges,563.59,Pays at 32.15% of Total Billed charges,365.31,Pays at 100% of Medicare OPPS Rate,563.59,Pays at 32.15% of Total Billed charges,1542.64,Pays at 88% of Total Billed charges,580.42,Pays at 33.11% of Total Billed charges,365.31,1577.7,1051.80
Outpatient Medical Services,RADIOLOGY,78226,(E) NM BILLIARY SCAN (GB),341,1493.25,1269.26,Pays at 85% of Billed charges for outpatient setting,480.08,Pays at 32.15% of Total Billed charges,1195.05,Pays at 80.03% of Total Billed charges,372.62,Pays at 102% of Medicare OPPS Rate,1343.93,Pays at 90% of Total Billed charges,480.08,Pays at 32.15% of Total Billed charges,365.31,Pays at 100% of Medicare OPPS Rate,480.08,Pays at 32.15% of Total Billed charges,1314.06,Pays at 88% of Total Billed charges,494.42,Pays at 33.11% of Total Billed charges,365.31,1343.93,895.95
Outpatient Medical Services,RADIOLOGY,78262,NM GASTROESOPHAGEAL REFLUX,341,1264.75,1075.04,Pays at 85% of Billed charges for outpatient setting,406.62,Pays at 32.15% of Total Billed charges,1012.18,Pays at 80.03% of Total Billed charges,372.62,Pays at 102% of Medicare OPPS Rate,1138.28,Pays at 90% of Total Billed charges,406.62,Pays at 32.15% of Total Billed charges,365.31,Pays at 100% of Medicare OPPS Rate,406.62,Pays at 32.15% of Total Billed charges,1112.98,Pays at 88% of Total Billed charges,418.76,Pays at 33.11% of Total Billed charges,365.31,1138.28,758.85
Outpatient Medical Services,RADIOLOGY,78264,(E) NM GASTRIC EMPTYING,341,1294.25,1100.11,Pays at 85% of Billed charges for outpatient setting,416.1,Pays at 32.15% of Total Billed charges,1035.79,Pays at 80.03% of Total Billed charges,372.62,Pays at 102% of Medicare OPPS Rate,1164.83,Pays at 90% of Total Billed charges,416.1,Pays at 32.15% of Total Billed charges,365.31,Pays at 100% of Medicare OPPS Rate,416.1,Pays at 32.15% of Total Billed charges,1138.94,Pays at 88% of Total Billed charges,428.53,Pays at 33.11% of Total Billed charges,365.31,1164.83,776.55
Outpatient Medical Services,RADIOLOGY,78264,GASTRIC EMPTYING STUDY,341,1264.75,1075.04,Pays at 85% of Billed charges for outpatient setting,406.62,Pays at 32.15% of Total Billed charges,1012.18,Pays at 80.03% of Total Billed charges,372.62,Pays at 102% of Medicare OPPS Rate,1138.28,Pays at 90% of Total Billed charges,406.62,Pays at 32.15% of Total Billed charges,365.31,Pays at 100% of Medicare OPPS Rate,406.62,Pays at 32.15% of Total Billed charges,1112.98,Pays at 88% of Total Billed charges,418.76,Pays at 33.11% of Total Billed charges,365.31,1138.28,758.85
Outpatient Medical Services,RADIOLOGY,78270,NM SCHILLINGS TEST W/OUT IF,341,741,629.85,Pays at 85% of Billed charges for outpatient setting,238.23,Pays at 32.15% of Total Billed charges,593.02,Pays at 80.03% of Total Billed charges,741,Not Applicable,666.9,Pays at 90% of Total Billed charges,238.23,Pays at 32.15% of Total Billed charges,741,Not Applicable,238.23,Pays at 32.15% of Total Billed charges,652.08,Pays at 88% of Total Billed charges,245.35,Pays at 33.11% of Total Billed charges,238.23,741,444.60
Outpatient Medical Services,RADIOLOGY,78271,NM SCHILLINGS TEST W/IF,341,741,629.85,Pays at 85% of Billed charges for outpatient setting,238.23,Pays at 32.15% of Total Billed charges,593.02,Pays at 80.03% of Total Billed charges,741,Not Applicable,666.9,Pays at 90% of Total Billed charges,238.23,Pays at 32.15% of Total Billed charges,741,Not Applicable,238.23,Pays at 32.15% of Total Billed charges,652.08,Pays at 88% of Total Billed charges,245.35,Pays at 33.11% of Total Billed charges,238.23,741,444.60
Outpatient Medical Services,RADIOLOGY,78278,(E) NM GI BLEED,341,2700.75,2295.64,Pays at 85% of Billed charges for outpatient setting,868.29,Pays at 32.15% of Total Billed charges,2161.41,Pays at 80.03% of Total Billed charges,372.62,Pays at 102% of Medicare OPPS Rate,2430.68,Pays at 90% of Total Billed charges,868.29,Pays at 32.15% of Total Billed charges,365.31,Pays at 100% of Medicare OPPS Rate,868.29,Pays at 32.15% of Total Billed charges,2376.66,Pays at 88% of Total Billed charges,894.22,Pays at 33.11% of Total Billed charges,365.31,2430.68,1620.45
Outpatient Medical Services,RADIOLOGY,78278,(E) GASTROINTESTINAL BLOOD LOSS STUDY,341,3066.25,2606.31,Pays at 85% of Billed charges for outpatient setting,985.8,Pays at 32.15% of Total Billed charges,2453.92,Pays at 80.03% of Total Billed charges,372.62,Pays at 102% of Medicare OPPS Rate,2759.63,Pays at 90% of Total Billed charges,985.8,Pays at 32.15% of Total Billed charges,365.31,Pays at 100% of Medicare OPPS Rate,985.8,Pays at 32.15% of Total Billed charges,2698.3,Pays at 88% of Total Billed charges,1015.24,Pays at 33.11% of Total Billed charges,365.31,2759.63,1839.75
Outpatient Medical Services,RADIOLOGY,78306,"A procedure most commonly ordered to detect areas of abnormal bone growth due to fractures, tumors, infection, or other bone issues",341,1423.5,1209.98,Pays at 85% of Billed charges for outpatient setting,457.66,Pays at 32.15% of Total Billed charges,1139.23,Pays at 80.03% of Total Billed charges,372.62,Pays at 102% of Medicare OPPS Rate,1281.15,Pays at 90% of Total Billed charges,457.66,Pays at 32.15% of Total Billed charges,365.31,Pays at 100% of Medicare OPPS Rate,457.66,Pays at 32.15% of Total Billed charges,1252.68,Pays at 88% of Total Billed charges,471.32,Pays at 33.11% of Total Billed charges,365.31,1281.15,854.10
Outpatient Medical Services,RADIOLOGY,78306,"A procedure most commonly ordered to detect areas of abnormal bone growth due to fractures, tumors, infection, or other bone issues",341,1493.25,1269.26,Pays at 85% of Billed charges for outpatient setting,480.08,Pays at 32.15% of Total Billed charges,1195.05,Pays at 80.03% of Total Billed charges,372.62,Pays at 102% of Medicare OPPS Rate,1343.93,Pays at 90% of Total Billed charges,480.08,Pays at 32.15% of Total Billed charges,365.31,Pays at 100% of Medicare OPPS Rate,480.08,Pays at 32.15% of Total Billed charges,1314.06,Pays at 88% of Total Billed charges,494.42,Pays at 33.11% of Total Billed charges,365.31,1343.93,895.95
Outpatient Medical Services,RADIOLOGY,78306,"A procedure most commonly ordered to detect areas of abnormal bone growth due to fractures, tumors, infection, or other bone issues",341,1205,1024.25,Pays at 85% of Billed charges for outpatient setting,387.41,Pays at 32.15% of Total Billed charges,964.36,Pays at 80.03% of Total Billed charges,372.62,Pays at 102% of Medicare OPPS Rate,1084.5,Pays at 90% of Total Billed charges,387.41,Pays at 32.15% of Total Billed charges,365.31,Pays at 100% of Medicare OPPS Rate,387.41,Pays at 32.15% of Total Billed charges,1060.4,Pays at 88% of Total Billed charges,398.98,Pays at 33.11% of Total Billed charges,365.31,1084.5,723.00
Outpatient Medical Services,RADIOLOGY,78315,NM BONE SCAN AND FLOW STUDY,341,637,541.45,Pays at 85% of Billed charges for outpatient setting,204.8,Pays at 32.15% of Total Billed charges,509.79,Pays at 80.03% of Total Billed charges,372.62,Pays at 102% of Medicare OPPS Rate,573.3,Pays at 90% of Total Billed charges,204.8,Pays at 32.15% of Total Billed charges,365.31,Pays at 100% of Medicare OPPS Rate,204.8,Pays at 32.15% of Total Billed charges,560.56,Pays at 88% of Total Billed charges,210.91,Pays at 33.11% of Total Billed charges,204.8,573.3,382.20
Outpatient Medical Services,RADIOLOGY,78315,(E) BONE SCAN THREE PHASE STUDY,341,1623,1379.55,Pays at 85% of Billed charges for outpatient setting,521.79,Pays at 32.15% of Total Billed charges,1298.89,Pays at 80.03% of Total Billed charges,372.62,Pays at 102% of Medicare OPPS Rate,1460.7,Pays at 90% of Total Billed charges,521.79,Pays at 32.15% of Total Billed charges,365.31,Pays at 100% of Medicare OPPS Rate,521.79,Pays at 32.15% of Total Billed charges,1428.24,Pays at 88% of Total Billed charges,537.38,Pays at 33.11% of Total Billed charges,365.31,1460.7,973.80
Outpatient Medical Services,RADIOLOGY,78315,BONE/JOINT THREE PHASE STUDY,341,1205,1024.25,Pays at 85% of Billed charges for outpatient setting,387.41,Pays at 32.15% of Total Billed charges,964.36,Pays at 80.03% of Total Billed charges,372.62,Pays at 102% of Medicare OPPS Rate,1084.5,Pays at 90% of Total Billed charges,387.41,Pays at 32.15% of Total Billed charges,365.31,Pays at 100% of Medicare OPPS Rate,387.41,Pays at 32.15% of Total Billed charges,1060.4,Pays at 88% of Total Billed charges,398.98,Pays at 33.11% of Total Billed charges,365.31,1084.5,723.00
Outpatient Medical Services,RADIOLOGY,78320,BONE/JOINT TOMOGRAPHIC (SPECT),341,457.25,388.66,Pays at 85% of Billed charges for outpatient setting,147.01,Pays at 32.15% of Total Billed charges,365.94,Pays at 80.03% of Total Billed charges,457.25,Not Applicable,411.53,Pays at 90% of Total Billed charges,147.01,Pays at 32.15% of Total Billed charges,457.25,Not Applicable,147.01,Pays at 32.15% of Total Billed charges,402.38,Pays at 88% of Total Billed charges,151.4,Pays at 33.11% of Total Billed charges,147.01,457.25,274.35
Outpatient Medical Services,RADIOLOGY,78452,Image of the heart to assess perfusion,341,2698,2293.3,Pays at 85% of Billed charges for outpatient setting,867.41,Pays at 32.15% of Total Billed charges,2159.21,Pays at 80.03% of Total Billed charges,1272.45,Pays at 102% of Medicare OPPS Rate,2428.2,Pays at 90% of Total Billed charges,867.41,Pays at 32.15% of Total Billed charges,1247.51,Pays at 100% of Medicare OPPS Rate,867.41,Pays at 32.15% of Total Billed charges,2374.24,Pays at 88% of Total Billed charges,893.31,Pays at 33.11% of Total Billed charges,867.41,2428.2,1618.80
Outpatient Medical Services,RADIOLOGY,78472,NM CARDIAC BLOOD POOL IMAGING,341,1383.5,1175.98,Pays at 85% of Billed charges for outpatient setting,444.8,Pays at 32.15% of Total Billed charges,1107.22,Pays at 80.03% of Total Billed charges,372.62,Pays at 102% of Medicare OPPS Rate,1245.15,Pays at 90% of Total Billed charges,444.8,Pays at 32.15% of Total Billed charges,365.31,Pays at 100% of Medicare OPPS Rate,444.8,Pays at 32.15% of Total Billed charges,1217.48,Pays at 88% of Total Billed charges,458.08,Pays at 33.11% of Total Billed charges,365.31,1245.15,830.10
Outpatient Medical Services,RADIOLOGY,78473,NM CARDIAC BLOOD POOL MULTI STUDIES,341,1911,1624.35,Pays at 85% of Billed charges for outpatient setting,614.39,Pays at 32.15% of Total Billed charges,1529.37,Pays at 80.03% of Total Billed charges,372.62,Pays at 102% of Medicare OPPS Rate,1719.9,Pays at 90% of Total Billed charges,614.39,Pays at 32.15% of Total Billed charges,365.31,Pays at 100% of Medicare OPPS Rate,614.39,Pays at 32.15% of Total Billed charges,1681.68,Pays at 88% of Total Billed charges,632.73,Pays at 33.11% of Total Billed charges,365.31,1719.9,1146.60
Outpatient Medical Services,RADIOLOGY,78481,NM CARDIAC BLOOD POOL FIRST PASS TE,341,1503,1277.55,Pays at 85% of Billed charges for outpatient setting,483.21,Pays at 32.15% of Total Billed charges,1202.85,Pays at 80.03% of Total Billed charges,483.66,Pays at 102% of Medicare OPPS Rate,1352.7,Pays at 90% of Total Billed charges,483.21,Pays at 32.15% of Total Billed charges,474.17,Pays at 100% of Medicare OPPS Rate,483.21,Pays at 32.15% of Total Billed charges,1322.64,Pays at 88% of Total Billed charges,497.64,Pays at 33.11% of Total Billed charges,474.17,1352.7,901.80
Outpatient Medical Services,RADIOLOGY,78483,NM CARDIAC BLOOD POOL MULTI STUDIES,341,1553.25,1320.26,Pays at 85% of Billed charges for outpatient setting,499.37,Pays at 32.15% of Total Billed charges,1243.07,Pays at 80.03% of Total Billed charges,483.66,Pays at 102% of Medicare OPPS Rate,1397.93,Pays at 90% of Total Billed charges,499.37,Pays at 32.15% of Total Billed charges,474.17,Pays at 100% of Medicare OPPS Rate,499.37,Pays at 32.15% of Total Billed charges,1366.86,Pays at 88% of Total Billed charges,514.28,Pays at 33.11% of Total Billed charges,474.17,1397.93,931.95
Outpatient Medical Services,RADIOLOGY,78499,NM ACUTE THROMBOSIS,341,1116.5,949.03,Pays at 85% of Billed charges for outpatient setting,358.95,Pays at 32.15% of Total Billed charges,893.53,Pays at 80.03% of Total Billed charges,372.62,Pays at 102% of Medicare OPPS Rate,1004.85,Pays at 90% of Total Billed charges,358.95,Pays at 32.15% of Total Billed charges,365.31,Pays at 100% of Medicare OPPS Rate,358.95,Pays at 32.15% of Total Billed charges,982.52,Pays at 88% of Total Billed charges,369.67,Pays at 33.11% of Total Billed charges,358.95,1004.85,669.90
Outpatient Medical Services,RADIOLOGY,78582,(E) NM LUNG SCAN VENT & PERFUSION,341,2290,1946.5,Pays at 85% of Billed charges for outpatient setting,736.24,Pays at 32.15% of Total Billed charges,1832.69,Pays at 80.03% of Total Billed charges,483.66,Pays at 102% of Medicare OPPS Rate,2061,Pays at 90% of Total Billed charges,736.24,Pays at 32.15% of Total Billed charges,474.17,Pays at 100% of Medicare OPPS Rate,736.24,Pays at 32.15% of Total Billed charges,2015.2,Pays at 88% of Total Billed charges,758.22,Pays at 33.11% of Total Billed charges,474.17,2061,1374.00
Outpatient Medical Services,RADIOLOGY,78582,NM LUNG PERF/VENT AEROSOL,341,1419,1206.15,Pays at 85% of Billed charges for outpatient setting,456.21,Pays at 32.15% of Total Billed charges,1135.63,Pays at 80.03% of Total Billed charges,483.66,Pays at 102% of Medicare OPPS Rate,1277.1,Pays at 90% of Total Billed charges,456.21,Pays at 32.15% of Total Billed charges,474.17,Pays at 100% of Medicare OPPS Rate,456.21,Pays at 32.15% of Total Billed charges,1248.72,Pays at 88% of Total Billed charges,469.83,Pays at 33.11% of Total Billed charges,456.21,1277.1,851.40
Outpatient Medical Services,RADIOLOGY,78597,(E) PULMONARY QUANTITATIVE DIFF FUNCTION,341,2707.75,2301.59,Pays at 85% of Billed charges for outpatient setting,870.54,Pays at 32.15% of Total Billed charges,2167.01,Pays at 80.03% of Total Billed charges,372.62,Pays at 102% of Medicare OPPS Rate,2436.98,Pays at 90% of Total Billed charges,870.54,Pays at 32.15% of Total Billed charges,365.31,Pays at 100% of Medicare OPPS Rate,870.54,Pays at 32.15% of Total Billed charges,2382.82,Pays at 88% of Total Billed charges,896.54,Pays at 33.11% of Total Billed charges,365.31,2436.98,1624.65
Outpatient Medical Services,RADIOLOGY,78597,NM PULMONARY QUANTITATIVE DIFF FUNCTION,341,2020.75,1717.64,Pays at 85% of Billed charges for outpatient setting,649.67,Pays at 32.15% of Total Billed charges,1617.21,Pays at 80.03% of Total Billed charges,372.62,Pays at 102% of Medicare OPPS Rate,1818.68,Pays at 90% of Total Billed charges,649.67,Pays at 32.15% of Total Billed charges,365.31,Pays at 100% of Medicare OPPS Rate,649.67,Pays at 32.15% of Total Billed charges,1778.26,Pays at 88% of Total Billed charges,669.07,Pays at 33.11% of Total Billed charges,365.31,1818.68,1212.45
Outpatient Medical Services,RADIOLOGY,78598,NM LUNG PERF/VENT XENON,341,1419,1206.15,Pays at 85% of Billed charges for outpatient setting,456.21,Pays at 32.15% of Total Billed charges,1135.63,Pays at 80.03% of Total Billed charges,483.66,Pays at 102% of Medicare OPPS Rate,1277.1,Pays at 90% of Total Billed charges,456.21,Pays at 32.15% of Total Billed charges,474.17,Pays at 100% of Medicare OPPS Rate,456.21,Pays at 32.15% of Total Billed charges,1248.72,Pays at 88% of Total Billed charges,469.83,Pays at 33.11% of Total Billed charges,456.21,1277.1,851.40
Outpatient Medical Services,RADIOLOGY,78600,NM BRAIN,341,1119.75,951.79,Pays at 85% of Billed charges for outpatient setting,360,Pays at 32.15% of Total Billed charges,896.14,Pays at 80.03% of Total Billed charges,372.62,Pays at 102% of Medicare OPPS Rate,1007.78,Pays at 90% of Total Billed charges,360,Pays at 32.15% of Total Billed charges,365.31,Pays at 100% of Medicare OPPS Rate,360,Pays at 32.15% of Total Billed charges,985.38,Pays at 88% of Total Billed charges,370.75,Pays at 33.11% of Total Billed charges,360,1007.78,671.85
Outpatient Medical Services,RADIOLOGY,78606,NM BRAIN SCAN COMPLETE/DYN,341,1125.75,956.89,Pays at 85% of Billed charges for outpatient setting,361.93,Pays at 32.15% of Total Billed charges,900.94,Pays at 80.03% of Total Billed charges,483.66,Pays at 102% of Medicare OPPS Rate,1013.18,Pays at 90% of Total Billed charges,361.93,Pays at 32.15% of Total Billed charges,474.17,Pays at 100% of Medicare OPPS Rate,361.93,Pays at 32.15% of Total Billed charges,990.66,Pays at 88% of Total Billed charges,372.74,Pays at 33.11% of Total Billed charges,361.93,1013.18,675.45
Outpatient Medical Services,RADIOLOGY,78610,NM CEREBRAL FLOW STUDY,341,1503,1277.55,Pays at 85% of Billed charges for outpatient setting,483.21,Pays at 32.15% of Total Billed charges,1202.85,Pays at 80.03% of Total Billed charges,483.66,Pays at 102% of Medicare OPPS Rate,1352.7,Pays at 90% of Total Billed charges,483.21,Pays at 32.15% of Total Billed charges,474.17,Pays at 100% of Medicare OPPS Rate,483.21,Pays at 32.15% of Total Billed charges,1322.64,Pays at 88% of Total Billed charges,497.64,Pays at 33.11% of Total Billed charges,474.17,1352.7,901.80
Outpatient Medical Services,RADIOLOGY,78630,NM CEREBROSPINAL FLUID FLOW,341,1960.5,1666.43,Pays at 85% of Billed charges for outpatient setting,630.3,Pays at 32.15% of Total Billed charges,1568.99,Pays at 80.03% of Total Billed charges,483.66,Pays at 102% of Medicare OPPS Rate,1764.45,Pays at 90% of Total Billed charges,630.3,Pays at 32.15% of Total Billed charges,474.17,Pays at 100% of Medicare OPPS Rate,630.3,Pays at 32.15% of Total Billed charges,1725.24,Pays at 88% of Total Billed charges,649.12,Pays at 33.11% of Total Billed charges,474.17,1764.45,1176.30
Outpatient Medical Services,RADIOLOGY,78700,NM RENAL SCAN,341,1821.75,1548.49,Pays at 85% of Billed charges for outpatient setting,585.69,Pays at 32.15% of Total Billed charges,1457.95,Pays at 80.03% of Total Billed charges,372.62,Pays at 102% of Medicare OPPS Rate,1639.58,Pays at 90% of Total Billed charges,585.69,Pays at 32.15% of Total Billed charges,365.31,Pays at 100% of Medicare OPPS Rate,585.69,Pays at 32.15% of Total Billed charges,1603.14,Pays at 88% of Total Billed charges,603.18,Pays at 33.11% of Total Billed charges,365.31,1639.58,1093.05
Outpatient Medical Services,RADIOLOGY,78700,(E) KIDNEY IMAGING STATIC ONLY,341,965.5,820.68,Pays at 85% of Billed charges for outpatient setting,310.41,Pays at 32.15% of Total Billed charges,772.69,Pays at 80.03% of Total Billed charges,372.62,Pays at 102% of Medicare OPPS Rate,868.95,Pays at 90% of Total Billed charges,310.41,Pays at 32.15% of Total Billed charges,365.31,Pays at 100% of Medicare OPPS Rate,310.41,Pays at 32.15% of Total Billed charges,849.64,Pays at 88% of Total Billed charges,319.68,Pays at 33.11% of Total Billed charges,310.41,868.95,579.30
Outpatient Medical Services,RADIOLOGY,78707,(E) NM RENAL W/FLOW,341,2439.75,2073.79,Pays at 85% of Billed charges for outpatient setting,784.38,Pays at 32.15% of Total Billed charges,1952.53,Pays at 80.03% of Total Billed charges,483.66,Pays at 102% of Medicare OPPS Rate,2195.78,Pays at 90% of Total Billed charges,784.38,Pays at 32.15% of Total Billed charges,474.17,Pays at 100% of Medicare OPPS Rate,784.38,Pays at 32.15% of Total Billed charges,2146.98,Pays at 88% of Total Billed charges,807.8,Pays at 33.11% of Total Billed charges,474.17,2195.78,1463.85
Outpatient Medical Services,RADIOLOGY,78740,(E) URETERAL REFLUX STUDY W/VASC FLOW,341,1722,1463.7,Pays at 85% of Billed charges for outpatient setting,553.62,Pays at 32.15% of Total Billed charges,1378.12,Pays at 80.03% of Total Billed charges,372.62,Pays at 102% of Medicare OPPS Rate,1549.8,Pays at 90% of Total Billed charges,553.62,Pays at 32.15% of Total Billed charges,365.31,Pays at 100% of Medicare OPPS Rate,553.62,Pays at 32.15% of Total Billed charges,1515.36,Pays at 88% of Total Billed charges,570.15,Pays at 33.11% of Total Billed charges,365.31,1549.8,1033.20
Outpatient Medical Services,RADIOLOGY,78761,NM TESTICULAR W/FLOW,341,993.75,844.69,Pays at 85% of Billed charges for outpatient setting,319.49,Pays at 32.15% of Total Billed charges,795.3,Pays at 80.03% of Total Billed charges,372.62,Pays at 102% of Medicare OPPS Rate,894.38,Pays at 90% of Total Billed charges,319.49,Pays at 32.15% of Total Billed charges,365.31,Pays at 100% of Medicare OPPS Rate,319.49,Pays at 32.15% of Total Billed charges,874.5,Pays at 88% of Total Billed charges,329.03,Pays at 33.11% of Total Billed charges,319.49,894.38,596.25
Outpatient Medical Services,RADIOLOGY,78801,NM GALLIUM TUMOR LOC,341,1662.5,1413.13,Pays at 85% of Billed charges for outpatient setting,534.49,Pays at 32.15% of Total Billed charges,1330.5,Pays at 80.03% of Total Billed charges,372.62,Pays at 102% of Medicare OPPS Rate,1496.25,Pays at 90% of Total Billed charges,534.49,Pays at 32.15% of Total Billed charges,365.31,Pays at 100% of Medicare OPPS Rate,534.49,Pays at 32.15% of Total Billed charges,1463,Pays at 88% of Total Billed charges,550.45,Pays at 33.11% of Total Billed charges,365.31,1496.25,997.50
Outpatient Medical Services,RADIOLOGY,78801,NM GALLIUM DAY 1 (MULTIPLE AREAS),341,1046.5,889.53,Pays at 85% of Billed charges for outpatient setting,336.45,Pays at 32.15% of Total Billed charges,837.51,Pays at 80.03% of Total Billed charges,372.62,Pays at 102% of Medicare OPPS Rate,941.85,Pays at 90% of Total Billed charges,336.45,Pays at 32.15% of Total Billed charges,365.31,Pays at 100% of Medicare OPPS Rate,336.45,Pays at 32.15% of Total Billed charges,920.92,Pays at 88% of Total Billed charges,346.5,Pays at 33.11% of Total Billed charges,336.45,941.85,627.90
Outpatient Medical Services,RADIOLOGY,78802,NM RADIONUCLIDE WHOLE BODY,341,1791.25,1522.56,Pays at 85% of Billed charges for outpatient setting,575.89,Pays at 32.15% of Total Billed charges,1433.54,Pays at 80.03% of Total Billed charges,1272.45,Pays at 102% of Medicare OPPS Rate,1612.13,Pays at 90% of Total Billed charges,575.89,Pays at 32.15% of Total Billed charges,1247.51,Pays at 100% of Medicare OPPS Rate,575.89,Pays at 32.15% of Total Billed charges,1576.3,Pays at 88% of Total Billed charges,593.08,Pays at 33.11% of Total Billed charges,575.89,1612.13,1074.75
Outpatient Medical Services,RADIOLOGY,78804,NM GALLIUM WB DAY 2,341,1152,979.2,Pays at 85% of Billed charges for outpatient setting,370.37,Pays at 32.15% of Total Billed charges,921.95,Pays at 80.03% of Total Billed charges,1272.45,Pays at 102% of Medicare OPPS Rate,1036.8,Pays at 90% of Total Billed charges,370.37,Pays at 32.15% of Total Billed charges,1247.51,Pays at 100% of Medicare OPPS Rate,370.37,Pays at 32.15% of Total Billed charges,1013.76,Pays at 88% of Total Billed charges,381.43,Pays at 33.11% of Total Billed charges,370.37,1272.45,691.20
Outpatient Medical Services,RADIOLOGY,78804,NM TUMOR LOC WHOLE BODY,341,1152,979.2,Pays at 85% of Billed charges for outpatient setting,370.37,Pays at 32.15% of Total Billed charges,921.95,Pays at 80.03% of Total Billed charges,1272.45,Pays at 102% of Medicare OPPS Rate,1036.8,Pays at 90% of Total Billed charges,370.37,Pays at 32.15% of Total Billed charges,1247.51,Pays at 100% of Medicare OPPS Rate,370.37,Pays at 32.15% of Total Billed charges,1013.76,Pays at 88% of Total Billed charges,381.43,Pays at 33.11% of Total Billed charges,370.37,1272.45,691.20
Outpatient Medical Services,RADIOLOGY,78805,(E) NM LIMITED AREA WBC IMAGING,341,2041,1734.85,Pays at 85% of Billed charges for outpatient setting,656.18,Pays at 32.15% of Total Billed charges,1633.41,Pays at 80.03% of Total Billed charges,2041,Not Applicable,1836.9,Pays at 90% of Total Billed charges,656.18,Pays at 32.15% of Total Billed charges,2041,Not Applicable,656.18,Pays at 32.15% of Total Billed charges,1796.08,Pays at 88% of Total Billed charges,675.78,Pays at 33.11% of Total Billed charges,656.18,2041,1224.60
Outpatient Medical Services,RADIOLOGY,78805,NM WBC SCAN CERETEC,341,1203.5,1022.98,Pays at 85% of Billed charges for outpatient setting,386.93,Pays at 32.15% of Total Billed charges,963.16,Pays at 80.03% of Total Billed charges,1203.5,Not Applicable,1083.15,Pays at 90% of Total Billed charges,386.93,Pays at 32.15% of Total Billed charges,1203.5,Not Applicable,386.93,Pays at 32.15% of Total Billed charges,1059.08,Pays at 88% of Total Billed charges,398.48,Pays at 33.11% of Total Billed charges,386.93,1203.5,722.10
Outpatient Medical Services,RADIOLOGY,78805,NM GALLIUM DAY 2 OR 3 (LIMITED AREAS),341,597.75,508.09,Pays at 85% of Billed charges for outpatient setting,192.18,Pays at 32.15% of Total Billed charges,478.38,Pays at 80.03% of Total Billed charges,597.75,Not Applicable,537.98,Pays at 90% of Total Billed charges,192.18,Pays at 32.15% of Total Billed charges,597.75,Not Applicable,192.18,Pays at 32.15% of Total Billed charges,526.02,Pays at 88% of Total Billed charges,197.92,Pays at 33.11% of Total Billed charges,192.18,597.75,358.65
Outpatient Medical Services,RADIOLOGY,78806,NM GALLIUM WB DAY 1,341,1152,979.2,Pays at 85% of Billed charges for outpatient setting,370.37,Pays at 32.15% of Total Billed charges,921.95,Pays at 80.03% of Total Billed charges,1152,Not Applicable,1036.8,Pays at 90% of Total Billed charges,370.37,Pays at 32.15% of Total Billed charges,1152,Not Applicable,370.37,Pays at 32.15% of Total Billed charges,1013.76,Pays at 88% of Total Billed charges,381.43,Pays at 33.11% of Total Billed charges,370.37,1152,691.20
Outpatient Medical Services,RADIOLOGY,79000,NM THYROID THERAPY 1131,341,627.5,533.38,Pays at 85% of Billed charges for outpatient setting,201.74,Pays at 32.15% of Total Billed charges,502.19,Pays at 80.03% of Total Billed charges,627.5,Not Applicable,564.75,Pays at 90% of Total Billed charges,201.74,Pays at 32.15% of Total Billed charges,627.5,Not Applicable,201.74,Pays at 32.15% of Total Billed charges,552.2,Pays at 88% of Total Billed charges,207.77,Pays at 33.11% of Total Billed charges,201.74,627.5,376.50
Outpatient Medical Services,RADIOLOGY,79000,NM THYROID THERAPY 1131 SUBSEQUENT EA DA,341,627.5,533.38,Pays at 85% of Billed charges for outpatient setting,201.74,Pays at 32.15% of Total Billed charges,502.19,Pays at 80.03% of Total Billed charges,627.5,Not Applicable,564.75,Pays at 90% of Total Billed charges,201.74,Pays at 32.15% of Total Billed charges,627.5,Not Applicable,201.74,Pays at 32.15% of Total Billed charges,552.2,Pays at 88% of Total Billed charges,207.77,Pays at 33.11% of Total Billed charges,201.74,627.5,376.50
Outpatient Medical Services,RADIOLOGY,78012,NM THYROID IMAGING,341,904.5,768.83,Pays at 85% of Billed charges for outpatient setting,290.8,Pays at 32.15% of Total Billed charges,723.87,Pays at 80.03% of Total Billed charges,372.62,Pays at 102% of Medicare OPPS Rate,814.05,Pays at 90% of Total Billed charges,290.8,Pays at 32.15% of Total Billed charges,365.31,Pays at 100% of Medicare OPPS Rate,290.8,Pays at 32.15% of Total Billed charges,795.96,Pays at 88% of Total Billed charges,299.48,Pays at 33.11% of Total Billed charges,290.8,814.05,542.70
Outpatient Medical Services,RADIOLOGY,78070,NM PARATHYROID IMAGING,341,904.5,768.83,Pays at 85% of Billed charges for outpatient setting,290.8,Pays at 32.15% of Total Billed charges,723.87,Pays at 80.03% of Total Billed charges,372.62,Pays at 102% of Medicare OPPS Rate,814.05,Pays at 90% of Total Billed charges,290.8,Pays at 32.15% of Total Billed charges,365.31,Pays at 100% of Medicare OPPS Rate,290.8,Pays at 32.15% of Total Billed charges,795.96,Pays at 88% of Total Billed charges,299.48,Pays at 33.11% of Total Billed charges,290.8,814.05,542.70
Outpatient Medical Services,RADIOLOGY,78140,NM RBC TAGGING,341,1084.75,922.04,Pays at 85% of Billed charges for outpatient setting,348.75,Pays at 32.15% of Total Billed charges,868.13,Pays at 80.03% of Total Billed charges,372.62,Pays at 102% of Medicare OPPS Rate,976.28,Pays at 90% of Total Billed charges,348.75,Pays at 32.15% of Total Billed charges,365.31,Pays at 100% of Medicare OPPS Rate,348.75,Pays at 32.15% of Total Billed charges,954.58,Pays at 88% of Total Billed charges,359.16,Pays at 33.11% of Total Billed charges,348.75,976.28,650.85
Outpatient Medical Services,RADIOLOGY,78195,NM SENTINEL NODE LYMPHOSCINTOGRAPHY,341,1406.5,1195.53,Pays at 85% of Billed charges for outpatient setting,452.19,Pays at 32.15% of Total Billed charges,1125.62,Pays at 80.03% of Total Billed charges,483.66,Pays at 102% of Medicare OPPS Rate,1265.85,Pays at 90% of Total Billed charges,452.19,Pays at 32.15% of Total Billed charges,474.17,Pays at 100% of Medicare OPPS Rate,452.19,Pays at 32.15% of Total Billed charges,1237.72,Pays at 88% of Total Billed charges,465.69,Pays at 33.11% of Total Billed charges,452.19,1265.85,843.90
Outpatient Medical Services,RADIOLOGY,78215,NM LIVER SPLEEN SCAN,341,1314.5,1117.33,Pays at 85% of Billed charges for outpatient setting,422.61,Pays at 32.15% of Total Billed charges,1051.99,Pays at 80.03% of Total Billed charges,372.62,Pays at 102% of Medicare OPPS Rate,1183.05,Pays at 90% of Total Billed charges,422.61,Pays at 32.15% of Total Billed charges,365.31,Pays at 100% of Medicare OPPS Rate,422.61,Pays at 32.15% of Total Billed charges,1156.76,Pays at 88% of Total Billed charges,435.23,Pays at 33.11% of Total Billed charges,365.31,1183.05,788.70
Outpatient Medical Services,RADIOLOGY,78227,NM HIDA,341,1172.75,996.84,Pays at 85% of Billed charges for outpatient setting,377.04,Pays at 32.15% of Total Billed charges,938.55,Pays at 80.03% of Total Billed charges,483.66,Pays at 102% of Medicare OPPS Rate,1055.48,Pays at 90% of Total Billed charges,377.04,Pays at 32.15% of Total Billed charges,474.17,Pays at 100% of Medicare OPPS Rate,377.04,Pays at 32.15% of Total Billed charges,1032.02,Pays at 88% of Total Billed charges,388.3,Pays at 33.11% of Total Billed charges,377.04,1055.48,703.65
Outpatient Medical Services,RADIOLOGY,78227,NM HIDA W/CCK,341,1672.5,1421.63,Pays at 85% of Billed charges for outpatient setting,537.71,Pays at 32.15% of Total Billed charges,1338.5,Pays at 80.03% of Total Billed charges,483.66,Pays at 102% of Medicare OPPS Rate,1505.25,Pays at 90% of Total Billed charges,537.71,Pays at 32.15% of Total Billed charges,474.17,Pays at 100% of Medicare OPPS Rate,537.71,Pays at 32.15% of Total Billed charges,1471.8,Pays at 88% of Total Billed charges,553.76,Pays at 33.11% of Total Billed charges,474.17,1505.25,1003.50
Outpatient Medical Services,RADIOLOGY,78264,NM GASTRIC EMPTYING STUDY,341,904.5,768.83,Pays at 85% of Billed charges for outpatient setting,290.8,Pays at 32.15% of Total Billed charges,723.87,Pays at 80.03% of Total Billed charges,372.62,Pays at 102% of Medicare OPPS Rate,814.05,Pays at 90% of Total Billed charges,290.8,Pays at 32.15% of Total Billed charges,365.31,Pays at 100% of Medicare OPPS Rate,290.8,Pays at 32.15% of Total Billed charges,795.96,Pays at 88% of Total Billed charges,299.48,Pays at 33.11% of Total Billed charges,290.8,814.05,542.70
Outpatient Medical Services,RADIOLOGY,78278,NM GI BLEED,341,1447,1229.95,Pays at 85% of Billed charges for outpatient setting,465.21,Pays at 32.15% of Total Billed charges,1158.03,Pays at 80.03% of Total Billed charges,372.62,Pays at 102% of Medicare OPPS Rate,1302.3,Pays at 90% of Total Billed charges,465.21,Pays at 32.15% of Total Billed charges,365.31,Pays at 100% of Medicare OPPS Rate,465.21,Pays at 32.15% of Total Billed charges,1273.36,Pays at 88% of Total Billed charges,479.1,Pays at 33.11% of Total Billed charges,365.31,1302.3,868.20
Outpatient Medical Services,RADIOLOGY,78290,NM MECKEL'S SCAN,341,707.25,601.16,Pays at 85% of Billed charges for outpatient setting,227.38,Pays at 32.15% of Total Billed charges,566.01,Pays at 80.03% of Total Billed charges,372.62,Pays at 102% of Medicare OPPS Rate,636.53,Pays at 90% of Total Billed charges,227.38,Pays at 32.15% of Total Billed charges,365.31,Pays at 100% of Medicare OPPS Rate,227.38,Pays at 32.15% of Total Billed charges,622.38,Pays at 88% of Total Billed charges,234.17,Pays at 33.11% of Total Billed charges,227.38,636.53,424.35
Outpatient Medical Services,RADIOLOGY,78300,NM LIMITED AREA BONE,341,699.25,594.36,Pays at 85% of Billed charges for outpatient setting,224.81,Pays at 32.15% of Total Billed charges,559.61,Pays at 80.03% of Total Billed charges,372.62,Pays at 102% of Medicare OPPS Rate,629.33,Pays at 90% of Total Billed charges,224.81,Pays at 32.15% of Total Billed charges,365.31,Pays at 100% of Medicare OPPS Rate,224.81,Pays at 32.15% of Total Billed charges,615.34,Pays at 88% of Total Billed charges,231.52,Pays at 33.11% of Total Billed charges,224.81,629.33,419.55
Outpatient Medical Services,RADIOLOGY,78306,"A procedure most commonly ordered to detect areas of abnormal bone growth due to fractures, tumors, infection, or other bone issues",341,741.69,630.44,Pays at 85% of Billed charges for outpatient setting,238.45,Pays at 32.15% of Total Billed charges,593.57,Pays at 80.03% of Total Billed charges,372.62,Pays at 102% of Medicare OPPS Rate,667.52,Pays at 90% of Total Billed charges,238.45,Pays at 32.15% of Total Billed charges,365.31,Pays at 100% of Medicare OPPS Rate,238.45,Pays at 32.15% of Total Billed charges,652.69,Pays at 88% of Total Billed charges,245.57,Pays at 33.11% of Total Billed charges,238.45,667.52,445.01
Outpatient Medical Services,RADIOLOGY,78315,NM BONE SCAN THREE PHASE STUDY,341,1084.75,922.04,Pays at 85% of Billed charges for outpatient setting,348.75,Pays at 32.15% of Total Billed charges,868.13,Pays at 80.03% of Total Billed charges,372.62,Pays at 102% of Medicare OPPS Rate,976.28,Pays at 90% of Total Billed charges,348.75,Pays at 32.15% of Total Billed charges,365.31,Pays at 100% of Medicare OPPS Rate,348.75,Pays at 32.15% of Total Billed charges,954.58,Pays at 88% of Total Billed charges,359.16,Pays at 33.11% of Total Billed charges,348.75,976.28,650.85
Outpatient Medical Services,RADIOLOGY,78320,NM BONE SPECT,341,995.75,846.39,Pays at 85% of Billed charges for outpatient setting,320.13,Pays at 32.15% of Total Billed charges,796.9,Pays at 80.03% of Total Billed charges,995.75,Not Applicable,896.18,Pays at 90% of Total Billed charges,320.13,Pays at 32.15% of Total Billed charges,995.75,Not Applicable,320.13,Pays at 32.15% of Total Billed charges,876.26,Pays at 88% of Total Billed charges,329.69,Pays at 33.11% of Total Billed charges,320.13,995.75,597.45
Outpatient Medical Services,RADIOLOGY,78451,NM WALL MOTION,341,289.75,246.29,Pays at 85% of Billed charges for outpatient setting,93.15,Pays at 32.15% of Total Billed charges,231.89,Pays at 80.03% of Total Billed charges,1272.45,Pays at 102% of Medicare OPPS Rate,260.78,Pays at 90% of Total Billed charges,93.15,Pays at 32.15% of Total Billed charges,1247.51,Pays at 100% of Medicare OPPS Rate,93.15,Pays at 32.15% of Total Billed charges,254.98,Pays at 88% of Total Billed charges,95.94,Pays at 33.11% of Total Billed charges,93.15,1272.45,173.85
Outpatient Medical Services,RADIOLOGY,78451,NM EF,341,319,271.15,Pays at 85% of Billed charges for outpatient setting,102.56,Pays at 32.15% of Total Billed charges,255.3,Pays at 80.03% of Total Billed charges,1272.45,Pays at 102% of Medicare OPPS Rate,287.1,Pays at 90% of Total Billed charges,102.56,Pays at 32.15% of Total Billed charges,1247.51,Pays at 100% of Medicare OPPS Rate,102.56,Pays at 32.15% of Total Billed charges,280.72,Pays at 88% of Total Billed charges,105.62,Pays at 33.11% of Total Billed charges,102.56,1272.45,191.40
Outpatient Medical Services,RADIOLOGY,78451,NM MYOCARDIAL SINGLE PERFUSION STUDY,341,498,423.3,Pays at 85% of Billed charges for outpatient setting,160.11,Pays at 32.15% of Total Billed charges,398.55,Pays at 80.03% of Total Billed charges,1272.45,Pays at 102% of Medicare OPPS Rate,448.2,Pays at 90% of Total Billed charges,160.11,Pays at 32.15% of Total Billed charges,1247.51,Pays at 100% of Medicare OPPS Rate,160.11,Pays at 32.15% of Total Billed charges,438.24,Pays at 88% of Total Billed charges,164.89,Pays at 33.11% of Total Billed charges,160.11,1272.45,298.80
Outpatient Medical Services,RADIOLOGY,78452,Image of the heart to assess perfusion,341,4133.75,3513.69,Pays at 85% of Billed charges for outpatient setting,1329,Pays at 32.15% of Total Billed charges,3308.24,Pays at 80.03% of Total Billed charges,1272.45,Pays at 102% of Medicare OPPS Rate,3720.38,Pays at 90% of Total Billed charges,1329,Pays at 32.15% of Total Billed charges,1247.51,Pays at 100% of Medicare OPPS Rate,1329,Pays at 32.15% of Total Billed charges,3637.7,Pays at 88% of Total Billed charges,1368.68,Pays at 33.11% of Total Billed charges,1247.51,3720.38,2480.25
Outpatient Medical Services,RADIOLOGY,78453,NM MYOCARDIAL STRESS ONLY,341,823.75,700.19,Pays at 85% of Billed charges for outpatient setting,264.84,Pays at 32.15% of Total Billed charges,659.25,Pays at 80.03% of Total Billed charges,1272.45,Pays at 102% of Medicare OPPS Rate,741.38,Pays at 90% of Total Billed charges,264.84,Pays at 32.15% of Total Billed charges,1247.51,Pays at 100% of Medicare OPPS Rate,264.84,Pays at 32.15% of Total Billed charges,724.9,Pays at 88% of Total Billed charges,272.74,Pays at 33.11% of Total Billed charges,264.84,1272.45,494.25
Outpatient Medical Services,RADIOLOGY,78457,NM VENOUS THROMBOSIS,341,1096.25,931.81,Pays at 85% of Billed charges for outpatient setting,352.44,Pays at 32.15% of Total Billed charges,877.33,Pays at 80.03% of Total Billed charges,483.66,Pays at 102% of Medicare OPPS Rate,986.63,Pays at 90% of Total Billed charges,352.44,Pays at 32.15% of Total Billed charges,474.17,Pays at 100% of Medicare OPPS Rate,352.44,Pays at 32.15% of Total Billed charges,964.7,Pays at 88% of Total Billed charges,362.97,Pays at 33.11% of Total Billed charges,352.44,986.63,657.75
Outpatient Medical Services,RADIOLOGY,78458,NM VENOUS THROMBOSIS BILAT,341,1363.5,1158.98,Pays at 85% of Billed charges for outpatient setting,438.37,Pays at 32.15% of Total Billed charges,1091.21,Pays at 80.03% of Total Billed charges,372.62,Pays at 102% of Medicare OPPS Rate,1227.15,Pays at 90% of Total Billed charges,438.37,Pays at 32.15% of Total Billed charges,365.31,Pays at 100% of Medicare OPPS Rate,438.37,Pays at 32.15% of Total Billed charges,1199.88,Pays at 88% of Total Billed charges,451.45,Pays at 33.11% of Total Billed charges,365.31,1227.15,818.10
Outpatient Medical Services,RADIOLOGY,78466,NM MYOCARDIAL IMAGING,341,797.25,677.66,Pays at 85% of Billed charges for outpatient setting,256.32,Pays at 32.15% of Total Billed charges,638.04,Pays at 80.03% of Total Billed charges,372.62,Pays at 102% of Medicare OPPS Rate,717.53,Pays at 90% of Total Billed charges,256.32,Pays at 32.15% of Total Billed charges,365.31,Pays at 100% of Medicare OPPS Rate,256.32,Pays at 32.15% of Total Billed charges,701.58,Pays at 88% of Total Billed charges,263.97,Pays at 33.11% of Total Billed charges,256.32,717.53,478.35
Outpatient Medical Services,RADIOLOGY,78472,NM MUGA RESTING,341,1394,1184.9,Pays at 85% of Billed charges for outpatient setting,448.17,Pays at 32.15% of Total Billed charges,1115.62,Pays at 80.03% of Total Billed charges,372.62,Pays at 102% of Medicare OPPS Rate,1254.6,Pays at 90% of Total Billed charges,448.17,Pays at 32.15% of Total Billed charges,365.31,Pays at 100% of Medicare OPPS Rate,448.17,Pays at 32.15% of Total Billed charges,1226.72,Pays at 88% of Total Billed charges,461.55,Pays at 33.11% of Total Billed charges,365.31,1254.6,836.40
Outpatient Medical Services,RADIOLOGY,78579,NM LUNG SCAN VENTILATION,341,1314.5,1117.33,Pays at 85% of Billed charges for outpatient setting,422.61,Pays at 32.15% of Total Billed charges,1051.99,Pays at 80.03% of Total Billed charges,372.62,Pays at 102% of Medicare OPPS Rate,1183.05,Pays at 90% of Total Billed charges,422.61,Pays at 32.15% of Total Billed charges,365.31,Pays at 100% of Medicare OPPS Rate,422.61,Pays at 32.15% of Total Billed charges,1156.76,Pays at 88% of Total Billed charges,435.23,Pays at 33.11% of Total Billed charges,365.31,1183.05,788.70
Outpatient Medical Services,RADIOLOGY,78580,NM LUNG SCAN PERFUSION,341,1314.5,1117.33,Pays at 85% of Billed charges for outpatient setting,422.61,Pays at 32.15% of Total Billed charges,1051.99,Pays at 80.03% of Total Billed charges,372.62,Pays at 102% of Medicare OPPS Rate,1183.05,Pays at 90% of Total Billed charges,422.61,Pays at 32.15% of Total Billed charges,365.31,Pays at 100% of Medicare OPPS Rate,422.61,Pays at 32.15% of Total Billed charges,1156.76,Pays at 88% of Total Billed charges,435.23,Pays at 33.11% of Total Billed charges,365.31,1183.05,788.70
Outpatient Medical Services,RADIOLOGY,78582,NM LUNG SCAN VENT & PERFUSION,341,1406.5,1195.53,Pays at 85% of Billed charges for outpatient setting,452.19,Pays at 32.15% of Total Billed charges,1125.62,Pays at 80.03% of Total Billed charges,483.66,Pays at 102% of Medicare OPPS Rate,1265.85,Pays at 90% of Total Billed charges,452.19,Pays at 32.15% of Total Billed charges,474.17,Pays at 100% of Medicare OPPS Rate,452.19,Pays at 32.15% of Total Billed charges,1237.72,Pays at 88% of Total Billed charges,465.69,Pays at 33.11% of Total Billed charges,452.19,1265.85,843.90
Outpatient Medical Services,RADIOLOGY,78701,NM RENAL W/FLOW,341,1084.75,922.04,Pays at 85% of Billed charges for outpatient setting,348.75,Pays at 32.15% of Total Billed charges,868.13,Pays at 80.03% of Total Billed charges,372.62,Pays at 102% of Medicare OPPS Rate,976.28,Pays at 90% of Total Billed charges,348.75,Pays at 32.15% of Total Billed charges,365.31,Pays at 100% of Medicare OPPS Rate,348.75,Pays at 32.15% of Total Billed charges,954.58,Pays at 88% of Total Billed charges,359.16,Pays at 33.11% of Total Billed charges,348.75,976.28,650.85
Outpatient Medical Services,RADIOLOGY,78708,NM RENAL FLOW W/ PHARMACOLOGIC,341,1419,1206.15,Pays at 85% of Billed charges for outpatient setting,456.21,Pays at 32.15% of Total Billed charges,1135.63,Pays at 80.03% of Total Billed charges,483.66,Pays at 102% of Medicare OPPS Rate,1277.1,Pays at 90% of Total Billed charges,456.21,Pays at 32.15% of Total Billed charges,474.17,Pays at 100% of Medicare OPPS Rate,456.21,Pays at 32.15% of Total Billed charges,1248.72,Pays at 88% of Total Billed charges,469.83,Pays at 33.11% of Total Billed charges,456.21,1277.1,851.40
Outpatient Medical Services,RADIOLOGY,78709,NM RENAL WITH AND W/O PHARMACOLOGICAL,341,2439.75,2073.79,Pays at 85% of Billed charges for outpatient setting,784.38,Pays at 32.15% of Total Billed charges,1952.53,Pays at 80.03% of Total Billed charges,483.66,Pays at 102% of Medicare OPPS Rate,2195.78,Pays at 90% of Total Billed charges,784.38,Pays at 32.15% of Total Billed charges,474.17,Pays at 100% of Medicare OPPS Rate,784.38,Pays at 32.15% of Total Billed charges,2146.98,Pays at 88% of Total Billed charges,807.8,Pays at 33.11% of Total Billed charges,474.17,2195.78,1463.85
Outpatient Medical Services,RADIOLOGY,78805,NM LIMITED AREA WHITE BLOOD CELL IMAGING,341,1673,1422.05,Pays at 85% of Billed charges for outpatient setting,537.87,Pays at 32.15% of Total Billed charges,1338.9,Pays at 80.03% of Total Billed charges,1673,Not Applicable,1505.7,Pays at 90% of Total Billed charges,537.87,Pays at 32.15% of Total Billed charges,1673,Not Applicable,537.87,Pays at 32.15% of Total Billed charges,1472.24,Pays at 88% of Total Billed charges,553.93,Pays at 33.11% of Total Billed charges,537.87,1673,1003.80
Outpatient Medical Services,RADIOLOGY,78806,NM SCAN WBC TAG LEVEL II,341,2177.25,1850.66,Pays at 85% of Billed charges for outpatient setting,699.99,Pays at 32.15% of Total Billed charges,1742.45,Pays at 80.03% of Total Billed charges,2177.25,Not Applicable,1959.53,Pays at 90% of Total Billed charges,699.99,Pays at 32.15% of Total Billed charges,2177.25,Not Applicable,699.99,Pays at 32.15% of Total Billed charges,1915.98,Pays at 88% of Total Billed charges,720.89,Pays at 33.11% of Total Billed charges,699.99,2177.25,1306.35
Outpatient Medical Services,RADIOLOGY,A9500,NM SESTAMIBI,343,532.5,452.63,Pays at 85% of Billed charges for outpatient setting,171.2,Pays at 32.15% of Total Billed charges,426.16,Pays at 80.03% of Total Billed charges,532.5,Not Applicable,479.25,Pays at 90% of Total Billed charges,171.2,Pays at 32.15% of Total Billed charges,532.5,Not Applicable,171.2,Pays at 32.15% of Total Billed charges,468.6,Pays at 88% of Total Billed charges,176.31,Pays at 33.11% of Total Billed charges,171.2,532.5,319.50
Outpatient Medical Services,RADIOLOGY,A9503,NM MDP,343,93.75,79.69,Pays at 85% of Billed charges for outpatient setting,30.14,Pays at 32.15% of Total Billed charges,75.03,Pays at 80.03% of Total Billed charges,93.75,Not Applicable,84.38,Pays at 90% of Total Billed charges,30.14,Pays at 32.15% of Total Billed charges,93.75,Not Applicable,30.14,Pays at 32.15% of Total Billed charges,82.5,Pays at 88% of Total Billed charges,31.04,Pays at 33.11% of Total Billed charges,30.14,93.75,56.25
Outpatient Medical Services,RADIOLOGY,A9504,NM TC 99/M KIT,343,45.84,38.96,Pays at 85% of Billed charges for outpatient setting,14.74,Pays at 32.15% of Total Billed charges,36.69,Pays at 80.03% of Total Billed charges,45.84,Not Applicable,41.26,Pays at 90% of Total Billed charges,14.74,Pays at 32.15% of Total Billed charges,45.84,Not Applicable,14.74,Pays at 32.15% of Total Billed charges,40.34,Pays at 88% of Total Billed charges,15.18,Pays at 33.11% of Total Billed charges,14.74,45.84,27.50
Outpatient Medical Services,RADIOLOGY,A9510,NM DISOFENIN,343,257.2,218.62,Pays at 85% of Billed charges for outpatient setting,82.69,Pays at 32.15% of Total Billed charges,205.84,Pays at 80.03% of Total Billed charges,257.2,Not Applicable,231.48,Pays at 90% of Total Billed charges,82.69,Pays at 32.15% of Total Billed charges,257.2,Not Applicable,82.69,Pays at 32.15% of Total Billed charges,226.34,Pays at 88% of Total Billed charges,85.16,Pays at 33.11% of Total Billed charges,82.69,257.2,154.32
Outpatient Medical Services,RADIOLOGY,A9516,NM IODINE 123,343,438.53,372.75,Pays at 85% of Billed charges for outpatient setting,140.99,Pays at 32.15% of Total Billed charges,350.96,Pays at 80.03% of Total Billed charges,438.53,Not Applicable,394.68,Pays at 90% of Total Billed charges,140.99,Pays at 32.15% of Total Billed charges,438.53,Not Applicable,140.99,Pays at 32.15% of Total Billed charges,385.91,Pays at 88% of Total Billed charges,145.2,Pays at 33.11% of Total Billed charges,140.99,438.53,263.12
Outpatient Medical Services,RADIOLOGY,A9537,NM CHOLETEC,343,315.3,268.01,Pays at 85% of Billed charges for outpatient setting,101.37,Pays at 32.15% of Total Billed charges,252.33,Pays at 80.03% of Total Billed charges,315.3,Not Applicable,283.77,Pays at 90% of Total Billed charges,101.37,Pays at 32.15% of Total Billed charges,315.3,Not Applicable,101.37,Pays at 32.15% of Total Billed charges,277.46,Pays at 88% of Total Billed charges,104.4,Pays at 33.11% of Total Billed charges,101.37,315.3,189.18
Outpatient Medical Services,RADIOLOGY,A9540,NM MAA,343,120.26,102.22,Pays at 85% of Billed charges for outpatient setting,38.66,Pays at 32.15% of Total Billed charges,96.24,Pays at 80.03% of Total Billed charges,120.26,Not Applicable,108.23,Pays at 90% of Total Billed charges,38.66,Pays at 32.15% of Total Billed charges,120.26,Not Applicable,38.66,Pays at 32.15% of Total Billed charges,105.83,Pays at 88% of Total Billed charges,39.82,Pays at 33.11% of Total Billed charges,38.66,120.26,72.16
Outpatient Medical Services,RADIOLOGY,A9541,NM SULFUR COLLOID,343,116.91,99.37,Pays at 85% of Billed charges for outpatient setting,37.59,Pays at 32.15% of Total Billed charges,93.56,Pays at 80.03% of Total Billed charges,116.91,Not Applicable,105.22,Pays at 90% of Total Billed charges,37.59,Pays at 32.15% of Total Billed charges,116.91,Not Applicable,37.59,Pays at 32.15% of Total Billed charges,102.88,Pays at 88% of Total Billed charges,38.71,Pays at 33.11% of Total Billed charges,37.59,116.91,70.15
Outpatient Medical Services,RADIOLOGY,A9567,NM DTPA,343,227.17,193.09,Pays at 85% of Billed charges for outpatient setting,73.04,Pays at 32.15% of Total Billed charges,181.8,Pays at 80.03% of Total Billed charges,227.17,Not Applicable,204.45,Pays at 90% of Total Billed charges,73.04,Pays at 32.15% of Total Billed charges,227.17,Not Applicable,73.04,Pays at 32.15% of Total Billed charges,199.91,Pays at 88% of Total Billed charges,75.22,Pays at 33.11% of Total Billed charges,73.04,227.17,136.30
Outpatient Medical Services,RADIOLOGY,76376,CT REFORMAT,350,224.75,191.04,Pays at 85% of Billed charges for outpatient setting,72.26,Pays at 32.15% of Total Billed charges,179.87,Pays at 80.03% of Total Billed charges,224.75,Not Applicable,202.28,Pays at 90% of Total Billed charges,72.26,Pays at 32.15% of Total Billed charges,224.75,Not Applicable,72.26,Pays at 32.15% of Total Billed charges,197.78,Pays at 88% of Total Billed charges,74.41,Pays at 33.11% of Total Billed charges,72.26,224.75,134.85
Outpatient Medical Services,RADIOLOGY,70450,CT scan head or brain without dye,351,1425.25,1211.46,Pays at 85% of Billed charges for outpatient setting,458.22,Pays at 32.15% of Total Billed charges,1140.63,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,1282.73,Pays at 90% of Total Billed charges,458.22,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,458.22,Pays at 32.15% of Total Billed charges,1254.22,Pays at 88% of Total Billed charges,471.9,Pays at 33.11% of Total Billed charges,100.44,1282.73,855.15
Outpatient Medical Services,RADIOLOGY,70460,(E) CT HEAD W/CONTRAST,351,1425.25,1211.46,Pays at 85% of Billed charges for outpatient setting,458.22,Pays at 32.15% of Total Billed charges,1140.63,Pays at 80.03% of Total Billed charges,172.88,Pays at 102% of Medicare OPPS Rate,1282.73,Pays at 90% of Total Billed charges,458.22,Pays at 32.15% of Total Billed charges,169.49,Pays at 100% of Medicare OPPS Rate,458.22,Pays at 32.15% of Total Billed charges,1254.22,Pays at 88% of Total Billed charges,471.9,Pays at 33.11% of Total Billed charges,169.49,1282.73,855.15
Outpatient Medical Services,RADIOLOGY,70470,(E) CT HEAD W & W/O CONTRAST,351,1900.25,1615.21,Pays at 85% of Billed charges for outpatient setting,610.93,Pays at 32.15% of Total Billed charges,1520.77,Pays at 80.03% of Total Billed charges,172.88,Pays at 102% of Medicare OPPS Rate,1710.23,Pays at 90% of Total Billed charges,610.93,Pays at 32.15% of Total Billed charges,169.49,Pays at 100% of Medicare OPPS Rate,610.93,Pays at 32.15% of Total Billed charges,1672.22,Pays at 88% of Total Billed charges,629.17,Pays at 33.11% of Total Billed charges,169.49,1710.23,1140.15
Outpatient Medical Services,RADIOLOGY,70480,(E) CT ORBITS W/O CONTRAST,351,1425.25,1211.46,Pays at 85% of Billed charges for outpatient setting,458.22,Pays at 32.15% of Total Billed charges,1140.63,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,1282.73,Pays at 90% of Total Billed charges,458.22,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,458.22,Pays at 32.15% of Total Billed charges,1254.22,Pays at 88% of Total Billed charges,471.9,Pays at 33.11% of Total Billed charges,100.44,1282.73,855.15
Outpatient Medical Services,RADIOLOGY,70481,(E) CT ORBITS W/CONTRAST,351,1425.25,1211.46,Pays at 85% of Billed charges for outpatient setting,458.22,Pays at 32.15% of Total Billed charges,1140.63,Pays at 80.03% of Total Billed charges,172.88,Pays at 102% of Medicare OPPS Rate,1282.73,Pays at 90% of Total Billed charges,458.22,Pays at 32.15% of Total Billed charges,169.49,Pays at 100% of Medicare OPPS Rate,458.22,Pays at 32.15% of Total Billed charges,1254.22,Pays at 88% of Total Billed charges,471.9,Pays at 33.11% of Total Billed charges,169.49,1282.73,855.15
Outpatient Medical Services,RADIOLOGY,70482,(E) CT ORBITS W & W/O CONTRAST,351,1900.25,1615.21,Pays at 85% of Billed charges for outpatient setting,610.93,Pays at 32.15% of Total Billed charges,1520.77,Pays at 80.03% of Total Billed charges,172.88,Pays at 102% of Medicare OPPS Rate,1710.23,Pays at 90% of Total Billed charges,610.93,Pays at 32.15% of Total Billed charges,169.49,Pays at 100% of Medicare OPPS Rate,610.93,Pays at 32.15% of Total Billed charges,1672.22,Pays at 88% of Total Billed charges,629.17,Pays at 33.11% of Total Billed charges,169.49,1710.23,1140.15
Outpatient Medical Services,RADIOLOGY,70486,CT Scan of the face and jaw without dye,351,1425.25,1211.46,Pays at 85% of Billed charges for outpatient setting,458.22,Pays at 32.15% of Total Billed charges,1140.63,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,1282.73,Pays at 90% of Total Billed charges,458.22,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,458.22,Pays at 32.15% of Total Billed charges,1254.22,Pays at 88% of Total Billed charges,471.9,Pays at 33.11% of Total Billed charges,100.44,1282.73,855.15
Outpatient Medical Services,RADIOLOGY,70486,CT Scan of the face and jaw without dye,351,1425.25,1211.46,Pays at 85% of Billed charges for outpatient setting,458.22,Pays at 32.15% of Total Billed charges,1140.63,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,1282.73,Pays at 90% of Total Billed charges,458.22,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,458.22,Pays at 32.15% of Total Billed charges,1254.22,Pays at 88% of Total Billed charges,471.9,Pays at 33.11% of Total Billed charges,100.44,1282.73,855.15
Outpatient Medical Services,RADIOLOGY,70486,CT Scan of the face and jaw without dye,351,1425.25,1211.46,Pays at 85% of Billed charges for outpatient setting,458.22,Pays at 32.15% of Total Billed charges,1140.63,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,1282.73,Pays at 90% of Total Billed charges,458.22,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,458.22,Pays at 32.15% of Total Billed charges,1254.22,Pays at 88% of Total Billed charges,471.9,Pays at 33.11% of Total Billed charges,100.44,1282.73,855.15
Outpatient Medical Services,RADIOLOGY,70491,CT scan of neck with dye,351,1425.25,1211.46,Pays at 85% of Billed charges for outpatient setting,458.22,Pays at 32.15% of Total Billed charges,1140.63,Pays at 80.03% of Total Billed charges,172.88,Pays at 102% of Medicare OPPS Rate,1282.73,Pays at 90% of Total Billed charges,458.22,Pays at 32.15% of Total Billed charges,169.49,Pays at 100% of Medicare OPPS Rate,458.22,Pays at 32.15% of Total Billed charges,1254.22,Pays at 88% of Total Billed charges,471.9,Pays at 33.11% of Total Billed charges,169.49,1282.73,855.15
Outpatient Medical Services,RADIOLOGY,70492,(E) CT SOFT TISSUE NECK W/WO CONTRAST,351,1900.25,1615.21,Pays at 85% of Billed charges for outpatient setting,610.93,Pays at 32.15% of Total Billed charges,1520.77,Pays at 80.03% of Total Billed charges,172.88,Pays at 102% of Medicare OPPS Rate,1710.23,Pays at 90% of Total Billed charges,610.93,Pays at 32.15% of Total Billed charges,169.49,Pays at 100% of Medicare OPPS Rate,610.93,Pays at 32.15% of Total Billed charges,1672.22,Pays at 88% of Total Billed charges,629.17,Pays at 33.11% of Total Billed charges,169.49,1710.23,1140.15
Outpatient Medical Services,RADIOLOGY,70450,CT scan head or brain without dye,351,784.5,666.83,Pays at 85% of Billed charges for outpatient setting,252.22,Pays at 32.15% of Total Billed charges,627.84,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,706.05,Pays at 90% of Total Billed charges,252.22,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,252.22,Pays at 32.15% of Total Billed charges,690.36,Pays at 88% of Total Billed charges,259.75,Pays at 33.11% of Total Billed charges,100.44,706.05,470.70
Outpatient Medical Services,RADIOLOGY,70460,CT HEAD W CONTRAST,351,1425.25,1211.46,Pays at 85% of Billed charges for outpatient setting,458.22,Pays at 32.15% of Total Billed charges,1140.63,Pays at 80.03% of Total Billed charges,172.88,Pays at 102% of Medicare OPPS Rate,1282.73,Pays at 90% of Total Billed charges,458.22,Pays at 32.15% of Total Billed charges,169.49,Pays at 100% of Medicare OPPS Rate,458.22,Pays at 32.15% of Total Billed charges,1254.22,Pays at 88% of Total Billed charges,471.9,Pays at 33.11% of Total Billed charges,169.49,1282.73,855.15
Outpatient Medical Services,RADIOLOGY,70470,CT HEAD WWO CONTRAST,351,1900.25,1615.21,Pays at 85% of Billed charges for outpatient setting,610.93,Pays at 32.15% of Total Billed charges,1520.77,Pays at 80.03% of Total Billed charges,172.88,Pays at 102% of Medicare OPPS Rate,1710.23,Pays at 90% of Total Billed charges,610.93,Pays at 32.15% of Total Billed charges,169.49,Pays at 100% of Medicare OPPS Rate,610.93,Pays at 32.15% of Total Billed charges,1672.22,Pays at 88% of Total Billed charges,629.17,Pays at 33.11% of Total Billed charges,169.49,1710.23,1140.15
Outpatient Medical Services,RADIOLOGY,70480,CT ORBITS WO CONTRAST,351,829,704.65,Pays at 85% of Billed charges for outpatient setting,266.52,Pays at 32.15% of Total Billed charges,663.45,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,746.1,Pays at 90% of Total Billed charges,266.52,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,266.52,Pays at 32.15% of Total Billed charges,729.52,Pays at 88% of Total Billed charges,274.48,Pays at 33.11% of Total Billed charges,100.44,746.1,497.40
Outpatient Medical Services,RADIOLOGY,70480,CT TEMPORAL BONE WO CONTRAST,351,829,704.65,Pays at 85% of Billed charges for outpatient setting,266.52,Pays at 32.15% of Total Billed charges,663.45,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,746.1,Pays at 90% of Total Billed charges,266.52,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,266.52,Pays at 32.15% of Total Billed charges,729.52,Pays at 88% of Total Billed charges,274.48,Pays at 33.11% of Total Billed charges,100.44,746.1,497.40
Outpatient Medical Services,RADIOLOGY,70480,CT MASTOIDS WO CONTRAST,351,1425.25,1211.46,Pays at 85% of Billed charges for outpatient setting,458.22,Pays at 32.15% of Total Billed charges,1140.63,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,1282.73,Pays at 90% of Total Billed charges,458.22,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,458.22,Pays at 32.15% of Total Billed charges,1254.22,Pays at 88% of Total Billed charges,471.9,Pays at 33.11% of Total Billed charges,100.44,1282.73,855.15
Outpatient Medical Services,RADIOLOGY,70481,CT ORBITS W CONTRAST,351,784.5,666.83,Pays at 85% of Billed charges for outpatient setting,252.22,Pays at 32.15% of Total Billed charges,627.84,Pays at 80.03% of Total Billed charges,172.88,Pays at 102% of Medicare OPPS Rate,706.05,Pays at 90% of Total Billed charges,252.22,Pays at 32.15% of Total Billed charges,169.49,Pays at 100% of Medicare OPPS Rate,252.22,Pays at 32.15% of Total Billed charges,690.36,Pays at 88% of Total Billed charges,259.75,Pays at 33.11% of Total Billed charges,169.49,706.05,470.70
Outpatient Medical Services,RADIOLOGY,70481,CT TEMPORAL BONE W CONTRAST,351,1425.25,1211.46,Pays at 85% of Billed charges for outpatient setting,458.22,Pays at 32.15% of Total Billed charges,1140.63,Pays at 80.03% of Total Billed charges,172.88,Pays at 102% of Medicare OPPS Rate,1282.73,Pays at 90% of Total Billed charges,458.22,Pays at 32.15% of Total Billed charges,169.49,Pays at 100% of Medicare OPPS Rate,458.22,Pays at 32.15% of Total Billed charges,1254.22,Pays at 88% of Total Billed charges,471.9,Pays at 33.11% of Total Billed charges,169.49,1282.73,855.15
Outpatient Medical Services,RADIOLOGY,70482,CT ORBITS WWO CONTRAST,351,654,555.9,Pays at 85% of Billed charges for outpatient setting,210.26,Pays at 32.15% of Total Billed charges,523.4,Pays at 80.03% of Total Billed charges,172.88,Pays at 102% of Medicare OPPS Rate,588.6,Pays at 90% of Total Billed charges,210.26,Pays at 32.15% of Total Billed charges,169.49,Pays at 100% of Medicare OPPS Rate,210.26,Pays at 32.15% of Total Billed charges,575.52,Pays at 88% of Total Billed charges,216.54,Pays at 33.11% of Total Billed charges,169.49,588.6,392.40
Outpatient Medical Services,RADIOLOGY,70486,CT Scan of the face and jaw without dye,351,948,805.8,Pays at 85% of Billed charges for outpatient setting,304.78,Pays at 32.15% of Total Billed charges,758.68,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,853.2,Pays at 90% of Total Billed charges,304.78,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,304.78,Pays at 32.15% of Total Billed charges,834.24,Pays at 88% of Total Billed charges,313.88,Pays at 33.11% of Total Billed charges,100.44,853.2,568.80
Outpatient Medical Services,RADIOLOGY,70486,CT Scan of the face and jaw without dye,351,1244,1057.4,Pays at 85% of Billed charges for outpatient setting,399.95,Pays at 32.15% of Total Billed charges,995.57,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,1119.6,Pays at 90% of Total Billed charges,399.95,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,399.95,Pays at 32.15% of Total Billed charges,1094.72,Pays at 88% of Total Billed charges,411.89,Pays at 33.11% of Total Billed charges,100.44,1119.6,746.40
Outpatient Medical Services,RADIOLOGY,70486,CT Scan of the face and jaw without dye,351,829,704.65,Pays at 85% of Billed charges for outpatient setting,266.52,Pays at 32.15% of Total Billed charges,663.45,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,746.1,Pays at 90% of Total Billed charges,266.52,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,266.52,Pays at 32.15% of Total Billed charges,729.52,Pays at 88% of Total Billed charges,274.48,Pays at 33.11% of Total Billed charges,100.44,746.1,497.40
Outpatient Medical Services,RADIOLOGY,70486,CT Scan of the face and jaw without dye,351,829,704.65,Pays at 85% of Billed charges for outpatient setting,266.52,Pays at 32.15% of Total Billed charges,663.45,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,746.1,Pays at 90% of Total Billed charges,266.52,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,266.52,Pays at 32.15% of Total Billed charges,729.52,Pays at 88% of Total Billed charges,274.48,Pays at 33.11% of Total Billed charges,100.44,746.1,497.40
Outpatient Medical Services,RADIOLOGY,70487,CT FACIAL BONES W CONTRAST,351,784.5,666.83,Pays at 85% of Billed charges for outpatient setting,252.22,Pays at 32.15% of Total Billed charges,627.84,Pays at 80.03% of Total Billed charges,172.88,Pays at 102% of Medicare OPPS Rate,706.05,Pays at 90% of Total Billed charges,252.22,Pays at 32.15% of Total Billed charges,169.49,Pays at 100% of Medicare OPPS Rate,252.22,Pays at 32.15% of Total Billed charges,690.36,Pays at 88% of Total Billed charges,259.75,Pays at 33.11% of Total Billed charges,169.49,706.05,470.70
Outpatient Medical Services,RADIOLOGY,70487,CT MAXILLO FACIAL W CONTRAST,351,822.75,699.34,Pays at 85% of Billed charges for outpatient setting,264.51,Pays at 32.15% of Total Billed charges,658.45,Pays at 80.03% of Total Billed charges,172.88,Pays at 102% of Medicare OPPS Rate,740.48,Pays at 90% of Total Billed charges,264.51,Pays at 32.15% of Total Billed charges,169.49,Pays at 100% of Medicare OPPS Rate,264.51,Pays at 32.15% of Total Billed charges,724.02,Pays at 88% of Total Billed charges,272.41,Pays at 33.11% of Total Billed charges,169.49,740.48,493.65
Outpatient Medical Services,RADIOLOGY,70488,CT FACIAL BONES W AND WO CONTRAST,351,654,555.9,Pays at 85% of Billed charges for outpatient setting,210.26,Pays at 32.15% of Total Billed charges,523.4,Pays at 80.03% of Total Billed charges,172.88,Pays at 102% of Medicare OPPS Rate,588.6,Pays at 90% of Total Billed charges,210.26,Pays at 32.15% of Total Billed charges,169.49,Pays at 100% of Medicare OPPS Rate,210.26,Pays at 32.15% of Total Billed charges,575.52,Pays at 88% of Total Billed charges,216.54,Pays at 33.11% of Total Billed charges,169.49,588.6,392.40
Outpatient Medical Services,RADIOLOGY,70490,CT SOFT TISS NECK WO CONTRAST,351,948,805.8,Pays at 85% of Billed charges for outpatient setting,304.78,Pays at 32.15% of Total Billed charges,758.68,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,853.2,Pays at 90% of Total Billed charges,304.78,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,304.78,Pays at 32.15% of Total Billed charges,834.24,Pays at 88% of Total Billed charges,313.88,Pays at 33.11% of Total Billed charges,100.44,853.2,568.80
Outpatient Medical Services,RADIOLOGY,70491,CT scan of neck with dye,351,1176.75,1000.24,Pays at 85% of Billed charges for outpatient setting,378.33,Pays at 32.15% of Total Billed charges,941.75,Pays at 80.03% of Total Billed charges,172.88,Pays at 102% of Medicare OPPS Rate,1059.08,Pays at 90% of Total Billed charges,378.33,Pays at 32.15% of Total Billed charges,169.49,Pays at 100% of Medicare OPPS Rate,378.33,Pays at 32.15% of Total Billed charges,1035.54,Pays at 88% of Total Billed charges,389.62,Pays at 33.11% of Total Billed charges,169.49,1059.08,706.05
Outpatient Medical Services,RADIOLOGY,70492,CT SOFT TISS NECK WWO CONTRAST,351,1308.25,1112.01,Pays at 85% of Billed charges for outpatient setting,420.6,Pays at 32.15% of Total Billed charges,1046.99,Pays at 80.03% of Total Billed charges,172.88,Pays at 102% of Medicare OPPS Rate,1177.43,Pays at 90% of Total Billed charges,420.6,Pays at 32.15% of Total Billed charges,169.49,Pays at 100% of Medicare OPPS Rate,420.6,Pays at 32.15% of Total Billed charges,1151.26,Pays at 88% of Total Billed charges,433.16,Pays at 33.11% of Total Billed charges,169.49,1177.43,784.95
Outpatient Medical Services,RADIOLOGY,70496,CTA HEAD,351,784.5,666.83,Pays at 85% of Billed charges for outpatient setting,252.22,Pays at 32.15% of Total Billed charges,627.84,Pays at 80.03% of Total Billed charges,172.88,Pays at 102% of Medicare OPPS Rate,706.05,Pays at 90% of Total Billed charges,252.22,Pays at 32.15% of Total Billed charges,169.49,Pays at 100% of Medicare OPPS Rate,252.22,Pays at 32.15% of Total Billed charges,690.36,Pays at 88% of Total Billed charges,259.75,Pays at 33.11% of Total Billed charges,169.49,706.05,470.70
Outpatient Medical Services,RADIOLOGY,70498,CTA NECK,351,784.5,666.83,Pays at 85% of Billed charges for outpatient setting,252.22,Pays at 32.15% of Total Billed charges,627.84,Pays at 80.03% of Total Billed charges,172.88,Pays at 102% of Medicare OPPS Rate,706.05,Pays at 90% of Total Billed charges,252.22,Pays at 32.15% of Total Billed charges,169.49,Pays at 100% of Medicare OPPS Rate,252.22,Pays at 32.15% of Total Billed charges,690.36,Pays at 88% of Total Billed charges,259.75,Pays at 33.11% of Total Billed charges,169.49,706.05,470.70
Outpatient Medical Services,RADIOLOGY,71250,CT scan of the thorax without dye,352,1425.25,1211.46,Pays at 85% of Billed charges for outpatient setting,458.22,Pays at 32.15% of Total Billed charges,1140.63,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,1282.73,Pays at 90% of Total Billed charges,458.22,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,458.22,Pays at 32.15% of Total Billed charges,1254.22,Pays at 88% of Total Billed charges,471.9,Pays at 33.11% of Total Billed charges,100.44,1282.73,855.15
Outpatient Medical Services,RADIOLOGY,71260,CT scan of the thorax with dye,352,1425.25,1211.46,Pays at 85% of Billed charges for outpatient setting,458.22,Pays at 32.15% of Total Billed charges,1140.63,Pays at 80.03% of Total Billed charges,172.88,Pays at 102% of Medicare OPPS Rate,1282.73,Pays at 90% of Total Billed charges,458.22,Pays at 32.15% of Total Billed charges,169.49,Pays at 100% of Medicare OPPS Rate,458.22,Pays at 32.15% of Total Billed charges,1254.22,Pays at 88% of Total Billed charges,471.9,Pays at 33.11% of Total Billed charges,169.49,1282.73,855.15
Outpatient Medical Services,RADIOLOGY,71271,CT LUNG SCREENING WO CONTRAST,352,442,375.7,Pays at 85% of Billed charges for outpatient setting,142.1,Pays at 32.15% of Total Billed charges,353.73,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,397.8,Pays at 90% of Total Billed charges,142.1,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,142.1,Pays at 32.15% of Total Billed charges,388.96,Pays at 88% of Total Billed charges,146.35,Pays at 33.11% of Total Billed charges,100.44,397.8,265.20
Outpatient Medical Services,RADIOLOGY,71275,Diagnostic Radiology (Diagnostic Imaging) Procedures of the Chest,352,1425.25,1211.46,Pays at 85% of Billed charges for outpatient setting,458.22,Pays at 32.15% of Total Billed charges,1140.63,Pays at 80.03% of Total Billed charges,172.88,Pays at 102% of Medicare OPPS Rate,1282.73,Pays at 90% of Total Billed charges,458.22,Pays at 32.15% of Total Billed charges,169.49,Pays at 100% of Medicare OPPS Rate,458.22,Pays at 32.15% of Total Billed charges,1254.22,Pays at 88% of Total Billed charges,471.9,Pays at 33.11% of Total Billed charges,169.49,1282.73,855.15
Outpatient Medical Services,RADIOLOGY,71275,Diagnostic Radiology (Diagnostic Imaging) Procedures of the Chest,352,1425.25,1211.46,Pays at 85% of Billed charges for outpatient setting,458.22,Pays at 32.15% of Total Billed charges,1140.63,Pays at 80.03% of Total Billed charges,172.88,Pays at 102% of Medicare OPPS Rate,1282.73,Pays at 90% of Total Billed charges,458.22,Pays at 32.15% of Total Billed charges,169.49,Pays at 100% of Medicare OPPS Rate,458.22,Pays at 32.15% of Total Billed charges,1254.22,Pays at 88% of Total Billed charges,471.9,Pays at 33.11% of Total Billed charges,169.49,1282.73,855.15
Outpatient Medical Services,RADIOLOGY,72125,(E) CT SPINE CERVICAL W/O CONTRAST,352,1425.25,1211.46,Pays at 85% of Billed charges for outpatient setting,458.22,Pays at 32.15% of Total Billed charges,1140.63,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,1282.73,Pays at 90% of Total Billed charges,458.22,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,458.22,Pays at 32.15% of Total Billed charges,1254.22,Pays at 88% of Total Billed charges,471.9,Pays at 33.11% of Total Billed charges,100.44,1282.73,855.15
Outpatient Medical Services,RADIOLOGY,72126,(E) CT SPINE CERVICAL W/CONTRAST,352,1425.25,1211.46,Pays at 85% of Billed charges for outpatient setting,458.22,Pays at 32.15% of Total Billed charges,1140.63,Pays at 80.03% of Total Billed charges,353.2,Pays at 102% of Medicare OPPS Rate,1282.73,Pays at 90% of Total Billed charges,458.22,Pays at 32.15% of Total Billed charges,346.28,Pays at 100% of Medicare OPPS Rate,458.22,Pays at 32.15% of Total Billed charges,1254.22,Pays at 88% of Total Billed charges,471.9,Pays at 33.11% of Total Billed charges,346.28,1282.73,855.15
Outpatient Medical Services,RADIOLOGY,72128,(E) CT SPINE THORACIC W/O CONTRAST,352,1425.25,1211.46,Pays at 85% of Billed charges for outpatient setting,458.22,Pays at 32.15% of Total Billed charges,1140.63,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,1282.73,Pays at 90% of Total Billed charges,458.22,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,458.22,Pays at 32.15% of Total Billed charges,1254.22,Pays at 88% of Total Billed charges,471.9,Pays at 33.11% of Total Billed charges,100.44,1282.73,855.15
Outpatient Medical Services,RADIOLOGY,72129,(E) CT SPINE THORACIC W/CONTRAST,352,1425.25,1211.46,Pays at 85% of Billed charges for outpatient setting,458.22,Pays at 32.15% of Total Billed charges,1140.63,Pays at 80.03% of Total Billed charges,172.88,Pays at 102% of Medicare OPPS Rate,1282.73,Pays at 90% of Total Billed charges,458.22,Pays at 32.15% of Total Billed charges,169.49,Pays at 100% of Medicare OPPS Rate,458.22,Pays at 32.15% of Total Billed charges,1254.22,Pays at 88% of Total Billed charges,471.9,Pays at 33.11% of Total Billed charges,169.49,1282.73,855.15
Outpatient Medical Services,RADIOLOGY,72131,CT scan of lower spine without dye,352,1425.25,1211.46,Pays at 85% of Billed charges for outpatient setting,458.22,Pays at 32.15% of Total Billed charges,1140.63,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,1282.73,Pays at 90% of Total Billed charges,458.22,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,458.22,Pays at 32.15% of Total Billed charges,1254.22,Pays at 88% of Total Billed charges,471.9,Pays at 33.11% of Total Billed charges,100.44,1282.73,855.15
Outpatient Medical Services,RADIOLOGY,72132,(E) CT SPINE LUMBAR W/CONTRAST,352,1425.25,1211.46,Pays at 85% of Billed charges for outpatient setting,458.22,Pays at 32.15% of Total Billed charges,1140.63,Pays at 80.03% of Total Billed charges,353.2,Pays at 102% of Medicare OPPS Rate,1282.73,Pays at 90% of Total Billed charges,458.22,Pays at 32.15% of Total Billed charges,346.28,Pays at 100% of Medicare OPPS Rate,458.22,Pays at 32.15% of Total Billed charges,1254.22,Pays at 88% of Total Billed charges,471.9,Pays at 33.11% of Total Billed charges,346.28,1282.73,855.15
Outpatient Medical Services,RADIOLOGY,72192,CT of pelvis without dye,352,1425.25,1211.46,Pays at 85% of Billed charges for outpatient setting,458.22,Pays at 32.15% of Total Billed charges,1140.63,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,1282.73,Pays at 90% of Total Billed charges,458.22,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,458.22,Pays at 32.15% of Total Billed charges,1254.22,Pays at 88% of Total Billed charges,471.9,Pays at 33.11% of Total Billed charges,100.44,1282.73,855.15
Outpatient Medical Services,RADIOLOGY,72193,"CT scan, pelvis, with contrast",352,1425.25,1211.46,Pays at 85% of Billed charges for outpatient setting,458.22,Pays at 32.15% of Total Billed charges,1140.63,Pays at 80.03% of Total Billed charges,172.88,Pays at 102% of Medicare OPPS Rate,1282.73,Pays at 90% of Total Billed charges,458.22,Pays at 32.15% of Total Billed charges,169.49,Pays at 100% of Medicare OPPS Rate,458.22,Pays at 32.15% of Total Billed charges,1254.22,Pays at 88% of Total Billed charges,471.9,Pays at 33.11% of Total Billed charges,169.49,1282.73,855.15
Outpatient Medical Services,RADIOLOGY,73200,(E) CT EXTREMITY UPPER W/O CONTRAST,352,1425.25,1211.46,Pays at 85% of Billed charges for outpatient setting,458.22,Pays at 32.15% of Total Billed charges,1140.63,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,1282.73,Pays at 90% of Total Billed charges,458.22,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,458.22,Pays at 32.15% of Total Billed charges,1254.22,Pays at 88% of Total Billed charges,471.9,Pays at 33.11% of Total Billed charges,100.44,1282.73,855.15
Outpatient Medical Services,RADIOLOGY,73201,(E) CT EXTREMITY UPPER WITH CONTRAST,352,1425.25,1211.46,Pays at 85% of Billed charges for outpatient setting,458.22,Pays at 32.15% of Total Billed charges,1140.63,Pays at 80.03% of Total Billed charges,353.2,Pays at 102% of Medicare OPPS Rate,1282.73,Pays at 90% of Total Billed charges,458.22,Pays at 32.15% of Total Billed charges,346.28,Pays at 100% of Medicare OPPS Rate,458.22,Pays at 32.15% of Total Billed charges,1254.22,Pays at 88% of Total Billed charges,471.9,Pays at 33.11% of Total Billed charges,346.28,1282.73,855.15
Outpatient Medical Services,RADIOLOGY,73700,CT scan of leg without dye,352,1425.25,1211.46,Pays at 85% of Billed charges for outpatient setting,458.22,Pays at 32.15% of Total Billed charges,1140.63,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,1282.73,Pays at 90% of Total Billed charges,458.22,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,458.22,Pays at 32.15% of Total Billed charges,1254.22,Pays at 88% of Total Billed charges,471.9,Pays at 33.11% of Total Billed charges,100.44,1282.73,855.15
Outpatient Medical Services,RADIOLOGY,73701,(E) CT EXTREMITY LOWER W/CONTRAST,352,1425.25,1211.46,Pays at 85% of Billed charges for outpatient setting,458.22,Pays at 32.15% of Total Billed charges,1140.63,Pays at 80.03% of Total Billed charges,172.88,Pays at 102% of Medicare OPPS Rate,1282.73,Pays at 90% of Total Billed charges,458.22,Pays at 32.15% of Total Billed charges,169.49,Pays at 100% of Medicare OPPS Rate,458.22,Pays at 32.15% of Total Billed charges,1254.22,Pays at 88% of Total Billed charges,471.9,Pays at 33.11% of Total Billed charges,169.49,1282.73,855.15
Outpatient Medical Services,RADIOLOGY,74150,CT of abdomen without dye,352,1425.25,1211.46,Pays at 85% of Billed charges for outpatient setting,458.22,Pays at 32.15% of Total Billed charges,1140.63,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,1282.73,Pays at 90% of Total Billed charges,458.22,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,458.22,Pays at 32.15% of Total Billed charges,1254.22,Pays at 88% of Total Billed charges,471.9,Pays at 33.11% of Total Billed charges,100.44,1282.73,855.15
Outpatient Medical Services,RADIOLOGY,74160,CT of abdomen with dye,352,1425.25,1211.46,Pays at 85% of Billed charges for outpatient setting,458.22,Pays at 32.15% of Total Billed charges,1140.63,Pays at 80.03% of Total Billed charges,172.88,Pays at 102% of Medicare OPPS Rate,1282.73,Pays at 90% of Total Billed charges,458.22,Pays at 32.15% of Total Billed charges,169.49,Pays at 100% of Medicare OPPS Rate,458.22,Pays at 32.15% of Total Billed charges,1254.22,Pays at 88% of Total Billed charges,471.9,Pays at 33.11% of Total Billed charges,169.49,1282.73,855.15
Outpatient Medical Services,RADIOLOGY,74170,CT of abdomen with and without dye,352,1900.25,1615.21,Pays at 85% of Billed charges for outpatient setting,610.93,Pays at 32.15% of Total Billed charges,1520.77,Pays at 80.03% of Total Billed charges,172.88,Pays at 102% of Medicare OPPS Rate,1710.23,Pays at 90% of Total Billed charges,610.93,Pays at 32.15% of Total Billed charges,169.49,Pays at 100% of Medicare OPPS Rate,610.93,Pays at 32.15% of Total Billed charges,1672.22,Pays at 88% of Total Billed charges,629.17,Pays at 33.11% of Total Billed charges,169.49,1710.23,1140.15
Outpatient Medical Services,RADIOLOGY,77078,PRO CT BONE DENSITY,352,228,193.8,Pays at 85% of Billed charges for outpatient setting,73.3,Pays at 32.15% of Total Billed charges,182.47,Pays at 80.03% of Total Billed charges,83.28,Pays at 102% of Medicare OPPS Rate,205.2,Pays at 90% of Total Billed charges,73.3,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,73.3,Pays at 32.15% of Total Billed charges,200.64,Pays at 88% of Total Billed charges,75.49,Pays at 33.11% of Total Billed charges,73.3,205.2,136.80
Outpatient Medical Services,RADIOLOGY,10022,CT FINE NEEDLE ASPIRATION,352,540.5,459.43,Pays at 85% of Billed charges for outpatient setting,173.77,Pays at 32.15% of Total Billed charges,432.56,Pays at 80.03% of Total Billed charges,540.5,Not Applicable,486.45,Pays at 90% of Total Billed charges,173.77,Pays at 32.15% of Total Billed charges,540.5,Not Applicable,173.77,Pays at 32.15% of Total Billed charges,475.64,Pays at 88% of Total Billed charges,178.96,Pays at 33.11% of Total Billed charges,173.77,540.5,324.30
Outpatient Medical Services,RADIOLOGY,20206,CT BIOPSY OF MUSCLE,352,519.25,441.36,Pays at 85% of Billed charges for outpatient setting,166.94,Pays at 32.15% of Total Billed charges,415.56,Pays at 80.03% of Total Billed charges,1437.62,Pays at 102% of Medicare OPPS Rate,467.33,Pays at 90% of Total Billed charges,166.94,Pays at 32.15% of Total Billed charges,1409.43,Pays at 100% of Medicare OPPS Rate,166.94,Pays at 32.15% of Total Billed charges,456.94,Pays at 88% of Total Billed charges,171.92,Pays at 33.11% of Total Billed charges,166.94,1437.62,311.55
Outpatient Medical Services,RADIOLOGY,20220,CT BONE BX SUPERFICIAL,352,1425.25,1211.46,Pays at 85% of Billed charges for outpatient setting,458.22,Pays at 32.15% of Total Billed charges,1140.63,Pays at 80.03% of Total Billed charges,1437.62,Pays at 102% of Medicare OPPS Rate,1282.73,Pays at 90% of Total Billed charges,458.22,Pays at 32.15% of Total Billed charges,1409.43,Pays at 100% of Medicare OPPS Rate,458.22,Pays at 32.15% of Total Billed charges,1254.22,Pays at 88% of Total Billed charges,471.9,Pays at 33.11% of Total Billed charges,458.22,1437.62,855.15
Outpatient Medical Services,RADIOLOGY,20225,CT BONE BX DEEP,352,1425.25,1211.46,Pays at 85% of Billed charges for outpatient setting,458.22,Pays at 32.15% of Total Billed charges,1140.63,Pays at 80.03% of Total Billed charges,1437.62,Pays at 102% of Medicare OPPS Rate,1282.73,Pays at 90% of Total Billed charges,458.22,Pays at 32.15% of Total Billed charges,1409.43,Pays at 100% of Medicare OPPS Rate,458.22,Pays at 32.15% of Total Billed charges,1254.22,Pays at 88% of Total Billed charges,471.9,Pays at 33.11% of Total Billed charges,458.22,1437.62,855.15
Outpatient Medical Services,RADIOLOGY,32405,CT LUNG BIOPSY,352,3838,3262.3,Pays at 85% of Billed charges for outpatient setting,1233.92,Pays at 32.15% of Total Billed charges,3071.55,Pays at 80.03% of Total Billed charges,3838,Not Applicable,3454.2,Pays at 90% of Total Billed charges,1233.92,Pays at 32.15% of Total Billed charges,3838,Not Applicable,1233.92,Pays at 32.15% of Total Billed charges,3377.44,Pays at 88% of Total Billed charges,1270.76,Pays at 33.11% of Total Billed charges,1233.92,3838,2302.80
Outpatient Medical Services,RADIOLOGY,71250,CT scan of the thorax without dye,352,784.5,666.83,Pays at 85% of Billed charges for outpatient setting,252.22,Pays at 32.15% of Total Billed charges,627.84,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,706.05,Pays at 90% of Total Billed charges,252.22,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,252.22,Pays at 32.15% of Total Billed charges,690.36,Pays at 88% of Total Billed charges,259.75,Pays at 33.11% of Total Billed charges,100.44,706.05,470.70
Outpatient Medical Services,RADIOLOGY,71260,CT scan of the thorax with dye,352,1149,976.65,Pays at 85% of Billed charges for outpatient setting,369.4,Pays at 32.15% of Total Billed charges,919.54,Pays at 80.03% of Total Billed charges,172.88,Pays at 102% of Medicare OPPS Rate,1034.1,Pays at 90% of Total Billed charges,369.4,Pays at 32.15% of Total Billed charges,169.49,Pays at 100% of Medicare OPPS Rate,369.4,Pays at 32.15% of Total Billed charges,1011.12,Pays at 88% of Total Billed charges,380.43,Pays at 33.11% of Total Billed charges,169.49,1034.1,689.40
Outpatient Medical Services,RADIOLOGY,71270,CT CHEST WWO CONTRAST,352,1425.25,1211.46,Pays at 85% of Billed charges for outpatient setting,458.22,Pays at 32.15% of Total Billed charges,1140.63,Pays at 80.03% of Total Billed charges,172.88,Pays at 102% of Medicare OPPS Rate,1282.73,Pays at 90% of Total Billed charges,458.22,Pays at 32.15% of Total Billed charges,169.49,Pays at 100% of Medicare OPPS Rate,458.22,Pays at 32.15% of Total Billed charges,1254.22,Pays at 88% of Total Billed charges,471.9,Pays at 33.11% of Total Billed charges,169.49,1282.73,855.15
Outpatient Medical Services,RADIOLOGY,71275,Diagnostic Radiology (Diagnostic Imaging) Procedures of the Chest,352,784.5,666.83,Pays at 85% of Billed charges for outpatient setting,252.22,Pays at 32.15% of Total Billed charges,627.84,Pays at 80.03% of Total Billed charges,172.88,Pays at 102% of Medicare OPPS Rate,706.05,Pays at 90% of Total Billed charges,252.22,Pays at 32.15% of Total Billed charges,169.49,Pays at 100% of Medicare OPPS Rate,252.22,Pays at 32.15% of Total Billed charges,690.36,Pays at 88% of Total Billed charges,259.75,Pays at 33.11% of Total Billed charges,169.49,706.05,470.70
Outpatient Medical Services,RADIOLOGY,72125,CT CERVICAL WO CONTRAST,352,1473,1252.05,Pays at 85% of Billed charges for outpatient setting,473.57,Pays at 32.15% of Total Billed charges,1178.84,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,1325.7,Pays at 90% of Total Billed charges,473.57,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,473.57,Pays at 32.15% of Total Billed charges,1296.24,Pays at 88% of Total Billed charges,487.71,Pays at 33.11% of Total Billed charges,100.44,1325.7,883.80
Outpatient Medical Services,RADIOLOGY,72126,CT CERVICAL W CONTRAST,352,784.5,666.83,Pays at 85% of Billed charges for outpatient setting,252.22,Pays at 32.15% of Total Billed charges,627.84,Pays at 80.03% of Total Billed charges,353.2,Pays at 102% of Medicare OPPS Rate,706.05,Pays at 90% of Total Billed charges,252.22,Pays at 32.15% of Total Billed charges,346.28,Pays at 100% of Medicare OPPS Rate,252.22,Pays at 32.15% of Total Billed charges,690.36,Pays at 88% of Total Billed charges,259.75,Pays at 33.11% of Total Billed charges,252.22,706.05,470.70
Outpatient Medical Services,RADIOLOGY,72127,CT CERVICAL WWO CONTRAST,352,1425.25,1211.46,Pays at 85% of Billed charges for outpatient setting,458.22,Pays at 32.15% of Total Billed charges,1140.63,Pays at 80.03% of Total Billed charges,172.88,Pays at 102% of Medicare OPPS Rate,1282.73,Pays at 90% of Total Billed charges,458.22,Pays at 32.15% of Total Billed charges,169.49,Pays at 100% of Medicare OPPS Rate,458.22,Pays at 32.15% of Total Billed charges,1254.22,Pays at 88% of Total Billed charges,471.9,Pays at 33.11% of Total Billed charges,169.49,1282.73,855.15
Outpatient Medical Services,RADIOLOGY,72128,CT THORACIC WO CONTRAST,352,654,555.9,Pays at 85% of Billed charges for outpatient setting,210.26,Pays at 32.15% of Total Billed charges,523.4,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,588.6,Pays at 90% of Total Billed charges,210.26,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,210.26,Pays at 32.15% of Total Billed charges,575.52,Pays at 88% of Total Billed charges,216.54,Pays at 33.11% of Total Billed charges,100.44,588.6,392.40
Outpatient Medical Services,RADIOLOGY,72129,CT THORACIC W CONTRAST,352,784.5,666.83,Pays at 85% of Billed charges for outpatient setting,252.22,Pays at 32.15% of Total Billed charges,627.84,Pays at 80.03% of Total Billed charges,172.88,Pays at 102% of Medicare OPPS Rate,706.05,Pays at 90% of Total Billed charges,252.22,Pays at 32.15% of Total Billed charges,169.49,Pays at 100% of Medicare OPPS Rate,252.22,Pays at 32.15% of Total Billed charges,690.36,Pays at 88% of Total Billed charges,259.75,Pays at 33.11% of Total Billed charges,169.49,706.05,470.70
Outpatient Medical Services,RADIOLOGY,72130,CT THORACIC WWO CONTRAST,352,1425.25,1211.46,Pays at 85% of Billed charges for outpatient setting,458.22,Pays at 32.15% of Total Billed charges,1140.63,Pays at 80.03% of Total Billed charges,172.88,Pays at 102% of Medicare OPPS Rate,1282.73,Pays at 90% of Total Billed charges,458.22,Pays at 32.15% of Total Billed charges,169.49,Pays at 100% of Medicare OPPS Rate,458.22,Pays at 32.15% of Total Billed charges,1254.22,Pays at 88% of Total Billed charges,471.9,Pays at 33.11% of Total Billed charges,169.49,1282.73,855.15
Outpatient Medical Services,RADIOLOGY,72130,CT T-SPINE WITH AND W/O CONTRAST,352,1900.25,1615.21,Pays at 85% of Billed charges for outpatient setting,610.93,Pays at 32.15% of Total Billed charges,1520.77,Pays at 80.03% of Total Billed charges,172.88,Pays at 102% of Medicare OPPS Rate,1710.23,Pays at 90% of Total Billed charges,610.93,Pays at 32.15% of Total Billed charges,169.49,Pays at 100% of Medicare OPPS Rate,610.93,Pays at 32.15% of Total Billed charges,1672.22,Pays at 88% of Total Billed charges,629.17,Pays at 33.11% of Total Billed charges,169.49,1710.23,1140.15
Outpatient Medical Services,RADIOLOGY,72131,CT scan of lower spine without dye,352,784.5,666.83,Pays at 85% of Billed charges for outpatient setting,252.22,Pays at 32.15% of Total Billed charges,627.84,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,706.05,Pays at 90% of Total Billed charges,252.22,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,252.22,Pays at 32.15% of Total Billed charges,690.36,Pays at 88% of Total Billed charges,259.75,Pays at 33.11% of Total Billed charges,100.44,706.05,470.70
Outpatient Medical Services,RADIOLOGY,72132,CT LUMBAR W CONTRAST,352,1181,1003.85,Pays at 85% of Billed charges for outpatient setting,379.69,Pays at 32.15% of Total Billed charges,945.15,Pays at 80.03% of Total Billed charges,353.2,Pays at 102% of Medicare OPPS Rate,1062.9,Pays at 90% of Total Billed charges,379.69,Pays at 32.15% of Total Billed charges,346.28,Pays at 100% of Medicare OPPS Rate,379.69,Pays at 32.15% of Total Billed charges,1039.28,Pays at 88% of Total Billed charges,391.03,Pays at 33.11% of Total Billed charges,346.28,1062.9,708.60
Outpatient Medical Services,RADIOLOGY,72133,CT LUMBAR W AND  W/O  CONTRAST,352,1425.25,1211.46,Pays at 85% of Billed charges for outpatient setting,458.22,Pays at 32.15% of Total Billed charges,1140.63,Pays at 80.03% of Total Billed charges,172.88,Pays at 102% of Medicare OPPS Rate,1282.73,Pays at 90% of Total Billed charges,458.22,Pays at 32.15% of Total Billed charges,169.49,Pays at 100% of Medicare OPPS Rate,458.22,Pays at 32.15% of Total Billed charges,1254.22,Pays at 88% of Total Billed charges,471.9,Pays at 33.11% of Total Billed charges,169.49,1282.73,855.15
Outpatient Medical Services,RADIOLOGY,72191,CTA PELVIS,352,1425.25,1211.46,Pays at 85% of Billed charges for outpatient setting,458.22,Pays at 32.15% of Total Billed charges,1140.63,Pays at 80.03% of Total Billed charges,172.88,Pays at 102% of Medicare OPPS Rate,1282.73,Pays at 90% of Total Billed charges,458.22,Pays at 32.15% of Total Billed charges,169.49,Pays at 100% of Medicare OPPS Rate,458.22,Pays at 32.15% of Total Billed charges,1254.22,Pays at 88% of Total Billed charges,471.9,Pays at 33.11% of Total Billed charges,169.49,1282.73,855.15
Outpatient Medical Services,RADIOLOGY,72192,CT of pelvis without dye,352,784.5,666.83,Pays at 85% of Billed charges for outpatient setting,252.22,Pays at 32.15% of Total Billed charges,627.84,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,706.05,Pays at 90% of Total Billed charges,252.22,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,252.22,Pays at 32.15% of Total Billed charges,690.36,Pays at 88% of Total Billed charges,259.75,Pays at 33.11% of Total Billed charges,100.44,706.05,470.70
Outpatient Medical Services,RADIOLOGY,72193,"CT scan, pelvis, with contrast",352,1125,956.25,Pays at 85% of Billed charges for outpatient setting,361.69,Pays at 32.15% of Total Billed charges,900.34,Pays at 80.03% of Total Billed charges,172.88,Pays at 102% of Medicare OPPS Rate,1012.5,Pays at 90% of Total Billed charges,361.69,Pays at 32.15% of Total Billed charges,169.49,Pays at 100% of Medicare OPPS Rate,361.69,Pays at 32.15% of Total Billed charges,990,Pays at 88% of Total Billed charges,372.49,Pays at 33.11% of Total Billed charges,169.49,1012.5,675.00
Outpatient Medical Services,RADIOLOGY,72194,CT PELVIS WWO CONTRAST,352,1900.25,1615.21,Pays at 85% of Billed charges for outpatient setting,610.93,Pays at 32.15% of Total Billed charges,1520.77,Pays at 80.03% of Total Billed charges,172.88,Pays at 102% of Medicare OPPS Rate,1710.23,Pays at 90% of Total Billed charges,610.93,Pays at 32.15% of Total Billed charges,169.49,Pays at 100% of Medicare OPPS Rate,610.93,Pays at 32.15% of Total Billed charges,1672.22,Pays at 88% of Total Billed charges,629.17,Pays at 33.11% of Total Billed charges,169.49,1710.23,1140.15
Outpatient Medical Services,RADIOLOGY,73200,CT EXTREM UP W/O CONTRAST BIL,352,2787.25,2369.16,Pays at 85% of Billed charges for outpatient setting,896.1,Pays at 32.15% of Total Billed charges,2230.64,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,2508.53,Pays at 90% of Total Billed charges,896.1,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,896.1,Pays at 32.15% of Total Billed charges,2452.78,Pays at 88% of Total Billed charges,922.86,Pays at 33.11% of Total Billed charges,100.44,2508.53,1672.35
Outpatient Medical Services,RADIOLOGY,73200,CT BILATERAL  EXTREM UP W/O CONTRAST,352,2787.25,2369.16,Pays at 85% of Billed charges for outpatient setting,896.1,Pays at 32.15% of Total Billed charges,2230.64,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,2508.53,Pays at 90% of Total Billed charges,896.1,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,896.1,Pays at 32.15% of Total Billed charges,2452.78,Pays at 88% of Total Billed charges,922.86,Pays at 33.11% of Total Billed charges,100.44,2508.53,1672.35
Outpatient Medical Services,RADIOLOGY,73200,CT EXTREM UP WO CONTRAST LT,352,654,555.9,Pays at 85% of Billed charges for outpatient setting,210.26,Pays at 32.15% of Total Billed charges,523.4,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,588.6,Pays at 90% of Total Billed charges,210.26,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,210.26,Pays at 32.15% of Total Billed charges,575.52,Pays at 88% of Total Billed charges,216.54,Pays at 33.11% of Total Billed charges,100.44,588.6,392.40
Outpatient Medical Services,RADIOLOGY,73200,CT EXTREM UP WO CONTRAST RT,352,654,555.9,Pays at 85% of Billed charges for outpatient setting,210.26,Pays at 32.15% of Total Billed charges,523.4,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,588.6,Pays at 90% of Total Billed charges,210.26,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,210.26,Pays at 32.15% of Total Billed charges,575.52,Pays at 88% of Total Billed charges,216.54,Pays at 33.11% of Total Billed charges,100.44,588.6,392.40
Outpatient Medical Services,RADIOLOGY,73201,CT EXTREM UP W CONTRAST LT,352,784.5,666.83,Pays at 85% of Billed charges for outpatient setting,252.22,Pays at 32.15% of Total Billed charges,627.84,Pays at 80.03% of Total Billed charges,353.2,Pays at 102% of Medicare OPPS Rate,706.05,Pays at 90% of Total Billed charges,252.22,Pays at 32.15% of Total Billed charges,346.28,Pays at 100% of Medicare OPPS Rate,252.22,Pays at 32.15% of Total Billed charges,690.36,Pays at 88% of Total Billed charges,259.75,Pays at 33.11% of Total Billed charges,252.22,706.05,470.70
Outpatient Medical Services,RADIOLOGY,73201,CT EXTREM UP W CONTRAST RT,352,784.5,666.83,Pays at 85% of Billed charges for outpatient setting,252.22,Pays at 32.15% of Total Billed charges,627.84,Pays at 80.03% of Total Billed charges,353.2,Pays at 102% of Medicare OPPS Rate,706.05,Pays at 90% of Total Billed charges,252.22,Pays at 32.15% of Total Billed charges,346.28,Pays at 100% of Medicare OPPS Rate,252.22,Pays at 32.15% of Total Billed charges,690.36,Pays at 88% of Total Billed charges,259.75,Pays at 33.11% of Total Billed charges,252.22,706.05,470.70
Outpatient Medical Services,RADIOLOGY,73202,CT EXTREM UP W/WO CONTRAST LT,352,1438.75,1222.94,Pays at 85% of Billed charges for outpatient setting,462.56,Pays at 32.15% of Total Billed charges,1151.43,Pays at 80.03% of Total Billed charges,172.88,Pays at 102% of Medicare OPPS Rate,1294.88,Pays at 90% of Total Billed charges,462.56,Pays at 32.15% of Total Billed charges,169.49,Pays at 100% of Medicare OPPS Rate,462.56,Pays at 32.15% of Total Billed charges,1266.1,Pays at 88% of Total Billed charges,476.37,Pays at 33.11% of Total Billed charges,169.49,1294.88,863.25
Outpatient Medical Services,RADIOLOGY,73202,CT EXTREM UP W/WO CONTRAST RT,352,1438.75,1222.94,Pays at 85% of Billed charges for outpatient setting,462.56,Pays at 32.15% of Total Billed charges,1151.43,Pays at 80.03% of Total Billed charges,172.88,Pays at 102% of Medicare OPPS Rate,1294.88,Pays at 90% of Total Billed charges,462.56,Pays at 32.15% of Total Billed charges,169.49,Pays at 100% of Medicare OPPS Rate,462.56,Pays at 32.15% of Total Billed charges,1266.1,Pays at 88% of Total Billed charges,476.37,Pays at 33.11% of Total Billed charges,169.49,1294.88,863.25
Outpatient Medical Services,RADIOLOGY,73206,CTA UPPER EXT LT,352,1425.25,1211.46,Pays at 85% of Billed charges for outpatient setting,458.22,Pays at 32.15% of Total Billed charges,1140.63,Pays at 80.03% of Total Billed charges,172.88,Pays at 102% of Medicare OPPS Rate,1282.73,Pays at 90% of Total Billed charges,458.22,Pays at 32.15% of Total Billed charges,169.49,Pays at 100% of Medicare OPPS Rate,458.22,Pays at 32.15% of Total Billed charges,1254.22,Pays at 88% of Total Billed charges,471.9,Pays at 33.11% of Total Billed charges,169.49,1282.73,855.15
Outpatient Medical Services,RADIOLOGY,73206,CTA UPPER EXT RT,352,1425.25,1211.46,Pays at 85% of Billed charges for outpatient setting,458.22,Pays at 32.15% of Total Billed charges,1140.63,Pays at 80.03% of Total Billed charges,172.88,Pays at 102% of Medicare OPPS Rate,1282.73,Pays at 90% of Total Billed charges,458.22,Pays at 32.15% of Total Billed charges,169.49,Pays at 100% of Medicare OPPS Rate,458.22,Pays at 32.15% of Total Billed charges,1254.22,Pays at 88% of Total Billed charges,471.9,Pays at 33.11% of Total Billed charges,169.49,1282.73,855.15
Outpatient Medical Services,RADIOLOGY,73700,CT scan of leg without dye,352,1438.75,1222.94,Pays at 85% of Billed charges for outpatient setting,462.56,Pays at 32.15% of Total Billed charges,1151.43,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,1294.88,Pays at 90% of Total Billed charges,462.56,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,462.56,Pays at 32.15% of Total Billed charges,1266.1,Pays at 88% of Total Billed charges,476.37,Pays at 33.11% of Total Billed charges,100.44,1294.88,863.25
Outpatient Medical Services,RADIOLOGY,73700,CT scan of leg without dye,352,654,555.9,Pays at 85% of Billed charges for outpatient setting,210.26,Pays at 32.15% of Total Billed charges,523.4,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,588.6,Pays at 90% of Total Billed charges,210.26,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,210.26,Pays at 32.15% of Total Billed charges,575.52,Pays at 88% of Total Billed charges,216.54,Pays at 33.11% of Total Billed charges,100.44,588.6,392.40
Outpatient Medical Services,RADIOLOGY,73700,CT scan of leg without dye,352,654,555.9,Pays at 85% of Billed charges for outpatient setting,210.26,Pays at 32.15% of Total Billed charges,523.4,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,588.6,Pays at 90% of Total Billed charges,210.26,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,210.26,Pays at 32.15% of Total Billed charges,575.52,Pays at 88% of Total Billed charges,216.54,Pays at 33.11% of Total Billed charges,100.44,588.6,392.40
Outpatient Medical Services,RADIOLOGY,73701,CT EXTREM LOW W CONTRAST LT,352,654,555.9,Pays at 85% of Billed charges for outpatient setting,210.26,Pays at 32.15% of Total Billed charges,523.4,Pays at 80.03% of Total Billed charges,172.88,Pays at 102% of Medicare OPPS Rate,588.6,Pays at 90% of Total Billed charges,210.26,Pays at 32.15% of Total Billed charges,169.49,Pays at 100% of Medicare OPPS Rate,210.26,Pays at 32.15% of Total Billed charges,575.52,Pays at 88% of Total Billed charges,216.54,Pays at 33.11% of Total Billed charges,169.49,588.6,392.40
Outpatient Medical Services,RADIOLOGY,73701,CT EXTREM LOW W CONTRAST RT,352,784.5,666.83,Pays at 85% of Billed charges for outpatient setting,252.22,Pays at 32.15% of Total Billed charges,627.84,Pays at 80.03% of Total Billed charges,172.88,Pays at 102% of Medicare OPPS Rate,706.05,Pays at 90% of Total Billed charges,252.22,Pays at 32.15% of Total Billed charges,169.49,Pays at 100% of Medicare OPPS Rate,252.22,Pays at 32.15% of Total Billed charges,690.36,Pays at 88% of Total Billed charges,259.75,Pays at 33.11% of Total Billed charges,169.49,706.05,470.70
Outpatient Medical Services,RADIOLOGY,73702,CT EXTREM LOW WWO CONTRAST LT,352,1900.25,1615.21,Pays at 85% of Billed charges for outpatient setting,610.93,Pays at 32.15% of Total Billed charges,1520.77,Pays at 80.03% of Total Billed charges,172.88,Pays at 102% of Medicare OPPS Rate,1710.23,Pays at 90% of Total Billed charges,610.93,Pays at 32.15% of Total Billed charges,169.49,Pays at 100% of Medicare OPPS Rate,610.93,Pays at 32.15% of Total Billed charges,1672.22,Pays at 88% of Total Billed charges,629.17,Pays at 33.11% of Total Billed charges,169.49,1710.23,1140.15
Outpatient Medical Services,RADIOLOGY,73702,CT EXTREM LOW WWO CONTRAST RT,352,1900.25,1615.21,Pays at 85% of Billed charges for outpatient setting,610.93,Pays at 32.15% of Total Billed charges,1520.77,Pays at 80.03% of Total Billed charges,172.88,Pays at 102% of Medicare OPPS Rate,1710.23,Pays at 90% of Total Billed charges,610.93,Pays at 32.15% of Total Billed charges,169.49,Pays at 100% of Medicare OPPS Rate,610.93,Pays at 32.15% of Total Billed charges,1672.22,Pays at 88% of Total Billed charges,629.17,Pays at 33.11% of Total Billed charges,169.49,1710.23,1140.15
Outpatient Medical Services,RADIOLOGY,73706,CTA BILATERAL LOWER EXTREM,352,1900.25,1615.21,Pays at 85% of Billed charges for outpatient setting,610.93,Pays at 32.15% of Total Billed charges,1520.77,Pays at 80.03% of Total Billed charges,172.88,Pays at 102% of Medicare OPPS Rate,1710.23,Pays at 90% of Total Billed charges,610.93,Pays at 32.15% of Total Billed charges,169.49,Pays at 100% of Medicare OPPS Rate,610.93,Pays at 32.15% of Total Billed charges,1672.22,Pays at 88% of Total Billed charges,629.17,Pays at 33.11% of Total Billed charges,169.49,1710.23,1140.15
Outpatient Medical Services,RADIOLOGY,73706,CTA LOWER EXTREM LT,352,1425.25,1211.46,Pays at 85% of Billed charges for outpatient setting,458.22,Pays at 32.15% of Total Billed charges,1140.63,Pays at 80.03% of Total Billed charges,172.88,Pays at 102% of Medicare OPPS Rate,1282.73,Pays at 90% of Total Billed charges,458.22,Pays at 32.15% of Total Billed charges,169.49,Pays at 100% of Medicare OPPS Rate,458.22,Pays at 32.15% of Total Billed charges,1254.22,Pays at 88% of Total Billed charges,471.9,Pays at 33.11% of Total Billed charges,169.49,1282.73,855.15
Outpatient Medical Services,RADIOLOGY,73706,CTA LOWER EXTREM RT,352,1425.25,1211.46,Pays at 85% of Billed charges for outpatient setting,458.22,Pays at 32.15% of Total Billed charges,1140.63,Pays at 80.03% of Total Billed charges,172.88,Pays at 102% of Medicare OPPS Rate,1282.73,Pays at 90% of Total Billed charges,458.22,Pays at 32.15% of Total Billed charges,169.49,Pays at 100% of Medicare OPPS Rate,458.22,Pays at 32.15% of Total Billed charges,1254.22,Pays at 88% of Total Billed charges,471.9,Pays at 33.11% of Total Billed charges,169.49,1282.73,855.15
Outpatient Medical Services,RADIOLOGY,74150,CT of abdomen without dye,352,916,778.6,Pays at 85% of Billed charges for outpatient setting,294.49,Pays at 32.15% of Total Billed charges,733.07,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,824.4,Pays at 90% of Total Billed charges,294.49,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,294.49,Pays at 32.15% of Total Billed charges,806.08,Pays at 88% of Total Billed charges,303.29,Pays at 33.11% of Total Billed charges,100.44,824.4,549.60
Outpatient Medical Services,RADIOLOGY,74160,CT of abdomen with dye,352,948,805.8,Pays at 85% of Billed charges for outpatient setting,304.78,Pays at 32.15% of Total Billed charges,758.68,Pays at 80.03% of Total Billed charges,172.88,Pays at 102% of Medicare OPPS Rate,853.2,Pays at 90% of Total Billed charges,304.78,Pays at 32.15% of Total Billed charges,169.49,Pays at 100% of Medicare OPPS Rate,304.78,Pays at 32.15% of Total Billed charges,834.24,Pays at 88% of Total Billed charges,313.88,Pays at 33.11% of Total Billed charges,169.49,853.2,568.80
Outpatient Medical Services,RADIOLOGY,74170,CT of abdomen with and without dye,352,1308.25,1112.01,Pays at 85% of Billed charges for outpatient setting,420.6,Pays at 32.15% of Total Billed charges,1046.99,Pays at 80.03% of Total Billed charges,172.88,Pays at 102% of Medicare OPPS Rate,1177.43,Pays at 90% of Total Billed charges,420.6,Pays at 32.15% of Total Billed charges,169.49,Pays at 100% of Medicare OPPS Rate,420.6,Pays at 32.15% of Total Billed charges,1151.26,Pays at 88% of Total Billed charges,433.16,Pays at 33.11% of Total Billed charges,169.49,1177.43,784.95
Outpatient Medical Services,RADIOLOGY,74174,CTA ABDOMEN/PELVIS,352,784.5,666.83,Pays at 85% of Billed charges for outpatient setting,252.22,Pays at 32.15% of Total Billed charges,627.84,Pays at 80.03% of Total Billed charges,353.2,Pays at 102% of Medicare OPPS Rate,706.05,Pays at 90% of Total Billed charges,252.22,Pays at 32.15% of Total Billed charges,346.28,Pays at 100% of Medicare OPPS Rate,252.22,Pays at 32.15% of Total Billed charges,690.36,Pays at 88% of Total Billed charges,259.75,Pays at 33.11% of Total Billed charges,252.22,706.05,470.70
Outpatient Medical Services,RADIOLOGY,74175,CTA ABDOMEN,352,784.5,666.83,Pays at 85% of Billed charges for outpatient setting,252.22,Pays at 32.15% of Total Billed charges,627.84,Pays at 80.03% of Total Billed charges,172.88,Pays at 102% of Medicare OPPS Rate,706.05,Pays at 90% of Total Billed charges,252.22,Pays at 32.15% of Total Billed charges,169.49,Pays at 100% of Medicare OPPS Rate,252.22,Pays at 32.15% of Total Billed charges,690.36,Pays at 88% of Total Billed charges,259.75,Pays at 33.11% of Total Billed charges,169.49,706.05,470.70
Outpatient Medical Services,RADIOLOGY,74175,MESENTERIC ANGIOGRAPHY,352,1851.5,1573.78,Pays at 85% of Billed charges for outpatient setting,595.26,Pays at 32.15% of Total Billed charges,1481.76,Pays at 80.03% of Total Billed charges,172.88,Pays at 102% of Medicare OPPS Rate,1666.35,Pays at 90% of Total Billed charges,595.26,Pays at 32.15% of Total Billed charges,169.49,Pays at 100% of Medicare OPPS Rate,595.26,Pays at 32.15% of Total Billed charges,1629.32,Pays at 88% of Total Billed charges,613.03,Pays at 33.11% of Total Billed charges,169.49,1666.35,1110.90
Outpatient Medical Services,RADIOLOGY,74176,CT of abdomen and pelvis without dye,352,1442.75,1226.34,Pays at 85% of Billed charges for outpatient setting,463.84,Pays at 32.15% of Total Billed charges,1154.63,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,1298.48,Pays at 90% of Total Billed charges,463.84,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,463.84,Pays at 32.15% of Total Billed charges,1269.62,Pays at 88% of Total Billed charges,477.69,Pays at 33.11% of Total Billed charges,219.48,1298.48,865.65
Outpatient Medical Services,RADIOLOGY,74176,CT of abdomen and pelvis without dye,352,1442.75,1226.34,Pays at 85% of Billed charges for outpatient setting,463.84,Pays at 32.15% of Total Billed charges,1154.63,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,1298.48,Pays at 90% of Total Billed charges,463.84,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,463.84,Pays at 32.15% of Total Billed charges,1269.62,Pays at 88% of Total Billed charges,477.69,Pays at 33.11% of Total Billed charges,219.48,1298.48,865.65
Outpatient Medical Services,RADIOLOGY,74177,CT scan of abdomen and pelvis with contrast,352,1900.25,1615.21,Pays at 85% of Billed charges for outpatient setting,610.93,Pays at 32.15% of Total Billed charges,1520.77,Pays at 80.03% of Total Billed charges,353.2,Pays at 102% of Medicare OPPS Rate,1710.23,Pays at 90% of Total Billed charges,610.93,Pays at 32.15% of Total Billed charges,346.28,Pays at 100% of Medicare OPPS Rate,610.93,Pays at 32.15% of Total Billed charges,1672.22,Pays at 88% of Total Billed charges,629.17,Pays at 33.11% of Total Billed charges,346.28,1710.23,1140.15
Outpatient Medical Services,RADIOLOGY,74178,"Computed tomography, abdomen and pelvis; without contrast material in one or both body regions, followed by contrast material(s) and further sections ",352,2354.75,2001.54,Pays at 85% of Billed charges for outpatient setting,757.05,Pays at 32.15% of Total Billed charges,1884.51,Pays at 80.03% of Total Billed charges,353.2,Pays at 102% of Medicare OPPS Rate,2119.28,Pays at 90% of Total Billed charges,757.05,Pays at 32.15% of Total Billed charges,346.28,Pays at 100% of Medicare OPPS Rate,757.05,Pays at 32.15% of Total Billed charges,2072.18,Pays at 88% of Total Billed charges,779.66,Pays at 33.11% of Total Billed charges,346.28,2119.28,1412.85
Outpatient Medical Services,RADIOLOGY,75635,CTA ABDOMEN AORTA,352,784.5,666.83,Pays at 85% of Billed charges for outpatient setting,252.22,Pays at 32.15% of Total Billed charges,627.84,Pays at 80.03% of Total Billed charges,172.89,Pays at 102% of Medicare OPPS Rate,706.05,Pays at 90% of Total Billed charges,252.22,Pays at 32.15% of Total Billed charges,169.5,Pays at 100% of Medicare OPPS Rate,252.22,Pays at 32.15% of Total Billed charges,690.36,Pays at 88% of Total Billed charges,259.75,Pays at 33.11% of Total Billed charges,169.5,706.05,470.70
Outpatient Medical Services,RADIOLOGY,76376,CT 3D RECONSTRUCTION,352,224.75,191.04,Pays at 85% of Billed charges for outpatient setting,72.26,Pays at 32.15% of Total Billed charges,179.87,Pays at 80.03% of Total Billed charges,224.75,Not Applicable,202.28,Pays at 90% of Total Billed charges,72.26,Pays at 32.15% of Total Billed charges,224.75,Not Applicable,72.26,Pays at 32.15% of Total Billed charges,197.78,Pays at 88% of Total Billed charges,74.41,Pays at 33.11% of Total Billed charges,72.26,224.75,134.85
Outpatient Medical Services,RADIOLOGY,77012,CT GUIDANCE CODE,352,618.5,525.73,Pays at 85% of Billed charges for outpatient setting,198.85,Pays at 32.15% of Total Billed charges,494.99,Pays at 80.03% of Total Billed charges,618.5,Not Applicable,556.65,Pays at 90% of Total Billed charges,198.85,Pays at 32.15% of Total Billed charges,618.5,Not Applicable,198.85,Pays at 32.15% of Total Billed charges,544.28,Pays at 88% of Total Billed charges,204.79,Pays at 33.11% of Total Billed charges,198.85,618.5,371.10
Outpatient Medical Services,RADIOLOGY,352,=> CT ORDER              <=,352,SERVICE NOT OFFERED,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,0,0,#VALUE!
Outpatient Medical Services,RADIOLOGY,19125,MM DIGITAL  MAMMO NEEDLE LOC,401,1482,1259.7,Pays at 85% of Billed charges for outpatient setting,476.46,Pays at 32.15% of Total Billed charges,1186.04,Pays at 80.03% of Total Billed charges,3295.83,Pays at 102% of Medicare OPPS Rate,1333.8,Pays at 90% of Total Billed charges,476.46,Pays at 32.15% of Total Billed charges,3231.21,Pays at 100% of Medicare OPPS Rate,476.46,Pays at 32.15% of Total Billed charges,1304.16,Pays at 88% of Total Billed charges,490.69,Pays at 33.11% of Total Billed charges,476.46,3295.83,889.20
Outpatient Medical Services,RADIOLOGY,77056,MM MAMMO DIAG BILAT,401,130.5,110.93,Pays at 85% of Billed charges for outpatient setting,41.96,Pays at 32.15% of Total Billed charges,104.44,Pays at 80.03% of Total Billed charges,130.5,Not Applicable,117.45,Pays at 90% of Total Billed charges,41.96,Pays at 32.15% of Total Billed charges,130.5,Not Applicable,41.96,Pays at 32.15% of Total Billed charges,114.84,Pays at 88% of Total Billed charges,43.21,Pays at 33.11% of Total Billed charges,41.96,130.5,78.30
Outpatient Medical Services,RADIOLOGY,77056,MM MAMMO SPOT COMPR BILAT,401,194.75,165.54,Pays at 85% of Billed charges for outpatient setting,62.61,Pays at 32.15% of Total Billed charges,155.86,Pays at 80.03% of Total Billed charges,194.75,Not Applicable,175.28,Pays at 90% of Total Billed charges,62.61,Pays at 32.15% of Total Billed charges,194.75,Not Applicable,62.61,Pays at 32.15% of Total Billed charges,171.38,Pays at 88% of Total Billed charges,64.48,Pays at 33.11% of Total Billed charges,62.61,194.75,116.85
Outpatient Medical Services,RADIOLOGY,77056,MM MAMMO SPOT COMPR UNILAT RT,401,97.25,82.66,Pays at 85% of Billed charges for outpatient setting,31.27,Pays at 32.15% of Total Billed charges,77.83,Pays at 80.03% of Total Billed charges,97.25,Not Applicable,87.53,Pays at 90% of Total Billed charges,31.27,Pays at 32.15% of Total Billed charges,97.25,Not Applicable,31.27,Pays at 32.15% of Total Billed charges,85.58,Pays at 88% of Total Billed charges,32.2,Pays at 33.11% of Total Billed charges,31.27,97.25,58.35
Outpatient Medical Services,RADIOLOGY,77056,MM MAMMO DIAG UNILAT RT,401,97.25,82.66,Pays at 85% of Billed charges for outpatient setting,31.27,Pays at 32.15% of Total Billed charges,77.83,Pays at 80.03% of Total Billed charges,97.25,Not Applicable,87.53,Pays at 90% of Total Billed charges,31.27,Pays at 32.15% of Total Billed charges,97.25,Not Applicable,31.27,Pays at 32.15% of Total Billed charges,85.58,Pays at 88% of Total Billed charges,32.2,Pays at 33.11% of Total Billed charges,31.27,97.25,58.35
Outpatient Medical Services,RADIOLOGY,77065,"Diagnostic mammography, including computer-aided detection (cad) when performed; unilateral",401,324,275.4,Pays at 85% of Billed charges for outpatient setting,104.17,Pays at 32.15% of Total Billed charges,259.3,Pays at 80.03% of Total Billed charges,79.83,Pays at 102% of Medicare OPPS Rate,291.6,Pays at 90% of Total Billed charges,104.17,Pays at 32.15% of Total Billed charges,78.26,Pays at 100% of Medicare OPPS Rate,104.17,Pays at 32.15% of Total Billed charges,285.12,Pays at 88% of Total Billed charges,107.28,Pays at 33.11% of Total Billed charges,78.26,291.6,194.40
Outpatient Medical Services,RADIOLOGY,77065,"Diagnostic mammography, including computer-aided detection (cad) when performed; unilateral",401,250.63,213.04,Pays at 85% of Billed charges for outpatient setting,80.58,Pays at 32.15% of Total Billed charges,200.58,Pays at 80.03% of Total Billed charges,79.83,Pays at 102% of Medicare OPPS Rate,225.57,Pays at 90% of Total Billed charges,80.58,Pays at 32.15% of Total Billed charges,78.26,Pays at 100% of Medicare OPPS Rate,80.58,Pays at 32.15% of Total Billed charges,220.55,Pays at 88% of Total Billed charges,82.98,Pays at 33.11% of Total Billed charges,78.26,225.57,150.38
Outpatient Medical Services,RADIOLOGY,77065,"Diagnostic mammography, including computer-aided detection (cad) when performed; unilateral",401,324,275.4,Pays at 85% of Billed charges for outpatient setting,104.17,Pays at 32.15% of Total Billed charges,259.3,Pays at 80.03% of Total Billed charges,79.83,Pays at 102% of Medicare OPPS Rate,291.6,Pays at 90% of Total Billed charges,104.17,Pays at 32.15% of Total Billed charges,78.26,Pays at 100% of Medicare OPPS Rate,104.17,Pays at 32.15% of Total Billed charges,285.12,Pays at 88% of Total Billed charges,107.28,Pays at 33.11% of Total Billed charges,78.26,291.6,194.40
Outpatient Medical Services,RADIOLOGY,77065,"Diagnostic mammography, including computer-aided detection (cad) when performed; unilateral",401,250.63,213.04,Pays at 85% of Billed charges for outpatient setting,80.58,Pays at 32.15% of Total Billed charges,200.58,Pays at 80.03% of Total Billed charges,79.83,Pays at 102% of Medicare OPPS Rate,225.57,Pays at 90% of Total Billed charges,80.58,Pays at 32.15% of Total Billed charges,78.26,Pays at 100% of Medicare OPPS Rate,80.58,Pays at 32.15% of Total Billed charges,220.55,Pays at 88% of Total Billed charges,82.98,Pays at 33.11% of Total Billed charges,78.26,225.57,150.38
Outpatient Medical Services,RADIOLOGY,77065,"Diagnostic mammography, including computer-aided detection (cad) when performed; unilateral",401,324,275.4,Pays at 85% of Billed charges for outpatient setting,104.17,Pays at 32.15% of Total Billed charges,259.3,Pays at 80.03% of Total Billed charges,79.83,Pays at 102% of Medicare OPPS Rate,291.6,Pays at 90% of Total Billed charges,104.17,Pays at 32.15% of Total Billed charges,78.26,Pays at 100% of Medicare OPPS Rate,104.17,Pays at 32.15% of Total Billed charges,285.12,Pays at 88% of Total Billed charges,107.28,Pays at 33.11% of Total Billed charges,78.26,291.6,194.40
Outpatient Medical Services,RADIOLOGY,77066,"Diagnostic mammography, including computer-aided detection (cad) when performed; bilateral",401,97.25,82.66,Pays at 85% of Billed charges for outpatient setting,31.27,Pays at 32.15% of Total Billed charges,77.83,Pays at 80.03% of Total Billed charges,99.2,Pays at 102% of Medicare OPPS Rate,87.53,Pays at 90% of Total Billed charges,31.27,Pays at 32.15% of Total Billed charges,97.25,Pays at 100% of Medicare OPPS Rate,31.27,Pays at 32.15% of Total Billed charges,85.58,Pays at 88% of Total Billed charges,32.2,Pays at 33.11% of Total Billed charges,31.27,99.2,58.35
Outpatient Medical Services,RADIOLOGY,77066,"Diagnostic mammography, including computer-aided detection (cad) when performed; bilateral",401,97.25,82.66,Pays at 85% of Billed charges for outpatient setting,31.27,Pays at 32.15% of Total Billed charges,77.83,Pays at 80.03% of Total Billed charges,99.2,Pays at 102% of Medicare OPPS Rate,87.53,Pays at 90% of Total Billed charges,31.27,Pays at 32.15% of Total Billed charges,97.25,Pays at 100% of Medicare OPPS Rate,31.27,Pays at 32.15% of Total Billed charges,85.58,Pays at 88% of Total Billed charges,32.2,Pays at 33.11% of Total Billed charges,31.27,99.2,58.35
Outpatient Medical Services,RADIOLOGY,77066,"Diagnostic mammography, including computer-aided detection (cad) when performed; bilateral",401,288,244.8,Pays at 85% of Billed charges for outpatient setting,92.59,Pays at 32.15% of Total Billed charges,230.49,Pays at 80.03% of Total Billed charges,101.75,Pays at 102% of Medicare OPPS Rate,259.2,Pays at 90% of Total Billed charges,92.59,Pays at 32.15% of Total Billed charges,99.75,Pays at 100% of Medicare OPPS Rate,92.59,Pays at 32.15% of Total Billed charges,253.44,Pays at 88% of Total Billed charges,95.36,Pays at 33.11% of Total Billed charges,92.59,259.2,172.80
Outpatient Medical Services,RADIOLOGY,77066,"Diagnostic mammography, including computer-aided detection (cad) when performed; bilateral",401,240,204,Pays at 85% of Billed charges for outpatient setting,77.16,Pays at 32.15% of Total Billed charges,192.07,Pays at 80.03% of Total Billed charges,101.75,Pays at 102% of Medicare OPPS Rate,216,Pays at 90% of Total Billed charges,77.16,Pays at 32.15% of Total Billed charges,99.75,Pays at 100% of Medicare OPPS Rate,77.16,Pays at 32.15% of Total Billed charges,211.2,Pays at 88% of Total Billed charges,79.46,Pays at 33.11% of Total Billed charges,77.16,216,144.00
Outpatient Medical Services,RADIOLOGY,G0279,MM ADD ON 3D  DIAG DIG TOM UNI/BIL,401,93.75,79.69,Pays at 85% of Billed charges for outpatient setting,30.14,Pays at 32.15% of Total Billed charges,75.03,Pays at 80.03% of Total Billed charges,21.92,Pays at 102% of Medicare OPPS Rate,84.38,Pays at 90% of Total Billed charges,30.14,Pays at 32.15% of Total Billed charges,21.49,Pays at 100% of Medicare OPPS Rate,30.14,Pays at 32.15% of Total Billed charges,82.5,Pays at 88% of Total Billed charges,31.04,Pays at 33.11% of Total Billed charges,21.49,84.38,56.25
Outpatient Medical Services,RADIOLOGY,50200,US RENAL BX,402,3488,2964.8,Pays at 85% of Billed charges for outpatient setting,1121.39,Pays at 32.15% of Total Billed charges,2791.45,Pays at 80.03% of Total Billed charges,1437.62,Pays at 102% of Medicare OPPS Rate,3139.2,Pays at 90% of Total Billed charges,1121.39,Pays at 32.15% of Total Billed charges,1409.43,Pays at 100% of Medicare OPPS Rate,1121.39,Pays at 32.15% of Total Billed charges,3069.44,Pays at 88% of Total Billed charges,1154.88,Pays at 33.11% of Total Billed charges,1121.39,3139.2,2092.80
Outpatient Medical Services,RADIOLOGY,76499,US EMERGENCY CHARGE,402,209.75,178.29,Pays at 85% of Billed charges for outpatient setting,67.43,Pays at 32.15% of Total Billed charges,167.86,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,188.78,Pays at 90% of Total Billed charges,67.43,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,67.43,Pays at 32.15% of Total Billed charges,184.58,Pays at 88% of Total Billed charges,69.45,Pays at 33.11% of Total Billed charges,67.43,188.78,125.85
Outpatient Medical Services,RADIOLOGY,76536,Ultrasound of head and neck,402,776.75,660.24,Pays at 85% of Billed charges for outpatient setting,249.73,Pays at 32.15% of Total Billed charges,621.63,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,699.08,Pays at 90% of Total Billed charges,249.73,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,249.73,Pays at 32.15% of Total Billed charges,683.54,Pays at 88% of Total Billed charges,257.18,Pays at 33.11% of Total Billed charges,100.45,699.08,466.05
Outpatient Medical Services,RADIOLOGY,76604,(E) US THORAX AND FLEURA,402,846.25,719.31,Pays at 85% of Billed charges for outpatient setting,272.07,Pays at 32.15% of Total Billed charges,677.25,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,761.63,Pays at 90% of Total Billed charges,272.07,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,272.07,Pays at 32.15% of Total Billed charges,744.7,Pays at 88% of Total Billed charges,280.19,Pays at 33.11% of Total Billed charges,100.45,761.63,507.75
Outpatient Medical Services,RADIOLOGY,76641,(E) US BREAST ECHOGRAPHY,402,547.75,465.59,Pays at 85% of Billed charges for outpatient setting,176.1,Pays at 32.15% of Total Billed charges,438.36,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,492.98,Pays at 90% of Total Billed charges,176.1,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,176.1,Pays at 32.15% of Total Billed charges,482.02,Pays at 88% of Total Billed charges,181.36,Pays at 33.11% of Total Billed charges,100.45,492.98,328.65
Outpatient Medical Services,RADIOLOGY,76700,Ultrasound of abdomen with all areas scanned,402,577.5,490.88,Pays at 85% of Billed charges for outpatient setting,185.67,Pays at 32.15% of Total Billed charges,462.17,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,519.75,Pays at 90% of Total Billed charges,185.67,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,185.67,Pays at 32.15% of Total Billed charges,508.2,Pays at 88% of Total Billed charges,191.21,Pays at 33.11% of Total Billed charges,100.44,519.75,346.50
Outpatient Medical Services,RADIOLOGY,76700,Ultrasound of abdomen with all areas scanned,402,866.25,736.31,Pays at 85% of Billed charges for outpatient setting,278.5,Pays at 32.15% of Total Billed charges,693.26,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,779.63,Pays at 90% of Total Billed charges,278.5,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,278.5,Pays at 32.15% of Total Billed charges,762.3,Pays at 88% of Total Billed charges,286.82,Pays at 33.11% of Total Billed charges,100.44,779.63,519.75
Outpatient Medical Services,RADIOLOGY,76705,A diagnostic procedure that allows a provider to see the organs and other structures in the abdomen,402,544.85,463.12,Pays at 85% of Billed charges for outpatient setting,175.17,Pays at 32.15% of Total Billed charges,436.04,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,490.37,Pays at 90% of Total Billed charges,175.17,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,175.17,Pays at 32.15% of Total Billed charges,479.47,Pays at 88% of Total Billed charges,180.4,Pays at 33.11% of Total Billed charges,100.44,490.37,326.91
Outpatient Medical Services,RADIOLOGY,76705,A diagnostic procedure that allows a provider to see the organs and other structures in the abdomen,402,787.5,669.38,Pays at 85% of Billed charges for outpatient setting,253.18,Pays at 32.15% of Total Billed charges,630.24,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,708.75,Pays at 90% of Total Billed charges,253.18,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,253.18,Pays at 32.15% of Total Billed charges,693,Pays at 88% of Total Billed charges,260.74,Pays at 33.11% of Total Billed charges,100.44,708.75,472.50
Outpatient Medical Services,RADIOLOGY,76705,A diagnostic procedure that allows a provider to see the organs and other structures in the abdomen,402,856.5,728.03,Pays at 85% of Billed charges for outpatient setting,275.36,Pays at 32.15% of Total Billed charges,685.46,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,770.85,Pays at 90% of Total Billed charges,275.36,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,275.36,Pays at 32.15% of Total Billed charges,753.72,Pays at 88% of Total Billed charges,283.59,Pays at 33.11% of Total Billed charges,100.44,770.85,513.90
Outpatient Medical Services,RADIOLOGY,76705,A diagnostic procedure that allows a provider to see the organs and other structures in the abdomen,402,825.75,701.89,Pays at 85% of Billed charges for outpatient setting,265.48,Pays at 32.15% of Total Billed charges,660.85,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,743.18,Pays at 90% of Total Billed charges,265.48,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,265.48,Pays at 32.15% of Total Billed charges,726.66,Pays at 88% of Total Billed charges,273.41,Pays at 33.11% of Total Billed charges,100.44,743.18,495.45
Outpatient Medical Services,RADIOLOGY,76705,A diagnostic procedure that allows a provider to see the organs and other structures in the abdomen,402,846.25,719.31,Pays at 85% of Billed charges for outpatient setting,272.07,Pays at 32.15% of Total Billed charges,677.25,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,761.63,Pays at 90% of Total Billed charges,272.07,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,272.07,Pays at 32.15% of Total Billed charges,744.7,Pays at 88% of Total Billed charges,280.19,Pays at 33.11% of Total Billed charges,100.44,761.63,507.75
Outpatient Medical Services,RADIOLOGY,76705,A diagnostic procedure that allows a provider to see the organs and other structures in the abdomen,402,488.5,415.23,Pays at 85% of Billed charges for outpatient setting,157.05,Pays at 32.15% of Total Billed charges,390.95,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,439.65,Pays at 90% of Total Billed charges,157.05,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,157.05,Pays at 32.15% of Total Billed charges,429.88,Pays at 88% of Total Billed charges,161.74,Pays at 33.11% of Total Billed charges,100.44,439.65,293.10
Outpatient Medical Services,RADIOLOGY,76770,Ultrasound of back wall of the abdomen with all areas viewed,402,956,812.6,Pays at 85% of Billed charges for outpatient setting,307.35,Pays at 32.15% of Total Billed charges,765.09,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,860.4,Pays at 90% of Total Billed charges,307.35,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,307.35,Pays at 32.15% of Total Billed charges,841.28,Pays at 88% of Total Billed charges,316.53,Pays at 33.11% of Total Billed charges,100.44,860.4,573.60
Outpatient Medical Services,RADIOLOGY,76775,Ultrasound of back wall of the abdomen with limited areas viewed,402,846.25,719.31,Pays at 85% of Billed charges for outpatient setting,272.07,Pays at 32.15% of Total Billed charges,677.25,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,761.63,Pays at 90% of Total Billed charges,272.07,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,272.07,Pays at 32.15% of Total Billed charges,744.7,Pays at 88% of Total Billed charges,280.19,Pays at 33.11% of Total Billed charges,100.45,761.63,507.75
Outpatient Medical Services,RADIOLOGY,76775,Ultrasound of back wall of the abdomen with limited areas viewed,402,806.75,685.74,Pays at 85% of Billed charges for outpatient setting,259.37,Pays at 32.15% of Total Billed charges,645.64,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,726.08,Pays at 90% of Total Billed charges,259.37,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,259.37,Pays at 32.15% of Total Billed charges,709.94,Pays at 88% of Total Billed charges,267.11,Pays at 33.11% of Total Billed charges,100.45,726.08,484.05
Outpatient Medical Services,RADIOLOGY,76775,Ultrasound of back wall of the abdomen with limited areas viewed,402,846.25,719.31,Pays at 85% of Billed charges for outpatient setting,272.07,Pays at 32.15% of Total Billed charges,677.25,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,761.63,Pays at 90% of Total Billed charges,272.07,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,272.07,Pays at 32.15% of Total Billed charges,744.7,Pays at 88% of Total Billed charges,280.19,Pays at 33.11% of Total Billed charges,100.45,761.63,507.75
Outpatient Medical Services,RADIOLOGY,76805,Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus,402,956,812.6,Pays at 85% of Billed charges for outpatient setting,307.35,Pays at 32.15% of Total Billed charges,765.09,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,860.4,Pays at 90% of Total Billed charges,307.35,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,307.35,Pays at 32.15% of Total Billed charges,841.28,Pays at 88% of Total Billed charges,316.53,Pays at 33.11% of Total Billed charges,100.44,860.4,573.60
Outpatient Medical Services,RADIOLOGY,76810,(E) US OB MULT GEST,402,1911,1624.35,Pays at 85% of Billed charges for outpatient setting,614.39,Pays at 32.15% of Total Billed charges,1529.37,Pays at 80.03% of Total Billed charges,1911,Not Applicable,1719.9,Pays at 90% of Total Billed charges,614.39,Pays at 32.15% of Total Billed charges,1911,Not Applicable,614.39,Pays at 32.15% of Total Billed charges,1681.68,Pays at 88% of Total Billed charges,632.73,Pays at 33.11% of Total Billed charges,614.39,1911,1146.60
Outpatient Medical Services,RADIOLOGY,76815,Ultrasound of fetus with limited views,402,279.25,237.36,Pays at 85% of Billed charges for outpatient setting,89.78,Pays at 32.15% of Total Billed charges,223.48,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,251.33,Pays at 90% of Total Billed charges,89.78,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,89.78,Pays at 32.15% of Total Billed charges,245.74,Pays at 88% of Total Billed charges,92.46,Pays at 33.11% of Total Billed charges,89.78,251.33,167.55
Outpatient Medical Services,RADIOLOGY,76815,Ultrasound of fetus with limited views,402,627.5,533.38,Pays at 85% of Billed charges for outpatient setting,201.74,Pays at 32.15% of Total Billed charges,502.19,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,564.75,Pays at 90% of Total Billed charges,201.74,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,201.74,Pays at 32.15% of Total Billed charges,552.2,Pays at 88% of Total Billed charges,207.77,Pays at 33.11% of Total Billed charges,100.45,564.75,376.50
Outpatient Medical Services,RADIOLOGY,76815,Ultrasound of fetus with limited views,402,296,251.6,Pays at 85% of Billed charges for outpatient setting,95.16,Pays at 32.15% of Total Billed charges,236.89,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,266.4,Pays at 90% of Total Billed charges,95.16,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,95.16,Pays at 32.15% of Total Billed charges,260.48,Pays at 88% of Total Billed charges,98.01,Pays at 33.11% of Total Billed charges,95.16,266.4,177.60
Outpatient Medical Services,RADIOLOGY,76817,Transvaginal ultrasound of uterus,402,627.5,533.38,Pays at 85% of Billed charges for outpatient setting,201.74,Pays at 32.15% of Total Billed charges,502.19,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,564.75,Pays at 90% of Total Billed charges,201.74,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,201.74,Pays at 32.15% of Total Billed charges,552.2,Pays at 88% of Total Billed charges,207.77,Pays at 33.11% of Total Billed charges,100.45,564.75,376.50
Outpatient Medical Services,RADIOLOGY,76830,Ultrasound of the pelvis through vagina,402,537.5,456.88,Pays at 85% of Billed charges for outpatient setting,172.81,Pays at 32.15% of Total Billed charges,430.16,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,483.75,Pays at 90% of Total Billed charges,172.81,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,172.81,Pays at 32.15% of Total Billed charges,473,Pays at 88% of Total Billed charges,177.97,Pays at 33.11% of Total Billed charges,100.44,483.75,322.50
Outpatient Medical Services,RADIOLOGY,76830,Ultrasound of the pelvis through vagina,402,577.5,490.88,Pays at 85% of Billed charges for outpatient setting,185.67,Pays at 32.15% of Total Billed charges,462.17,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,519.75,Pays at 90% of Total Billed charges,185.67,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,185.67,Pays at 32.15% of Total Billed charges,508.2,Pays at 88% of Total Billed charges,191.21,Pays at 33.11% of Total Billed charges,100.44,519.75,346.50
Outpatient Medical Services,RADIOLOGY,76856,Complete ultrasound of the pelvis,402,956,812.6,Pays at 85% of Billed charges for outpatient setting,307.35,Pays at 32.15% of Total Billed charges,765.09,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,860.4,Pays at 90% of Total Billed charges,307.35,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,307.35,Pays at 32.15% of Total Billed charges,841.28,Pays at 88% of Total Billed charges,316.53,Pays at 33.11% of Total Billed charges,100.44,860.4,573.60
Outpatient Medical Services,RADIOLOGY,76857,Limited ultrasound of the pelvis,402,279.25,237.36,Pays at 85% of Billed charges for outpatient setting,89.78,Pays at 32.15% of Total Billed charges,223.48,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,251.33,Pays at 90% of Total Billed charges,89.78,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,89.78,Pays at 32.15% of Total Billed charges,245.74,Pays at 88% of Total Billed charges,92.46,Pays at 33.11% of Total Billed charges,89.78,251.33,167.55
Outpatient Medical Services,RADIOLOGY,76857,Limited ultrasound of the pelvis,402,627.5,533.38,Pays at 85% of Billed charges for outpatient setting,201.74,Pays at 32.15% of Total Billed charges,502.19,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,564.75,Pays at 90% of Total Billed charges,201.74,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,201.74,Pays at 32.15% of Total Billed charges,552.2,Pays at 88% of Total Billed charges,207.77,Pays at 33.11% of Total Billed charges,100.44,564.75,376.50
Outpatient Medical Services,RADIOLOGY,76870,Ultrasound of the scrotum,402,846.25,719.31,Pays at 85% of Billed charges for outpatient setting,272.07,Pays at 32.15% of Total Billed charges,677.25,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,761.63,Pays at 90% of Total Billed charges,272.07,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,272.07,Pays at 32.15% of Total Billed charges,744.7,Pays at 88% of Total Billed charges,280.19,Pays at 33.11% of Total Billed charges,100.45,761.63,507.75
Outpatient Medical Services,RADIOLOGY,76881,(E) US EXT NON-VASCULAR,402,736.75,626.24,Pays at 85% of Billed charges for outpatient setting,236.87,Pays at 32.15% of Total Billed charges,589.62,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,663.08,Pays at 90% of Total Billed charges,236.87,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,236.87,Pays at 32.15% of Total Billed charges,648.34,Pays at 88% of Total Billed charges,243.94,Pays at 33.11% of Total Billed charges,100.44,663.08,442.05
Outpatient Medical Services,RADIOLOGY,76882,"Diagnostic ultrasound of an extremity excluding the bone, joints or vessels",402,846.25,719.31,Pays at 85% of Billed charges for outpatient setting,272.07,Pays at 32.15% of Total Billed charges,677.25,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,761.63,Pays at 90% of Total Billed charges,272.07,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,272.07,Pays at 32.15% of Total Billed charges,744.7,Pays at 88% of Total Billed charges,280.19,Pays at 33.11% of Total Billed charges,100.45,761.63,507.75
Outpatient Medical Services,RADIOLOGY,76942,PORT US CHEST FOR FLUID,402,557.5,473.88,Pays at 85% of Billed charges for outpatient setting,179.24,Pays at 32.15% of Total Billed charges,446.17,Pays at 80.03% of Total Billed charges,557.5,Not Applicable,501.75,Pays at 90% of Total Billed charges,179.24,Pays at 32.15% of Total Billed charges,557.5,Not Applicable,179.24,Pays at 32.15% of Total Billed charges,490.6,Pays at 88% of Total Billed charges,184.59,Pays at 33.11% of Total Billed charges,179.24,557.5,334.50
Outpatient Medical Services,RADIOLOGY,76942,PORT US CYST ASPIRATION,402,557.5,473.88,Pays at 85% of Billed charges for outpatient setting,179.24,Pays at 32.15% of Total Billed charges,446.17,Pays at 80.03% of Total Billed charges,557.5,Not Applicable,501.75,Pays at 90% of Total Billed charges,179.24,Pays at 32.15% of Total Billed charges,557.5,Not Applicable,179.24,Pays at 32.15% of Total Billed charges,490.6,Pays at 88% of Total Billed charges,184.59,Pays at 33.11% of Total Billed charges,179.24,557.5,334.50
Outpatient Medical Services,RADIOLOGY,76942,PORT US NEEDLE BX,402,557.5,473.88,Pays at 85% of Billed charges for outpatient setting,179.24,Pays at 32.15% of Total Billed charges,446.17,Pays at 80.03% of Total Billed charges,557.5,Not Applicable,501.75,Pays at 90% of Total Billed charges,179.24,Pays at 32.15% of Total Billed charges,557.5,Not Applicable,179.24,Pays at 32.15% of Total Billed charges,490.6,Pays at 88% of Total Billed charges,184.59,Pays at 33.11% of Total Billed charges,179.24,557.5,334.50
Outpatient Medical Services,RADIOLOGY,76942,(E) US CYST ASPIRATION,402,846.25,719.31,Pays at 85% of Billed charges for outpatient setting,272.07,Pays at 32.15% of Total Billed charges,677.25,Pays at 80.03% of Total Billed charges,846.25,Not Applicable,761.63,Pays at 90% of Total Billed charges,272.07,Pays at 32.15% of Total Billed charges,846.25,Not Applicable,272.07,Pays at 32.15% of Total Billed charges,744.7,Pays at 88% of Total Billed charges,280.19,Pays at 33.11% of Total Billed charges,272.07,846.25,507.75
Outpatient Medical Services,RADIOLOGY,76942,(E) US NEEDLE BX,402,846.25,719.31,Pays at 85% of Billed charges for outpatient setting,272.07,Pays at 32.15% of Total Billed charges,677.25,Pays at 80.03% of Total Billed charges,846.25,Not Applicable,761.63,Pays at 90% of Total Billed charges,272.07,Pays at 32.15% of Total Billed charges,846.25,Not Applicable,272.07,Pays at 32.15% of Total Billed charges,744.7,Pays at 88% of Total Billed charges,280.19,Pays at 33.11% of Total Billed charges,272.07,846.25,507.75
Outpatient Medical Services,RADIOLOGY,76946,(E) AMNIOCENTESIS,402,746.25,634.31,Pays at 85% of Billed charges for outpatient setting,239.92,Pays at 32.15% of Total Billed charges,597.22,Pays at 80.03% of Total Billed charges,746.25,Not Applicable,671.63,Pays at 90% of Total Billed charges,239.92,Pays at 32.15% of Total Billed charges,746.25,Not Applicable,239.92,Pays at 32.15% of Total Billed charges,656.7,Pays at 88% of Total Billed charges,247.08,Pays at 33.11% of Total Billed charges,239.92,746.25,447.75
Outpatient Medical Services,RADIOLOGY,93308,US LIMITED ECHO,402,305.25,259.46,Pays at 85% of Billed charges for outpatient setting,98.14,Pays at 32.15% of Total Billed charges,244.29,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,274.73,Pays at 90% of Total Billed charges,98.14,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,98.14,Pays at 32.15% of Total Billed charges,268.62,Pays at 88% of Total Billed charges,101.07,Pays at 33.11% of Total Billed charges,98.14,274.73,183.15
Outpatient Medical Services,RADIOLOGY,10005,"Fine needle aspiration biopsy, including ultrasound guidance; first lesion",402,1482,1259.7,Pays at 85% of Billed charges for outpatient setting,476.46,Pays at 32.15% of Total Billed charges,1186.04,Pays at 80.03% of Total Billed charges,622.15,Pays at 102% of Medicare OPPS Rate,1333.8,Pays at 90% of Total Billed charges,476.46,Pays at 32.15% of Total Billed charges,609.96,Pays at 100% of Medicare OPPS Rate,476.46,Pays at 32.15% of Total Billed charges,1304.16,Pays at 88% of Total Billed charges,490.69,Pays at 33.11% of Total Billed charges,476.46,1333.8,889.20
Outpatient Medical Services,RADIOLOGY,10006,US FINE NEEDLE ASPIRATION EA ADD LESION,402,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,414,Not Applicable,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,414,Not Applicable,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,414,248.40
Outpatient Medical Services,RADIOLOGY,10022,US THYROID BIOPSY,402,1482,1259.7,Pays at 85% of Billed charges for outpatient setting,476.46,Pays at 32.15% of Total Billed charges,1186.04,Pays at 80.03% of Total Billed charges,1482,Not Applicable,1333.8,Pays at 90% of Total Billed charges,476.46,Pays at 32.15% of Total Billed charges,1482,Not Applicable,476.46,Pays at 32.15% of Total Billed charges,1304.16,Pays at 88% of Total Billed charges,490.69,Pays at 33.11% of Total Billed charges,476.46,1482,889.20
Outpatient Medical Services,RADIOLOGY,10022,US ASPIRATION OF THYROID,402,207.25,176.16,Pays at 85% of Billed charges for outpatient setting,66.63,Pays at 32.15% of Total Billed charges,165.86,Pays at 80.03% of Total Billed charges,207.25,Not Applicable,186.53,Pays at 90% of Total Billed charges,66.63,Pays at 32.15% of Total Billed charges,207.25,Not Applicable,66.63,Pays at 32.15% of Total Billed charges,182.38,Pays at 88% of Total Billed charges,68.62,Pays at 33.11% of Total Billed charges,66.63,207.25,124.35
Outpatient Medical Services,RADIOLOGY,60300,US ASPIRATION OF THYROID,402,339.5,288.58,Pays at 85% of Billed charges for outpatient setting,109.15,Pays at 32.15% of Total Billed charges,271.7,Pays at 80.03% of Total Billed charges,622.15,Pays at 102% of Medicare OPPS Rate,305.55,Pays at 90% of Total Billed charges,109.15,Pays at 32.15% of Total Billed charges,609.96,Pays at 100% of Medicare OPPS Rate,109.15,Pays at 32.15% of Total Billed charges,298.76,Pays at 88% of Total Billed charges,112.41,Pays at 33.11% of Total Billed charges,109.15,622.15,203.70
Outpatient Medical Services,RADIOLOGY,76536,Ultrasound of head and neck,402,522.5,444.13,Pays at 85% of Billed charges for outpatient setting,167.98,Pays at 32.15% of Total Billed charges,418.16,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,470.25,Pays at 90% of Total Billed charges,167.98,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,167.98,Pays at 32.15% of Total Billed charges,459.8,Pays at 88% of Total Billed charges,173,Pays at 33.11% of Total Billed charges,100.45,470.25,313.50
Outpatient Medical Services,RADIOLOGY,76536,Ultrasound of head and neck,402,488.5,415.23,Pays at 85% of Billed charges for outpatient setting,157.05,Pays at 32.15% of Total Billed charges,390.95,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,439.65,Pays at 90% of Total Billed charges,157.05,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,157.05,Pays at 32.15% of Total Billed charges,429.88,Pays at 88% of Total Billed charges,161.74,Pays at 33.11% of Total Billed charges,100.45,439.65,293.10
Outpatient Medical Services,RADIOLOGY,76536,Ultrasound of head and neck,402,296,251.6,Pays at 85% of Billed charges for outpatient setting,95.16,Pays at 32.15% of Total Billed charges,236.89,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,266.4,Pays at 90% of Total Billed charges,95.16,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,95.16,Pays at 32.15% of Total Billed charges,260.48,Pays at 88% of Total Billed charges,98.01,Pays at 33.11% of Total Billed charges,95.16,266.4,177.60
Outpatient Medical Services,RADIOLOGY,76604,US THORAX AND PLEURA,402,488.5,415.23,Pays at 85% of Billed charges for outpatient setting,157.05,Pays at 32.15% of Total Billed charges,390.95,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,439.65,Pays at 90% of Total Billed charges,157.05,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,157.05,Pays at 32.15% of Total Billed charges,429.88,Pays at 88% of Total Billed charges,161.74,Pays at 33.11% of Total Billed charges,100.45,439.65,293.10
Outpatient Medical Services,RADIOLOGY,76604,PORT US THORAX AND PLEURA,402,557.5,473.88,Pays at 85% of Billed charges for outpatient setting,179.24,Pays at 32.15% of Total Billed charges,446.17,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,501.75,Pays at 90% of Total Billed charges,179.24,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,179.24,Pays at 32.15% of Total Billed charges,490.6,Pays at 88% of Total Billed charges,184.59,Pays at 33.11% of Total Billed charges,100.45,501.75,334.50
Outpatient Medical Services,RADIOLOGY,76604,US CHEST WALL,402,726.75,617.74,Pays at 85% of Billed charges for outpatient setting,233.65,Pays at 32.15% of Total Billed charges,581.62,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,654.08,Pays at 90% of Total Billed charges,233.65,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,233.65,Pays at 32.15% of Total Billed charges,639.54,Pays at 88% of Total Billed charges,240.63,Pays at 33.11% of Total Billed charges,100.45,654.08,436.05
Outpatient Medical Services,RADIOLOGY,76641,US BREAST BILATERAL,402,681,578.85,Pays at 85% of Billed charges for outpatient setting,218.94,Pays at 32.15% of Total Billed charges,545,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,612.9,Pays at 90% of Total Billed charges,218.94,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,218.94,Pays at 32.15% of Total Billed charges,599.28,Pays at 88% of Total Billed charges,225.48,Pays at 33.11% of Total Billed charges,100.45,612.9,408.60
Outpatient Medical Services,RADIOLOGY,76641,US BREAST COMPLETE BILATERAL,402,474,402.9,Pays at 85% of Billed charges for outpatient setting,152.39,Pays at 32.15% of Total Billed charges,379.34,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,426.6,Pays at 90% of Total Billed charges,152.39,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,152.39,Pays at 32.15% of Total Billed charges,417.12,Pays at 88% of Total Billed charges,156.94,Pays at 33.11% of Total Billed charges,100.45,426.6,284.40
Outpatient Medical Services,RADIOLOGY,76641,US BREAST UNILATERAL LT,402,443.75,377.19,Pays at 85% of Billed charges for outpatient setting,142.67,Pays at 32.15% of Total Billed charges,355.13,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,399.38,Pays at 90% of Total Billed charges,142.67,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,142.67,Pays at 32.15% of Total Billed charges,390.5,Pays at 88% of Total Billed charges,146.93,Pays at 33.11% of Total Billed charges,100.45,399.38,266.25
Outpatient Medical Services,RADIOLOGY,76641,US BREAST UNILATERAL COMPLETE LT,402,296,251.6,Pays at 85% of Billed charges for outpatient setting,95.16,Pays at 32.15% of Total Billed charges,236.89,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,266.4,Pays at 90% of Total Billed charges,95.16,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,95.16,Pays at 32.15% of Total Billed charges,260.48,Pays at 88% of Total Billed charges,98.01,Pays at 33.11% of Total Billed charges,95.16,266.4,177.60
Outpatient Medical Services,RADIOLOGY,76641,US BREAST UNILATERAL COMPLETE RT,402,296,251.6,Pays at 85% of Billed charges for outpatient setting,95.16,Pays at 32.15% of Total Billed charges,236.89,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,266.4,Pays at 90% of Total Billed charges,95.16,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,95.16,Pays at 32.15% of Total Billed charges,260.48,Pays at 88% of Total Billed charges,98.01,Pays at 33.11% of Total Billed charges,95.16,266.4,177.60
Outpatient Medical Services,RADIOLOGY,76641,US BREAST UNILATERAL RT,402,443.75,377.19,Pays at 85% of Billed charges for outpatient setting,142.67,Pays at 32.15% of Total Billed charges,355.13,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,399.38,Pays at 90% of Total Billed charges,142.67,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,142.67,Pays at 32.15% of Total Billed charges,390.5,Pays at 88% of Total Billed charges,146.93,Pays at 33.11% of Total Billed charges,100.45,399.38,266.25
Outpatient Medical Services,RADIOLOGY,76641,PORT US BREAST ECHOGRAPHY UNIL,402,258.5,219.73,Pays at 85% of Billed charges for outpatient setting,83.11,Pays at 32.15% of Total Billed charges,206.88,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,232.65,Pays at 90% of Total Billed charges,83.11,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,83.11,Pays at 32.15% of Total Billed charges,227.48,Pays at 88% of Total Billed charges,85.59,Pays at 33.11% of Total Billed charges,83.11,232.65,155.10
Outpatient Medical Services,RADIOLOGY,76700,Ultrasound of abdomen with all areas scanned,402,544.85,463.12,Pays at 85% of Billed charges for outpatient setting,175.17,Pays at 32.15% of Total Billed charges,436.04,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,490.37,Pays at 90% of Total Billed charges,175.17,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,175.17,Pays at 32.15% of Total Billed charges,479.47,Pays at 88% of Total Billed charges,180.4,Pays at 33.11% of Total Billed charges,100.44,490.37,326.91
Outpatient Medical Services,RADIOLOGY,76700,Ultrasound of abdomen with all areas scanned,402,296,251.6,Pays at 85% of Billed charges for outpatient setting,95.16,Pays at 32.15% of Total Billed charges,236.89,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,266.4,Pays at 90% of Total Billed charges,95.16,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,95.16,Pays at 32.15% of Total Billed charges,260.48,Pays at 88% of Total Billed charges,98.01,Pays at 33.11% of Total Billed charges,95.16,266.4,177.60
Outpatient Medical Services,RADIOLOGY,76705,A diagnostic procedure that allows a provider to see the organs and other structures in the abdomen,402,427.5,363.38,Pays at 85% of Billed charges for outpatient setting,137.44,Pays at 32.15% of Total Billed charges,342.13,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,384.75,Pays at 90% of Total Billed charges,137.44,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,137.44,Pays at 32.15% of Total Billed charges,376.2,Pays at 88% of Total Billed charges,141.55,Pays at 33.11% of Total Billed charges,100.44,384.75,256.50
Outpatient Medical Services,RADIOLOGY,76705,A diagnostic procedure that allows a provider to see the organs and other structures in the abdomen,402,508,431.8,Pays at 85% of Billed charges for outpatient setting,163.32,Pays at 32.15% of Total Billed charges,406.55,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,457.2,Pays at 90% of Total Billed charges,163.32,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,163.32,Pays at 32.15% of Total Billed charges,447.04,Pays at 88% of Total Billed charges,168.2,Pays at 33.11% of Total Billed charges,100.44,457.2,304.80
Outpatient Medical Services,RADIOLOGY,76705,A diagnostic procedure that allows a provider to see the organs and other structures in the abdomen,402,478.75,406.94,Pays at 85% of Billed charges for outpatient setting,153.92,Pays at 32.15% of Total Billed charges,383.14,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,430.88,Pays at 90% of Total Billed charges,153.92,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,153.92,Pays at 32.15% of Total Billed charges,421.3,Pays at 88% of Total Billed charges,158.51,Pays at 33.11% of Total Billed charges,100.44,430.88,287.25
Outpatient Medical Services,RADIOLOGY,76705,A diagnostic procedure that allows a provider to see the organs and other structures in the abdomen,402,557.5,473.88,Pays at 85% of Billed charges for outpatient setting,179.24,Pays at 32.15% of Total Billed charges,446.17,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,501.75,Pays at 90% of Total Billed charges,179.24,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,179.24,Pays at 32.15% of Total Billed charges,490.6,Pays at 88% of Total Billed charges,184.59,Pays at 33.11% of Total Billed charges,100.44,501.75,334.50
Outpatient Medical Services,RADIOLOGY,76705,A diagnostic procedure that allows a provider to see the organs and other structures in the abdomen,402,537.5,456.88,Pays at 85% of Billed charges for outpatient setting,172.81,Pays at 32.15% of Total Billed charges,430.16,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,483.75,Pays at 90% of Total Billed charges,172.81,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,172.81,Pays at 32.15% of Total Billed charges,473,Pays at 88% of Total Billed charges,177.97,Pays at 33.11% of Total Billed charges,100.44,483.75,322.50
Outpatient Medical Services,RADIOLOGY,76705,A diagnostic procedure that allows a provider to see the organs and other structures in the abdomen,402,547.75,465.59,Pays at 85% of Billed charges for outpatient setting,176.1,Pays at 32.15% of Total Billed charges,438.36,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,492.98,Pays at 90% of Total Billed charges,176.1,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,176.1,Pays at 32.15% of Total Billed charges,482.02,Pays at 88% of Total Billed charges,181.36,Pays at 33.11% of Total Billed charges,100.44,492.98,328.65
Outpatient Medical Services,RADIOLOGY,76705,A diagnostic procedure that allows a provider to see the organs and other structures in the abdomen,402,498,423.3,Pays at 85% of Billed charges for outpatient setting,160.11,Pays at 32.15% of Total Billed charges,398.55,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,448.2,Pays at 90% of Total Billed charges,160.11,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,160.11,Pays at 32.15% of Total Billed charges,438.24,Pays at 88% of Total Billed charges,164.89,Pays at 33.11% of Total Billed charges,100.44,448.2,298.80
Outpatient Medical Services,RADIOLOGY,76705,A diagnostic procedure that allows a provider to see the organs and other structures in the abdomen,402,296,251.6,Pays at 85% of Billed charges for outpatient setting,95.16,Pays at 32.15% of Total Billed charges,236.89,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,266.4,Pays at 90% of Total Billed charges,95.16,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,95.16,Pays at 32.15% of Total Billed charges,260.48,Pays at 88% of Total Billed charges,98.01,Pays at 33.11% of Total Billed charges,95.16,266.4,177.60
Outpatient Medical Services,RADIOLOGY,76705,A diagnostic procedure that allows a provider to see the organs and other structures in the abdomen,402,726.75,617.74,Pays at 85% of Billed charges for outpatient setting,233.65,Pays at 32.15% of Total Billed charges,581.62,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,654.08,Pays at 90% of Total Billed charges,233.65,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,233.65,Pays at 32.15% of Total Billed charges,639.54,Pays at 88% of Total Billed charges,240.63,Pays at 33.11% of Total Billed charges,100.44,654.08,436.05
Outpatient Medical Services,RADIOLOGY,76706,US ABDOMINAL AORTIC ANEURYSM SCREENING,402,518.25,440.51,Pays at 85% of Billed charges for outpatient setting,166.62,Pays at 32.15% of Total Billed charges,414.76,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,466.43,Pays at 90% of Total Billed charges,166.62,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,166.62,Pays at 32.15% of Total Billed charges,456.06,Pays at 88% of Total Billed charges,171.59,Pays at 33.11% of Total Billed charges,100.44,466.43,310.95
Outpatient Medical Services,RADIOLOGY,76770,Ultrasound of back wall of the abdomen with all areas viewed,402,946.5,804.53,Pays at 85% of Billed charges for outpatient setting,304.3,Pays at 32.15% of Total Billed charges,757.48,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,851.85,Pays at 90% of Total Billed charges,304.3,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,304.3,Pays at 32.15% of Total Billed charges,832.92,Pays at 88% of Total Billed charges,313.39,Pays at 33.11% of Total Billed charges,100.44,851.85,567.90
Outpatient Medical Services,RADIOLOGY,76770,Ultrasound of back wall of the abdomen with all areas viewed,402,677.5,575.88,Pays at 85% of Billed charges for outpatient setting,217.82,Pays at 32.15% of Total Billed charges,542.2,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,609.75,Pays at 90% of Total Billed charges,217.82,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,217.82,Pays at 32.15% of Total Billed charges,596.2,Pays at 88% of Total Billed charges,224.32,Pays at 33.11% of Total Billed charges,100.44,609.75,406.50
Outpatient Medical Services,RADIOLOGY,76775,Ultrasound of back wall of the abdomen with limited areas viewed,402,443.75,377.19,Pays at 85% of Billed charges for outpatient setting,142.67,Pays at 32.15% of Total Billed charges,355.13,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,399.38,Pays at 90% of Total Billed charges,142.67,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,142.67,Pays at 32.15% of Total Billed charges,390.5,Pays at 88% of Total Billed charges,146.93,Pays at 33.11% of Total Billed charges,100.45,399.38,266.25
Outpatient Medical Services,RADIOLOGY,76775,Ultrasound of back wall of the abdomen with limited areas viewed,402,457.25,388.66,Pays at 85% of Billed charges for outpatient setting,147.01,Pays at 32.15% of Total Billed charges,365.94,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,411.53,Pays at 90% of Total Billed charges,147.01,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,147.01,Pays at 32.15% of Total Billed charges,402.38,Pays at 88% of Total Billed charges,151.4,Pays at 33.11% of Total Billed charges,100.45,411.53,274.35
Outpatient Medical Services,RADIOLOGY,76775,Ultrasound of back wall of the abdomen with limited areas viewed,402,518.25,440.51,Pays at 85% of Billed charges for outpatient setting,166.62,Pays at 32.15% of Total Billed charges,414.76,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,466.43,Pays at 90% of Total Billed charges,166.62,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,166.62,Pays at 32.15% of Total Billed charges,456.06,Pays at 88% of Total Billed charges,171.59,Pays at 33.11% of Total Billed charges,100.45,466.43,310.95
Outpatient Medical Services,RADIOLOGY,76775,Ultrasound of back wall of the abdomen with limited areas viewed,402,557.5,473.88,Pays at 85% of Billed charges for outpatient setting,179.24,Pays at 32.15% of Total Billed charges,446.17,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,501.75,Pays at 90% of Total Billed charges,179.24,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,179.24,Pays at 32.15% of Total Billed charges,490.6,Pays at 88% of Total Billed charges,184.59,Pays at 33.11% of Total Billed charges,100.45,501.75,334.50
Outpatient Medical Services,RADIOLOGY,76775,Ultrasound of back wall of the abdomen with limited areas viewed,402,296,251.6,Pays at 85% of Billed charges for outpatient setting,95.16,Pays at 32.15% of Total Billed charges,236.89,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,266.4,Pays at 90% of Total Billed charges,95.16,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,95.16,Pays at 32.15% of Total Billed charges,260.48,Pays at 88% of Total Billed charges,98.01,Pays at 33.11% of Total Billed charges,95.16,266.4,177.60
Outpatient Medical Services,RADIOLOGY,76801,Abdominal ultrasound of pregnant uterus (less than 14 weeks) single or first fetus,402,370,314.5,Pays at 85% of Billed charges for outpatient setting,118.96,Pays at 32.15% of Total Billed charges,296.11,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,333,Pays at 90% of Total Billed charges,118.96,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,118.96,Pays at 32.15% of Total Billed charges,325.6,Pays at 88% of Total Billed charges,122.51,Pays at 33.11% of Total Billed charges,100.44,333,222.00
Outpatient Medical Services,RADIOLOGY,76805,Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus,402,518.75,440.94,Pays at 85% of Billed charges for outpatient setting,166.78,Pays at 32.15% of Total Billed charges,415.16,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,466.88,Pays at 90% of Total Billed charges,166.78,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,166.78,Pays at 32.15% of Total Billed charges,456.5,Pays at 88% of Total Billed charges,171.76,Pays at 33.11% of Total Billed charges,100.44,466.88,311.25
Outpatient Medical Services,RADIOLOGY,76805,Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus,402,657.25,558.66,Pays at 85% of Billed charges for outpatient setting,211.31,Pays at 32.15% of Total Billed charges,526,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,591.53,Pays at 90% of Total Billed charges,211.31,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,211.31,Pays at 32.15% of Total Billed charges,578.38,Pays at 88% of Total Billed charges,217.62,Pays at 33.11% of Total Billed charges,100.44,591.53,394.35
Outpatient Medical Services,RADIOLOGY,76810,US OB MULT GEST,402,411.75,349.99,Pays at 85% of Billed charges for outpatient setting,132.38,Pays at 32.15% of Total Billed charges,329.52,Pays at 80.03% of Total Billed charges,411.75,Not Applicable,370.58,Pays at 90% of Total Billed charges,132.38,Pays at 32.15% of Total Billed charges,411.75,Not Applicable,132.38,Pays at 32.15% of Total Billed charges,362.34,Pays at 88% of Total Billed charges,136.33,Pays at 33.11% of Total Billed charges,132.38,411.75,247.05
Outpatient Medical Services,RADIOLOGY,76810,PORT US OB MULT GEST,402,2110,1793.5,Pays at 85% of Billed charges for outpatient setting,678.37,Pays at 32.15% of Total Billed charges,1688.63,Pays at 80.03% of Total Billed charges,2110,Not Applicable,1899,Pays at 90% of Total Billed charges,678.37,Pays at 32.15% of Total Billed charges,2110,Not Applicable,678.37,Pays at 32.15% of Total Billed charges,1856.8,Pays at 88% of Total Billed charges,698.62,Pays at 33.11% of Total Billed charges,678.37,2110,1266.00
Outpatient Medical Services,RADIOLOGY,76815,Ultrasound of fetus with limited views,402,349.06,296.7,Pays at 85% of Billed charges for outpatient setting,112.22,Pays at 32.15% of Total Billed charges,279.35,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,314.15,Pays at 90% of Total Billed charges,112.22,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,112.22,Pays at 32.15% of Total Billed charges,307.17,Pays at 88% of Total Billed charges,115.57,Pays at 33.11% of Total Billed charges,100.45,314.15,209.44
Outpatient Medical Services,RADIOLOGY,76816,US OB FOLLOW-UP PER FETUS,402,381,323.85,Pays at 85% of Billed charges for outpatient setting,122.49,Pays at 32.15% of Total Billed charges,304.91,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,342.9,Pays at 90% of Total Billed charges,122.49,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,122.49,Pays at 32.15% of Total Billed charges,335.28,Pays at 88% of Total Billed charges,126.15,Pays at 33.11% of Total Billed charges,100.45,342.9,228.60
Outpatient Medical Services,RADIOLOGY,76817,Transvaginal ultrasound of uterus,402,577.5,490.88,Pays at 85% of Billed charges for outpatient setting,185.67,Pays at 32.15% of Total Billed charges,462.17,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,519.75,Pays at 90% of Total Billed charges,185.67,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,185.67,Pays at 32.15% of Total Billed charges,508.2,Pays at 88% of Total Billed charges,191.21,Pays at 33.11% of Total Billed charges,100.45,519.75,346.50
Outpatient Medical Services,RADIOLOGY,76819,Fetal biophysical profile without non-stress test,402,381,323.85,Pays at 85% of Billed charges for outpatient setting,122.49,Pays at 32.15% of Total Billed charges,304.91,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,342.9,Pays at 90% of Total Billed charges,122.49,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,122.49,Pays at 32.15% of Total Billed charges,335.28,Pays at 88% of Total Billed charges,126.15,Pays at 33.11% of Total Billed charges,100.44,342.9,228.60
Outpatient Medical Services,RADIOLOGY,76830,Ultrasound of the pelvis through vagina,402,577.5,490.88,Pays at 85% of Billed charges for outpatient setting,185.67,Pays at 32.15% of Total Billed charges,462.17,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,519.75,Pays at 90% of Total Billed charges,185.67,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,185.67,Pays at 32.15% of Total Billed charges,508.2,Pays at 88% of Total Billed charges,191.21,Pays at 33.11% of Total Billed charges,100.44,519.75,346.50
Outpatient Medical Services,RADIOLOGY,76830,Ultrasound of the pelvis through vagina,402,296,251.6,Pays at 85% of Billed charges for outpatient setting,95.16,Pays at 32.15% of Total Billed charges,236.89,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,266.4,Pays at 90% of Total Billed charges,95.16,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,95.16,Pays at 32.15% of Total Billed charges,260.48,Pays at 88% of Total Billed charges,98.01,Pays at 33.11% of Total Billed charges,95.16,266.4,177.60
Outpatient Medical Services,RADIOLOGY,76856,Complete ultrasound of the pelvis,402,596.5,507.03,Pays at 85% of Billed charges for outpatient setting,191.77,Pays at 32.15% of Total Billed charges,477.38,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,536.85,Pays at 90% of Total Billed charges,191.77,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,191.77,Pays at 32.15% of Total Billed charges,524.92,Pays at 88% of Total Billed charges,197.5,Pays at 33.11% of Total Billed charges,100.44,536.85,357.90
Outpatient Medical Services,RADIOLOGY,76856,Complete ultrasound of the pelvis,402,657.25,558.66,Pays at 85% of Billed charges for outpatient setting,211.31,Pays at 32.15% of Total Billed charges,526,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,591.53,Pays at 90% of Total Billed charges,211.31,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,211.31,Pays at 32.15% of Total Billed charges,578.38,Pays at 88% of Total Billed charges,217.62,Pays at 33.11% of Total Billed charges,100.44,591.53,394.35
Outpatient Medical Services,RADIOLOGY,76870,Ultrasound of the scrotum,402,407.5,346.38,Pays at 85% of Billed charges for outpatient setting,131.01,Pays at 32.15% of Total Billed charges,326.12,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,366.75,Pays at 90% of Total Billed charges,131.01,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,131.01,Pays at 32.15% of Total Billed charges,358.6,Pays at 88% of Total Billed charges,134.92,Pays at 33.11% of Total Billed charges,100.45,366.75,244.50
Outpatient Medical Services,RADIOLOGY,76870,Ultrasound of the scrotum,402,557.5,473.88,Pays at 85% of Billed charges for outpatient setting,179.24,Pays at 32.15% of Total Billed charges,446.17,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,501.75,Pays at 90% of Total Billed charges,179.24,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,179.24,Pays at 32.15% of Total Billed charges,490.6,Pays at 88% of Total Billed charges,184.59,Pays at 33.11% of Total Billed charges,100.45,501.75,334.50
Outpatient Medical Services,RADIOLOGY,76872,Transrectal ultrasound,402,457.25,388.66,Pays at 85% of Billed charges for outpatient setting,147.01,Pays at 32.15% of Total Billed charges,365.94,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,411.53,Pays at 90% of Total Billed charges,147.01,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,147.01,Pays at 32.15% of Total Billed charges,402.38,Pays at 88% of Total Billed charges,151.4,Pays at 33.11% of Total Billed charges,100.44,411.53,274.35
Outpatient Medical Services,RADIOLOGY,76881,US KNEE POPLITEAL AREA NON-VASCULAR,402,296,251.6,Pays at 85% of Billed charges for outpatient setting,95.16,Pays at 32.15% of Total Billed charges,236.89,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,266.4,Pays at 90% of Total Billed charges,95.16,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,95.16,Pays at 32.15% of Total Billed charges,260.48,Pays at 88% of Total Billed charges,98.01,Pays at 33.11% of Total Billed charges,95.16,266.4,177.60
Outpatient Medical Services,RADIOLOGY,76881,PORT US EXTREMITY NON-VASCUL,402,448.5,381.23,Pays at 85% of Billed charges for outpatient setting,144.19,Pays at 32.15% of Total Billed charges,358.93,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,403.65,Pays at 90% of Total Billed charges,144.19,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,144.19,Pays at 32.15% of Total Billed charges,394.68,Pays at 88% of Total Billed charges,148.5,Pays at 33.11% of Total Billed charges,100.44,403.65,269.10
Outpatient Medical Services,RADIOLOGY,76881,US HEMATOMA OR MUSCLE,402,355,301.75,Pays at 85% of Billed charges for outpatient setting,114.13,Pays at 32.15% of Total Billed charges,284.11,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,319.5,Pays at 90% of Total Billed charges,114.13,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,114.13,Pays at 32.15% of Total Billed charges,312.4,Pays at 88% of Total Billed charges,117.54,Pays at 33.11% of Total Billed charges,100.44,319.5,213.00
Outpatient Medical Services,RADIOLOGY,76881,US GROIN,402,296,251.6,Pays at 85% of Billed charges for outpatient setting,95.16,Pays at 32.15% of Total Billed charges,236.89,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,266.4,Pays at 90% of Total Billed charges,95.16,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,95.16,Pays at 32.15% of Total Billed charges,260.48,Pays at 88% of Total Billed charges,98.01,Pays at 33.11% of Total Billed charges,95.16,266.4,177.60
Outpatient Medical Services,RADIOLOGY,76882,"Diagnostic ultrasound of an extremity excluding the bone, joints or vessels",402,388.25,330.01,Pays at 85% of Billed charges for outpatient setting,124.82,Pays at 32.15% of Total Billed charges,310.72,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,349.43,Pays at 90% of Total Billed charges,124.82,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,124.82,Pays at 32.15% of Total Billed charges,341.66,Pays at 88% of Total Billed charges,128.55,Pays at 33.11% of Total Billed charges,100.45,349.43,232.95
Outpatient Medical Services,RADIOLOGY,76882,"Diagnostic ultrasound of an extremity excluding the bone, joints or vessels",402,296,251.6,Pays at 85% of Billed charges for outpatient setting,95.16,Pays at 32.15% of Total Billed charges,236.89,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,266.4,Pays at 90% of Total Billed charges,95.16,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,95.16,Pays at 32.15% of Total Billed charges,260.48,Pays at 88% of Total Billed charges,98.01,Pays at 33.11% of Total Billed charges,95.16,266.4,177.60
Outpatient Medical Services,RADIOLOGY,76942,US CHEST FOR FLUID,402,488.5,415.23,Pays at 85% of Billed charges for outpatient setting,157.05,Pays at 32.15% of Total Billed charges,390.95,Pays at 80.03% of Total Billed charges,488.5,Not Applicable,439.65,Pays at 90% of Total Billed charges,157.05,Pays at 32.15% of Total Billed charges,488.5,Not Applicable,157.05,Pays at 32.15% of Total Billed charges,429.88,Pays at 88% of Total Billed charges,161.74,Pays at 33.11% of Total Billed charges,157.05,488.5,293.10
Outpatient Medical Services,RADIOLOGY,76942,US CYST ASPIRATION,402,488.5,415.23,Pays at 85% of Billed charges for outpatient setting,157.05,Pays at 32.15% of Total Billed charges,390.95,Pays at 80.03% of Total Billed charges,488.5,Not Applicable,439.65,Pays at 90% of Total Billed charges,157.05,Pays at 32.15% of Total Billed charges,488.5,Not Applicable,157.05,Pays at 32.15% of Total Billed charges,429.88,Pays at 88% of Total Billed charges,161.74,Pays at 33.11% of Total Billed charges,157.05,488.5,293.10
Outpatient Medical Services,RADIOLOGY,76942,US NEEDLE BX,402,596.5,507.03,Pays at 85% of Billed charges for outpatient setting,191.77,Pays at 32.15% of Total Billed charges,477.38,Pays at 80.03% of Total Billed charges,596.5,Not Applicable,536.85,Pays at 90% of Total Billed charges,191.77,Pays at 32.15% of Total Billed charges,596.5,Not Applicable,191.77,Pays at 32.15% of Total Billed charges,524.92,Pays at 88% of Total Billed charges,197.5,Pays at 33.11% of Total Billed charges,191.77,596.5,357.90
Outpatient Medical Services,RADIOLOGY,76942,US BREAST WITH ASPIRATION,402,418,355.3,Pays at 85% of Billed charges for outpatient setting,134.39,Pays at 32.15% of Total Billed charges,334.53,Pays at 80.03% of Total Billed charges,418,Not Applicable,376.2,Pays at 90% of Total Billed charges,134.39,Pays at 32.15% of Total Billed charges,418,Not Applicable,134.39,Pays at 32.15% of Total Billed charges,367.84,Pays at 88% of Total Billed charges,138.4,Pays at 33.11% of Total Billed charges,134.39,418,250.80
Outpatient Medical Services,RADIOLOGY,76946,US AMNIOCENTESIS,402,398.25,338.51,Pays at 85% of Billed charges for outpatient setting,128.04,Pays at 32.15% of Total Billed charges,318.72,Pays at 80.03% of Total Billed charges,398.25,Not Applicable,358.43,Pays at 90% of Total Billed charges,128.04,Pays at 32.15% of Total Billed charges,398.25,Not Applicable,128.04,Pays at 32.15% of Total Billed charges,350.46,Pays at 88% of Total Billed charges,131.86,Pays at 33.11% of Total Billed charges,128.04,398.25,238.95
Outpatient Medical Services,RADIOLOGY,76998,US INTRAOP,402,596.5,507.03,Pays at 85% of Billed charges for outpatient setting,191.77,Pays at 32.15% of Total Billed charges,477.38,Pays at 80.03% of Total Billed charges,596.5,Not Applicable,536.85,Pays at 90% of Total Billed charges,191.77,Pays at 32.15% of Total Billed charges,596.5,Not Applicable,191.77,Pays at 32.15% of Total Billed charges,524.92,Pays at 88% of Total Billed charges,197.5,Pays at 33.11% of Total Billed charges,191.77,596.5,357.90
Outpatient Medical Services,RADIOLOGY,76999,US FOR CYST,402,418,355.3,Pays at 85% of Billed charges for outpatient setting,134.39,Pays at 32.15% of Total Billed charges,334.53,Pays at 80.03% of Total Billed charges,83.29,Pays at 102% of Medicare OPPS Rate,376.2,Pays at 90% of Total Billed charges,134.39,Pays at 32.15% of Total Billed charges,81.65,Pays at 100% of Medicare OPPS Rate,134.39,Pays at 32.15% of Total Billed charges,367.84,Pays at 88% of Total Billed charges,138.4,Pays at 33.11% of Total Billed charges,81.65,376.2,250.80
Outpatient Medical Services,RADIOLOGY,402,=> ULTRASOUND ORDER      <=,402,SERVICE NOT OFFERED,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,0,0,#VALUE!
Outpatient Medical Services,RADIOLOGY,19285,MM BREAST LOCALIZATION PLACEMENT 1ST LES,403,1775,1508.75,Pays at 85% of Billed charges for outpatient setting,570.66,Pays at 32.15% of Total Billed charges,1420.53,Pays at 80.03% of Total Billed charges,622.16,Pays at 102% of Medicare OPPS Rate,1597.5,Pays at 90% of Total Billed charges,570.66,Pays at 32.15% of Total Billed charges,609.97,Pays at 100% of Medicare OPPS Rate,570.66,Pays at 32.15% of Total Billed charges,1562,Pays at 88% of Total Billed charges,587.7,Pays at 33.11% of Total Billed charges,570.66,1597.5,1065.00
Outpatient Medical Services,RADIOLOGY,19286,MM BREAST LOCALIZATION PLACEMENT 2ND LES,403,719.25,611.36,Pays at 85% of Billed charges for outpatient setting,231.24,Pays at 32.15% of Total Billed charges,575.62,Pays at 80.03% of Total Billed charges,719.25,Not Applicable,647.33,Pays at 90% of Total Billed charges,231.24,Pays at 32.15% of Total Billed charges,719.25,Not Applicable,231.24,Pays at 32.15% of Total Billed charges,632.94,Pays at 88% of Total Billed charges,238.14,Pays at 33.11% of Total Billed charges,231.24,719.25,431.55
Outpatient Medical Services,RADIOLOGY,76092,MM MAMMO SCREEN EMPLOYEE,403,81,68.85,Pays at 85% of Billed charges for outpatient setting,26.04,Pays at 32.15% of Total Billed charges,64.82,Pays at 80.03% of Total Billed charges,81,Not Applicable,72.9,Pays at 90% of Total Billed charges,26.04,Pays at 32.15% of Total Billed charges,81,Not Applicable,26.04,Pays at 32.15% of Total Billed charges,71.28,Pays at 88% of Total Billed charges,26.82,Pays at 33.11% of Total Billed charges,26.04,81,48.60
Outpatient Medical Services,RADIOLOGY,77057,MM MAMMO DIAG EMPLOYEE,403,81,68.85,Pays at 85% of Billed charges for outpatient setting,26.04,Pays at 32.15% of Total Billed charges,64.82,Pays at 80.03% of Total Billed charges,81,Not Applicable,72.9,Pays at 90% of Total Billed charges,26.04,Pays at 32.15% of Total Billed charges,81,Not Applicable,26.04,Pays at 32.15% of Total Billed charges,71.28,Pays at 88% of Total Billed charges,26.82,Pays at 33.11% of Total Billed charges,26.04,81,48.60
Outpatient Medical Services,RADIOLOGY,77063,MM 3D MAMMO SCREENING BILAT,403,97.19,82.61,Pays at 85% of Billed charges for outpatient setting,31.25,Pays at 32.15% of Total Billed charges,77.78,Pays at 80.03% of Total Billed charges,21.92,Pays at 102% of Medicare OPPS Rate,87.47,Pays at 90% of Total Billed charges,31.25,Pays at 32.15% of Total Billed charges,21.49,Pays at 100% of Medicare OPPS Rate,31.25,Pays at 32.15% of Total Billed charges,85.53,Pays at 88% of Total Billed charges,32.18,Pays at 33.11% of Total Billed charges,21.49,87.47,58.31
Outpatient Medical Services,RADIOLOGY,77063,MM ADD-ON 3D MAMMO BILAT,403,75,63.75,Pays at 85% of Billed charges for outpatient setting,24.11,Pays at 32.15% of Total Billed charges,60.02,Pays at 80.03% of Total Billed charges,21.92,Pays at 102% of Medicare OPPS Rate,67.5,Pays at 90% of Total Billed charges,24.11,Pays at 32.15% of Total Billed charges,21.49,Pays at 100% of Medicare OPPS Rate,24.11,Pays at 32.15% of Total Billed charges,66,Pays at 88% of Total Billed charges,24.83,Pays at 33.11% of Total Billed charges,21.49,67.5,45.00
Outpatient Medical Services,RADIOLOGY,77067,Mammography of both breasts-2 or more views,403,126,107.1,Pays at 85% of Billed charges for outpatient setting,40.51,Pays at 32.15% of Total Billed charges,100.84,Pays at 80.03% of Total Billed charges,84.39,Pays at 102% of Medicare OPPS Rate,113.4,Pays at 90% of Total Billed charges,40.51,Pays at 32.15% of Total Billed charges,82.74,Pays at 100% of Medicare OPPS Rate,40.51,Pays at 32.15% of Total Billed charges,110.88,Pays at 88% of Total Billed charges,41.72,Pays at 33.11% of Total Billed charges,40.51,113.4,75.60
Outpatient Medical Services,RADIOLOGY,77067,Mammography of both breasts-2 or more views,403,77.75,66.09,Pays at 85% of Billed charges for outpatient setting,25,Pays at 32.15% of Total Billed charges,62.22,Pays at 80.03% of Total Billed charges,79.31,Pays at 102% of Medicare OPPS Rate,69.98,Pays at 90% of Total Billed charges,25,Pays at 32.15% of Total Billed charges,77.75,Pays at 100% of Medicare OPPS Rate,25,Pays at 32.15% of Total Billed charges,68.42,Pays at 88% of Total Billed charges,25.74,Pays at 33.11% of Total Billed charges,25,79.31,46.65
Outpatient Medical Services,RADIOLOGY,77067,Mammography of both breasts-2 or more views,403,77.75,66.09,Pays at 85% of Billed charges for outpatient setting,25,Pays at 32.15% of Total Billed charges,62.22,Pays at 80.03% of Total Billed charges,79.31,Pays at 102% of Medicare OPPS Rate,69.98,Pays at 90% of Total Billed charges,25,Pays at 32.15% of Total Billed charges,77.75,Pays at 100% of Medicare OPPS Rate,25,Pays at 32.15% of Total Billed charges,68.42,Pays at 88% of Total Billed charges,25.74,Pays at 33.11% of Total Billed charges,25,79.31,46.65
Outpatient Medical Services,RADIOLOGY,77056,MM MAMMO UNILAT EMPLOYEE RT,403,90.5,76.93,Pays at 85% of Billed charges for outpatient setting,29.1,Pays at 32.15% of Total Billed charges,72.43,Pays at 80.03% of Total Billed charges,90.5,Not Applicable,81.45,Pays at 90% of Total Billed charges,29.1,Pays at 32.15% of Total Billed charges,90.5,Not Applicable,29.1,Pays at 32.15% of Total Billed charges,79.64,Pays at 88% of Total Billed charges,29.96,Pays at 33.11% of Total Billed charges,29.1,90.5,54.30
Outpatient Medical Services,RADIOLOGY,77066,"Diagnostic mammography, including computer-aided detection (cad) when performed; bilateral",403,90.5,76.93,Pays at 85% of Billed charges for outpatient setting,29.1,Pays at 32.15% of Total Billed charges,72.43,Pays at 80.03% of Total Billed charges,92.31,Pays at 102% of Medicare OPPS Rate,81.45,Pays at 90% of Total Billed charges,29.1,Pays at 32.15% of Total Billed charges,90.5,Pays at 100% of Medicare OPPS Rate,29.1,Pays at 32.15% of Total Billed charges,79.64,Pays at 88% of Total Billed charges,29.96,Pays at 33.11% of Total Billed charges,29.1,92.31,54.30
Outpatient Medical Services,RADIOLOGY,77066,"Diagnostic mammography, including computer-aided detection (cad) when performed; bilateral",403,408.75,347.44,Pays at 85% of Billed charges for outpatient setting,131.41,Pays at 32.15% of Total Billed charges,327.12,Pays at 80.03% of Total Billed charges,101.75,Pays at 102% of Medicare OPPS Rate,367.88,Pays at 90% of Total Billed charges,131.41,Pays at 32.15% of Total Billed charges,99.75,Pays at 100% of Medicare OPPS Rate,131.41,Pays at 32.15% of Total Billed charges,359.7,Pays at 88% of Total Billed charges,135.34,Pays at 33.11% of Total Billed charges,99.75,367.88,245.25
Outpatient Medical Services,RADIOLOGY,77067,Mammography of both breasts-2 or more views,403,308.75,262.44,Pays at 85% of Billed charges for outpatient setting,99.26,Pays at 32.15% of Total Billed charges,247.09,Pays at 80.03% of Total Billed charges,84.39,Pays at 102% of Medicare OPPS Rate,277.88,Pays at 90% of Total Billed charges,99.26,Pays at 32.15% of Total Billed charges,82.74,Pays at 100% of Medicare OPPS Rate,99.26,Pays at 32.15% of Total Billed charges,271.7,Pays at 88% of Total Billed charges,102.23,Pays at 33.11% of Total Billed charges,82.74,277.88,185.25
Outpatient Medical Services,RADIOLOGY,77067,Mammography of both breasts-2 or more views,403,129.25,109.86,Pays at 85% of Billed charges for outpatient setting,41.55,Pays at 32.15% of Total Billed charges,103.44,Pays at 80.03% of Total Billed charges,84.39,Pays at 102% of Medicare OPPS Rate,116.33,Pays at 90% of Total Billed charges,41.55,Pays at 32.15% of Total Billed charges,82.74,Pays at 100% of Medicare OPPS Rate,41.55,Pays at 32.15% of Total Billed charges,113.74,Pays at 88% of Total Billed charges,42.79,Pays at 33.11% of Total Billed charges,41.55,116.33,77.55
Outpatient Medical Services,RADIOLOGY,403,=> MAMMOGRAPHY ORDER     <=,403,SERVICE NOT OFFERED,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,0,0,#VALUE!
Outpatient Medical Services,RADIOLOGY,70540,MRI FACE SINUS WITHOUT,610,1662.75,1413.34,Pays at 85% of Billed charges for outpatient setting,534.57,Pays at 32.15% of Total Billed charges,1330.7,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,1496.48,Pays at 90% of Total Billed charges,534.57,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,534.57,Pays at 32.15% of Total Billed charges,1463.22,Pays at 88% of Total Billed charges,550.54,Pays at 33.11% of Total Billed charges,219.48,1496.48,997.65
Outpatient Medical Services,RADIOLOGY,73720,MRI EXT LOW NON-JNT WWO CONTRAST,610,1417,1204.45,Pays at 85% of Billed charges for outpatient setting,455.57,Pays at 32.15% of Total Billed charges,1134.03,Pays at 80.03% of Total Billed charges,353.2,Pays at 102% of Medicare OPPS Rate,1275.3,Pays at 90% of Total Billed charges,455.57,Pays at 32.15% of Total Billed charges,346.28,Pays at 100% of Medicare OPPS Rate,455.57,Pays at 32.15% of Total Billed charges,1246.96,Pays at 88% of Total Billed charges,469.17,Pays at 33.11% of Total Billed charges,346.28,1275.3,850.20
Outpatient Medical Services,RADIOLOGY,73718,MRI of leg without dye,610,1442.75,1226.34,Pays at 85% of Billed charges for outpatient setting,463.84,Pays at 32.15% of Total Billed charges,1154.63,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,1298.48,Pays at 90% of Total Billed charges,463.84,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,463.84,Pays at 32.15% of Total Billed charges,1269.62,Pays at 88% of Total Billed charges,477.69,Pays at 33.11% of Total Billed charges,219.48,1298.48,865.65
Outpatient Medical Services,RADIOLOGY,73718,MRI of leg without dye,610,1442.75,1226.34,Pays at 85% of Billed charges for outpatient setting,463.84,Pays at 32.15% of Total Billed charges,1154.63,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,1298.48,Pays at 90% of Total Billed charges,463.84,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,463.84,Pays at 32.15% of Total Billed charges,1269.62,Pays at 88% of Total Billed charges,477.69,Pays at 33.11% of Total Billed charges,219.48,1298.48,865.65
Outpatient Medical Services,RADIOLOGY,73718,MRI of leg without dye,610,4518.75,3840.94,Pays at 85% of Billed charges for outpatient setting,1452.78,Pays at 32.15% of Total Billed charges,3616.36,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,4066.88,Pays at 90% of Total Billed charges,1452.78,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,1452.78,Pays at 32.15% of Total Billed charges,3976.5,Pays at 88% of Total Billed charges,1496.16,Pays at 33.11% of Total Billed charges,219.48,4066.88,2711.25
Outpatient Medical Services,RADIOLOGY,0159T,CAD FOR MRI,610,31.5,26.78,Pays at 85% of Billed charges for outpatient setting,10.13,Pays at 32.15% of Total Billed charges,25.21,Pays at 80.03% of Total Billed charges,31.5,Not Applicable,28.35,Pays at 90% of Total Billed charges,10.13,Pays at 32.15% of Total Billed charges,31.5,Not Applicable,10.13,Pays at 32.15% of Total Billed charges,27.72,Pays at 88% of Total Billed charges,10.43,Pays at 33.11% of Total Billed charges,10.13,31.5,18.90
Outpatient Medical Services,RADIOLOGY,70336,MRI TEMPOROMANDIBULAR JOINT,610,1662.75,1413.34,Pays at 85% of Billed charges for outpatient setting,534.57,Pays at 32.15% of Total Billed charges,1330.7,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,1496.48,Pays at 90% of Total Billed charges,534.57,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,534.57,Pays at 32.15% of Total Billed charges,1463.22,Pays at 88% of Total Billed charges,550.54,Pays at 33.11% of Total Billed charges,219.48,1496.48,997.65
Outpatient Medical Services,RADIOLOGY,70336,MRI TMJ WITH OR WITHOUT,610,961.5,817.28,Pays at 85% of Billed charges for outpatient setting,309.12,Pays at 32.15% of Total Billed charges,769.49,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,865.35,Pays at 90% of Total Billed charges,309.12,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,309.12,Pays at 32.15% of Total Billed charges,846.12,Pays at 88% of Total Billed charges,318.35,Pays at 33.11% of Total Billed charges,219.48,865.35,576.90
Outpatient Medical Services,RADIOLOGY,70336,MRI TMJ WITHOUT,610,1662.75,1413.34,Pays at 85% of Billed charges for outpatient setting,534.57,Pays at 32.15% of Total Billed charges,1330.7,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,1496.48,Pays at 90% of Total Billed charges,534.57,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,534.57,Pays at 32.15% of Total Billed charges,1463.22,Pays at 88% of Total Billed charges,550.54,Pays at 33.11% of Total Billed charges,219.48,1496.48,997.65
Outpatient Medical Services,RADIOLOGY,70540,MRI ORBIT WO CONTRAST,610,961.5,817.28,Pays at 85% of Billed charges for outpatient setting,309.12,Pays at 32.15% of Total Billed charges,769.49,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,865.35,Pays at 90% of Total Billed charges,309.12,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,309.12,Pays at 32.15% of Total Billed charges,846.12,Pays at 88% of Total Billed charges,318.35,Pays at 33.11% of Total Billed charges,219.48,865.35,576.90
Outpatient Medical Services,RADIOLOGY,70540,MRI BRACHIAL PLEXUS WO CONTRAST,610,1662.75,1413.34,Pays at 85% of Billed charges for outpatient setting,534.57,Pays at 32.15% of Total Billed charges,1330.7,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,1496.48,Pays at 90% of Total Billed charges,534.57,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,534.57,Pays at 32.15% of Total Billed charges,1463.22,Pays at 88% of Total Billed charges,550.54,Pays at 33.11% of Total Billed charges,219.48,1496.48,997.65
Outpatient Medical Services,RADIOLOGY,70540,MRI THYROID SOFT TISS WO CONTRAST,610,1662.75,1413.34,Pays at 85% of Billed charges for outpatient setting,534.57,Pays at 32.15% of Total Billed charges,1330.7,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,1496.48,Pays at 90% of Total Billed charges,534.57,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,534.57,Pays at 32.15% of Total Billed charges,1463.22,Pays at 88% of Total Billed charges,550.54,Pays at 33.11% of Total Billed charges,219.48,1496.48,997.65
Outpatient Medical Services,RADIOLOGY,70540,MRI NECK SOFT TISSUE W/O CONTRAST,610,1662.75,1413.34,Pays at 85% of Billed charges for outpatient setting,534.57,Pays at 32.15% of Total Billed charges,1330.7,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,1496.48,Pays at 90% of Total Billed charges,534.57,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,534.57,Pays at 32.15% of Total Billed charges,1463.22,Pays at 88% of Total Billed charges,550.54,Pays at 33.11% of Total Billed charges,219.48,1496.48,997.65
Outpatient Medical Services,RADIOLOGY,70542,MRI THYROID SOFT TISSUE WITH CONTRAST,610,1662.75,1413.34,Pays at 85% of Billed charges for outpatient setting,534.57,Pays at 32.15% of Total Billed charges,1330.7,Pays at 80.03% of Total Billed charges,353.2,Pays at 102% of Medicare OPPS Rate,1496.48,Pays at 90% of Total Billed charges,534.57,Pays at 32.15% of Total Billed charges,346.28,Pays at 100% of Medicare OPPS Rate,534.57,Pays at 32.15% of Total Billed charges,1463.22,Pays at 88% of Total Billed charges,550.54,Pays at 33.11% of Total Billed charges,346.28,1496.48,997.65
Outpatient Medical Services,RADIOLOGY,70543,MRI ORBIT WWO CONTRAST,610,2138,1817.3,Pays at 85% of Billed charges for outpatient setting,687.37,Pays at 32.15% of Total Billed charges,1711.04,Pays at 80.03% of Total Billed charges,353.2,Pays at 102% of Medicare OPPS Rate,1924.2,Pays at 90% of Total Billed charges,687.37,Pays at 32.15% of Total Billed charges,346.28,Pays at 100% of Medicare OPPS Rate,687.37,Pays at 32.15% of Total Billed charges,1881.44,Pays at 88% of Total Billed charges,707.89,Pays at 33.11% of Total Billed charges,346.28,1924.2,1282.80
Outpatient Medical Services,RADIOLOGY,70543,MRI THYROID SOFT TISS WWO CONTRAST,610,2138,1817.3,Pays at 85% of Billed charges for outpatient setting,687.37,Pays at 32.15% of Total Billed charges,1711.04,Pays at 80.03% of Total Billed charges,353.2,Pays at 102% of Medicare OPPS Rate,1924.2,Pays at 90% of Total Billed charges,687.37,Pays at 32.15% of Total Billed charges,346.28,Pays at 100% of Medicare OPPS Rate,687.37,Pays at 32.15% of Total Billed charges,1881.44,Pays at 88% of Total Billed charges,707.89,Pays at 33.11% of Total Billed charges,346.28,1924.2,1282.80
Outpatient Medical Services,RADIOLOGY,70543,MRI NECK SOFT TISSUE WWO CONTRAST,610,2138,1817.3,Pays at 85% of Billed charges for outpatient setting,687.37,Pays at 32.15% of Total Billed charges,1711.04,Pays at 80.03% of Total Billed charges,353.2,Pays at 102% of Medicare OPPS Rate,1924.2,Pays at 90% of Total Billed charges,687.37,Pays at 32.15% of Total Billed charges,346.28,Pays at 100% of Medicare OPPS Rate,687.37,Pays at 32.15% of Total Billed charges,1881.44,Pays at 88% of Total Billed charges,707.89,Pays at 33.11% of Total Billed charges,346.28,1924.2,1282.80
Outpatient Medical Services,RADIOLOGY,70543,MRI FACE SINUS WITH AND  WO CONTRAST,610,2138,1817.3,Pays at 85% of Billed charges for outpatient setting,687.37,Pays at 32.15% of Total Billed charges,1711.04,Pays at 80.03% of Total Billed charges,353.2,Pays at 102% of Medicare OPPS Rate,1924.2,Pays at 90% of Total Billed charges,687.37,Pays at 32.15% of Total Billed charges,346.28,Pays at 100% of Medicare OPPS Rate,687.37,Pays at 32.15% of Total Billed charges,1881.44,Pays at 88% of Total Billed charges,707.89,Pays at 33.11% of Total Billed charges,346.28,1924.2,1282.80
Outpatient Medical Services,RADIOLOGY,70543,MRI BRACHIAL PLEXUS WWO CONTRAST,610,2138,1817.3,Pays at 85% of Billed charges for outpatient setting,687.37,Pays at 32.15% of Total Billed charges,1711.04,Pays at 80.03% of Total Billed charges,353.2,Pays at 102% of Medicare OPPS Rate,1924.2,Pays at 90% of Total Billed charges,687.37,Pays at 32.15% of Total Billed charges,346.28,Pays at 100% of Medicare OPPS Rate,687.37,Pays at 32.15% of Total Billed charges,1881.44,Pays at 88% of Total Billed charges,707.89,Pays at 33.11% of Total Billed charges,346.28,1924.2,1282.80
Outpatient Medical Services,RADIOLOGY,70547,MRA CAROTID WITHOUT CONTRAST,610,961.5,817.28,Pays at 85% of Billed charges for outpatient setting,309.12,Pays at 32.15% of Total Billed charges,769.49,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,865.35,Pays at 90% of Total Billed charges,309.12,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,309.12,Pays at 32.15% of Total Billed charges,846.12,Pays at 88% of Total Billed charges,318.35,Pays at 33.11% of Total Billed charges,219.48,865.35,576.90
Outpatient Medical Services,RADIOLOGY,70548,MRA CAROTID WITH CONTRAST,610,1662.75,1413.34,Pays at 85% of Billed charges for outpatient setting,534.57,Pays at 32.15% of Total Billed charges,1330.7,Pays at 80.03% of Total Billed charges,353.2,Pays at 102% of Medicare OPPS Rate,1496.48,Pays at 90% of Total Billed charges,534.57,Pays at 32.15% of Total Billed charges,346.28,Pays at 100% of Medicare OPPS Rate,534.57,Pays at 32.15% of Total Billed charges,1463.22,Pays at 88% of Total Billed charges,550.54,Pays at 33.11% of Total Billed charges,346.28,1496.48,997.65
Outpatient Medical Services,RADIOLOGY,70549,MRA CAROTID WWO CONTRAST,610,1181,1003.85,Pays at 85% of Billed charges for outpatient setting,379.69,Pays at 32.15% of Total Billed charges,945.15,Pays at 80.03% of Total Billed charges,353.2,Pays at 102% of Medicare OPPS Rate,1062.9,Pays at 90% of Total Billed charges,379.69,Pays at 32.15% of Total Billed charges,346.28,Pays at 100% of Medicare OPPS Rate,379.69,Pays at 32.15% of Total Billed charges,1039.28,Pays at 88% of Total Billed charges,391.03,Pays at 33.11% of Total Billed charges,346.28,1062.9,708.60
Outpatient Medical Services,RADIOLOGY,70551,MRI of brain stem without dye,610,1662.75,1413.34,Pays at 85% of Billed charges for outpatient setting,534.57,Pays at 32.15% of Total Billed charges,1330.7,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,1496.48,Pays at 90% of Total Billed charges,534.57,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,534.57,Pays at 32.15% of Total Billed charges,1463.22,Pays at 88% of Total Billed charges,550.54,Pays at 33.11% of Total Billed charges,219.48,1496.48,997.65
Outpatient Medical Services,RADIOLOGY,70551,MRI of brain stem without dye,610,601.25,511.06,Pays at 85% of Billed charges for outpatient setting,193.3,Pays at 32.15% of Total Billed charges,481.18,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,541.13,Pays at 90% of Total Billed charges,193.3,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,193.3,Pays at 32.15% of Total Billed charges,529.1,Pays at 88% of Total Billed charges,199.07,Pays at 33.11% of Total Billed charges,193.3,541.13,360.75
Outpatient Medical Services,RADIOLOGY,70551,MRI of brain stem without dye,610,1662.75,1413.34,Pays at 85% of Billed charges for outpatient setting,534.57,Pays at 32.15% of Total Billed charges,1330.7,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,1496.48,Pays at 90% of Total Billed charges,534.57,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,534.57,Pays at 32.15% of Total Billed charges,1463.22,Pays at 88% of Total Billed charges,550.54,Pays at 33.11% of Total Billed charges,219.48,1496.48,997.65
Outpatient Medical Services,RADIOLOGY,70552,MRI BRAIN W CONTRAST,610,1662.75,1413.34,Pays at 85% of Billed charges for outpatient setting,534.57,Pays at 32.15% of Total Billed charges,1330.7,Pays at 80.03% of Total Billed charges,353.2,Pays at 102% of Medicare OPPS Rate,1496.48,Pays at 90% of Total Billed charges,534.57,Pays at 32.15% of Total Billed charges,346.28,Pays at 100% of Medicare OPPS Rate,534.57,Pays at 32.15% of Total Billed charges,1463.22,Pays at 88% of Total Billed charges,550.54,Pays at 33.11% of Total Billed charges,346.28,1496.48,997.65
Outpatient Medical Services,RADIOLOGY,70552,MRI IACS W CONTRAST,610,1662.75,1413.34,Pays at 85% of Billed charges for outpatient setting,534.57,Pays at 32.15% of Total Billed charges,1330.7,Pays at 80.03% of Total Billed charges,353.2,Pays at 102% of Medicare OPPS Rate,1496.48,Pays at 90% of Total Billed charges,534.57,Pays at 32.15% of Total Billed charges,346.28,Pays at 100% of Medicare OPPS Rate,534.57,Pays at 32.15% of Total Billed charges,1463.22,Pays at 88% of Total Billed charges,550.54,Pays at 33.11% of Total Billed charges,346.28,1496.48,997.65
Outpatient Medical Services,RADIOLOGY,70553,MRI scan of brain before and after contrast,610,1771,1505.35,Pays at 85% of Billed charges for outpatient setting,569.38,Pays at 32.15% of Total Billed charges,1417.33,Pays at 80.03% of Total Billed charges,353.2,Pays at 102% of Medicare OPPS Rate,1593.9,Pays at 90% of Total Billed charges,569.38,Pays at 32.15% of Total Billed charges,346.28,Pays at 100% of Medicare OPPS Rate,569.38,Pays at 32.15% of Total Billed charges,1558.48,Pays at 88% of Total Billed charges,586.38,Pays at 33.11% of Total Billed charges,346.28,1593.9,1062.60
Outpatient Medical Services,RADIOLOGY,70553,MRI scan of brain before and after contrast,610,1417,1204.45,Pays at 85% of Billed charges for outpatient setting,455.57,Pays at 32.15% of Total Billed charges,1134.03,Pays at 80.03% of Total Billed charges,353.2,Pays at 102% of Medicare OPPS Rate,1275.3,Pays at 90% of Total Billed charges,455.57,Pays at 32.15% of Total Billed charges,346.28,Pays at 100% of Medicare OPPS Rate,455.57,Pays at 32.15% of Total Billed charges,1246.96,Pays at 88% of Total Billed charges,469.17,Pays at 33.11% of Total Billed charges,346.28,1275.3,850.20
Outpatient Medical Services,RADIOLOGY,70553,MRI scan of brain before and after contrast,610,1417,1204.45,Pays at 85% of Billed charges for outpatient setting,455.57,Pays at 32.15% of Total Billed charges,1134.03,Pays at 80.03% of Total Billed charges,353.2,Pays at 102% of Medicare OPPS Rate,1275.3,Pays at 90% of Total Billed charges,455.57,Pays at 32.15% of Total Billed charges,346.28,Pays at 100% of Medicare OPPS Rate,455.57,Pays at 32.15% of Total Billed charges,1246.96,Pays at 88% of Total Billed charges,469.17,Pays at 33.11% of Total Billed charges,346.28,1275.3,850.20
Outpatient Medical Services,RADIOLOGY,71550,MRI CHEST WITHOUT  CONTRAST,610,1662.75,1413.34,Pays at 85% of Billed charges for outpatient setting,534.57,Pays at 32.15% of Total Billed charges,1330.7,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,1496.48,Pays at 90% of Total Billed charges,534.57,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,534.57,Pays at 32.15% of Total Billed charges,1463.22,Pays at 88% of Total Billed charges,550.54,Pays at 33.11% of Total Billed charges,219.48,1496.48,997.65
Outpatient Medical Services,RADIOLOGY,71551,MRI CHEST W CONTRAST,610,1662.75,1413.34,Pays at 85% of Billed charges for outpatient setting,534.57,Pays at 32.15% of Total Billed charges,1330.7,Pays at 80.03% of Total Billed charges,710.15,Pays at 102% of Medicare OPPS Rate,1496.48,Pays at 90% of Total Billed charges,534.57,Pays at 32.15% of Total Billed charges,696.23,Pays at 100% of Medicare OPPS Rate,534.57,Pays at 32.15% of Total Billed charges,1463.22,Pays at 88% of Total Billed charges,550.54,Pays at 33.11% of Total Billed charges,534.57,1496.48,997.65
Outpatient Medical Services,RADIOLOGY,71552,MRI CHEST WITH AND  WITHOUT  CONTRAST,610,2138,1817.3,Pays at 85% of Billed charges for outpatient setting,687.37,Pays at 32.15% of Total Billed charges,1711.04,Pays at 80.03% of Total Billed charges,353.2,Pays at 102% of Medicare OPPS Rate,1924.2,Pays at 90% of Total Billed charges,687.37,Pays at 32.15% of Total Billed charges,346.28,Pays at 100% of Medicare OPPS Rate,687.37,Pays at 32.15% of Total Billed charges,1881.44,Pays at 88% of Total Billed charges,707.89,Pays at 33.11% of Total Billed charges,346.28,1924.2,1282.80
Outpatient Medical Services,RADIOLOGY,71555,MRA OF CHEST WITH AND WITHOUT,610,1995.75,1696.39,Pays at 85% of Billed charges for outpatient setting,641.63,Pays at 32.15% of Total Billed charges,1597.2,Pays at 80.03% of Total Billed charges,1995.75,Not Applicable,1796.18,Pays at 90% of Total Billed charges,641.63,Pays at 32.15% of Total Billed charges,1995.75,Not Applicable,641.63,Pays at 32.15% of Total Billed charges,1756.26,Pays at 88% of Total Billed charges,660.79,Pays at 33.11% of Total Billed charges,641.63,1995.75,1197.45
Outpatient Medical Services,RADIOLOGY,72142,MRI CERVICAL W CONTRAST,610,1662.75,1413.34,Pays at 85% of Billed charges for outpatient setting,534.57,Pays at 32.15% of Total Billed charges,1330.7,Pays at 80.03% of Total Billed charges,353.2,Pays at 102% of Medicare OPPS Rate,1496.48,Pays at 90% of Total Billed charges,534.57,Pays at 32.15% of Total Billed charges,346.28,Pays at 100% of Medicare OPPS Rate,534.57,Pays at 32.15% of Total Billed charges,1463.22,Pays at 88% of Total Billed charges,550.54,Pays at 33.11% of Total Billed charges,346.28,1496.48,997.65
Outpatient Medical Services,RADIOLOGY,72146,MRI of chest and spine without dye,610,1382.75,1175.34,Pays at 85% of Billed charges for outpatient setting,444.55,Pays at 32.15% of Total Billed charges,1106.61,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,1244.48,Pays at 90% of Total Billed charges,444.55,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,444.55,Pays at 32.15% of Total Billed charges,1216.82,Pays at 88% of Total Billed charges,457.83,Pays at 33.11% of Total Billed charges,219.48,1244.48,829.65
Outpatient Medical Services,RADIOLOGY,72147,MRI THORACIC W CONTRAST,610,1662.75,1413.34,Pays at 85% of Billed charges for outpatient setting,534.57,Pays at 32.15% of Total Billed charges,1330.7,Pays at 80.03% of Total Billed charges,353.2,Pays at 102% of Medicare OPPS Rate,1496.48,Pays at 90% of Total Billed charges,534.57,Pays at 32.15% of Total Billed charges,346.28,Pays at 100% of Medicare OPPS Rate,534.57,Pays at 32.15% of Total Billed charges,1463.22,Pays at 88% of Total Billed charges,550.54,Pays at 33.11% of Total Billed charges,346.28,1496.48,997.65
Outpatient Medical Services,RADIOLOGY,72149,MRI LUMBAR W CONTRAST,610,1181,1003.85,Pays at 85% of Billed charges for outpatient setting,379.69,Pays at 32.15% of Total Billed charges,945.15,Pays at 80.03% of Total Billed charges,353.2,Pays at 102% of Medicare OPPS Rate,1062.9,Pays at 90% of Total Billed charges,379.69,Pays at 32.15% of Total Billed charges,346.28,Pays at 100% of Medicare OPPS Rate,379.69,Pays at 32.15% of Total Billed charges,1039.28,Pays at 88% of Total Billed charges,391.03,Pays at 33.11% of Total Billed charges,346.28,1062.9,708.60
Outpatient Medical Services,RADIOLOGY,72156,MRI of neck/spine with and without dye,610,1417,1204.45,Pays at 85% of Billed charges for outpatient setting,455.57,Pays at 32.15% of Total Billed charges,1134.03,Pays at 80.03% of Total Billed charges,353.2,Pays at 102% of Medicare OPPS Rate,1275.3,Pays at 90% of Total Billed charges,455.57,Pays at 32.15% of Total Billed charges,346.28,Pays at 100% of Medicare OPPS Rate,455.57,Pays at 32.15% of Total Billed charges,1246.96,Pays at 88% of Total Billed charges,469.17,Pays at 33.11% of Total Billed charges,346.28,1275.3,850.20
Outpatient Medical Services,RADIOLOGY,72157,MRI of chest and spine with and without dye,610,1417,1204.45,Pays at 85% of Billed charges for outpatient setting,455.57,Pays at 32.15% of Total Billed charges,1134.03,Pays at 80.03% of Total Billed charges,353.2,Pays at 102% of Medicare OPPS Rate,1275.3,Pays at 90% of Total Billed charges,455.57,Pays at 32.15% of Total Billed charges,346.28,Pays at 100% of Medicare OPPS Rate,455.57,Pays at 32.15% of Total Billed charges,1246.96,Pays at 88% of Total Billed charges,469.17,Pays at 33.11% of Total Billed charges,346.28,1275.3,850.20
Outpatient Medical Services,RADIOLOGY,72195,MRI of pelvis without dye,610,961.5,817.28,Pays at 85% of Billed charges for outpatient setting,309.12,Pays at 32.15% of Total Billed charges,769.49,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,865.35,Pays at 90% of Total Billed charges,309.12,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,309.12,Pays at 32.15% of Total Billed charges,846.12,Pays at 88% of Total Billed charges,318.35,Pays at 33.11% of Total Billed charges,219.48,865.35,576.90
Outpatient Medical Services,RADIOLOGY,72196,MRI PELVIS W CONTRAST,610,1662.75,1413.34,Pays at 85% of Billed charges for outpatient setting,534.57,Pays at 32.15% of Total Billed charges,1330.7,Pays at 80.03% of Total Billed charges,353.2,Pays at 102% of Medicare OPPS Rate,1496.48,Pays at 90% of Total Billed charges,534.57,Pays at 32.15% of Total Billed charges,346.28,Pays at 100% of Medicare OPPS Rate,534.57,Pays at 32.15% of Total Billed charges,1463.22,Pays at 88% of Total Billed charges,550.54,Pays at 33.11% of Total Billed charges,346.28,1496.48,997.65
Outpatient Medical Services,RADIOLOGY,72197,MRI of pelvis before and after dye,610,1417,1204.45,Pays at 85% of Billed charges for outpatient setting,455.57,Pays at 32.15% of Total Billed charges,1134.03,Pays at 80.03% of Total Billed charges,353.2,Pays at 102% of Medicare OPPS Rate,1275.3,Pays at 90% of Total Billed charges,455.57,Pays at 32.15% of Total Billed charges,346.28,Pays at 100% of Medicare OPPS Rate,455.57,Pays at 32.15% of Total Billed charges,1246.96,Pays at 88% of Total Billed charges,469.17,Pays at 33.11% of Total Billed charges,346.28,1275.3,850.20
Outpatient Medical Services,RADIOLOGY,72198,MRA OF PELVIS WITH OR W/O CONTRAST,610,1767,1501.95,Pays at 85% of Billed charges for outpatient setting,568.09,Pays at 32.15% of Total Billed charges,1414.13,Pays at 80.03% of Total Billed charges,1767,Not Applicable,1590.3,Pays at 90% of Total Billed charges,568.09,Pays at 32.15% of Total Billed charges,1767,Not Applicable,568.09,Pays at 32.15% of Total Billed charges,1554.96,Pays at 88% of Total Billed charges,585.05,Pays at 33.11% of Total Billed charges,568.09,1767,1060.20
Outpatient Medical Services,RADIOLOGY,73218,MRI EXT UP NON JOINT BILAT WO CONTRAST,610,2138,1817.3,Pays at 85% of Billed charges for outpatient setting,687.37,Pays at 32.15% of Total Billed charges,1711.04,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,1924.2,Pays at 90% of Total Billed charges,687.37,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,687.37,Pays at 32.15% of Total Billed charges,1881.44,Pays at 88% of Total Billed charges,707.89,Pays at 33.11% of Total Billed charges,219.48,1924.2,1282.80
Outpatient Medical Services,RADIOLOGY,73218,MRI EXT UP NON-JNT WO CONTRAST LT,610,961.5,817.28,Pays at 85% of Billed charges for outpatient setting,309.12,Pays at 32.15% of Total Billed charges,769.49,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,865.35,Pays at 90% of Total Billed charges,309.12,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,309.12,Pays at 32.15% of Total Billed charges,846.12,Pays at 88% of Total Billed charges,318.35,Pays at 33.11% of Total Billed charges,219.48,865.35,576.90
Outpatient Medical Services,RADIOLOGY,73218,MRI EXT UP NON-JNT WO CONTRAST RT,610,961.5,817.28,Pays at 85% of Billed charges for outpatient setting,309.12,Pays at 32.15% of Total Billed charges,769.49,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,865.35,Pays at 90% of Total Billed charges,309.12,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,309.12,Pays at 32.15% of Total Billed charges,846.12,Pays at 88% of Total Billed charges,318.35,Pays at 33.11% of Total Billed charges,219.48,865.35,576.90
Outpatient Medical Services,RADIOLOGY,73220,MRI EXT UP NON-JNT WWO CONTRAST LT,610,1181,1003.85,Pays at 85% of Billed charges for outpatient setting,379.69,Pays at 32.15% of Total Billed charges,945.15,Pays at 80.03% of Total Billed charges,353.2,Pays at 102% of Medicare OPPS Rate,1062.9,Pays at 90% of Total Billed charges,379.69,Pays at 32.15% of Total Billed charges,346.28,Pays at 100% of Medicare OPPS Rate,379.69,Pays at 32.15% of Total Billed charges,1039.28,Pays at 88% of Total Billed charges,391.03,Pays at 33.11% of Total Billed charges,346.28,1062.9,708.60
Outpatient Medical Services,RADIOLOGY,73220,MRI EXT UP NON-JNT WWO CONTRAST RT,610,2138,1817.3,Pays at 85% of Billed charges for outpatient setting,687.37,Pays at 32.15% of Total Billed charges,1711.04,Pays at 80.03% of Total Billed charges,353.2,Pays at 102% of Medicare OPPS Rate,1924.2,Pays at 90% of Total Billed charges,687.37,Pays at 32.15% of Total Billed charges,346.28,Pays at 100% of Medicare OPPS Rate,687.37,Pays at 32.15% of Total Billed charges,1881.44,Pays at 88% of Total Billed charges,707.89,Pays at 33.11% of Total Billed charges,346.28,1924.2,1282.80
Outpatient Medical Services,RADIOLOGY,73221,MRI of upper extremity without dye,610,2138,1817.3,Pays at 85% of Billed charges for outpatient setting,687.37,Pays at 32.15% of Total Billed charges,1711.04,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,1924.2,Pays at 90% of Total Billed charges,687.37,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,687.37,Pays at 32.15% of Total Billed charges,1881.44,Pays at 88% of Total Billed charges,707.89,Pays at 33.11% of Total Billed charges,219.48,1924.2,1282.80
Outpatient Medical Services,RADIOLOGY,73221,MRI of upper extremity without dye,610,1382.75,1175.34,Pays at 85% of Billed charges for outpatient setting,444.55,Pays at 32.15% of Total Billed charges,1106.61,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,1244.48,Pays at 90% of Total Billed charges,444.55,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,444.55,Pays at 32.15% of Total Billed charges,1216.82,Pays at 88% of Total Billed charges,457.83,Pays at 33.11% of Total Billed charges,219.48,1244.48,829.65
Outpatient Medical Services,RADIOLOGY,73221,MRI of upper extremity without dye,610,1662.75,1413.34,Pays at 85% of Billed charges for outpatient setting,534.57,Pays at 32.15% of Total Billed charges,1330.7,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,1496.48,Pays at 90% of Total Billed charges,534.57,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,534.57,Pays at 32.15% of Total Billed charges,1463.22,Pays at 88% of Total Billed charges,550.54,Pays at 33.11% of Total Billed charges,219.48,1496.48,997.65
Outpatient Medical Services,RADIOLOGY,73222,MRI EXT UP JOINT W CONTRAST LT,610,1662.75,1413.34,Pays at 85% of Billed charges for outpatient setting,534.57,Pays at 32.15% of Total Billed charges,1330.7,Pays at 80.03% of Total Billed charges,710.15,Pays at 102% of Medicare OPPS Rate,1496.48,Pays at 90% of Total Billed charges,534.57,Pays at 32.15% of Total Billed charges,696.23,Pays at 100% of Medicare OPPS Rate,534.57,Pays at 32.15% of Total Billed charges,1463.22,Pays at 88% of Total Billed charges,550.54,Pays at 33.11% of Total Billed charges,534.57,1496.48,997.65
Outpatient Medical Services,RADIOLOGY,73222,MRI EXT UP ANY JNT W CONTRAST LT,610,1662.75,1413.34,Pays at 85% of Billed charges for outpatient setting,534.57,Pays at 32.15% of Total Billed charges,1330.7,Pays at 80.03% of Total Billed charges,710.15,Pays at 102% of Medicare OPPS Rate,1496.48,Pays at 90% of Total Billed charges,534.57,Pays at 32.15% of Total Billed charges,696.23,Pays at 100% of Medicare OPPS Rate,534.57,Pays at 32.15% of Total Billed charges,1463.22,Pays at 88% of Total Billed charges,550.54,Pays at 33.11% of Total Billed charges,534.57,1496.48,997.65
Outpatient Medical Services,RADIOLOGY,73222,MRI EXT UP ANY-JNT W CONTRAST RT,610,1662.75,1413.34,Pays at 85% of Billed charges for outpatient setting,534.57,Pays at 32.15% of Total Billed charges,1330.7,Pays at 80.03% of Total Billed charges,710.15,Pays at 102% of Medicare OPPS Rate,1496.48,Pays at 90% of Total Billed charges,534.57,Pays at 32.15% of Total Billed charges,696.23,Pays at 100% of Medicare OPPS Rate,534.57,Pays at 32.15% of Total Billed charges,1463.22,Pays at 88% of Total Billed charges,550.54,Pays at 33.11% of Total Billed charges,534.57,1496.48,997.65
Outpatient Medical Services,RADIOLOGY,73222,MRI EXT UP JOINT W CONTRAST RT,610,1764.75,1500.04,Pays at 85% of Billed charges for outpatient setting,567.37,Pays at 32.15% of Total Billed charges,1412.33,Pays at 80.03% of Total Billed charges,710.15,Pays at 102% of Medicare OPPS Rate,1588.28,Pays at 90% of Total Billed charges,567.37,Pays at 32.15% of Total Billed charges,696.23,Pays at 100% of Medicare OPPS Rate,567.37,Pays at 32.15% of Total Billed charges,1552.98,Pays at 88% of Total Billed charges,584.31,Pays at 33.11% of Total Billed charges,567.37,1588.28,1058.85
Outpatient Medical Services,RADIOLOGY,73223,MRI EXT UP JOINT BILAT WWO CONTRAST,610,3088,2624.8,Pays at 85% of Billed charges for outpatient setting,992.79,Pays at 32.15% of Total Billed charges,2471.33,Pays at 80.03% of Total Billed charges,353.2,Pays at 102% of Medicare OPPS Rate,2779.2,Pays at 90% of Total Billed charges,992.79,Pays at 32.15% of Total Billed charges,346.28,Pays at 100% of Medicare OPPS Rate,992.79,Pays at 32.15% of Total Billed charges,2717.44,Pays at 88% of Total Billed charges,1022.44,Pays at 33.11% of Total Billed charges,346.28,2779.2,1852.80
Outpatient Medical Services,RADIOLOGY,73223,MRI EXT UP JOINT WWO CONTRAST LT,610,1181,1003.85,Pays at 85% of Billed charges for outpatient setting,379.69,Pays at 32.15% of Total Billed charges,945.15,Pays at 80.03% of Total Billed charges,353.2,Pays at 102% of Medicare OPPS Rate,1062.9,Pays at 90% of Total Billed charges,379.69,Pays at 32.15% of Total Billed charges,346.28,Pays at 100% of Medicare OPPS Rate,379.69,Pays at 32.15% of Total Billed charges,1039.28,Pays at 88% of Total Billed charges,391.03,Pays at 33.11% of Total Billed charges,346.28,1062.9,708.60
Outpatient Medical Services,RADIOLOGY,73223,MRI EXT UP JOINT WWO CONTRAST RT,610,1417,1204.45,Pays at 85% of Billed charges for outpatient setting,455.57,Pays at 32.15% of Total Billed charges,1134.03,Pays at 80.03% of Total Billed charges,353.2,Pays at 102% of Medicare OPPS Rate,1275.3,Pays at 90% of Total Billed charges,455.57,Pays at 32.15% of Total Billed charges,346.28,Pays at 100% of Medicare OPPS Rate,455.57,Pays at 32.15% of Total Billed charges,1246.96,Pays at 88% of Total Billed charges,469.17,Pays at 33.11% of Total Billed charges,346.28,1275.3,850.20
Outpatient Medical Services,RADIOLOGY,73718,MRI of leg without dye,610,1662.75,1413.34,Pays at 85% of Billed charges for outpatient setting,534.57,Pays at 32.15% of Total Billed charges,1330.7,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,1496.48,Pays at 90% of Total Billed charges,534.57,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,534.57,Pays at 32.15% of Total Billed charges,1463.22,Pays at 88% of Total Billed charges,550.54,Pays at 33.11% of Total Billed charges,219.48,1496.48,997.65
Outpatient Medical Services,RADIOLOGY,74181,MRI of abdomen without dye,610,961.5,817.28,Pays at 85% of Billed charges for outpatient setting,309.12,Pays at 32.15% of Total Billed charges,769.49,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,865.35,Pays at 90% of Total Billed charges,309.12,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,309.12,Pays at 32.15% of Total Billed charges,846.12,Pays at 88% of Total Billed charges,318.35,Pays at 33.11% of Total Billed charges,219.48,865.35,576.90
Outpatient Medical Services,RADIOLOGY,74181,MRI of abdomen without dye,610,1662.75,1413.34,Pays at 85% of Billed charges for outpatient setting,534.57,Pays at 32.15% of Total Billed charges,1330.7,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,1496.48,Pays at 90% of Total Billed charges,534.57,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,534.57,Pays at 32.15% of Total Billed charges,1463.22,Pays at 88% of Total Billed charges,550.54,Pays at 33.11% of Total Billed charges,219.48,1496.48,997.65
Outpatient Medical Services,RADIOLOGY,74181,MRI of abdomen without dye,610,1662.75,1413.34,Pays at 85% of Billed charges for outpatient setting,534.57,Pays at 32.15% of Total Billed charges,1330.7,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,1496.48,Pays at 90% of Total Billed charges,534.57,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,534.57,Pays at 32.15% of Total Billed charges,1463.22,Pays at 88% of Total Billed charges,550.54,Pays at 33.11% of Total Billed charges,219.48,1496.48,997.65
Outpatient Medical Services,RADIOLOGY,74181,MRI of abdomen without dye,610,1662.75,1413.34,Pays at 85% of Billed charges for outpatient setting,534.57,Pays at 32.15% of Total Billed charges,1330.7,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,1496.48,Pays at 90% of Total Billed charges,534.57,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,534.57,Pays at 32.15% of Total Billed charges,1463.22,Pays at 88% of Total Billed charges,550.54,Pays at 33.11% of Total Billed charges,219.48,1496.48,997.65
Outpatient Medical Services,RADIOLOGY,74182,MRI KIDNEY WITH CONTRAST,610,1662.75,1413.34,Pays at 85% of Billed charges for outpatient setting,534.57,Pays at 32.15% of Total Billed charges,1330.7,Pays at 80.03% of Total Billed charges,353.2,Pays at 102% of Medicare OPPS Rate,1496.48,Pays at 90% of Total Billed charges,534.57,Pays at 32.15% of Total Billed charges,346.28,Pays at 100% of Medicare OPPS Rate,534.57,Pays at 32.15% of Total Billed charges,1463.22,Pays at 88% of Total Billed charges,550.54,Pays at 33.11% of Total Billed charges,346.28,1496.48,997.65
Outpatient Medical Services,RADIOLOGY,74182,MRI ABDOMEN WITH CONTRAST,610,1662.75,1413.34,Pays at 85% of Billed charges for outpatient setting,534.57,Pays at 32.15% of Total Billed charges,1330.7,Pays at 80.03% of Total Billed charges,353.2,Pays at 102% of Medicare OPPS Rate,1496.48,Pays at 90% of Total Billed charges,534.57,Pays at 32.15% of Total Billed charges,346.28,Pays at 100% of Medicare OPPS Rate,534.57,Pays at 32.15% of Total Billed charges,1463.22,Pays at 88% of Total Billed charges,550.54,Pays at 33.11% of Total Billed charges,346.28,1496.48,997.65
Outpatient Medical Services,RADIOLOGY,74183,MRI of abdomen without and with dye,610,1417,1204.45,Pays at 85% of Billed charges for outpatient setting,455.57,Pays at 32.15% of Total Billed charges,1134.03,Pays at 80.03% of Total Billed charges,353.2,Pays at 102% of Medicare OPPS Rate,1275.3,Pays at 90% of Total Billed charges,455.57,Pays at 32.15% of Total Billed charges,346.28,Pays at 100% of Medicare OPPS Rate,455.57,Pays at 32.15% of Total Billed charges,1246.96,Pays at 88% of Total Billed charges,469.17,Pays at 33.11% of Total Billed charges,346.28,1275.3,850.20
Outpatient Medical Services,RADIOLOGY,74183,MRI of abdomen without and with dye,610,1417,1204.45,Pays at 85% of Billed charges for outpatient setting,455.57,Pays at 32.15% of Total Billed charges,1134.03,Pays at 80.03% of Total Billed charges,353.2,Pays at 102% of Medicare OPPS Rate,1275.3,Pays at 90% of Total Billed charges,455.57,Pays at 32.15% of Total Billed charges,346.28,Pays at 100% of Medicare OPPS Rate,455.57,Pays at 32.15% of Total Billed charges,1246.96,Pays at 88% of Total Billed charges,469.17,Pays at 33.11% of Total Billed charges,346.28,1275.3,850.20
Outpatient Medical Services,RADIOLOGY,74183,MRI of abdomen without and with dye,610,1417,1204.45,Pays at 85% of Billed charges for outpatient setting,455.57,Pays at 32.15% of Total Billed charges,1134.03,Pays at 80.03% of Total Billed charges,353.2,Pays at 102% of Medicare OPPS Rate,1275.3,Pays at 90% of Total Billed charges,455.57,Pays at 32.15% of Total Billed charges,346.28,Pays at 100% of Medicare OPPS Rate,455.57,Pays at 32.15% of Total Billed charges,1246.96,Pays at 88% of Total Billed charges,469.17,Pays at 33.11% of Total Billed charges,346.28,1275.3,850.20
Outpatient Medical Services,RADIOLOGY,76376,MRI  REFORMAT,610,230.5,195.93,Pays at 85% of Billed charges for outpatient setting,74.11,Pays at 32.15% of Total Billed charges,184.47,Pays at 80.03% of Total Billed charges,230.5,Not Applicable,207.45,Pays at 90% of Total Billed charges,74.11,Pays at 32.15% of Total Billed charges,230.5,Not Applicable,74.11,Pays at 32.15% of Total Billed charges,202.84,Pays at 88% of Total Billed charges,76.32,Pays at 33.11% of Total Billed charges,74.11,230.5,138.30
Outpatient Medical Services,RADIOLOGY,77021,MRI BREAST BIOPSY,610,658.5,559.73,Pays at 85% of Billed charges for outpatient setting,211.71,Pays at 32.15% of Total Billed charges,527,Pays at 80.03% of Total Billed charges,658.5,Not Applicable,592.65,Pays at 90% of Total Billed charges,211.71,Pays at 32.15% of Total Billed charges,658.5,Not Applicable,211.71,Pays at 32.15% of Total Billed charges,579.48,Pays at 88% of Total Billed charges,218.03,Pays at 33.11% of Total Billed charges,211.71,658.5,395.10
Outpatient Medical Services,RADIOLOGY,77058,MRI OF BREAST WITHOUT UNILAT,610,1662.75,1413.34,Pays at 85% of Billed charges for outpatient setting,534.57,Pays at 32.15% of Total Billed charges,1330.7,Pays at 80.03% of Total Billed charges,1662.75,Not Applicable,1496.48,Pays at 90% of Total Billed charges,534.57,Pays at 32.15% of Total Billed charges,1662.75,Not Applicable,534.57,Pays at 32.15% of Total Billed charges,1463.22,Pays at 88% of Total Billed charges,550.54,Pays at 33.11% of Total Billed charges,534.57,1662.75,997.65
Outpatient Medical Services,RADIOLOGY,77058,MRI OF BREAST WITH  UNILAT,610,1662.75,1413.34,Pays at 85% of Billed charges for outpatient setting,534.57,Pays at 32.15% of Total Billed charges,1330.7,Pays at 80.03% of Total Billed charges,1662.75,Not Applicable,1496.48,Pays at 90% of Total Billed charges,534.57,Pays at 32.15% of Total Billed charges,1662.75,Not Applicable,534.57,Pays at 32.15% of Total Billed charges,1463.22,Pays at 88% of Total Billed charges,550.54,Pays at 33.11% of Total Billed charges,534.57,1662.75,997.65
Outpatient Medical Services,RADIOLOGY,77058,MRI OF BREAST WITH  AND WITHOUT  UNILAT,610,2138,1817.3,Pays at 85% of Billed charges for outpatient setting,687.37,Pays at 32.15% of Total Billed charges,1711.04,Pays at 80.03% of Total Billed charges,2138,Not Applicable,1924.2,Pays at 90% of Total Billed charges,687.37,Pays at 32.15% of Total Billed charges,2138,Not Applicable,687.37,Pays at 32.15% of Total Billed charges,1881.44,Pays at 88% of Total Billed charges,707.89,Pays at 33.11% of Total Billed charges,687.37,2138,1282.80
Outpatient Medical Services,RADIOLOGY,77059,MRI OF BREAST WITHOUT BILAT,610,2138,1817.3,Pays at 85% of Billed charges for outpatient setting,687.37,Pays at 32.15% of Total Billed charges,1711.04,Pays at 80.03% of Total Billed charges,2138,Not Applicable,1924.2,Pays at 90% of Total Billed charges,687.37,Pays at 32.15% of Total Billed charges,2138,Not Applicable,687.37,Pays at 32.15% of Total Billed charges,1881.44,Pays at 88% of Total Billed charges,707.89,Pays at 33.11% of Total Billed charges,687.37,2138,1282.80
Outpatient Medical Services,RADIOLOGY,77059,MRI OF BREAST WITH  BILAT,610,2138,1817.3,Pays at 85% of Billed charges for outpatient setting,687.37,Pays at 32.15% of Total Billed charges,1711.04,Pays at 80.03% of Total Billed charges,2138,Not Applicable,1924.2,Pays at 90% of Total Billed charges,687.37,Pays at 32.15% of Total Billed charges,2138,Not Applicable,687.37,Pays at 32.15% of Total Billed charges,1881.44,Pays at 88% of Total Billed charges,707.89,Pays at 33.11% of Total Billed charges,687.37,2138,1282.80
Outpatient Medical Services,RADIOLOGY,77059,MRI OF BREAST WITH AND WITHOUT BILAT,610,3088,2624.8,Pays at 85% of Billed charges for outpatient setting,992.79,Pays at 32.15% of Total Billed charges,2471.33,Pays at 80.03% of Total Billed charges,3088,Not Applicable,2779.2,Pays at 90% of Total Billed charges,992.79,Pays at 32.15% of Total Billed charges,3088,Not Applicable,992.79,Pays at 32.15% of Total Billed charges,2717.44,Pays at 88% of Total Billed charges,1022.44,Pays at 33.11% of Total Billed charges,992.79,3088,1852.80
Outpatient Medical Services,RADIOLOGY,77084,MRI BONE MARROW,610,1662.75,1413.34,Pays at 85% of Billed charges for outpatient setting,534.57,Pays at 32.15% of Total Billed charges,1330.7,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,1496.48,Pays at 90% of Total Billed charges,534.57,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,534.57,Pays at 32.15% of Total Billed charges,1463.22,Pays at 88% of Total Billed charges,550.54,Pays at 33.11% of Total Billed charges,219.48,1496.48,997.65
Outpatient Medical Services,RADIOLOGY,610,=> MRI ORDER             <=,610,SERVICE NOT OFFERED,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,0,0,#VALUE!
Outpatient Medical Services,RADIOLOGY,72141,MRI of the neck or spine without dye,612,1662.75,1413.34,Pays at 85% of Billed charges for outpatient setting,534.57,Pays at 32.15% of Total Billed charges,1330.7,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,1496.48,Pays at 90% of Total Billed charges,534.57,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,534.57,Pays at 32.15% of Total Billed charges,1463.22,Pays at 88% of Total Billed charges,550.54,Pays at 33.11% of Total Billed charges,219.48,1496.48,997.65
Outpatient Medical Services,RADIOLOGY,72148,MRI scan of lower spinal canal,612,1662.75,1413.34,Pays at 85% of Billed charges for outpatient setting,534.57,Pays at 32.15% of Total Billed charges,1330.7,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,1496.48,Pays at 90% of Total Billed charges,534.57,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,534.57,Pays at 32.15% of Total Billed charges,1463.22,Pays at 88% of Total Billed charges,550.54,Pays at 33.11% of Total Billed charges,219.48,1496.48,997.65
Outpatient Medical Services,RADIOLOGY,72158,MRI of lower back with and without dye,612,2138,1817.3,Pays at 85% of Billed charges for outpatient setting,687.37,Pays at 32.15% of Total Billed charges,1711.04,Pays at 80.03% of Total Billed charges,353.2,Pays at 102% of Medicare OPPS Rate,1924.2,Pays at 90% of Total Billed charges,687.37,Pays at 32.15% of Total Billed charges,346.28,Pays at 100% of Medicare OPPS Rate,687.37,Pays at 32.15% of Total Billed charges,1881.44,Pays at 88% of Total Billed charges,707.89,Pays at 33.11% of Total Billed charges,346.28,1924.2,1282.80
Outpatient Medical Services,RADIOLOGY,73718,MRI of leg without dye,614,961.5,817.28,Pays at 85% of Billed charges for outpatient setting,309.12,Pays at 32.15% of Total Billed charges,769.49,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,865.35,Pays at 90% of Total Billed charges,309.12,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,309.12,Pays at 32.15% of Total Billed charges,846.12,Pays at 88% of Total Billed charges,318.35,Pays at 33.11% of Total Billed charges,219.48,865.35,576.90
Outpatient Medical Services,RADIOLOGY,73718,MRI of leg without dye,614,961.5,817.28,Pays at 85% of Billed charges for outpatient setting,309.12,Pays at 32.15% of Total Billed charges,769.49,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,865.35,Pays at 90% of Total Billed charges,309.12,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,309.12,Pays at 32.15% of Total Billed charges,846.12,Pays at 88% of Total Billed charges,318.35,Pays at 33.11% of Total Billed charges,219.48,865.35,576.90
Outpatient Medical Services,RADIOLOGY,73718,MRI of leg without dye,614,961.5,817.28,Pays at 85% of Billed charges for outpatient setting,309.12,Pays at 32.15% of Total Billed charges,769.49,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,865.35,Pays at 90% of Total Billed charges,309.12,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,309.12,Pays at 32.15% of Total Billed charges,846.12,Pays at 88% of Total Billed charges,318.35,Pays at 33.11% of Total Billed charges,219.48,865.35,576.90
Outpatient Medical Services,RADIOLOGY,73718,MRI of leg without dye,614,961.5,817.28,Pays at 85% of Billed charges for outpatient setting,309.12,Pays at 32.15% of Total Billed charges,769.49,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,865.35,Pays at 90% of Total Billed charges,309.12,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,309.12,Pays at 32.15% of Total Billed charges,846.12,Pays at 88% of Total Billed charges,318.35,Pays at 33.11% of Total Billed charges,219.48,865.35,576.90
Outpatient Medical Services,RADIOLOGY,73719,MRI FORE FOOT - W CONTRAST LT,614,1662.75,1413.34,Pays at 85% of Billed charges for outpatient setting,534.57,Pays at 32.15% of Total Billed charges,1330.7,Pays at 80.03% of Total Billed charges,353.2,Pays at 102% of Medicare OPPS Rate,1496.48,Pays at 90% of Total Billed charges,534.57,Pays at 32.15% of Total Billed charges,346.28,Pays at 100% of Medicare OPPS Rate,534.57,Pays at 32.15% of Total Billed charges,1463.22,Pays at 88% of Total Billed charges,550.54,Pays at 33.11% of Total Billed charges,346.28,1496.48,997.65
Outpatient Medical Services,RADIOLOGY,73719,MRI FORE FOOT - W CONTRAST RT,614,1662.75,1413.34,Pays at 85% of Billed charges for outpatient setting,534.57,Pays at 32.15% of Total Billed charges,1330.7,Pays at 80.03% of Total Billed charges,353.2,Pays at 102% of Medicare OPPS Rate,1496.48,Pays at 90% of Total Billed charges,534.57,Pays at 32.15% of Total Billed charges,346.28,Pays at 100% of Medicare OPPS Rate,534.57,Pays at 32.15% of Total Billed charges,1463.22,Pays at 88% of Total Billed charges,550.54,Pays at 33.11% of Total Billed charges,346.28,1496.48,997.65
Outpatient Medical Services,RADIOLOGY,73720,MRI EXT LOW NON-JNT BILAT WWO CONTRAST,614,1889,1605.65,Pays at 85% of Billed charges for outpatient setting,607.31,Pays at 32.15% of Total Billed charges,1511.77,Pays at 80.03% of Total Billed charges,353.2,Pays at 102% of Medicare OPPS Rate,1700.1,Pays at 90% of Total Billed charges,607.31,Pays at 32.15% of Total Billed charges,346.28,Pays at 100% of Medicare OPPS Rate,607.31,Pays at 32.15% of Total Billed charges,1662.32,Pays at 88% of Total Billed charges,625.45,Pays at 33.11% of Total Billed charges,346.28,1700.1,1133.40
Outpatient Medical Services,RADIOLOGY,73720,MRI FORE FOOT - W WO CONTRAST LT,614,1417,1204.45,Pays at 85% of Billed charges for outpatient setting,455.57,Pays at 32.15% of Total Billed charges,1134.03,Pays at 80.03% of Total Billed charges,353.2,Pays at 102% of Medicare OPPS Rate,1275.3,Pays at 90% of Total Billed charges,455.57,Pays at 32.15% of Total Billed charges,346.28,Pays at 100% of Medicare OPPS Rate,455.57,Pays at 32.15% of Total Billed charges,1246.96,Pays at 88% of Total Billed charges,469.17,Pays at 33.11% of Total Billed charges,346.28,1275.3,850.20
Outpatient Medical Services,RADIOLOGY,73720,MRI FORE FOOT - W WO CONTRAST RT,614,1417,1204.45,Pays at 85% of Billed charges for outpatient setting,455.57,Pays at 32.15% of Total Billed charges,1134.03,Pays at 80.03% of Total Billed charges,353.2,Pays at 102% of Medicare OPPS Rate,1275.3,Pays at 90% of Total Billed charges,455.57,Pays at 32.15% of Total Billed charges,346.28,Pays at 100% of Medicare OPPS Rate,455.57,Pays at 32.15% of Total Billed charges,1246.96,Pays at 88% of Total Billed charges,469.17,Pays at 33.11% of Total Billed charges,346.28,1275.3,850.20
Outpatient Medical Services,RADIOLOGY,73720,MRI EXT LOW NON-JNT WWO CONTRAST,614,1417,1204.45,Pays at 85% of Billed charges for outpatient setting,455.57,Pays at 32.15% of Total Billed charges,1134.03,Pays at 80.03% of Total Billed charges,353.2,Pays at 102% of Medicare OPPS Rate,1275.3,Pays at 90% of Total Billed charges,455.57,Pays at 32.15% of Total Billed charges,346.28,Pays at 100% of Medicare OPPS Rate,455.57,Pays at 32.15% of Total Billed charges,1246.96,Pays at 88% of Total Billed charges,469.17,Pays at 33.11% of Total Billed charges,346.28,1275.3,850.20
Outpatient Medical Services,RADIOLOGY,73721,MRI of lower extremity joint (knee/ankle) without dye,614,2138,1817.3,Pays at 85% of Billed charges for outpatient setting,687.37,Pays at 32.15% of Total Billed charges,1711.04,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,1924.2,Pays at 90% of Total Billed charges,687.37,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,687.37,Pays at 32.15% of Total Billed charges,1881.44,Pays at 88% of Total Billed charges,707.89,Pays at 33.11% of Total Billed charges,219.48,1924.2,1282.80
Outpatient Medical Services,RADIOLOGY,73721,MRI of lower extremity joint (knee/ankle) without dye,614,1322.75,1124.34,Pays at 85% of Billed charges for outpatient setting,425.26,Pays at 32.15% of Total Billed charges,1058.6,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,1190.48,Pays at 90% of Total Billed charges,425.26,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,425.26,Pays at 32.15% of Total Billed charges,1164.02,Pays at 88% of Total Billed charges,437.96,Pays at 33.11% of Total Billed charges,219.48,1190.48,793.65
Outpatient Medical Services,RADIOLOGY,73721,MRI of lower extremity joint (knee/ankle) without dye,614,961.5,817.28,Pays at 85% of Billed charges for outpatient setting,309.12,Pays at 32.15% of Total Billed charges,769.49,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,865.35,Pays at 90% of Total Billed charges,309.12,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,309.12,Pays at 32.15% of Total Billed charges,846.12,Pays at 88% of Total Billed charges,318.35,Pays at 33.11% of Total Billed charges,219.48,865.35,576.90
Outpatient Medical Services,RADIOLOGY,73721,MRI of lower extremity joint (knee/ankle) without dye,614,1322.75,1124.34,Pays at 85% of Billed charges for outpatient setting,425.26,Pays at 32.15% of Total Billed charges,1058.6,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,1190.48,Pays at 90% of Total Billed charges,425.26,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,425.26,Pays at 32.15% of Total Billed charges,1164.02,Pays at 88% of Total Billed charges,437.96,Pays at 33.11% of Total Billed charges,219.48,1190.48,793.65
Outpatient Medical Services,RADIOLOGY,73721,MRI of lower extremity joint (knee/ankle) without dye,614,961.5,817.28,Pays at 85% of Billed charges for outpatient setting,309.12,Pays at 32.15% of Total Billed charges,769.49,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,865.35,Pays at 90% of Total Billed charges,309.12,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,309.12,Pays at 32.15% of Total Billed charges,846.12,Pays at 88% of Total Billed charges,318.35,Pays at 33.11% of Total Billed charges,219.48,865.35,576.90
Outpatient Medical Services,RADIOLOGY,73722,MRI of lower extremity joint (knee/ankle) with dye,614,1662.75,1413.34,Pays at 85% of Billed charges for outpatient setting,534.57,Pays at 32.15% of Total Billed charges,1330.7,Pays at 80.03% of Total Billed charges,710.15,Pays at 102% of Medicare OPPS Rate,1496.48,Pays at 90% of Total Billed charges,534.57,Pays at 32.15% of Total Billed charges,696.23,Pays at 100% of Medicare OPPS Rate,534.57,Pays at 32.15% of Total Billed charges,1463.22,Pays at 88% of Total Billed charges,550.54,Pays at 33.11% of Total Billed charges,534.57,1496.48,997.65
Outpatient Medical Services,RADIOLOGY,73722,MRI of lower extremity joint (knee/ankle) with dye,614,1662.75,1413.34,Pays at 85% of Billed charges for outpatient setting,534.57,Pays at 32.15% of Total Billed charges,1330.7,Pays at 80.03% of Total Billed charges,710.15,Pays at 102% of Medicare OPPS Rate,1496.48,Pays at 90% of Total Billed charges,534.57,Pays at 32.15% of Total Billed charges,696.23,Pays at 100% of Medicare OPPS Rate,534.57,Pays at 32.15% of Total Billed charges,1463.22,Pays at 88% of Total Billed charges,550.54,Pays at 33.11% of Total Billed charges,534.57,1496.48,997.65
Outpatient Medical Services,RADIOLOGY,73722,MRI of lower extremity joint (knee/ankle) with dye,614,1662.75,1413.34,Pays at 85% of Billed charges for outpatient setting,534.57,Pays at 32.15% of Total Billed charges,1330.7,Pays at 80.03% of Total Billed charges,710.15,Pays at 102% of Medicare OPPS Rate,1496.48,Pays at 90% of Total Billed charges,534.57,Pays at 32.15% of Total Billed charges,696.23,Pays at 100% of Medicare OPPS Rate,534.57,Pays at 32.15% of Total Billed charges,1463.22,Pays at 88% of Total Billed charges,550.54,Pays at 33.11% of Total Billed charges,534.57,1496.48,997.65
Outpatient Medical Services,RADIOLOGY,73722,MRI of lower extremity joint (knee/ankle) with dye,614,1662.75,1413.34,Pays at 85% of Billed charges for outpatient setting,534.57,Pays at 32.15% of Total Billed charges,1330.7,Pays at 80.03% of Total Billed charges,710.15,Pays at 102% of Medicare OPPS Rate,1496.48,Pays at 90% of Total Billed charges,534.57,Pays at 32.15% of Total Billed charges,696.23,Pays at 100% of Medicare OPPS Rate,534.57,Pays at 32.15% of Total Billed charges,1463.22,Pays at 88% of Total Billed charges,550.54,Pays at 33.11% of Total Billed charges,534.57,1496.48,997.65
Outpatient Medical Services,RADIOLOGY,73723,MRI of lower extremity joint (knee/ankle) with and without dye,614,1417,1204.45,Pays at 85% of Billed charges for outpatient setting,455.57,Pays at 32.15% of Total Billed charges,1134.03,Pays at 80.03% of Total Billed charges,353.2,Pays at 102% of Medicare OPPS Rate,1275.3,Pays at 90% of Total Billed charges,455.57,Pays at 32.15% of Total Billed charges,346.28,Pays at 100% of Medicare OPPS Rate,455.57,Pays at 32.15% of Total Billed charges,1246.96,Pays at 88% of Total Billed charges,469.17,Pays at 33.11% of Total Billed charges,346.28,1275.3,850.20
Outpatient Medical Services,RADIOLOGY,73723,MRI of lower extremity joint (knee/ankle) with and without dye,614,1417,1204.45,Pays at 85% of Billed charges for outpatient setting,455.57,Pays at 32.15% of Total Billed charges,1134.03,Pays at 80.03% of Total Billed charges,353.2,Pays at 102% of Medicare OPPS Rate,1275.3,Pays at 90% of Total Billed charges,455.57,Pays at 32.15% of Total Billed charges,346.28,Pays at 100% of Medicare OPPS Rate,455.57,Pays at 32.15% of Total Billed charges,1246.96,Pays at 88% of Total Billed charges,469.17,Pays at 33.11% of Total Billed charges,346.28,1275.3,850.20
Outpatient Medical Services,RADIOLOGY,73723,MRI of lower extremity joint (knee/ankle) with and without dye,614,1181,1003.85,Pays at 85% of Billed charges for outpatient setting,379.69,Pays at 32.15% of Total Billed charges,945.15,Pays at 80.03% of Total Billed charges,353.2,Pays at 102% of Medicare OPPS Rate,1062.9,Pays at 90% of Total Billed charges,379.69,Pays at 32.15% of Total Billed charges,346.28,Pays at 100% of Medicare OPPS Rate,379.69,Pays at 32.15% of Total Billed charges,1039.28,Pays at 88% of Total Billed charges,391.03,Pays at 33.11% of Total Billed charges,346.28,1062.9,708.60
Outpatient Medical Services,RADIOLOGY,73723,MRI of lower extremity joint (knee/ankle) with and without dye,614,1181,1003.85,Pays at 85% of Billed charges for outpatient setting,379.69,Pays at 32.15% of Total Billed charges,945.15,Pays at 80.03% of Total Billed charges,353.2,Pays at 102% of Medicare OPPS Rate,1062.9,Pays at 90% of Total Billed charges,379.69,Pays at 32.15% of Total Billed charges,346.28,Pays at 100% of Medicare OPPS Rate,379.69,Pays at 32.15% of Total Billed charges,1039.28,Pays at 88% of Total Billed charges,391.03,Pays at 33.11% of Total Billed charges,346.28,1062.9,708.60
Outpatient Medical Services,RADIOLOGY,77049,MRI BREAST SCREENING,614,1181,1003.85,Pays at 85% of Billed charges for outpatient setting,379.69,Pays at 32.15% of Total Billed charges,945.15,Pays at 80.03% of Total Billed charges,1181,Not Applicable,1062.9,Pays at 90% of Total Billed charges,379.69,Pays at 32.15% of Total Billed charges,1181,Not Applicable,379.69,Pays at 32.15% of Total Billed charges,1039.28,Pays at 88% of Total Billed charges,391.03,Pays at 33.11% of Total Billed charges,379.69,1181,708.60
Outpatient Medical Services,RADIOLOGY,77061,DIGITAL BREAST TOMOSYNTHESIS; UNILATERAL,614,38.75,32.94,Pays at 85% of Billed charges for outpatient setting,12.46,Pays at 32.15% of Total Billed charges,31.01,Pays at 80.03% of Total Billed charges,38.75,Not Applicable,34.88,Pays at 90% of Total Billed charges,12.46,Pays at 32.15% of Total Billed charges,38.75,Not Applicable,12.46,Pays at 32.15% of Total Billed charges,34.1,Pays at 88% of Total Billed charges,12.83,Pays at 33.11% of Total Billed charges,12.46,38.75,23.25
Outpatient Medical Services,RADIOLOGY,77062,DIGITAL BREAST TOMOSYNTHESIS; BILATERAL,614,77.75,66.09,Pays at 85% of Billed charges for outpatient setting,25,Pays at 32.15% of Total Billed charges,62.22,Pays at 80.03% of Total Billed charges,77.75,Not Applicable,69.98,Pays at 90% of Total Billed charges,25,Pays at 32.15% of Total Billed charges,77.75,Not Applicable,25,Pays at 32.15% of Total Billed charges,68.42,Pays at 88% of Total Billed charges,25.74,Pays at 33.11% of Total Billed charges,25,77.75,46.65
Outpatient Medical Services,RADIOLOGY,73720,MRI EXT LOW W/WO CONTRAST BIL,616,2237.75,1902.09,Pays at 85% of Billed charges for outpatient setting,719.44,Pays at 32.15% of Total Billed charges,1790.87,Pays at 80.03% of Total Billed charges,353.2,Pays at 102% of Medicare OPPS Rate,2013.98,Pays at 90% of Total Billed charges,719.44,Pays at 32.15% of Total Billed charges,346.28,Pays at 100% of Medicare OPPS Rate,719.44,Pays at 32.15% of Total Billed charges,1969.22,Pays at 88% of Total Billed charges,740.92,Pays at 33.11% of Total Billed charges,346.28,2013.98,1342.65
Outpatient Medical Services,RADIOLOGY,73725,MRA LOWER EXTREMITY W/ORW/O CONTRAST,616,2138,1817.3,Pays at 85% of Billed charges for outpatient setting,687.37,Pays at 32.15% of Total Billed charges,1711.04,Pays at 80.03% of Total Billed charges,2138,Not Applicable,1924.2,Pays at 90% of Total Billed charges,687.37,Pays at 32.15% of Total Billed charges,2138,Not Applicable,687.37,Pays at 32.15% of Total Billed charges,1881.44,Pays at 88% of Total Billed charges,707.89,Pays at 33.11% of Total Billed charges,687.37,2138,1282.80
Outpatient Medical Services,Surgery,10060,Incision and drainage of abscess; simple or single and complex or multiple,761,436.75,371.24,Pays at 85% of Billed charges for outpatient setting,140.42,Pays at 32.15% of Total Billed charges,349.53,Pays at 80.03% of Total Billed charges,173.11,Pays at 102% of Medicare OPPS Rate,393.08,Pays at 90% of Total Billed charges,140.42,Pays at 32.15% of Total Billed charges,169.72,Pays at 100% of Medicare OPPS Rate,140.42,Pays at 32.15% of Total Billed charges,384.34,Pays at 88% of Total Billed charges,144.61,Pays at 33.11% of Total Billed charges,140.42,393.08,262.05
Outpatient Medical Services,Surgery,10061,I AND D ABSCESS COMPLICATED/MULTIPLE,761,515.5,438.18,Pays at 85% of Billed charges for outpatient setting,165.73,Pays at 32.15% of Total Billed charges,412.55,Pays at 80.03% of Total Billed charges,357.66,Pays at 102% of Medicare OPPS Rate,463.95,Pays at 90% of Total Billed charges,165.73,Pays at 32.15% of Total Billed charges,350.64,Pays at 100% of Medicare OPPS Rate,165.73,Pays at 32.15% of Total Billed charges,453.64,Pays at 88% of Total Billed charges,170.68,Pays at 33.11% of Total Billed charges,165.73,463.95,309.30
Outpatient Medical Services,Surgery,10120,I & D REM FOREIGN BODY - SIMPLE,360,319.75,271.79,Pays at 85% of Billed charges for outpatient setting,102.8,Pays at 32.15% of Total Billed charges,255.9,Pays at 80.03% of Total Billed charges,357.66,Pays at 102% of Medicare OPPS Rate,287.78,Pays at 90% of Total Billed charges,102.8,Pays at 32.15% of Total Billed charges,350.64,Pays at 100% of Medicare OPPS Rate,102.8,Pays at 32.15% of Total Billed charges,281.38,Pays at 88% of Total Billed charges,105.87,Pays at 33.11% of Total Billed charges,102.8,357.66,191.85
Outpatient Medical Services,Surgery,10140,"Incision and drainage of hematoma, seroma or fluid collection",761,2558.5,2174.73,Pays at 85% of Billed charges for outpatient setting,822.56,Pays at 32.15% of Total Billed charges,2047.57,Pays at 80.03% of Total Billed charges,1437.62,Pays at 102% of Medicare OPPS Rate,2302.65,Pays at 90% of Total Billed charges,822.56,Pays at 32.15% of Total Billed charges,1409.43,Pays at 100% of Medicare OPPS Rate,822.56,Pays at 32.15% of Total Billed charges,2251.48,Pays at 88% of Total Billed charges,847.12,Pays at 33.11% of Total Billed charges,822.56,2302.65,1535.10
Outpatient Medical Services,Surgery,11040,WOUND MANAGEMENT I,490,26.3,22.36,Pays at 85% of Billed charges for outpatient setting,8.46,Pays at 32.15% of Total Billed charges,21.05,Pays at 80.03% of Total Billed charges,26.3,Not Applicable,23.67,Pays at 90% of Total Billed charges,8.46,Pays at 32.15% of Total Billed charges,26.3,Not Applicable,8.46,Pays at 32.15% of Total Billed charges,23.14,Pays at 88% of Total Billed charges,8.71,Pays at 33.11% of Total Billed charges,8.46,26.3,15.78
Outpatient Medical Services,Surgery,11040,WOUND MANAGEMENT II,490,47.3,40.21,Pays at 85% of Billed charges for outpatient setting,15.21,Pays at 32.15% of Total Billed charges,37.85,Pays at 80.03% of Total Billed charges,47.3,Not Applicable,42.57,Pays at 90% of Total Billed charges,15.21,Pays at 32.15% of Total Billed charges,47.3,Not Applicable,15.21,Pays at 32.15% of Total Billed charges,41.62,Pays at 88% of Total Billed charges,15.66,Pays at 33.11% of Total Billed charges,15.21,47.3,28.38
Outpatient Medical Services,Surgery,11040,WOUND MANAGEMENT III,490,68.3,58.06,Pays at 85% of Billed charges for outpatient setting,21.96,Pays at 32.15% of Total Billed charges,54.66,Pays at 80.03% of Total Billed charges,68.3,Not Applicable,61.47,Pays at 90% of Total Billed charges,21.96,Pays at 32.15% of Total Billed charges,68.3,Not Applicable,21.96,Pays at 32.15% of Total Billed charges,60.1,Pays at 88% of Total Billed charges,22.61,Pays at 33.11% of Total Billed charges,21.96,68.3,40.98
Outpatient Medical Services,Surgery,11040,WOUND MANAGEMENT IV,490,89.3,75.91,Pays at 85% of Billed charges for outpatient setting,28.71,Pays at 32.15% of Total Billed charges,71.47,Pays at 80.03% of Total Billed charges,89.3,Not Applicable,80.37,Pays at 90% of Total Billed charges,28.71,Pays at 32.15% of Total Billed charges,89.3,Not Applicable,28.71,Pays at 32.15% of Total Billed charges,78.58,Pays at 88% of Total Billed charges,29.57,Pays at 33.11% of Total Billed charges,28.71,89.3,53.58
Outpatient Medical Services,Surgery,11040,VENOUS STASIS ULCER RX,420,162.8,138.38,Pays at 85% of Billed charges for outpatient setting,52.34,Pays at 32.15% of Total Billed charges,130.29,Pays at 80.03% of Total Billed charges,162.8,Not Applicable,146.52,Pays at 90% of Total Billed charges,52.34,Pays at 32.15% of Total Billed charges,162.8,Not Applicable,52.34,Pays at 32.15% of Total Billed charges,143.26,Pays at 88% of Total Billed charges,53.9,Pays at 33.11% of Total Billed charges,52.34,162.8,97.68
Outpatient Medical Services,Surgery,11042,DEBRIDEMENT SUB Q FIRST 20 SQ CM OR LESS,761,1005.31,854.51,Pays at 85% of Billed charges for outpatient setting,323.21,Pays at 32.15% of Total Billed charges,804.55,Pays at 80.03% of Total Billed charges,357.66,Pays at 102% of Medicare OPPS Rate,904.78,Pays at 90% of Total Billed charges,323.21,Pays at 32.15% of Total Billed charges,350.64,Pays at 100% of Medicare OPPS Rate,323.21,Pays at 32.15% of Total Billed charges,884.67,Pays at 88% of Total Billed charges,332.86,Pays at 33.11% of Total Billed charges,323.21,904.78,603.19
Outpatient Medical Services,Surgery,11043,DEBRIDEMENT MUSCLE/FASCIA EADDT'L 20 SQ,761,1036.28,880.84,Pays at 85% of Billed charges for outpatient setting,333.16,Pays at 32.15% of Total Billed charges,829.33,Pays at 80.03% of Total Billed charges,556.95,Pays at 102% of Medicare OPPS Rate,932.65,Pays at 90% of Total Billed charges,333.16,Pays at 32.15% of Total Billed charges,546.03,Pays at 100% of Medicare OPPS Rate,333.16,Pays at 32.15% of Total Billed charges,911.93,Pays at 88% of Total Billed charges,343.11,Pays at 33.11% of Total Billed charges,333.16,932.65,621.77
Outpatient Medical Services,Surgery,11044,DEBRIDEMENT BONE FIRST 20SQ CM OR LESS,761,3755.2,3191.92,Pays at 85% of Billed charges for outpatient setting,1207.3,Pays at 32.15% of Total Billed charges,3005.29,Pays at 80.03% of Total Billed charges,1437.62,Pays at 102% of Medicare OPPS Rate,3379.68,Pays at 90% of Total Billed charges,1207.3,Pays at 32.15% of Total Billed charges,1409.43,Pays at 100% of Medicare OPPS Rate,1207.3,Pays at 32.15% of Total Billed charges,3304.58,Pays at 88% of Total Billed charges,1243.35,Pays at 33.11% of Total Billed charges,1207.3,3379.68,2253.12
Outpatient Medical Services,Surgery,11045,DEBRIDEMENT SUB Q ADD'L 20 SQ CM OR LESS,761,567.24,482.15,Pays at 85% of Billed charges for outpatient setting,182.37,Pays at 32.15% of Total Billed charges,453.96,Pays at 80.03% of Total Billed charges,567.24,Not Applicable,510.52,Pays at 90% of Total Billed charges,182.37,Pays at 32.15% of Total Billed charges,567.24,Not Applicable,182.37,Pays at 32.15% of Total Billed charges,499.17,Pays at 88% of Total Billed charges,187.81,Pays at 33.11% of Total Billed charges,182.37,567.24,340.34
Outpatient Medical Services,Surgery,11046,DEBRIDEMENT MUSCLE/FASCIA EADDT'L 20 SQ,761,691.75,587.99,Pays at 85% of Billed charges for outpatient setting,222.4,Pays at 32.15% of Total Billed charges,553.61,Pays at 80.03% of Total Billed charges,691.75,Not Applicable,622.58,Pays at 90% of Total Billed charges,222.4,Pays at 32.15% of Total Billed charges,691.75,Not Applicable,222.4,Pays at 32.15% of Total Billed charges,608.74,Pays at 88% of Total Billed charges,229.04,Pays at 33.11% of Total Billed charges,222.4,691.75,415.05
Outpatient Medical Services,Surgery,11047,DEBRIDEMENT BONEEA ADDT'L 20 SQ CM,761,1111.75,944.99,Pays at 85% of Billed charges for outpatient setting,357.43,Pays at 32.15% of Total Billed charges,889.73,Pays at 80.03% of Total Billed charges,1111.75,Not Applicable,1000.58,Pays at 90% of Total Billed charges,357.43,Pays at 32.15% of Total Billed charges,1111.75,Not Applicable,357.43,Pays at 32.15% of Total Billed charges,978.34,Pays at 88% of Total Billed charges,368.1,Pays at 33.11% of Total Billed charges,357.43,1111.75,667.05
Outpatient Medical Services,Surgery,11055,PARING OR CUTTING BENIGN HYPER LESION,761,268,227.8,Pays at 85% of Billed charges for outpatient setting,86.16,Pays at 32.15% of Total Billed charges,214.48,Pays at 80.03% of Total Billed charges,173.12,Pays at 102% of Medicare OPPS Rate,241.2,Pays at 90% of Total Billed charges,86.16,Pays at 32.15% of Total Billed charges,169.72,Pays at 100% of Medicare OPPS Rate,86.16,Pays at 32.15% of Total Billed charges,235.84,Pays at 88% of Total Billed charges,88.73,Pays at 33.11% of Total Billed charges,86.16,241.2,160.80
Outpatient Medical Services,Surgery,11055,PARING OR CUTTING BENIGN HYPERKERATOTIC,761,436.75,371.24,Pays at 85% of Billed charges for outpatient setting,140.42,Pays at 32.15% of Total Billed charges,349.53,Pays at 80.03% of Total Billed charges,173.12,Pays at 102% of Medicare OPPS Rate,393.08,Pays at 90% of Total Billed charges,140.42,Pays at 32.15% of Total Billed charges,169.72,Pays at 100% of Medicare OPPS Rate,140.42,Pays at 32.15% of Total Billed charges,384.34,Pays at 88% of Total Billed charges,144.61,Pays at 33.11% of Total Billed charges,140.42,393.08,262.05
Outpatient Medical Services,Surgery,11055,PARING/ CUT BENIGN HYPER LESION OVER 4,761,471,400.35,Pays at 85% of Billed charges for outpatient setting,151.43,Pays at 32.15% of Total Billed charges,376.94,Pays at 80.03% of Total Billed charges,173.12,Pays at 102% of Medicare OPPS Rate,423.9,Pays at 90% of Total Billed charges,151.43,Pays at 32.15% of Total Billed charges,169.72,Pays at 100% of Medicare OPPS Rate,151.43,Pays at 32.15% of Total Billed charges,414.48,Pays at 88% of Total Billed charges,155.95,Pays at 33.11% of Total Billed charges,151.43,423.9,282.60
Outpatient Medical Services,Surgery,11100,BIOPSY OF SKIN,761,804.25,683.61,Pays at 85% of Billed charges for outpatient setting,258.57,Pays at 32.15% of Total Billed charges,643.64,Pays at 80.03% of Total Billed charges,804.25,Not Applicable,723.83,Pays at 90% of Total Billed charges,258.57,Pays at 32.15% of Total Billed charges,804.25,Not Applicable,258.57,Pays at 32.15% of Total Billed charges,707.74,Pays at 88% of Total Billed charges,266.29,Pays at 33.11% of Total Billed charges,258.57,804.25,482.55
Outpatient Medical Services,Surgery,11101,BIOPSY OF SKIN EA SEPARATE,761,804.25,683.61,Pays at 85% of Billed charges for outpatient setting,258.57,Pays at 32.15% of Total Billed charges,643.64,Pays at 80.03% of Total Billed charges,804.25,Not Applicable,723.83,Pays at 90% of Total Billed charges,258.57,Pays at 32.15% of Total Billed charges,804.25,Not Applicable,258.57,Pays at 32.15% of Total Billed charges,707.74,Pays at 88% of Total Billed charges,266.29,Pays at 33.11% of Total Billed charges,258.57,804.25,482.55
Outpatient Medical Services,Surgery,11102,"Tangential biopsy of skin (e.g., for example, shave, scoop, saucerize, curette); single lesion",761,457.5,388.88,Pays at 85% of Billed charges for outpatient setting,147.09,Pays at 32.15% of Total Billed charges,366.14,Pays at 80.03% of Total Billed charges,173.11,Pays at 102% of Medicare OPPS Rate,411.75,Pays at 90% of Total Billed charges,147.09,Pays at 32.15% of Total Billed charges,169.72,Pays at 100% of Medicare OPPS Rate,147.09,Pays at 32.15% of Total Billed charges,402.6,Pays at 88% of Total Billed charges,151.48,Pays at 33.11% of Total Billed charges,147.09,411.75,274.50
Outpatient Medical Services,Surgery,11103,"Tangential biopsy of skin (e.g., for example, shave, scoop, saucerize, curette); each separate/additional lesion",761,113.75,96.69,Pays at 85% of Billed charges for outpatient setting,36.57,Pays at 32.15% of Total Billed charges,91.03,Pays at 80.03% of Total Billed charges,113.75,Not Applicable,102.38,Pays at 90% of Total Billed charges,36.57,Pays at 32.15% of Total Billed charges,113.75,Not Applicable,36.57,Pays at 32.15% of Total Billed charges,100.1,Pays at 88% of Total Billed charges,37.66,Pays at 33.11% of Total Billed charges,36.57,113.75,68.25
Outpatient Medical Services,Surgery,11104,PUNCH BIOPSY OF SKIN SINGLE LESION,761,457.5,388.88,Pays at 85% of Billed charges for outpatient setting,147.09,Pays at 32.15% of Total Billed charges,366.14,Pays at 80.03% of Total Billed charges,357.66,Pays at 102% of Medicare OPPS Rate,411.75,Pays at 90% of Total Billed charges,147.09,Pays at 32.15% of Total Billed charges,350.64,Pays at 100% of Medicare OPPS Rate,147.09,Pays at 32.15% of Total Billed charges,402.6,Pays at 88% of Total Billed charges,151.48,Pays at 33.11% of Total Billed charges,147.09,411.75,274.50
Outpatient Medical Services,Surgery,11105,PUNCH BIOPSY OF SKIN-EA  ADD LESION,761,113.75,96.69,Pays at 85% of Billed charges for outpatient setting,36.57,Pays at 32.15% of Total Billed charges,91.03,Pays at 80.03% of Total Billed charges,113.75,Not Applicable,102.38,Pays at 90% of Total Billed charges,36.57,Pays at 32.15% of Total Billed charges,113.75,Not Applicable,36.57,Pays at 32.15% of Total Billed charges,100.1,Pays at 88% of Total Billed charges,37.66,Pays at 33.11% of Total Billed charges,36.57,113.75,68.25
Outpatient Medical Services,Surgery,11106,INCISIONAL BIOPSY OF SKIN SINGLE LESION,761,457.5,388.88,Pays at 85% of Billed charges for outpatient setting,147.09,Pays at 32.15% of Total Billed charges,366.14,Pays at 80.03% of Total Billed charges,556.95,Pays at 102% of Medicare OPPS Rate,411.75,Pays at 90% of Total Billed charges,147.09,Pays at 32.15% of Total Billed charges,546.03,Pays at 100% of Medicare OPPS Rate,147.09,Pays at 32.15% of Total Billed charges,402.6,Pays at 88% of Total Billed charges,151.48,Pays at 33.11% of Total Billed charges,147.09,556.95,274.50
Outpatient Medical Services,Surgery,11107,INCISIONAL BIOPSY OF SKIN-EA  ADD LESION,761,113.75,96.69,Pays at 85% of Billed charges for outpatient setting,36.57,Pays at 32.15% of Total Billed charges,91.03,Pays at 80.03% of Total Billed charges,113.75,Not Applicable,102.38,Pays at 90% of Total Billed charges,36.57,Pays at 32.15% of Total Billed charges,113.75,Not Applicable,36.57,Pays at 32.15% of Total Billed charges,100.1,Pays at 88% of Total Billed charges,37.66,Pays at 33.11% of Total Billed charges,36.57,113.75,68.25
Outpatient Medical Services,Surgery,11200,"Removal of skin tags, multiple fibrocutaneous tags, any area",761,210,178.5,Pays at 85% of Billed charges for outpatient setting,67.52,Pays at 32.15% of Total Billed charges,168.06,Pays at 80.03% of Total Billed charges,173.12,Pays at 102% of Medicare OPPS Rate,189,Pays at 90% of Total Billed charges,67.52,Pays at 32.15% of Total Billed charges,169.72,Pays at 100% of Medicare OPPS Rate,67.52,Pays at 32.15% of Total Billed charges,184.8,Pays at 88% of Total Billed charges,69.53,Pays at 33.11% of Total Billed charges,67.52,189,126.00
Outpatient Medical Services,Surgery,11401,Under Excision-Benign Lesions Procedures on the Skin 0.6-1 CM,761,214.25,182.11,Pays at 85% of Billed charges for outpatient setting,68.88,Pays at 32.15% of Total Billed charges,171.46,Pays at 80.03% of Total Billed charges,357.66,Pays at 102% of Medicare OPPS Rate,192.83,Pays at 90% of Total Billed charges,68.88,Pays at 32.15% of Total Billed charges,350.64,Pays at 100% of Medicare OPPS Rate,68.88,Pays at 32.15% of Total Billed charges,188.54,Pays at 88% of Total Billed charges,70.94,Pays at 33.11% of Total Billed charges,68.88,357.66,128.55
Outpatient Medical Services,Surgery,11719,TRIMMING OF NONDYSTROPHIC NAILS ANY #,761,145,123.25,Pays at 85% of Billed charges for outpatient setting,46.62,Pays at 32.15% of Total Billed charges,116.04,Pays at 80.03% of Total Billed charges,55.1,Pays at 102% of Medicare OPPS Rate,130.5,Pays at 90% of Total Billed charges,46.62,Pays at 32.15% of Total Billed charges,54.02,Pays at 100% of Medicare OPPS Rate,46.62,Pays at 32.15% of Total Billed charges,127.6,Pays at 88% of Total Billed charges,48.01,Pays at 33.11% of Total Billed charges,46.62,130.5,87.00
Outpatient Medical Services,Surgery,11720,DEBRIDEMENT OF NAILS BY ANY METHOD,761,145,123.25,Pays at 85% of Billed charges for outpatient setting,46.62,Pays at 32.15% of Total Billed charges,116.04,Pays at 80.03% of Total Billed charges,55.1,Pays at 102% of Medicare OPPS Rate,130.5,Pays at 90% of Total Billed charges,46.62,Pays at 32.15% of Total Billed charges,54.02,Pays at 100% of Medicare OPPS Rate,46.62,Pays at 32.15% of Total Billed charges,127.6,Pays at 88% of Total Billed charges,48.01,Pays at 33.11% of Total Billed charges,46.62,130.5,87.00
Outpatient Medical Services,Surgery,11721,Removal of 6 or more nails,761,145,123.25,Pays at 85% of Billed charges for outpatient setting,46.62,Pays at 32.15% of Total Billed charges,116.04,Pays at 80.03% of Total Billed charges,55.1,Pays at 102% of Medicare OPPS Rate,130.5,Pays at 90% of Total Billed charges,46.62,Pays at 32.15% of Total Billed charges,54.02,Pays at 100% of Medicare OPPS Rate,46.62,Pays at 32.15% of Total Billed charges,127.6,Pays at 88% of Total Billed charges,48.01,Pays at 33.11% of Total Billed charges,46.62,130.5,87.00
Outpatient Medical Services,Surgery,11730,Separation and removal of the entire nail plate or a portion of nail plate,761,436.75,371.24,Pays at 85% of Billed charges for outpatient setting,140.42,Pays at 32.15% of Total Billed charges,349.53,Pays at 80.03% of Total Billed charges,173.12,Pays at 102% of Medicare OPPS Rate,393.08,Pays at 90% of Total Billed charges,140.42,Pays at 32.15% of Total Billed charges,169.72,Pays at 100% of Medicare OPPS Rate,140.42,Pays at 32.15% of Total Billed charges,384.34,Pays at 88% of Total Billed charges,144.61,Pays at 33.11% of Total Billed charges,140.42,393.08,262.05
Outpatient Medical Services,Surgery,11732,AVULSION OF NAIL  PLATE EACH ADDT'L NAIL,761,236.25,200.81,Pays at 85% of Billed charges for outpatient setting,75.95,Pays at 32.15% of Total Billed charges,189.07,Pays at 80.03% of Total Billed charges,236.25,Not Applicable,212.63,Pays at 90% of Total Billed charges,75.95,Pays at 32.15% of Total Billed charges,236.25,Not Applicable,75.95,Pays at 32.15% of Total Billed charges,207.9,Pays at 88% of Total Billed charges,78.22,Pays at 33.11% of Total Billed charges,75.95,236.25,141.75
Outpatient Medical Services,Surgery,11750,EXCISION OF NAIL AND NAIL MATRIX PART/CO,761,804.25,683.61,Pays at 85% of Billed charges for outpatient setting,258.57,Pays at 32.15% of Total Billed charges,643.64,Pays at 80.03% of Total Billed charges,357.66,Pays at 102% of Medicare OPPS Rate,723.83,Pays at 90% of Total Billed charges,258.57,Pays at 32.15% of Total Billed charges,350.64,Pays at 100% of Medicare OPPS Rate,258.57,Pays at 32.15% of Total Billed charges,707.74,Pays at 88% of Total Billed charges,266.29,Pays at 33.11% of Total Billed charges,258.57,723.83,482.55
Outpatient Medical Services,Surgery,12004,SIMPLE REPAIR - TRUNK - 7.6-12.5 CM,761,277.25,235.66,Pays at 85% of Billed charges for outpatient setting,89.14,Pays at 32.15% of Total Billed charges,221.88,Pays at 80.03% of Total Billed charges,173.12,Pays at 102% of Medicare OPPS Rate,249.53,Pays at 90% of Total Billed charges,89.14,Pays at 32.15% of Total Billed charges,169.72,Pays at 100% of Medicare OPPS Rate,89.14,Pays at 32.15% of Total Billed charges,243.98,Pays at 88% of Total Billed charges,91.8,Pays at 33.11% of Total Billed charges,89.14,249.53,166.35
Outpatient Medical Services,Surgery,13160,SECONDARY CLOSURE WOUND DEHIS EXTENSIVE,761,1758.24,1494.5,Pays at 85% of Billed charges for outpatient setting,565.27,Pays at 32.15% of Total Billed charges,1407.12,Pays at 80.03% of Total Billed charges,1654.58,Pays at 102% of Medicare OPPS Rate,1582.42,Pays at 90% of Total Billed charges,565.27,Pays at 32.15% of Total Billed charges,1622.14,Pays at 100% of Medicare OPPS Rate,565.27,Pays at 32.15% of Total Billed charges,1547.25,Pays at 88% of Total Billed charges,582.15,Pays at 33.11% of Total Billed charges,565.27,1654.58,1054.94
Outpatient Medical Services,Surgery,15271,APP LOW COST SKIN SUB GRAFT 1ST 25CM,761,1355,1151.75,Pays at 85% of Billed charges for outpatient setting,435.63,Pays at 32.15% of Total Billed charges,1084.41,Pays at 80.03% of Total Billed charges,1654.58,Pays at 102% of Medicare OPPS Rate,1219.5,Pays at 90% of Total Billed charges,435.63,Pays at 32.15% of Total Billed charges,1622.14,Pays at 100% of Medicare OPPS Rate,435.63,Pays at 32.15% of Total Billed charges,1192.4,Pays at 88% of Total Billed charges,448.64,Pays at 33.11% of Total Billed charges,435.63,1654.58,813.00
Outpatient Medical Services,Surgery,15271,APPLICATION SKIN SUB GRAFT/ARM/LEG,761,4058.25,3449.51,Pays at 85% of Billed charges for outpatient setting,1304.73,Pays at 32.15% of Total Billed charges,3247.82,Pays at 80.03% of Total Billed charges,1654.58,Pays at 102% of Medicare OPPS Rate,3652.43,Pays at 90% of Total Billed charges,1304.73,Pays at 32.15% of Total Billed charges,1622.14,Pays at 100% of Medicare OPPS Rate,1304.73,Pays at 32.15% of Total Billed charges,3571.26,Pays at 88% of Total Billed charges,1343.69,Pays at 33.11% of Total Billed charges,1304.73,3652.43,2434.95
Outpatient Medical Services,Surgery,15272,APPLICATION SKIN SUB GRAFT/ARM/LEG EA AD,761,282.75,240.34,Pays at 85% of Billed charges for outpatient setting,90.9,Pays at 32.15% of Total Billed charges,226.28,Pays at 80.03% of Total Billed charges,282.75,Not Applicable,254.48,Pays at 90% of Total Billed charges,90.9,Pays at 32.15% of Total Billed charges,282.75,Not Applicable,90.9,Pays at 32.15% of Total Billed charges,248.82,Pays at 88% of Total Billed charges,93.62,Pays at 33.11% of Total Billed charges,90.9,282.75,169.65
Outpatient Medical Services,Surgery,15272,APP LOW COST SKIN SUB GRAFT ADD 25CM,761,462.5,393.13,Pays at 85% of Billed charges for outpatient setting,148.69,Pays at 32.15% of Total Billed charges,370.14,Pays at 80.03% of Total Billed charges,462.5,Not Applicable,416.25,Pays at 90% of Total Billed charges,148.69,Pays at 32.15% of Total Billed charges,462.5,Not Applicable,148.69,Pays at 32.15% of Total Billed charges,407,Pays at 88% of Total Billed charges,153.13,Pays at 33.11% of Total Billed charges,148.69,462.5,277.50
Outpatient Medical Services,Surgery,15273,APPLICATION SKIN SUB GRAFT/ARM/LEG 25SQ,761,3366.75,2861.74,Pays at 85% of Billed charges for outpatient setting,1082.41,Pays at 32.15% of Total Billed charges,2694.41,Pays at 80.03% of Total Billed charges,3118.7,Pays at 102% of Medicare OPPS Rate,3030.08,Pays at 90% of Total Billed charges,1082.41,Pays at 32.15% of Total Billed charges,3057.55,Pays at 100% of Medicare OPPS Rate,1082.41,Pays at 32.15% of Total Billed charges,2962.74,Pays at 88% of Total Billed charges,1114.73,Pays at 33.11% of Total Billed charges,1082.41,3118.7,2020.05
Outpatient Medical Services,Surgery,15273,APP LOW COST SKIN SUB GRAFT 1ST 100CM,761,4539.25,3858.36,Pays at 85% of Billed charges for outpatient setting,1459.37,Pays at 32.15% of Total Billed charges,3632.76,Pays at 80.03% of Total Billed charges,3118.7,Pays at 102% of Medicare OPPS Rate,4085.33,Pays at 90% of Total Billed charges,1459.37,Pays at 32.15% of Total Billed charges,3057.55,Pays at 100% of Medicare OPPS Rate,1459.37,Pays at 32.15% of Total Billed charges,3994.54,Pays at 88% of Total Billed charges,1502.95,Pays at 33.11% of Total Billed charges,1459.37,4085.33,2723.55
Outpatient Medical Services,Surgery,15274,APPLICATION SKIN SUB GRAFT/ARM/LEG INFAN,761,830.5,705.93,Pays at 85% of Billed charges for outpatient setting,267.01,Pays at 32.15% of Total Billed charges,664.65,Pays at 80.03% of Total Billed charges,830.5,Not Applicable,747.45,Pays at 90% of Total Billed charges,267.01,Pays at 32.15% of Total Billed charges,830.5,Not Applicable,267.01,Pays at 32.15% of Total Billed charges,730.84,Pays at 88% of Total Billed charges,274.98,Pays at 33.11% of Total Billed charges,267.01,830.5,498.30
Outpatient Medical Services,Surgery,15274,APP LOW COST SKIN SUB GRAFT ADD 100CM,761,2901.5,2466.28,Pays at 85% of Billed charges for outpatient setting,932.83,Pays at 32.15% of Total Billed charges,2322.07,Pays at 80.03% of Total Billed charges,2901.5,Not Applicable,2611.35,Pays at 90% of Total Billed charges,932.83,Pays at 32.15% of Total Billed charges,2901.5,Not Applicable,932.83,Pays at 32.15% of Total Billed charges,2553.32,Pays at 88% of Total Billed charges,960.69,Pays at 33.11% of Total Billed charges,932.83,2901.5,1740.90
Outpatient Medical Services,Surgery,15275,APP LOW COST SKIN SUB GRAFT ADD 25CM,761,1355,1151.75,Pays at 85% of Billed charges for outpatient setting,435.63,Pays at 32.15% of Total Billed charges,1084.41,Pays at 80.03% of Total Billed charges,1654.58,Pays at 102% of Medicare OPPS Rate,1219.5,Pays at 90% of Total Billed charges,435.63,Pays at 32.15% of Total Billed charges,1622.14,Pays at 100% of Medicare OPPS Rate,435.63,Pays at 32.15% of Total Billed charges,1192.4,Pays at 88% of Total Billed charges,448.64,Pays at 33.11% of Total Billed charges,435.63,1654.58,813.00
Outpatient Medical Services,Surgery,15275,APPLICATION SKIN SUB GRAFT/FACE/SCALP,761,4058.25,3449.51,Pays at 85% of Billed charges for outpatient setting,1304.73,Pays at 32.15% of Total Billed charges,3247.82,Pays at 80.03% of Total Billed charges,1654.58,Pays at 102% of Medicare OPPS Rate,3652.43,Pays at 90% of Total Billed charges,1304.73,Pays at 32.15% of Total Billed charges,1622.14,Pays at 100% of Medicare OPPS Rate,1304.73,Pays at 32.15% of Total Billed charges,3571.26,Pays at 88% of Total Billed charges,1343.69,Pays at 33.11% of Total Billed charges,1304.73,3652.43,2434.95
Outpatient Medical Services,Surgery,15276,APPLICATION SKIN SUB GRAFT/FACE/SCALP,761,284,241.4,Pays at 85% of Billed charges for outpatient setting,91.31,Pays at 32.15% of Total Billed charges,227.29,Pays at 80.03% of Total Billed charges,284,Not Applicable,255.6,Pays at 90% of Total Billed charges,91.31,Pays at 32.15% of Total Billed charges,284,Not Applicable,91.31,Pays at 32.15% of Total Billed charges,249.92,Pays at 88% of Total Billed charges,94.03,Pays at 33.11% of Total Billed charges,91.31,284,170.40
Outpatient Medical Services,Surgery,15276,APP LOW COST SKIN SUB GRAFT ADD 25CM,761,462.5,393.13,Pays at 85% of Billed charges for outpatient setting,148.69,Pays at 32.15% of Total Billed charges,370.14,Pays at 80.03% of Total Billed charges,462.5,Not Applicable,416.25,Pays at 90% of Total Billed charges,148.69,Pays at 32.15% of Total Billed charges,462.5,Not Applicable,148.69,Pays at 32.15% of Total Billed charges,407,Pays at 88% of Total Billed charges,153.13,Pays at 33.11% of Total Billed charges,148.69,462.5,277.50
Outpatient Medical Services,Surgery,15277,APP LOW COST SKIN SUB GRAFT 1ST 100 CM,761,1355,1151.75,Pays at 85% of Billed charges for outpatient setting,435.63,Pays at 32.15% of Total Billed charges,1084.41,Pays at 80.03% of Total Billed charges,1654.58,Pays at 102% of Medicare OPPS Rate,1219.5,Pays at 90% of Total Billed charges,435.63,Pays at 32.15% of Total Billed charges,1622.14,Pays at 100% of Medicare OPPS Rate,435.63,Pays at 32.15% of Total Billed charges,1192.4,Pays at 88% of Total Billed charges,448.64,Pays at 33.11% of Total Billed charges,435.63,1654.58,813.00
Outpatient Medical Services,Surgery,15277,APPLICATION SKIN SUB GRAFT/FACE/SCALP,761,1947.75,1655.59,Pays at 85% of Billed charges for outpatient setting,626.2,Pays at 32.15% of Total Billed charges,1558.78,Pays at 80.03% of Total Billed charges,1654.58,Pays at 102% of Medicare OPPS Rate,1752.98,Pays at 90% of Total Billed charges,626.2,Pays at 32.15% of Total Billed charges,1622.14,Pays at 100% of Medicare OPPS Rate,626.2,Pays at 32.15% of Total Billed charges,1714.02,Pays at 88% of Total Billed charges,644.9,Pays at 33.11% of Total Billed charges,626.2,1752.98,1168.65
Outpatient Medical Services,Surgery,15278,APPLICATION SKIN SUB GRAFT/FACE/SCALP,761,830.5,705.93,Pays at 85% of Billed charges for outpatient setting,267.01,Pays at 32.15% of Total Billed charges,664.65,Pays at 80.03% of Total Billed charges,830.5,Not Applicable,747.45,Pays at 90% of Total Billed charges,267.01,Pays at 32.15% of Total Billed charges,830.5,Not Applicable,267.01,Pays at 32.15% of Total Billed charges,730.84,Pays at 88% of Total Billed charges,274.98,Pays at 33.11% of Total Billed charges,267.01,830.5,498.30
Outpatient Medical Services,Surgery,15278,APP LOW COST SKIN SUB GRAFT ADD 100CM,761,866.5,736.53,Pays at 85% of Billed charges for outpatient setting,278.58,Pays at 32.15% of Total Billed charges,693.46,Pays at 80.03% of Total Billed charges,866.5,Not Applicable,779.85,Pays at 90% of Total Billed charges,278.58,Pays at 32.15% of Total Billed charges,866.5,Not Applicable,278.58,Pays at 32.15% of Total Billed charges,762.52,Pays at 88% of Total Billed charges,286.9,Pays at 33.11% of Total Billed charges,278.58,866.5,519.90
Outpatient Medical Services,Surgery,16020,DRESS AND/OR DEBRIDE PARTIAL BURN SMALL,761,436.75,371.24,Pays at 85% of Billed charges for outpatient setting,140.42,Pays at 32.15% of Total Billed charges,349.53,Pays at 80.03% of Total Billed charges,173.12,Pays at 102% of Medicare OPPS Rate,393.08,Pays at 90% of Total Billed charges,140.42,Pays at 32.15% of Total Billed charges,169.72,Pays at 100% of Medicare OPPS Rate,140.42,Pays at 32.15% of Total Billed charges,384.34,Pays at 88% of Total Billed charges,144.61,Pays at 33.11% of Total Billed charges,140.42,393.08,262.05
Outpatient Medical Services,Surgery,16025,DRESS AND/OR DEBRIDE PARTIAL BURN MEDIUM,761,487.75,414.59,Pays at 85% of Billed charges for outpatient setting,156.81,Pays at 32.15% of Total Billed charges,390.35,Pays at 80.03% of Total Billed charges,173.11,Pays at 102% of Medicare OPPS Rate,438.98,Pays at 90% of Total Billed charges,156.81,Pays at 32.15% of Total Billed charges,169.72,Pays at 100% of Medicare OPPS Rate,156.81,Pays at 32.15% of Total Billed charges,429.22,Pays at 88% of Total Billed charges,161.49,Pays at 33.11% of Total Billed charges,156.81,438.98,292.65
Outpatient Medical Services,Surgery,16030,DRESS AND/OR DEBRIDE PARTIAL BURN LARGE,761,487.75,414.59,Pays at 85% of Billed charges for outpatient setting,156.81,Pays at 32.15% of Total Billed charges,390.35,Pays at 80.03% of Total Billed charges,357.66,Pays at 102% of Medicare OPPS Rate,438.98,Pays at 90% of Total Billed charges,156.81,Pays at 32.15% of Total Billed charges,350.64,Pays at 100% of Medicare OPPS Rate,156.81,Pays at 32.15% of Total Billed charges,429.22,Pays at 88% of Total Billed charges,161.49,Pays at 33.11% of Total Billed charges,156.81,438.98,292.65
Outpatient Medical Services,Surgery,17250,Chemical destruction of pre-cancerous lesions of the skin,761,436.75,371.24,Pays at 85% of Billed charges for outpatient setting,140.42,Pays at 32.15% of Total Billed charges,349.53,Pays at 80.03% of Total Billed charges,173.12,Pays at 102% of Medicare OPPS Rate,393.08,Pays at 90% of Total Billed charges,140.42,Pays at 32.15% of Total Billed charges,169.72,Pays at 100% of Medicare OPPS Rate,140.42,Pays at 32.15% of Total Billed charges,384.34,Pays at 88% of Total Billed charges,144.61,Pays at 33.11% of Total Billed charges,140.42,393.08,262.05
Outpatient Medical Services,Surgery,19101,MM BIOPSY WO PROBE,360,697.75,593.09,Pays at 85% of Billed charges for outpatient setting,224.33,Pays at 32.15% of Total Billed charges,558.41,Pays at 80.03% of Total Billed charges,3295.83,Pays at 102% of Medicare OPPS Rate,627.98,Pays at 90% of Total Billed charges,224.33,Pays at 32.15% of Total Billed charges,3231.21,Pays at 100% of Medicare OPPS Rate,224.33,Pays at 32.15% of Total Billed charges,614.02,Pays at 88% of Total Billed charges,231.03,Pays at 33.11% of Total Billed charges,224.33,3295.83,418.65
Outpatient Medical Services,Surgery,20240,SUPERFICIAL BONE BIOPSY - OPEN,761,1863,1583.55,Pays at 85% of Billed charges for outpatient setting,598.95,Pays at 32.15% of Total Billed charges,1490.96,Pays at 80.03% of Total Billed charges,2476.56,Pays at 102% of Medicare OPPS Rate,1676.7,Pays at 90% of Total Billed charges,598.95,Pays at 32.15% of Total Billed charges,2428.02,Pays at 100% of Medicare OPPS Rate,598.95,Pays at 32.15% of Total Billed charges,1639.44,Pays at 88% of Total Billed charges,616.84,Pays at 33.11% of Total Billed charges,598.95,2476.56,1117.80
Outpatient Medical Services,Surgery,20600,Draining or injecting medication into a small joint/bursa without ultrasound,761,633.5,538.48,Pays at 85% of Billed charges for outpatient setting,203.67,Pays at 32.15% of Total Billed charges,506.99,Pays at 80.03% of Total Billed charges,260.64,Pays at 102% of Medicare OPPS Rate,570.15,Pays at 90% of Total Billed charges,203.67,Pays at 32.15% of Total Billed charges,255.55,Pays at 100% of Medicare OPPS Rate,203.67,Pays at 32.15% of Total Billed charges,557.48,Pays at 88% of Total Billed charges,209.75,Pays at 33.11% of Total Billed charges,203.67,570.15,380.10
Outpatient Medical Services,Surgery,29445,APPLY TOTAL CONTACT LEG CAST,761,454.5,386.33,Pays at 85% of Billed charges for outpatient setting,146.12,Pays at 32.15% of Total Billed charges,363.74,Pays at 80.03% of Total Billed charges,229.98,Pays at 102% of Medicare OPPS Rate,409.05,Pays at 90% of Total Billed charges,146.12,Pays at 32.15% of Total Billed charges,225.48,Pays at 100% of Medicare OPPS Rate,146.12,Pays at 32.15% of Total Billed charges,399.96,Pays at 88% of Total Billed charges,150.48,Pays at 33.11% of Total Billed charges,146.12,409.05,272.70
Outpatient Medical Services,Surgery,29580,APPLY UNNA BOOT,761,454.5,386.33,Pays at 85% of Billed charges for outpatient setting,146.12,Pays at 32.15% of Total Billed charges,363.74,Pays at 80.03% of Total Billed charges,139.72,Pays at 102% of Medicare OPPS Rate,409.05,Pays at 90% of Total Billed charges,146.12,Pays at 32.15% of Total Billed charges,137,Pays at 100% of Medicare OPPS Rate,146.12,Pays at 32.15% of Total Billed charges,399.96,Pays at 88% of Total Billed charges,150.48,Pays at 33.11% of Total Billed charges,137,409.05,272.70
Outpatient Medical Services,Surgery,29581,APPLY MULTILAYER COMP LOWER LEG,761,438.44,372.67,Pays at 85% of Billed charges for outpatient setting,140.96,Pays at 32.15% of Total Billed charges,350.88,Pays at 80.03% of Total Billed charges,139.72,Pays at 102% of Medicare OPPS Rate,394.6,Pays at 90% of Total Billed charges,140.96,Pays at 32.15% of Total Billed charges,137,Pays at 100% of Medicare OPPS Rate,140.96,Pays at 32.15% of Total Billed charges,385.83,Pays at 88% of Total Billed charges,145.17,Pays at 33.11% of Total Billed charges,137,394.6,263.06
Outpatient Medical Services,Surgery,31500,RESP THERAPY INTUBATION,410,461.5,392.28,Pays at 85% of Billed charges for outpatient setting,148.37,Pays at 32.15% of Total Billed charges,369.34,Pays at 80.03% of Total Billed charges,199.23,Pays at 102% of Medicare OPPS Rate,415.35,Pays at 90% of Total Billed charges,148.37,Pays at 32.15% of Total Billed charges,195.33,Pays at 100% of Medicare OPPS Rate,148.37,Pays at 32.15% of Total Billed charges,406.12,Pays at 88% of Total Billed charges,152.8,Pays at 33.11% of Total Billed charges,148.37,415.35,276.90
Outpatient Medical Services,Surgery,31525,LARYNGOSCOPY WITH BIOPSY,761,1643.5,1396.98,Pays at 85% of Billed charges for outpatient setting,528.39,Pays at 32.15% of Total Billed charges,1315.29,Pays at 80.03% of Total Billed charges,1532.54,Pays at 102% of Medicare OPPS Rate,1479.15,Pays at 90% of Total Billed charges,528.39,Pays at 32.15% of Total Billed charges,1502.49,Pays at 100% of Medicare OPPS Rate,528.39,Pays at 32.15% of Total Billed charges,1446.28,Pays at 88% of Total Billed charges,544.16,Pays at 33.11% of Total Billed charges,528.39,1532.54,986.10
Outpatient Medical Services,Surgery,31575,"Flexible, fiberoptic diagnostic laryngoscopy",761,229.75,195.29,Pays at 85% of Billed charges for outpatient setting,73.86,Pays at 32.15% of Total Billed charges,183.87,Pays at 80.03% of Total Billed charges,171.36,Pays at 102% of Medicare OPPS Rate,206.78,Pays at 90% of Total Billed charges,73.86,Pays at 32.15% of Total Billed charges,168,Pays at 100% of Medicare OPPS Rate,73.86,Pays at 32.15% of Total Billed charges,202.18,Pays at 88% of Total Billed charges,76.07,Pays at 33.11% of Total Billed charges,73.86,206.78,137.85
Outpatient Medical Services,Surgery,31720,SUCTION INPATIENT,410,187.88,159.7,Pays at 85% of Billed charges for outpatient setting,60.4,Pays at 32.15% of Total Billed charges,150.36,Pays at 80.03% of Total Billed charges,183.59,Pays at 102% of Medicare OPPS Rate,169.09,Pays at 90% of Total Billed charges,60.4,Pays at 32.15% of Total Billed charges,179.99,Pays at 100% of Medicare OPPS Rate,60.4,Pays at 32.15% of Total Billed charges,165.33,Pays at 88% of Total Billed charges,62.21,Pays at 33.11% of Total Billed charges,60.4,183.59,112.73
Outpatient Medical Services,Surgery,31720,SUCTION OUTPATIENT,410,482.25,409.91,Pays at 85% of Billed charges for outpatient setting,155.04,Pays at 32.15% of Total Billed charges,385.94,Pays at 80.03% of Total Billed charges,183.59,Pays at 102% of Medicare OPPS Rate,434.03,Pays at 90% of Total Billed charges,155.04,Pays at 32.15% of Total Billed charges,179.99,Pays at 100% of Medicare OPPS Rate,155.04,Pays at 32.15% of Total Billed charges,424.38,Pays at 88% of Total Billed charges,159.67,Pays at 33.11% of Total Billed charges,155.04,434.03,289.35
Outpatient Medical Services,Surgery,32000,THORACENTESIS,761,119.5,101.58,Pays at 85% of Billed charges for outpatient setting,38.42,Pays at 32.15% of Total Billed charges,95.64,Pays at 80.03% of Total Billed charges,119.5,Not Applicable,107.55,Pays at 90% of Total Billed charges,38.42,Pays at 32.15% of Total Billed charges,119.5,Not Applicable,38.42,Pays at 32.15% of Total Billed charges,105.16,Pays at 88% of Total Billed charges,39.57,Pays at 33.11% of Total Billed charges,38.42,119.5,71.70
Outpatient Medical Services,Surgery,32000,CHEST TUBE FOR DRAINAGE,360,466.25,396.31,Pays at 85% of Billed charges for outpatient setting,149.9,Pays at 32.15% of Total Billed charges,373.14,Pays at 80.03% of Total Billed charges,466.25,Not Applicable,419.63,Pays at 90% of Total Billed charges,149.9,Pays at 32.15% of Total Billed charges,466.25,Not Applicable,149.9,Pays at 32.15% of Total Billed charges,410.3,Pays at 88% of Total Billed charges,154.38,Pays at 33.11% of Total Billed charges,149.9,466.25,279.75
Outpatient Medical Services,Surgery,32551,LEVEL 1 VASCULAR PROCEDURES,360,2543,2161.55,Pays at 85% of Billed charges for outpatient setting,817.57,Pays at 32.15% of Total Billed charges,2035.16,Pays at 80.03% of Total Billed charges,1426.4,Pays at 102% of Medicare OPPS Rate,2288.7,Pays at 90% of Total Billed charges,817.57,Pays at 32.15% of Total Billed charges,1398.43,Pays at 100% of Medicare OPPS Rate,817.57,Pays at 32.15% of Total Billed charges,2237.84,Pays at 88% of Total Billed charges,841.99,Pays at 33.11% of Total Billed charges,817.57,2288.7,1525.80
Outpatient Medical Services,Surgery,32555,US THORACENTESIS WITH IMAGING GUIDANCE,761,1609.5,1368.08,Pays at 85% of Billed charges for outpatient setting,517.45,Pays at 32.15% of Total Billed charges,1288.08,Pays at 80.03% of Total Billed charges,554.6,Pays at 102% of Medicare OPPS Rate,1448.55,Pays at 90% of Total Billed charges,517.45,Pays at 32.15% of Total Billed charges,543.73,Pays at 100% of Medicare OPPS Rate,517.45,Pays at 32.15% of Total Billed charges,1416.36,Pays at 88% of Total Billed charges,532.91,Pays at 33.11% of Total Billed charges,517.45,1448.55,965.70
Outpatient Medical Services,Surgery,32556,LEVEL 2 UPPER GI : CHEST TUBE INSERTION,360,3838.25,3262.51,Pays at 85% of Billed charges for outpatient setting,1234,Pays at 32.15% of Total Billed charges,3071.75,Pays at 80.03% of Total Billed charges,1669.66,Pays at 102% of Medicare OPPS Rate,3454.43,Pays at 90% of Total Billed charges,1234,Pays at 32.15% of Total Billed charges,1636.93,Pays at 100% of Medicare OPPS Rate,1234,Pays at 32.15% of Total Billed charges,3377.66,Pays at 88% of Total Billed charges,1270.84,Pays at 33.11% of Total Billed charges,1234,3454.43,2302.95
Outpatient Medical Services,Surgery,36410,MIDLINE INSERTION PROCEDURE,761,2087.72,1774.56,Pays at 85% of Billed charges for outpatient setting,671.2,Pays at 32.15% of Total Billed charges,1670.8,Pays at 80.03% of Total Billed charges,2087.72,Not Applicable,1878.95,Pays at 90% of Total Billed charges,671.2,Pays at 32.15% of Total Billed charges,2087.72,Not Applicable,671.2,Pays at 32.15% of Total Billed charges,1837.19,Pays at 88% of Total Billed charges,691.24,Pays at 33.11% of Total Billed charges,671.2,2087.72,1252.63
Outpatient Medical Services,Surgery,36430,BLOOD ADMINISTRATION FEE,381,512,435.2,Pays at 85% of Billed charges for outpatient setting,164.61,Pays at 32.15% of Total Billed charges,409.75,Pays at 80.03% of Total Billed charges,390.9,Pays at 102% of Medicare OPPS Rate,460.8,Pays at 90% of Total Billed charges,164.61,Pays at 32.15% of Total Billed charges,383.24,Pays at 100% of Medicare OPPS Rate,164.61,Pays at 32.15% of Total Billed charges,450.56,Pays at 88% of Total Billed charges,169.52,Pays at 33.11% of Total Billed charges,164.61,460.8,307.20
Outpatient Medical Services,Surgery,36430,TRANSFUSION,391,779.25,662.36,Pays at 85% of Billed charges for outpatient setting,250.53,Pays at 32.15% of Total Billed charges,623.63,Pays at 80.03% of Total Billed charges,390.9,Pays at 102% of Medicare OPPS Rate,701.33,Pays at 90% of Total Billed charges,250.53,Pays at 32.15% of Total Billed charges,383.24,Pays at 100% of Medicare OPPS Rate,250.53,Pays at 32.15% of Total Billed charges,685.74,Pays at 88% of Total Billed charges,258.01,Pays at 33.11% of Total Billed charges,250.53,701.33,467.55
Outpatient Medical Services,Surgery,36430,TRANSFUSION,391,779.25,662.36,Pays at 85% of Billed charges for outpatient setting,250.53,Pays at 32.15% of Total Billed charges,623.63,Pays at 80.03% of Total Billed charges,390.9,Pays at 102% of Medicare OPPS Rate,701.33,Pays at 90% of Total Billed charges,250.53,Pays at 32.15% of Total Billed charges,383.24,Pays at 100% of Medicare OPPS Rate,250.53,Pays at 32.15% of Total Billed charges,685.74,Pays at 88% of Total Billed charges,258.01,Pays at 33.11% of Total Billed charges,250.53,701.33,467.55
Outpatient Medical Services,Surgery,36430,TRANSFUSION  BLOOD OR COMPONENT,391,796.02,676.62,Pays at 85% of Billed charges for outpatient setting,255.92,Pays at 32.15% of Total Billed charges,637.05,Pays at 80.03% of Total Billed charges,390.9,Pays at 102% of Medicare OPPS Rate,716.42,Pays at 90% of Total Billed charges,255.92,Pays at 32.15% of Total Billed charges,383.24,Pays at 100% of Medicare OPPS Rate,255.92,Pays at 32.15% of Total Billed charges,700.5,Pays at 88% of Total Billed charges,263.56,Pays at 33.11% of Total Billed charges,255.92,716.42,477.61
Outpatient Medical Services,Surgery,36430,TRANSFUSION,391,807.25,686.16,Pays at 85% of Billed charges for outpatient setting,259.53,Pays at 32.15% of Total Billed charges,646.04,Pays at 80.03% of Total Billed charges,390.9,Pays at 102% of Medicare OPPS Rate,726.53,Pays at 90% of Total Billed charges,259.53,Pays at 32.15% of Total Billed charges,383.24,Pays at 100% of Medicare OPPS Rate,259.53,Pays at 32.15% of Total Billed charges,710.38,Pays at 88% of Total Billed charges,267.28,Pays at 33.11% of Total Billed charges,259.53,726.53,484.35
Outpatient Medical Services,Surgery,36430,TRANSFUSION,391,970.75,825.14,Pays at 85% of Billed charges for outpatient setting,312.1,Pays at 32.15% of Total Billed charges,776.89,Pays at 80.03% of Total Billed charges,390.9,Pays at 102% of Medicare OPPS Rate,873.68,Pays at 90% of Total Billed charges,312.1,Pays at 32.15% of Total Billed charges,383.24,Pays at 100% of Medicare OPPS Rate,312.1,Pays at 32.15% of Total Billed charges,854.26,Pays at 88% of Total Billed charges,321.42,Pays at 33.11% of Total Billed charges,312.1,873.68,582.45
Outpatient Medical Services,Surgery,36430,TRANSFUSION  BLOOD OR COMPONENT,391,1213.44,1031.42,Pays at 85% of Billed charges for outpatient setting,390.12,Pays at 32.15% of Total Billed charges,971.12,Pays at 80.03% of Total Billed charges,390.9,Pays at 102% of Medicare OPPS Rate,1092.1,Pays at 90% of Total Billed charges,390.12,Pays at 32.15% of Total Billed charges,383.24,Pays at 100% of Medicare OPPS Rate,390.12,Pays at 32.15% of Total Billed charges,1067.83,Pays at 88% of Total Billed charges,401.77,Pays at 33.11% of Total Billed charges,383.24,1092.1,728.06
Outpatient Medical Services,Surgery,36556,CVC PERCUTANEUOS > 5YO,360,2543,2161.55,Pays at 85% of Billed charges for outpatient setting,817.57,Pays at 32.15% of Total Billed charges,2035.16,Pays at 80.03% of Total Billed charges,2855.95,Pays at 102% of Medicare OPPS Rate,2288.7,Pays at 90% of Total Billed charges,817.57,Pays at 32.15% of Total Billed charges,2799.95,Pays at 100% of Medicare OPPS Rate,817.57,Pays at 32.15% of Total Billed charges,2237.84,Pays at 88% of Total Billed charges,841.99,Pays at 33.11% of Total Billed charges,817.57,2855.95,1525.80
Outpatient Medical Services,Surgery,36556,CVC PERCUTANEUOS > 5YO,360,2543,2161.55,Pays at 85% of Billed charges for outpatient setting,817.57,Pays at 32.15% of Total Billed charges,2035.16,Pays at 80.03% of Total Billed charges,2855.95,Pays at 102% of Medicare OPPS Rate,2288.7,Pays at 90% of Total Billed charges,817.57,Pays at 32.15% of Total Billed charges,2799.95,Pays at 100% of Medicare OPPS Rate,817.57,Pays at 32.15% of Total Billed charges,2237.84,Pays at 88% of Total Billed charges,841.99,Pays at 33.11% of Total Billed charges,817.57,2855.95,1525.80
Outpatient Medical Services,Surgery,36556,CVC PERCUTANEUOS > 5YO,360,2543,2161.55,Pays at 85% of Billed charges for outpatient setting,817.57,Pays at 32.15% of Total Billed charges,2035.16,Pays at 80.03% of Total Billed charges,2855.95,Pays at 102% of Medicare OPPS Rate,2288.7,Pays at 90% of Total Billed charges,817.57,Pays at 32.15% of Total Billed charges,2799.95,Pays at 100% of Medicare OPPS Rate,817.57,Pays at 32.15% of Total Billed charges,2237.84,Pays at 88% of Total Billed charges,841.99,Pays at 33.11% of Total Billed charges,817.57,2855.95,1525.80
Outpatient Medical Services,Surgery,36569,PICC LINE INSERTION PROCEDURE,761,2087.72,1774.56,Pays at 85% of Billed charges for outpatient setting,671.2,Pays at 32.15% of Total Billed charges,1670.8,Pays at 80.03% of Total Billed charges,1426.4,Pays at 102% of Medicare OPPS Rate,1878.95,Pays at 90% of Total Billed charges,671.2,Pays at 32.15% of Total Billed charges,1398.43,Pays at 100% of Medicare OPPS Rate,671.2,Pays at 32.15% of Total Billed charges,1837.19,Pays at 88% of Total Billed charges,691.24,Pays at 33.11% of Total Billed charges,671.2,1878.95,1252.63
Outpatient Medical Services,Surgery,36569,CVC PERCUTANEOUS > 2YO,360,2543,2161.55,Pays at 85% of Billed charges for outpatient setting,817.57,Pays at 32.15% of Total Billed charges,2035.16,Pays at 80.03% of Total Billed charges,1426.4,Pays at 102% of Medicare OPPS Rate,2288.7,Pays at 90% of Total Billed charges,817.57,Pays at 32.15% of Total Billed charges,1398.43,Pays at 100% of Medicare OPPS Rate,817.57,Pays at 32.15% of Total Billed charges,2237.84,Pays at 88% of Total Billed charges,841.99,Pays at 33.11% of Total Billed charges,817.57,2288.7,1525.80
Outpatient Medical Services,Surgery,36584,PICC CATH EXCHANGE,761,2543,2161.55,Pays at 85% of Billed charges for outpatient setting,817.57,Pays at 32.15% of Total Billed charges,2035.16,Pays at 80.03% of Total Billed charges,1426.4,Pays at 102% of Medicare OPPS Rate,2288.7,Pays at 90% of Total Billed charges,817.57,Pays at 32.15% of Total Billed charges,1398.43,Pays at 100% of Medicare OPPS Rate,817.57,Pays at 32.15% of Total Billed charges,2237.84,Pays at 88% of Total Billed charges,841.99,Pays at 33.11% of Total Billed charges,817.57,2288.7,1525.80
Outpatient Medical Services,Surgery,36589,PICC CATH REMOVAL,761,1584.5,1346.83,Pays at 85% of Billed charges for outpatient setting,509.42,Pays at 32.15% of Total Billed charges,1268.08,Pays at 80.03% of Total Billed charges,554.61,Pays at 102% of Medicare OPPS Rate,1426.05,Pays at 90% of Total Billed charges,509.42,Pays at 32.15% of Total Billed charges,543.73,Pays at 100% of Medicare OPPS Rate,509.42,Pays at 32.15% of Total Billed charges,1394.36,Pays at 88% of Total Billed charges,524.63,Pays at 33.11% of Total Billed charges,509.42,1426.05,950.70
Outpatient Medical Services,Surgery,36589,REMOVE TUNNELED CV CATH W/O SUBQ PORT,360,4235.25,3599.96,Pays at 85% of Billed charges for outpatient setting,1361.63,Pays at 32.15% of Total Billed charges,3389.47,Pays at 80.03% of Total Billed charges,554.61,Pays at 102% of Medicare OPPS Rate,3811.73,Pays at 90% of Total Billed charges,1361.63,Pays at 32.15% of Total Billed charges,543.73,Pays at 100% of Medicare OPPS Rate,1361.63,Pays at 32.15% of Total Billed charges,3727.02,Pays at 88% of Total Billed charges,1402.29,Pays at 33.11% of Total Billed charges,543.73,3811.73,2541.15
Outpatient Medical Services,Surgery,36592,LAB DRAW CATHETER / PICC LINE,761,111.95,95.16,Pays at 85% of Billed charges for outpatient setting,35.99,Pays at 32.15% of Total Billed charges,89.59,Pays at 80.03% of Total Billed charges,111.31,Pays at 102% of Medicare OPPS Rate,100.76,Pays at 90% of Total Billed charges,35.99,Pays at 32.15% of Total Billed charges,109.13,Pays at 100% of Medicare OPPS Rate,35.99,Pays at 32.15% of Total Billed charges,98.52,Pays at 88% of Total Billed charges,37.07,Pays at 33.11% of Total Billed charges,35.99,111.31,67.17
Outpatient Medical Services,Surgery,36593,PICC DECLOT LINE PROCEDURE,761,770,654.5,Pays at 85% of Billed charges for outpatient setting,247.56,Pays at 32.15% of Total Billed charges,616.23,Pays at 80.03% of Total Billed charges,318.87,Pays at 102% of Medicare OPPS Rate,693,Pays at 90% of Total Billed charges,247.56,Pays at 32.15% of Total Billed charges,312.62,Pays at 100% of Medicare OPPS Rate,247.56,Pays at 32.15% of Total Billed charges,677.6,Pays at 88% of Total Billed charges,254.95,Pays at 33.11% of Total Billed charges,247.56,693,462.00
Outpatient Medical Services,Surgery,36597,REPOSITION CENTRAL VENOUS CATH,360,978,831.3,Pays at 85% of Billed charges for outpatient setting,314.43,Pays at 32.15% of Total Billed charges,782.69,Pays at 80.03% of Total Billed charges,1426.4,Pays at 102% of Medicare OPPS Rate,880.2,Pays at 90% of Total Billed charges,314.43,Pays at 32.15% of Total Billed charges,1398.43,Pays at 100% of Medicare OPPS Rate,314.43,Pays at 32.15% of Total Billed charges,860.64,Pays at 88% of Total Billed charges,323.82,Pays at 33.11% of Total Billed charges,314.43,1426.4,586.80
Outpatient Medical Services,Surgery,36600,ABG COLLECTION,761,111.95,95.16,Pays at 85% of Billed charges for outpatient setting,35.99,Pays at 32.15% of Total Billed charges,89.59,Pays at 80.03% of Total Billed charges,111.31,Pays at 102% of Medicare OPPS Rate,100.76,Pays at 90% of Total Billed charges,35.99,Pays at 32.15% of Total Billed charges,109.13,Pays at 100% of Medicare OPPS Rate,35.99,Pays at 32.15% of Total Billed charges,98.52,Pays at 88% of Total Billed charges,37.07,Pays at 33.11% of Total Billed charges,35.99,111.31,67.17
Outpatient Medical Services,Surgery,38221,BONE MARROW BX,761,323.22,274.74,Pays at 85% of Billed charges for outpatient setting,103.92,Pays at 32.15% of Total Billed charges,258.67,Pays at 80.03% of Total Billed charges,1437.62,Pays at 102% of Medicare OPPS Rate,290.9,Pays at 90% of Total Billed charges,103.92,Pays at 32.15% of Total Billed charges,1409.43,Pays at 100% of Medicare OPPS Rate,103.92,Pays at 32.15% of Total Billed charges,284.43,Pays at 88% of Total Billed charges,107.02,Pays at 33.11% of Total Billed charges,103.92,1437.62,193.93
Outpatient Medical Services,Surgery,49083,US PARACENTESIS WITH IMAGING GUIDANCE,761,530,450.5,Pays at 85% of Billed charges for outpatient setting,170.4,Pays at 32.15% of Total Billed charges,424.16,Pays at 80.03% of Total Billed charges,791.41,Pays at 102% of Medicare OPPS Rate,477,Pays at 90% of Total Billed charges,170.4,Pays at 32.15% of Total Billed charges,775.89,Pays at 100% of Medicare OPPS Rate,170.4,Pays at 32.15% of Total Billed charges,466.4,Pays at 88% of Total Billed charges,175.48,Pays at 33.11% of Total Billed charges,170.4,791.41,318.00
Outpatient Medical Services,Surgery,51701,INSERT NON INDWELLING BLADDER CATH,761,272.25,231.41,Pays at 85% of Billed charges for outpatient setting,87.53,Pays at 32.15% of Total Billed charges,217.88,Pays at 80.03% of Total Billed charges,111.31,Pays at 102% of Medicare OPPS Rate,245.03,Pays at 90% of Total Billed charges,87.53,Pays at 32.15% of Total Billed charges,109.13,Pays at 100% of Medicare OPPS Rate,87.53,Pays at 32.15% of Total Billed charges,239.58,Pays at 88% of Total Billed charges,90.14,Pays at 33.11% of Total Billed charges,87.53,245.03,163.35
Outpatient Medical Services,Surgery,51702,INSERTION OF FOLEY CATH,761,326,277.1,Pays at 85% of Billed charges for outpatient setting,104.81,Pays at 32.15% of Total Billed charges,260.9,Pays at 80.03% of Total Billed charges,111.31,Pays at 102% of Medicare OPPS Rate,293.4,Pays at 90% of Total Billed charges,104.81,Pays at 32.15% of Total Billed charges,109.13,Pays at 100% of Medicare OPPS Rate,104.81,Pays at 32.15% of Total Billed charges,286.88,Pays at 88% of Total Billed charges,107.94,Pays at 33.11% of Total Billed charges,104.81,293.4,195.60
Outpatient Medical Services,Surgery,51702,INSERTION OF FOLEY CATH,761,326,277.1,Pays at 85% of Billed charges for outpatient setting,104.81,Pays at 32.15% of Total Billed charges,260.9,Pays at 80.03% of Total Billed charges,111.31,Pays at 102% of Medicare OPPS Rate,293.4,Pays at 90% of Total Billed charges,104.81,Pays at 32.15% of Total Billed charges,109.13,Pays at 100% of Medicare OPPS Rate,104.81,Pays at 32.15% of Total Billed charges,286.88,Pays at 88% of Total Billed charges,107.94,Pays at 33.11% of Total Billed charges,104.81,293.4,195.60
Outpatient Medical Services,Surgery,51702,INSERTION OF FOLEY CATH,761,326,277.1,Pays at 85% of Billed charges for outpatient setting,104.81,Pays at 32.15% of Total Billed charges,260.9,Pays at 80.03% of Total Billed charges,111.31,Pays at 102% of Medicare OPPS Rate,293.4,Pays at 90% of Total Billed charges,104.81,Pays at 32.15% of Total Billed charges,109.13,Pays at 100% of Medicare OPPS Rate,104.81,Pays at 32.15% of Total Billed charges,286.88,Pays at 88% of Total Billed charges,107.94,Pays at 33.11% of Total Billed charges,104.81,293.4,195.60
Outpatient Medical Services,Surgery,51702,INSERTION OF FOLEY CATH,761,407.5,346.38,Pays at 85% of Billed charges for outpatient setting,131.01,Pays at 32.15% of Total Billed charges,326.12,Pays at 80.03% of Total Billed charges,111.31,Pays at 102% of Medicare OPPS Rate,366.75,Pays at 90% of Total Billed charges,131.01,Pays at 32.15% of Total Billed charges,109.13,Pays at 100% of Medicare OPPS Rate,131.01,Pays at 32.15% of Total Billed charges,358.6,Pays at 88% of Total Billed charges,134.92,Pays at 33.11% of Total Billed charges,109.13,366.75,244.50
Outpatient Medical Services,Surgery,54150,"CIRCUMCISION, CLAMP OR OTHER DEVICE W LO",360,1792.99,1524.04,Pays at 85% of Billed charges for outpatient setting,576.45,Pays at 32.15% of Total Billed charges,1434.93,Pays at 80.03% of Total Billed charges,1778.27,Pays at 102% of Medicare OPPS Rate,1613.69,Pays at 90% of Total Billed charges,576.45,Pays at 32.15% of Total Billed charges,1743.41,Pays at 100% of Medicare OPPS Rate,576.45,Pays at 32.15% of Total Billed charges,1577.83,Pays at 88% of Total Billed charges,593.66,Pays at 33.11% of Total Billed charges,576.45,1778.27,1075.79
Outpatient Medical Services,Surgery,59050,FETAL MONITORING EXTERNAL/INTERNAL,721,298.75,253.94,Pays at 85% of Billed charges for outpatient setting,96.05,Pays at 32.15% of Total Billed charges,239.09,Pays at 80.03% of Total Billed charges,298.75,Not Applicable,268.88,Pays at 90% of Total Billed charges,96.05,Pays at 32.15% of Total Billed charges,298.75,Not Applicable,96.05,Pays at 32.15% of Total Billed charges,262.9,Pays at 88% of Total Billed charges,98.92,Pays at 33.11% of Total Billed charges,96.05,298.75,179.25
Outpatient Medical Services,Surgery,62270,LUMBAR PUNCTURE,360,1049.5,892.08,Pays at 85% of Billed charges for outpatient setting,337.41,Pays at 32.15% of Total Billed charges,839.91,Pays at 80.03% of Total Billed charges,617.72,Pays at 102% of Medicare OPPS Rate,944.55,Pays at 90% of Total Billed charges,337.41,Pays at 32.15% of Total Billed charges,605.61,Pays at 100% of Medicare OPPS Rate,337.41,Pays at 32.15% of Total Billed charges,923.56,Pays at 88% of Total Billed charges,347.49,Pays at 33.11% of Total Billed charges,337.41,944.55,629.70
Outpatient Medical Services,Surgery,62273,BLOOD PATCH,761,1049.5,892.08,Pays at 85% of Billed charges for outpatient setting,337.41,Pays at 32.15% of Total Billed charges,839.91,Pays at 80.03% of Total Billed charges,617.72,Pays at 102% of Medicare OPPS Rate,944.55,Pays at 90% of Total Billed charges,337.41,Pays at 32.15% of Total Billed charges,605.61,Pays at 100% of Medicare OPPS Rate,337.41,Pays at 32.15% of Total Billed charges,923.56,Pays at 88% of Total Billed charges,347.49,Pays at 33.11% of Total Billed charges,337.41,944.55,629.70
Outpatient Medical Services,Surgery,62273,BLOOD PATCH,761,1105.5,939.68,Pays at 85% of Billed charges for outpatient setting,355.42,Pays at 32.15% of Total Billed charges,884.73,Pays at 80.03% of Total Billed charges,617.72,Pays at 102% of Medicare OPPS Rate,994.95,Pays at 90% of Total Billed charges,355.42,Pays at 32.15% of Total Billed charges,605.61,Pays at 100% of Medicare OPPS Rate,355.42,Pays at 32.15% of Total Billed charges,972.84,Pays at 88% of Total Billed charges,366.03,Pays at 33.11% of Total Billed charges,355.42,994.95,663.30
Outpatient Medical Services,Surgery,62322,Injection of substance into spinal canal of lower back or sacrum using imaging guidance,370,295.63,251.29,Pays at 85% of Billed charges for outpatient setting,95.05,Pays at 32.15% of Total Billed charges,236.59,Pays at 80.03% of Total Billed charges,816.98,Pays at 102% of Medicare OPPS Rate,266.07,Pays at 90% of Total Billed charges,95.05,Pays at 32.15% of Total Billed charges,800.96,Pays at 100% of Medicare OPPS Rate,95.05,Pays at 32.15% of Total Billed charges,260.15,Pays at 88% of Total Billed charges,97.88,Pays at 33.11% of Total Billed charges,95.05,816.98,177.38
Outpatient Medical Services,Surgery,65820,GONIOTMY WITH KAHOOK,361,7636.65,6491.15,Pays at 85% of Billed charges for outpatient setting,2455.18,Pays at 32.15% of Total Billed charges,6111.61,Pays at 80.03% of Total Billed charges,3830.59,Pays at 102% of Medicare OPPS Rate,6872.99,Pays at 90% of Total Billed charges,2455.18,Pays at 32.15% of Total Billed charges,3755.48,Pays at 100% of Medicare OPPS Rate,2455.18,Pays at 32.15% of Total Billed charges,6720.25,Pays at 88% of Total Billed charges,2528.49,Pays at 33.11% of Total Billed charges,2455.18,6872.99,4581.99
Outpatient Medical Services,Surgery,66982,CATARACT COMPLEX,361,4043.7,3437.15,Pays at 85% of Billed charges for outpatient setting,1300.05,Pays at 32.15% of Total Billed charges,3236.17,Pays at 80.03% of Total Billed charges,2070.25,Pays at 102% of Medicare OPPS Rate,3639.33,Pays at 90% of Total Billed charges,1300.05,Pays at 32.15% of Total Billed charges,2029.67,Pays at 100% of Medicare OPPS Rate,1300.05,Pays at 32.15% of Total Billed charges,3558.46,Pays at 88% of Total Billed charges,1338.87,Pays at 33.11% of Total Billed charges,1300.05,3639.33,2426.22
Outpatient Medical Services,Surgery,66984,Removal of cataract with insertion of lens,361,5054.63,4296.44,Pays at 85% of Billed charges for outpatient setting,1625.06,Pays at 32.15% of Total Billed charges,4045.22,Pays at 80.03% of Total Billed charges,2070.25,Pays at 102% of Medicare OPPS Rate,4549.17,Pays at 90% of Total Billed charges,1625.06,Pays at 32.15% of Total Billed charges,2029.67,Pays at 100% of Medicare OPPS Rate,1625.06,Pays at 32.15% of Total Billed charges,4448.07,Pays at 88% of Total Billed charges,1673.59,Pays at 33.11% of Total Billed charges,1625.06,4549.17,3032.78
Outpatient Medical Services,Surgery,69210,Removal of ear wax from one or both ears,761,177.5,150.88,Pays at 85% of Billed charges for outpatient setting,57.07,Pays at 32.15% of Total Billed charges,142.05,Pays at 80.03% of Total Billed charges,55.1,Pays at 102% of Medicare OPPS Rate,159.75,Pays at 90% of Total Billed charges,57.07,Pays at 32.15% of Total Billed charges,54.02,Pays at 100% of Medicare OPPS Rate,57.07,Pays at 32.15% of Total Billed charges,156.2,Pays at 88% of Total Billed charges,58.77,Pays at 33.11% of Total Billed charges,54.02,159.75,106.50
Outpatient Medical Services,Surgery,86063,1ST/UNIT/XM/TYPE/RH/ABS,391,260.5,221.43,Pays at 85% of Billed charges for outpatient setting,7.26,Pays at 100% of GA Medicaid Fee Schedule,208.48,Pays at 80.03% of Total Billed charges,5.88,Pays at 102% of Medicare OPPS Rate,234.45,Pays at 90% of Total Billed charges,7.26,Pays at 100% of GA Medicaid Fee Schedule,5.77,Pays at 100% of Medicare OPPS Rate,7.26,Pays at 100% of GA Medicaid Fee Schedule,229.24,Pays at 88% of Total Billed charges,7.48,Pays at 103% of GA Medicaid Fee Schedule,5.77,234.45,156.30
Outpatient Medical Services,Surgery,86078,TRANSFUSION REACTION IVESTIGATION,391,334.25,284.11,Pays at 85% of Billed charges for outpatient setting,45,Pays at 100% of GA Medicaid Fee Schedule,267.5,Pays at 80.03% of Total Billed charges,150.75,Pays at 102% of Medicare OPPS Rate,300.83,Pays at 90% of Total Billed charges,45,Pays at 100% of GA Medicaid Fee Schedule,147.8,Pays at 100% of Medicare OPPS Rate,45,Pays at 100% of GA Medicaid Fee Schedule,294.14,Pays at 88% of Total Billed charges,46.35,Pays at 103% of GA Medicaid Fee Schedule,45,300.83,200.55
Outpatient Medical Services,Surgery,86904,CROSSMATCH LEUKO-REDUCED,390,36.75,31.24,Pays at 85% of Billed charges for outpatient setting,11.95,Pays at 100% of GA Medicaid Fee Schedule,29.41,Pays at 80.03% of Total Billed charges,32.54,Pays at 102% of Medicare OPPS Rate,33.08,Pays at 90% of Total Billed charges,11.95,Pays at 100% of GA Medicaid Fee Schedule,31.91,Pays at 100% of Medicare OPPS Rate,11.95,Pays at 100% of GA Medicaid Fee Schedule,32.34,Pays at 88% of Total Billed charges,12.31,Pays at 103% of GA Medicaid Fee Schedule,11.95,33.08,22.05
Outpatient Medical Services,Surgery,86927,FRESH FROZEN PLASMA,390,196.88,167.35,Pays at 85% of Billed charges for outpatient setting,63.3,Pays at 32.15% of Total Billed charges,157.56,Pays at 80.03% of Total Billed charges,150.74,Pays at 102% of Medicare OPPS Rate,177.19,Pays at 90% of Total Billed charges,63.3,Pays at 32.15% of Total Billed charges,147.79,Pays at 100% of Medicare OPPS Rate,63.3,Pays at 32.15% of Total Billed charges,173.25,Pays at 88% of Total Billed charges,65.19,Pays at 33.11% of Total Billed charges,63.3,177.19,118.13
Outpatient Medical Services,Surgery,86945,IRRADIATED BLOOD PROD,390,256.5,218.03,Pays at 85% of Billed charges for outpatient setting,36.05,Pays at 100% of GA Medicaid Fee Schedule,205.28,Pays at 80.03% of Total Billed charges,32.54,Pays at 102% of Medicare OPPS Rate,230.85,Pays at 90% of Total Billed charges,36.05,Pays at 100% of GA Medicaid Fee Schedule,31.91,Pays at 100% of Medicare OPPS Rate,36.05,Pays at 100% of GA Medicaid Fee Schedule,225.72,Pays at 88% of Total Billed charges,37.13,Pays at 103% of GA Medicaid Fee Schedule,31.91,230.85,153.90
Outpatient Medical Services,Surgery,86999,DEGLYCEROLIZED RED BLOOD CELLS,391,311,264.35,Pays at 85% of Billed charges for outpatient setting,99.99,Pays at 32.15% of Total Billed charges,248.89,Pays at 80.03% of Total Billed charges,23.92,Pays at 102% of Medicare OPPS Rate,279.9,Pays at 90% of Total Billed charges,99.99,Pays at 32.15% of Total Billed charges,23.46,Pays at 100% of Medicare OPPS Rate,99.99,Pays at 32.15% of Total Billed charges,273.68,Pays at 88% of Total Billed charges,102.97,Pays at 33.11% of Total Billed charges,23.46,279.9,186.60
Outpatient Medical Services,Surgery,90784,INTRAVENOUS INJECTION,761,80,68,Pays at 85% of Billed charges for outpatient setting,25.72,Pays at 32.15% of Total Billed charges,64.02,Pays at 80.03% of Total Billed charges,80,Not Applicable,72,Pays at 90% of Total Billed charges,25.72,Pays at 32.15% of Total Billed charges,80,Not Applicable,25.72,Pays at 32.15% of Total Billed charges,70.4,Pays at 88% of Total Billed charges,26.49,Pays at 33.11% of Total Billed charges,25.72,80,48.00
Outpatient Medical Services,Surgery,90788,INTRAMUSCULAR INJECTION OF ANTIBIOTIC,761,80,68,Pays at 85% of Billed charges for outpatient setting,25.72,Pays at 32.15% of Total Billed charges,64.02,Pays at 80.03% of Total Billed charges,80,Not Applicable,72,Pays at 90% of Total Billed charges,25.72,Pays at 32.15% of Total Billed charges,80,Not Applicable,25.72,Pays at 32.15% of Total Billed charges,70.4,Pays at 88% of Total Billed charges,26.49,Pays at 33.11% of Total Billed charges,25.72,80,48.00
Outpatient Medical Services,Surgery,90935,IP  HEMODIALYSIS - ESRD,801,1160.63,986.54,Pays at 85% of Billed charges for outpatient setting,373.14,Pays at 32.15% of Total Billed charges,928.85,Pays at 80.03% of Total Billed charges,604.48,Pays at 102% of Medicare OPPS Rate,1044.57,Pays at 90% of Total Billed charges,373.14,Pays at 32.15% of Total Billed charges,592.62,Pays at 100% of Medicare OPPS Rate,373.14,Pays at 32.15% of Total Billed charges,1021.35,Pays at 88% of Total Billed charges,384.28,Pays at 33.11% of Total Billed charges,373.14,1044.57,696.38
Outpatient Medical Services,Surgery,93923,TRANSCUTANEOUS MONITOR,410,152.75,129.84,Pays at 85% of Billed charges for outpatient setting,49.11,Pays at 32.15% of Total Billed charges,122.25,Pays at 80.03% of Total Billed charges,139.41,Pays at 102% of Medicare OPPS Rate,137.48,Pays at 90% of Total Billed charges,49.11,Pays at 32.15% of Total Billed charges,136.69,Pays at 100% of Medicare OPPS Rate,49.11,Pays at 32.15% of Total Billed charges,134.42,Pays at 88% of Total Billed charges,50.58,Pays at 33.11% of Total Billed charges,49.11,139.41,91.65
Outpatient Medical Services,Surgery,94002,EXTUBATION/SUCTION,410,129.25,109.86,Pays at 85% of Billed charges for outpatient setting,41.55,Pays at 32.15% of Total Billed charges,103.44,Pays at 80.03% of Total Billed charges,533.72,Pays at 102% of Medicare OPPS Rate,116.33,Pays at 90% of Total Billed charges,41.55,Pays at 32.15% of Total Billed charges,523.25,Pays at 100% of Medicare OPPS Rate,41.55,Pays at 32.15% of Total Billed charges,113.74,Pays at 88% of Total Billed charges,42.79,Pays at 33.11% of Total Billed charges,41.55,533.72,77.55
Outpatient Medical Services,Surgery,94002,VENTILATOR TRANSPORT PER HOUR,410,180,153,Pays at 85% of Billed charges for outpatient setting,57.87,Pays at 32.15% of Total Billed charges,144.05,Pays at 80.03% of Total Billed charges,533.72,Pays at 102% of Medicare OPPS Rate,162,Pays at 90% of Total Billed charges,57.87,Pays at 32.15% of Total Billed charges,523.25,Pays at 100% of Medicare OPPS Rate,57.87,Pays at 32.15% of Total Billed charges,158.4,Pays at 88% of Total Billed charges,59.6,Pays at 33.11% of Total Billed charges,57.87,533.72,108.00
Outpatient Medical Services,Surgery,94002,VENTILATOR INITIAL,410,630,535.5,Pays at 85% of Billed charges for outpatient setting,202.55,Pays at 32.15% of Total Billed charges,504.19,Pays at 80.03% of Total Billed charges,533.72,Pays at 102% of Medicare OPPS Rate,567,Pays at 90% of Total Billed charges,202.55,Pays at 32.15% of Total Billed charges,523.25,Pays at 100% of Medicare OPPS Rate,202.55,Pays at 32.15% of Total Billed charges,554.4,Pays at 88% of Total Billed charges,208.59,Pays at 33.11% of Total Billed charges,202.55,567,378.00
Outpatient Medical Services,Surgery,94002,INITIAL TRANSPORT VENTILATOR PER DAY,410,710.94,604.3,Pays at 85% of Billed charges for outpatient setting,228.57,Pays at 32.15% of Total Billed charges,568.97,Pays at 80.03% of Total Billed charges,533.72,Pays at 102% of Medicare OPPS Rate,639.85,Pays at 90% of Total Billed charges,228.57,Pays at 32.15% of Total Billed charges,523.25,Pays at 100% of Medicare OPPS Rate,228.57,Pays at 32.15% of Total Billed charges,625.63,Pays at 88% of Total Billed charges,235.39,Pays at 33.11% of Total Billed charges,228.57,639.85,426.56
Outpatient Medical Services,Surgery,94002,INITIAL VENTILATOR PER DAY,410,1172.81,996.89,Pays at 85% of Billed charges for outpatient setting,377.06,Pays at 32.15% of Total Billed charges,938.6,Pays at 80.03% of Total Billed charges,533.72,Pays at 102% of Medicare OPPS Rate,1055.53,Pays at 90% of Total Billed charges,377.06,Pays at 32.15% of Total Billed charges,523.25,Pays at 100% of Medicare OPPS Rate,377.06,Pays at 32.15% of Total Billed charges,1032.07,Pays at 88% of Total Billed charges,388.32,Pays at 33.11% of Total Billed charges,377.06,1055.53,703.69
Outpatient Medical Services,Surgery,94003,VENTILATOR SUBSEQUENT PER DAY,410,1166.66,991.66,Pays at 85% of Billed charges for outpatient setting,375.08,Pays at 32.15% of Total Billed charges,933.68,Pays at 80.03% of Total Billed charges,533.72,Pays at 102% of Medicare OPPS Rate,1049.99,Pays at 90% of Total Billed charges,375.08,Pays at 32.15% of Total Billed charges,523.25,Pays at 100% of Medicare OPPS Rate,375.08,Pays at 32.15% of Total Billed charges,1026.66,Pays at 88% of Total Billed charges,386.28,Pays at 33.11% of Total Billed charges,375.08,1049.99,700.00
Outpatient Medical Services,Surgery,94640,HAND HELD NEBULIZER TX,410,40.25,34.21,Pays at 85% of Billed charges for outpatient setting,12.94,Pays at 32.15% of Total Billed charges,32.21,Pays at 80.03% of Total Billed charges,183.59,Pays at 102% of Medicare OPPS Rate,36.23,Pays at 90% of Total Billed charges,12.94,Pays at 32.15% of Total Billed charges,179.99,Pays at 100% of Medicare OPPS Rate,12.94,Pays at 32.15% of Total Billed charges,35.42,Pays at 88% of Total Billed charges,13.33,Pays at 33.11% of Total Billed charges,12.94,183.59,24.15
Outpatient Medical Services,Surgery,94640,SUBQ INCENTIVE SPIROMETRY,410,50,42.5,Pays at 85% of Billed charges for outpatient setting,16.08,Pays at 32.15% of Total Billed charges,40.02,Pays at 80.03% of Total Billed charges,183.59,Pays at 102% of Medicare OPPS Rate,45,Pays at 90% of Total Billed charges,16.08,Pays at 32.15% of Total Billed charges,179.99,Pays at 100% of Medicare OPPS Rate,16.08,Pays at 32.15% of Total Billed charges,44,Pays at 88% of Total Billed charges,16.56,Pays at 33.11% of Total Billed charges,16.08,183.59,30.00
Outpatient Medical Services,Surgery,94640,MDI TREATMENT,410,50,42.5,Pays at 85% of Billed charges for outpatient setting,16.08,Pays at 32.15% of Total Billed charges,40.02,Pays at 80.03% of Total Billed charges,183.59,Pays at 102% of Medicare OPPS Rate,45,Pays at 90% of Total Billed charges,16.08,Pays at 32.15% of Total Billed charges,179.99,Pays at 100% of Medicare OPPS Rate,16.08,Pays at 32.15% of Total Billed charges,44,Pays at 88% of Total Billed charges,16.56,Pays at 33.11% of Total Billed charges,16.08,183.59,30.00
Outpatient Medical Services,Surgery,94640,INITIAL HAND HELD NEBULIZER,410,395.45,336.13,Pays at 85% of Billed charges for outpatient setting,127.14,Pays at 32.15% of Total Billed charges,316.48,Pays at 80.03% of Total Billed charges,183.59,Pays at 102% of Medicare OPPS Rate,355.91,Pays at 90% of Total Billed charges,127.14,Pays at 32.15% of Total Billed charges,179.99,Pays at 100% of Medicare OPPS Rate,127.14,Pays at 32.15% of Total Billed charges,348,Pays at 88% of Total Billed charges,130.93,Pays at 33.11% of Total Billed charges,127.14,355.91,237.27
Outpatient Medical Services,Surgery,94640,INITIAL MDI THERAPY,410,395.45,336.13,Pays at 85% of Billed charges for outpatient setting,127.14,Pays at 32.15% of Total Billed charges,316.48,Pays at 80.03% of Total Billed charges,183.59,Pays at 102% of Medicare OPPS Rate,355.91,Pays at 90% of Total Billed charges,127.14,Pays at 32.15% of Total Billed charges,179.99,Pays at 100% of Medicare OPPS Rate,127.14,Pays at 32.15% of Total Billed charges,348,Pays at 88% of Total Billed charges,130.93,Pays at 33.11% of Total Billed charges,127.14,355.91,237.27
Outpatient Medical Services,Surgery,94640,INCENTIVE SPIROMETRY,410,482.25,409.91,Pays at 85% of Billed charges for outpatient setting,155.04,Pays at 32.15% of Total Billed charges,385.94,Pays at 80.03% of Total Billed charges,183.59,Pays at 102% of Medicare OPPS Rate,434.03,Pays at 90% of Total Billed charges,155.04,Pays at 32.15% of Total Billed charges,179.99,Pays at 100% of Medicare OPPS Rate,155.04,Pays at 32.15% of Total Billed charges,424.38,Pays at 88% of Total Billed charges,159.67,Pays at 33.11% of Total Billed charges,155.04,434.03,289.35
Outpatient Medical Services,Surgery,94640,SPUTUM INDUCTION,410,482.25,409.91,Pays at 85% of Billed charges for outpatient setting,155.04,Pays at 32.15% of Total Billed charges,385.94,Pays at 80.03% of Total Billed charges,183.59,Pays at 102% of Medicare OPPS Rate,434.03,Pays at 90% of Total Billed charges,155.04,Pays at 32.15% of Total Billed charges,179.99,Pays at 100% of Medicare OPPS Rate,155.04,Pays at 32.15% of Total Billed charges,424.38,Pays at 88% of Total Billed charges,159.67,Pays at 33.11% of Total Billed charges,155.04,434.03,289.35
Outpatient Medical Services,Surgery,94640,CONTINUOUS NEB 1ST 2 HOURS,410,602.81,512.39,Pays at 85% of Billed charges for outpatient setting,193.8,Pays at 32.15% of Total Billed charges,482.43,Pays at 80.03% of Total Billed charges,183.59,Pays at 102% of Medicare OPPS Rate,542.53,Pays at 90% of Total Billed charges,193.8,Pays at 32.15% of Total Billed charges,179.99,Pays at 100% of Medicare OPPS Rate,193.8,Pays at 32.15% of Total Billed charges,530.47,Pays at 88% of Total Billed charges,199.59,Pays at 33.11% of Total Billed charges,179.99,542.53,361.69
Outpatient Medical Services,Surgery,94650,**TEST**,410,69.25,58.86,Pays at 85% of Billed charges for outpatient setting,22.26,Pays at 32.15% of Total Billed charges,55.42,Pays at 80.03% of Total Billed charges,69.25,Not Applicable,62.33,Pays at 90% of Total Billed charges,22.26,Pays at 32.15% of Total Billed charges,69.25,Not Applicable,22.26,Pays at 32.15% of Total Billed charges,60.94,Pays at 88% of Total Billed charges,22.93,Pays at 33.11% of Total Billed charges,22.26,69.25,41.55
Outpatient Medical Services,Surgery,94660,CPAP,410,406.52,345.54,Pays at 85% of Billed charges for outpatient setting,130.7,Pays at 32.15% of Total Billed charges,325.34,Pays at 80.03% of Total Billed charges,183.59,Pays at 102% of Medicare OPPS Rate,365.87,Pays at 90% of Total Billed charges,130.7,Pays at 32.15% of Total Billed charges,179.99,Pays at 100% of Medicare OPPS Rate,130.7,Pays at 32.15% of Total Billed charges,357.74,Pays at 88% of Total Billed charges,134.6,Pays at 33.11% of Total Billed charges,130.7,365.87,243.91
Outpatient Medical Services,Surgery,94660,BiPAP,410,700.49,595.42,Pays at 85% of Billed charges for outpatient setting,225.21,Pays at 32.15% of Total Billed charges,560.6,Pays at 80.03% of Total Billed charges,183.59,Pays at 102% of Medicare OPPS Rate,630.44,Pays at 90% of Total Billed charges,225.21,Pays at 32.15% of Total Billed charges,179.99,Pays at 100% of Medicare OPPS Rate,225.21,Pays at 32.15% of Total Billed charges,616.43,Pays at 88% of Total Billed charges,231.93,Pays at 33.11% of Total Billed charges,179.99,630.44,420.29
Outpatient Medical Services,Surgery,94664,PATIENT EVALUATION,410,482.25,409.91,Pays at 85% of Billed charges for outpatient setting,155.04,Pays at 32.15% of Total Billed charges,385.94,Pays at 80.03% of Total Billed charges,183.59,Pays at 102% of Medicare OPPS Rate,434.03,Pays at 90% of Total Billed charges,155.04,Pays at 32.15% of Total Billed charges,179.99,Pays at 100% of Medicare OPPS Rate,155.04,Pays at 32.15% of Total Billed charges,424.38,Pays at 88% of Total Billed charges,159.67,Pays at 33.11% of Total Billed charges,155.04,434.03,289.35
Outpatient Medical Services,Surgery,94667,INITIAL CPT/POSTURAL DRAINAGE,410,272.25,231.41,Pays at 85% of Billed charges for outpatient setting,87.53,Pays at 32.15% of Total Billed charges,217.88,Pays at 80.03% of Total Billed charges,111.31,Pays at 102% of Medicare OPPS Rate,245.03,Pays at 90% of Total Billed charges,87.53,Pays at 32.15% of Total Billed charges,109.13,Pays at 100% of Medicare OPPS Rate,87.53,Pays at 32.15% of Total Billed charges,239.58,Pays at 88% of Total Billed charges,90.14,Pays at 33.11% of Total Billed charges,87.53,245.03,163.35
Outpatient Medical Services,Surgery,94669,MECHANICAL CHEST WALL  OSCOILL,410,482.25,409.91,Pays at 85% of Billed charges for outpatient setting,155.04,Pays at 32.15% of Total Billed charges,385.94,Pays at 80.03% of Total Billed charges,183.59,Pays at 102% of Medicare OPPS Rate,434.03,Pays at 90% of Total Billed charges,155.04,Pays at 32.15% of Total Billed charges,179.99,Pays at 100% of Medicare OPPS Rate,155.04,Pays at 32.15% of Total Billed charges,424.38,Pays at 88% of Total Billed charges,159.67,Pays at 33.11% of Total Billed charges,155.04,434.03,289.35
Outpatient Medical Services,Surgery,94680,OXYGEN ROUNDS,412,5,4.25,Pays at 85% of Billed charges for outpatient setting,1.61,Pays at 32.15% of Total Billed charges,4,Pays at 80.03% of Total Billed charges,139.41,Pays at 102% of Medicare OPPS Rate,4.5,Pays at 90% of Total Billed charges,1.61,Pays at 32.15% of Total Billed charges,136.69,Pays at 100% of Medicare OPPS Rate,1.61,Pays at 32.15% of Total Billed charges,4.4,Pays at 88% of Total Billed charges,1.66,Pays at 33.11% of Total Billed charges,1.61,139.41,3.00
Outpatient Medical Services,Surgery,94760,EXHALED CARBON MONOXIDE,410,66.5,56.53,Pays at 85% of Billed charges for outpatient setting,21.38,Pays at 32.15% of Total Billed charges,53.22,Pays at 80.03% of Total Billed charges,66.5,Not Applicable,59.85,Pays at 90% of Total Billed charges,21.38,Pays at 32.15% of Total Billed charges,66.5,Not Applicable,21.38,Pays at 32.15% of Total Billed charges,58.52,Pays at 88% of Total Billed charges,22.02,Pays at 33.11% of Total Billed charges,21.38,66.5,39.90
Outpatient Medical Services,Surgery,95805,MULTIPLE SLEEP LATENCY TEST,410,1802,1531.7,Pays at 85% of Billed charges for outpatient setting,579.34,Pays at 32.15% of Total Billed charges,1442.14,Pays at 80.03% of Total Billed charges,463.45,Pays at 102% of Medicare OPPS Rate,1621.8,Pays at 90% of Total Billed charges,579.34,Pays at 32.15% of Total Billed charges,454.37,Pays at 100% of Medicare OPPS Rate,579.34,Pays at 32.15% of Total Billed charges,1585.76,Pays at 88% of Total Billed charges,596.64,Pays at 33.11% of Total Billed charges,454.37,1621.8,1081.20
Outpatient Medical Services,Surgery,96523,IRRIGATION OF VENUOU ACCESS (HEP FLUSH),761,181.25,154.06,Pays at 85% of Billed charges for outpatient setting,58.27,Pays at 32.15% of Total Billed charges,145.05,Pays at 80.03% of Total Billed charges,55.1,Pays at 102% of Medicare OPPS Rate,163.13,Pays at 90% of Total Billed charges,58.27,Pays at 32.15% of Total Billed charges,54.02,Pays at 100% of Medicare OPPS Rate,58.27,Pays at 32.15% of Total Billed charges,159.5,Pays at 88% of Total Billed charges,60.01,Pays at 33.11% of Total Billed charges,54.02,163.13,108.75
Outpatient Medical Services,Surgery,97597,"Debridement (for example, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps)",761,440.63,374.54,Pays at 85% of Billed charges for outpatient setting,141.66,Pays at 32.15% of Total Billed charges,352.64,Pays at 80.03% of Total Billed charges,173.11,Pays at 102% of Medicare OPPS Rate,396.57,Pays at 90% of Total Billed charges,141.66,Pays at 32.15% of Total Billed charges,169.72,Pays at 100% of Medicare OPPS Rate,141.66,Pays at 32.15% of Total Billed charges,387.75,Pays at 88% of Total Billed charges,145.89,Pays at 33.11% of Total Billed charges,141.66,396.57,264.38
Outpatient Medical Services,Surgery,97598,DEBRIDEMENT OPEN WOUND EA ADD 20 SQ CM,761,289.05,245.69,Pays at 85% of Billed charges for outpatient setting,92.93,Pays at 32.15% of Total Billed charges,231.33,Pays at 80.03% of Total Billed charges,289.05,Not Applicable,260.15,Pays at 90% of Total Billed charges,92.93,Pays at 32.15% of Total Billed charges,289.05,Not Applicable,92.93,Pays at 32.15% of Total Billed charges,254.36,Pays at 88% of Total Billed charges,95.7,Pays at 33.11% of Total Billed charges,92.93,289.05,173.43
Outpatient Medical Services,Surgery,97602,REMOVAL OF DEVITALIZED TISSUE,761,277.25,235.66,Pays at 85% of Billed charges for outpatient setting,89.14,Pays at 32.15% of Total Billed charges,221.88,Pays at 80.03% of Total Billed charges,173.12,Pays at 102% of Medicare OPPS Rate,249.53,Pays at 90% of Total Billed charges,89.14,Pays at 32.15% of Total Billed charges,169.72,Pays at 100% of Medicare OPPS Rate,89.14,Pays at 32.15% of Total Billed charges,243.98,Pays at 88% of Total Billed charges,91.8,Pays at 33.11% of Total Billed charges,89.14,249.53,166.35
Outpatient Medical Services,Surgery,97605,NEGATIVE PRESSURE WOUND THERAPY,761,545.94,464.05,Pays at 85% of Billed charges for outpatient setting,175.52,Pays at 32.15% of Total Billed charges,436.92,Pays at 80.03% of Total Billed charges,173.12,Pays at 102% of Medicare OPPS Rate,491.35,Pays at 90% of Total Billed charges,175.52,Pays at 32.15% of Total Billed charges,169.72,Pays at 100% of Medicare OPPS Rate,175.52,Pays at 32.15% of Total Billed charges,480.43,Pays at 88% of Total Billed charges,180.76,Pays at 33.11% of Total Billed charges,169.72,491.35,327.56
Outpatient Medical Services,Surgery,97606,NEG PRESSURE WOUND THERAPY VACUUM ASSIST,761,487.75,414.59,Pays at 85% of Billed charges for outpatient setting,156.81,Pays at 32.15% of Total Billed charges,390.35,Pays at 80.03% of Total Billed charges,357.66,Pays at 102% of Medicare OPPS Rate,438.98,Pays at 90% of Total Billed charges,156.81,Pays at 32.15% of Total Billed charges,350.65,Pays at 100% of Medicare OPPS Rate,156.81,Pays at 32.15% of Total Billed charges,429.22,Pays at 88% of Total Billed charges,161.49,Pays at 33.11% of Total Billed charges,156.81,438.98,292.65
Outpatient Medical Services,Surgery,97607,NEG PRESSURE WOUND THERAPY VACUUM ASSIST,360,804.25,683.61,Pays at 85% of Billed charges for outpatient setting,258.57,Pays at 32.15% of Total Billed charges,643.64,Pays at 80.03% of Total Billed charges,357.66,Pays at 102% of Medicare OPPS Rate,723.83,Pays at 90% of Total Billed charges,258.57,Pays at 32.15% of Total Billed charges,350.64,Pays at 100% of Medicare OPPS Rate,258.57,Pays at 32.15% of Total Billed charges,707.74,Pays at 88% of Total Billed charges,266.29,Pays at 33.11% of Total Billed charges,258.57,723.83,482.55
Outpatient Medical Services,Surgery,97608,NEG PRESSURE WOUND THPY VACUUM >50 SQ CM,360,804.25,683.61,Pays at 85% of Billed charges for outpatient setting,258.57,Pays at 32.15% of Total Billed charges,643.64,Pays at 80.03% of Total Billed charges,357.66,Pays at 102% of Medicare OPPS Rate,723.83,Pays at 90% of Total Billed charges,258.57,Pays at 32.15% of Total Billed charges,350.64,Pays at 100% of Medicare OPPS Rate,258.57,Pays at 32.15% of Total Billed charges,707.74,Pays at 88% of Total Billed charges,266.29,Pays at 33.11% of Total Billed charges,258.57,723.83,482.55
Outpatient Medical Services,Surgery,99151,CONSCIOUS SEDATION 1ST 15 MIN.,372,408.5,347.23,Pays at 85% of Billed charges for outpatient setting,131.33,Pays at 32.15% of Total Billed charges,326.92,Pays at 80.03% of Total Billed charges,408.5,Not Applicable,367.65,Pays at 90% of Total Billed charges,131.33,Pays at 32.15% of Total Billed charges,408.5,Not Applicable,131.33,Pays at 32.15% of Total Billed charges,359.48,Pays at 88% of Total Billed charges,135.25,Pays at 33.11% of Total Billed charges,131.33,408.5,245.10
Outpatient Medical Services,Surgery,99153,CONSCIOUS SEDATION EA ADDITIONAL 15 MIN,372,179.75,152.79,Pays at 85% of Billed charges for outpatient setting,57.79,Pays at 32.15% of Total Billed charges,143.85,Pays at 80.03% of Total Billed charges,179.75,Not Applicable,161.78,Pays at 90% of Total Billed charges,57.79,Pays at 32.15% of Total Billed charges,179.75,Not Applicable,57.79,Pays at 32.15% of Total Billed charges,158.18,Pays at 88% of Total Billed charges,59.52,Pays at 33.11% of Total Billed charges,57.79,179.75,107.85
Outpatient Medical Services,Surgery,99153,CONSCIOUS SEDATION ADDL 15 MIN OVER 5 YR,372,408.5,347.23,Pays at 85% of Billed charges for outpatient setting,131.33,Pays at 32.15% of Total Billed charges,326.92,Pays at 80.03% of Total Billed charges,408.5,Not Applicable,367.65,Pays at 90% of Total Billed charges,131.33,Pays at 32.15% of Total Billed charges,408.5,Not Applicable,131.33,Pays at 32.15% of Total Billed charges,359.48,Pays at 88% of Total Billed charges,135.25,Pays at 33.11% of Total Billed charges,131.33,408.5,245.10
Outpatient Medical Services,Surgery,99183,HYPERBARIC O2 PER SESSION,413,1468,1247.8,Pays at 85% of Billed charges for outpatient setting,471.96,Pays at 32.15% of Total Billed charges,1174.84,Pays at 80.03% of Total Billed charges,1468,Not Applicable,1321.2,Pays at 90% of Total Billed charges,471.96,Pays at 32.15% of Total Billed charges,1468,Not Applicable,471.96,Pays at 32.15% of Total Billed charges,1291.84,Pays at 88% of Total Billed charges,486.05,Pays at 33.11% of Total Billed charges,471.96,1468,880.80
Outpatient Medical Services,Surgery,99211,Outpatient visit of established patient not requiring a physician,761,28,23.8,Pays at 85% of Billed charges for outpatient setting,9,Pays at 32.15% of Total Billed charges,22.41,Pays at 80.03% of Total Billed charges,28,Not Applicable,25.2,Pays at 90% of Total Billed charges,9,Pays at 32.15% of Total Billed charges,28,Not Applicable,9,Pays at 32.15% of Total Billed charges,24.64,Pays at 88% of Total Billed charges,9.27,Pays at 33.11% of Total Billed charges,9,28,16.80
Outpatient Medical Services,Surgery,99212,Outpatient visit of established patient requiring a physician,761,29.25,24.86,Pays at 85% of Billed charges for outpatient setting,9.4,Pays at 32.15% of Total Billed charges,23.41,Pays at 80.03% of Total Billed charges,29.25,Not Applicable,26.33,Pays at 90% of Total Billed charges,9.4,Pays at 32.15% of Total Billed charges,29.25,Not Applicable,9.4,Pays at 32.15% of Total Billed charges,25.74,Pays at 88% of Total Billed charges,9.68,Pays at 33.11% of Total Billed charges,9.4,29.25,17.55
Outpatient Medical Services,Surgery,99212,Outpatient visit of established patient requiring a physician,761,115,97.75,Pays at 85% of Billed charges for outpatient setting,36.97,Pays at 32.15% of Total Billed charges,92.03,Pays at 80.03% of Total Billed charges,115,Not Applicable,103.5,Pays at 90% of Total Billed charges,36.97,Pays at 32.15% of Total Billed charges,115,Not Applicable,36.97,Pays at 32.15% of Total Billed charges,101.2,Pays at 88% of Total Billed charges,38.08,Pays at 33.11% of Total Billed charges,36.97,115,69.00
Outpatient Medical Services,Surgery,29580,APPLICATION OF UNNA BOOT,761,914.75,777.54,Pays at 85% of Billed charges for outpatient setting,294.09,Pays at 32.15% of Total Billed charges,732.07,Pays at 80.03% of Total Billed charges,139.72,Pays at 102% of Medicare OPPS Rate,823.28,Pays at 90% of Total Billed charges,294.09,Pays at 32.15% of Total Billed charges,137,Pays at 100% of Medicare OPPS Rate,294.09,Pays at 32.15% of Total Billed charges,804.98,Pays at 88% of Total Billed charges,302.87,Pays at 33.11% of Total Billed charges,137,823.28,548.85
Outpatient Medical Services,Surgery,29581,APPLICATION OF BILATERAL MULTI LAYER,761,420.25,357.21,Pays at 85% of Billed charges for outpatient setting,135.11,Pays at 32.15% of Total Billed charges,336.33,Pays at 80.03% of Total Billed charges,139.72,Pays at 102% of Medicare OPPS Rate,378.23,Pays at 90% of Total Billed charges,135.11,Pays at 32.15% of Total Billed charges,137,Pays at 100% of Medicare OPPS Rate,135.11,Pays at 32.15% of Total Billed charges,369.82,Pays at 88% of Total Billed charges,139.14,Pays at 33.11% of Total Billed charges,135.11,378.23,252.15
Outpatient Medical Services,Surgery,94640,SUBSEQUENT HAND HELD NEBULIZER,410,187.88,159.7,Pays at 85% of Billed charges for outpatient setting,60.4,Pays at 32.15% of Total Billed charges,150.36,Pays at 80.03% of Total Billed charges,183.59,Pays at 102% of Medicare OPPS Rate,169.09,Pays at 90% of Total Billed charges,60.4,Pays at 32.15% of Total Billed charges,179.99,Pays at 100% of Medicare OPPS Rate,60.4,Pays at 32.15% of Total Billed charges,165.33,Pays at 88% of Total Billed charges,62.21,Pays at 33.11% of Total Billed charges,60.4,183.59,112.73
Outpatient Medical Services,Surgery,0191T,GLAUKOS EYE STENT,361,7636.65,6491.15,Pays at 85% of Billed charges for outpatient setting,2455.18,Pays at 32.15% of Total Billed charges,6111.61,Pays at 80.03% of Total Billed charges,7636.65,Not Applicable,6872.99,Pays at 90% of Total Billed charges,2455.18,Pays at 32.15% of Total Billed charges,7636.65,Not Applicable,2455.18,Pays at 32.15% of Total Billed charges,6720.25,Pays at 88% of Total Billed charges,2528.49,Pays at 33.11% of Total Billed charges,2455.18,7636.65,4581.99
Outpatient Medical Services,Surgery,0376T,GLAUKOS 2ND STENT,361,142.65,121.25,Pays at 85% of Billed charges for outpatient setting,45.86,Pays at 32.15% of Total Billed charges,114.16,Pays at 80.03% of Total Billed charges,142.65,Not Applicable,128.39,Pays at 90% of Total Billed charges,45.86,Pays at 32.15% of Total Billed charges,142.65,Not Applicable,45.86,Pays at 32.15% of Total Billed charges,125.53,Pays at 88% of Total Billed charges,47.23,Pays at 33.11% of Total Billed charges,45.86,142.65,85.59
Outpatient Medical Services,Surgery,19000,US ASPIRATION OF BREAST,761,297.5,252.88,Pays at 85% of Billed charges for outpatient setting,95.65,Pays at 32.15% of Total Billed charges,238.09,Pays at 80.03% of Total Billed charges,622.15,Pays at 102% of Medicare OPPS Rate,267.75,Pays at 90% of Total Billed charges,95.65,Pays at 32.15% of Total Billed charges,609.96,Pays at 100% of Medicare OPPS Rate,95.65,Pays at 32.15% of Total Billed charges,261.8,Pays at 88% of Total Billed charges,98.5,Pays at 33.11% of Total Billed charges,95.65,622.15,178.50
Outpatient Medical Services,Surgery,19001,US ASPIRATION OF BREAST MULTIPLE,761,357.25,303.66,Pays at 85% of Billed charges for outpatient setting,114.86,Pays at 32.15% of Total Billed charges,285.91,Pays at 80.03% of Total Billed charges,357.25,Not Applicable,321.53,Pays at 90% of Total Billed charges,114.86,Pays at 32.15% of Total Billed charges,357.25,Not Applicable,114.86,Pays at 32.15% of Total Billed charges,314.38,Pays at 88% of Total Billed charges,118.29,Pays at 33.11% of Total Billed charges,114.86,357.25,214.35
Outpatient Medical Services,Surgery,55700,Biopsy of prostate gland,360,4387.25,3729.16,Pays at 85% of Billed charges for outpatient setting,1410.5,Pays at 32.15% of Total Billed charges,3511.12,Pays at 80.03% of Total Billed charges,1778.27,Pays at 102% of Medicare OPPS Rate,3948.53,Pays at 90% of Total Billed charges,1410.5,Pays at 32.15% of Total Billed charges,1743.41,Pays at 100% of Medicare OPPS Rate,1410.5,Pays at 32.15% of Total Billed charges,3860.78,Pays at 88% of Total Billed charges,1452.62,Pays at 33.11% of Total Billed charges,1410.5,3948.53,2632.35
Outpatient Medical Services,Surgery,64450,OR NERVE BLOCK ONLY,360,1405.5,1194.68,Pays at 85% of Billed charges for outpatient setting,451.87,Pays at 32.15% of Total Billed charges,1124.82,Pays at 80.03% of Total Billed charges,617.72,Pays at 102% of Medicare OPPS Rate,1264.95,Pays at 90% of Total Billed charges,451.87,Pays at 32.15% of Total Billed charges,605.61,Pays at 100% of Medicare OPPS Rate,451.87,Pays at 32.15% of Total Billed charges,1236.84,Pays at 88% of Total Billed charges,465.36,Pays at 33.11% of Total Billed charges,451.87,1264.95,843.30
Outpatient Medical Services,Surgery,G0237,THERAPUTIC RESPIRATORY FUNCTION,419,80,68,Pays at 85% of Billed charges for outpatient setting,25.72,Pays at 32.15% of Total Billed charges,64.02,Pays at 80.03% of Total Billed charges,23.91,Pays at 102% of Medicare OPPS Rate,72,Pays at 90% of Total Billed charges,25.72,Pays at 32.15% of Total Billed charges,23.45,Pays at 100% of Medicare OPPS Rate,25.72,Pays at 32.15% of Total Billed charges,70.4,Pays at 88% of Total Billed charges,26.49,Pays at 33.11% of Total Billed charges,23.45,72,48.00
Outpatient Medical Services,Surgery,G0239,THERAPUTIC RESP FUNCTION (2 OR MORE),419,60,51,Pays at 85% of Billed charges for outpatient setting,19.29,Pays at 32.15% of Total Billed charges,48.02,Pays at 80.03% of Total Billed charges,32.54,Pays at 102% of Medicare OPPS Rate,54,Pays at 90% of Total Billed charges,19.29,Pays at 32.15% of Total Billed charges,31.91,Pays at 100% of Medicare OPPS Rate,19.29,Pays at 32.15% of Total Billed charges,52.8,Pays at 88% of Total Billed charges,19.87,Pays at 33.11% of Total Billed charges,19.29,54,36.00
Outpatient Medical Services,Surgery,G0257,EMERGENCY UNSCHEDULED HEMODIALYSIS,880,928.5,789.23,Pays at 85% of Billed charges for outpatient setting,298.51,Pays at 32.15% of Total Billed charges,743.08,Pays at 80.03% of Total Billed charges,604.48,Pays at 102% of Medicare OPPS Rate,835.65,Pays at 90% of Total Billed charges,298.51,Pays at 32.15% of Total Billed charges,592.62,Pays at 100% of Medicare OPPS Rate,298.51,Pays at 32.15% of Total Billed charges,817.08,Pays at 88% of Total Billed charges,307.43,Pays at 33.11% of Total Billed charges,298.51,835.65,557.10
Outpatient Medical Services,Surgery,G0277,HYPERBARIC O2 PER 30 MINUTES,413,459.06,390.2,Pays at 85% of Billed charges for outpatient setting,147.59,Pays at 32.15% of Total Billed charges,367.39,Pays at 80.03% of Total Billed charges,119.89,Pays at 102% of Medicare OPPS Rate,413.15,Pays at 90% of Total Billed charges,147.59,Pays at 32.15% of Total Billed charges,117.55,Pays at 100% of Medicare OPPS Rate,147.59,Pays at 32.15% of Total Billed charges,403.97,Pays at 88% of Total Billed charges,151.99,Pays at 33.11% of Total Billed charges,117.55,413.15,275.44
Outpatient Medical Services,Surgery,P9021,RED BLOOD CELL EACH,390,211.23,179.55,Pays at 85% of Billed charges for outpatient setting,67.91,Pays at 32.15% of Total Billed charges,169.05,Pays at 80.03% of Total Billed charges,138.22,Pays at 102% of Medicare OPPS Rate,190.11,Pays at 90% of Total Billed charges,67.91,Pays at 32.15% of Total Billed charges,135.52,Pays at 100% of Medicare OPPS Rate,67.91,Pays at 32.15% of Total Billed charges,185.88,Pays at 88% of Total Billed charges,69.94,Pays at 33.11% of Total Billed charges,67.91,190.11,126.74
Outpatient Medical Services,Surgery,P9022,WASHED RED CELLS,390,168.75,143.44,Pays at 85% of Billed charges for outpatient setting,54.25,Pays at 32.15% of Total Billed charges,135.05,Pays at 80.03% of Total Billed charges,403.69,Pays at 102% of Medicare OPPS Rate,151.88,Pays at 90% of Total Billed charges,54.25,Pays at 32.15% of Total Billed charges,395.78,Pays at 100% of Medicare OPPS Rate,54.25,Pays at 32.15% of Total Billed charges,148.5,Pays at 88% of Total Billed charges,55.87,Pays at 33.11% of Total Billed charges,54.25,403.69,101.25
Outpatient Medical Services,Surgery,P9034,PLATELET PHERESIS PRODUCT,390,607.6,516.46,Pays at 85% of Billed charges for outpatient setting,195.34,Pays at 32.15% of Total Billed charges,486.26,Pays at 80.03% of Total Billed charges,340.64,Pays at 102% of Medicare OPPS Rate,546.84,Pays at 90% of Total Billed charges,195.34,Pays at 32.15% of Total Billed charges,333.97,Pays at 100% of Medicare OPPS Rate,195.34,Pays at 32.15% of Total Billed charges,534.69,Pays at 88% of Total Billed charges,201.18,Pays at 33.11% of Total Billed charges,195.34,546.84,364.56
Outpatient Medical Services,Ambulance,A0425,BLS MILEAGE (PER MILE),540,10.3,8.76,Pays at 85% of Billed charges for outpatient setting,3.31,Pays at 32.15% of Total Billed charges,8.24,Pays at 80.03% of Total Billed charges,NA,Not Applicable,9.27,Pays at 90% of Total Billed charges,3.31,Pays at 32.15% of Total Billed charges,NA,Not Applicable,3.31,Pays at 32.15% of Total Billed charges,9.06,Pays at 88% of Total Billed charges,3.41,Pays at 33.11% of Total Billed charges,3.31,9.27,6.18
Outpatient Medical Services,Ambulance,A0425,ALS MILEAGE (PER MILE),540,10.3,8.76,Pays at 85% of Billed charges for outpatient setting,3.31,Pays at 32.15% of Total Billed charges,8.24,Pays at 80.03% of Total Billed charges,NA,Not Applicable,9.27,Pays at 90% of Total Billed charges,3.31,Pays at 32.15% of Total Billed charges,NA,Not Applicable,3.31,Pays at 32.15% of Total Billed charges,9.06,Pays at 88% of Total Billed charges,3.41,Pays at 33.11% of Total Billed charges,3.31,9.27,6.18
Outpatient Medical Services,Ambulance,A0425,GROUND MILEAGE,540,12.88,10.95,Pays at 85% of Billed charges for outpatient setting,4.14,Pays at 32.15% of Total Billed charges,10.31,Pays at 80.03% of Total Billed charges,NA,Not Applicable,11.59,Pays at 90% of Total Billed charges,4.14,Pays at 32.15% of Total Billed charges,NA,Not Applicable,4.14,Pays at 32.15% of Total Billed charges,11.33,Pays at 88% of Total Billed charges,4.26,Pays at 33.11% of Total Billed charges,4.14,11.59,7.73
Outpatient Medical Services,Ambulance,A0426,ALS NONEMERGENCY TRANSPORT NO SPEC ALS,540,420.55,357.47,Pays at 85% of Billed charges for outpatient setting,135.21,Pays at 32.15% of Total Billed charges,336.57,Pays at 80.03% of Total Billed charges,NA,Not Applicable,378.5,Pays at 90% of Total Billed charges,135.21,Pays at 32.15% of Total Billed charges,NA,Not Applicable,135.21,Pays at 32.15% of Total Billed charges,370.08,Pays at 88% of Total Billed charges,139.24,Pays at 33.11% of Total Billed charges,135.21,378.5,252.33
Outpatient Medical Services,Ambulance,A0426,ALS NONEMERGENCY TRANSPORT SPEC ALS,540,520.3,442.26,Pays at 85% of Billed charges for outpatient setting,167.28,Pays at 32.15% of Total Billed charges,416.4,Pays at 80.03% of Total Billed charges,NA,Not Applicable,468.27,Pays at 90% of Total Billed charges,167.28,Pays at 32.15% of Total Billed charges,NA,Not Applicable,167.28,Pays at 32.15% of Total Billed charges,457.86,Pays at 88% of Total Billed charges,172.27,Pays at 33.11% of Total Billed charges,167.28,468.27,312.18
Outpatient Medical Services,Ambulance,A0427,ALS EMERGENCY TRANSPORT NO SPEC ALS,540,570.5,484.93,Pays at 85% of Billed charges for outpatient setting,183.42,Pays at 32.15% of Total Billed charges,456.57,Pays at 80.03% of Total Billed charges,NA,Not Applicable,513.45,Pays at 90% of Total Billed charges,183.42,Pays at 32.15% of Total Billed charges,NA,Not Applicable,183.42,Pays at 32.15% of Total Billed charges,502.04,Pays at 88% of Total Billed charges,188.89,Pays at 33.11% of Total Billed charges,183.42,513.45,342.30
Outpatient Medical Services,Ambulance,A0427,ALS EMERGENCY LEVEL 1 SERVICES,540,570.5,484.93,Pays at 85% of Billed charges for outpatient setting,183.42,Pays at 32.15% of Total Billed charges,456.57,Pays at 80.03% of Total Billed charges,NA,Not Applicable,513.45,Pays at 90% of Total Billed charges,183.42,Pays at 32.15% of Total Billed charges,NA,Not Applicable,183.42,Pays at 32.15% of Total Billed charges,502.04,Pays at 88% of Total Billed charges,188.89,Pays at 33.11% of Total Billed charges,183.42,513.45,342.30
Outpatient Medical Services,Ambulance,A0428,BLS NONEMERGENCY TRANSPORT,540,370.65,315.05,Pays at 85% of Billed charges for outpatient setting,119.16,Pays at 32.15% of Total Billed charges,296.63,Pays at 80.03% of Total Billed charges,NA,Not Applicable,333.59,Pays at 90% of Total Billed charges,119.16,Pays at 32.15% of Total Billed charges,NA,Not Applicable,119.16,Pays at 32.15% of Total Billed charges,326.17,Pays at 88% of Total Billed charges,122.72,Pays at 33.11% of Total Billed charges,119.16,333.59,222.39
Outpatient Medical Services,Ambulance,A0428,BLS NONEMERGENCY TRANSPORT,540,370.65,315.05,Pays at 85% of Billed charges for outpatient setting,119.16,Pays at 32.15% of Total Billed charges,296.63,Pays at 80.03% of Total Billed charges,NA,Not Applicable,333.59,Pays at 90% of Total Billed charges,119.16,Pays at 32.15% of Total Billed charges,NA,Not Applicable,119.16,Pays at 32.15% of Total Billed charges,326.17,Pays at 88% of Total Billed charges,122.72,Pays at 33.11% of Total Billed charges,119.16,333.59,222.39
Outpatient Medical Services,Ambulance,A0429,BLS EMERGENCY TRANSPORT,540,470.45,399.88,Pays at 85% of Billed charges for outpatient setting,151.25,Pays at 32.15% of Total Billed charges,376.5,Pays at 80.03% of Total Billed charges,NA,Not Applicable,423.41,Pays at 90% of Total Billed charges,151.25,Pays at 32.15% of Total Billed charges,NA,Not Applicable,151.25,Pays at 32.15% of Total Billed charges,414,Pays at 88% of Total Billed charges,155.77,Pays at 33.11% of Total Billed charges,151.25,423.41,282.27
Outpatient Medical Services,Ambulance,A0429,BLS EMERGENCY TRANSPORT,540,470.45,399.88,Pays at 85% of Billed charges for outpatient setting,151.25,Pays at 32.15% of Total Billed charges,376.5,Pays at 80.03% of Total Billed charges,NA,Not Applicable,423.41,Pays at 90% of Total Billed charges,151.25,Pays at 32.15% of Total Billed charges,NA,Not Applicable,151.25,Pays at 32.15% of Total Billed charges,414,Pays at 88% of Total Billed charges,155.77,Pays at 33.11% of Total Billed charges,151.25,423.41,282.27
Outpatient Medical Services,Ambulance,A0433,ALS NONEMERGENCY TRANSPORT SPEC ALS,540,520.3,442.26,Pays at 85% of Billed charges for outpatient setting,167.28,Pays at 32.15% of Total Billed charges,416.4,Pays at 80.03% of Total Billed charges,NA,Not Applicable,468.27,Pays at 90% of Total Billed charges,167.28,Pays at 32.15% of Total Billed charges,NA,Not Applicable,167.28,Pays at 32.15% of Total Billed charges,457.86,Pays at 88% of Total Billed charges,172.27,Pays at 33.11% of Total Billed charges,167.28,468.27,312.18
Outpatient Medical Services,Ambulance,A0433,ALS LEVEL 2 SERVICE,540,810,688.5,Pays at 85% of Billed charges for outpatient setting,260.42,Pays at 32.15% of Total Billed charges,648.24,Pays at 80.03% of Total Billed charges,NA,Not Applicable,729,Pays at 90% of Total Billed charges,260.42,Pays at 32.15% of Total Billed charges,NA,Not Applicable,260.42,Pays at 32.15% of Total Billed charges,712.8,Pays at 88% of Total Billed charges,268.19,Pays at 33.11% of Total Billed charges,260.42,729,486.00
Outpatient Medical Services,Ambulance,A0433,ALS LEVEL 2  STEMI,540,947.5,805.38,Pays at 85% of Billed charges for outpatient setting,304.62,Pays at 32.15% of Total Billed charges,758.28,Pays at 80.03% of Total Billed charges,NA,Not Applicable,852.75,Pays at 90% of Total Billed charges,304.62,Pays at 32.15% of Total Billed charges,NA,Not Applicable,304.62,Pays at 32.15% of Total Billed charges,833.8,Pays at 88% of Total Billed charges,313.72,Pays at 33.11% of Total Billed charges,304.62,852.75,568.50
Outpatient Medical Services,Ambulance,A0434,ALS EMERGENCY TRANSPORT SPECIALIZED,540,621.25,528.06,Pays at 85% of Billed charges for outpatient setting,199.73,Pays at 32.15% of Total Billed charges,497.19,Pays at 80.03% of Total Billed charges,NA,Not Applicable,559.13,Pays at 90% of Total Billed charges,199.73,Pays at 32.15% of Total Billed charges,NA,Not Applicable,199.73,Pays at 32.15% of Total Billed charges,546.7,Pays at 88% of Total Billed charges,205.7,Pays at 33.11% of Total Billed charges,199.73,559.13,372.75
Outpatient Medical Services,Ambulance,A0434,SPECIALTY CARE TRANSPORT,540,1048.05,890.84,Pays at 85% of Billed charges for outpatient setting,336.95,Pays at 32.15% of Total Billed charges,838.75,Pays at 80.03% of Total Billed charges,NA,Not Applicable,943.25,Pays at 90% of Total Billed charges,336.95,Pays at 32.15% of Total Billed charges,NA,Not Applicable,336.95,Pays at 32.15% of Total Billed charges,922.28,Pays at 88% of Total Billed charges,347.01,Pays at 33.11% of Total Billed charges,336.95,943.25,628.83
Outpatient Medical Services,Ambulance,A0998,AMB RESP & TREATMENT WITH NO TRANSPORT,540,123.15,104.68,Pays at 85% of Billed charges for outpatient setting,39.59,Pays at 32.15% of Total Billed charges,98.56,Pays at 80.03% of Total Billed charges,NA,Not Applicable,110.84,Pays at 90% of Total Billed charges,39.59,Pays at 32.15% of Total Billed charges,NA,Not Applicable,39.59,Pays at 32.15% of Total Billed charges,108.37,Pays at 88% of Total Billed charges,40.77,Pays at 33.11% of Total Billed charges,39.59,110.84,73.89
Outpatient Medical Services,Ambulance,A0888,NONCOVERED MILEAGE,549,10.3,8.76,Pays at 85% of Billed charges for outpatient setting,3.31,Pays at 32.15% of Total Billed charges,8.24,Pays at 80.03% of Total Billed charges,NA,Not Applicable,9.27,Pays at 90% of Total Billed charges,3.31,Pays at 32.15% of Total Billed charges,NA,Not Applicable,3.31,Pays at 32.15% of Total Billed charges,9.06,Pays at 88% of Total Billed charges,3.41,Pays at 33.11% of Total Billed charges,3.31,9.27,6.18
Outpatient Medical Services,THERAPY,92502,FEEDING/DYSPHAGIA EV(INACTIVE),440,90,76.5,Pays at 85% of Billed charges for outpatient setting,28.94,Pays at 32.15% of Total Billed charges,72.03,Pays at 80.03% of Total Billed charges,437.94,Pays at 102% of Medicare OPPS Rate,81,Pays at 90% of Total Billed charges,28.94,Pays at 32.15% of Total Billed charges,429.36,Pays at 100% of Medicare OPPS Rate,28.94,Pays at 32.15% of Total Billed charges,79.2,Pays at 88% of Total Billed charges,29.8,Pays at 33.11% of Total Billed charges,28.94,437.94,54.00
Outpatient Medical Services,THERAPY,92506,FEEDING/SWALLOW EVALUATION,440,165,140.25,Pays at 85% of Billed charges for outpatient setting,53.05,Pays at 32.15% of Total Billed charges,132.05,Pays at 80.03% of Total Billed charges,NA,Not Applicable,148.5,Pays at 90% of Total Billed charges,53.05,Pays at 32.15% of Total Billed charges,NA,Not Applicable,53.05,Pays at 32.15% of Total Billed charges,145.2,Pays at 88% of Total Billed charges,54.63,Pays at 33.11% of Total Billed charges,53.05,148.5,99.00
Outpatient Medical Services,THERAPY,92507,Therapy for speech or hearing,440,25,21.25,Pays at 85% of Billed charges for outpatient setting,8.04,Pays at 32.15% of Total Billed charges,20.01,Pays at 80.03% of Total Billed charges,74.96,Pays at 102% of Medicare OPPS Rate,22.5,Pays at 90% of Total Billed charges,8.04,Pays at 32.15% of Total Billed charges,73.49,Pays at 100% of Medicare OPPS Rate,8.04,Pays at 32.15% of Total Billed charges,22,Pays at 88% of Total Billed charges,8.28,Pays at 33.11% of Total Billed charges,8.04,74.96,15.00
Outpatient Medical Services,THERAPY,92507,Therapy for speech or hearing,440,35,29.75,Pays at 85% of Billed charges for outpatient setting,11.25,Pays at 32.15% of Total Billed charges,28.01,Pays at 80.03% of Total Billed charges,74.96,Pays at 102% of Medicare OPPS Rate,31.5,Pays at 90% of Total Billed charges,11.25,Pays at 32.15% of Total Billed charges,73.49,Pays at 100% of Medicare OPPS Rate,11.25,Pays at 32.15% of Total Billed charges,30.8,Pays at 88% of Total Billed charges,11.59,Pays at 33.11% of Total Billed charges,11.25,74.96,21.00
Outpatient Medical Services,THERAPY,92507,Therapy for speech or hearing,440,55,46.75,Pays at 85% of Billed charges for outpatient setting,17.68,Pays at 32.15% of Total Billed charges,44.02,Pays at 80.03% of Total Billed charges,74.96,Pays at 102% of Medicare OPPS Rate,49.5,Pays at 90% of Total Billed charges,17.68,Pays at 32.15% of Total Billed charges,73.49,Pays at 100% of Medicare OPPS Rate,17.68,Pays at 32.15% of Total Billed charges,48.4,Pays at 88% of Total Billed charges,18.21,Pays at 33.11% of Total Billed charges,17.68,74.96,33.00
Outpatient Medical Services,THERAPY,92507,Therapy for speech or hearing,440,65,55.25,Pays at 85% of Billed charges for outpatient setting,20.9,Pays at 32.15% of Total Billed charges,52.02,Pays at 80.03% of Total Billed charges,74.96,Pays at 102% of Medicare OPPS Rate,58.5,Pays at 90% of Total Billed charges,20.9,Pays at 32.15% of Total Billed charges,73.49,Pays at 100% of Medicare OPPS Rate,20.9,Pays at 32.15% of Total Billed charges,57.2,Pays at 88% of Total Billed charges,21.52,Pays at 33.11% of Total Billed charges,20.9,74.96,39.00
Outpatient Medical Services,THERAPY,92507,Therapy for speech or hearing,440,100,85,Pays at 85% of Billed charges for outpatient setting,32.15,Pays at 32.15% of Total Billed charges,80.03,Pays at 80.03% of Total Billed charges,74.96,Pays at 102% of Medicare OPPS Rate,90,Pays at 90% of Total Billed charges,32.15,Pays at 32.15% of Total Billed charges,73.49,Pays at 100% of Medicare OPPS Rate,32.15,Pays at 32.15% of Total Billed charges,88,Pays at 88% of Total Billed charges,33.11,Pays at 33.11% of Total Billed charges,32.15,90,60.00
Outpatient Medical Services,THERAPY,92508,SPEECH GROUP ACTIVITY,440,40,34,Pays at 85% of Billed charges for outpatient setting,12.86,Pays at 32.15% of Total Billed charges,32.01,Pays at 80.03% of Total Billed charges,23.02,Pays at 102% of Medicare OPPS Rate,36,Pays at 90% of Total Billed charges,12.86,Pays at 32.15% of Total Billed charges,22.57,Pays at 100% of Medicare OPPS Rate,12.86,Pays at 32.15% of Total Billed charges,35.2,Pays at 88% of Total Billed charges,13.24,Pays at 33.11% of Total Billed charges,12.86,36,24.00
Outpatient Medical Services,THERAPY,95833,O/T RANGE OF MOTION/MOBILITY,430,30,25.5,Pays at 85% of Billed charges for outpatient setting,9.65,Pays at 32.15% of Total Billed charges,24.01,Pays at 80.03% of Total Billed charges,NA,Not Applicable,27,Pays at 90% of Total Billed charges,9.65,Pays at 32.15% of Total Billed charges,NA,Not Applicable,9.65,Pays at 32.15% of Total Billed charges,26.4,Pays at 88% of Total Billed charges,9.93,Pays at 33.11% of Total Billed charges,9.65,27,18.00
Outpatient Medical Services,THERAPY,95833,MMT-TOTAL BODY EXCLUDING HANDS,430,68.3,58.06,Pays at 85% of Billed charges for outpatient setting,21.96,Pays at 32.15% of Total Billed charges,54.66,Pays at 80.03% of Total Billed charges,NA,Not Applicable,61.47,Pays at 90% of Total Billed charges,21.96,Pays at 32.15% of Total Billed charges,NA,Not Applicable,21.96,Pays at 32.15% of Total Billed charges,60.1,Pays at 88% of Total Billed charges,22.61,Pays at 33.11% of Total Billed charges,21.96,61.47,40.98
Outpatient Medical Services,THERAPY,95852,"R5CP/EASSSET,BSC           Ei",424,71.85,61.07,Pays at 85% of Billed charges for outpatient setting,23.1,Pays at 32.15% of Total Billed charges,57.5,Pays at 80.03% of Total Billed charges,5.37,Pays at 102% of Medicare OPPS Rate,64.67,Pays at 90% of Total Billed charges,23.1,Pays at 32.15% of Total Billed charges,5.26,Pays at 100% of Medicare OPPS Rate,23.1,Pays at 32.15% of Total Billed charges,63.23,Pays at 88% of Total Billed charges,23.79,Pays at 33.11% of Total Billed charges,5.26,64.67,43.11
Outpatient Medical Services,THERAPY,97002,P/T REASSESSMENT,420,120,102,Pays at 85% of Billed charges for outpatient setting,38.58,Pays at 32.15% of Total Billed charges,96.04,Pays at 80.03% of Total Billed charges,NA,Not Applicable,108,Pays at 90% of Total Billed charges,38.58,Pays at 32.15% of Total Billed charges,NA,Not Applicable,38.58,Pays at 32.15% of Total Billed charges,105.6,Pays at 88% of Total Billed charges,39.73,Pays at 33.11% of Total Billed charges,38.58,108,72.00
Outpatient Medical Services,THERAPY,97010,Use of external hot or cold packs,430,15,12.75,Pays at 85% of Billed charges for outpatient setting,4.82,Pays at 32.15% of Total Billed charges,12,Pays at 80.03% of Total Billed charges,6.07,Pays at 102% of Medicare OPPS Rate,13.5,Pays at 90% of Total Billed charges,4.82,Pays at 32.15% of Total Billed charges,5.95,Pays at 100% of Medicare OPPS Rate,4.82,Pays at 32.15% of Total Billed charges,13.2,Pays at 88% of Total Billed charges,4.97,Pays at 33.11% of Total Billed charges,4.82,13.5,9.00
Outpatient Medical Services,THERAPY,97012,Form of decompression therapy of the spine,420,20,17,Pays at 85% of Billed charges for outpatient setting,6.43,Pays at 32.15% of Total Billed charges,16.01,Pays at 80.03% of Total Billed charges,14.17,Pays at 102% of Medicare OPPS Rate,18,Pays at 90% of Total Billed charges,6.43,Pays at 32.15% of Total Billed charges,13.89,Pays at 100% of Medicare OPPS Rate,6.43,Pays at 32.15% of Total Billed charges,17.6,Pays at 88% of Total Billed charges,6.62,Pays at 33.11% of Total Billed charges,6.43,18,12.00
Outpatient Medical Services,THERAPY,97012,Form of decompression therapy of the spine,420,35,29.75,Pays at 85% of Billed charges for outpatient setting,11.25,Pays at 32.15% of Total Billed charges,28.01,Pays at 80.03% of Total Billed charges,14.17,Pays at 102% of Medicare OPPS Rate,31.5,Pays at 90% of Total Billed charges,11.25,Pays at 32.15% of Total Billed charges,13.89,Pays at 100% of Medicare OPPS Rate,11.25,Pays at 32.15% of Total Billed charges,30.8,Pays at 88% of Total Billed charges,11.59,Pays at 33.11% of Total Billed charges,11.25,31.5,21.00
Outpatient Medical Services,THERAPY,97014,One time use unattended,430,20,17,Pays at 85% of Billed charges for outpatient setting,6.43,Pays at 32.15% of Total Billed charges,16.01,Pays at 80.03% of Total Billed charges,NA,Not Applicable,18,Pays at 90% of Total Billed charges,6.43,Pays at 32.15% of Total Billed charges,NA,Not Applicable,6.43,Pays at 32.15% of Total Billed charges,17.6,Pays at 88% of Total Billed charges,6.62,Pays at 33.11% of Total Billed charges,6.43,18,12.00
Outpatient Medical Services,THERAPY,97014,One time use unattended,420,40,34,Pays at 85% of Billed charges for outpatient setting,12.86,Pays at 32.15% of Total Billed charges,32.01,Pays at 80.03% of Total Billed charges,NA,Not Applicable,36,Pays at 90% of Total Billed charges,12.86,Pays at 32.15% of Total Billed charges,NA,Not Applicable,12.86,Pays at 32.15% of Total Billed charges,35.2,Pays at 88% of Total Billed charges,13.24,Pays at 33.11% of Total Billed charges,12.86,36,24.00
Outpatient Medical Services,THERAPY,97016,"Machines designed to pump cold water into an inflatable wrap or brace, compressing the enveloped area of the body",430,15,12.75,Pays at 85% of Billed charges for outpatient setting,4.82,Pays at 32.15% of Total Billed charges,12,Pays at 80.03% of Total Billed charges,11.44,Pays at 102% of Medicare OPPS Rate,13.5,Pays at 90% of Total Billed charges,4.82,Pays at 32.15% of Total Billed charges,11.22,Pays at 100% of Medicare OPPS Rate,4.82,Pays at 32.15% of Total Billed charges,13.2,Pays at 88% of Total Billed charges,4.97,Pays at 33.11% of Total Billed charges,4.82,13.5,9.00
Outpatient Medical Services,THERAPY,97016,"Machines designed to pump cold water into an inflatable wrap or brace, compressing the enveloped area of the body",430,34.7,29.5,Pays at 85% of Billed charges for outpatient setting,11.16,Pays at 32.15% of Total Billed charges,27.77,Pays at 80.03% of Total Billed charges,11.44,Pays at 102% of Medicare OPPS Rate,31.23,Pays at 90% of Total Billed charges,11.16,Pays at 32.15% of Total Billed charges,11.22,Pays at 100% of Medicare OPPS Rate,11.16,Pays at 32.15% of Total Billed charges,30.54,Pays at 88% of Total Billed charges,11.49,Pays at 33.11% of Total Billed charges,11.16,31.23,20.82
Outpatient Medical Services,THERAPY,97016,"Machines designed to pump cold water into an inflatable wrap or brace, compressing the enveloped area of the body",420,40,34,Pays at 85% of Billed charges for outpatient setting,12.86,Pays at 32.15% of Total Billed charges,32.01,Pays at 80.03% of Total Billed charges,11.44,Pays at 102% of Medicare OPPS Rate,36,Pays at 90% of Total Billed charges,12.86,Pays at 32.15% of Total Billed charges,11.22,Pays at 100% of Medicare OPPS Rate,12.86,Pays at 32.15% of Total Billed charges,35.2,Pays at 88% of Total Billed charges,13.24,Pays at 33.11% of Total Billed charges,11.22,36,24.00
Outpatient Medical Services,THERAPY,97018,PARAFFIN BATH,430,15,12.75,Pays at 85% of Billed charges for outpatient setting,4.82,Pays at 32.15% of Total Billed charges,12,Pays at 80.03% of Total Billed charges,5.47,Pays at 102% of Medicare OPPS Rate,13.5,Pays at 90% of Total Billed charges,4.82,Pays at 32.15% of Total Billed charges,5.36,Pays at 100% of Medicare OPPS Rate,4.82,Pays at 32.15% of Total Billed charges,13.2,Pays at 88% of Total Billed charges,4.97,Pays at 33.11% of Total Billed charges,4.82,13.5,9.00
Outpatient Medical Services,THERAPY,97018,DO NOT USE,420,30,25.5,Pays at 85% of Billed charges for outpatient setting,9.65,Pays at 32.15% of Total Billed charges,24.01,Pays at 80.03% of Total Billed charges,5.47,Pays at 102% of Medicare OPPS Rate,27,Pays at 90% of Total Billed charges,9.65,Pays at 32.15% of Total Billed charges,5.36,Pays at 100% of Medicare OPPS Rate,9.65,Pays at 32.15% of Total Billed charges,26.4,Pays at 88% of Total Billed charges,9.93,Pays at 33.11% of Total Billed charges,5.36,27,18.00
Outpatient Medical Services,THERAPY,97018,O/T PARAFFIN BATH,430,48.8,41.48,Pays at 85% of Billed charges for outpatient setting,15.69,Pays at 32.15% of Total Billed charges,39.05,Pays at 80.03% of Total Billed charges,5.47,Pays at 102% of Medicare OPPS Rate,43.92,Pays at 90% of Total Billed charges,15.69,Pays at 32.15% of Total Billed charges,5.36,Pays at 100% of Medicare OPPS Rate,15.69,Pays at 32.15% of Total Billed charges,42.94,Pays at 88% of Total Billed charges,16.16,Pays at 33.11% of Total Billed charges,5.36,43.92,29.28
Outpatient Medical Services,THERAPY,97022,DO NOT USE,420,60,51,Pays at 85% of Billed charges for outpatient setting,19.29,Pays at 32.15% of Total Billed charges,48.02,Pays at 80.03% of Total Billed charges,16.27,Pays at 102% of Medicare OPPS Rate,54,Pays at 90% of Total Billed charges,19.29,Pays at 32.15% of Total Billed charges,15.95,Pays at 100% of Medicare OPPS Rate,19.29,Pays at 32.15% of Total Billed charges,52.8,Pays at 88% of Total Billed charges,19.87,Pays at 33.11% of Total Billed charges,15.95,54,36.00
Outpatient Medical Services,THERAPY,97022,P/T WHIRLPOOL,420,90,76.5,Pays at 85% of Billed charges for outpatient setting,28.94,Pays at 32.15% of Total Billed charges,72.03,Pays at 80.03% of Total Billed charges,16.27,Pays at 102% of Medicare OPPS Rate,81,Pays at 90% of Total Billed charges,28.94,Pays at 32.15% of Total Billed charges,15.95,Pays at 100% of Medicare OPPS Rate,28.94,Pays at 32.15% of Total Billed charges,79.2,Pays at 88% of Total Billed charges,29.8,Pays at 33.11% of Total Billed charges,15.95,81,54.00
Outpatient Medical Services,THERAPY,97022,MINI WHIRLPOOL,430,90.4,76.84,Pays at 85% of Billed charges for outpatient setting,29.06,Pays at 32.15% of Total Billed charges,72.35,Pays at 80.03% of Total Billed charges,16.27,Pays at 102% of Medicare OPPS Rate,81.36,Pays at 90% of Total Billed charges,29.06,Pays at 32.15% of Total Billed charges,15.95,Pays at 100% of Medicare OPPS Rate,29.06,Pays at 32.15% of Total Billed charges,79.55,Pays at 88% of Total Billed charges,29.93,Pays at 33.11% of Total Billed charges,15.95,81.36,54.24
Outpatient Medical Services,THERAPY,97022,P/T STERILE WHIRLPOOL I,420,120,102,Pays at 85% of Billed charges for outpatient setting,38.58,Pays at 32.15% of Total Billed charges,96.04,Pays at 80.03% of Total Billed charges,16.27,Pays at 102% of Medicare OPPS Rate,108,Pays at 90% of Total Billed charges,38.58,Pays at 32.15% of Total Billed charges,15.95,Pays at 100% of Medicare OPPS Rate,38.58,Pays at 32.15% of Total Billed charges,105.6,Pays at 88% of Total Billed charges,39.73,Pays at 33.11% of Total Billed charges,15.95,108,72.00
Outpatient Medical Services,THERAPY,97022,DO NOT USE,420,155,131.75,Pays at 85% of Billed charges for outpatient setting,49.83,Pays at 32.15% of Total Billed charges,124.05,Pays at 80.03% of Total Billed charges,16.27,Pays at 102% of Medicare OPPS Rate,139.5,Pays at 90% of Total Billed charges,49.83,Pays at 32.15% of Total Billed charges,15.95,Pays at 100% of Medicare OPPS Rate,49.83,Pays at 32.15% of Total Billed charges,136.4,Pays at 88% of Total Billed charges,51.32,Pays at 33.11% of Total Billed charges,15.95,139.5,93.00
Outpatient Medical Services,THERAPY,97032,Repeated application to one or more parts of the body,420,30,25.5,Pays at 85% of Billed charges for outpatient setting,9.65,Pays at 32.15% of Total Billed charges,24.01,Pays at 80.03% of Total Billed charges,14.17,Pays at 102% of Medicare OPPS Rate,27,Pays at 90% of Total Billed charges,9.65,Pays at 32.15% of Total Billed charges,13.89,Pays at 100% of Medicare OPPS Rate,9.65,Pays at 32.15% of Total Billed charges,26.4,Pays at 88% of Total Billed charges,9.93,Pays at 33.11% of Total Billed charges,9.65,27,18.00
Outpatient Medical Services,THERAPY,97032,Repeated application to one or more parts of the body,420,40,34,Pays at 85% of Billed charges for outpatient setting,12.86,Pays at 32.15% of Total Billed charges,32.01,Pays at 80.03% of Total Billed charges,14.17,Pays at 102% of Medicare OPPS Rate,36,Pays at 90% of Total Billed charges,12.86,Pays at 32.15% of Total Billed charges,13.89,Pays at 100% of Medicare OPPS Rate,12.86,Pays at 32.15% of Total Billed charges,35.2,Pays at 88% of Total Billed charges,13.24,Pays at 33.11% of Total Billed charges,12.86,36,24.00
Outpatient Medical Services,THERAPY,97032,Repeated application to one or more parts of the body,420,60,51,Pays at 85% of Billed charges for outpatient setting,19.29,Pays at 32.15% of Total Billed charges,48.02,Pays at 80.03% of Total Billed charges,14.17,Pays at 102% of Medicare OPPS Rate,54,Pays at 90% of Total Billed charges,19.29,Pays at 32.15% of Total Billed charges,13.89,Pays at 100% of Medicare OPPS Rate,19.29,Pays at 32.15% of Total Billed charges,52.8,Pays at 88% of Total Billed charges,19.87,Pays at 33.11% of Total Billed charges,13.89,54,36.00
Outpatient Medical Services,THERAPY,97033,Psychiatric treatment in which seizures are electrically induced in patients to provide relief from mental disorders,430,20,17,Pays at 85% of Billed charges for outpatient setting,6.43,Pays at 32.15% of Total Billed charges,16.01,Pays at 80.03% of Total Billed charges,19.07,Pays at 102% of Medicare OPPS Rate,18,Pays at 90% of Total Billed charges,6.43,Pays at 32.15% of Total Billed charges,18.7,Pays at 100% of Medicare OPPS Rate,6.43,Pays at 32.15% of Total Billed charges,17.6,Pays at 88% of Total Billed charges,6.62,Pays at 33.11% of Total Billed charges,6.43,19.07,12.00
Outpatient Medical Services,THERAPY,97033,Psychiatric treatment in which seizures are electrically induced in patients to provide relief from mental disorders,420,40,34,Pays at 85% of Billed charges for outpatient setting,12.86,Pays at 32.15% of Total Billed charges,32.01,Pays at 80.03% of Total Billed charges,19.07,Pays at 102% of Medicare OPPS Rate,36,Pays at 90% of Total Billed charges,12.86,Pays at 32.15% of Total Billed charges,18.7,Pays at 100% of Medicare OPPS Rate,12.86,Pays at 32.15% of Total Billed charges,35.2,Pays at 88% of Total Billed charges,13.24,Pays at 33.11% of Total Billed charges,12.86,36,24.00
Outpatient Medical Services,THERAPY,97035,"Use of sound waves to treat medical problems, especially musculoskeletal problems like inflammation from injuries",430,20,17,Pays at 85% of Billed charges for outpatient setting,6.43,Pays at 32.15% of Total Billed charges,16.01,Pays at 80.03% of Total Billed charges,13.99,Pays at 102% of Medicare OPPS Rate,18,Pays at 90% of Total Billed charges,6.43,Pays at 32.15% of Total Billed charges,13.72,Pays at 100% of Medicare OPPS Rate,6.43,Pays at 32.15% of Total Billed charges,17.6,Pays at 88% of Total Billed charges,6.62,Pays at 33.11% of Total Billed charges,6.43,18,12.00
Outpatient Medical Services,THERAPY,97035,"Use of sound waves to treat medical problems, especially musculoskeletal problems like inflammation from injuries",420,30,25.5,Pays at 85% of Billed charges for outpatient setting,9.65,Pays at 32.15% of Total Billed charges,24.01,Pays at 80.03% of Total Billed charges,13.99,Pays at 102% of Medicare OPPS Rate,27,Pays at 90% of Total Billed charges,9.65,Pays at 32.15% of Total Billed charges,13.72,Pays at 100% of Medicare OPPS Rate,9.65,Pays at 32.15% of Total Billed charges,26.4,Pays at 88% of Total Billed charges,9.93,Pays at 33.11% of Total Billed charges,9.65,27,18.00
Outpatient Medical Services,THERAPY,97035,"Use of sound waves to treat medical problems, especially musculoskeletal problems like inflammation from injuries",420,40,34,Pays at 85% of Billed charges for outpatient setting,12.86,Pays at 32.15% of Total Billed charges,32.01,Pays at 80.03% of Total Billed charges,13.99,Pays at 102% of Medicare OPPS Rate,36,Pays at 90% of Total Billed charges,12.86,Pays at 32.15% of Total Billed charges,13.72,Pays at 100% of Medicare OPPS Rate,12.86,Pays at 32.15% of Total Billed charges,35.2,Pays at 88% of Total Billed charges,13.24,Pays at 33.11% of Total Billed charges,12.86,36,24.00
Outpatient Medical Services,THERAPY,97039,FLUIDO,430,20,17,Pays at 85% of Billed charges for outpatient setting,6.43,Pays at 32.15% of Total Billed charges,16.01,Pays at 80.03% of Total Billed charges,NA,Not Applicable,18,Pays at 90% of Total Billed charges,6.43,Pays at 32.15% of Total Billed charges,NA,Not Applicable,6.43,Pays at 32.15% of Total Billed charges,17.6,Pays at 88% of Total Billed charges,6.62,Pays at 33.11% of Total Billed charges,6.43,18,12.00
Outpatient Medical Services,THERAPY,97039,DO NOT USE,420,40,34,Pays at 85% of Billed charges for outpatient setting,12.86,Pays at 32.15% of Total Billed charges,32.01,Pays at 80.03% of Total Billed charges,NA,Not Applicable,36,Pays at 90% of Total Billed charges,12.86,Pays at 32.15% of Total Billed charges,NA,Not Applicable,12.86,Pays at 32.15% of Total Billed charges,35.2,Pays at 88% of Total Billed charges,13.24,Pays at 33.11% of Total Billed charges,12.86,36,24.00
Outpatient Medical Services,THERAPY,97110,"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",430,20,17,Pays at 85% of Billed charges for outpatient setting,6.43,Pays at 32.15% of Total Billed charges,16.01,Pays at 80.03% of Total Billed charges,28.69,Pays at 102% of Medicare OPPS Rate,18,Pays at 90% of Total Billed charges,6.43,Pays at 32.15% of Total Billed charges,28.13,Pays at 100% of Medicare OPPS Rate,6.43,Pays at 32.15% of Total Billed charges,17.6,Pays at 88% of Total Billed charges,6.62,Pays at 33.11% of Total Billed charges,6.43,28.69,12.00
Outpatient Medical Services,THERAPY,97110,"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",420,30,25.5,Pays at 85% of Billed charges for outpatient setting,9.65,Pays at 32.15% of Total Billed charges,24.01,Pays at 80.03% of Total Billed charges,28.69,Pays at 102% of Medicare OPPS Rate,27,Pays at 90% of Total Billed charges,9.65,Pays at 32.15% of Total Billed charges,28.13,Pays at 100% of Medicare OPPS Rate,9.65,Pays at 32.15% of Total Billed charges,26.4,Pays at 88% of Total Billed charges,9.93,Pays at 33.11% of Total Billed charges,9.65,28.69,18.00
Outpatient Medical Services,THERAPY,97110,"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",420,40,34,Pays at 85% of Billed charges for outpatient setting,12.86,Pays at 32.15% of Total Billed charges,32.01,Pays at 80.03% of Total Billed charges,28.69,Pays at 102% of Medicare OPPS Rate,36,Pays at 90% of Total Billed charges,12.86,Pays at 32.15% of Total Billed charges,28.13,Pays at 100% of Medicare OPPS Rate,12.86,Pays at 32.15% of Total Billed charges,35.2,Pays at 88% of Total Billed charges,13.24,Pays at 33.11% of Total Billed charges,12.86,36,24.00
Outpatient Medical Services,THERAPY,97110,"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",430,40,34,Pays at 85% of Billed charges for outpatient setting,12.86,Pays at 32.15% of Total Billed charges,32.01,Pays at 80.03% of Total Billed charges,28.69,Pays at 102% of Medicare OPPS Rate,36,Pays at 90% of Total Billed charges,12.86,Pays at 32.15% of Total Billed charges,28.13,Pays at 100% of Medicare OPPS Rate,12.86,Pays at 32.15% of Total Billed charges,35.2,Pays at 88% of Total Billed charges,13.24,Pays at 33.11% of Total Billed charges,12.86,36,24.00
Outpatient Medical Services,THERAPY,97110,"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",430,48.8,41.48,Pays at 85% of Billed charges for outpatient setting,15.69,Pays at 32.15% of Total Billed charges,39.05,Pays at 80.03% of Total Billed charges,28.69,Pays at 102% of Medicare OPPS Rate,43.92,Pays at 90% of Total Billed charges,15.69,Pays at 32.15% of Total Billed charges,28.13,Pays at 100% of Medicare OPPS Rate,15.69,Pays at 32.15% of Total Billed charges,42.94,Pays at 88% of Total Billed charges,16.16,Pays at 33.11% of Total Billed charges,15.69,43.92,29.28
Outpatient Medical Services,THERAPY,97110,"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",430,48.8,41.48,Pays at 85% of Billed charges for outpatient setting,15.69,Pays at 32.15% of Total Billed charges,39.05,Pays at 80.03% of Total Billed charges,28.69,Pays at 102% of Medicare OPPS Rate,43.92,Pays at 90% of Total Billed charges,15.69,Pays at 32.15% of Total Billed charges,28.13,Pays at 100% of Medicare OPPS Rate,15.69,Pays at 32.15% of Total Billed charges,42.94,Pays at 88% of Total Billed charges,16.16,Pays at 33.11% of Total Billed charges,15.69,43.92,29.28
Outpatient Medical Services,THERAPY,97110,"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",420,50,42.5,Pays at 85% of Billed charges for outpatient setting,16.08,Pays at 32.15% of Total Billed charges,40.02,Pays at 80.03% of Total Billed charges,28.69,Pays at 102% of Medicare OPPS Rate,45,Pays at 90% of Total Billed charges,16.08,Pays at 32.15% of Total Billed charges,28.13,Pays at 100% of Medicare OPPS Rate,16.08,Pays at 32.15% of Total Billed charges,44,Pays at 88% of Total Billed charges,16.56,Pays at 33.11% of Total Billed charges,16.08,45,30.00
Outpatient Medical Services,THERAPY,97110,"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",420,60,51,Pays at 85% of Billed charges for outpatient setting,19.29,Pays at 32.15% of Total Billed charges,48.02,Pays at 80.03% of Total Billed charges,28.69,Pays at 102% of Medicare OPPS Rate,54,Pays at 90% of Total Billed charges,19.29,Pays at 32.15% of Total Billed charges,28.13,Pays at 100% of Medicare OPPS Rate,19.29,Pays at 32.15% of Total Billed charges,52.8,Pays at 88% of Total Billed charges,19.87,Pays at 33.11% of Total Billed charges,19.29,54,36.00
Outpatient Medical Services,THERAPY,97110,"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",420,60,51,Pays at 85% of Billed charges for outpatient setting,19.29,Pays at 32.15% of Total Billed charges,48.02,Pays at 80.03% of Total Billed charges,28.69,Pays at 102% of Medicare OPPS Rate,54,Pays at 90% of Total Billed charges,19.29,Pays at 32.15% of Total Billed charges,28.13,Pays at 100% of Medicare OPPS Rate,19.29,Pays at 32.15% of Total Billed charges,52.8,Pays at 88% of Total Billed charges,19.87,Pays at 33.11% of Total Billed charges,19.29,54,36.00
Outpatient Medical Services,THERAPY,97110,"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",430,60,51,Pays at 85% of Billed charges for outpatient setting,19.29,Pays at 32.15% of Total Billed charges,48.02,Pays at 80.03% of Total Billed charges,28.69,Pays at 102% of Medicare OPPS Rate,54,Pays at 90% of Total Billed charges,19.29,Pays at 32.15% of Total Billed charges,28.13,Pays at 100% of Medicare OPPS Rate,19.29,Pays at 32.15% of Total Billed charges,52.8,Pays at 88% of Total Billed charges,19.87,Pays at 33.11% of Total Billed charges,19.29,54,36.00
Outpatient Medical Services,THERAPY,97110,"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",430,65,55.25,Pays at 85% of Billed charges for outpatient setting,20.9,Pays at 32.15% of Total Billed charges,52.02,Pays at 80.03% of Total Billed charges,28.69,Pays at 102% of Medicare OPPS Rate,58.5,Pays at 90% of Total Billed charges,20.9,Pays at 32.15% of Total Billed charges,28.13,Pays at 100% of Medicare OPPS Rate,20.9,Pays at 32.15% of Total Billed charges,57.2,Pays at 88% of Total Billed charges,21.52,Pays at 33.11% of Total Billed charges,20.9,58.5,39.00
Outpatient Medical Services,THERAPY,97110,"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",420,75,63.75,Pays at 85% of Billed charges for outpatient setting,24.11,Pays at 32.15% of Total Billed charges,60.02,Pays at 80.03% of Total Billed charges,28.69,Pays at 102% of Medicare OPPS Rate,67.5,Pays at 90% of Total Billed charges,24.11,Pays at 32.15% of Total Billed charges,28.13,Pays at 100% of Medicare OPPS Rate,24.11,Pays at 32.15% of Total Billed charges,66,Pays at 88% of Total Billed charges,24.83,Pays at 33.11% of Total Billed charges,24.11,67.5,45.00
Outpatient Medical Services,THERAPY,97110,"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",430,90.4,76.84,Pays at 85% of Billed charges for outpatient setting,29.06,Pays at 32.15% of Total Billed charges,72.35,Pays at 80.03% of Total Billed charges,28.69,Pays at 102% of Medicare OPPS Rate,81.36,Pays at 90% of Total Billed charges,29.06,Pays at 32.15% of Total Billed charges,28.13,Pays at 100% of Medicare OPPS Rate,29.06,Pays at 32.15% of Total Billed charges,79.55,Pays at 88% of Total Billed charges,29.93,Pays at 33.11% of Total Billed charges,28.13,81.36,54.24
Outpatient Medical Services,THERAPY,97110,"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",420,100,85,Pays at 85% of Billed charges for outpatient setting,32.15,Pays at 32.15% of Total Billed charges,80.03,Pays at 80.03% of Total Billed charges,28.69,Pays at 102% of Medicare OPPS Rate,90,Pays at 90% of Total Billed charges,32.15,Pays at 32.15% of Total Billed charges,28.13,Pays at 100% of Medicare OPPS Rate,32.15,Pays at 32.15% of Total Billed charges,88,Pays at 88% of Total Billed charges,33.11,Pays at 33.11% of Total Billed charges,28.13,90,60.00
Outpatient Medical Services,THERAPY,97110,"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",430,100,85,Pays at 85% of Billed charges for outpatient setting,32.15,Pays at 32.15% of Total Billed charges,80.03,Pays at 80.03% of Total Billed charges,28.69,Pays at 102% of Medicare OPPS Rate,90,Pays at 90% of Total Billed charges,32.15,Pays at 32.15% of Total Billed charges,28.13,Pays at 100% of Medicare OPPS Rate,32.15,Pays at 32.15% of Total Billed charges,88,Pays at 88% of Total Billed charges,33.11,Pays at 33.11% of Total Billed charges,28.13,90,60.00
Outpatient Medical Services,THERAPY,97110,"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",420,110,93.5,Pays at 85% of Billed charges for outpatient setting,35.37,Pays at 32.15% of Total Billed charges,88.03,Pays at 80.03% of Total Billed charges,28.69,Pays at 102% of Medicare OPPS Rate,99,Pays at 90% of Total Billed charges,35.37,Pays at 32.15% of Total Billed charges,28.13,Pays at 100% of Medicare OPPS Rate,35.37,Pays at 32.15% of Total Billed charges,96.8,Pays at 88% of Total Billed charges,36.42,Pays at 33.11% of Total Billed charges,28.13,99,66.00
Outpatient Medical Services,THERAPY,97110,"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",420,120,102,Pays at 85% of Billed charges for outpatient setting,38.58,Pays at 32.15% of Total Billed charges,96.04,Pays at 80.03% of Total Billed charges,28.69,Pays at 102% of Medicare OPPS Rate,108,Pays at 90% of Total Billed charges,38.58,Pays at 32.15% of Total Billed charges,28.13,Pays at 100% of Medicare OPPS Rate,38.58,Pays at 32.15% of Total Billed charges,105.6,Pays at 88% of Total Billed charges,39.73,Pays at 33.11% of Total Billed charges,28.13,108,72.00
Outpatient Medical Services,THERAPY,97110,"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",420,120,102,Pays at 85% of Billed charges for outpatient setting,38.58,Pays at 32.15% of Total Billed charges,96.04,Pays at 80.03% of Total Billed charges,28.69,Pays at 102% of Medicare OPPS Rate,108,Pays at 90% of Total Billed charges,38.58,Pays at 32.15% of Total Billed charges,28.13,Pays at 100% of Medicare OPPS Rate,38.58,Pays at 32.15% of Total Billed charges,105.6,Pays at 88% of Total Billed charges,39.73,Pays at 33.11% of Total Billed charges,28.13,108,72.00
Outpatient Medical Services,THERAPY,97110,"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",430,120,102,Pays at 85% of Billed charges for outpatient setting,38.58,Pays at 32.15% of Total Billed charges,96.04,Pays at 80.03% of Total Billed charges,28.69,Pays at 102% of Medicare OPPS Rate,108,Pays at 90% of Total Billed charges,38.58,Pays at 32.15% of Total Billed charges,28.13,Pays at 100% of Medicare OPPS Rate,38.58,Pays at 32.15% of Total Billed charges,105.6,Pays at 88% of Total Billed charges,39.73,Pays at 33.11% of Total Billed charges,28.13,108,72.00
Outpatient Medical Services,THERAPY,97110,"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",430,132.55,112.67,Pays at 85% of Billed charges for outpatient setting,42.61,Pays at 32.15% of Total Billed charges,106.08,Pays at 80.03% of Total Billed charges,28.69,Pays at 102% of Medicare OPPS Rate,119.3,Pays at 90% of Total Billed charges,42.61,Pays at 32.15% of Total Billed charges,28.13,Pays at 100% of Medicare OPPS Rate,42.61,Pays at 32.15% of Total Billed charges,116.64,Pays at 88% of Total Billed charges,43.89,Pays at 33.11% of Total Billed charges,28.13,119.3,79.53
Outpatient Medical Services,THERAPY,97112,A technique used by physical therapists to restore normal body movement patterns,430,25,21.25,Pays at 85% of Billed charges for outpatient setting,8.04,Pays at 32.15% of Total Billed charges,20.01,Pays at 80.03% of Total Billed charges,32.85,Pays at 102% of Medicare OPPS Rate,22.5,Pays at 90% of Total Billed charges,8.04,Pays at 32.15% of Total Billed charges,32.21,Pays at 100% of Medicare OPPS Rate,8.04,Pays at 32.15% of Total Billed charges,22,Pays at 88% of Total Billed charges,8.28,Pays at 33.11% of Total Billed charges,8.04,32.85,15.00
Outpatient Medical Services,THERAPY,97112,A technique used by physical therapists to restore normal body movement patterns,430,55,46.75,Pays at 85% of Billed charges for outpatient setting,17.68,Pays at 32.15% of Total Billed charges,44.02,Pays at 80.03% of Total Billed charges,32.85,Pays at 102% of Medicare OPPS Rate,49.5,Pays at 90% of Total Billed charges,17.68,Pays at 32.15% of Total Billed charges,32.21,Pays at 100% of Medicare OPPS Rate,17.68,Pays at 32.15% of Total Billed charges,48.4,Pays at 88% of Total Billed charges,18.21,Pays at 33.11% of Total Billed charges,17.68,49.5,33.00
Outpatient Medical Services,THERAPY,97112,A technique used by physical therapists to restore normal body movement patterns,430,55,46.75,Pays at 85% of Billed charges for outpatient setting,17.68,Pays at 32.15% of Total Billed charges,44.02,Pays at 80.03% of Total Billed charges,32.85,Pays at 102% of Medicare OPPS Rate,49.5,Pays at 90% of Total Billed charges,17.68,Pays at 32.15% of Total Billed charges,32.21,Pays at 100% of Medicare OPPS Rate,17.68,Pays at 32.15% of Total Billed charges,48.4,Pays at 88% of Total Billed charges,18.21,Pays at 33.11% of Total Billed charges,17.68,49.5,33.00
Outpatient Medical Services,THERAPY,97112,A technique used by physical therapists to restore normal body movement patterns,420,60,51,Pays at 85% of Billed charges for outpatient setting,19.29,Pays at 32.15% of Total Billed charges,48.02,Pays at 80.03% of Total Billed charges,32.85,Pays at 102% of Medicare OPPS Rate,54,Pays at 90% of Total Billed charges,19.29,Pays at 32.15% of Total Billed charges,32.21,Pays at 100% of Medicare OPPS Rate,19.29,Pays at 32.15% of Total Billed charges,52.8,Pays at 88% of Total Billed charges,19.87,Pays at 33.11% of Total Billed charges,19.29,54,36.00
Outpatient Medical Services,THERAPY,97112,A technique used by physical therapists to restore normal body movement patterns,420,60,51,Pays at 85% of Billed charges for outpatient setting,19.29,Pays at 32.15% of Total Billed charges,48.02,Pays at 80.03% of Total Billed charges,32.85,Pays at 102% of Medicare OPPS Rate,54,Pays at 90% of Total Billed charges,19.29,Pays at 32.15% of Total Billed charges,32.21,Pays at 100% of Medicare OPPS Rate,19.29,Pays at 32.15% of Total Billed charges,52.8,Pays at 88% of Total Billed charges,19.87,Pays at 33.11% of Total Billed charges,19.29,54,36.00
Outpatient Medical Services,THERAPY,97112,A technique used by physical therapists to restore normal body movement patterns,430,60,51,Pays at 85% of Billed charges for outpatient setting,19.29,Pays at 32.15% of Total Billed charges,48.02,Pays at 80.03% of Total Billed charges,32.85,Pays at 102% of Medicare OPPS Rate,54,Pays at 90% of Total Billed charges,19.29,Pays at 32.15% of Total Billed charges,32.21,Pays at 100% of Medicare OPPS Rate,19.29,Pays at 32.15% of Total Billed charges,52.8,Pays at 88% of Total Billed charges,19.87,Pays at 33.11% of Total Billed charges,19.29,54,36.00
Outpatient Medical Services,THERAPY,97112,A technique used by physical therapists to restore normal body movement patterns,430,65,55.25,Pays at 85% of Billed charges for outpatient setting,20.9,Pays at 32.15% of Total Billed charges,52.02,Pays at 80.03% of Total Billed charges,32.85,Pays at 102% of Medicare OPPS Rate,58.5,Pays at 90% of Total Billed charges,20.9,Pays at 32.15% of Total Billed charges,32.21,Pays at 100% of Medicare OPPS Rate,20.9,Pays at 32.15% of Total Billed charges,57.2,Pays at 88% of Total Billed charges,21.52,Pays at 33.11% of Total Billed charges,20.9,58.5,39.00
Outpatient Medical Services,THERAPY,97112,A technique used by physical therapists to restore normal body movement patterns,430,65,55.25,Pays at 85% of Billed charges for outpatient setting,20.9,Pays at 32.15% of Total Billed charges,52.02,Pays at 80.03% of Total Billed charges,32.85,Pays at 102% of Medicare OPPS Rate,58.5,Pays at 90% of Total Billed charges,20.9,Pays at 32.15% of Total Billed charges,32.21,Pays at 100% of Medicare OPPS Rate,20.9,Pays at 32.15% of Total Billed charges,57.2,Pays at 88% of Total Billed charges,21.52,Pays at 33.11% of Total Billed charges,20.9,58.5,39.00
Outpatient Medical Services,THERAPY,97112,A technique used by physical therapists to restore normal body movement patterns,420,90,76.5,Pays at 85% of Billed charges for outpatient setting,28.94,Pays at 32.15% of Total Billed charges,72.03,Pays at 80.03% of Total Billed charges,32.85,Pays at 102% of Medicare OPPS Rate,81,Pays at 90% of Total Billed charges,28.94,Pays at 32.15% of Total Billed charges,32.21,Pays at 100% of Medicare OPPS Rate,28.94,Pays at 32.15% of Total Billed charges,79.2,Pays at 88% of Total Billed charges,29.8,Pays at 33.11% of Total Billed charges,28.94,81,54.00
Outpatient Medical Services,THERAPY,97112,A technique used by physical therapists to restore normal body movement patterns,430,90.4,76.84,Pays at 85% of Billed charges for outpatient setting,29.06,Pays at 32.15% of Total Billed charges,72.35,Pays at 80.03% of Total Billed charges,32.85,Pays at 102% of Medicare OPPS Rate,81.36,Pays at 90% of Total Billed charges,29.06,Pays at 32.15% of Total Billed charges,32.21,Pays at 100% of Medicare OPPS Rate,29.06,Pays at 32.15% of Total Billed charges,79.55,Pays at 88% of Total Billed charges,29.93,Pays at 33.11% of Total Billed charges,29.06,81.36,54.24
Outpatient Medical Services,THERAPY,97112,A technique used by physical therapists to restore normal body movement patterns,420,100,85,Pays at 85% of Billed charges for outpatient setting,32.15,Pays at 32.15% of Total Billed charges,80.03,Pays at 80.03% of Total Billed charges,32.85,Pays at 102% of Medicare OPPS Rate,90,Pays at 90% of Total Billed charges,32.15,Pays at 32.15% of Total Billed charges,32.21,Pays at 100% of Medicare OPPS Rate,32.15,Pays at 32.15% of Total Billed charges,88,Pays at 88% of Total Billed charges,33.11,Pays at 33.11% of Total Billed charges,32.15,90,60.00
Outpatient Medical Services,THERAPY,97112,A technique used by physical therapists to restore normal body movement patterns,430,100,85,Pays at 85% of Billed charges for outpatient setting,32.15,Pays at 32.15% of Total Billed charges,80.03,Pays at 80.03% of Total Billed charges,32.85,Pays at 102% of Medicare OPPS Rate,90,Pays at 90% of Total Billed charges,32.15,Pays at 32.15% of Total Billed charges,32.21,Pays at 100% of Medicare OPPS Rate,32.15,Pays at 32.15% of Total Billed charges,88,Pays at 88% of Total Billed charges,33.11,Pays at 33.11% of Total Billed charges,32.15,90,60.00
Outpatient Medical Services,THERAPY,97112,A technique used by physical therapists to restore normal body movement patterns,430,111.5,94.78,Pays at 85% of Billed charges for outpatient setting,35.85,Pays at 32.15% of Total Billed charges,89.23,Pays at 80.03% of Total Billed charges,32.85,Pays at 102% of Medicare OPPS Rate,100.35,Pays at 90% of Total Billed charges,35.85,Pays at 32.15% of Total Billed charges,32.21,Pays at 100% of Medicare OPPS Rate,35.85,Pays at 32.15% of Total Billed charges,98.12,Pays at 88% of Total Billed charges,36.92,Pays at 33.11% of Total Billed charges,32.21,100.35,66.90
Outpatient Medical Services,THERAPY,97112,A technique used by physical therapists to restore normal body movement patterns,420,120,102,Pays at 85% of Billed charges for outpatient setting,38.58,Pays at 32.15% of Total Billed charges,96.04,Pays at 80.03% of Total Billed charges,32.85,Pays at 102% of Medicare OPPS Rate,108,Pays at 90% of Total Billed charges,38.58,Pays at 32.15% of Total Billed charges,32.21,Pays at 100% of Medicare OPPS Rate,38.58,Pays at 32.15% of Total Billed charges,105.6,Pays at 88% of Total Billed charges,39.73,Pays at 33.11% of Total Billed charges,32.21,108,72.00
Outpatient Medical Services,THERAPY,97112,A technique used by physical therapists to restore normal body movement patterns,420,120,102,Pays at 85% of Billed charges for outpatient setting,38.58,Pays at 32.15% of Total Billed charges,96.04,Pays at 80.03% of Total Billed charges,32.85,Pays at 102% of Medicare OPPS Rate,108,Pays at 90% of Total Billed charges,38.58,Pays at 32.15% of Total Billed charges,32.21,Pays at 100% of Medicare OPPS Rate,38.58,Pays at 32.15% of Total Billed charges,105.6,Pays at 88% of Total Billed charges,39.73,Pays at 33.11% of Total Billed charges,32.21,108,72.00
Outpatient Medical Services,THERAPY,97112,A technique used by physical therapists to restore normal body movement patterns,430,120,102,Pays at 85% of Billed charges for outpatient setting,38.58,Pays at 32.15% of Total Billed charges,96.04,Pays at 80.03% of Total Billed charges,32.85,Pays at 102% of Medicare OPPS Rate,108,Pays at 90% of Total Billed charges,38.58,Pays at 32.15% of Total Billed charges,32.21,Pays at 100% of Medicare OPPS Rate,38.58,Pays at 32.15% of Total Billed charges,105.6,Pays at 88% of Total Billed charges,39.73,Pays at 33.11% of Total Billed charges,32.21,108,72.00
Outpatient Medical Services,THERAPY,97112,A technique used by physical therapists to restore normal body movement patterns,430,132.55,112.67,Pays at 85% of Billed charges for outpatient setting,42.61,Pays at 32.15% of Total Billed charges,106.08,Pays at 80.03% of Total Billed charges,32.85,Pays at 102% of Medicare OPPS Rate,119.3,Pays at 90% of Total Billed charges,42.61,Pays at 32.15% of Total Billed charges,32.21,Pays at 100% of Medicare OPPS Rate,42.61,Pays at 32.15% of Total Billed charges,116.64,Pays at 88% of Total Billed charges,43.89,Pays at 33.11% of Total Billed charges,32.21,119.3,79.53
Outpatient Medical Services,THERAPY,97112,A technique used by physical therapists to restore normal body movement patterns,430,160.3,136.26,Pays at 85% of Billed charges for outpatient setting,51.54,Pays at 32.15% of Total Billed charges,128.29,Pays at 80.03% of Total Billed charges,32.85,Pays at 102% of Medicare OPPS Rate,144.27,Pays at 90% of Total Billed charges,51.54,Pays at 32.15% of Total Billed charges,32.21,Pays at 100% of Medicare OPPS Rate,51.54,Pays at 32.15% of Total Billed charges,141.06,Pays at 88% of Total Billed charges,53.08,Pays at 33.11% of Total Billed charges,32.21,144.27,96.18
Outpatient Medical Services,THERAPY,97116,A type of physical therapy,420,30,25.5,Pays at 85% of Billed charges for outpatient setting,9.65,Pays at 32.15% of Total Billed charges,24.01,Pays at 80.03% of Total Billed charges,28.69,Pays at 102% of Medicare OPPS Rate,27,Pays at 90% of Total Billed charges,9.65,Pays at 32.15% of Total Billed charges,28.13,Pays at 100% of Medicare OPPS Rate,9.65,Pays at 32.15% of Total Billed charges,26.4,Pays at 88% of Total Billed charges,9.93,Pays at 33.11% of Total Billed charges,9.65,28.69,18.00
Outpatient Medical Services,THERAPY,97116,A type of physical therapy,420,45,38.25,Pays at 85% of Billed charges for outpatient setting,14.47,Pays at 32.15% of Total Billed charges,36.01,Pays at 80.03% of Total Billed charges,28.69,Pays at 102% of Medicare OPPS Rate,40.5,Pays at 90% of Total Billed charges,14.47,Pays at 32.15% of Total Billed charges,28.13,Pays at 100% of Medicare OPPS Rate,14.47,Pays at 32.15% of Total Billed charges,39.6,Pays at 88% of Total Billed charges,14.9,Pays at 33.11% of Total Billed charges,14.47,40.5,27.00
Outpatient Medical Services,THERAPY,97116,A type of physical therapy,420,60,51,Pays at 85% of Billed charges for outpatient setting,19.29,Pays at 32.15% of Total Billed charges,48.02,Pays at 80.03% of Total Billed charges,28.69,Pays at 102% of Medicare OPPS Rate,54,Pays at 90% of Total Billed charges,19.29,Pays at 32.15% of Total Billed charges,28.13,Pays at 100% of Medicare OPPS Rate,19.29,Pays at 32.15% of Total Billed charges,52.8,Pays at 88% of Total Billed charges,19.87,Pays at 33.11% of Total Billed charges,19.29,54,36.00
Outpatient Medical Services,THERAPY,97116,A type of physical therapy,420,60,51,Pays at 85% of Billed charges for outpatient setting,19.29,Pays at 32.15% of Total Billed charges,48.02,Pays at 80.03% of Total Billed charges,28.69,Pays at 102% of Medicare OPPS Rate,54,Pays at 90% of Total Billed charges,19.29,Pays at 32.15% of Total Billed charges,28.13,Pays at 100% of Medicare OPPS Rate,19.29,Pays at 32.15% of Total Billed charges,52.8,Pays at 88% of Total Billed charges,19.87,Pays at 33.11% of Total Billed charges,19.29,54,36.00
Outpatient Medical Services,THERAPY,97116,A type of physical therapy,420,90,76.5,Pays at 85% of Billed charges for outpatient setting,28.94,Pays at 32.15% of Total Billed charges,72.03,Pays at 80.03% of Total Billed charges,28.69,Pays at 102% of Medicare OPPS Rate,81,Pays at 90% of Total Billed charges,28.94,Pays at 32.15% of Total Billed charges,28.13,Pays at 100% of Medicare OPPS Rate,28.94,Pays at 32.15% of Total Billed charges,79.2,Pays at 88% of Total Billed charges,29.8,Pays at 33.11% of Total Billed charges,28.13,81,54.00
Outpatient Medical Services,THERAPY,97122,P/T SETUP TRAPEZE,420,40,34,Pays at 85% of Billed charges for outpatient setting,12.86,Pays at 32.15% of Total Billed charges,32.01,Pays at 80.03% of Total Billed charges,NA,Not Applicable,36,Pays at 90% of Total Billed charges,12.86,Pays at 32.15% of Total Billed charges,NA,Not Applicable,12.86,Pays at 32.15% of Total Billed charges,35.2,Pays at 88% of Total Billed charges,13.24,Pays at 33.11% of Total Billed charges,12.86,36,24.00
Outpatient Medical Services,THERAPY,97124,Use of massage,420,30,25.5,Pays at 85% of Billed charges for outpatient setting,9.65,Pays at 32.15% of Total Billed charges,24.01,Pays at 80.03% of Total Billed charges,28.89,Pays at 102% of Medicare OPPS Rate,27,Pays at 90% of Total Billed charges,9.65,Pays at 32.15% of Total Billed charges,28.32,Pays at 100% of Medicare OPPS Rate,9.65,Pays at 32.15% of Total Billed charges,26.4,Pays at 88% of Total Billed charges,9.93,Pays at 33.11% of Total Billed charges,9.65,28.89,18.00
Outpatient Medical Services,THERAPY,97124,Use of massage,430,34.7,29.5,Pays at 85% of Billed charges for outpatient setting,11.16,Pays at 32.15% of Total Billed charges,27.77,Pays at 80.03% of Total Billed charges,28.89,Pays at 102% of Medicare OPPS Rate,31.23,Pays at 90% of Total Billed charges,11.16,Pays at 32.15% of Total Billed charges,28.32,Pays at 100% of Medicare OPPS Rate,11.16,Pays at 32.15% of Total Billed charges,30.54,Pays at 88% of Total Billed charges,11.49,Pays at 33.11% of Total Billed charges,11.16,31.23,20.82
Outpatient Medical Services,THERAPY,97124,Use of massage,420,45,38.25,Pays at 85% of Billed charges for outpatient setting,14.47,Pays at 32.15% of Total Billed charges,36.01,Pays at 80.03% of Total Billed charges,28.89,Pays at 102% of Medicare OPPS Rate,40.5,Pays at 90% of Total Billed charges,14.47,Pays at 32.15% of Total Billed charges,28.32,Pays at 100% of Medicare OPPS Rate,14.47,Pays at 32.15% of Total Billed charges,39.6,Pays at 88% of Total Billed charges,14.9,Pays at 33.11% of Total Billed charges,14.47,40.5,27.00
Outpatient Medical Services,THERAPY,97124,Use of massage,420,60,51,Pays at 85% of Billed charges for outpatient setting,19.29,Pays at 32.15% of Total Billed charges,48.02,Pays at 80.03% of Total Billed charges,28.89,Pays at 102% of Medicare OPPS Rate,54,Pays at 90% of Total Billed charges,19.29,Pays at 32.15% of Total Billed charges,28.32,Pays at 100% of Medicare OPPS Rate,19.29,Pays at 32.15% of Total Billed charges,52.8,Pays at 88% of Total Billed charges,19.87,Pays at 33.11% of Total Billed charges,19.29,54,36.00
Outpatient Medical Services,THERAPY,97124,Use of massage,430,60,51,Pays at 85% of Billed charges for outpatient setting,19.29,Pays at 32.15% of Total Billed charges,48.02,Pays at 80.03% of Total Billed charges,28.89,Pays at 102% of Medicare OPPS Rate,54,Pays at 90% of Total Billed charges,19.29,Pays at 32.15% of Total Billed charges,28.32,Pays at 100% of Medicare OPPS Rate,19.29,Pays at 32.15% of Total Billed charges,52.8,Pays at 88% of Total Billed charges,19.87,Pays at 33.11% of Total Billed charges,19.29,54,36.00
Outpatient Medical Services,THERAPY,97124,Use of massage,430,62.7,53.3,Pays at 85% of Billed charges for outpatient setting,20.16,Pays at 32.15% of Total Billed charges,50.18,Pays at 80.03% of Total Billed charges,28.89,Pays at 102% of Medicare OPPS Rate,56.43,Pays at 90% of Total Billed charges,20.16,Pays at 32.15% of Total Billed charges,28.32,Pays at 100% of Medicare OPPS Rate,20.16,Pays at 32.15% of Total Billed charges,55.18,Pays at 88% of Total Billed charges,20.76,Pays at 33.11% of Total Billed charges,20.16,56.43,37.62
Outpatient Medical Services,THERAPY,97130,S/T COGNITIVE RETRAINING EACH ADD 15 MIN,440,91,77.35,Pays at 85% of Billed charges for outpatient setting,29.26,Pays at 32.15% of Total Billed charges,72.83,Pays at 80.03% of Total Billed charges,21.5,Pays at 102% of Medicare OPPS Rate,81.9,Pays at 90% of Total Billed charges,29.26,Pays at 32.15% of Total Billed charges,21.08,Pays at 100% of Medicare OPPS Rate,29.26,Pays at 32.15% of Total Billed charges,80.08,Pays at 88% of Total Billed charges,30.13,Pays at 33.11% of Total Billed charges,21.08,81.9,54.60
Outpatient Medical Services,THERAPY,97139,P/T CPM TREATMENT/CHECK,420,20,17,Pays at 85% of Billed charges for outpatient setting,6.43,Pays at 32.15% of Total Billed charges,16.01,Pays at 80.03% of Total Billed charges,NA,Not Applicable,18,Pays at 90% of Total Billed charges,6.43,Pays at 32.15% of Total Billed charges,NA,Not Applicable,6.43,Pays at 32.15% of Total Billed charges,17.6,Pays at 88% of Total Billed charges,6.62,Pays at 33.11% of Total Billed charges,6.43,18,12.00
Outpatient Medical Services,THERAPY,97139,P/T DEBRIDEMENT SKIN,420,20,17,Pays at 85% of Billed charges for outpatient setting,6.43,Pays at 32.15% of Total Billed charges,16.01,Pays at 80.03% of Total Billed charges,NA,Not Applicable,18,Pays at 90% of Total Billed charges,6.43,Pays at 32.15% of Total Billed charges,NA,Not Applicable,6.43,Pays at 32.15% of Total Billed charges,17.6,Pays at 88% of Total Billed charges,6.62,Pays at 33.11% of Total Billed charges,6.43,18,12.00
Outpatient Medical Services,THERAPY,97139,P/T CONSULT/EDUCATE I-15 MIN,420,30,25.5,Pays at 85% of Billed charges for outpatient setting,9.65,Pays at 32.15% of Total Billed charges,24.01,Pays at 80.03% of Total Billed charges,NA,Not Applicable,27,Pays at 90% of Total Billed charges,9.65,Pays at 32.15% of Total Billed charges,NA,Not Applicable,9.65,Pays at 32.15% of Total Billed charges,26.4,Pays at 88% of Total Billed charges,9.93,Pays at 33.11% of Total Billed charges,9.65,27,18.00
Outpatient Medical Services,THERAPY,97139,DO NOT USE,420,30,25.5,Pays at 85% of Billed charges for outpatient setting,9.65,Pays at 32.15% of Total Billed charges,24.01,Pays at 80.03% of Total Billed charges,NA,Not Applicable,27,Pays at 90% of Total Billed charges,9.65,Pays at 32.15% of Total Billed charges,NA,Not Applicable,9.65,Pays at 32.15% of Total Billed charges,26.4,Pays at 88% of Total Billed charges,9.93,Pays at 33.11% of Total Billed charges,9.65,27,18.00
Outpatient Medical Services,THERAPY,97139,WOUND MANAGEMENT,420,40,34,Pays at 85% of Billed charges for outpatient setting,12.86,Pays at 32.15% of Total Billed charges,32.01,Pays at 80.03% of Total Billed charges,NA,Not Applicable,36,Pays at 90% of Total Billed charges,12.86,Pays at 32.15% of Total Billed charges,NA,Not Applicable,12.86,Pays at 32.15% of Total Billed charges,35.2,Pays at 88% of Total Billed charges,13.24,Pays at 33.11% of Total Billed charges,12.86,36,24.00
Outpatient Medical Services,THERAPY,97139,WOUND MANAGEMENT,420,40,34,Pays at 85% of Billed charges for outpatient setting,12.86,Pays at 32.15% of Total Billed charges,32.01,Pays at 80.03% of Total Billed charges,NA,Not Applicable,36,Pays at 90% of Total Billed charges,12.86,Pays at 32.15% of Total Billed charges,NA,Not Applicable,12.86,Pays at 32.15% of Total Billed charges,35.2,Pays at 88% of Total Billed charges,13.24,Pays at 33.11% of Total Billed charges,12.86,36,24.00
Outpatient Medical Services,THERAPY,97139,P/T DEBRIDEMENT MEDIUM BURN,420,45,38.25,Pays at 85% of Billed charges for outpatient setting,14.47,Pays at 32.15% of Total Billed charges,36.01,Pays at 80.03% of Total Billed charges,NA,Not Applicable,40.5,Pays at 90% of Total Billed charges,14.47,Pays at 32.15% of Total Billed charges,NA,Not Applicable,14.47,Pays at 32.15% of Total Billed charges,39.6,Pays at 88% of Total Billed charges,14.9,Pays at 33.11% of Total Billed charges,14.47,40.5,27.00
Outpatient Medical Services,THERAPY,97139,BODY MECHANICS TRAINING II,420,60,51,Pays at 85% of Billed charges for outpatient setting,19.29,Pays at 32.15% of Total Billed charges,48.02,Pays at 80.03% of Total Billed charges,NA,Not Applicable,54,Pays at 90% of Total Billed charges,19.29,Pays at 32.15% of Total Billed charges,NA,Not Applicable,19.29,Pays at 32.15% of Total Billed charges,52.8,Pays at 88% of Total Billed charges,19.87,Pays at 33.11% of Total Billed charges,19.29,54,36.00
Outpatient Medical Services,THERAPY,97139,P/T CONSULT/EDUCATE II,420,60,51,Pays at 85% of Billed charges for outpatient setting,19.29,Pays at 32.15% of Total Billed charges,48.02,Pays at 80.03% of Total Billed charges,NA,Not Applicable,54,Pays at 90% of Total Billed charges,19.29,Pays at 32.15% of Total Billed charges,NA,Not Applicable,19.29,Pays at 32.15% of Total Billed charges,52.8,Pays at 88% of Total Billed charges,19.87,Pays at 33.11% of Total Billed charges,19.29,54,36.00
Outpatient Medical Services,THERAPY,97139,INPATIENT TRACTION ASSEMBLY II,420,60,51,Pays at 85% of Billed charges for outpatient setting,19.29,Pays at 32.15% of Total Billed charges,48.02,Pays at 80.03% of Total Billed charges,NA,Not Applicable,54,Pays at 90% of Total Billed charges,19.29,Pays at 32.15% of Total Billed charges,NA,Not Applicable,19.29,Pays at 32.15% of Total Billed charges,52.8,Pays at 88% of Total Billed charges,19.87,Pays at 33.11% of Total Billed charges,19.29,54,36.00
Outpatient Medical Services,THERAPY,97139,P/T CONSULT/EDUCATE II-30 MIN.,420,60,51,Pays at 85% of Billed charges for outpatient setting,19.29,Pays at 32.15% of Total Billed charges,48.02,Pays at 80.03% of Total Billed charges,NA,Not Applicable,54,Pays at 90% of Total Billed charges,19.29,Pays at 32.15% of Total Billed charges,NA,Not Applicable,19.29,Pays at 32.15% of Total Billed charges,52.8,Pays at 88% of Total Billed charges,19.87,Pays at 33.11% of Total Billed charges,19.29,54,36.00
Outpatient Medical Services,THERAPY,97139,DO NOT USE,420,60,51,Pays at 85% of Billed charges for outpatient setting,19.29,Pays at 32.15% of Total Billed charges,48.02,Pays at 80.03% of Total Billed charges,NA,Not Applicable,54,Pays at 90% of Total Billed charges,19.29,Pays at 32.15% of Total Billed charges,NA,Not Applicable,19.29,Pays at 32.15% of Total Billed charges,52.8,Pays at 88% of Total Billed charges,19.87,Pays at 33.11% of Total Billed charges,19.29,54,36.00
Outpatient Medical Services,THERAPY,97139,O/T CONSULT/EDUCATE II,430,60,51,Pays at 85% of Billed charges for outpatient setting,19.29,Pays at 32.15% of Total Billed charges,48.02,Pays at 80.03% of Total Billed charges,NA,Not Applicable,54,Pays at 90% of Total Billed charges,19.29,Pays at 32.15% of Total Billed charges,NA,Not Applicable,19.29,Pays at 32.15% of Total Billed charges,52.8,Pays at 88% of Total Billed charges,19.87,Pays at 33.11% of Total Billed charges,19.29,54,36.00
Outpatient Medical Services,THERAPY,97139,O/T SPLINTING ASSESSMENT,430,60,51,Pays at 85% of Billed charges for outpatient setting,19.29,Pays at 32.15% of Total Billed charges,48.02,Pays at 80.03% of Total Billed charges,NA,Not Applicable,54,Pays at 90% of Total Billed charges,19.29,Pays at 32.15% of Total Billed charges,NA,Not Applicable,19.29,Pays at 32.15% of Total Billed charges,52.8,Pays at 88% of Total Billed charges,19.87,Pays at 33.11% of Total Billed charges,19.29,54,36.00
Outpatient Medical Services,THERAPY,97139,CPM TREATMENT/CHECK,420,61.05,51.89,Pays at 85% of Billed charges for outpatient setting,19.63,Pays at 32.15% of Total Billed charges,48.86,Pays at 80.03% of Total Billed charges,NA,Not Applicable,54.95,Pays at 90% of Total Billed charges,19.63,Pays at 32.15% of Total Billed charges,NA,Not Applicable,19.63,Pays at 32.15% of Total Billed charges,53.72,Pays at 88% of Total Billed charges,20.21,Pays at 33.11% of Total Billed charges,19.63,54.95,36.63
Outpatient Medical Services,THERAPY,97139,INPATIENT TRACTION ASSEMBLY III,420,95,80.75,Pays at 85% of Billed charges for outpatient setting,30.54,Pays at 32.15% of Total Billed charges,76.03,Pays at 80.03% of Total Billed charges,NA,Not Applicable,85.5,Pays at 90% of Total Billed charges,30.54,Pays at 32.15% of Total Billed charges,NA,Not Applicable,30.54,Pays at 32.15% of Total Billed charges,83.6,Pays at 88% of Total Billed charges,31.45,Pays at 33.11% of Total Billed charges,30.54,85.5,57.00
Outpatient Medical Services,THERAPY,97139,INPATIENT TRACTION ASSEMBLY IV,420,120,102,Pays at 85% of Billed charges for outpatient setting,38.58,Pays at 32.15% of Total Billed charges,96.04,Pays at 80.03% of Total Billed charges,NA,Not Applicable,108,Pays at 90% of Total Billed charges,38.58,Pays at 32.15% of Total Billed charges,NA,Not Applicable,38.58,Pays at 32.15% of Total Billed charges,105.6,Pays at 88% of Total Billed charges,39.73,Pays at 33.11% of Total Billed charges,38.58,108,72.00
Outpatient Medical Services,THERAPY,97139,P/T HOME PROGRAM,420,120,102,Pays at 85% of Billed charges for outpatient setting,38.58,Pays at 32.15% of Total Billed charges,96.04,Pays at 80.03% of Total Billed charges,NA,Not Applicable,108,Pays at 90% of Total Billed charges,38.58,Pays at 32.15% of Total Billed charges,NA,Not Applicable,38.58,Pays at 32.15% of Total Billed charges,105.6,Pays at 88% of Total Billed charges,39.73,Pays at 33.11% of Total Billed charges,38.58,108,72.00
Outpatient Medical Services,THERAPY,97139,O/T HOME EXERCISE PROGRAM,430,120,102,Pays at 85% of Billed charges for outpatient setting,38.58,Pays at 32.15% of Total Billed charges,96.04,Pays at 80.03% of Total Billed charges,NA,Not Applicable,108,Pays at 90% of Total Billed charges,38.58,Pays at 32.15% of Total Billed charges,NA,Not Applicable,38.58,Pays at 32.15% of Total Billed charges,105.6,Pays at 88% of Total Billed charges,39.73,Pays at 33.11% of Total Billed charges,38.58,108,72.00
Outpatient Medical Services,THERAPY,97139,P/T SETUP CONT PASS MOTION DEVICE,420,850,722.5,Pays at 85% of Billed charges for outpatient setting,273.28,Pays at 32.15% of Total Billed charges,680.26,Pays at 80.03% of Total Billed charges,NA,Not Applicable,765,Pays at 90% of Total Billed charges,273.28,Pays at 32.15% of Total Billed charges,NA,Not Applicable,273.28,Pays at 32.15% of Total Billed charges,748,Pays at 88% of Total Billed charges,281.44,Pays at 33.11% of Total Billed charges,273.28,765,510.00
Outpatient Medical Services,THERAPY,97140,Manipulation of 1 or more regions of the body,420,30,25.5,Pays at 85% of Billed charges for outpatient setting,9.65,Pays at 32.15% of Total Billed charges,24.01,Pays at 80.03% of Total Billed charges,26.48,Pays at 102% of Medicare OPPS Rate,27,Pays at 90% of Total Billed charges,9.65,Pays at 32.15% of Total Billed charges,25.96,Pays at 100% of Medicare OPPS Rate,9.65,Pays at 32.15% of Total Billed charges,26.4,Pays at 88% of Total Billed charges,9.93,Pays at 33.11% of Total Billed charges,9.65,27,18.00
Outpatient Medical Services,THERAPY,97140,Manipulation of 1 or more regions of the body,430,30,25.5,Pays at 85% of Billed charges for outpatient setting,9.65,Pays at 32.15% of Total Billed charges,24.01,Pays at 80.03% of Total Billed charges,26.48,Pays at 102% of Medicare OPPS Rate,27,Pays at 90% of Total Billed charges,9.65,Pays at 32.15% of Total Billed charges,25.96,Pays at 100% of Medicare OPPS Rate,9.65,Pays at 32.15% of Total Billed charges,26.4,Pays at 88% of Total Billed charges,9.93,Pays at 33.11% of Total Billed charges,9.65,27,18.00
Outpatient Medical Services,THERAPY,97140,Manipulation of 1 or more regions of the body,420,40,34,Pays at 85% of Billed charges for outpatient setting,12.86,Pays at 32.15% of Total Billed charges,32.01,Pays at 80.03% of Total Billed charges,26.48,Pays at 102% of Medicare OPPS Rate,36,Pays at 90% of Total Billed charges,12.86,Pays at 32.15% of Total Billed charges,25.96,Pays at 100% of Medicare OPPS Rate,12.86,Pays at 32.15% of Total Billed charges,35.2,Pays at 88% of Total Billed charges,13.24,Pays at 33.11% of Total Billed charges,12.86,36,24.00
Outpatient Medical Services,THERAPY,97140,Manipulation of 1 or more regions of the body,430,40,34,Pays at 85% of Billed charges for outpatient setting,12.86,Pays at 32.15% of Total Billed charges,32.01,Pays at 80.03% of Total Billed charges,26.48,Pays at 102% of Medicare OPPS Rate,36,Pays at 90% of Total Billed charges,12.86,Pays at 32.15% of Total Billed charges,25.96,Pays at 100% of Medicare OPPS Rate,12.86,Pays at 32.15% of Total Billed charges,35.2,Pays at 88% of Total Billed charges,13.24,Pays at 33.11% of Total Billed charges,12.86,36,24.00
Outpatient Medical Services,THERAPY,97140,Manipulation of 1 or more regions of the body,420,42,35.7,Pays at 85% of Billed charges for outpatient setting,13.5,Pays at 32.15% of Total Billed charges,33.61,Pays at 80.03% of Total Billed charges,26.48,Pays at 102% of Medicare OPPS Rate,37.8,Pays at 90% of Total Billed charges,13.5,Pays at 32.15% of Total Billed charges,25.96,Pays at 100% of Medicare OPPS Rate,13.5,Pays at 32.15% of Total Billed charges,36.96,Pays at 88% of Total Billed charges,13.91,Pays at 33.11% of Total Billed charges,13.5,37.8,25.20
Outpatient Medical Services,THERAPY,97140,Manipulation of 1 or more regions of the body,420,60,51,Pays at 85% of Billed charges for outpatient setting,19.29,Pays at 32.15% of Total Billed charges,48.02,Pays at 80.03% of Total Billed charges,26.48,Pays at 102% of Medicare OPPS Rate,54,Pays at 90% of Total Billed charges,19.29,Pays at 32.15% of Total Billed charges,25.96,Pays at 100% of Medicare OPPS Rate,19.29,Pays at 32.15% of Total Billed charges,52.8,Pays at 88% of Total Billed charges,19.87,Pays at 33.11% of Total Billed charges,19.29,54,36.00
Outpatient Medical Services,THERAPY,97140,Manipulation of 1 or more regions of the body,420,65,55.25,Pays at 85% of Billed charges for outpatient setting,20.9,Pays at 32.15% of Total Billed charges,52.02,Pays at 80.03% of Total Billed charges,26.48,Pays at 102% of Medicare OPPS Rate,58.5,Pays at 90% of Total Billed charges,20.9,Pays at 32.15% of Total Billed charges,25.96,Pays at 100% of Medicare OPPS Rate,20.9,Pays at 32.15% of Total Billed charges,57.2,Pays at 88% of Total Billed charges,21.52,Pays at 33.11% of Total Billed charges,20.9,58.5,39.00
Outpatient Medical Services,THERAPY,97140,Manipulation of 1 or more regions of the body,420,80,68,Pays at 85% of Billed charges for outpatient setting,25.72,Pays at 32.15% of Total Billed charges,64.02,Pays at 80.03% of Total Billed charges,26.48,Pays at 102% of Medicare OPPS Rate,72,Pays at 90% of Total Billed charges,25.72,Pays at 32.15% of Total Billed charges,25.96,Pays at 100% of Medicare OPPS Rate,25.72,Pays at 32.15% of Total Billed charges,70.4,Pays at 88% of Total Billed charges,26.49,Pays at 33.11% of Total Billed charges,25.72,72,48.00
Outpatient Medical Services,THERAPY,97140,Manipulation of 1 or more regions of the body,420,95,80.75,Pays at 85% of Billed charges for outpatient setting,30.54,Pays at 32.15% of Total Billed charges,76.03,Pays at 80.03% of Total Billed charges,26.48,Pays at 102% of Medicare OPPS Rate,85.5,Pays at 90% of Total Billed charges,30.54,Pays at 32.15% of Total Billed charges,25.96,Pays at 100% of Medicare OPPS Rate,30.54,Pays at 32.15% of Total Billed charges,83.6,Pays at 88% of Total Billed charges,31.45,Pays at 33.11% of Total Billed charges,25.96,85.5,57.00
Outpatient Medical Services,THERAPY,97140,Manipulation of 1 or more regions of the body,420,115,97.75,Pays at 85% of Billed charges for outpatient setting,36.97,Pays at 32.15% of Total Billed charges,92.03,Pays at 80.03% of Total Billed charges,26.48,Pays at 102% of Medicare OPPS Rate,103.5,Pays at 90% of Total Billed charges,36.97,Pays at 32.15% of Total Billed charges,25.96,Pays at 100% of Medicare OPPS Rate,36.97,Pays at 32.15% of Total Billed charges,101.2,Pays at 88% of Total Billed charges,38.08,Pays at 33.11% of Total Billed charges,25.96,103.5,69.00
Outpatient Medical Services,THERAPY,97140,Manipulation of 1 or more regions of the body,420,120,102,Pays at 85% of Billed charges for outpatient setting,38.58,Pays at 32.15% of Total Billed charges,96.04,Pays at 80.03% of Total Billed charges,26.48,Pays at 102% of Medicare OPPS Rate,108,Pays at 90% of Total Billed charges,38.58,Pays at 32.15% of Total Billed charges,25.96,Pays at 100% of Medicare OPPS Rate,38.58,Pays at 32.15% of Total Billed charges,105.6,Pays at 88% of Total Billed charges,39.73,Pays at 33.11% of Total Billed charges,25.96,108,72.00
Outpatient Medical Services,THERAPY,97150,DO NOT USE,420,50,42.5,Pays at 85% of Billed charges for outpatient setting,16.08,Pays at 32.15% of Total Billed charges,40.02,Pays at 80.03% of Total Billed charges,17.37,Pays at 102% of Medicare OPPS Rate,45,Pays at 90% of Total Billed charges,16.08,Pays at 32.15% of Total Billed charges,17.03,Pays at 100% of Medicare OPPS Rate,16.08,Pays at 32.15% of Total Billed charges,44,Pays at 88% of Total Billed charges,16.56,Pays at 33.11% of Total Billed charges,16.08,45,30.00
Outpatient Medical Services,THERAPY,97250,O/T MYOFASCIAL RELEASE II,430,60,51,Pays at 85% of Billed charges for outpatient setting,19.29,Pays at 32.15% of Total Billed charges,48.02,Pays at 80.03% of Total Billed charges,NA,Not Applicable,54,Pays at 90% of Total Billed charges,19.29,Pays at 32.15% of Total Billed charges,NA,Not Applicable,19.29,Pays at 32.15% of Total Billed charges,52.8,Pays at 88% of Total Billed charges,19.87,Pays at 33.11% of Total Billed charges,19.29,54,36.00
Outpatient Medical Services,THERAPY,97250,O/T MYOFASCIAL RELEASE III,430,95,80.75,Pays at 85% of Billed charges for outpatient setting,30.54,Pays at 32.15% of Total Billed charges,76.03,Pays at 80.03% of Total Billed charges,NA,Not Applicable,85.5,Pays at 90% of Total Billed charges,30.54,Pays at 32.15% of Total Billed charges,NA,Not Applicable,30.54,Pays at 32.15% of Total Billed charges,83.6,Pays at 88% of Total Billed charges,31.45,Pays at 33.11% of Total Billed charges,30.54,85.5,57.00
Outpatient Medical Services,THERAPY,97250,O/T MYOFASCIAL RELEASE IV,430,120,102,Pays at 85% of Billed charges for outpatient setting,38.58,Pays at 32.15% of Total Billed charges,96.04,Pays at 80.03% of Total Billed charges,NA,Not Applicable,108,Pays at 90% of Total Billed charges,38.58,Pays at 32.15% of Total Billed charges,NA,Not Applicable,38.58,Pays at 32.15% of Total Billed charges,105.6,Pays at 88% of Total Billed charges,39.73,Pays at 33.11% of Total Billed charges,38.58,108,72.00
Outpatient Medical Services,THERAPY,97265,O/T JOINT/SPINAL MOBILIZATION II,430,65,55.25,Pays at 85% of Billed charges for outpatient setting,20.9,Pays at 32.15% of Total Billed charges,52.02,Pays at 80.03% of Total Billed charges,NA,Not Applicable,58.5,Pays at 90% of Total Billed charges,20.9,Pays at 32.15% of Total Billed charges,NA,Not Applicable,20.9,Pays at 32.15% of Total Billed charges,57.2,Pays at 88% of Total Billed charges,21.52,Pays at 33.11% of Total Billed charges,20.9,58.5,39.00
Outpatient Medical Services,THERAPY,97504,FITTING PRE-FAB SPLINT STATIC,430,20,17,Pays at 85% of Billed charges for outpatient setting,6.43,Pays at 32.15% of Total Billed charges,16.01,Pays at 80.03% of Total Billed charges,NA,Not Applicable,18,Pays at 90% of Total Billed charges,6.43,Pays at 32.15% of Total Billed charges,NA,Not Applicable,6.43,Pays at 32.15% of Total Billed charges,17.6,Pays at 88% of Total Billed charges,6.62,Pays at 33.11% of Total Billed charges,6.43,18,12.00
Outpatient Medical Services,THERAPY,97504,HAND SPLINT FIT/CONSTRUCTION I,430,48.8,41.48,Pays at 85% of Billed charges for outpatient setting,15.69,Pays at 32.15% of Total Billed charges,39.05,Pays at 80.03% of Total Billed charges,NA,Not Applicable,43.92,Pays at 90% of Total Billed charges,15.69,Pays at 32.15% of Total Billed charges,NA,Not Applicable,15.69,Pays at 32.15% of Total Billed charges,42.94,Pays at 88% of Total Billed charges,16.16,Pays at 33.11% of Total Billed charges,15.69,43.92,29.28
Outpatient Medical Services,THERAPY,97504,O/T SPLINT ADJUST I - 15 MINUTES,430,48.8,41.48,Pays at 85% of Billed charges for outpatient setting,15.69,Pays at 32.15% of Total Billed charges,39.05,Pays at 80.03% of Total Billed charges,NA,Not Applicable,43.92,Pays at 90% of Total Billed charges,15.69,Pays at 32.15% of Total Billed charges,NA,Not Applicable,15.69,Pays at 32.15% of Total Billed charges,42.94,Pays at 88% of Total Billed charges,16.16,Pays at 33.11% of Total Billed charges,15.69,43.92,29.28
Outpatient Medical Services,THERAPY,97504,HAND SPLINT ADJUSTMENT,430,62.7,53.3,Pays at 85% of Billed charges for outpatient setting,20.16,Pays at 32.15% of Total Billed charges,50.18,Pays at 80.03% of Total Billed charges,NA,Not Applicable,56.43,Pays at 90% of Total Billed charges,20.16,Pays at 32.15% of Total Billed charges,NA,Not Applicable,20.16,Pays at 32.15% of Total Billed charges,55.18,Pays at 88% of Total Billed charges,20.76,Pays at 33.11% of Total Billed charges,20.16,56.43,37.62
Outpatient Medical Services,THERAPY,97504,O/T BRACE/ORTHOTICS FIT/ADJUSTMENT II,430,90.4,76.84,Pays at 85% of Billed charges for outpatient setting,29.06,Pays at 32.15% of Total Billed charges,72.35,Pays at 80.03% of Total Billed charges,NA,Not Applicable,81.36,Pays at 90% of Total Billed charges,29.06,Pays at 32.15% of Total Billed charges,NA,Not Applicable,29.06,Pays at 32.15% of Total Billed charges,79.55,Pays at 88% of Total Billed charges,29.93,Pays at 33.11% of Total Billed charges,29.06,81.36,54.24
Outpatient Medical Services,THERAPY,97504,HAND SPLINT FIT/CONSTRUCTION II,430,90.4,76.84,Pays at 85% of Billed charges for outpatient setting,29.06,Pays at 32.15% of Total Billed charges,72.35,Pays at 80.03% of Total Billed charges,NA,Not Applicable,81.36,Pays at 90% of Total Billed charges,29.06,Pays at 32.15% of Total Billed charges,NA,Not Applicable,29.06,Pays at 32.15% of Total Billed charges,79.55,Pays at 88% of Total Billed charges,29.93,Pays at 33.11% of Total Billed charges,29.06,81.36,54.24
Outpatient Medical Services,THERAPY,97504,O/T SPLINT ADJUSTMENT,430,90.4,76.84,Pays at 85% of Billed charges for outpatient setting,29.06,Pays at 32.15% of Total Billed charges,72.35,Pays at 80.03% of Total Billed charges,NA,Not Applicable,81.36,Pays at 90% of Total Billed charges,29.06,Pays at 32.15% of Total Billed charges,NA,Not Applicable,29.06,Pays at 32.15% of Total Billed charges,79.55,Pays at 88% of Total Billed charges,29.93,Pays at 33.11% of Total Billed charges,29.06,81.36,54.24
Outpatient Medical Services,THERAPY,97504,HAND SPLINT FIT/CONSTRUCTION III,430,139.2,118.32,Pays at 85% of Billed charges for outpatient setting,44.75,Pays at 32.15% of Total Billed charges,111.4,Pays at 80.03% of Total Billed charges,NA,Not Applicable,125.28,Pays at 90% of Total Billed charges,44.75,Pays at 32.15% of Total Billed charges,NA,Not Applicable,44.75,Pays at 32.15% of Total Billed charges,122.5,Pays at 88% of Total Billed charges,46.09,Pays at 33.11% of Total Billed charges,44.75,125.28,83.52
Outpatient Medical Services,THERAPY,97504,HAND SPLINT FIT/CONSTRUCTION IV,430,174.35,148.2,Pays at 85% of Billed charges for outpatient setting,56.05,Pays at 32.15% of Total Billed charges,139.53,Pays at 80.03% of Total Billed charges,NA,Not Applicable,156.92,Pays at 90% of Total Billed charges,56.05,Pays at 32.15% of Total Billed charges,NA,Not Applicable,56.05,Pays at 32.15% of Total Billed charges,153.43,Pays at 88% of Total Billed charges,57.73,Pays at 33.11% of Total Billed charges,56.05,156.92,104.61
Outpatient Medical Services,THERAPY,97535,Occupational therapy,430,20,17,Pays at 85% of Billed charges for outpatient setting,6.43,Pays at 32.15% of Total Billed charges,16.01,Pays at 80.03% of Total Billed charges,31.73,Pays at 102% of Medicare OPPS Rate,18,Pays at 90% of Total Billed charges,6.43,Pays at 32.15% of Total Billed charges,31.11,Pays at 100% of Medicare OPPS Rate,6.43,Pays at 32.15% of Total Billed charges,17.6,Pays at 88% of Total Billed charges,6.62,Pays at 33.11% of Total Billed charges,6.43,31.73,12.00
Outpatient Medical Services,THERAPY,97535,Occupational therapy,430,20,17,Pays at 85% of Billed charges for outpatient setting,6.43,Pays at 32.15% of Total Billed charges,16.01,Pays at 80.03% of Total Billed charges,31.73,Pays at 102% of Medicare OPPS Rate,18,Pays at 90% of Total Billed charges,6.43,Pays at 32.15% of Total Billed charges,31.11,Pays at 100% of Medicare OPPS Rate,6.43,Pays at 32.15% of Total Billed charges,17.6,Pays at 88% of Total Billed charges,6.62,Pays at 33.11% of Total Billed charges,6.43,31.73,12.00
Outpatient Medical Services,THERAPY,97535,Occupational therapy,430,48.8,41.48,Pays at 85% of Billed charges for outpatient setting,15.69,Pays at 32.15% of Total Billed charges,39.05,Pays at 80.03% of Total Billed charges,31.73,Pays at 102% of Medicare OPPS Rate,43.92,Pays at 90% of Total Billed charges,15.69,Pays at 32.15% of Total Billed charges,31.11,Pays at 100% of Medicare OPPS Rate,15.69,Pays at 32.15% of Total Billed charges,42.94,Pays at 88% of Total Billed charges,16.16,Pays at 33.11% of Total Billed charges,15.69,43.92,29.28
Outpatient Medical Services,THERAPY,97535,Occupational therapy,430,60,51,Pays at 85% of Billed charges for outpatient setting,19.29,Pays at 32.15% of Total Billed charges,48.02,Pays at 80.03% of Total Billed charges,31.73,Pays at 102% of Medicare OPPS Rate,54,Pays at 90% of Total Billed charges,19.29,Pays at 32.15% of Total Billed charges,31.11,Pays at 100% of Medicare OPPS Rate,19.29,Pays at 32.15% of Total Billed charges,52.8,Pays at 88% of Total Billed charges,19.87,Pays at 33.11% of Total Billed charges,19.29,54,36.00
Outpatient Medical Services,THERAPY,97535,Occupational therapy,430,60,51,Pays at 85% of Billed charges for outpatient setting,19.29,Pays at 32.15% of Total Billed charges,48.02,Pays at 80.03% of Total Billed charges,31.73,Pays at 102% of Medicare OPPS Rate,54,Pays at 90% of Total Billed charges,19.29,Pays at 32.15% of Total Billed charges,31.11,Pays at 100% of Medicare OPPS Rate,19.29,Pays at 32.15% of Total Billed charges,52.8,Pays at 88% of Total Billed charges,19.87,Pays at 33.11% of Total Billed charges,19.29,54,36.00
Outpatient Medical Services,THERAPY,97535,Occupational therapy,430,90.4,76.84,Pays at 85% of Billed charges for outpatient setting,29.06,Pays at 32.15% of Total Billed charges,72.35,Pays at 80.03% of Total Billed charges,31.73,Pays at 102% of Medicare OPPS Rate,81.36,Pays at 90% of Total Billed charges,29.06,Pays at 32.15% of Total Billed charges,31.11,Pays at 100% of Medicare OPPS Rate,29.06,Pays at 32.15% of Total Billed charges,79.55,Pays at 88% of Total Billed charges,29.93,Pays at 33.11% of Total Billed charges,29.06,81.36,54.24
Outpatient Medical Services,THERAPY,97535,Occupational therapy,430,95,80.75,Pays at 85% of Billed charges for outpatient setting,30.54,Pays at 32.15% of Total Billed charges,76.03,Pays at 80.03% of Total Billed charges,31.73,Pays at 102% of Medicare OPPS Rate,85.5,Pays at 90% of Total Billed charges,30.54,Pays at 32.15% of Total Billed charges,31.11,Pays at 100% of Medicare OPPS Rate,30.54,Pays at 32.15% of Total Billed charges,83.6,Pays at 88% of Total Billed charges,31.45,Pays at 33.11% of Total Billed charges,30.54,85.5,57.00
Outpatient Medical Services,THERAPY,97535,Occupational therapy,430,120,102,Pays at 85% of Billed charges for outpatient setting,38.58,Pays at 32.15% of Total Billed charges,96.04,Pays at 80.03% of Total Billed charges,31.73,Pays at 102% of Medicare OPPS Rate,108,Pays at 90% of Total Billed charges,38.58,Pays at 32.15% of Total Billed charges,31.11,Pays at 100% of Medicare OPPS Rate,38.58,Pays at 32.15% of Total Billed charges,105.6,Pays at 88% of Total Billed charges,39.73,Pays at 33.11% of Total Billed charges,31.11,108,72.00
Outpatient Medical Services,THERAPY,97535,Occupational therapy,430,132.55,112.67,Pays at 85% of Billed charges for outpatient setting,42.61,Pays at 32.15% of Total Billed charges,106.08,Pays at 80.03% of Total Billed charges,31.73,Pays at 102% of Medicare OPPS Rate,119.3,Pays at 90% of Total Billed charges,42.61,Pays at 32.15% of Total Billed charges,31.11,Pays at 100% of Medicare OPPS Rate,42.61,Pays at 32.15% of Total Billed charges,116.64,Pays at 88% of Total Billed charges,43.89,Pays at 33.11% of Total Billed charges,31.11,119.3,79.53
Outpatient Medical Services,THERAPY,97535,Occupational therapy,430,139.2,118.32,Pays at 85% of Billed charges for outpatient setting,44.75,Pays at 32.15% of Total Billed charges,111.4,Pays at 80.03% of Total Billed charges,31.73,Pays at 102% of Medicare OPPS Rate,125.28,Pays at 90% of Total Billed charges,44.75,Pays at 32.15% of Total Billed charges,31.11,Pays at 100% of Medicare OPPS Rate,44.75,Pays at 32.15% of Total Billed charges,122.5,Pays at 88% of Total Billed charges,46.09,Pays at 33.11% of Total Billed charges,31.11,125.28,83.52
Outpatient Medical Services,THERAPY,97542,W/C MOBILITY II,420,60,51,Pays at 85% of Billed charges for outpatient setting,19.29,Pays at 32.15% of Total Billed charges,48.02,Pays at 80.03% of Total Billed charges,30.95,Pays at 102% of Medicare OPPS Rate,54,Pays at 90% of Total Billed charges,19.29,Pays at 32.15% of Total Billed charges,30.34,Pays at 100% of Medicare OPPS Rate,19.29,Pays at 32.15% of Total Billed charges,52.8,Pays at 88% of Total Billed charges,19.87,Pays at 33.11% of Total Billed charges,19.29,54,36.00
Outpatient Medical Services,THERAPY,97542,W/C MOBILITY III,420,95,80.75,Pays at 85% of Billed charges for outpatient setting,30.54,Pays at 32.15% of Total Billed charges,76.03,Pays at 80.03% of Total Billed charges,30.95,Pays at 102% of Medicare OPPS Rate,85.5,Pays at 90% of Total Billed charges,30.54,Pays at 32.15% of Total Billed charges,30.34,Pays at 100% of Medicare OPPS Rate,30.54,Pays at 32.15% of Total Billed charges,83.6,Pays at 88% of Total Billed charges,31.45,Pays at 33.11% of Total Billed charges,30.34,85.5,57.00
Outpatient Medical Services,THERAPY,97542,W/C MOBILITY IV,420,120,102,Pays at 85% of Billed charges for outpatient setting,38.58,Pays at 32.15% of Total Billed charges,96.04,Pays at 80.03% of Total Billed charges,30.95,Pays at 102% of Medicare OPPS Rate,108,Pays at 90% of Total Billed charges,38.58,Pays at 32.15% of Total Billed charges,30.34,Pays at 100% of Medicare OPPS Rate,38.58,Pays at 32.15% of Total Billed charges,105.6,Pays at 88% of Total Billed charges,39.73,Pays at 33.11% of Total Billed charges,30.34,108,72.00
Outpatient Medical Services,THERAPY,97750,OT EVALUATION,430,40,34,Pays at 85% of Billed charges for outpatient setting,12.86,Pays at 32.15% of Total Billed charges,32.01,Pays at 80.03% of Total Billed charges,32.65,Pays at 102% of Medicare OPPS Rate,36,Pays at 90% of Total Billed charges,12.86,Pays at 32.15% of Total Billed charges,32.01,Pays at 100% of Medicare OPPS Rate,12.86,Pays at 32.15% of Total Billed charges,35.2,Pays at 88% of Total Billed charges,13.24,Pays at 33.11% of Total Billed charges,12.86,36,24.00
Outpatient Medical Services,THERAPY,97750,"P/T INPATIENT EVAL, BASIC",420,60,51,Pays at 85% of Billed charges for outpatient setting,19.29,Pays at 32.15% of Total Billed charges,48.02,Pays at 80.03% of Total Billed charges,32.65,Pays at 102% of Medicare OPPS Rate,54,Pays at 90% of Total Billed charges,19.29,Pays at 32.15% of Total Billed charges,32.01,Pays at 100% of Medicare OPPS Rate,19.29,Pays at 32.15% of Total Billed charges,52.8,Pays at 88% of Total Billed charges,19.87,Pays at 33.11% of Total Billed charges,19.29,54,36.00
Outpatient Medical Services,THERAPY,97750,DO NOT USE,420,60,51,Pays at 85% of Billed charges for outpatient setting,19.29,Pays at 32.15% of Total Billed charges,48.02,Pays at 80.03% of Total Billed charges,32.65,Pays at 102% of Medicare OPPS Rate,54,Pays at 90% of Total Billed charges,19.29,Pays at 32.15% of Total Billed charges,32.01,Pays at 100% of Medicare OPPS Rate,19.29,Pays at 32.15% of Total Billed charges,52.8,Pays at 88% of Total Billed charges,19.87,Pays at 33.11% of Total Billed charges,19.29,54,36.00
Outpatient Medical Services,THERAPY,97750,"P/T OUTPATIENT EVAL, BASIC",420,60,51,Pays at 85% of Billed charges for outpatient setting,19.29,Pays at 32.15% of Total Billed charges,48.02,Pays at 80.03% of Total Billed charges,32.65,Pays at 102% of Medicare OPPS Rate,54,Pays at 90% of Total Billed charges,19.29,Pays at 32.15% of Total Billed charges,32.01,Pays at 100% of Medicare OPPS Rate,19.29,Pays at 32.15% of Total Billed charges,52.8,Pays at 88% of Total Billed charges,19.87,Pays at 33.11% of Total Billed charges,19.29,54,36.00
Outpatient Medical Services,THERAPY,97750,OT PEDIATRIC EVALUATION,430,80,68,Pays at 85% of Billed charges for outpatient setting,25.72,Pays at 32.15% of Total Billed charges,64.02,Pays at 80.03% of Total Billed charges,32.65,Pays at 102% of Medicare OPPS Rate,72,Pays at 90% of Total Billed charges,25.72,Pays at 32.15% of Total Billed charges,32.01,Pays at 100% of Medicare OPPS Rate,25.72,Pays at 32.15% of Total Billed charges,70.4,Pays at 88% of Total Billed charges,26.49,Pays at 33.11% of Total Billed charges,25.72,72,48.00
Outpatient Medical Services,THERAPY,97750,ADULT NEURO EVALUATION,430,85,72.25,Pays at 85% of Billed charges for outpatient setting,27.33,Pays at 32.15% of Total Billed charges,68.03,Pays at 80.03% of Total Billed charges,32.65,Pays at 102% of Medicare OPPS Rate,76.5,Pays at 90% of Total Billed charges,27.33,Pays at 32.15% of Total Billed charges,32.01,Pays at 100% of Medicare OPPS Rate,27.33,Pays at 32.15% of Total Billed charges,74.8,Pays at 88% of Total Billed charges,28.14,Pays at 33.11% of Total Billed charges,27.33,76.5,51.00
Outpatient Medical Services,THERAPY,97750,"O/T EVALUATION, BASIC",430,90.4,76.84,Pays at 85% of Billed charges for outpatient setting,29.06,Pays at 32.15% of Total Billed charges,72.35,Pays at 80.03% of Total Billed charges,32.65,Pays at 102% of Medicare OPPS Rate,81.36,Pays at 90% of Total Billed charges,29.06,Pays at 32.15% of Total Billed charges,32.01,Pays at 100% of Medicare OPPS Rate,29.06,Pays at 32.15% of Total Billed charges,79.55,Pays at 88% of Total Billed charges,29.93,Pays at 33.11% of Total Billed charges,29.06,81.36,54.24
Outpatient Medical Services,THERAPY,97750,DO NOT USE,420,120,102,Pays at 85% of Billed charges for outpatient setting,38.58,Pays at 32.15% of Total Billed charges,96.04,Pays at 80.03% of Total Billed charges,32.65,Pays at 102% of Medicare OPPS Rate,108,Pays at 90% of Total Billed charges,38.58,Pays at 32.15% of Total Billed charges,32.01,Pays at 100% of Medicare OPPS Rate,38.58,Pays at 32.15% of Total Billed charges,105.6,Pays at 88% of Total Billed charges,39.73,Pays at 33.11% of Total Billed charges,32.01,108,72.00
Outpatient Medical Services,THERAPY,97750,P/T ADULT NEURO EVALUATION,420,185,157.25,Pays at 85% of Billed charges for outpatient setting,59.48,Pays at 32.15% of Total Billed charges,148.06,Pays at 80.03% of Total Billed charges,32.65,Pays at 102% of Medicare OPPS Rate,166.5,Pays at 90% of Total Billed charges,59.48,Pays at 32.15% of Total Billed charges,32.01,Pays at 100% of Medicare OPPS Rate,59.48,Pays at 32.15% of Total Billed charges,162.8,Pays at 88% of Total Billed charges,61.25,Pays at 33.11% of Total Billed charges,32.01,166.5,111.00
Outpatient Medical Services,THERAPY,97750,DO NOT USE,420,195,165.75,Pays at 85% of Billed charges for outpatient setting,62.69,Pays at 32.15% of Total Billed charges,156.06,Pays at 80.03% of Total Billed charges,32.65,Pays at 102% of Medicare OPPS Rate,175.5,Pays at 90% of Total Billed charges,62.69,Pays at 32.15% of Total Billed charges,32.01,Pays at 100% of Medicare OPPS Rate,62.69,Pays at 32.15% of Total Billed charges,171.6,Pays at 88% of Total Billed charges,64.56,Pays at 33.11% of Total Billed charges,32.01,175.5,117.00
Outpatient Medical Services,THERAPY,97750,O/T ADULT NEURO EVALUATION,430,271.7,230.95,Pays at 85% of Billed charges for outpatient setting,87.35,Pays at 32.15% of Total Billed charges,217.44,Pays at 80.03% of Total Billed charges,32.65,Pays at 102% of Medicare OPPS Rate,244.53,Pays at 90% of Total Billed charges,87.35,Pays at 32.15% of Total Billed charges,32.01,Pays at 100% of Medicare OPPS Rate,87.35,Pays at 32.15% of Total Billed charges,239.1,Pays at 88% of Total Billed charges,89.96,Pays at 33.11% of Total Billed charges,32.01,244.53,163.02
Outpatient Medical Services,THERAPY,97760,O/T BRACE/ORTHOTICS FIT,430,62.7,53.3,Pays at 85% of Billed charges for outpatient setting,20.16,Pays at 32.15% of Total Billed charges,50.18,Pays at 80.03% of Total Billed charges,46.26,Pays at 102% of Medicare OPPS Rate,56.43,Pays at 90% of Total Billed charges,20.16,Pays at 32.15% of Total Billed charges,45.35,Pays at 100% of Medicare OPPS Rate,20.16,Pays at 32.15% of Total Billed charges,55.18,Pays at 88% of Total Billed charges,20.76,Pays at 33.11% of Total Billed charges,20.16,56.43,37.62
Outpatient Medical Services,THERAPY,97761,P/T PROSTHETIC INITIAL ENCOUNTER,420,91,77.35,Pays at 85% of Billed charges for outpatient setting,29.26,Pays at 32.15% of Total Billed charges,72.83,Pays at 80.03% of Total Billed charges,40.16,Pays at 102% of Medicare OPPS Rate,81.9,Pays at 90% of Total Billed charges,29.26,Pays at 32.15% of Total Billed charges,39.37,Pays at 100% of Medicare OPPS Rate,29.26,Pays at 32.15% of Total Billed charges,80.08,Pays at 88% of Total Billed charges,30.13,Pays at 33.11% of Total Billed charges,29.26,81.9,54.60
Outpatient Medical Services,THERAPY,97763,P/T PROSTHETIC SUBSEQUENT TRAINING,420,136.5,116.03,Pays at 85% of Billed charges for outpatient setting,43.88,Pays at 32.15% of Total Billed charges,109.24,Pays at 80.03% of Total Billed charges,50.43,Pays at 102% of Medicare OPPS Rate,122.85,Pays at 90% of Total Billed charges,43.88,Pays at 32.15% of Total Billed charges,49.44,Pays at 100% of Medicare OPPS Rate,43.88,Pays at 32.15% of Total Billed charges,120.12,Pays at 88% of Total Billed charges,45.2,Pays at 33.11% of Total Billed charges,43.88,122.85,81.90
Outpatient Medical Services,THERAPY,97770,O/T COGNITIVE RETRAINING II,430,60,51,Pays at 85% of Billed charges for outpatient setting,19.29,Pays at 32.15% of Total Billed charges,48.02,Pays at 80.03% of Total Billed charges,NA,Not Applicable,54,Pays at 90% of Total Billed charges,19.29,Pays at 32.15% of Total Billed charges,NA,Not Applicable,19.29,Pays at 32.15% of Total Billed charges,52.8,Pays at 88% of Total Billed charges,19.87,Pays at 33.11% of Total Billed charges,19.29,54,36.00
Outpatient Medical Services,THERAPY,97770,O/T COGNITIVE RETRAINING',430,60,51,Pays at 85% of Billed charges for outpatient setting,19.29,Pays at 32.15% of Total Billed charges,48.02,Pays at 80.03% of Total Billed charges,NA,Not Applicable,54,Pays at 90% of Total Billed charges,19.29,Pays at 32.15% of Total Billed charges,NA,Not Applicable,19.29,Pays at 32.15% of Total Billed charges,52.8,Pays at 88% of Total Billed charges,19.87,Pays at 33.11% of Total Billed charges,19.29,54,36.00
Outpatient Medical Services,THERAPY,97770,O/T COGNITIVE RETRAININING III,430,95,80.75,Pays at 85% of Billed charges for outpatient setting,30.54,Pays at 32.15% of Total Billed charges,76.03,Pays at 80.03% of Total Billed charges,NA,Not Applicable,85.5,Pays at 90% of Total Billed charges,30.54,Pays at 32.15% of Total Billed charges,NA,Not Applicable,30.54,Pays at 32.15% of Total Billed charges,83.6,Pays at 88% of Total Billed charges,31.45,Pays at 33.11% of Total Billed charges,30.54,85.5,57.00
Outpatient Medical Services,THERAPY,97770,O/T COGNITIVE RETRAINING IV,430,95,80.75,Pays at 85% of Billed charges for outpatient setting,30.54,Pays at 32.15% of Total Billed charges,76.03,Pays at 80.03% of Total Billed charges,NA,Not Applicable,85.5,Pays at 90% of Total Billed charges,30.54,Pays at 32.15% of Total Billed charges,NA,Not Applicable,30.54,Pays at 32.15% of Total Billed charges,83.6,Pays at 88% of Total Billed charges,31.45,Pays at 33.11% of Total Billed charges,30.54,85.5,57.00
Outpatient Medical Services,THERAPY,97799,P/T DEBRIDEMENT(S),420,36.8,31.28,Pays at 85% of Billed charges for outpatient setting,11.83,Pays at 32.15% of Total Billed charges,29.45,Pays at 80.03% of Total Billed charges,NA,Not Applicable,33.12,Pays at 90% of Total Billed charges,11.83,Pays at 32.15% of Total Billed charges,NA,Not Applicable,11.83,Pays at 32.15% of Total Billed charges,32.38,Pays at 88% of Total Billed charges,12.18,Pays at 33.11% of Total Billed charges,11.83,33.12,22.08
Outpatient Medical Services,THERAPY,97799,P/T MIN EXUDATE WOUND,420,110.3,93.76,Pays at 85% of Billed charges for outpatient setting,35.46,Pays at 32.15% of Total Billed charges,88.27,Pays at 80.03% of Total Billed charges,NA,Not Applicable,99.27,Pays at 90% of Total Billed charges,35.46,Pays at 32.15% of Total Billed charges,NA,Not Applicable,35.46,Pays at 32.15% of Total Billed charges,97.06,Pays at 88% of Total Billed charges,36.52,Pays at 33.11% of Total Billed charges,35.46,99.27,66.18
Outpatient Medical Services,THERAPY,97799,P/T MOD EXUDATE WOUNDS,420,110.3,93.76,Pays at 85% of Billed charges for outpatient setting,35.46,Pays at 32.15% of Total Billed charges,88.27,Pays at 80.03% of Total Billed charges,NA,Not Applicable,99.27,Pays at 90% of Total Billed charges,35.46,Pays at 32.15% of Total Billed charges,NA,Not Applicable,35.46,Pays at 32.15% of Total Billed charges,97.06,Pays at 88% of Total Billed charges,36.52,Pays at 33.11% of Total Billed charges,35.46,99.27,66.18
Outpatient Medical Services,THERAPY,97799,P/T DRY WOUND,420,123.9,105.32,Pays at 85% of Billed charges for outpatient setting,39.83,Pays at 32.15% of Total Billed charges,99.16,Pays at 80.03% of Total Billed charges,NA,Not Applicable,111.51,Pays at 90% of Total Billed charges,39.83,Pays at 32.15% of Total Billed charges,NA,Not Applicable,39.83,Pays at 32.15% of Total Billed charges,109.03,Pays at 88% of Total Billed charges,41.02,Pays at 33.11% of Total Billed charges,39.83,111.51,74.34
Outpatient Medical Services,THERAPY,97799,P/T HEAVY EXUDATE WOUNDS,420,126,107.1,Pays at 85% of Billed charges for outpatient setting,40.51,Pays at 32.15% of Total Billed charges,100.84,Pays at 80.03% of Total Billed charges,NA,Not Applicable,113.4,Pays at 90% of Total Billed charges,40.51,Pays at 32.15% of Total Billed charges,NA,Not Applicable,40.51,Pays at 32.15% of Total Billed charges,110.88,Pays at 88% of Total Billed charges,41.72,Pays at 33.11% of Total Billed charges,40.51,113.4,75.60
Outpatient Medical Services,THERAPY,97799,P/T MIN DEBRIDEMENT,420,147,124.95,Pays at 85% of Billed charges for outpatient setting,47.26,Pays at 32.15% of Total Billed charges,117.64,Pays at 80.03% of Total Billed charges,NA,Not Applicable,132.3,Pays at 90% of Total Billed charges,47.26,Pays at 32.15% of Total Billed charges,NA,Not Applicable,47.26,Pays at 32.15% of Total Billed charges,129.36,Pays at 88% of Total Billed charges,48.67,Pays at 33.11% of Total Billed charges,47.26,132.3,88.20
Outpatient Medical Services,THERAPY,97799,P/T MOD DEBRIDEMENT,420,147,124.95,Pays at 85% of Billed charges for outpatient setting,47.26,Pays at 32.15% of Total Billed charges,117.64,Pays at 80.03% of Total Billed charges,NA,Not Applicable,132.3,Pays at 90% of Total Billed charges,47.26,Pays at 32.15% of Total Billed charges,NA,Not Applicable,47.26,Pays at 32.15% of Total Billed charges,129.36,Pays at 88% of Total Billed charges,48.67,Pays at 33.11% of Total Billed charges,47.26,132.3,88.20
Outpatient Medical Services,THERAPY,97799,P/T HEAVY DEBRIDEMENT,420,162.8,138.38,Pays at 85% of Billed charges for outpatient setting,52.34,Pays at 32.15% of Total Billed charges,130.29,Pays at 80.03% of Total Billed charges,NA,Not Applicable,146.52,Pays at 90% of Total Billed charges,52.34,Pays at 32.15% of Total Billed charges,NA,Not Applicable,52.34,Pays at 32.15% of Total Billed charges,143.26,Pays at 88% of Total Billed charges,53.9,Pays at 33.11% of Total Billed charges,52.34,146.52,97.68
Outpatient Medical Services,THERAPY,97799,P/T MULTI STATUS WOUNDS,420,231,196.35,Pays at 85% of Billed charges for outpatient setting,74.27,Pays at 32.15% of Total Billed charges,184.87,Pays at 80.03% of Total Billed charges,NA,Not Applicable,207.9,Pays at 90% of Total Billed charges,74.27,Pays at 32.15% of Total Billed charges,NA,Not Applicable,74.27,Pays at 32.15% of Total Billed charges,203.28,Pays at 88% of Total Billed charges,76.48,Pays at 33.11% of Total Billed charges,74.27,207.9,138.60
Outpatient Medical Services,THERAPY,97799,O/T  HEAVY EXUDATE WOUNDS,430,247.6,210.46,Pays at 85% of Billed charges for outpatient setting,79.6,Pays at 32.15% of Total Billed charges,198.15,Pays at 80.03% of Total Billed charges,NA,Not Applicable,222.84,Pays at 90% of Total Billed charges,79.6,Pays at 32.15% of Total Billed charges,NA,Not Applicable,79.6,Pays at 32.15% of Total Billed charges,217.89,Pays at 88% of Total Billed charges,81.98,Pays at 33.11% of Total Billed charges,79.6,222.84,148.56
Outpatient Medical Services,THERAPY,29200,O/T STRAPPING OF THORAX,430,206,175.1,Pays at 85% of Billed charges for outpatient setting,66.23,Pays at 32.15% of Total Billed charges,164.86,Pays at 80.03% of Total Billed charges,139.72,Pays at 102% of Medicare OPPS Rate,185.4,Pays at 90% of Total Billed charges,66.23,Pays at 32.15% of Total Billed charges,137,Pays at 100% of Medicare OPPS Rate,66.23,Pays at 32.15% of Total Billed charges,181.28,Pays at 88% of Total Billed charges,68.21,Pays at 33.11% of Total Billed charges,66.23,185.4,123.60
Outpatient Medical Services,THERAPY,29200,P/T STRAPPING OF THORAX,420,206,175.1,Pays at 85% of Billed charges for outpatient setting,66.23,Pays at 32.15% of Total Billed charges,164.86,Pays at 80.03% of Total Billed charges,139.72,Pays at 102% of Medicare OPPS Rate,185.4,Pays at 90% of Total Billed charges,66.23,Pays at 32.15% of Total Billed charges,137,Pays at 100% of Medicare OPPS Rate,66.23,Pays at 32.15% of Total Billed charges,181.28,Pays at 88% of Total Billed charges,68.21,Pays at 33.11% of Total Billed charges,66.23,185.4,123.60
Outpatient Medical Services,THERAPY,29240,O/T STRAPPING OF SHOULDER,430,216.25,183.81,Pays at 85% of Billed charges for outpatient setting,69.52,Pays at 32.15% of Total Billed charges,173.06,Pays at 80.03% of Total Billed charges,111.31,Pays at 102% of Medicare OPPS Rate,194.63,Pays at 90% of Total Billed charges,69.52,Pays at 32.15% of Total Billed charges,109.13,Pays at 100% of Medicare OPPS Rate,69.52,Pays at 32.15% of Total Billed charges,190.3,Pays at 88% of Total Billed charges,71.6,Pays at 33.11% of Total Billed charges,69.52,194.63,129.75
Outpatient Medical Services,THERAPY,29240,P/T STRAPPING OF SHOULDER,420,216.25,183.81,Pays at 85% of Billed charges for outpatient setting,69.52,Pays at 32.15% of Total Billed charges,173.06,Pays at 80.03% of Total Billed charges,111.31,Pays at 102% of Medicare OPPS Rate,194.63,Pays at 90% of Total Billed charges,69.52,Pays at 32.15% of Total Billed charges,109.13,Pays at 100% of Medicare OPPS Rate,69.52,Pays at 32.15% of Total Billed charges,190.3,Pays at 88% of Total Billed charges,71.6,Pays at 33.11% of Total Billed charges,69.52,194.63,129.75
Outpatient Medical Services,THERAPY,29260,O/T STRAPPING OF ELBOW OR WRIST,430,177,150.45,Pays at 85% of Billed charges for outpatient setting,56.91,Pays at 32.15% of Total Billed charges,141.65,Pays at 80.03% of Total Billed charges,55.1,Pays at 102% of Medicare OPPS Rate,159.3,Pays at 90% of Total Billed charges,56.91,Pays at 32.15% of Total Billed charges,54.02,Pays at 100% of Medicare OPPS Rate,56.91,Pays at 32.15% of Total Billed charges,155.76,Pays at 88% of Total Billed charges,58.6,Pays at 33.11% of Total Billed charges,54.02,159.3,106.20
Outpatient Medical Services,THERAPY,29260,P/T STRAPPING OF ELBOW OR WRIST,420,177,150.45,Pays at 85% of Billed charges for outpatient setting,56.91,Pays at 32.15% of Total Billed charges,141.65,Pays at 80.03% of Total Billed charges,55.1,Pays at 102% of Medicare OPPS Rate,159.3,Pays at 90% of Total Billed charges,56.91,Pays at 32.15% of Total Billed charges,54.02,Pays at 100% of Medicare OPPS Rate,56.91,Pays at 32.15% of Total Billed charges,155.76,Pays at 88% of Total Billed charges,58.6,Pays at 33.11% of Total Billed charges,54.02,159.3,106.20
Outpatient Medical Services,THERAPY,29280,O/T STRAPPING OF HAND OR FINGER,430,177,150.45,Pays at 85% of Billed charges for outpatient setting,56.91,Pays at 32.15% of Total Billed charges,141.65,Pays at 80.03% of Total Billed charges,55.1,Pays at 102% of Medicare OPPS Rate,159.3,Pays at 90% of Total Billed charges,56.91,Pays at 32.15% of Total Billed charges,54.02,Pays at 100% of Medicare OPPS Rate,56.91,Pays at 32.15% of Total Billed charges,155.76,Pays at 88% of Total Billed charges,58.6,Pays at 33.11% of Total Billed charges,54.02,159.3,106.20
Outpatient Medical Services,THERAPY,29280,P/T STRAPPING OF HAND OR FINGER,420,177,150.45,Pays at 85% of Billed charges for outpatient setting,56.91,Pays at 32.15% of Total Billed charges,141.65,Pays at 80.03% of Total Billed charges,55.1,Pays at 102% of Medicare OPPS Rate,159.3,Pays at 90% of Total Billed charges,56.91,Pays at 32.15% of Total Billed charges,54.02,Pays at 100% of Medicare OPPS Rate,56.91,Pays at 32.15% of Total Billed charges,155.76,Pays at 88% of Total Billed charges,58.6,Pays at 33.11% of Total Billed charges,54.02,159.3,106.20
Outpatient Medical Services,THERAPY,29520,P/T STRAPPING OF HIP,420,216.25,183.81,Pays at 85% of Billed charges for outpatient setting,69.52,Pays at 32.15% of Total Billed charges,173.06,Pays at 80.03% of Total Billed charges,111.31,Pays at 102% of Medicare OPPS Rate,194.63,Pays at 90% of Total Billed charges,69.52,Pays at 32.15% of Total Billed charges,109.13,Pays at 100% of Medicare OPPS Rate,69.52,Pays at 32.15% of Total Billed charges,190.3,Pays at 88% of Total Billed charges,71.6,Pays at 33.11% of Total Billed charges,69.52,194.63,129.75
Outpatient Medical Services,THERAPY,29530,P/T STRAPPING OF KNEE,420,187.25,159.16,Pays at 85% of Billed charges for outpatient setting,60.2,Pays at 32.15% of Total Billed charges,149.86,Pays at 80.03% of Total Billed charges,111.31,Pays at 102% of Medicare OPPS Rate,168.53,Pays at 90% of Total Billed charges,60.2,Pays at 32.15% of Total Billed charges,109.13,Pays at 100% of Medicare OPPS Rate,60.2,Pays at 32.15% of Total Billed charges,164.78,Pays at 88% of Total Billed charges,62,Pays at 33.11% of Total Billed charges,60.2,168.53,112.35
Outpatient Medical Services,THERAPY,29540,P/T STRAPPING OF ANKLE,420,168.75,143.44,Pays at 85% of Billed charges for outpatient setting,54.25,Pays at 32.15% of Total Billed charges,135.05,Pays at 80.03% of Total Billed charges,139.72,Pays at 102% of Medicare OPPS Rate,151.88,Pays at 90% of Total Billed charges,54.25,Pays at 32.15% of Total Billed charges,137,Pays at 100% of Medicare OPPS Rate,54.25,Pays at 32.15% of Total Billed charges,148.5,Pays at 88% of Total Billed charges,55.87,Pays at 33.11% of Total Billed charges,54.25,151.88,101.25
Outpatient Medical Services,THERAPY,29580,"P/T UNNA BOOT, EA",420,129.38,109.97,Pays at 85% of Billed charges for outpatient setting,41.6,Pays at 32.15% of Total Billed charges,103.54,Pays at 80.03% of Total Billed charges,139.72,Pays at 102% of Medicare OPPS Rate,116.44,Pays at 90% of Total Billed charges,41.6,Pays at 32.15% of Total Billed charges,137,Pays at 100% of Medicare OPPS Rate,41.6,Pays at 32.15% of Total Billed charges,113.85,Pays at 88% of Total Billed charges,42.84,Pays at 33.11% of Total Billed charges,41.6,139.72,77.63
Outpatient Medical Services,THERAPY,29580,P/T APPLICATION OF UNNA BOOT,420,239,203.15,Pays at 85% of Billed charges for outpatient setting,76.84,Pays at 32.15% of Total Billed charges,191.27,Pays at 80.03% of Total Billed charges,139.72,Pays at 102% of Medicare OPPS Rate,215.1,Pays at 90% of Total Billed charges,76.84,Pays at 32.15% of Total Billed charges,137,Pays at 100% of Medicare OPPS Rate,76.84,Pays at 32.15% of Total Billed charges,210.32,Pays at 88% of Total Billed charges,79.13,Pays at 33.11% of Total Billed charges,76.84,215.1,143.40
Outpatient Medical Services,THERAPY,29581,P/T 4 LAYER COMPRESSION WRAPS,420,77.75,66.09,Pays at 85% of Billed charges for outpatient setting,25,Pays at 32.15% of Total Billed charges,62.22,Pays at 80.03% of Total Billed charges,139.72,Pays at 102% of Medicare OPPS Rate,69.98,Pays at 90% of Total Billed charges,25,Pays at 32.15% of Total Billed charges,137,Pays at 100% of Medicare OPPS Rate,25,Pays at 32.15% of Total Billed charges,68.42,Pays at 88% of Total Billed charges,25.74,Pays at 33.11% of Total Billed charges,25,139.72,46.65
Outpatient Medical Services,THERAPY,29581,P/T 2-3 LAYER COMPRESSION WRAPS,420,103.5,87.98,Pays at 85% of Billed charges for outpatient setting,33.28,Pays at 32.15% of Total Billed charges,82.83,Pays at 80.03% of Total Billed charges,139.72,Pays at 102% of Medicare OPPS Rate,93.15,Pays at 90% of Total Billed charges,33.28,Pays at 32.15% of Total Billed charges,137,Pays at 100% of Medicare OPPS Rate,33.28,Pays at 32.15% of Total Billed charges,91.08,Pays at 88% of Total Billed charges,34.27,Pays at 33.11% of Total Billed charges,33.28,139.72,62.10
Outpatient Medical Services,THERAPY,29799,P/T STRAPPING OF LOW BACK,420,187.25,159.16,Pays at 85% of Billed charges for outpatient setting,60.2,Pays at 32.15% of Total Billed charges,149.86,Pays at 80.03% of Total Billed charges,139.72,Pays at 102% of Medicare OPPS Rate,168.53,Pays at 90% of Total Billed charges,60.2,Pays at 32.15% of Total Billed charges,137,Pays at 100% of Medicare OPPS Rate,60.2,Pays at 32.15% of Total Billed charges,164.78,Pays at 88% of Total Billed charges,62,Pays at 33.11% of Total Billed charges,60.2,168.53,112.35
Outpatient Medical Services,THERAPY,64550,O/T TNS MAINTENANCE/CHECK,430,74.25,63.11,Pays at 85% of Billed charges for outpatient setting,23.87,Pays at 32.15% of Total Billed charges,59.42,Pays at 80.03% of Total Billed charges,NA,Not Applicable,66.83,Pays at 90% of Total Billed charges,23.87,Pays at 32.15% of Total Billed charges,NA,Not Applicable,23.87,Pays at 32.15% of Total Billed charges,65.34,Pays at 88% of Total Billed charges,24.58,Pays at 33.11% of Total Billed charges,23.87,66.83,44.55
Outpatient Medical Services,THERAPY,64550,O/T TNS INSTRUCTION,430,138.5,117.73,Pays at 85% of Billed charges for outpatient setting,44.53,Pays at 32.15% of Total Billed charges,110.84,Pays at 80.03% of Total Billed charges,NA,Not Applicable,124.65,Pays at 90% of Total Billed charges,44.53,Pays at 32.15% of Total Billed charges,NA,Not Applicable,44.53,Pays at 32.15% of Total Billed charges,121.88,Pays at 88% of Total Billed charges,45.86,Pays at 33.11% of Total Billed charges,44.53,124.65,83.10
Outpatient Medical Services,THERAPY,64550,P/T TNS MAINTENANCE/CHECK,420,74.25,63.11,Pays at 85% of Billed charges for outpatient setting,23.87,Pays at 32.15% of Total Billed charges,59.42,Pays at 80.03% of Total Billed charges,NA,Not Applicable,66.83,Pays at 90% of Total Billed charges,23.87,Pays at 32.15% of Total Billed charges,NA,Not Applicable,23.87,Pays at 32.15% of Total Billed charges,65.34,Pays at 88% of Total Billed charges,24.58,Pays at 33.11% of Total Billed charges,23.87,66.83,44.55
Outpatient Medical Services,THERAPY,64550,P/T TNS INSTRUCTION,420,138.5,117.73,Pays at 85% of Billed charges for outpatient setting,44.53,Pays at 32.15% of Total Billed charges,110.84,Pays at 80.03% of Total Billed charges,NA,Not Applicable,124.65,Pays at 90% of Total Billed charges,44.53,Pays at 32.15% of Total Billed charges,NA,Not Applicable,44.53,Pays at 32.15% of Total Billed charges,121.88,Pays at 88% of Total Billed charges,45.86,Pays at 33.11% of Total Billed charges,44.53,124.65,83.10
Outpatient Medical Services,THERAPY,90901,O/T EMG BIOFEEDBACK,430,152.75,129.84,Pays at 85% of Billed charges for outpatient setting,49.11,Pays at 32.15% of Total Billed charges,122.25,Pays at 80.03% of Total Billed charges,18.78,Pays at 102% of Medicare OPPS Rate,137.48,Pays at 90% of Total Billed charges,49.11,Pays at 32.15% of Total Billed charges,18.41,Pays at 100% of Medicare OPPS Rate,49.11,Pays at 32.15% of Total Billed charges,134.42,Pays at 88% of Total Billed charges,50.58,Pays at 33.11% of Total Billed charges,18.41,137.48,91.65
Outpatient Medical Services,THERAPY,90901,P/T EMG BIOFEEDBACK,420,152.75,129.84,Pays at 85% of Billed charges for outpatient setting,49.11,Pays at 32.15% of Total Billed charges,122.25,Pays at 80.03% of Total Billed charges,18.78,Pays at 102% of Medicare OPPS Rate,137.48,Pays at 90% of Total Billed charges,49.11,Pays at 32.15% of Total Billed charges,18.41,Pays at 100% of Medicare OPPS Rate,49.11,Pays at 32.15% of Total Billed charges,134.42,Pays at 88% of Total Billed charges,50.58,Pays at 33.11% of Total Billed charges,18.41,137.48,91.65
Outpatient Medical Services,THERAPY,90911,"P/T EMG BIOFEEDBACK, PELVIC",420,196.75,167.24,Pays at 85% of Billed charges for outpatient setting,63.26,Pays at 32.15% of Total Billed charges,157.46,Pays at 80.03% of Total Billed charges,NA,Not Applicable,177.08,Pays at 90% of Total Billed charges,63.26,Pays at 32.15% of Total Billed charges,NA,Not Applicable,63.26,Pays at 32.15% of Total Billed charges,173.14,Pays at 88% of Total Billed charges,65.14,Pays at 33.11% of Total Billed charges,63.26,177.08,118.05
Outpatient Medical Services,THERAPY,90912,"O/T EMG BIOFEEDBACK, INITIAL 15 MIN",430,196.75,167.24,Pays at 85% of Billed charges for outpatient setting,63.26,Pays at 32.15% of Total Billed charges,157.46,Pays at 80.03% of Total Billed charges,42.25,Pays at 102% of Medicare OPPS Rate,177.08,Pays at 90% of Total Billed charges,63.26,Pays at 32.15% of Total Billed charges,41.42,Pays at 100% of Medicare OPPS Rate,63.26,Pays at 32.15% of Total Billed charges,173.14,Pays at 88% of Total Billed charges,65.14,Pays at 33.11% of Total Billed charges,41.42,177.08,118.05
Outpatient Medical Services,THERAPY,90912,"P/T EMG BIOFEEDBACK, INITIAL 15 MIN",420,196.75,167.24,Pays at 85% of Billed charges for outpatient setting,63.26,Pays at 32.15% of Total Billed charges,157.46,Pays at 80.03% of Total Billed charges,42.25,Pays at 102% of Medicare OPPS Rate,177.08,Pays at 90% of Total Billed charges,63.26,Pays at 32.15% of Total Billed charges,41.42,Pays at 100% of Medicare OPPS Rate,63.26,Pays at 32.15% of Total Billed charges,173.14,Pays at 88% of Total Billed charges,65.14,Pays at 33.11% of Total Billed charges,41.42,177.08,118.05
Outpatient Medical Services,THERAPY,90913,"O/T EMG BIOFEEDBACK, EACH ADD 15 MIN",430,196.75,167.24,Pays at 85% of Billed charges for outpatient setting,63.26,Pays at 32.15% of Total Billed charges,157.46,Pays at 80.03% of Total Billed charges,24.16,Pays at 102% of Medicare OPPS Rate,177.08,Pays at 90% of Total Billed charges,63.26,Pays at 32.15% of Total Billed charges,23.69,Pays at 100% of Medicare OPPS Rate,63.26,Pays at 32.15% of Total Billed charges,173.14,Pays at 88% of Total Billed charges,65.14,Pays at 33.11% of Total Billed charges,23.69,177.08,118.05
Outpatient Medical Services,THERAPY,90913,"P/T EMG BIOFEEDBACK, EACH ADD 15 MIN",420,196.75,167.24,Pays at 85% of Billed charges for outpatient setting,63.26,Pays at 32.15% of Total Billed charges,157.46,Pays at 80.03% of Total Billed charges,24.16,Pays at 102% of Medicare OPPS Rate,177.08,Pays at 90% of Total Billed charges,63.26,Pays at 32.15% of Total Billed charges,23.69,Pays at 100% of Medicare OPPS Rate,63.26,Pays at 32.15% of Total Billed charges,173.14,Pays at 88% of Total Billed charges,65.14,Pays at 33.11% of Total Billed charges,23.69,177.08,118.05
Outpatient Medical Services,THERAPY,92506,DO NOT USE,440,203.5,172.98,Pays at 85% of Billed charges for outpatient setting,65.43,Pays at 32.15% of Total Billed charges,162.86,Pays at 80.03% of Total Billed charges,NA,Not Applicable,183.15,Pays at 90% of Total Billed charges,65.43,Pays at 32.15% of Total Billed charges,NA,Not Applicable,65.43,Pays at 32.15% of Total Billed charges,179.08,Pays at 88% of Total Billed charges,67.38,Pays at 33.11% of Total Billed charges,65.43,183.15,122.10
Outpatient Medical Services,THERAPY,92506,DO NOT USE,440,224.75,191.04,Pays at 85% of Billed charges for outpatient setting,72.26,Pays at 32.15% of Total Billed charges,179.87,Pays at 80.03% of Total Billed charges,NA,Not Applicable,202.28,Pays at 90% of Total Billed charges,72.26,Pays at 32.15% of Total Billed charges,NA,Not Applicable,72.26,Pays at 32.15% of Total Billed charges,197.78,Pays at 88% of Total Billed charges,74.41,Pays at 33.11% of Total Billed charges,72.26,202.28,134.85
Outpatient Medical Services,THERAPY,92506,DO NOT USE,440,232.5,197.63,Pays at 85% of Billed charges for outpatient setting,74.75,Pays at 32.15% of Total Billed charges,186.07,Pays at 80.03% of Total Billed charges,NA,Not Applicable,209.25,Pays at 90% of Total Billed charges,74.75,Pays at 32.15% of Total Billed charges,NA,Not Applicable,74.75,Pays at 32.15% of Total Billed charges,204.6,Pays at 88% of Total Billed charges,76.98,Pays at 33.11% of Total Billed charges,74.75,209.25,139.50
Outpatient Medical Services,THERAPY,92506,DO NOT USE,440,254.5,216.33,Pays at 85% of Billed charges for outpatient setting,81.82,Pays at 32.15% of Total Billed charges,203.68,Pays at 80.03% of Total Billed charges,NA,Not Applicable,229.05,Pays at 90% of Total Billed charges,81.82,Pays at 32.15% of Total Billed charges,NA,Not Applicable,81.82,Pays at 32.15% of Total Billed charges,223.96,Pays at 88% of Total Billed charges,84.26,Pays at 33.11% of Total Billed charges,81.82,229.05,152.70
Outpatient Medical Services,THERAPY,92506,DO NOT USE,440,384,326.4,Pays at 85% of Billed charges for outpatient setting,123.46,Pays at 32.15% of Total Billed charges,307.32,Pays at 80.03% of Total Billed charges,NA,Not Applicable,345.6,Pays at 90% of Total Billed charges,123.46,Pays at 32.15% of Total Billed charges,NA,Not Applicable,123.46,Pays at 32.15% of Total Billed charges,337.92,Pays at 88% of Total Billed charges,127.14,Pays at 33.11% of Total Billed charges,123.46,345.6,230.40
Outpatient Medical Services,THERAPY,92506,S/T EVAL III,440,481.5,409.28,Pays at 85% of Billed charges for outpatient setting,154.8,Pays at 32.15% of Total Billed charges,385.34,Pays at 80.03% of Total Billed charges,NA,Not Applicable,433.35,Pays at 90% of Total Billed charges,154.8,Pays at 32.15% of Total Billed charges,NA,Not Applicable,154.8,Pays at 32.15% of Total Billed charges,423.72,Pays at 88% of Total Billed charges,159.42,Pays at 33.11% of Total Billed charges,154.8,433.35,288.90
Outpatient Medical Services,THERAPY,92506,DO NOT USE,440,535.75,455.39,Pays at 85% of Billed charges for outpatient setting,172.24,Pays at 32.15% of Total Billed charges,428.76,Pays at 80.03% of Total Billed charges,NA,Not Applicable,482.18,Pays at 90% of Total Billed charges,172.24,Pays at 32.15% of Total Billed charges,NA,Not Applicable,172.24,Pays at 32.15% of Total Billed charges,471.46,Pays at 88% of Total Billed charges,177.39,Pays at 33.11% of Total Billed charges,172.24,482.18,321.45
Outpatient Medical Services,THERAPY,92507,Therapy for speech or hearing,440,138.5,117.73,Pays at 85% of Billed charges for outpatient setting,44.53,Pays at 32.15% of Total Billed charges,110.84,Pays at 80.03% of Total Billed charges,74.96,Pays at 102% of Medicare OPPS Rate,124.65,Pays at 90% of Total Billed charges,44.53,Pays at 32.15% of Total Billed charges,73.49,Pays at 100% of Medicare OPPS Rate,44.53,Pays at 32.15% of Total Billed charges,121.88,Pays at 88% of Total Billed charges,45.86,Pays at 33.11% of Total Billed charges,44.53,124.65,83.10
Outpatient Medical Services,THERAPY,92507,Therapy for speech or hearing,440,203.5,172.98,Pays at 85% of Billed charges for outpatient setting,65.43,Pays at 32.15% of Total Billed charges,162.86,Pays at 80.03% of Total Billed charges,74.96,Pays at 102% of Medicare OPPS Rate,183.15,Pays at 90% of Total Billed charges,65.43,Pays at 32.15% of Total Billed charges,73.49,Pays at 100% of Medicare OPPS Rate,65.43,Pays at 32.15% of Total Billed charges,179.08,Pays at 88% of Total Billed charges,67.38,Pays at 33.11% of Total Billed charges,65.43,183.15,122.10
Outpatient Medical Services,THERAPY,92507,Therapy for speech or hearing,440,203.5,172.98,Pays at 85% of Billed charges for outpatient setting,65.43,Pays at 32.15% of Total Billed charges,162.86,Pays at 80.03% of Total Billed charges,74.96,Pays at 102% of Medicare OPPS Rate,183.15,Pays at 90% of Total Billed charges,65.43,Pays at 32.15% of Total Billed charges,73.49,Pays at 100% of Medicare OPPS Rate,65.43,Pays at 32.15% of Total Billed charges,179.08,Pays at 88% of Total Billed charges,67.38,Pays at 33.11% of Total Billed charges,65.43,183.15,122.10
Outpatient Medical Services,THERAPY,92507,Therapy for speech or hearing,440,254.38,216.22,Pays at 85% of Billed charges for outpatient setting,81.78,Pays at 32.15% of Total Billed charges,203.58,Pays at 80.03% of Total Billed charges,74.96,Pays at 102% of Medicare OPPS Rate,228.94,Pays at 90% of Total Billed charges,81.78,Pays at 32.15% of Total Billed charges,73.49,Pays at 100% of Medicare OPPS Rate,81.78,Pays at 32.15% of Total Billed charges,223.85,Pays at 88% of Total Billed charges,84.23,Pays at 33.11% of Total Billed charges,73.49,228.94,152.63
Outpatient Medical Services,THERAPY,92507,Therapy for speech or hearing,440,275.25,233.96,Pays at 85% of Billed charges for outpatient setting,88.49,Pays at 32.15% of Total Billed charges,220.28,Pays at 80.03% of Total Billed charges,74.96,Pays at 102% of Medicare OPPS Rate,247.73,Pays at 90% of Total Billed charges,88.49,Pays at 32.15% of Total Billed charges,73.49,Pays at 100% of Medicare OPPS Rate,88.49,Pays at 32.15% of Total Billed charges,242.22,Pays at 88% of Total Billed charges,91.14,Pays at 33.11% of Total Billed charges,73.49,247.73,165.15
Outpatient Medical Services,THERAPY,92507,Therapy for speech or hearing,440,279.5,237.58,Pays at 85% of Billed charges for outpatient setting,89.86,Pays at 32.15% of Total Billed charges,223.68,Pays at 80.03% of Total Billed charges,74.96,Pays at 102% of Medicare OPPS Rate,251.55,Pays at 90% of Total Billed charges,89.86,Pays at 32.15% of Total Billed charges,73.49,Pays at 100% of Medicare OPPS Rate,89.86,Pays at 32.15% of Total Billed charges,245.96,Pays at 88% of Total Billed charges,92.54,Pays at 33.11% of Total Billed charges,73.49,251.55,167.70
Outpatient Medical Services,THERAPY,92507,Therapy for speech or hearing,440,283.75,241.19,Pays at 85% of Billed charges for outpatient setting,91.23,Pays at 32.15% of Total Billed charges,227.09,Pays at 80.03% of Total Billed charges,74.96,Pays at 102% of Medicare OPPS Rate,255.38,Pays at 90% of Total Billed charges,91.23,Pays at 32.15% of Total Billed charges,73.49,Pays at 100% of Medicare OPPS Rate,91.23,Pays at 32.15% of Total Billed charges,249.7,Pays at 88% of Total Billed charges,93.95,Pays at 33.11% of Total Billed charges,73.49,255.38,170.25
Outpatient Medical Services,THERAPY,92507,Therapy for speech or hearing,440,305.25,259.46,Pays at 85% of Billed charges for outpatient setting,98.14,Pays at 32.15% of Total Billed charges,244.29,Pays at 80.03% of Total Billed charges,74.96,Pays at 102% of Medicare OPPS Rate,274.73,Pays at 90% of Total Billed charges,98.14,Pays at 32.15% of Total Billed charges,73.49,Pays at 100% of Medicare OPPS Rate,98.14,Pays at 32.15% of Total Billed charges,268.62,Pays at 88% of Total Billed charges,101.07,Pays at 33.11% of Total Billed charges,73.49,274.73,183.15
Outpatient Medical Services,THERAPY,92507,Therapy for speech or hearing,440,335.5,285.18,Pays at 85% of Billed charges for outpatient setting,107.86,Pays at 32.15% of Total Billed charges,268.5,Pays at 80.03% of Total Billed charges,74.96,Pays at 102% of Medicare OPPS Rate,301.95,Pays at 90% of Total Billed charges,107.86,Pays at 32.15% of Total Billed charges,73.49,Pays at 100% of Medicare OPPS Rate,107.86,Pays at 32.15% of Total Billed charges,295.24,Pays at 88% of Total Billed charges,111.08,Pays at 33.11% of Total Billed charges,73.49,301.95,201.30
Outpatient Medical Services,THERAPY,92507,Therapy for speech or hearing,440,365,310.25,Pays at 85% of Billed charges for outpatient setting,117.35,Pays at 32.15% of Total Billed charges,292.11,Pays at 80.03% of Total Billed charges,74.96,Pays at 102% of Medicare OPPS Rate,328.5,Pays at 90% of Total Billed charges,117.35,Pays at 32.15% of Total Billed charges,73.49,Pays at 100% of Medicare OPPS Rate,117.35,Pays at 32.15% of Total Billed charges,321.2,Pays at 88% of Total Billed charges,120.85,Pays at 33.11% of Total Billed charges,73.49,328.5,219.00
Outpatient Medical Services,THERAPY,92507,Therapy for speech or hearing,440,376.25,319.81,Pays at 85% of Billed charges for outpatient setting,120.96,Pays at 32.15% of Total Billed charges,301.11,Pays at 80.03% of Total Billed charges,74.96,Pays at 102% of Medicare OPPS Rate,338.63,Pays at 90% of Total Billed charges,120.96,Pays at 32.15% of Total Billed charges,73.49,Pays at 100% of Medicare OPPS Rate,120.96,Pays at 32.15% of Total Billed charges,331.1,Pays at 88% of Total Billed charges,124.58,Pays at 33.11% of Total Billed charges,73.49,338.63,225.75
Outpatient Medical Services,THERAPY,92507,Therapy for speech or hearing,440,447.25,380.16,Pays at 85% of Billed charges for outpatient setting,143.79,Pays at 32.15% of Total Billed charges,357.93,Pays at 80.03% of Total Billed charges,74.96,Pays at 102% of Medicare OPPS Rate,402.53,Pays at 90% of Total Billed charges,143.79,Pays at 32.15% of Total Billed charges,73.49,Pays at 100% of Medicare OPPS Rate,143.79,Pays at 32.15% of Total Billed charges,393.58,Pays at 88% of Total Billed charges,148.08,Pays at 33.11% of Total Billed charges,73.49,402.53,268.35
Outpatient Medical Services,THERAPY,92508,S/T SPEECH GROUP ACTIVITY,440,121.5,103.28,Pays at 85% of Billed charges for outpatient setting,39.06,Pays at 32.15% of Total Billed charges,97.24,Pays at 80.03% of Total Billed charges,23.02,Pays at 102% of Medicare OPPS Rate,109.35,Pays at 90% of Total Billed charges,39.06,Pays at 32.15% of Total Billed charges,22.57,Pays at 100% of Medicare OPPS Rate,39.06,Pays at 32.15% of Total Billed charges,106.92,Pays at 88% of Total Billed charges,40.23,Pays at 33.11% of Total Billed charges,22.57,109.35,72.90
Outpatient Medical Services,THERAPY,92510,DO NOT USE,440,131.75,111.99,Pays at 85% of Billed charges for outpatient setting,42.36,Pays at 32.15% of Total Billed charges,105.44,Pays at 80.03% of Total Billed charges,NA,Not Applicable,118.58,Pays at 90% of Total Billed charges,42.36,Pays at 32.15% of Total Billed charges,NA,Not Applicable,42.36,Pays at 32.15% of Total Billed charges,115.94,Pays at 88% of Total Billed charges,43.62,Pays at 33.11% of Total Billed charges,42.36,118.58,79.05
Outpatient Medical Services,THERAPY,92510,DO NOT USE,440,263.25,223.76,Pays at 85% of Billed charges for outpatient setting,84.63,Pays at 32.15% of Total Billed charges,210.68,Pays at 80.03% of Total Billed charges,NA,Not Applicable,236.93,Pays at 90% of Total Billed charges,84.63,Pays at 32.15% of Total Billed charges,NA,Not Applicable,84.63,Pays at 32.15% of Total Billed charges,231.66,Pays at 88% of Total Billed charges,87.16,Pays at 33.11% of Total Billed charges,84.63,236.93,157.95
Outpatient Medical Services,THERAPY,92510,DO NOT USE,440,355.25,301.96,Pays at 85% of Billed charges for outpatient setting,114.21,Pays at 32.15% of Total Billed charges,284.31,Pays at 80.03% of Total Billed charges,NA,Not Applicable,319.73,Pays at 90% of Total Billed charges,114.21,Pays at 32.15% of Total Billed charges,NA,Not Applicable,114.21,Pays at 32.15% of Total Billed charges,312.62,Pays at 88% of Total Billed charges,117.62,Pays at 33.11% of Total Billed charges,114.21,319.73,213.15
Outpatient Medical Services,THERAPY,92510,DO NOT USE,440,406.25,345.31,Pays at 85% of Billed charges for outpatient setting,130.61,Pays at 32.15% of Total Billed charges,325.12,Pays at 80.03% of Total Billed charges,NA,Not Applicable,365.63,Pays at 90% of Total Billed charges,130.61,Pays at 32.15% of Total Billed charges,NA,Not Applicable,130.61,Pays at 32.15% of Total Billed charges,357.5,Pays at 88% of Total Billed charges,134.51,Pays at 33.11% of Total Billed charges,130.61,365.63,243.75
Outpatient Medical Services,THERAPY,92510,DO NOT USE,440,587.5,499.38,Pays at 85% of Billed charges for outpatient setting,188.88,Pays at 32.15% of Total Billed charges,470.18,Pays at 80.03% of Total Billed charges,NA,Not Applicable,528.75,Pays at 90% of Total Billed charges,188.88,Pays at 32.15% of Total Billed charges,NA,Not Applicable,188.88,Pays at 32.15% of Total Billed charges,517,Pays at 88% of Total Billed charges,194.52,Pays at 33.11% of Total Billed charges,188.88,528.75,352.50
Outpatient Medical Services,THERAPY,92521,S/T EVAL FLUENCY (Stuttering/Cluttering),440,464.75,395.04,Pays at 85% of Billed charges for outpatient setting,149.42,Pays at 32.15% of Total Billed charges,371.94,Pays at 80.03% of Total Billed charges,130.07,Pays at 102% of Medicare OPPS Rate,418.28,Pays at 90% of Total Billed charges,149.42,Pays at 32.15% of Total Billed charges,127.52,Pays at 100% of Medicare OPPS Rate,149.42,Pays at 32.15% of Total Billed charges,408.98,Pays at 88% of Total Billed charges,153.88,Pays at 33.11% of Total Billed charges,127.52,418.28,278.85
Outpatient Medical Services,THERAPY,92522,"S/T EVAL (ARTIC., APRAX., DYSART, PHONO)",440,320.75,272.64,Pays at 85% of Billed charges for outpatient setting,103.12,Pays at 32.15% of Total Billed charges,256.7,Pays at 80.03% of Total Billed charges,109.01,Pays at 102% of Medicare OPPS Rate,288.68,Pays at 90% of Total Billed charges,103.12,Pays at 32.15% of Total Billed charges,106.87,Pays at 100% of Medicare OPPS Rate,103.12,Pays at 32.15% of Total Billed charges,282.26,Pays at 88% of Total Billed charges,106.2,Pays at 33.11% of Total Billed charges,103.12,288.68,192.45
Outpatient Medical Services,THERAPY,92523,Evaluation of speech sound production with evaluation of language comprehension,440,856.56,728.08,Pays at 85% of Billed charges for outpatient setting,275.38,Pays at 32.15% of Total Billed charges,685.5,Pays at 80.03% of Total Billed charges,223.02,Pays at 102% of Medicare OPPS Rate,770.9,Pays at 90% of Total Billed charges,275.38,Pays at 32.15% of Total Billed charges,218.65,Pays at 100% of Medicare OPPS Rate,275.38,Pays at 32.15% of Total Billed charges,753.77,Pays at 88% of Total Billed charges,283.61,Pays at 33.11% of Total Billed charges,218.65,770.9,513.94
Outpatient Medical Services,THERAPY,92524,S/T EVAL BEHAV-QUANT (VOICE/REASONAN),440,309.5,263.08,Pays at 85% of Billed charges for outpatient setting,99.5,Pays at 32.15% of Total Billed charges,247.69,Pays at 80.03% of Total Billed charges,107.79,Pays at 102% of Medicare OPPS Rate,278.55,Pays at 90% of Total Billed charges,99.5,Pays at 32.15% of Total Billed charges,105.68,Pays at 100% of Medicare OPPS Rate,99.5,Pays at 32.15% of Total Billed charges,272.36,Pays at 88% of Total Billed charges,102.48,Pays at 33.11% of Total Billed charges,99.5,278.55,185.70
Outpatient Medical Services,THERAPY,92526,S/T DYSPHAGIA TX,440,123.75,105.19,Pays at 85% of Billed charges for outpatient setting,39.79,Pays at 32.15% of Total Billed charges,99.04,Pays at 80.03% of Total Billed charges,82.73,Pays at 102% of Medicare OPPS Rate,111.38,Pays at 90% of Total Billed charges,39.79,Pays at 32.15% of Total Billed charges,81.11,Pays at 100% of Medicare OPPS Rate,39.79,Pays at 32.15% of Total Billed charges,108.9,Pays at 88% of Total Billed charges,40.97,Pays at 33.11% of Total Billed charges,39.79,111.38,74.25
Outpatient Medical Services,THERAPY,92526,S/T SWALLOWING TREATMENT,440,266.88,226.85,Pays at 85% of Billed charges for outpatient setting,85.8,Pays at 32.15% of Total Billed charges,213.58,Pays at 80.03% of Total Billed charges,82.73,Pays at 102% of Medicare OPPS Rate,240.19,Pays at 90% of Total Billed charges,85.8,Pays at 32.15% of Total Billed charges,81.11,Pays at 100% of Medicare OPPS Rate,85.8,Pays at 32.15% of Total Billed charges,234.85,Pays at 88% of Total Billed charges,88.36,Pays at 33.11% of Total Billed charges,81.11,240.19,160.13
Outpatient Medical Services,THERAPY,92526,S/T FEEDING/SWALLOWING TX 15-Min,440,299,254.15,Pays at 85% of Billed charges for outpatient setting,96.13,Pays at 32.15% of Total Billed charges,239.29,Pays at 80.03% of Total Billed charges,82.73,Pays at 102% of Medicare OPPS Rate,269.1,Pays at 90% of Total Billed charges,96.13,Pays at 32.15% of Total Billed charges,81.11,Pays at 100% of Medicare OPPS Rate,96.13,Pays at 32.15% of Total Billed charges,263.12,Pays at 88% of Total Billed charges,99,Pays at 33.11% of Total Billed charges,81.11,269.1,179.40
Outpatient Medical Services,THERAPY,92526,S/T 30-Min FEEDING/SWALLOWING TX,440,299,254.15,Pays at 85% of Billed charges for outpatient setting,96.13,Pays at 32.15% of Total Billed charges,239.29,Pays at 80.03% of Total Billed charges,82.73,Pays at 102% of Medicare OPPS Rate,269.1,Pays at 90% of Total Billed charges,96.13,Pays at 32.15% of Total Billed charges,81.11,Pays at 100% of Medicare OPPS Rate,96.13,Pays at 32.15% of Total Billed charges,263.12,Pays at 88% of Total Billed charges,99,Pays at 33.11% of Total Billed charges,81.11,269.1,179.40
Outpatient Medical Services,THERAPY,92526,S/T FEEDING/SWALLOWING Tx 45-Min,440,299,254.15,Pays at 85% of Billed charges for outpatient setting,96.13,Pays at 32.15% of Total Billed charges,239.29,Pays at 80.03% of Total Billed charges,82.73,Pays at 102% of Medicare OPPS Rate,269.1,Pays at 90% of Total Billed charges,96.13,Pays at 32.15% of Total Billed charges,81.11,Pays at 100% of Medicare OPPS Rate,96.13,Pays at 32.15% of Total Billed charges,263.12,Pays at 88% of Total Billed charges,99,Pays at 33.11% of Total Billed charges,81.11,269.1,179.40
Outpatient Medical Services,THERAPY,92526,S/T FEEDING/SWALLOWING TREATMENT IV,440,299,254.15,Pays at 85% of Billed charges for outpatient setting,96.13,Pays at 32.15% of Total Billed charges,239.29,Pays at 80.03% of Total Billed charges,82.73,Pays at 102% of Medicare OPPS Rate,269.1,Pays at 90% of Total Billed charges,96.13,Pays at 32.15% of Total Billed charges,81.11,Pays at 100% of Medicare OPPS Rate,96.13,Pays at 32.15% of Total Billed charges,263.12,Pays at 88% of Total Billed charges,99,Pays at 33.11% of Total Billed charges,81.11,269.1,179.40
Outpatient Medical Services,THERAPY,92597,S/T EVAL FOR VOICE PROSTHETIC DEVICE,440,266.25,226.31,Pays at 85% of Billed charges for outpatient setting,85.6,Pays at 32.15% of Total Billed charges,213.08,Pays at 80.03% of Total Billed charges,70.53,Pays at 102% of Medicare OPPS Rate,239.63,Pays at 90% of Total Billed charges,85.6,Pays at 32.15% of Total Billed charges,69.15,Pays at 100% of Medicare OPPS Rate,85.6,Pays at 32.15% of Total Billed charges,234.3,Pays at 88% of Total Billed charges,88.16,Pays at 33.11% of Total Billed charges,69.15,239.63,159.75
Outpatient Medical Services,THERAPY,92601,S/T EVAL COCHLEAR IMPLANT Pt. <7 years,440,406.25,345.31,Pays at 85% of Billed charges for outpatient setting,130.61,Pays at 32.15% of Total Billed charges,325.12,Pays at 80.03% of Total Billed charges,139.41,Pays at 102% of Medicare OPPS Rate,365.63,Pays at 90% of Total Billed charges,130.61,Pays at 32.15% of Total Billed charges,136.69,Pays at 100% of Medicare OPPS Rate,130.61,Pays at 32.15% of Total Billed charges,357.5,Pays at 88% of Total Billed charges,134.51,Pays at 33.11% of Total Billed charges,130.61,365.63,243.75
Outpatient Medical Services,THERAPY,92602,S/T Reasses COCH. IMPLANT Pt. <7 years,440,406.25,345.31,Pays at 85% of Billed charges for outpatient setting,130.61,Pays at 32.15% of Total Billed charges,325.12,Pays at 80.03% of Total Billed charges,139.41,Pays at 102% of Medicare OPPS Rate,365.63,Pays at 90% of Total Billed charges,130.61,Pays at 32.15% of Total Billed charges,136.69,Pays at 100% of Medicare OPPS Rate,130.61,Pays at 32.15% of Total Billed charges,357.5,Pays at 88% of Total Billed charges,134.51,Pays at 33.11% of Total Billed charges,130.61,365.63,243.75
Outpatient Medical Services,THERAPY,92603,S/T EVAL COCHLEAR IMPLANT Pt. >7 years,440,406.25,345.31,Pays at 85% of Billed charges for outpatient setting,130.61,Pays at 32.15% of Total Billed charges,325.12,Pays at 80.03% of Total Billed charges,139.41,Pays at 102% of Medicare OPPS Rate,365.63,Pays at 90% of Total Billed charges,130.61,Pays at 32.15% of Total Billed charges,136.69,Pays at 100% of Medicare OPPS Rate,130.61,Pays at 32.15% of Total Billed charges,357.5,Pays at 88% of Total Billed charges,134.51,Pays at 33.11% of Total Billed charges,130.61,365.63,243.75
Outpatient Medical Services,THERAPY,92604,S/T Reasses COCH. IMPLANT Pt. >7 years,440,406.25,345.31,Pays at 85% of Billed charges for outpatient setting,130.61,Pays at 32.15% of Total Billed charges,325.12,Pays at 80.03% of Total Billed charges,139.41,Pays at 102% of Medicare OPPS Rate,365.63,Pays at 90% of Total Billed charges,130.61,Pays at 32.15% of Total Billed charges,136.69,Pays at 100% of Medicare OPPS Rate,130.61,Pays at 32.15% of Total Billed charges,357.5,Pays at 88% of Total Billed charges,134.51,Pays at 33.11% of Total Billed charges,130.61,365.63,243.75
Outpatient Medical Services,THERAPY,92605,S/T EVAL NON-SPEECH DEVICE,440,406.25,345.31,Pays at 85% of Billed charges for outpatient setting,130.61,Pays at 32.15% of Total Billed charges,325.12,Pays at 80.03% of Total Billed charges,85.05,Pays at 102% of Medicare OPPS Rate,365.63,Pays at 90% of Total Billed charges,130.61,Pays at 32.15% of Total Billed charges,83.38,Pays at 100% of Medicare OPPS Rate,130.61,Pays at 32.15% of Total Billed charges,357.5,Pays at 88% of Total Billed charges,134.51,Pays at 33.11% of Total Billed charges,83.38,365.63,243.75
Outpatient Medical Services,THERAPY,92606,"S/T TREATMENT, NON-SPEECH DEVICE",440,406.25,345.31,Pays at 85% of Billed charges for outpatient setting,130.61,Pays at 32.15% of Total Billed charges,325.12,Pays at 80.03% of Total Billed charges,67.64,Pays at 102% of Medicare OPPS Rate,365.63,Pays at 90% of Total Billed charges,130.61,Pays at 32.15% of Total Billed charges,66.31,Pays at 100% of Medicare OPPS Rate,130.61,Pays at 32.15% of Total Billed charges,357.5,Pays at 88% of Total Billed charges,134.51,Pays at 33.11% of Total Billed charges,66.31,365.63,243.75
Outpatient Medical Services,THERAPY,92607,S/T EVAL SPEECH GENERATING DEVICE,440,406.25,345.31,Pays at 85% of Billed charges for outpatient setting,130.61,Pays at 32.15% of Total Billed charges,325.12,Pays at 80.03% of Total Billed charges,120.16,Pays at 102% of Medicare OPPS Rate,365.63,Pays at 90% of Total Billed charges,130.61,Pays at 32.15% of Total Billed charges,117.8,Pays at 100% of Medicare OPPS Rate,130.61,Pays at 32.15% of Total Billed charges,357.5,Pays at 88% of Total Billed charges,134.51,Pays at 33.11% of Total Billed charges,117.8,365.63,243.75
Outpatient Medical Services,THERAPY,92608,S/T EVAL SPEECH GEN DEVICE  ADD 30 MIN,440,203.25,172.76,Pays at 85% of Billed charges for outpatient setting,65.34,Pays at 32.15% of Total Billed charges,162.66,Pays at 80.03% of Total Billed charges,47.12,Pays at 102% of Medicare OPPS Rate,182.93,Pays at 90% of Total Billed charges,65.34,Pays at 32.15% of Total Billed charges,46.2,Pays at 100% of Medicare OPPS Rate,65.34,Pays at 32.15% of Total Billed charges,178.86,Pays at 88% of Total Billed charges,67.3,Pays at 33.11% of Total Billed charges,46.2,182.93,121.95
Outpatient Medical Services,THERAPY,92609,S/T TX SPEECH GENERATING DEVICE,440,138.5,117.73,Pays at 85% of Billed charges for outpatient setting,44.53,Pays at 32.15% of Total Billed charges,110.84,Pays at 80.03% of Total Billed charges,100.14,Pays at 102% of Medicare OPPS Rate,124.65,Pays at 90% of Total Billed charges,44.53,Pays at 32.15% of Total Billed charges,98.18,Pays at 100% of Medicare OPPS Rate,44.53,Pays at 32.15% of Total Billed charges,121.88,Pays at 88% of Total Billed charges,45.86,Pays at 33.11% of Total Billed charges,44.53,124.65,83.10
Outpatient Medical Services,THERAPY,92610,S/T SWALLOWING REASSESSMENT,440,120.75,102.64,Pays at 85% of Billed charges for outpatient setting,38.82,Pays at 32.15% of Total Billed charges,96.64,Pays at 80.03% of Total Billed charges,68.87,Pays at 102% of Medicare OPPS Rate,108.68,Pays at 90% of Total Billed charges,38.82,Pays at 32.15% of Total Billed charges,67.52,Pays at 100% of Medicare OPPS Rate,38.82,Pays at 32.15% of Total Billed charges,106.26,Pays at 88% of Total Billed charges,39.98,Pays at 33.11% of Total Billed charges,38.82,108.68,72.45
Outpatient Medical Services,THERAPY,92610,S/T FEEDING/SWALLOWING EVAL 30-Min,440,138.5,117.73,Pays at 85% of Billed charges for outpatient setting,44.53,Pays at 32.15% of Total Billed charges,110.84,Pays at 80.03% of Total Billed charges,68.87,Pays at 102% of Medicare OPPS Rate,124.65,Pays at 90% of Total Billed charges,44.53,Pays at 32.15% of Total Billed charges,67.52,Pays at 100% of Medicare OPPS Rate,44.53,Pays at 32.15% of Total Billed charges,121.88,Pays at 88% of Total Billed charges,45.86,Pays at 33.11% of Total Billed charges,44.53,124.65,83.10
Outpatient Medical Services,THERAPY,92610,S/T FEEDING/SWALLOWING EVAL 45-Min,440,258.75,219.94,Pays at 85% of Billed charges for outpatient setting,83.19,Pays at 32.15% of Total Billed charges,207.08,Pays at 80.03% of Total Billed charges,68.87,Pays at 102% of Medicare OPPS Rate,232.88,Pays at 90% of Total Billed charges,83.19,Pays at 32.15% of Total Billed charges,67.52,Pays at 100% of Medicare OPPS Rate,83.19,Pays at 32.15% of Total Billed charges,227.7,Pays at 88% of Total Billed charges,85.67,Pays at 33.11% of Total Billed charges,67.52,232.88,155.25
Outpatient Medical Services,THERAPY,92610,S/T FEEDING/SWALLOWING EVAL 60-Min,440,258.75,219.94,Pays at 85% of Billed charges for outpatient setting,83.19,Pays at 32.15% of Total Billed charges,207.08,Pays at 80.03% of Total Billed charges,68.87,Pays at 102% of Medicare OPPS Rate,232.88,Pays at 90% of Total Billed charges,83.19,Pays at 32.15% of Total Billed charges,67.52,Pays at 100% of Medicare OPPS Rate,83.19,Pays at 32.15% of Total Billed charges,227.7,Pays at 88% of Total Billed charges,85.67,Pays at 33.11% of Total Billed charges,67.52,232.88,155.25
Outpatient Medical Services,THERAPY,92610,S/T SWALLOWING EVAL,440,338.85,288.02,Pays at 85% of Billed charges for outpatient setting,108.94,Pays at 32.15% of Total Billed charges,271.18,Pays at 80.03% of Total Billed charges,68.87,Pays at 102% of Medicare OPPS Rate,304.97,Pays at 90% of Total Billed charges,108.94,Pays at 32.15% of Total Billed charges,67.52,Pays at 100% of Medicare OPPS Rate,108.94,Pays at 32.15% of Total Billed charges,298.19,Pays at 88% of Total Billed charges,112.19,Pays at 33.11% of Total Billed charges,67.52,304.97,203.31
Outpatient Medical Services,THERAPY,92610,S/T FEEDING/SWALLOWING EVAL 90-Min,440,341.5,290.28,Pays at 85% of Billed charges for outpatient setting,109.79,Pays at 32.15% of Total Billed charges,273.3,Pays at 80.03% of Total Billed charges,68.87,Pays at 102% of Medicare OPPS Rate,307.35,Pays at 90% of Total Billed charges,109.79,Pays at 32.15% of Total Billed charges,67.52,Pays at 100% of Medicare OPPS Rate,109.79,Pays at 32.15% of Total Billed charges,300.52,Pays at 88% of Total Billed charges,113.07,Pays at 33.11% of Total Billed charges,67.52,307.35,204.90
Outpatient Medical Services,THERAPY,92610,DO NOT USE,440,837,711.45,Pays at 85% of Billed charges for outpatient setting,269.1,Pays at 32.15% of Total Billed charges,669.85,Pays at 80.03% of Total Billed charges,68.87,Pays at 102% of Medicare OPPS Rate,753.3,Pays at 90% of Total Billed charges,269.1,Pays at 32.15% of Total Billed charges,67.52,Pays at 100% of Medicare OPPS Rate,269.1,Pays at 32.15% of Total Billed charges,736.56,Pays at 88% of Total Billed charges,277.13,Pays at 33.11% of Total Billed charges,67.52,753.3,502.20
Outpatient Medical Services,THERAPY,92611,S/T MBS (SLP EVALUATION),440,484.5,411.83,Pays at 85% of Billed charges for outpatient setting,155.77,Pays at 32.15% of Total Billed charges,387.75,Pays at 80.03% of Total Billed charges,89.02,Pays at 102% of Medicare OPPS Rate,436.05,Pays at 90% of Total Billed charges,155.77,Pays at 32.15% of Total Billed charges,87.27,Pays at 100% of Medicare OPPS Rate,155.77,Pays at 32.15% of Total Billed charges,426.36,Pays at 88% of Total Billed charges,160.42,Pays at 33.11% of Total Billed charges,87.27,436.05,290.70
Outpatient Medical Services,THERAPY,92612,S/T BEDSIDE FEES STUDY,440,592.5,503.63,Pays at 85% of Billed charges for outpatient setting,190.49,Pays at 32.15% of Total Billed charges,474.18,Pays at 80.03% of Total Billed charges,65.48,Pays at 102% of Medicare OPPS Rate,533.25,Pays at 90% of Total Billed charges,190.49,Pays at 32.15% of Total Billed charges,64.2,Pays at 100% of Medicare OPPS Rate,190.49,Pays at 32.15% of Total Billed charges,521.4,Pays at 88% of Total Billed charges,196.18,Pays at 33.11% of Total Billed charges,64.2,533.25,355.50
Outpatient Medical Services,THERAPY,92618,S/T EVAL NON-SPEECH DEVICE ADD 30 MIN,440,203.25,172.76,Pays at 85% of Billed charges for outpatient setting,65.34,Pays at 32.15% of Total Billed charges,162.66,Pays at 80.03% of Total Billed charges,31.48,Pays at 102% of Medicare OPPS Rate,182.93,Pays at 90% of Total Billed charges,65.34,Pays at 32.15% of Total Billed charges,30.86,Pays at 100% of Medicare OPPS Rate,65.34,Pays at 32.15% of Total Billed charges,178.86,Pays at 88% of Total Billed charges,67.3,Pays at 33.11% of Total Billed charges,30.86,182.93,121.95
Outpatient Medical Services,THERAPY,92626,"S/T EVAL AUDITORY REHAB STATUS, 1HR",440,406.25,345.31,Pays at 85% of Billed charges for outpatient setting,130.61,Pays at 32.15% of Total Billed charges,325.12,Pays at 80.03% of Total Billed charges,139.41,Pays at 102% of Medicare OPPS Rate,365.63,Pays at 90% of Total Billed charges,130.61,Pays at 32.15% of Total Billed charges,136.69,Pays at 100% of Medicare OPPS Rate,130.61,Pays at 32.15% of Total Billed charges,357.5,Pays at 88% of Total Billed charges,134.51,Pays at 33.11% of Total Billed charges,130.61,365.63,243.75
Outpatient Medical Services,THERAPY,92627,"S/T EVAL AUDITORY REHAB,  Ea  ADD 15 MIN",440,406.25,345.31,Pays at 85% of Billed charges for outpatient setting,130.61,Pays at 32.15% of Total Billed charges,325.12,Pays at 80.03% of Total Billed charges,NA,Not Applicable,365.63,Pays at 90% of Total Billed charges,130.61,Pays at 32.15% of Total Billed charges,NA,Not Applicable,130.61,Pays at 32.15% of Total Billed charges,357.5,Pays at 88% of Total Billed charges,134.51,Pays at 33.11% of Total Billed charges,130.61,365.63,243.75
Outpatient Medical Services,THERAPY,92630,S/T AUDITORY REHAB; PRE-LINGUAL LOSS,440,406.25,345.31,Pays at 85% of Billed charges for outpatient setting,130.61,Pays at 32.15% of Total Billed charges,325.12,Pays at 80.03% of Total Billed charges,NA,Not Applicable,365.63,Pays at 90% of Total Billed charges,130.61,Pays at 32.15% of Total Billed charges,NA,Not Applicable,130.61,Pays at 32.15% of Total Billed charges,357.5,Pays at 88% of Total Billed charges,134.51,Pays at 33.11% of Total Billed charges,130.61,365.63,243.75
Outpatient Medical Services,THERAPY,92633,S/T AUDITORY REHAB; POST-LINGUAL LOSS,440,406.25,345.31,Pays at 85% of Billed charges for outpatient setting,130.61,Pays at 32.15% of Total Billed charges,325.12,Pays at 80.03% of Total Billed charges,NA,Not Applicable,365.63,Pays at 90% of Total Billed charges,130.61,Pays at 32.15% of Total Billed charges,NA,Not Applicable,130.61,Pays at 32.15% of Total Billed charges,357.5,Pays at 88% of Total Billed charges,134.51,Pays at 33.11% of Total Billed charges,130.61,365.63,243.75
Outpatient Medical Services,THERAPY,95831,O/T MMT- EXTREMITY AND TRUNK (NO HAND),430,91,77.35,Pays at 85% of Billed charges for outpatient setting,29.26,Pays at 32.15% of Total Billed charges,72.83,Pays at 80.03% of Total Billed charges,NA,Not Applicable,81.9,Pays at 90% of Total Billed charges,29.26,Pays at 32.15% of Total Billed charges,NA,Not Applicable,29.26,Pays at 32.15% of Total Billed charges,80.08,Pays at 88% of Total Billed charges,30.13,Pays at 33.11% of Total Billed charges,29.26,81.9,54.60
Outpatient Medical Services,THERAPY,95831,P/T MMT - EXTREMITY AND TRUNK (NO HAND),424,91,77.35,Pays at 85% of Billed charges for outpatient setting,29.26,Pays at 32.15% of Total Billed charges,72.83,Pays at 80.03% of Total Billed charges,NA,Not Applicable,81.9,Pays at 90% of Total Billed charges,29.26,Pays at 32.15% of Total Billed charges,NA,Not Applicable,29.26,Pays at 32.15% of Total Billed charges,80.08,Pays at 88% of Total Billed charges,30.13,Pays at 33.11% of Total Billed charges,29.26,81.9,54.60
Outpatient Medical Services,THERAPY,95832,O/T MMT - HAND,430,86.75,73.74,Pays at 85% of Billed charges for outpatient setting,27.89,Pays at 32.15% of Total Billed charges,69.43,Pays at 80.03% of Total Billed charges,NA,Not Applicable,78.08,Pays at 90% of Total Billed charges,27.89,Pays at 32.15% of Total Billed charges,NA,Not Applicable,27.89,Pays at 32.15% of Total Billed charges,76.34,Pays at 88% of Total Billed charges,28.72,Pays at 33.11% of Total Billed charges,27.89,78.08,52.05
Outpatient Medical Services,THERAPY,95832,P/T MMT - HAND,424,91,77.35,Pays at 85% of Billed charges for outpatient setting,29.26,Pays at 32.15% of Total Billed charges,72.83,Pays at 80.03% of Total Billed charges,NA,Not Applicable,81.9,Pays at 90% of Total Billed charges,29.26,Pays at 32.15% of Total Billed charges,NA,Not Applicable,29.26,Pays at 32.15% of Total Billed charges,80.08,Pays at 88% of Total Billed charges,30.13,Pays at 33.11% of Total Billed charges,29.26,81.9,54.60
Outpatient Medical Services,THERAPY,95833,MMT-TOTAL BODY INCLUDING HANDS,430,138.5,117.73,Pays at 85% of Billed charges for outpatient setting,44.53,Pays at 32.15% of Total Billed charges,110.84,Pays at 80.03% of Total Billed charges,NA,Not Applicable,124.65,Pays at 90% of Total Billed charges,44.53,Pays at 32.15% of Total Billed charges,NA,Not Applicable,44.53,Pays at 32.15% of Total Billed charges,121.88,Pays at 88% of Total Billed charges,45.86,Pays at 33.11% of Total Billed charges,44.53,124.65,83.10
Outpatient Medical Services,THERAPY,95851,O/T ROM TEST - EXTREMITY AND OR TRUNK,434,81.25,69.06,Pays at 85% of Billed charges for outpatient setting,26.12,Pays at 32.15% of Total Billed charges,65.02,Pays at 80.03% of Total Billed charges,7.7,Pays at 102% of Medicare OPPS Rate,73.13,Pays at 90% of Total Billed charges,26.12,Pays at 32.15% of Total Billed charges,7.55,Pays at 100% of Medicare OPPS Rate,26.12,Pays at 32.15% of Total Billed charges,71.5,Pays at 88% of Total Billed charges,26.9,Pays at 33.11% of Total Billed charges,7.55,73.13,48.75
Outpatient Medical Services,THERAPY,95851,P/T ROM TEST- EXTREMITY OR TRUNK,424,81.25,69.06,Pays at 85% of Billed charges for outpatient setting,26.12,Pays at 32.15% of Total Billed charges,65.02,Pays at 80.03% of Total Billed charges,7.7,Pays at 102% of Medicare OPPS Rate,73.13,Pays at 90% of Total Billed charges,26.12,Pays at 32.15% of Total Billed charges,7.55,Pays at 100% of Medicare OPPS Rate,26.12,Pays at 32.15% of Total Billed charges,71.5,Pays at 88% of Total Billed charges,26.9,Pays at 33.11% of Total Billed charges,7.55,73.13,48.75
Outpatient Medical Services,THERAPY,95852,O/T ROM TEST - HAND,434,74.25,63.11,Pays at 85% of Billed charges for outpatient setting,23.87,Pays at 32.15% of Total Billed charges,59.42,Pays at 80.03% of Total Billed charges,5.37,Pays at 102% of Medicare OPPS Rate,66.83,Pays at 90% of Total Billed charges,23.87,Pays at 32.15% of Total Billed charges,5.26,Pays at 100% of Medicare OPPS Rate,23.87,Pays at 32.15% of Total Billed charges,65.34,Pays at 88% of Total Billed charges,24.58,Pays at 33.11% of Total Billed charges,5.26,66.83,44.55
Outpatient Medical Services,THERAPY,96105,S/T EVALUATION OF APHASIA,440,406.25,345.31,Pays at 85% of Billed charges for outpatient setting,130.61,Pays at 32.15% of Total Billed charges,325.12,Pays at 80.03% of Total Billed charges,95.96,Pays at 102% of Medicare OPPS Rate,365.63,Pays at 90% of Total Billed charges,130.61,Pays at 32.15% of Total Billed charges,94.08,Pays at 100% of Medicare OPPS Rate,130.61,Pays at 32.15% of Total Billed charges,357.5,Pays at 88% of Total Billed charges,134.51,Pays at 33.11% of Total Billed charges,94.08,365.63,243.75
Outpatient Medical Services,THERAPY,96110,Childhood test to screen for developmental disabilities,440,406.25,345.31,Pays at 85% of Billed charges for outpatient setting,130.61,Pays at 32.15% of Total Billed charges,325.12,Pays at 80.03% of Total Billed charges,NA,Not Applicable,365.63,Pays at 90% of Total Billed charges,130.61,Pays at 32.15% of Total Billed charges,NA,Not Applicable,130.61,Pays at 32.15% of Total Billed charges,357.5,Pays at 88% of Total Billed charges,134.51,Pays at 33.11% of Total Billed charges,130.61,365.63,243.75
Outpatient Medical Services,THERAPY,96111,S/T DEVELOPMENTAL TESTING W/ STNDRD FORM,440,406.25,345.31,Pays at 85% of Billed charges for outpatient setting,130.61,Pays at 32.15% of Total Billed charges,325.12,Pays at 80.03% of Total Billed charges,NA,Not Applicable,365.63,Pays at 90% of Total Billed charges,130.61,Pays at 32.15% of Total Billed charges,NA,Not Applicable,130.61,Pays at 32.15% of Total Billed charges,357.5,Pays at 88% of Total Billed charges,134.51,Pays at 33.11% of Total Billed charges,130.61,365.63,243.75
Outpatient Medical Services,THERAPY,96125,S/T COGNITIVE TESTING W/ STNDRDZD FORM,440,406.25,345.31,Pays at 85% of Billed charges for outpatient setting,130.61,Pays at 32.15% of Total Billed charges,325.12,Pays at 80.03% of Total Billed charges,100.14,Pays at 102% of Medicare OPPS Rate,365.63,Pays at 90% of Total Billed charges,130.61,Pays at 32.15% of Total Billed charges,98.18,Pays at 100% of Medicare OPPS Rate,130.61,Pays at 32.15% of Total Billed charges,357.5,Pays at 88% of Total Billed charges,134.51,Pays at 33.11% of Total Billed charges,98.18,365.63,243.75
Outpatient Medical Services,THERAPY,97001,P/T EVAL FOR OT MODALITY,424,138.4,117.64,Pays at 85% of Billed charges for outpatient setting,44.5,Pays at 32.15% of Total Billed charges,110.76,Pays at 80.03% of Total Billed charges,NA,Not Applicable,124.56,Pays at 90% of Total Billed charges,44.5,Pays at 32.15% of Total Billed charges,NA,Not Applicable,44.5,Pays at 32.15% of Total Billed charges,121.79,Pays at 88% of Total Billed charges,45.82,Pays at 33.11% of Total Billed charges,44.5,124.56,83.04
Outpatient Medical Services,THERAPY,97001,P/T EVAL DO NOT USE AFTER 12/16,424,208,176.8,Pays at 85% of Billed charges for outpatient setting,66.87,Pays at 32.15% of Total Billed charges,166.46,Pays at 80.03% of Total Billed charges,NA,Not Applicable,187.2,Pays at 90% of Total Billed charges,66.87,Pays at 32.15% of Total Billed charges,NA,Not Applicable,66.87,Pays at 32.15% of Total Billed charges,183.04,Pays at 88% of Total Billed charges,68.87,Pays at 33.11% of Total Billed charges,66.87,187.2,124.80
Outpatient Medical Services,THERAPY,97001,P/T EVAL DO NOT USE AFTER 12/2016,424,264.5,224.83,Pays at 85% of Billed charges for outpatient setting,85.04,Pays at 32.15% of Total Billed charges,211.68,Pays at 80.03% of Total Billed charges,NA,Not Applicable,238.05,Pays at 90% of Total Billed charges,85.04,Pays at 32.15% of Total Billed charges,NA,Not Applicable,85.04,Pays at 32.15% of Total Billed charges,232.76,Pays at 88% of Total Billed charges,87.58,Pays at 33.11% of Total Billed charges,85.04,238.05,158.70
Outpatient Medical Services,THERAPY,97001,P/T EVAL DO NOT USE AFTER 12/2106,424,345.25,293.46,Pays at 85% of Billed charges for outpatient setting,111,Pays at 32.15% of Total Billed charges,276.3,Pays at 80.03% of Total Billed charges,NA,Not Applicable,310.73,Pays at 90% of Total Billed charges,111,Pays at 32.15% of Total Billed charges,NA,Not Applicable,111,Pays at 32.15% of Total Billed charges,303.82,Pays at 88% of Total Billed charges,114.31,Pays at 33.11% of Total Billed charges,111,310.73,207.15
Outpatient Medical Services,THERAPY,97001,P/T EVAL DO NOT USE AFTER 12/2016,424,447.25,380.16,Pays at 85% of Billed charges for outpatient setting,143.79,Pays at 32.15% of Total Billed charges,357.93,Pays at 80.03% of Total Billed charges,NA,Not Applicable,402.53,Pays at 90% of Total Billed charges,143.79,Pays at 32.15% of Total Billed charges,NA,Not Applicable,143.79,Pays at 32.15% of Total Billed charges,393.58,Pays at 88% of Total Billed charges,148.08,Pays at 33.11% of Total Billed charges,143.79,402.53,268.35
Outpatient Medical Services,THERAPY,97003,O/T EVAL DO NOT USE AFTER 12/2016,434,223.5,189.98,Pays at 85% of Billed charges for outpatient setting,71.86,Pays at 32.15% of Total Billed charges,178.87,Pays at 80.03% of Total Billed charges,NA,Not Applicable,201.15,Pays at 90% of Total Billed charges,71.86,Pays at 32.15% of Total Billed charges,NA,Not Applicable,71.86,Pays at 32.15% of Total Billed charges,196.68,Pays at 88% of Total Billed charges,74,Pays at 33.11% of Total Billed charges,71.86,201.15,134.10
Outpatient Medical Services,THERAPY,97003,O/T EVAL DO NOT USE AFTER 12/2106,434,264.5,224.83,Pays at 85% of Billed charges for outpatient setting,85.04,Pays at 32.15% of Total Billed charges,211.68,Pays at 80.03% of Total Billed charges,NA,Not Applicable,238.05,Pays at 90% of Total Billed charges,85.04,Pays at 32.15% of Total Billed charges,NA,Not Applicable,85.04,Pays at 32.15% of Total Billed charges,232.76,Pays at 88% of Total Billed charges,87.58,Pays at 33.11% of Total Billed charges,85.04,238.05,158.70
Outpatient Medical Services,THERAPY,97003,O/T EVAL DO NOT USE AFTER 12/2016,434,345.25,293.46,Pays at 85% of Billed charges for outpatient setting,111,Pays at 32.15% of Total Billed charges,276.3,Pays at 80.03% of Total Billed charges,NA,Not Applicable,310.73,Pays at 90% of Total Billed charges,111,Pays at 32.15% of Total Billed charges,NA,Not Applicable,111,Pays at 32.15% of Total Billed charges,303.82,Pays at 88% of Total Billed charges,114.31,Pays at 33.11% of Total Billed charges,111,310.73,207.15
Outpatient Medical Services,THERAPY,97003,O/T EVAL DO NOT USE AFTER 12/2016,434,447.25,380.16,Pays at 85% of Billed charges for outpatient setting,143.79,Pays at 32.15% of Total Billed charges,357.93,Pays at 80.03% of Total Billed charges,NA,Not Applicable,402.53,Pays at 90% of Total Billed charges,143.79,Pays at 32.15% of Total Billed charges,NA,Not Applicable,143.79,Pays at 32.15% of Total Billed charges,393.58,Pays at 88% of Total Billed charges,148.08,Pays at 33.11% of Total Billed charges,143.79,402.53,268.35
Outpatient Medical Services,THERAPY,97012,Form of decompression therapy of the spine,420,51.75,43.99,Pays at 85% of Billed charges for outpatient setting,16.64,Pays at 32.15% of Total Billed charges,41.42,Pays at 80.03% of Total Billed charges,14.17,Pays at 102% of Medicare OPPS Rate,46.58,Pays at 90% of Total Billed charges,16.64,Pays at 32.15% of Total Billed charges,13.89,Pays at 100% of Medicare OPPS Rate,16.64,Pays at 32.15% of Total Billed charges,45.54,Pays at 88% of Total Billed charges,17.13,Pays at 33.11% of Total Billed charges,13.89,46.58,31.05
Outpatient Medical Services,THERAPY,97012,Form of decompression therapy of the spine,420,51.75,43.99,Pays at 85% of Billed charges for outpatient setting,16.64,Pays at 32.15% of Total Billed charges,41.42,Pays at 80.03% of Total Billed charges,14.17,Pays at 102% of Medicare OPPS Rate,46.58,Pays at 90% of Total Billed charges,16.64,Pays at 32.15% of Total Billed charges,13.89,Pays at 100% of Medicare OPPS Rate,16.64,Pays at 32.15% of Total Billed charges,45.54,Pays at 88% of Total Billed charges,17.13,Pays at 33.11% of Total Billed charges,13.89,46.58,31.05
Outpatient Medical Services,THERAPY,97014,One time use unattended,430,106.75,90.74,Pays at 85% of Billed charges for outpatient setting,34.32,Pays at 32.15% of Total Billed charges,85.43,Pays at 80.03% of Total Billed charges,NA,Not Applicable,96.08,Pays at 90% of Total Billed charges,34.32,Pays at 32.15% of Total Billed charges,NA,Not Applicable,34.32,Pays at 32.15% of Total Billed charges,93.94,Pays at 88% of Total Billed charges,35.34,Pays at 33.11% of Total Billed charges,34.32,96.08,64.05
Outpatient Medical Services,THERAPY,97014,One time use unattended,420,102.75,87.34,Pays at 85% of Billed charges for outpatient setting,33.03,Pays at 32.15% of Total Billed charges,82.23,Pays at 80.03% of Total Billed charges,NA,Not Applicable,92.48,Pays at 90% of Total Billed charges,33.03,Pays at 32.15% of Total Billed charges,NA,Not Applicable,33.03,Pays at 32.15% of Total Billed charges,90.42,Pays at 88% of Total Billed charges,34.02,Pays at 33.11% of Total Billed charges,33.03,92.48,61.65
Outpatient Medical Services,THERAPY,97016,"Machines designed to pump cold water into an inflatable wrap or brace, compressing the enveloped area of the body",430,93.15,79.18,Pays at 85% of Billed charges for outpatient setting,29.95,Pays at 32.15% of Total Billed charges,74.55,Pays at 80.03% of Total Billed charges,11.44,Pays at 102% of Medicare OPPS Rate,83.84,Pays at 90% of Total Billed charges,29.95,Pays at 32.15% of Total Billed charges,11.22,Pays at 100% of Medicare OPPS Rate,29.95,Pays at 32.15% of Total Billed charges,81.97,Pays at 88% of Total Billed charges,30.84,Pays at 33.11% of Total Billed charges,11.22,83.84,55.89
Outpatient Medical Services,THERAPY,97016,"Machines designed to pump cold water into an inflatable wrap or brace, compressing the enveloped area of the body",420,93.15,79.18,Pays at 85% of Billed charges for outpatient setting,29.95,Pays at 32.15% of Total Billed charges,74.55,Pays at 80.03% of Total Billed charges,11.44,Pays at 102% of Medicare OPPS Rate,83.84,Pays at 90% of Total Billed charges,29.95,Pays at 32.15% of Total Billed charges,11.22,Pays at 100% of Medicare OPPS Rate,29.95,Pays at 32.15% of Total Billed charges,81.97,Pays at 88% of Total Billed charges,30.84,Pays at 33.11% of Total Billed charges,11.22,83.84,55.89
Outpatient Medical Services,THERAPY,97018,O/T PARAFFIN BATH,430,74.25,63.11,Pays at 85% of Billed charges for outpatient setting,23.87,Pays at 32.15% of Total Billed charges,59.42,Pays at 80.03% of Total Billed charges,5.47,Pays at 102% of Medicare OPPS Rate,66.83,Pays at 90% of Total Billed charges,23.87,Pays at 32.15% of Total Billed charges,5.36,Pays at 100% of Medicare OPPS Rate,23.87,Pays at 32.15% of Total Billed charges,65.34,Pays at 88% of Total Billed charges,24.58,Pays at 33.11% of Total Billed charges,5.36,66.83,44.55
Outpatient Medical Services,THERAPY,97018,P/T PARAFFIN BATH,420,74.25,63.11,Pays at 85% of Billed charges for outpatient setting,23.87,Pays at 32.15% of Total Billed charges,59.42,Pays at 80.03% of Total Billed charges,5.47,Pays at 102% of Medicare OPPS Rate,66.83,Pays at 90% of Total Billed charges,23.87,Pays at 32.15% of Total Billed charges,5.36,Pays at 100% of Medicare OPPS Rate,23.87,Pays at 32.15% of Total Billed charges,65.34,Pays at 88% of Total Billed charges,24.58,Pays at 33.11% of Total Billed charges,5.36,66.83,44.55
Outpatient Medical Services,THERAPY,97022,O/T FLUIDOTHERAPY,430,62.7,53.3,Pays at 85% of Billed charges for outpatient setting,20.16,Pays at 32.15% of Total Billed charges,50.18,Pays at 80.03% of Total Billed charges,16.27,Pays at 102% of Medicare OPPS Rate,56.43,Pays at 90% of Total Billed charges,20.16,Pays at 32.15% of Total Billed charges,15.95,Pays at 100% of Medicare OPPS Rate,20.16,Pays at 32.15% of Total Billed charges,55.18,Pays at 88% of Total Billed charges,20.76,Pays at 33.11% of Total Billed charges,15.95,56.43,37.62
Outpatient Medical Services,THERAPY,97022,P/T FLUIDOTHERAPY,420,60,51,Pays at 85% of Billed charges for outpatient setting,19.29,Pays at 32.15% of Total Billed charges,48.02,Pays at 80.03% of Total Billed charges,16.27,Pays at 102% of Medicare OPPS Rate,54,Pays at 90% of Total Billed charges,19.29,Pays at 32.15% of Total Billed charges,15.95,Pays at 100% of Medicare OPPS Rate,19.29,Pays at 32.15% of Total Billed charges,52.8,Pays at 88% of Total Billed charges,19.87,Pays at 33.11% of Total Billed charges,15.95,54,36.00
Outpatient Medical Services,THERAPY,97022,STERILE WHIRLPOOL: SMALL TANK,420,106.75,90.74,Pays at 85% of Billed charges for outpatient setting,34.32,Pays at 32.15% of Total Billed charges,85.43,Pays at 80.03% of Total Billed charges,16.27,Pays at 102% of Medicare OPPS Rate,96.08,Pays at 90% of Total Billed charges,34.32,Pays at 32.15% of Total Billed charges,15.95,Pays at 100% of Medicare OPPS Rate,34.32,Pays at 32.15% of Total Billed charges,93.94,Pays at 88% of Total Billed charges,35.34,Pays at 33.11% of Total Billed charges,15.95,96.08,64.05
Outpatient Medical Services,THERAPY,97022,STERILE WHIRLPOOL: LARGE TANK,420,113.5,96.48,Pays at 85% of Billed charges for outpatient setting,36.49,Pays at 32.15% of Total Billed charges,90.83,Pays at 80.03% of Total Billed charges,16.27,Pays at 102% of Medicare OPPS Rate,102.15,Pays at 90% of Total Billed charges,36.49,Pays at 32.15% of Total Billed charges,15.95,Pays at 100% of Medicare OPPS Rate,36.49,Pays at 32.15% of Total Billed charges,99.88,Pays at 88% of Total Billed charges,37.58,Pays at 33.11% of Total Billed charges,15.95,102.15,68.10
Outpatient Medical Services,THERAPY,97032,Repeated application to one or more parts of the body,420,96.5,82.03,Pays at 85% of Billed charges for outpatient setting,31.02,Pays at 32.15% of Total Billed charges,77.23,Pays at 80.03% of Total Billed charges,14.17,Pays at 102% of Medicare OPPS Rate,86.85,Pays at 90% of Total Billed charges,31.02,Pays at 32.15% of Total Billed charges,13.89,Pays at 100% of Medicare OPPS Rate,31.02,Pays at 32.15% of Total Billed charges,84.92,Pays at 88% of Total Billed charges,31.95,Pays at 33.11% of Total Billed charges,13.89,86.85,57.90
Outpatient Medical Services,THERAPY,97032,Repeated application to one or more parts of the body,440,93.5,79.48,Pays at 85% of Billed charges for outpatient setting,30.06,Pays at 32.15% of Total Billed charges,74.83,Pays at 80.03% of Total Billed charges,14.17,Pays at 102% of Medicare OPPS Rate,84.15,Pays at 90% of Total Billed charges,30.06,Pays at 32.15% of Total Billed charges,13.89,Pays at 100% of Medicare OPPS Rate,30.06,Pays at 32.15% of Total Billed charges,82.28,Pays at 88% of Total Billed charges,30.96,Pays at 33.11% of Total Billed charges,13.89,84.15,56.10
Outpatient Medical Services,THERAPY,97032,Repeated application to one or more parts of the body,430,65.25,55.46,Pays at 85% of Billed charges for outpatient setting,20.98,Pays at 32.15% of Total Billed charges,52.22,Pays at 80.03% of Total Billed charges,14.17,Pays at 102% of Medicare OPPS Rate,58.73,Pays at 90% of Total Billed charges,20.98,Pays at 32.15% of Total Billed charges,13.89,Pays at 100% of Medicare OPPS Rate,20.98,Pays at 32.15% of Total Billed charges,57.42,Pays at 88% of Total Billed charges,21.6,Pays at 33.11% of Total Billed charges,13.89,58.73,39.15
Outpatient Medical Services,THERAPY,97032,Repeated application to one or more parts of the body,420,53.75,45.69,Pays at 85% of Billed charges for outpatient setting,17.28,Pays at 32.15% of Total Billed charges,43.02,Pays at 80.03% of Total Billed charges,14.17,Pays at 102% of Medicare OPPS Rate,48.38,Pays at 90% of Total Billed charges,17.28,Pays at 32.15% of Total Billed charges,13.89,Pays at 100% of Medicare OPPS Rate,17.28,Pays at 32.15% of Total Billed charges,47.3,Pays at 88% of Total Billed charges,17.8,Pays at 33.11% of Total Billed charges,13.89,48.38,32.25
Outpatient Medical Services,THERAPY,97032,Repeated application to one or more parts of the body,420,96.5,82.03,Pays at 85% of Billed charges for outpatient setting,31.02,Pays at 32.15% of Total Billed charges,77.23,Pays at 80.03% of Total Billed charges,14.17,Pays at 102% of Medicare OPPS Rate,86.85,Pays at 90% of Total Billed charges,31.02,Pays at 32.15% of Total Billed charges,13.89,Pays at 100% of Medicare OPPS Rate,31.02,Pays at 32.15% of Total Billed charges,84.92,Pays at 88% of Total Billed charges,31.95,Pays at 33.11% of Total Billed charges,13.89,86.85,57.90
Outpatient Medical Services,THERAPY,97033,Psychiatric treatment in which seizures are electrically induced in patients to provide relief from mental disorders,420,70.5,59.93,Pays at 85% of Billed charges for outpatient setting,22.67,Pays at 32.15% of Total Billed charges,56.42,Pays at 80.03% of Total Billed charges,19.07,Pays at 102% of Medicare OPPS Rate,63.45,Pays at 90% of Total Billed charges,22.67,Pays at 32.15% of Total Billed charges,18.7,Pays at 100% of Medicare OPPS Rate,22.67,Pays at 32.15% of Total Billed charges,62.04,Pays at 88% of Total Billed charges,23.34,Pays at 33.11% of Total Billed charges,18.7,63.45,42.30
Outpatient Medical Services,THERAPY,97033,Psychiatric treatment in which seizures are electrically induced in patients to provide relief from mental disorders,430,70.5,59.93,Pays at 85% of Billed charges for outpatient setting,22.67,Pays at 32.15% of Total Billed charges,56.42,Pays at 80.03% of Total Billed charges,19.07,Pays at 102% of Medicare OPPS Rate,63.45,Pays at 90% of Total Billed charges,22.67,Pays at 32.15% of Total Billed charges,18.7,Pays at 100% of Medicare OPPS Rate,22.67,Pays at 32.15% of Total Billed charges,62.04,Pays at 88% of Total Billed charges,23.34,Pays at 33.11% of Total Billed charges,18.7,63.45,42.30
Outpatient Medical Services,THERAPY,97033,Psychiatric treatment in which seizures are electrically induced in patients to provide relief from mental disorders,430,118.5,100.73,Pays at 85% of Billed charges for outpatient setting,38.1,Pays at 32.15% of Total Billed charges,94.84,Pays at 80.03% of Total Billed charges,19.07,Pays at 102% of Medicare OPPS Rate,106.65,Pays at 90% of Total Billed charges,38.1,Pays at 32.15% of Total Billed charges,18.7,Pays at 100% of Medicare OPPS Rate,38.1,Pays at 32.15% of Total Billed charges,104.28,Pays at 88% of Total Billed charges,39.24,Pays at 33.11% of Total Billed charges,18.7,106.65,71.10
Outpatient Medical Services,THERAPY,97033,Psychiatric treatment in which seizures are electrically induced in patients to provide relief from mental disorders,420,70.5,59.93,Pays at 85% of Billed charges for outpatient setting,22.67,Pays at 32.15% of Total Billed charges,56.42,Pays at 80.03% of Total Billed charges,19.07,Pays at 102% of Medicare OPPS Rate,63.45,Pays at 90% of Total Billed charges,22.67,Pays at 32.15% of Total Billed charges,18.7,Pays at 100% of Medicare OPPS Rate,22.67,Pays at 32.15% of Total Billed charges,62.04,Pays at 88% of Total Billed charges,23.34,Pays at 33.11% of Total Billed charges,18.7,63.45,42.30
Outpatient Medical Services,THERAPY,97033,Psychiatric treatment in which seizures are electrically induced in patients to provide relief from mental disorders,420,118.5,100.73,Pays at 85% of Billed charges for outpatient setting,38.1,Pays at 32.15% of Total Billed charges,94.84,Pays at 80.03% of Total Billed charges,19.07,Pays at 102% of Medicare OPPS Rate,106.65,Pays at 90% of Total Billed charges,38.1,Pays at 32.15% of Total Billed charges,18.7,Pays at 100% of Medicare OPPS Rate,38.1,Pays at 32.15% of Total Billed charges,104.28,Pays at 88% of Total Billed charges,39.24,Pays at 33.11% of Total Billed charges,18.7,106.65,71.10
Outpatient Medical Services,THERAPY,97034,"O/T CONTRAST BATH, EACH AREA",430,96.5,82.03,Pays at 85% of Billed charges for outpatient setting,31.02,Pays at 32.15% of Total Billed charges,77.23,Pays at 80.03% of Total Billed charges,13.99,Pays at 102% of Medicare OPPS Rate,86.85,Pays at 90% of Total Billed charges,31.02,Pays at 32.15% of Total Billed charges,13.72,Pays at 100% of Medicare OPPS Rate,31.02,Pays at 32.15% of Total Billed charges,84.92,Pays at 88% of Total Billed charges,31.95,Pays at 33.11% of Total Billed charges,13.72,86.85,57.90
Outpatient Medical Services,THERAPY,97034,"P/T CONTRAST BATH, EACH AREA",420,96.5,82.03,Pays at 85% of Billed charges for outpatient setting,31.02,Pays at 32.15% of Total Billed charges,77.23,Pays at 80.03% of Total Billed charges,13.99,Pays at 102% of Medicare OPPS Rate,86.85,Pays at 90% of Total Billed charges,31.02,Pays at 32.15% of Total Billed charges,13.72,Pays at 100% of Medicare OPPS Rate,31.02,Pays at 32.15% of Total Billed charges,84.92,Pays at 88% of Total Billed charges,31.95,Pays at 33.11% of Total Billed charges,13.72,86.85,57.90
Outpatient Medical Services,THERAPY,97035,"Use of sound waves to treat medical problems, especially musculoskeletal problems like inflammation from injuries",420,106.75,90.74,Pays at 85% of Billed charges for outpatient setting,34.32,Pays at 32.15% of Total Billed charges,85.43,Pays at 80.03% of Total Billed charges,13.99,Pays at 102% of Medicare OPPS Rate,96.08,Pays at 90% of Total Billed charges,34.32,Pays at 32.15% of Total Billed charges,13.72,Pays at 100% of Medicare OPPS Rate,34.32,Pays at 32.15% of Total Billed charges,93.94,Pays at 88% of Total Billed charges,35.34,Pays at 33.11% of Total Billed charges,13.72,96.08,64.05
Outpatient Medical Services,THERAPY,97035,"Use of sound waves to treat medical problems, especially musculoskeletal problems like inflammation from injuries",430,68.85,58.52,Pays at 85% of Billed charges for outpatient setting,22.14,Pays at 32.15% of Total Billed charges,55.1,Pays at 80.03% of Total Billed charges,13.99,Pays at 102% of Medicare OPPS Rate,61.97,Pays at 90% of Total Billed charges,22.14,Pays at 32.15% of Total Billed charges,13.72,Pays at 100% of Medicare OPPS Rate,22.14,Pays at 32.15% of Total Billed charges,60.59,Pays at 88% of Total Billed charges,22.8,Pays at 33.11% of Total Billed charges,13.72,61.97,41.31
Outpatient Medical Services,THERAPY,97035,"Use of sound waves to treat medical problems, especially musculoskeletal problems like inflammation from injuries",430,74.25,63.11,Pays at 85% of Billed charges for outpatient setting,23.87,Pays at 32.15% of Total Billed charges,59.42,Pays at 80.03% of Total Billed charges,13.99,Pays at 102% of Medicare OPPS Rate,66.83,Pays at 90% of Total Billed charges,23.87,Pays at 32.15% of Total Billed charges,13.72,Pays at 100% of Medicare OPPS Rate,23.87,Pays at 32.15% of Total Billed charges,65.34,Pays at 88% of Total Billed charges,24.58,Pays at 33.11% of Total Billed charges,13.72,66.83,44.55
Outpatient Medical Services,THERAPY,97035,"Use of sound waves to treat medical problems, especially musculoskeletal problems like inflammation from injuries",420,74.25,63.11,Pays at 85% of Billed charges for outpatient setting,23.87,Pays at 32.15% of Total Billed charges,59.42,Pays at 80.03% of Total Billed charges,13.99,Pays at 102% of Medicare OPPS Rate,66.83,Pays at 90% of Total Billed charges,23.87,Pays at 32.15% of Total Billed charges,13.72,Pays at 100% of Medicare OPPS Rate,23.87,Pays at 32.15% of Total Billed charges,65.34,Pays at 88% of Total Billed charges,24.58,Pays at 33.11% of Total Billed charges,13.72,66.83,44.55
Outpatient Medical Services,THERAPY,97035,"Use of sound waves to treat medical problems, especially musculoskeletal problems like inflammation from injuries",420,106.75,90.74,Pays at 85% of Billed charges for outpatient setting,34.32,Pays at 32.15% of Total Billed charges,85.43,Pays at 80.03% of Total Billed charges,13.99,Pays at 102% of Medicare OPPS Rate,96.08,Pays at 90% of Total Billed charges,34.32,Pays at 32.15% of Total Billed charges,13.72,Pays at 100% of Medicare OPPS Rate,34.32,Pays at 32.15% of Total Billed charges,93.94,Pays at 88% of Total Billed charges,35.34,Pays at 33.11% of Total Billed charges,13.72,96.08,64.05
Outpatient Medical Services,THERAPY,97110,"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",420,102.5,87.13,Pays at 85% of Billed charges for outpatient setting,32.95,Pays at 32.15% of Total Billed charges,82.03,Pays at 80.03% of Total Billed charges,28.69,Pays at 102% of Medicare OPPS Rate,92.25,Pays at 90% of Total Billed charges,32.95,Pays at 32.15% of Total Billed charges,28.13,Pays at 100% of Medicare OPPS Rate,32.95,Pays at 32.15% of Total Billed charges,90.2,Pays at 88% of Total Billed charges,33.94,Pays at 33.11% of Total Billed charges,28.13,92.25,61.50
Outpatient Medical Services,THERAPY,97110,"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",430,87.54,74.41,Pays at 85% of Billed charges for outpatient setting,28.14,Pays at 32.15% of Total Billed charges,70.06,Pays at 80.03% of Total Billed charges,28.69,Pays at 102% of Medicare OPPS Rate,78.79,Pays at 90% of Total Billed charges,28.14,Pays at 32.15% of Total Billed charges,28.13,Pays at 100% of Medicare OPPS Rate,28.14,Pays at 32.15% of Total Billed charges,77.04,Pays at 88% of Total Billed charges,28.98,Pays at 33.11% of Total Billed charges,28.13,78.79,52.52
Outpatient Medical Services,THERAPY,97110,"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",420,84.05,71.44,Pays at 85% of Billed charges for outpatient setting,27.02,Pays at 32.15% of Total Billed charges,67.27,Pays at 80.03% of Total Billed charges,28.69,Pays at 102% of Medicare OPPS Rate,75.65,Pays at 90% of Total Billed charges,27.02,Pays at 32.15% of Total Billed charges,28.13,Pays at 100% of Medicare OPPS Rate,27.02,Pays at 32.15% of Total Billed charges,73.96,Pays at 88% of Total Billed charges,27.83,Pays at 33.11% of Total Billed charges,27.02,75.65,50.43
Outpatient Medical Services,THERAPY,97110,"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",420,100,85,Pays at 85% of Billed charges for outpatient setting,32.15,Pays at 32.15% of Total Billed charges,80.03,Pays at 80.03% of Total Billed charges,28.69,Pays at 102% of Medicare OPPS Rate,90,Pays at 90% of Total Billed charges,32.15,Pays at 32.15% of Total Billed charges,28.13,Pays at 100% of Medicare OPPS Rate,32.15,Pays at 32.15% of Total Billed charges,88,Pays at 88% of Total Billed charges,33.11,Pays at 33.11% of Total Billed charges,28.13,90,60.00
Outpatient Medical Services,THERAPY,97112,A technique used by physical therapists to restore normal body movement patterns,420,120,102,Pays at 85% of Billed charges for outpatient setting,38.58,Pays at 32.15% of Total Billed charges,96.04,Pays at 80.03% of Total Billed charges,32.85,Pays at 102% of Medicare OPPS Rate,108,Pays at 90% of Total Billed charges,38.58,Pays at 32.15% of Total Billed charges,32.21,Pays at 100% of Medicare OPPS Rate,38.58,Pays at 32.15% of Total Billed charges,105.6,Pays at 88% of Total Billed charges,39.73,Pays at 33.11% of Total Billed charges,32.21,108,72.00
Outpatient Medical Services,THERAPY,97112,A technique used by physical therapists to restore normal body movement patterns,430,150,127.5,Pays at 85% of Billed charges for outpatient setting,48.23,Pays at 32.15% of Total Billed charges,120.05,Pays at 80.03% of Total Billed charges,32.85,Pays at 102% of Medicare OPPS Rate,135,Pays at 90% of Total Billed charges,48.23,Pays at 32.15% of Total Billed charges,32.21,Pays at 100% of Medicare OPPS Rate,48.23,Pays at 32.15% of Total Billed charges,132,Pays at 88% of Total Billed charges,49.67,Pays at 33.11% of Total Billed charges,32.21,135,90.00
Outpatient Medical Services,THERAPY,97112,A technique used by physical therapists to restore normal body movement patterns,420,74.62,63.43,Pays at 85% of Billed charges for outpatient setting,23.99,Pays at 32.15% of Total Billed charges,59.72,Pays at 80.03% of Total Billed charges,32.85,Pays at 102% of Medicare OPPS Rate,67.16,Pays at 90% of Total Billed charges,23.99,Pays at 32.15% of Total Billed charges,32.21,Pays at 100% of Medicare OPPS Rate,23.99,Pays at 32.15% of Total Billed charges,65.67,Pays at 88% of Total Billed charges,24.71,Pays at 33.11% of Total Billed charges,23.99,67.16,44.77
Outpatient Medical Services,THERAPY,97113,Use of water for therapy/exercises,430,79,67.15,Pays at 85% of Billed charges for outpatient setting,25.4,Pays at 32.15% of Total Billed charges,63.22,Pays at 80.03% of Total Billed charges,35.52,Pays at 102% of Medicare OPPS Rate,71.1,Pays at 90% of Total Billed charges,25.4,Pays at 32.15% of Total Billed charges,34.82,Pays at 100% of Medicare OPPS Rate,25.4,Pays at 32.15% of Total Billed charges,69.52,Pays at 88% of Total Billed charges,26.16,Pays at 33.11% of Total Billed charges,25.4,71.1,47.40
Outpatient Medical Services,THERAPY,97113,Use of water for therapy/exercises,420,79,67.15,Pays at 85% of Billed charges for outpatient setting,25.4,Pays at 32.15% of Total Billed charges,63.22,Pays at 80.03% of Total Billed charges,35.52,Pays at 102% of Medicare OPPS Rate,71.1,Pays at 90% of Total Billed charges,25.4,Pays at 32.15% of Total Billed charges,34.82,Pays at 100% of Medicare OPPS Rate,25.4,Pays at 32.15% of Total Billed charges,69.52,Pays at 88% of Total Billed charges,26.16,Pays at 33.11% of Total Billed charges,25.4,71.1,47.40
Outpatient Medical Services,THERAPY,97113,Use of water for therapy/exercises,420,340.7,289.6,Pays at 85% of Billed charges for outpatient setting,109.54,Pays at 32.15% of Total Billed charges,272.66,Pays at 80.03% of Total Billed charges,35.52,Pays at 102% of Medicare OPPS Rate,306.63,Pays at 90% of Total Billed charges,109.54,Pays at 32.15% of Total Billed charges,34.82,Pays at 100% of Medicare OPPS Rate,109.54,Pays at 32.15% of Total Billed charges,299.82,Pays at 88% of Total Billed charges,112.81,Pays at 33.11% of Total Billed charges,34.82,306.63,204.42
Outpatient Medical Services,THERAPY,97116,A type of physical therapy,420,104.5,88.83,Pays at 85% of Billed charges for outpatient setting,33.6,Pays at 32.15% of Total Billed charges,83.63,Pays at 80.03% of Total Billed charges,28.69,Pays at 102% of Medicare OPPS Rate,94.05,Pays at 90% of Total Billed charges,33.6,Pays at 32.15% of Total Billed charges,28.13,Pays at 100% of Medicare OPPS Rate,33.6,Pays at 32.15% of Total Billed charges,91.96,Pays at 88% of Total Billed charges,34.6,Pays at 33.11% of Total Billed charges,28.13,94.05,62.70
Outpatient Medical Services,THERAPY,97116,A type of physical therapy,420,85.69,72.84,Pays at 85% of Billed charges for outpatient setting,27.55,Pays at 32.15% of Total Billed charges,68.58,Pays at 80.03% of Total Billed charges,28.69,Pays at 102% of Medicare OPPS Rate,77.12,Pays at 90% of Total Billed charges,27.55,Pays at 32.15% of Total Billed charges,28.13,Pays at 100% of Medicare OPPS Rate,27.55,Pays at 32.15% of Total Billed charges,75.41,Pays at 88% of Total Billed charges,28.37,Pays at 33.11% of Total Billed charges,27.55,77.12,51.41
Outpatient Medical Services,THERAPY,97124,Use of massage,430,74.25,63.11,Pays at 85% of Billed charges for outpatient setting,23.87,Pays at 32.15% of Total Billed charges,59.42,Pays at 80.03% of Total Billed charges,28.89,Pays at 102% of Medicare OPPS Rate,66.83,Pays at 90% of Total Billed charges,23.87,Pays at 32.15% of Total Billed charges,28.32,Pays at 100% of Medicare OPPS Rate,23.87,Pays at 32.15% of Total Billed charges,65.34,Pays at 88% of Total Billed charges,24.58,Pays at 33.11% of Total Billed charges,23.87,66.83,44.55
Outpatient Medical Services,THERAPY,97124,Use of massage,420,102.5,87.13,Pays at 85% of Billed charges for outpatient setting,32.95,Pays at 32.15% of Total Billed charges,82.03,Pays at 80.03% of Total Billed charges,28.89,Pays at 102% of Medicare OPPS Rate,92.25,Pays at 90% of Total Billed charges,32.95,Pays at 32.15% of Total Billed charges,28.32,Pays at 100% of Medicare OPPS Rate,32.95,Pays at 32.15% of Total Billed charges,90.2,Pays at 88% of Total Billed charges,33.94,Pays at 33.11% of Total Billed charges,28.32,92.25,61.50
Outpatient Medical Services,THERAPY,97127,O/T COGNITIVE RETRAINING,430,91,77.35,Pays at 85% of Billed charges for outpatient setting,29.26,Pays at 32.15% of Total Billed charges,72.83,Pays at 80.03% of Total Billed charges,91,Not Applicable,81.9,Pays at 90% of Total Billed charges,29.26,Pays at 32.15% of Total Billed charges,91,Not Applicable,29.26,Pays at 32.15% of Total Billed charges,80.08,Pays at 88% of Total Billed charges,30.13,Pays at 33.11% of Total Billed charges,29.26,91,54.60
Outpatient Medical Services,THERAPY,97129,S/T COGNITIVE RETRAINING INITIAL 15 MIN,440,91,77.35,Pays at 85% of Billed charges for outpatient setting,29.26,Pays at 32.15% of Total Billed charges,72.83,Pays at 80.03% of Total Billed charges,22.2,Pays at 102% of Medicare OPPS Rate,81.9,Pays at 90% of Total Billed charges,29.26,Pays at 32.15% of Total Billed charges,21.76,Pays at 100% of Medicare OPPS Rate,29.26,Pays at 32.15% of Total Billed charges,80.08,Pays at 88% of Total Billed charges,30.13,Pays at 33.11% of Total Billed charges,21.76,81.9,54.60
Outpatient Medical Services,THERAPY,97129,O/T COGNITIVE RETRAINING INITIAL 15 MIN,430,91,77.35,Pays at 85% of Billed charges for outpatient setting,29.26,Pays at 32.15% of Total Billed charges,72.83,Pays at 80.03% of Total Billed charges,22.2,Pays at 102% of Medicare OPPS Rate,81.9,Pays at 90% of Total Billed charges,29.26,Pays at 32.15% of Total Billed charges,21.76,Pays at 100% of Medicare OPPS Rate,29.26,Pays at 32.15% of Total Billed charges,80.08,Pays at 88% of Total Billed charges,30.13,Pays at 33.11% of Total Billed charges,21.76,81.9,54.60
Outpatient Medical Services,THERAPY,97130,O/T COGNITIVE RETRAINING EACH ADD 15 MIN,430,91,77.35,Pays at 85% of Billed charges for outpatient setting,29.26,Pays at 32.15% of Total Billed charges,72.83,Pays at 80.03% of Total Billed charges,21.5,Pays at 102% of Medicare OPPS Rate,81.9,Pays at 90% of Total Billed charges,29.26,Pays at 32.15% of Total Billed charges,21.08,Pays at 100% of Medicare OPPS Rate,29.26,Pays at 32.15% of Total Billed charges,80.08,Pays at 88% of Total Billed charges,30.13,Pays at 33.11% of Total Billed charges,21.08,81.9,54.60
Outpatient Medical Services,THERAPY,97139,INPATIENT BED TRACTION TREATMENT,430,71.85,61.07,Pays at 85% of Billed charges for outpatient setting,23.1,Pays at 32.15% of Total Billed charges,57.5,Pays at 80.03% of Total Billed charges,NA,Not Applicable,64.67,Pays at 90% of Total Billed charges,23.1,Pays at 32.15% of Total Billed charges,NA,Not Applicable,23.1,Pays at 32.15% of Total Billed charges,63.23,Pays at 88% of Total Billed charges,23.79,Pays at 33.11% of Total Billed charges,23.1,64.67,43.11
Outpatient Medical Services,THERAPY,97139,O/T CONSULT/EDUCATE,430,74.25,63.11,Pays at 85% of Billed charges for outpatient setting,23.87,Pays at 32.15% of Total Billed charges,59.42,Pays at 80.03% of Total Billed charges,NA,Not Applicable,66.83,Pays at 90% of Total Billed charges,23.87,Pays at 32.15% of Total Billed charges,NA,Not Applicable,23.87,Pays at 32.15% of Total Billed charges,65.34,Pays at 88% of Total Billed charges,24.58,Pays at 33.11% of Total Billed charges,23.87,66.83,44.55
Outpatient Medical Services,THERAPY,97139,INPATIENT TRACTION ASSEMBLY,420,71.85,61.07,Pays at 85% of Billed charges for outpatient setting,23.1,Pays at 32.15% of Total Billed charges,57.5,Pays at 80.03% of Total Billed charges,NA,Not Applicable,64.67,Pays at 90% of Total Billed charges,23.1,Pays at 32.15% of Total Billed charges,NA,Not Applicable,23.1,Pays at 32.15% of Total Billed charges,63.23,Pays at 88% of Total Billed charges,23.79,Pays at 33.11% of Total Billed charges,23.1,64.67,43.11
Outpatient Medical Services,THERAPY,97139,P/T CONSULT/EDUCATE,420,74.25,63.11,Pays at 85% of Billed charges for outpatient setting,23.87,Pays at 32.15% of Total Billed charges,59.42,Pays at 80.03% of Total Billed charges,NA,Not Applicable,66.83,Pays at 90% of Total Billed charges,23.87,Pays at 32.15% of Total Billed charges,NA,Not Applicable,23.87,Pays at 32.15% of Total Billed charges,65.34,Pays at 88% of Total Billed charges,24.58,Pays at 33.11% of Total Billed charges,23.87,66.83,44.55
Outpatient Medical Services,THERAPY,97140,Manipulation of 1 or more regions of the body,430,91,77.35,Pays at 85% of Billed charges for outpatient setting,29.26,Pays at 32.15% of Total Billed charges,72.83,Pays at 80.03% of Total Billed charges,26.48,Pays at 102% of Medicare OPPS Rate,81.9,Pays at 90% of Total Billed charges,29.26,Pays at 32.15% of Total Billed charges,25.96,Pays at 100% of Medicare OPPS Rate,29.26,Pays at 32.15% of Total Billed charges,80.08,Pays at 88% of Total Billed charges,30.13,Pays at 33.11% of Total Billed charges,25.96,81.9,54.60
Outpatient Medical Services,THERAPY,97140,Manipulation of 1 or more regions of the body,430,91,77.35,Pays at 85% of Billed charges for outpatient setting,29.26,Pays at 32.15% of Total Billed charges,72.83,Pays at 80.03% of Total Billed charges,26.48,Pays at 102% of Medicare OPPS Rate,81.9,Pays at 90% of Total Billed charges,29.26,Pays at 32.15% of Total Billed charges,25.96,Pays at 100% of Medicare OPPS Rate,29.26,Pays at 32.15% of Total Billed charges,80.08,Pays at 88% of Total Billed charges,30.13,Pays at 33.11% of Total Billed charges,25.96,81.9,54.60
Outpatient Medical Services,THERAPY,97140,Manipulation of 1 or more regions of the body,430,113.75,96.69,Pays at 85% of Billed charges for outpatient setting,36.57,Pays at 32.15% of Total Billed charges,91.03,Pays at 80.03% of Total Billed charges,26.48,Pays at 102% of Medicare OPPS Rate,102.38,Pays at 90% of Total Billed charges,36.57,Pays at 32.15% of Total Billed charges,25.96,Pays at 100% of Medicare OPPS Rate,36.57,Pays at 32.15% of Total Billed charges,100.1,Pays at 88% of Total Billed charges,37.66,Pays at 33.11% of Total Billed charges,25.96,102.38,68.25
Outpatient Medical Services,THERAPY,97140,Manipulation of 1 or more regions of the body,420,91,77.35,Pays at 85% of Billed charges for outpatient setting,29.26,Pays at 32.15% of Total Billed charges,72.83,Pays at 80.03% of Total Billed charges,26.48,Pays at 102% of Medicare OPPS Rate,81.9,Pays at 90% of Total Billed charges,29.26,Pays at 32.15% of Total Billed charges,25.96,Pays at 100% of Medicare OPPS Rate,29.26,Pays at 32.15% of Total Billed charges,80.08,Pays at 88% of Total Billed charges,30.13,Pays at 33.11% of Total Billed charges,25.96,81.9,54.60
Outpatient Medical Services,THERAPY,97140,Manipulation of 1 or more regions of the body,420,91,77.35,Pays at 85% of Billed charges for outpatient setting,29.26,Pays at 32.15% of Total Billed charges,72.83,Pays at 80.03% of Total Billed charges,26.48,Pays at 102% of Medicare OPPS Rate,81.9,Pays at 90% of Total Billed charges,29.26,Pays at 32.15% of Total Billed charges,25.96,Pays at 100% of Medicare OPPS Rate,29.26,Pays at 32.15% of Total Billed charges,80.08,Pays at 88% of Total Billed charges,30.13,Pays at 33.11% of Total Billed charges,25.96,81.9,54.60
Outpatient Medical Services,THERAPY,97140,Manipulation of 1 or more regions of the body,420,97.25,82.66,Pays at 85% of Billed charges for outpatient setting,31.27,Pays at 32.15% of Total Billed charges,77.83,Pays at 80.03% of Total Billed charges,26.48,Pays at 102% of Medicare OPPS Rate,87.53,Pays at 90% of Total Billed charges,31.27,Pays at 32.15% of Total Billed charges,25.96,Pays at 100% of Medicare OPPS Rate,31.27,Pays at 32.15% of Total Billed charges,85.58,Pays at 88% of Total Billed charges,32.2,Pays at 33.11% of Total Billed charges,25.96,87.53,58.35
Outpatient Medical Services,THERAPY,97140,Manipulation of 1 or more regions of the body,420,121.56,103.33,Pays at 85% of Billed charges for outpatient setting,39.08,Pays at 32.15% of Total Billed charges,97.28,Pays at 80.03% of Total Billed charges,26.48,Pays at 102% of Medicare OPPS Rate,109.4,Pays at 90% of Total Billed charges,39.08,Pays at 32.15% of Total Billed charges,25.96,Pays at 100% of Medicare OPPS Rate,39.08,Pays at 32.15% of Total Billed charges,106.97,Pays at 88% of Total Billed charges,40.25,Pays at 33.11% of Total Billed charges,25.96,109.4,72.94
Outpatient Medical Services,THERAPY,97150,O/T GROUP THERAPY,430,48.5,41.23,Pays at 85% of Billed charges for outpatient setting,15.59,Pays at 32.15% of Total Billed charges,38.81,Pays at 80.03% of Total Billed charges,17.37,Pays at 102% of Medicare OPPS Rate,43.65,Pays at 90% of Total Billed charges,15.59,Pays at 32.15% of Total Billed charges,17.03,Pays at 100% of Medicare OPPS Rate,15.59,Pays at 32.15% of Total Billed charges,42.68,Pays at 88% of Total Billed charges,16.06,Pays at 33.11% of Total Billed charges,15.59,43.65,29.10
Outpatient Medical Services,THERAPY,97150,P/T GROUP  THERAPY,420,48.5,41.23,Pays at 85% of Billed charges for outpatient setting,15.59,Pays at 32.15% of Total Billed charges,38.81,Pays at 80.03% of Total Billed charges,17.37,Pays at 102% of Medicare OPPS Rate,43.65,Pays at 90% of Total Billed charges,15.59,Pays at 32.15% of Total Billed charges,17.03,Pays at 100% of Medicare OPPS Rate,15.59,Pays at 32.15% of Total Billed charges,42.68,Pays at 88% of Total Billed charges,16.06,Pays at 33.11% of Total Billed charges,15.59,43.65,29.10
Outpatient Medical Services,THERAPY,97161,P/T EVAL LOW COMPLEXITY,424,144.32,122.67,Pays at 85% of Billed charges for outpatient setting,46.4,Pays at 32.15% of Total Billed charges,115.5,Pays at 80.03% of Total Billed charges,97.87,Pays at 102% of Medicare OPPS Rate,129.89,Pays at 90% of Total Billed charges,46.4,Pays at 32.15% of Total Billed charges,95.95,Pays at 100% of Medicare OPPS Rate,46.4,Pays at 32.15% of Total Billed charges,127,Pays at 88% of Total Billed charges,47.78,Pays at 33.11% of Total Billed charges,46.4,129.89,86.59
Outpatient Medical Services,THERAPY,97162,P/T EVAL MOD COMPLEXITY,424,236.78,201.26,Pays at 85% of Billed charges for outpatient setting,76.12,Pays at 32.15% of Total Billed charges,189.5,Pays at 80.03% of Total Billed charges,97.87,Pays at 102% of Medicare OPPS Rate,213.1,Pays at 90% of Total Billed charges,76.12,Pays at 32.15% of Total Billed charges,95.95,Pays at 100% of Medicare OPPS Rate,76.12,Pays at 32.15% of Total Billed charges,208.37,Pays at 88% of Total Billed charges,78.4,Pays at 33.11% of Total Billed charges,76.12,213.1,142.07
Outpatient Medical Services,THERAPY,97163,P/T EVAL HIGH COMPLEXITY,424,349.38,296.97,Pays at 85% of Billed charges for outpatient setting,112.33,Pays at 32.15% of Total Billed charges,279.61,Pays at 80.03% of Total Billed charges,97.87,Pays at 102% of Medicare OPPS Rate,314.44,Pays at 90% of Total Billed charges,112.33,Pays at 32.15% of Total Billed charges,95.95,Pays at 100% of Medicare OPPS Rate,112.33,Pays at 32.15% of Total Billed charges,307.45,Pays at 88% of Total Billed charges,115.68,Pays at 33.11% of Total Billed charges,95.95,314.44,209.63
Outpatient Medical Services,THERAPY,97164,"P/T REASSESSMENT, BASIC",424,111.5,94.78,Pays at 85% of Billed charges for outpatient setting,35.85,Pays at 32.15% of Total Billed charges,89.23,Pays at 80.03% of Total Billed charges,67.47,Pays at 102% of Medicare OPPS Rate,100.35,Pays at 90% of Total Billed charges,35.85,Pays at 32.15% of Total Billed charges,66.15,Pays at 100% of Medicare OPPS Rate,35.85,Pays at 32.15% of Total Billed charges,98.12,Pays at 88% of Total Billed charges,36.92,Pays at 33.11% of Total Billed charges,35.85,100.35,66.90
Outpatient Medical Services,THERAPY,97165,O/T EVAL LOW COMPLEXITY,434,152.73,129.82,Pays at 85% of Billed charges for outpatient setting,49.1,Pays at 32.15% of Total Billed charges,122.23,Pays at 80.03% of Total Billed charges,97.87,Pays at 102% of Medicare OPPS Rate,137.46,Pays at 90% of Total Billed charges,49.1,Pays at 32.15% of Total Billed charges,95.95,Pays at 100% of Medicare OPPS Rate,49.1,Pays at 32.15% of Total Billed charges,134.4,Pays at 88% of Total Billed charges,50.57,Pays at 33.11% of Total Billed charges,49.1,137.46,91.64
Outpatient Medical Services,THERAPY,97166,O/T EVAL MOD COMPLEXITY,434,252.97,215.02,Pays at 85% of Billed charges for outpatient setting,81.33,Pays at 32.15% of Total Billed charges,202.45,Pays at 80.03% of Total Billed charges,97.87,Pays at 102% of Medicare OPPS Rate,227.67,Pays at 90% of Total Billed charges,81.33,Pays at 32.15% of Total Billed charges,95.95,Pays at 100% of Medicare OPPS Rate,81.33,Pays at 32.15% of Total Billed charges,222.61,Pays at 88% of Total Billed charges,83.76,Pays at 33.11% of Total Billed charges,81.33,227.67,151.78
Outpatient Medical Services,THERAPY,97167,O/T EVAL HIGH COMPLEXITY,434,252.97,215.02,Pays at 85% of Billed charges for outpatient setting,81.33,Pays at 32.15% of Total Billed charges,202.45,Pays at 80.03% of Total Billed charges,97.87,Pays at 102% of Medicare OPPS Rate,227.67,Pays at 90% of Total Billed charges,81.33,Pays at 32.15% of Total Billed charges,95.95,Pays at 100% of Medicare OPPS Rate,81.33,Pays at 32.15% of Total Billed charges,222.61,Pays at 88% of Total Billed charges,83.76,Pays at 33.11% of Total Billed charges,81.33,227.67,151.78
Outpatient Medical Services,THERAPY,97168,"O/T REASSESSMENT, BASIC",434,111.5,94.78,Pays at 85% of Billed charges for outpatient setting,35.85,Pays at 32.15% of Total Billed charges,89.23,Pays at 80.03% of Total Billed charges,67.17,Pays at 102% of Medicare OPPS Rate,100.35,Pays at 90% of Total Billed charges,35.85,Pays at 32.15% of Total Billed charges,65.85,Pays at 100% of Medicare OPPS Rate,35.85,Pays at 32.15% of Total Billed charges,98.12,Pays at 88% of Total Billed charges,36.92,Pays at 33.11% of Total Billed charges,35.85,100.35,66.90
Outpatient Medical Services,THERAPY,97504,NOT CHARGEABLE ITEM,420,48.8,41.48,Pays at 85% of Billed charges for outpatient setting,15.69,Pays at 32.15% of Total Billed charges,39.05,Pays at 80.03% of Total Billed charges,NA,Not Applicable,43.92,Pays at 90% of Total Billed charges,15.69,Pays at 32.15% of Total Billed charges,NA,Not Applicable,15.69,Pays at 32.15% of Total Billed charges,42.94,Pays at 88% of Total Billed charges,16.16,Pays at 33.11% of Total Billed charges,15.69,43.92,29.28
Outpatient Medical Services,THERAPY,97530,"Incorporates the use of multiple parameters, such as balance, strength, and range of motion, for a functional activity",420,97.5,82.88,Pays at 85% of Billed charges for outpatient setting,31.35,Pays at 32.15% of Total Billed charges,78.03,Pays at 80.03% of Total Billed charges,35.65,Pays at 102% of Medicare OPPS Rate,87.75,Pays at 90% of Total Billed charges,31.35,Pays at 32.15% of Total Billed charges,34.95,Pays at 100% of Medicare OPPS Rate,31.35,Pays at 32.15% of Total Billed charges,85.8,Pays at 88% of Total Billed charges,32.28,Pays at 33.11% of Total Billed charges,31.35,87.75,58.50
Outpatient Medical Services,THERAPY,97530,"Incorporates the use of multiple parameters, such as balance, strength, and range of motion, for a functional activity",430,45.76,38.9,Pays at 85% of Billed charges for outpatient setting,14.71,Pays at 32.15% of Total Billed charges,36.62,Pays at 80.03% of Total Billed charges,35.65,Pays at 102% of Medicare OPPS Rate,41.18,Pays at 90% of Total Billed charges,14.71,Pays at 32.15% of Total Billed charges,34.95,Pays at 100% of Medicare OPPS Rate,14.71,Pays at 32.15% of Total Billed charges,40.27,Pays at 88% of Total Billed charges,15.15,Pays at 33.11% of Total Billed charges,14.71,41.18,27.46
Outpatient Medical Services,THERAPY,97530,"Incorporates the use of multiple parameters, such as balance, strength, and range of motion, for a functional activity",420,63.96,54.37,Pays at 85% of Billed charges for outpatient setting,20.56,Pays at 32.15% of Total Billed charges,51.19,Pays at 80.03% of Total Billed charges,35.65,Pays at 102% of Medicare OPPS Rate,57.56,Pays at 90% of Total Billed charges,20.56,Pays at 32.15% of Total Billed charges,34.95,Pays at 100% of Medicare OPPS Rate,20.56,Pays at 32.15% of Total Billed charges,56.28,Pays at 88% of Total Billed charges,21.18,Pays at 33.11% of Total Billed charges,20.56,57.56,38.38
Outpatient Medical Services,THERAPY,97532,"S/T COGNITIVE RETRAINING, EA 15-MIN",440,81.25,69.06,Pays at 85% of Billed charges for outpatient setting,26.12,Pays at 32.15% of Total Billed charges,65.02,Pays at 80.03% of Total Billed charges,NA,Not Applicable,73.13,Pays at 90% of Total Billed charges,26.12,Pays at 32.15% of Total Billed charges,NA,Not Applicable,26.12,Pays at 32.15% of Total Billed charges,71.5,Pays at 88% of Total Billed charges,26.9,Pays at 33.11% of Total Billed charges,26.12,73.13,48.75
Outpatient Medical Services,THERAPY,97532,O/T COGNITIVE RETRAINING,430,70.5,59.93,Pays at 85% of Billed charges for outpatient setting,22.67,Pays at 32.15% of Total Billed charges,56.42,Pays at 80.03% of Total Billed charges,NA,Not Applicable,63.45,Pays at 90% of Total Billed charges,22.67,Pays at 32.15% of Total Billed charges,NA,Not Applicable,22.67,Pays at 32.15% of Total Billed charges,62.04,Pays at 88% of Total Billed charges,23.34,Pays at 33.11% of Total Billed charges,22.67,63.45,42.30
Outpatient Medical Services,THERAPY,97532,O/T COGNITIVE RETRAINING,430,78.5,66.73,Pays at 85% of Billed charges for outpatient setting,25.24,Pays at 32.15% of Total Billed charges,62.82,Pays at 80.03% of Total Billed charges,NA,Not Applicable,70.65,Pays at 90% of Total Billed charges,25.24,Pays at 32.15% of Total Billed charges,NA,Not Applicable,25.24,Pays at 32.15% of Total Billed charges,69.08,Pays at 88% of Total Billed charges,25.99,Pays at 33.11% of Total Billed charges,25.24,70.65,47.10
Outpatient Medical Services,THERAPY,97532,P/T COGNITIVE RETRAINING,420,81.25,69.06,Pays at 85% of Billed charges for outpatient setting,26.12,Pays at 32.15% of Total Billed charges,65.02,Pays at 80.03% of Total Billed charges,NA,Not Applicable,73.13,Pays at 90% of Total Billed charges,26.12,Pays at 32.15% of Total Billed charges,NA,Not Applicable,26.12,Pays at 32.15% of Total Billed charges,71.5,Pays at 88% of Total Billed charges,26.9,Pays at 33.11% of Total Billed charges,26.12,73.13,48.75
Outpatient Medical Services,THERAPY,97533,"S/T SENSORY INTEGRATION, EA 15 MINUTES",440,91,77.35,Pays at 85% of Billed charges for outpatient setting,29.26,Pays at 32.15% of Total Billed charges,72.83,Pays at 80.03% of Total Billed charges,59.87,Pays at 102% of Medicare OPPS Rate,81.9,Pays at 90% of Total Billed charges,29.26,Pays at 32.15% of Total Billed charges,58.7,Pays at 100% of Medicare OPPS Rate,29.26,Pays at 32.15% of Total Billed charges,80.08,Pays at 88% of Total Billed charges,30.13,Pays at 33.11% of Total Billed charges,29.26,81.9,54.60
Outpatient Medical Services,THERAPY,97533,O/T SENSORY INTEGRATION,430,91,77.35,Pays at 85% of Billed charges for outpatient setting,29.26,Pays at 32.15% of Total Billed charges,72.83,Pays at 80.03% of Total Billed charges,59.87,Pays at 102% of Medicare OPPS Rate,81.9,Pays at 90% of Total Billed charges,29.26,Pays at 32.15% of Total Billed charges,58.7,Pays at 100% of Medicare OPPS Rate,29.26,Pays at 32.15% of Total Billed charges,80.08,Pays at 88% of Total Billed charges,30.13,Pays at 33.11% of Total Billed charges,29.26,81.9,54.60
Outpatient Medical Services,THERAPY,97533,O/T KINESIO TAPING,430,91,77.35,Pays at 85% of Billed charges for outpatient setting,29.26,Pays at 32.15% of Total Billed charges,72.83,Pays at 80.03% of Total Billed charges,59.87,Pays at 102% of Medicare OPPS Rate,81.9,Pays at 90% of Total Billed charges,29.26,Pays at 32.15% of Total Billed charges,58.7,Pays at 100% of Medicare OPPS Rate,29.26,Pays at 32.15% of Total Billed charges,80.08,Pays at 88% of Total Billed charges,30.13,Pays at 33.11% of Total Billed charges,29.26,81.9,54.60
Outpatient Medical Services,THERAPY,97533,P/T SENSORY INTEGRATION,420,91,77.35,Pays at 85% of Billed charges for outpatient setting,29.26,Pays at 32.15% of Total Billed charges,72.83,Pays at 80.03% of Total Billed charges,59.87,Pays at 102% of Medicare OPPS Rate,81.9,Pays at 90% of Total Billed charges,29.26,Pays at 32.15% of Total Billed charges,58.7,Pays at 100% of Medicare OPPS Rate,29.26,Pays at 32.15% of Total Billed charges,80.08,Pays at 88% of Total Billed charges,30.13,Pays at 33.11% of Total Billed charges,29.26,81.9,54.60
Outpatient Medical Services,THERAPY,97535,Occupational therapy,430,113.75,96.69,Pays at 85% of Billed charges for outpatient setting,36.57,Pays at 32.15% of Total Billed charges,91.03,Pays at 80.03% of Total Billed charges,31.73,Pays at 102% of Medicare OPPS Rate,102.38,Pays at 90% of Total Billed charges,36.57,Pays at 32.15% of Total Billed charges,31.11,Pays at 100% of Medicare OPPS Rate,36.57,Pays at 32.15% of Total Billed charges,100.1,Pays at 88% of Total Billed charges,37.66,Pays at 33.11% of Total Billed charges,31.11,102.38,68.25
Outpatient Medical Services,THERAPY,97535,Occupational therapy,420,74.25,63.11,Pays at 85% of Billed charges for outpatient setting,23.87,Pays at 32.15% of Total Billed charges,59.42,Pays at 80.03% of Total Billed charges,31.73,Pays at 102% of Medicare OPPS Rate,66.83,Pays at 90% of Total Billed charges,23.87,Pays at 32.15% of Total Billed charges,31.11,Pays at 100% of Medicare OPPS Rate,23.87,Pays at 32.15% of Total Billed charges,65.34,Pays at 88% of Total Billed charges,24.58,Pays at 33.11% of Total Billed charges,23.87,66.83,44.55
Outpatient Medical Services,THERAPY,97537,O/T COMMUNITY/WORK RE-INTEGRATION,430,81.25,69.06,Pays at 85% of Billed charges for outpatient setting,26.12,Pays at 32.15% of Total Billed charges,65.02,Pays at 80.03% of Total Billed charges,30.95,Pays at 102% of Medicare OPPS Rate,73.13,Pays at 90% of Total Billed charges,26.12,Pays at 32.15% of Total Billed charges,30.34,Pays at 100% of Medicare OPPS Rate,26.12,Pays at 32.15% of Total Billed charges,71.5,Pays at 88% of Total Billed charges,26.9,Pays at 33.11% of Total Billed charges,26.12,73.13,48.75
Outpatient Medical Services,THERAPY,97537,P/T HOME CARE,420,113.75,96.69,Pays at 85% of Billed charges for outpatient setting,36.57,Pays at 32.15% of Total Billed charges,91.03,Pays at 80.03% of Total Billed charges,30.95,Pays at 102% of Medicare OPPS Rate,102.38,Pays at 90% of Total Billed charges,36.57,Pays at 32.15% of Total Billed charges,30.34,Pays at 100% of Medicare OPPS Rate,36.57,Pays at 32.15% of Total Billed charges,100.1,Pays at 88% of Total Billed charges,37.66,Pays at 33.11% of Total Billed charges,30.34,102.38,68.25
Outpatient Medical Services,THERAPY,97542,W/C MOBILITY,420,92.81,78.89,Pays at 85% of Billed charges for outpatient setting,29.84,Pays at 32.15% of Total Billed charges,74.28,Pays at 80.03% of Total Billed charges,30.95,Pays at 102% of Medicare OPPS Rate,83.53,Pays at 90% of Total Billed charges,29.84,Pays at 32.15% of Total Billed charges,30.34,Pays at 100% of Medicare OPPS Rate,29.84,Pays at 32.15% of Total Billed charges,81.67,Pays at 88% of Total Billed charges,30.73,Pays at 33.11% of Total Billed charges,29.84,83.53,55.69
Outpatient Medical Services,THERAPY,97597,"Debridement (for example, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps)",420,264.06,224.45,Pays at 85% of Billed charges for outpatient setting,84.9,Pays at 32.15% of Total Billed charges,211.33,Pays at 80.03% of Total Billed charges,173.11,Pays at 102% of Medicare OPPS Rate,237.65,Pays at 90% of Total Billed charges,84.9,Pays at 32.15% of Total Billed charges,169.72,Pays at 100% of Medicare OPPS Rate,84.9,Pays at 32.15% of Total Billed charges,232.37,Pays at 88% of Total Billed charges,87.43,Pays at 33.11% of Total Billed charges,84.9,237.65,158.44
Outpatient Medical Services,THERAPY,97598,P/T WOUND EA ADDTNL 20CM2-ALL OR PART,420,122.7,104.3,Pays at 85% of Billed charges for outpatient setting,39.45,Pays at 32.15% of Total Billed charges,98.2,Pays at 80.03% of Total Billed charges,NA,Not Applicable,110.43,Pays at 90% of Total Billed charges,39.45,Pays at 32.15% of Total Billed charges,NA,Not Applicable,39.45,Pays at 32.15% of Total Billed charges,107.98,Pays at 88% of Total Billed charges,40.63,Pays at 33.11% of Total Billed charges,39.45,110.43,73.62
Outpatient Medical Services,THERAPY,97598,P/T WOUND >20cm2,420,330.7,281.1,Pays at 85% of Billed charges for outpatient setting,106.32,Pays at 32.15% of Total Billed charges,264.66,Pays at 80.03% of Total Billed charges,NA,Not Applicable,297.63,Pays at 90% of Total Billed charges,106.32,Pays at 32.15% of Total Billed charges,NA,Not Applicable,106.32,Pays at 32.15% of Total Billed charges,291.02,Pays at 88% of Total Billed charges,109.49,Pays at 33.11% of Total Billed charges,106.32,297.63,198.42
Outpatient Medical Services,THERAPY,97601,O/T SELECTIVE DEBRIDEMENT,420,211.25,179.56,Pays at 85% of Billed charges for outpatient setting,67.92,Pays at 32.15% of Total Billed charges,169.06,Pays at 80.03% of Total Billed charges,NA,Not Applicable,190.13,Pays at 90% of Total Billed charges,67.92,Pays at 32.15% of Total Billed charges,NA,Not Applicable,67.92,Pays at 32.15% of Total Billed charges,185.9,Pays at 88% of Total Billed charges,69.94,Pays at 33.11% of Total Billed charges,67.92,190.13,126.75
Outpatient Medical Services,THERAPY,97602,O/T NON-SELECTIVE DEBRIDEMENT,430,213,181.05,Pays at 85% of Billed charges for outpatient setting,68.48,Pays at 32.15% of Total Billed charges,170.46,Pays at 80.03% of Total Billed charges,173.12,Pays at 102% of Medicare OPPS Rate,191.7,Pays at 90% of Total Billed charges,68.48,Pays at 32.15% of Total Billed charges,169.72,Pays at 100% of Medicare OPPS Rate,68.48,Pays at 32.15% of Total Billed charges,187.44,Pays at 88% of Total Billed charges,70.52,Pays at 33.11% of Total Billed charges,68.48,191.7,127.80
Outpatient Medical Services,THERAPY,97602,P/T NON-SELECTIVE DEBRIDEMENT,420,545.94,464.05,Pays at 85% of Billed charges for outpatient setting,175.52,Pays at 32.15% of Total Billed charges,436.92,Pays at 80.03% of Total Billed charges,173.12,Pays at 102% of Medicare OPPS Rate,491.35,Pays at 90% of Total Billed charges,175.52,Pays at 32.15% of Total Billed charges,169.72,Pays at 100% of Medicare OPPS Rate,175.52,Pays at 32.15% of Total Billed charges,480.43,Pays at 88% of Total Billed charges,180.76,Pays at 33.11% of Total Billed charges,169.72,491.35,327.56
Outpatient Medical Services,THERAPY,97605,P/T NPWT <50cm2,420,191.5,162.78,Pays at 85% of Billed charges for outpatient setting,61.57,Pays at 32.15% of Total Billed charges,153.26,Pays at 80.03% of Total Billed charges,173.12,Pays at 102% of Medicare OPPS Rate,172.35,Pays at 90% of Total Billed charges,61.57,Pays at 32.15% of Total Billed charges,169.72,Pays at 100% of Medicare OPPS Rate,61.57,Pays at 32.15% of Total Billed charges,168.52,Pays at 88% of Total Billed charges,63.41,Pays at 33.11% of Total Billed charges,61.57,173.12,114.90
Outpatient Medical Services,THERAPY,97606,P/T NPWT >50cm2,420,103.5,87.98,Pays at 85% of Billed charges for outpatient setting,33.28,Pays at 32.15% of Total Billed charges,82.83,Pays at 80.03% of Total Billed charges,357.66,Pays at 102% of Medicare OPPS Rate,93.15,Pays at 90% of Total Billed charges,33.28,Pays at 32.15% of Total Billed charges,350.65,Pays at 100% of Medicare OPPS Rate,33.28,Pays at 32.15% of Total Billed charges,91.08,Pays at 88% of Total Billed charges,34.27,Pays at 33.11% of Total Billed charges,33.28,357.66,62.10
Outpatient Medical Services,THERAPY,97750,O/T FUNCTIONAL FCE PER 15 MIN.,430,85.4,72.59,Pays at 85% of Billed charges for outpatient setting,27.46,Pays at 32.15% of Total Billed charges,68.35,Pays at 80.03% of Total Billed charges,32.65,Pays at 102% of Medicare OPPS Rate,76.86,Pays at 90% of Total Billed charges,27.46,Pays at 32.15% of Total Billed charges,32.01,Pays at 100% of Medicare OPPS Rate,27.46,Pays at 32.15% of Total Billed charges,75.15,Pays at 88% of Total Billed charges,28.28,Pays at 33.11% of Total Billed charges,27.46,76.86,51.24
Outpatient Medical Services,THERAPY,97750,O/T PHYSICAL PERFORMANCE TEST,430,90.5,76.93,Pays at 85% of Billed charges for outpatient setting,29.1,Pays at 32.15% of Total Billed charges,72.43,Pays at 80.03% of Total Billed charges,32.65,Pays at 102% of Medicare OPPS Rate,81.45,Pays at 90% of Total Billed charges,29.1,Pays at 32.15% of Total Billed charges,32.01,Pays at 100% of Medicare OPPS Rate,29.1,Pays at 32.15% of Total Billed charges,79.64,Pays at 88% of Total Billed charges,29.96,Pays at 33.11% of Total Billed charges,29.1,81.45,54.30
Outpatient Medical Services,THERAPY,97750,P/T FUNCTIONAL CAPACITY EVALUATION,424,85.4,72.59,Pays at 85% of Billed charges for outpatient setting,27.46,Pays at 32.15% of Total Billed charges,68.35,Pays at 80.03% of Total Billed charges,32.65,Pays at 102% of Medicare OPPS Rate,76.86,Pays at 90% of Total Billed charges,27.46,Pays at 32.15% of Total Billed charges,32.01,Pays at 100% of Medicare OPPS Rate,27.46,Pays at 32.15% of Total Billed charges,75.15,Pays at 88% of Total Billed charges,28.28,Pays at 33.11% of Total Billed charges,27.46,76.86,51.24
Outpatient Medical Services,THERAPY,97760,"P/T ORTHOTIC, INITIAL, EA 15 MIN",420,91,77.35,Pays at 85% of Billed charges for outpatient setting,29.26,Pays at 32.15% of Total Billed charges,72.83,Pays at 80.03% of Total Billed charges,46.26,Pays at 102% of Medicare OPPS Rate,81.9,Pays at 90% of Total Billed charges,29.26,Pays at 32.15% of Total Billed charges,45.35,Pays at 100% of Medicare OPPS Rate,29.26,Pays at 32.15% of Total Billed charges,80.08,Pays at 88% of Total Billed charges,30.13,Pays at 33.11% of Total Billed charges,29.26,81.9,54.60
Outpatient Medical Services,THERAPY,97761,"P/T PROSTHETIC, INITIAL, EA 15 MIN",420,91,77.35,Pays at 85% of Billed charges for outpatient setting,29.26,Pays at 32.15% of Total Billed charges,72.83,Pays at 80.03% of Total Billed charges,40.16,Pays at 102% of Medicare OPPS Rate,81.9,Pays at 90% of Total Billed charges,29.26,Pays at 32.15% of Total Billed charges,39.37,Pays at 100% of Medicare OPPS Rate,29.26,Pays at 32.15% of Total Billed charges,80.08,Pays at 88% of Total Billed charges,30.13,Pays at 33.11% of Total Billed charges,29.26,81.9,54.60
Outpatient Medical Services,THERAPY,97763,"P/T ORTH/PROS, SUB, EA 15 MIN",420,113.75,96.69,Pays at 85% of Billed charges for outpatient setting,36.57,Pays at 32.15% of Total Billed charges,91.03,Pays at 80.03% of Total Billed charges,50.43,Pays at 102% of Medicare OPPS Rate,102.38,Pays at 90% of Total Billed charges,36.57,Pays at 32.15% of Total Billed charges,49.44,Pays at 100% of Medicare OPPS Rate,36.57,Pays at 32.15% of Total Billed charges,100.1,Pays at 88% of Total Billed charges,37.66,Pays at 33.11% of Total Billed charges,36.57,102.38,68.25
Outpatient Medical Services,THERAPY,A5503,P/T ORTHOTIC SHOE FOR DIABETIC ONLY,420,110,93.5,Pays at 85% of Billed charges for outpatient setting,35.37,Pays at 32.15% of Total Billed charges,88.03,Pays at 80.03% of Total Billed charges,NA,Not Applicable,99,Pays at 90% of Total Billed charges,35.37,Pays at 32.15% of Total Billed charges,NA,Not Applicable,35.37,Pays at 32.15% of Total Billed charges,96.8,Pays at 88% of Total Billed charges,36.42,Pays at 33.11% of Total Billed charges,35.37,99,66.00
Outpatient Medical Services,THERAPY,E1802,O/T PRE-FORMED DYNAMIC PRONATION/SUPINAT,430,233.45,198.43,Pays at 85% of Billed charges for outpatient setting,75.05,Pays at 32.15% of Total Billed charges,186.83,Pays at 80.03% of Total Billed charges,NA,Not Applicable,210.11,Pays at 90% of Total Billed charges,75.05,Pays at 32.15% of Total Billed charges,NA,Not Applicable,75.05,Pays at 32.15% of Total Billed charges,205.44,Pays at 88% of Total Billed charges,77.3,Pays at 33.11% of Total Billed charges,75.05,210.11,140.07
Outpatient Medical Services,THERAPY,G0169,O/T DRY WOUND,430,243.4,206.89,Pays at 85% of Billed charges for outpatient setting,78.25,Pays at 32.15% of Total Billed charges,194.79,Pays at 80.03% of Total Billed charges,NA,Not Applicable,219.06,Pays at 90% of Total Billed charges,78.25,Pays at 32.15% of Total Billed charges,NA,Not Applicable,78.25,Pays at 32.15% of Total Billed charges,214.19,Pays at 88% of Total Billed charges,80.59,Pays at 33.11% of Total Billed charges,78.25,219.06,146.04
Outpatient Medical Services,THERAPY,G0283,ELECTRICAL STIMULATION - SUPERVISED,420,102.75,87.34,Pays at 85% of Billed charges for outpatient setting,33.03,Pays at 32.15% of Total Billed charges,82.23,Pays at 80.03% of Total Billed charges,11.74,Pays at 102% of Medicare OPPS Rate,92.48,Pays at 90% of Total Billed charges,33.03,Pays at 32.15% of Total Billed charges,11.51,Pays at 100% of Medicare OPPS Rate,33.03,Pays at 32.15% of Total Billed charges,90.42,Pays at 88% of Total Billed charges,34.02,Pays at 33.11% of Total Billed charges,11.51,92.48,61.65
Outpatient Medical Services,THERAPY,G0515,O/T COGNITIVE RETRAINING EA 15 MIN,430,91,77.35,Pays at 85% of Billed charges for outpatient setting,29.26,Pays at 32.15% of Total Billed charges,72.83,Pays at 80.03% of Total Billed charges,NA,Not Applicable,81.9,Pays at 90% of Total Billed charges,29.26,Pays at 32.15% of Total Billed charges,NA,Not Applicable,29.26,Pays at 32.15% of Total Billed charges,80.08,Pays at 88% of Total Billed charges,30.13,Pays at 33.11% of Total Billed charges,29.26,81.9,54.60
Outpatient Medical Services,THERAPY,G2061,"OT E-VISIT, 5-10 MIN",420,29.88,25.4,Pays at 85% of Billed charges for outpatient setting,9.61,Pays at 32.15% of Total Billed charges,23.91,Pays at 80.03% of Total Billed charges,NA,Not Applicable,26.89,Pays at 90% of Total Billed charges,9.61,Pays at 32.15% of Total Billed charges,NA,Not Applicable,9.61,Pays at 32.15% of Total Billed charges,26.29,Pays at 88% of Total Billed charges,9.89,Pays at 33.11% of Total Billed charges,9.61,26.89,17.93
Outpatient Medical Services,THERAPY,G2061,PT E- VISIT 5-10 MIN,420,29.88,25.4,Pays at 85% of Billed charges for outpatient setting,9.61,Pays at 32.15% of Total Billed charges,23.91,Pays at 80.03% of Total Billed charges,NA,Not Applicable,26.89,Pays at 90% of Total Billed charges,9.61,Pays at 32.15% of Total Billed charges,NA,Not Applicable,9.61,Pays at 32.15% of Total Billed charges,26.29,Pays at 88% of Total Billed charges,9.89,Pays at 33.11% of Total Billed charges,9.61,26.89,17.93
Outpatient Medical Services,THERAPY,G2062,"OT E-VISIT, 11-20 MIN",420,52.7,44.8,Pays at 85% of Billed charges for outpatient setting,16.94,Pays at 32.15% of Total Billed charges,42.18,Pays at 80.03% of Total Billed charges,NA,Not Applicable,47.43,Pays at 90% of Total Billed charges,16.94,Pays at 32.15% of Total Billed charges,NA,Not Applicable,16.94,Pays at 32.15% of Total Billed charges,46.38,Pays at 88% of Total Billed charges,17.45,Pays at 33.11% of Total Billed charges,16.94,47.43,31.62
Outpatient Medical Services,THERAPY,G2062,PT E-VISIT 11-20 MIN,420,52.7,44.8,Pays at 85% of Billed charges for outpatient setting,16.94,Pays at 32.15% of Total Billed charges,42.18,Pays at 80.03% of Total Billed charges,NA,Not Applicable,47.43,Pays at 90% of Total Billed charges,16.94,Pays at 32.15% of Total Billed charges,NA,Not Applicable,16.94,Pays at 32.15% of Total Billed charges,46.38,Pays at 88% of Total Billed charges,17.45,Pays at 33.11% of Total Billed charges,16.94,47.43,31.62
Outpatient Medical Services,THERAPY,G2063,"OT E-VISIT, = OR > 21 MIN",420,81.78,69.51,Pays at 85% of Billed charges for outpatient setting,26.29,Pays at 32.15% of Total Billed charges,65.45,Pays at 80.03% of Total Billed charges,NA,Not Applicable,73.6,Pays at 90% of Total Billed charges,26.29,Pays at 32.15% of Total Billed charges,NA,Not Applicable,26.29,Pays at 32.15% of Total Billed charges,71.97,Pays at 88% of Total Billed charges,27.08,Pays at 33.11% of Total Billed charges,26.29,73.6,49.07
Outpatient Medical Services,THERAPY,G2063,PT E-VISIT = OR > 21 MIN,420,81.78,69.51,Pays at 85% of Billed charges for outpatient setting,26.29,Pays at 32.15% of Total Billed charges,65.45,Pays at 80.03% of Total Billed charges,NA,Not Applicable,73.6,Pays at 90% of Total Billed charges,26.29,Pays at 32.15% of Total Billed charges,NA,Not Applicable,26.29,Pays at 32.15% of Total Billed charges,71.97,Pays at 88% of Total Billed charges,27.08,Pays at 33.11% of Total Billed charges,26.29,73.6,49.07
Outpatient Medical Services,THERAPY,G8996,S/T DO NOT USE,440,0.4,0.34,Pays at 85% of Billed charges for outpatient setting,0.13,Pays at 32.15% of Total Billed charges,0.32,Pays at 80.03% of Total Billed charges,NA,Not Applicable,0.36,Pays at 90% of Total Billed charges,0.13,Pays at 32.15% of Total Billed charges,NA,Not Applicable,0.13,Pays at 32.15% of Total Billed charges,0.35,Pays at 88% of Total Billed charges,0.13,Pays at 33.11% of Total Billed charges,0.13,0.36,0.24
Outpatient Medical Services,THERAPY,L1499,MATERNITY BACK SUPPORT,420,153.5,130.48,Pays at 85% of Billed charges for outpatient setting,49.35,Pays at 32.15% of Total Billed charges,122.85,Pays at 80.03% of Total Billed charges,NA,Not Applicable,138.15,Pays at 90% of Total Billed charges,49.35,Pays at 32.15% of Total Billed charges,NA,Not Applicable,49.35,Pays at 32.15% of Total Billed charges,135.08,Pays at 88% of Total Billed charges,50.82,Pays at 33.11% of Total Billed charges,49.35,138.15,92.10
Outpatient Medical Services,THERAPY,L1834,O/T BKA SPLINT CUSTOM,430,62.7,53.3,Pays at 85% of Billed charges for outpatient setting,20.16,Pays at 32.15% of Total Billed charges,50.18,Pays at 80.03% of Total Billed charges,NA,Not Applicable,56.43,Pays at 90% of Total Billed charges,20.16,Pays at 32.15% of Total Billed charges,NA,Not Applicable,20.16,Pays at 32.15% of Total Billed charges,55.18,Pays at 88% of Total Billed charges,20.76,Pays at 33.11% of Total Billed charges,20.16,56.43,37.62
Outpatient Medical Services,THERAPY,L1940,O/T ANKLE/FOOT ORTHOSIS SPLINT,430,173.35,147.35,Pays at 85% of Billed charges for outpatient setting,55.73,Pays at 32.15% of Total Billed charges,138.73,Pays at 80.03% of Total Billed charges,NA,Not Applicable,156.02,Pays at 90% of Total Billed charges,55.73,Pays at 32.15% of Total Billed charges,NA,Not Applicable,55.73,Pays at 32.15% of Total Billed charges,152.55,Pays at 88% of Total Billed charges,57.4,Pays at 33.11% of Total Billed charges,55.73,156.02,104.01
Outpatient Medical Services,THERAPY,L3660,O/T SHOULDER IMMOBILIZER FAST WRAP,430,87.7,74.55,Pays at 85% of Billed charges for outpatient setting,28.2,Pays at 32.15% of Total Billed charges,70.19,Pays at 80.03% of Total Billed charges,NA,Not Applicable,78.93,Pays at 90% of Total Billed charges,28.2,Pays at 32.15% of Total Billed charges,NA,Not Applicable,28.2,Pays at 32.15% of Total Billed charges,77.18,Pays at 88% of Total Billed charges,29.04,Pays at 33.11% of Total Billed charges,28.2,78.93,52.62
Outpatient Medical Services,THERAPY,L3700,P/T NEOPRENE TENNIS ELBOW STRAP,424,146.75,124.74,Pays at 85% of Billed charges for outpatient setting,47.18,Pays at 32.15% of Total Billed charges,117.44,Pays at 80.03% of Total Billed charges,NA,Not Applicable,132.08,Pays at 90% of Total Billed charges,47.18,Pays at 32.15% of Total Billed charges,NA,Not Applicable,47.18,Pays at 32.15% of Total Billed charges,129.14,Pays at 88% of Total Billed charges,48.59,Pays at 33.11% of Total Billed charges,47.18,132.08,88.05
Outpatient Medical Services,THERAPY,L3700,O/T NEOPRENE TENNIS ELBOW STRAP,430,146.75,124.74,Pays at 85% of Billed charges for outpatient setting,47.18,Pays at 32.15% of Total Billed charges,117.44,Pays at 80.03% of Total Billed charges,NA,Not Applicable,132.08,Pays at 90% of Total Billed charges,47.18,Pays at 32.15% of Total Billed charges,NA,Not Applicable,47.18,Pays at 32.15% of Total Billed charges,129.14,Pays at 88% of Total Billed charges,48.59,Pays at 33.11% of Total Billed charges,47.18,132.08,88.05
Outpatient Medical Services,THERAPY,L3701,O/T NEOPRENE ELBOW SLEEVE,430,194,164.9,Pays at 85% of Billed charges for outpatient setting,62.37,Pays at 32.15% of Total Billed charges,155.26,Pays at 80.03% of Total Billed charges,NA,Not Applicable,174.6,Pays at 90% of Total Billed charges,62.37,Pays at 32.15% of Total Billed charges,NA,Not Applicable,62.37,Pays at 32.15% of Total Billed charges,170.72,Pays at 88% of Total Billed charges,64.23,Pays at 33.11% of Total Billed charges,62.37,174.6,116.40
Outpatient Medical Services,THERAPY,L3805,O/T ULNAR NERVE OR MCP FLEXION SPLINTORT,430,467,396.95,Pays at 85% of Billed charges for outpatient setting,150.14,Pays at 32.15% of Total Billed charges,373.74,Pays at 80.03% of Total Billed charges,NA,Not Applicable,420.3,Pays at 90% of Total Billed charges,150.14,Pays at 32.15% of Total Billed charges,NA,Not Applicable,150.14,Pays at 32.15% of Total Billed charges,410.96,Pays at 88% of Total Billed charges,154.62,Pays at 33.11% of Total Billed charges,150.14,420.3,280.20
Outpatient Medical Services,THERAPY,L3805,O/T DORSAL BLOCKING SPLINT W/O DYNAMICS,430,548.25,466.01,Pays at 85% of Billed charges for outpatient setting,176.26,Pays at 32.15% of Total Billed charges,438.76,Pays at 80.03% of Total Billed charges,NA,Not Applicable,493.43,Pays at 90% of Total Billed charges,176.26,Pays at 32.15% of Total Billed charges,NA,Not Applicable,176.26,Pays at 32.15% of Total Billed charges,482.46,Pays at 88% of Total Billed charges,181.53,Pays at 33.11% of Total Billed charges,176.26,493.43,328.95
Outpatient Medical Services,THERAPY,L3805,O/T RADIUS/ULNAR FRACTURE BRACE FIT/ADJ,430,609.5,518.08,Pays at 85% of Billed charges for outpatient setting,195.95,Pays at 32.15% of Total Billed charges,487.78,Pays at 80.03% of Total Billed charges,NA,Not Applicable,548.55,Pays at 90% of Total Billed charges,195.95,Pays at 32.15% of Total Billed charges,NA,Not Applicable,195.95,Pays at 32.15% of Total Billed charges,536.36,Pays at 88% of Total Billed charges,201.81,Pays at 33.11% of Total Billed charges,195.95,548.55,365.70
Outpatient Medical Services,THERAPY,L3901,O/T DORSAL BLOCKING SPLINT WITH DYNAMICS,430,2361,2006.85,Pays at 85% of Billed charges for outpatient setting,759.06,Pays at 32.15% of Total Billed charges,1889.51,Pays at 80.03% of Total Billed charges,NA,Not Applicable,2124.9,Pays at 90% of Total Billed charges,759.06,Pays at 32.15% of Total Billed charges,NA,Not Applicable,759.06,Pays at 32.15% of Total Billed charges,2077.68,Pays at 88% of Total Billed charges,781.73,Pays at 33.11% of Total Billed charges,759.06,2124.9,1416.60
Outpatient Medical Services,THERAPY,L3906,O/T CUSTOM ULNAR GUTTER SPLINT,430,96.5,82.03,Pays at 85% of Billed charges for outpatient setting,31.02,Pays at 32.15% of Total Billed charges,77.23,Pays at 80.03% of Total Billed charges,NA,Not Applicable,86.85,Pays at 90% of Total Billed charges,31.02,Pays at 32.15% of Total Billed charges,NA,Not Applicable,31.02,Pays at 32.15% of Total Billed charges,84.92,Pays at 88% of Total Billed charges,31.95,Pays at 33.11% of Total Billed charges,31.02,86.85,57.90
Outpatient Medical Services,THERAPY,L3908,O/T WRIST DAY/TIMER,430,203.5,172.98,Pays at 85% of Billed charges for outpatient setting,65.43,Pays at 32.15% of Total Billed charges,162.86,Pays at 80.03% of Total Billed charges,NA,Not Applicable,183.15,Pays at 90% of Total Billed charges,65.43,Pays at 32.15% of Total Billed charges,NA,Not Applicable,65.43,Pays at 32.15% of Total Billed charges,179.08,Pays at 88% of Total Billed charges,67.38,Pays at 33.11% of Total Billed charges,65.43,183.15,122.10
Outpatient Medical Services,THERAPY,L3908,O/T WRIST NIGHT TIMER,430,203.5,172.98,Pays at 85% of Billed charges for outpatient setting,65.43,Pays at 32.15% of Total Billed charges,162.86,Pays at 80.03% of Total Billed charges,NA,Not Applicable,183.15,Pays at 90% of Total Billed charges,65.43,Pays at 32.15% of Total Billed charges,NA,Not Applicable,65.43,Pays at 32.15% of Total Billed charges,179.08,Pays at 88% of Total Billed charges,67.38,Pays at 33.11% of Total Billed charges,65.43,183.15,122.10
Outpatient Medical Services,THERAPY,L3911,O/T NEOPRENE THUMB SUPPORT,430,203.5,172.98,Pays at 85% of Billed charges for outpatient setting,65.43,Pays at 32.15% of Total Billed charges,162.86,Pays at 80.03% of Total Billed charges,NA,Not Applicable,183.15,Pays at 90% of Total Billed charges,65.43,Pays at 32.15% of Total Billed charges,NA,Not Applicable,65.43,Pays at 32.15% of Total Billed charges,179.08,Pays at 88% of Total Billed charges,67.38,Pays at 33.11% of Total Billed charges,65.43,183.15,122.10
Outpatient Medical Services,THERAPY,L3912,O/T FLEXION GLOVE & ELASTIC FINGER FIT/A,430,283.75,241.19,Pays at 85% of Billed charges for outpatient setting,91.23,Pays at 32.15% of Total Billed charges,227.09,Pays at 80.03% of Total Billed charges,NA,Not Applicable,255.38,Pays at 90% of Total Billed charges,91.23,Pays at 32.15% of Total Billed charges,NA,Not Applicable,91.23,Pays at 32.15% of Total Billed charges,249.7,Pays at 88% of Total Billed charges,93.95,Pays at 33.11% of Total Billed charges,91.23,255.38,170.25
Outpatient Medical Services,THERAPY,L3920,O/T FINGER SPLINT WITH OUTRIGGER,430,272.25,231.41,Pays at 85% of Billed charges for outpatient setting,87.53,Pays at 32.15% of Total Billed charges,217.88,Pays at 80.03% of Total Billed charges,NA,Not Applicable,245.03,Pays at 90% of Total Billed charges,87.53,Pays at 32.15% of Total Billed charges,NA,Not Applicable,87.53,Pays at 32.15% of Total Billed charges,239.58,Pays at 88% of Total Billed charges,90.14,Pays at 33.11% of Total Billed charges,87.53,245.03,163.35
Outpatient Medical Services,THERAPY,L3948,O/T FINGER BUDDY STRAP,430,121.5,103.28,Pays at 85% of Billed charges for outpatient setting,39.06,Pays at 32.15% of Total Billed charges,97.24,Pays at 80.03% of Total Billed charges,NA,Not Applicable,109.35,Pays at 90% of Total Billed charges,39.06,Pays at 32.15% of Total Billed charges,NA,Not Applicable,39.06,Pays at 32.15% of Total Billed charges,106.92,Pays at 88% of Total Billed charges,40.23,Pays at 33.11% of Total Billed charges,39.06,109.35,72.90
Outpatient Medical Services,THERAPY,L3980,O/T HUMERAL FRACTURE BRACE,430,619.5,526.58,Pays at 85% of Billed charges for outpatient setting,199.17,Pays at 32.15% of Total Billed charges,495.79,Pays at 80.03% of Total Billed charges,NA,Not Applicable,557.55,Pays at 90% of Total Billed charges,199.17,Pays at 32.15% of Total Billed charges,NA,Not Applicable,199.17,Pays at 32.15% of Total Billed charges,545.16,Pays at 88% of Total Billed charges,205.12,Pays at 33.11% of Total Billed charges,199.17,557.55,371.70
Outpatient Medical Services,THERAPY,S8424,O/T COMPRESSION SLEEVE,430,284.75,242.04,Pays at 85% of Billed charges for outpatient setting,91.55,Pays at 32.15% of Total Billed charges,227.89,Pays at 80.03% of Total Billed charges,NA,Not Applicable,256.28,Pays at 90% of Total Billed charges,91.55,Pays at 32.15% of Total Billed charges,NA,Not Applicable,91.55,Pays at 32.15% of Total Billed charges,250.58,Pays at 88% of Total Billed charges,94.28,Pays at 33.11% of Total Billed charges,91.55,256.28,170.85
Outpatient Medical Services,SLEEP,730,SLEEP APNEA STUDY,730,669.37,568.96,Pays at 85% of Billed charges for outpatient setting,215.2,Pays at 32.15% of Total Billed charges,535.7,Pays at 80.03% of Total Billed charges,NA,Not Applicable,602.43,Pays at 90% of Total Billed charges,215.2,Pays at 32.15% of Total Billed charges,NA,Not Applicable,215.2,Pays at 32.15% of Total Billed charges,589.05,Pays at 88% of Total Billed charges,221.63,Pays at 33.11% of Total Billed charges,215.2,602.43,401.62
Outpatient Medical Services,SLEEP,59020,STRESS TEST OCT,920,356,302.6,Pays at 85% of Billed charges for outpatient setting,114.45,Pays at 32.15% of Total Billed charges,284.91,Pays at 80.03% of Total Billed charges,170.77,Pays at 102% of Medicare OPPS Rate,320.4,Pays at 90% of Total Billed charges,114.45,Pays at 32.15% of Total Billed charges,167.41,Pays at 100% of Medicare OPPS Rate,114.45,Pays at 32.15% of Total Billed charges,313.28,Pays at 88% of Total Billed charges,117.87,Pays at 33.11% of Total Billed charges,114.45,320.4,213.60
Outpatient Medical Services,SLEEP,59025,A common prenatal test used to check on a baby's health.,920,416,353.6,Pays at 85% of Billed charges for outpatient setting,133.74,Pays at 32.15% of Total Billed charges,332.92,Pays at 80.03% of Total Billed charges,170.77,Pays at 102% of Medicare OPPS Rate,374.4,Pays at 90% of Total Billed charges,133.74,Pays at 32.15% of Total Billed charges,167.41,Pays at 100% of Medicare OPPS Rate,133.74,Pays at 32.15% of Total Billed charges,366.08,Pays at 88% of Total Billed charges,137.74,Pays at 33.11% of Total Billed charges,133.74,374.4,249.60
Outpatient Medical Services,SLEEP,95805,MAINTENANCE OF WAKEFULLNESS TESTING,920,772,656.2,Pays at 85% of Billed charges for outpatient setting,248.2,Pays at 32.15% of Total Billed charges,617.83,Pays at 80.03% of Total Billed charges,463.45,Pays at 102% of Medicare OPPS Rate,694.8,Pays at 90% of Total Billed charges,248.2,Pays at 32.15% of Total Billed charges,454.37,Pays at 100% of Medicare OPPS Rate,248.2,Pays at 32.15% of Total Billed charges,679.36,Pays at 88% of Total Billed charges,255.61,Pays at 33.11% of Total Billed charges,248.2,694.8,463.20
Outpatient Medical Services,SLEEP,95810,Sleep monitoring of patient (6 years or older) in sleep lab,920,2727.75,2318.59,Pays at 85% of Billed charges for outpatient setting,876.97,Pays at 32.15% of Total Billed charges,2183.02,Pays at 80.03% of Total Billed charges,895.78,Pays at 102% of Medicare OPPS Rate,2454.98,Pays at 90% of Total Billed charges,876.97,Pays at 32.15% of Total Billed charges,878.23,Pays at 100% of Medicare OPPS Rate,876.97,Pays at 32.15% of Total Billed charges,2400.42,Pays at 88% of Total Billed charges,903.16,Pays at 33.11% of Total Billed charges,876.97,2454.98,1636.65
Outpatient Medical Services,SLEEP,95811,Sleep monitoring of patient (6 years or older) in sleep lab using CPAP,920,3270.5,2779.93,Pays at 85% of Billed charges for outpatient setting,1051.47,Pays at 32.15% of Total Billed charges,2617.38,Pays at 80.03% of Total Billed charges,895.78,Pays at 102% of Medicare OPPS Rate,2943.45,Pays at 90% of Total Billed charges,1051.47,Pays at 32.15% of Total Billed charges,878.23,Pays at 100% of Medicare OPPS Rate,1051.47,Pays at 32.15% of Total Billed charges,2878.04,Pays at 88% of Total Billed charges,1082.86,Pays at 33.11% of Total Billed charges,878.23,2943.45,1962.30
Outpatient Medical Services,SLEEP,95972,ANALYSIS OF NEUROSTIM PULSE GENERATOR,920,251.5,213.78,Pays at 85% of Billed charges for outpatient setting,80.86,Pays at 32.15% of Total Billed charges,201.28,Pays at 80.03% of Total Billed charges,95.67,Pays at 102% of Medicare OPPS Rate,226.35,Pays at 90% of Total Billed charges,80.86,Pays at 32.15% of Total Billed charges,93.8,Pays at 100% of Medicare OPPS Rate,80.86,Pays at 32.15% of Total Billed charges,221.32,Pays at 88% of Total Billed charges,83.27,Pays at 33.11% of Total Billed charges,80.86,226.35,150.90
Outpatient Medical Services,SLEEP,95810,Sleep monitoring of patient (6 years or older) in sleep lab,920,2336,1985.6,Pays at 85% of Billed charges for outpatient setting,751.02,Pays at 32.15% of Total Billed charges,1869.5,Pays at 80.03% of Total Billed charges,895.78,Pays at 102% of Medicare OPPS Rate,2102.4,Pays at 90% of Total Billed charges,751.02,Pays at 32.15% of Total Billed charges,878.23,Pays at 100% of Medicare OPPS Rate,751.02,Pays at 32.15% of Total Billed charges,2055.68,Pays at 88% of Total Billed charges,773.45,Pays at 33.11% of Total Billed charges,751.02,2102.4,1401.60
Outpatient Medical Services,SLEEP,95811,Sleep monitoring of patient (6 years or older) in sleep lab using CPAP,920,2336,1985.6,Pays at 85% of Billed charges for outpatient setting,751.02,Pays at 32.15% of Total Billed charges,1869.5,Pays at 80.03% of Total Billed charges,895.78,Pays at 102% of Medicare OPPS Rate,2102.4,Pays at 90% of Total Billed charges,751.02,Pays at 32.15% of Total Billed charges,878.23,Pays at 100% of Medicare OPPS Rate,751.02,Pays at 32.15% of Total Billed charges,2055.68,Pays at 88% of Total Billed charges,773.45,Pays at 33.11% of Total Billed charges,751.02,2102.4,1401.60
Outpatient Medical Services,EMERGENCY ROOM,10060,Incision and drainage of abscess; simple or single and complex or multiple,450,307.5,261.38,Pays at 85% of Billed charges for outpatient setting,98.86,Pays at 32.15% of Total Billed charges,246.09,Pays at 80.03% of Total Billed charges,173.11,Pays at 102% of Medicare OPPS Rate,276.75,Pays at 90% of Total Billed charges,98.86,Pays at 32.15% of Total Billed charges,169.72,Pays at 100% of Medicare OPPS Rate,98.86,Pays at 32.15% of Total Billed charges,270.6,Pays at 88% of Total Billed charges,101.81,Pays at 33.11% of Total Billed charges,98.86,276.75,184.50
Outpatient Medical Services,EMERGENCY ROOM,10060,Incision and drainage of abscess; simple or single and complex or multiple,450,545.94,464.05,Pays at 85% of Billed charges for outpatient setting,175.52,Pays at 32.15% of Total Billed charges,436.92,Pays at 80.03% of Total Billed charges,173.11,Pays at 102% of Medicare OPPS Rate,491.35,Pays at 90% of Total Billed charges,175.52,Pays at 32.15% of Total Billed charges,169.72,Pays at 100% of Medicare OPPS Rate,175.52,Pays at 32.15% of Total Billed charges,480.43,Pays at 88% of Total Billed charges,180.76,Pays at 33.11% of Total Billed charges,169.72,491.35,327.56
Outpatient Medical Services,EMERGENCY ROOM,10061,I & D ABSCESS COMPLICATED OR MULTIPLE,450,605.5,514.68,Pays at 85% of Billed charges for outpatient setting,194.67,Pays at 32.15% of Total Billed charges,484.58,Pays at 80.03% of Total Billed charges,357.66,Pays at 102% of Medicare OPPS Rate,544.95,Pays at 90% of Total Billed charges,194.67,Pays at 32.15% of Total Billed charges,350.64,Pays at 100% of Medicare OPPS Rate,194.67,Pays at 32.15% of Total Billed charges,532.84,Pays at 88% of Total Billed charges,200.48,Pays at 33.11% of Total Billed charges,194.67,544.95,363.30
Outpatient Medical Services,EMERGENCY ROOM,10080,I & D PILONIDAL CYST,450,1078,916.3,Pays at 85% of Billed charges for outpatient setting,346.58,Pays at 32.15% of Total Billed charges,862.72,Pays at 80.03% of Total Billed charges,622.15,Pays at 102% of Medicare OPPS Rate,970.2,Pays at 90% of Total Billed charges,346.58,Pays at 32.15% of Total Billed charges,609.96,Pays at 100% of Medicare OPPS Rate,346.58,Pays at 32.15% of Total Billed charges,948.64,Pays at 88% of Total Billed charges,356.93,Pays at 33.11% of Total Billed charges,346.58,970.2,646.80
Outpatient Medical Services,EMERGENCY ROOM,10081,I & D PILONIDAL CYST-COMPLICATED,450,1115.75,948.39,Pays at 85% of Billed charges for outpatient setting,358.71,Pays at 32.15% of Total Billed charges,892.93,Pays at 80.03% of Total Billed charges,622.15,Pays at 102% of Medicare OPPS Rate,1004.18,Pays at 90% of Total Billed charges,358.71,Pays at 32.15% of Total Billed charges,609.96,Pays at 100% of Medicare OPPS Rate,358.71,Pays at 32.15% of Total Billed charges,981.86,Pays at 88% of Total Billed charges,369.42,Pays at 33.11% of Total Billed charges,358.71,1004.18,669.45
Outpatient Medical Services,EMERGENCY ROOM,10120,I & REM F.B. SIMPLE,450,804.25,683.61,Pays at 85% of Billed charges for outpatient setting,258.57,Pays at 32.15% of Total Billed charges,643.64,Pays at 80.03% of Total Billed charges,357.66,Pays at 102% of Medicare OPPS Rate,723.83,Pays at 90% of Total Billed charges,258.57,Pays at 32.15% of Total Billed charges,350.64,Pays at 100% of Medicare OPPS Rate,258.57,Pays at 32.15% of Total Billed charges,707.74,Pays at 88% of Total Billed charges,266.29,Pays at 33.11% of Total Billed charges,258.57,723.83,482.55
Outpatient Medical Services,EMERGENCY ROOM,10121,I & REM F.B. COMPLICATED,450,2558.5,2174.73,Pays at 85% of Billed charges for outpatient setting,822.56,Pays at 32.15% of Total Billed charges,2047.57,Pays at 80.03% of Total Billed charges,1437.62,Pays at 102% of Medicare OPPS Rate,2302.65,Pays at 90% of Total Billed charges,822.56,Pays at 32.15% of Total Billed charges,1409.43,Pays at 100% of Medicare OPPS Rate,822.56,Pays at 32.15% of Total Billed charges,2251.48,Pays at 88% of Total Billed charges,847.12,Pays at 33.11% of Total Billed charges,822.56,2302.65,1535.10
Outpatient Medical Services,EMERGENCY ROOM,10140,"Incision and drainage of hematoma, seroma or fluid collection",450,2558.5,2174.73,Pays at 85% of Billed charges for outpatient setting,822.56,Pays at 32.15% of Total Billed charges,2047.57,Pays at 80.03% of Total Billed charges,1437.62,Pays at 102% of Medicare OPPS Rate,2302.65,Pays at 90% of Total Billed charges,822.56,Pays at 32.15% of Total Billed charges,1409.43,Pays at 100% of Medicare OPPS Rate,822.56,Pays at 32.15% of Total Billed charges,2251.48,Pays at 88% of Total Billed charges,847.12,Pays at 33.11% of Total Billed charges,822.56,2302.65,1535.10
Outpatient Medical Services,EMERGENCY ROOM,10160,"Puncture aspiration of abscess, hematoma, bulla, or cyst",450,605.5,514.68,Pays at 85% of Billed charges for outpatient setting,194.67,Pays at 32.15% of Total Billed charges,484.58,Pays at 80.03% of Total Billed charges,357.66,Pays at 102% of Medicare OPPS Rate,544.95,Pays at 90% of Total Billed charges,194.67,Pays at 32.15% of Total Billed charges,350.64,Pays at 100% of Medicare OPPS Rate,194.67,Pays at 32.15% of Total Billed charges,532.84,Pays at 88% of Total Billed charges,200.48,Pays at 33.11% of Total Billed charges,194.67,544.95,363.30
Outpatient Medical Services,EMERGENCY ROOM,11000,Removal of infected skin,450,656.25,557.81,Pays at 85% of Billed charges for outpatient setting,210.98,Pays at 32.15% of Total Billed charges,525.2,Pays at 80.03% of Total Billed charges,556.95,Pays at 102% of Medicare OPPS Rate,590.63,Pays at 90% of Total Billed charges,210.98,Pays at 32.15% of Total Billed charges,546.03,Pays at 100% of Medicare OPPS Rate,210.98,Pays at 32.15% of Total Billed charges,577.5,Pays at 88% of Total Billed charges,217.28,Pays at 33.11% of Total Billed charges,210.98,590.63,393.75
Outpatient Medical Services,EMERGENCY ROOM,11012,DEBRIDE SKIN/BONE AT FRACTURE SITE,450,4446.25,3779.31,Pays at 85% of Billed charges for outpatient setting,1429.47,Pays at 32.15% of Total Billed charges,3558.33,Pays at 80.03% of Total Billed charges,2476.56,Pays at 102% of Medicare OPPS Rate,4001.63,Pays at 90% of Total Billed charges,1429.47,Pays at 32.15% of Total Billed charges,2428.02,Pays at 100% of Medicare OPPS Rate,1429.47,Pays at 32.15% of Total Billed charges,3912.7,Pays at 88% of Total Billed charges,1472.15,Pays at 33.11% of Total Billed charges,1429.47,4001.63,2667.75
Outpatient Medical Services,EMERGENCY ROOM,11042,"DEBRIDEMENT SKIN, PARTIAL THICKNESS",450,605.5,514.68,Pays at 85% of Billed charges for outpatient setting,194.67,Pays at 32.15% of Total Billed charges,484.58,Pays at 80.03% of Total Billed charges,357.66,Pays at 102% of Medicare OPPS Rate,544.95,Pays at 90% of Total Billed charges,194.67,Pays at 32.15% of Total Billed charges,350.64,Pays at 100% of Medicare OPPS Rate,194.67,Pays at 32.15% of Total Billed charges,532.84,Pays at 88% of Total Billed charges,200.48,Pays at 33.11% of Total Billed charges,194.67,544.95,363.30
Outpatient Medical Services,EMERGENCY ROOM,11403,EXCISION BENIGN LESION,450,1115.75,948.39,Pays at 85% of Billed charges for outpatient setting,358.71,Pays at 32.15% of Total Billed charges,892.93,Pays at 80.03% of Total Billed charges,622.15,Pays at 102% of Medicare OPPS Rate,1004.18,Pays at 90% of Total Billed charges,358.71,Pays at 32.15% of Total Billed charges,609.96,Pays at 100% of Medicare OPPS Rate,358.71,Pays at 32.15% of Total Billed charges,981.86,Pays at 88% of Total Billed charges,369.42,Pays at 33.11% of Total Billed charges,358.71,1004.18,669.45
Outpatient Medical Services,EMERGENCY ROOM,11421,EXCIS BEN LSN SCLP NK HNDS FT GEN 0.6-1C,450,1033,878.05,Pays at 85% of Billed charges for outpatient setting,332.11,Pays at 32.15% of Total Billed charges,826.71,Pays at 80.03% of Total Billed charges,622.15,Pays at 102% of Medicare OPPS Rate,929.7,Pays at 90% of Total Billed charges,332.11,Pays at 32.15% of Total Billed charges,609.96,Pays at 100% of Medicare OPPS Rate,332.11,Pays at 32.15% of Total Billed charges,909.04,Pays at 88% of Total Billed charges,342.03,Pays at 33.11% of Total Billed charges,332.11,929.7,619.80
Outpatient Medical Services,EMERGENCY ROOM,11603,EXCISION MALIGNANT LESION,450,1482,1259.7,Pays at 85% of Billed charges for outpatient setting,476.46,Pays at 32.15% of Total Billed charges,1186.04,Pays at 80.03% of Total Billed charges,622.15,Pays at 102% of Medicare OPPS Rate,1333.8,Pays at 90% of Total Billed charges,476.46,Pays at 32.15% of Total Billed charges,609.96,Pays at 100% of Medicare OPPS Rate,476.46,Pays at 32.15% of Total Billed charges,1304.16,Pays at 88% of Total Billed charges,490.69,Pays at 33.11% of Total Billed charges,476.46,1333.8,889.20
Outpatient Medical Services,EMERGENCY ROOM,11720,DEBRIDEMENT OF NAIL NAY METHOD 1-5,450,112.75,95.84,Pays at 85% of Billed charges for outpatient setting,36.25,Pays at 32.15% of Total Billed charges,90.23,Pays at 80.03% of Total Billed charges,55.1,Pays at 102% of Medicare OPPS Rate,101.48,Pays at 90% of Total Billed charges,36.25,Pays at 32.15% of Total Billed charges,54.02,Pays at 100% of Medicare OPPS Rate,36.25,Pays at 32.15% of Total Billed charges,99.22,Pays at 88% of Total Billed charges,37.33,Pays at 33.11% of Total Billed charges,36.25,101.48,67.65
Outpatient Medical Services,EMERGENCY ROOM,11721,Removal of 6 or more nails,450,112.75,95.84,Pays at 85% of Billed charges for outpatient setting,36.25,Pays at 32.15% of Total Billed charges,90.23,Pays at 80.03% of Total Billed charges,55.1,Pays at 102% of Medicare OPPS Rate,101.48,Pays at 90% of Total Billed charges,36.25,Pays at 32.15% of Total Billed charges,54.02,Pays at 100% of Medicare OPPS Rate,36.25,Pays at 32.15% of Total Billed charges,99.22,Pays at 88% of Total Billed charges,37.33,Pays at 33.11% of Total Billed charges,36.25,101.48,67.65
Outpatient Medical Services,EMERGENCY ROOM,11730,Separation and removal of the entire nail plate or a portion of nail plate,450,436.75,371.24,Pays at 85% of Billed charges for outpatient setting,140.42,Pays at 32.15% of Total Billed charges,349.53,Pays at 80.03% of Total Billed charges,173.12,Pays at 102% of Medicare OPPS Rate,393.08,Pays at 90% of Total Billed charges,140.42,Pays at 32.15% of Total Billed charges,169.72,Pays at 100% of Medicare OPPS Rate,140.42,Pays at 32.15% of Total Billed charges,384.34,Pays at 88% of Total Billed charges,144.61,Pays at 33.11% of Total Billed charges,140.42,393.08,262.05
Outpatient Medical Services,EMERGENCY ROOM,11732,EACH ADDITIONAL NAIL PLATE,450,236,200.6,Pays at 85% of Billed charges for outpatient setting,75.87,Pays at 32.15% of Total Billed charges,188.87,Pays at 80.03% of Total Billed charges,NA,Not Applicable,212.4,Pays at 90% of Total Billed charges,75.87,Pays at 32.15% of Total Billed charges,NA,Not Applicable,75.87,Pays at 32.15% of Total Billed charges,207.68,Pays at 88% of Total Billed charges,78.14,Pays at 33.11% of Total Billed charges,75.87,212.4,141.60
Outpatient Medical Services,EMERGENCY ROOM,11740,EVAC. SUBUNGUAL HEM,450,112.75,95.84,Pays at 85% of Billed charges for outpatient setting,36.25,Pays at 32.15% of Total Billed charges,90.23,Pays at 80.03% of Total Billed charges,111.31,Pays at 102% of Medicare OPPS Rate,101.48,Pays at 90% of Total Billed charges,36.25,Pays at 32.15% of Total Billed charges,109.13,Pays at 100% of Medicare OPPS Rate,36.25,Pays at 32.15% of Total Billed charges,99.22,Pays at 88% of Total Billed charges,37.33,Pays at 33.11% of Total Billed charges,36.25,111.31,67.65
Outpatient Medical Services,EMERGENCY ROOM,11750,REMOVAL OF NAIL BED PERMANENT,450,804.25,683.61,Pays at 85% of Billed charges for outpatient setting,258.57,Pays at 32.15% of Total Billed charges,643.64,Pays at 80.03% of Total Billed charges,357.66,Pays at 102% of Medicare OPPS Rate,723.83,Pays at 90% of Total Billed charges,258.57,Pays at 32.15% of Total Billed charges,350.64,Pays at 100% of Medicare OPPS Rate,258.57,Pays at 32.15% of Total Billed charges,707.74,Pays at 88% of Total Billed charges,266.29,Pays at 33.11% of Total Billed charges,258.57,723.83,482.55
Outpatient Medical Services,EMERGENCY ROOM,11760,REPAIR OF NAIL BED SIMPLE,450,937.75,797.09,Pays at 85% of Billed charges for outpatient setting,301.49,Pays at 32.15% of Total Billed charges,750.48,Pays at 80.03% of Total Billed charges,556.95,Pays at 102% of Medicare OPPS Rate,843.98,Pays at 90% of Total Billed charges,301.49,Pays at 32.15% of Total Billed charges,546.03,Pays at 100% of Medicare OPPS Rate,301.49,Pays at 32.15% of Total Billed charges,825.22,Pays at 88% of Total Billed charges,310.49,Pays at 33.11% of Total Billed charges,301.49,843.98,562.65
Outpatient Medical Services,EMERGENCY ROOM,11765,WEDGE EXCISION INGROWN NAIL,450,605.5,514.68,Pays at 85% of Billed charges for outpatient setting,194.67,Pays at 32.15% of Total Billed charges,484.58,Pays at 80.03% of Total Billed charges,357.66,Pays at 102% of Medicare OPPS Rate,544.95,Pays at 90% of Total Billed charges,194.67,Pays at 32.15% of Total Billed charges,350.65,Pays at 100% of Medicare OPPS Rate,194.67,Pays at 32.15% of Total Billed charges,532.84,Pays at 88% of Total Billed charges,200.48,Pays at 33.11% of Total Billed charges,194.67,544.95,363.30
Outpatient Medical Services,EMERGENCY ROOM,12001,"Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities",450,545.94,464.05,Pays at 85% of Billed charges for outpatient setting,175.52,Pays at 32.15% of Total Billed charges,436.92,Pays at 80.03% of Total Billed charges,173.12,Pays at 102% of Medicare OPPS Rate,491.35,Pays at 90% of Total Billed charges,175.52,Pays at 32.15% of Total Billed charges,169.72,Pays at 100% of Medicare OPPS Rate,175.52,Pays at 32.15% of Total Billed charges,480.43,Pays at 88% of Total Billed charges,180.76,Pays at 33.11% of Total Billed charges,169.72,491.35,327.56
Outpatient Medical Services,EMERGENCY ROOM,12002,SIM LAC 2.6-7.5 CM,450,545.94,464.05,Pays at 85% of Billed charges for outpatient setting,175.52,Pays at 32.15% of Total Billed charges,436.92,Pays at 80.03% of Total Billed charges,173.12,Pays at 102% of Medicare OPPS Rate,491.35,Pays at 90% of Total Billed charges,175.52,Pays at 32.15% of Total Billed charges,169.72,Pays at 100% of Medicare OPPS Rate,175.52,Pays at 32.15% of Total Billed charges,480.43,Pays at 88% of Total Billed charges,180.76,Pays at 33.11% of Total Billed charges,169.72,491.35,327.56
Outpatient Medical Services,EMERGENCY ROOM,12004,SIM LAC 7.6-12.5 CM,450,436.75,371.24,Pays at 85% of Billed charges for outpatient setting,140.42,Pays at 32.15% of Total Billed charges,349.53,Pays at 80.03% of Total Billed charges,173.12,Pays at 102% of Medicare OPPS Rate,393.08,Pays at 90% of Total Billed charges,140.42,Pays at 32.15% of Total Billed charges,169.72,Pays at 100% of Medicare OPPS Rate,140.42,Pays at 32.15% of Total Billed charges,384.34,Pays at 88% of Total Billed charges,144.61,Pays at 33.11% of Total Billed charges,140.42,393.08,262.05
Outpatient Medical Services,EMERGENCY ROOM,12005,SIMPLE LAC 12.6-20.0 CM,450,804.25,683.61,Pays at 85% of Billed charges for outpatient setting,258.57,Pays at 32.15% of Total Billed charges,643.64,Pays at 80.03% of Total Billed charges,357.66,Pays at 102% of Medicare OPPS Rate,723.83,Pays at 90% of Total Billed charges,258.57,Pays at 32.15% of Total Billed charges,350.65,Pays at 100% of Medicare OPPS Rate,258.57,Pays at 32.15% of Total Billed charges,707.74,Pays at 88% of Total Billed charges,266.29,Pays at 33.11% of Total Billed charges,258.57,723.83,482.55
Outpatient Medical Services,EMERGENCY ROOM,12006,"SIM LAC BDY,SCLP,20.1-30.0 CM",450,605.5,514.68,Pays at 85% of Billed charges for outpatient setting,194.67,Pays at 32.15% of Total Billed charges,484.58,Pays at 80.03% of Total Billed charges,357.66,Pays at 102% of Medicare OPPS Rate,544.95,Pays at 90% of Total Billed charges,194.67,Pays at 32.15% of Total Billed charges,350.65,Pays at 100% of Medicare OPPS Rate,194.67,Pays at 32.15% of Total Billed charges,532.84,Pays at 88% of Total Billed charges,200.48,Pays at 33.11% of Total Billed charges,194.67,544.95,363.30
Outpatient Medical Services,EMERGENCY ROOM,12007,"SIM LAC RPR >30.0 CM BODY,SCALP",450,316.75,269.24,Pays at 85% of Billed charges for outpatient setting,101.84,Pays at 32.15% of Total Billed charges,253.5,Pays at 80.03% of Total Billed charges,173.11,Pays at 102% of Medicare OPPS Rate,285.08,Pays at 90% of Total Billed charges,101.84,Pays at 32.15% of Total Billed charges,169.72,Pays at 100% of Medicare OPPS Rate,101.84,Pays at 32.15% of Total Billed charges,278.74,Pays at 88% of Total Billed charges,104.88,Pays at 33.11% of Total Billed charges,101.84,285.08,190.05
Outpatient Medical Services,EMERGENCY ROOM,12011,"Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes",450,545.94,464.05,Pays at 85% of Billed charges for outpatient setting,175.52,Pays at 32.15% of Total Billed charges,436.92,Pays at 80.03% of Total Billed charges,173.12,Pays at 102% of Medicare OPPS Rate,491.35,Pays at 90% of Total Billed charges,175.52,Pays at 32.15% of Total Billed charges,169.72,Pays at 100% of Medicare OPPS Rate,175.52,Pays at 32.15% of Total Billed charges,480.43,Pays at 88% of Total Billed charges,180.76,Pays at 33.11% of Total Billed charges,169.72,491.35,327.56
Outpatient Medical Services,EMERGENCY ROOM,12013,SIM LAC 2.6-5.0 CM,450,436.75,371.24,Pays at 85% of Billed charges for outpatient setting,140.42,Pays at 32.15% of Total Billed charges,349.53,Pays at 80.03% of Total Billed charges,173.12,Pays at 102% of Medicare OPPS Rate,393.08,Pays at 90% of Total Billed charges,140.42,Pays at 32.15% of Total Billed charges,169.72,Pays at 100% of Medicare OPPS Rate,140.42,Pays at 32.15% of Total Billed charges,384.34,Pays at 88% of Total Billed charges,144.61,Pays at 33.11% of Total Billed charges,140.42,393.08,262.05
Outpatient Medical Services,EMERGENCY ROOM,12014,SIM LAC 5.1-7.5 CM,450,316.75,269.24,Pays at 85% of Billed charges for outpatient setting,101.84,Pays at 32.15% of Total Billed charges,253.5,Pays at 80.03% of Total Billed charges,173.12,Pays at 102% of Medicare OPPS Rate,285.08,Pays at 90% of Total Billed charges,101.84,Pays at 32.15% of Total Billed charges,169.72,Pays at 100% of Medicare OPPS Rate,101.84,Pays at 32.15% of Total Billed charges,278.74,Pays at 88% of Total Billed charges,104.88,Pays at 33.11% of Total Billed charges,101.84,285.08,190.05
Outpatient Medical Services,EMERGENCY ROOM,12015,SIM LAC 7.6-12.5 CM,450,436.75,371.24,Pays at 85% of Billed charges for outpatient setting,140.42,Pays at 32.15% of Total Billed charges,349.53,Pays at 80.03% of Total Billed charges,173.12,Pays at 102% of Medicare OPPS Rate,393.08,Pays at 90% of Total Billed charges,140.42,Pays at 32.15% of Total Billed charges,169.72,Pays at 100% of Medicare OPPS Rate,140.42,Pays at 32.15% of Total Billed charges,384.34,Pays at 88% of Total Billed charges,144.61,Pays at 33.11% of Total Billed charges,140.42,393.08,262.05
Outpatient Medical Services,EMERGENCY ROOM,12016,SIM LAC 12.6-20.0 CM,450,316.75,269.24,Pays at 85% of Billed charges for outpatient setting,101.84,Pays at 32.15% of Total Billed charges,253.5,Pays at 80.03% of Total Billed charges,357.66,Pays at 102% of Medicare OPPS Rate,285.08,Pays at 90% of Total Billed charges,101.84,Pays at 32.15% of Total Billed charges,350.65,Pays at 100% of Medicare OPPS Rate,101.84,Pays at 32.15% of Total Billed charges,278.74,Pays at 88% of Total Billed charges,104.88,Pays at 33.11% of Total Billed charges,101.84,357.66,190.05
Outpatient Medical Services,EMERGENCY ROOM,12017,SIM LAC 20.1-30.0 CM,450,605.5,514.68,Pays at 85% of Billed charges for outpatient setting,194.67,Pays at 32.15% of Total Billed charges,484.58,Pays at 80.03% of Total Billed charges,357.66,Pays at 102% of Medicare OPPS Rate,544.95,Pays at 90% of Total Billed charges,194.67,Pays at 32.15% of Total Billed charges,350.65,Pays at 100% of Medicare OPPS Rate,194.67,Pays at 32.15% of Total Billed charges,532.84,Pays at 88% of Total Billed charges,200.48,Pays at 33.11% of Total Billed charges,194.67,544.95,363.30
Outpatient Medical Services,EMERGENCY ROOM,12018,SIM LAC >30.0 CM,450,316.75,269.24,Pays at 85% of Billed charges for outpatient setting,101.84,Pays at 32.15% of Total Billed charges,253.5,Pays at 80.03% of Total Billed charges,173.12,Pays at 102% of Medicare OPPS Rate,285.08,Pays at 90% of Total Billed charges,101.84,Pays at 32.15% of Total Billed charges,169.72,Pays at 100% of Medicare OPPS Rate,101.84,Pays at 32.15% of Total Billed charges,278.74,Pays at 88% of Total Billed charges,104.88,Pays at 33.11% of Total Billed charges,101.84,285.08,190.05
Outpatient Medical Services,EMERGENCY ROOM,12020,"TX SUPERFICIAL WOUND DEHISCIENCE,SIMPLEC",450,937.75,797.09,Pays at 85% of Billed charges for outpatient setting,301.49,Pays at 32.15% of Total Billed charges,750.48,Pays at 80.03% of Total Billed charges,556.95,Pays at 102% of Medicare OPPS Rate,843.98,Pays at 90% of Total Billed charges,301.49,Pays at 32.15% of Total Billed charges,546.03,Pays at 100% of Medicare OPPS Rate,301.49,Pays at 32.15% of Total Billed charges,825.22,Pays at 88% of Total Billed charges,310.49,Pays at 33.11% of Total Billed charges,301.49,843.98,562.65
Outpatient Medical Services,EMERGENCY ROOM,12021,"TX SUPERFICIAL WOUND DEHISCIENCE,W/PACKI",450,605.5,514.68,Pays at 85% of Billed charges for outpatient setting,194.67,Pays at 32.15% of Total Billed charges,484.58,Pays at 80.03% of Total Billed charges,357.66,Pays at 102% of Medicare OPPS Rate,544.95,Pays at 90% of Total Billed charges,194.67,Pays at 32.15% of Total Billed charges,350.64,Pays at 100% of Medicare OPPS Rate,194.67,Pays at 32.15% of Total Billed charges,532.84,Pays at 88% of Total Billed charges,200.48,Pays at 33.11% of Total Billed charges,194.67,544.95,363.30
Outpatient Medical Services,EMERGENCY ROOM,12031,LYR CLS SCLP TRNK AXL EXTR < 2.5 CM,450,605.5,514.68,Pays at 85% of Billed charges for outpatient setting,194.67,Pays at 32.15% of Total Billed charges,484.58,Pays at 80.03% of Total Billed charges,357.66,Pays at 102% of Medicare OPPS Rate,544.95,Pays at 90% of Total Billed charges,194.67,Pays at 32.15% of Total Billed charges,350.64,Pays at 100% of Medicare OPPS Rate,194.67,Pays at 32.15% of Total Billed charges,532.84,Pays at 88% of Total Billed charges,200.48,Pays at 33.11% of Total Billed charges,194.67,544.95,363.30
Outpatient Medical Services,EMERGENCY ROOM,12032,"LAC INT BODY,SCALP 2.6-7.5 CM",450,605.5,514.68,Pays at 85% of Billed charges for outpatient setting,194.67,Pays at 32.15% of Total Billed charges,484.58,Pays at 80.03% of Total Billed charges,357.66,Pays at 102% of Medicare OPPS Rate,544.95,Pays at 90% of Total Billed charges,194.67,Pays at 32.15% of Total Billed charges,350.64,Pays at 100% of Medicare OPPS Rate,194.67,Pays at 32.15% of Total Billed charges,532.84,Pays at 88% of Total Billed charges,200.48,Pays at 33.11% of Total Billed charges,194.67,544.95,363.30
Outpatient Medical Services,EMERGENCY ROOM,12034,"INT LAC 7.6-12.5 CM BD,SC",450,605.5,514.68,Pays at 85% of Billed charges for outpatient setting,194.67,Pays at 32.15% of Total Billed charges,484.58,Pays at 80.03% of Total Billed charges,357.66,Pays at 102% of Medicare OPPS Rate,544.95,Pays at 90% of Total Billed charges,194.67,Pays at 32.15% of Total Billed charges,350.64,Pays at 100% of Medicare OPPS Rate,194.67,Pays at 32.15% of Total Billed charges,532.84,Pays at 88% of Total Billed charges,200.48,Pays at 33.11% of Total Billed charges,194.67,544.95,363.30
Outpatient Medical Services,EMERGENCY ROOM,12035,INT LAC 12.6-20.0 CM BD SC,450,605.5,514.68,Pays at 85% of Billed charges for outpatient setting,194.67,Pays at 32.15% of Total Billed charges,484.58,Pays at 80.03% of Total Billed charges,357.66,Pays at 102% of Medicare OPPS Rate,544.95,Pays at 90% of Total Billed charges,194.67,Pays at 32.15% of Total Billed charges,350.64,Pays at 100% of Medicare OPPS Rate,194.67,Pays at 32.15% of Total Billed charges,532.84,Pays at 88% of Total Billed charges,200.48,Pays at 33.11% of Total Billed charges,194.67,544.95,363.30
Outpatient Medical Services,EMERGENCY ROOM,12036,INT LAC 20.1-30CM BD SC,450,937.75,797.09,Pays at 85% of Billed charges for outpatient setting,301.49,Pays at 32.15% of Total Billed charges,750.48,Pays at 80.03% of Total Billed charges,556.95,Pays at 102% of Medicare OPPS Rate,843.98,Pays at 90% of Total Billed charges,301.49,Pays at 32.15% of Total Billed charges,546.03,Pays at 100% of Medicare OPPS Rate,301.49,Pays at 32.15% of Total Billed charges,825.22,Pays at 88% of Total Billed charges,310.49,Pays at 33.11% of Total Billed charges,301.49,843.98,562.65
Outpatient Medical Services,EMERGENCY ROOM,12037,LYR CLS SCLP TRNK AXL EXTR > 30.0 CM,450,5182.25,4404.91,Pays at 85% of Billed charges for outpatient setting,1666.09,Pays at 32.15% of Total Billed charges,4147.35,Pays at 80.03% of Total Billed charges,1654.58,Pays at 102% of Medicare OPPS Rate,4664.03,Pays at 90% of Total Billed charges,1666.09,Pays at 32.15% of Total Billed charges,1622.14,Pays at 100% of Medicare OPPS Rate,1666.09,Pays at 32.15% of Total Billed charges,4560.38,Pays at 88% of Total Billed charges,1715.84,Pays at 33.11% of Total Billed charges,1622.14,4664.03,3109.35
Outpatient Medical Services,EMERGENCY ROOM,12041,"INT LAC <2.5 CM NECK,HAND,FEET",450,605.5,514.68,Pays at 85% of Billed charges for outpatient setting,194.67,Pays at 32.15% of Total Billed charges,484.58,Pays at 80.03% of Total Billed charges,357.66,Pays at 102% of Medicare OPPS Rate,544.95,Pays at 90% of Total Billed charges,194.67,Pays at 32.15% of Total Billed charges,350.65,Pays at 100% of Medicare OPPS Rate,194.67,Pays at 32.15% of Total Billed charges,532.84,Pays at 88% of Total Billed charges,200.48,Pays at 33.11% of Total Billed charges,194.67,544.95,363.30
Outpatient Medical Services,EMERGENCY ROOM,12042,INT LAC 2.6-7.5 CM,450,605.5,514.68,Pays at 85% of Billed charges for outpatient setting,194.67,Pays at 32.15% of Total Billed charges,484.58,Pays at 80.03% of Total Billed charges,357.66,Pays at 102% of Medicare OPPS Rate,544.95,Pays at 90% of Total Billed charges,194.67,Pays at 32.15% of Total Billed charges,350.64,Pays at 100% of Medicare OPPS Rate,194.67,Pays at 32.15% of Total Billed charges,532.84,Pays at 88% of Total Billed charges,200.48,Pays at 33.11% of Total Billed charges,194.67,544.95,363.30
Outpatient Medical Services,EMERGENCY ROOM,12044,INT LAC 7.6-12.5 CM,450,937.75,797.09,Pays at 85% of Billed charges for outpatient setting,301.49,Pays at 32.15% of Total Billed charges,750.48,Pays at 80.03% of Total Billed charges,556.95,Pays at 102% of Medicare OPPS Rate,843.98,Pays at 90% of Total Billed charges,301.49,Pays at 32.15% of Total Billed charges,546.03,Pays at 100% of Medicare OPPS Rate,301.49,Pays at 32.15% of Total Billed charges,825.22,Pays at 88% of Total Billed charges,310.49,Pays at 33.11% of Total Billed charges,301.49,843.98,562.65
Outpatient Medical Services,EMERGENCY ROOM,12045,INT LAC 12.6-20.0 CM,450,937.75,797.09,Pays at 85% of Billed charges for outpatient setting,301.49,Pays at 32.15% of Total Billed charges,750.48,Pays at 80.03% of Total Billed charges,556.95,Pays at 102% of Medicare OPPS Rate,843.98,Pays at 90% of Total Billed charges,301.49,Pays at 32.15% of Total Billed charges,546.03,Pays at 100% of Medicare OPPS Rate,301.49,Pays at 32.15% of Total Billed charges,825.22,Pays at 88% of Total Billed charges,310.49,Pays at 33.11% of Total Billed charges,301.49,843.98,562.65
Outpatient Medical Services,EMERGENCY ROOM,12046,INT LAC 20.1-30.0 CM NHF,450,605.5,514.68,Pays at 85% of Billed charges for outpatient setting,194.67,Pays at 32.15% of Total Billed charges,484.58,Pays at 80.03% of Total Billed charges,556.95,Pays at 102% of Medicare OPPS Rate,544.95,Pays at 90% of Total Billed charges,194.67,Pays at 32.15% of Total Billed charges,546.03,Pays at 100% of Medicare OPPS Rate,194.67,Pays at 32.15% of Total Billed charges,532.84,Pays at 88% of Total Billed charges,200.48,Pays at 33.11% of Total Billed charges,194.67,556.95,363.30
Outpatient Medical Services,EMERGENCY ROOM,12047,INT LAC >30.0 CM NHF,450,2954,2510.9,Pays at 85% of Billed charges for outpatient setting,949.71,Pays at 32.15% of Total Billed charges,2364.09,Pays at 80.03% of Total Billed charges,1654.58,Pays at 102% of Medicare OPPS Rate,2658.6,Pays at 90% of Total Billed charges,949.71,Pays at 32.15% of Total Billed charges,1622.14,Pays at 100% of Medicare OPPS Rate,949.71,Pays at 32.15% of Total Billed charges,2599.52,Pays at 88% of Total Billed charges,978.07,Pays at 33.11% of Total Billed charges,949.71,2658.6,1772.40
Outpatient Medical Services,EMERGENCY ROOM,12051,"INT LAC <2.5 CM FACE,EARS,EYES",450,316.75,269.24,Pays at 85% of Billed charges for outpatient setting,101.84,Pays at 32.15% of Total Billed charges,253.5,Pays at 80.03% of Total Billed charges,357.66,Pays at 102% of Medicare OPPS Rate,285.08,Pays at 90% of Total Billed charges,101.84,Pays at 32.15% of Total Billed charges,350.64,Pays at 100% of Medicare OPPS Rate,101.84,Pays at 32.15% of Total Billed charges,278.74,Pays at 88% of Total Billed charges,104.88,Pays at 33.11% of Total Billed charges,101.84,357.66,190.05
Outpatient Medical Services,EMERGENCY ROOM,12052,INT LAC 2.6-5.0 CM,450,605.5,514.68,Pays at 85% of Billed charges for outpatient setting,194.67,Pays at 32.15% of Total Billed charges,484.58,Pays at 80.03% of Total Billed charges,357.66,Pays at 102% of Medicare OPPS Rate,544.95,Pays at 90% of Total Billed charges,194.67,Pays at 32.15% of Total Billed charges,350.64,Pays at 100% of Medicare OPPS Rate,194.67,Pays at 32.15% of Total Billed charges,532.84,Pays at 88% of Total Billed charges,200.48,Pays at 33.11% of Total Billed charges,194.67,544.95,363.30
Outpatient Medical Services,EMERGENCY ROOM,12053,INT LAC 5.1-7.5 CM,450,605.5,514.68,Pays at 85% of Billed charges for outpatient setting,194.67,Pays at 32.15% of Total Billed charges,484.58,Pays at 80.03% of Total Billed charges,357.66,Pays at 102% of Medicare OPPS Rate,544.95,Pays at 90% of Total Billed charges,194.67,Pays at 32.15% of Total Billed charges,350.64,Pays at 100% of Medicare OPPS Rate,194.67,Pays at 32.15% of Total Billed charges,532.84,Pays at 88% of Total Billed charges,200.48,Pays at 33.11% of Total Billed charges,194.67,544.95,363.30
Outpatient Medical Services,EMERGENCY ROOM,12054,INT LAC 7.6-12.5 CM,450,605.5,514.68,Pays at 85% of Billed charges for outpatient setting,194.67,Pays at 32.15% of Total Billed charges,484.58,Pays at 80.03% of Total Billed charges,357.66,Pays at 102% of Medicare OPPS Rate,544.95,Pays at 90% of Total Billed charges,194.67,Pays at 32.15% of Total Billed charges,350.65,Pays at 100% of Medicare OPPS Rate,194.67,Pays at 32.15% of Total Billed charges,532.84,Pays at 88% of Total Billed charges,200.48,Pays at 33.11% of Total Billed charges,194.67,544.95,363.30
Outpatient Medical Services,EMERGENCY ROOM,12055,INT LAC 12.6-20.0 CM,450,605.5,514.68,Pays at 85% of Billed charges for outpatient setting,194.67,Pays at 32.15% of Total Billed charges,484.58,Pays at 80.03% of Total Billed charges,357.66,Pays at 102% of Medicare OPPS Rate,544.95,Pays at 90% of Total Billed charges,194.67,Pays at 32.15% of Total Billed charges,350.64,Pays at 100% of Medicare OPPS Rate,194.67,Pays at 32.15% of Total Billed charges,532.84,Pays at 88% of Total Billed charges,200.48,Pays at 33.11% of Total Billed charges,194.67,544.95,363.30
Outpatient Medical Services,EMERGENCY ROOM,12056,INT LAC 20.6-30CM F/E,450,605.5,514.68,Pays at 85% of Billed charges for outpatient setting,194.67,Pays at 32.15% of Total Billed charges,484.58,Pays at 80.03% of Total Billed charges,357.66,Pays at 102% of Medicare OPPS Rate,544.95,Pays at 90% of Total Billed charges,194.67,Pays at 32.15% of Total Billed charges,350.65,Pays at 100% of Medicare OPPS Rate,194.67,Pays at 32.15% of Total Billed charges,532.84,Pays at 88% of Total Billed charges,200.48,Pays at 33.11% of Total Billed charges,194.67,544.95,363.30
Outpatient Medical Services,EMERGENCY ROOM,12057,"INT LAC RPR>30CM FACE,EARS,EYES",450,316.75,269.24,Pays at 85% of Billed charges for outpatient setting,101.84,Pays at 32.15% of Total Billed charges,253.5,Pays at 80.03% of Total Billed charges,357.66,Pays at 102% of Medicare OPPS Rate,285.08,Pays at 90% of Total Billed charges,101.84,Pays at 32.15% of Total Billed charges,350.64,Pays at 100% of Medicare OPPS Rate,101.84,Pays at 32.15% of Total Billed charges,278.74,Pays at 88% of Total Billed charges,104.88,Pays at 33.11% of Total Billed charges,101.84,357.66,190.05
Outpatient Medical Services,EMERGENCY ROOM,13100,CMPLX LAC 1.1-2.5 CM TRUNK,450,937.75,797.09,Pays at 85% of Billed charges for outpatient setting,301.49,Pays at 32.15% of Total Billed charges,750.48,Pays at 80.03% of Total Billed charges,556.95,Pays at 102% of Medicare OPPS Rate,843.98,Pays at 90% of Total Billed charges,301.49,Pays at 32.15% of Total Billed charges,546.03,Pays at 100% of Medicare OPPS Rate,301.49,Pays at 32.15% of Total Billed charges,825.22,Pays at 88% of Total Billed charges,310.49,Pays at 33.11% of Total Billed charges,301.49,843.98,562.65
Outpatient Medical Services,EMERGENCY ROOM,13101,CMPLX LAC 2.6-7.5 CM TRK,450,937.75,797.09,Pays at 85% of Billed charges for outpatient setting,301.49,Pays at 32.15% of Total Billed charges,750.48,Pays at 80.03% of Total Billed charges,556.95,Pays at 102% of Medicare OPPS Rate,843.98,Pays at 90% of Total Billed charges,301.49,Pays at 32.15% of Total Billed charges,546.03,Pays at 100% of Medicare OPPS Rate,301.49,Pays at 32.15% of Total Billed charges,825.22,Pays at 88% of Total Billed charges,310.49,Pays at 33.11% of Total Billed charges,301.49,843.98,562.65
Outpatient Medical Services,EMERGENCY ROOM,13102,CMPLX LAC TRK EACH ADDITIONAL 5CM OR LES,450,335.5,285.18,Pays at 85% of Billed charges for outpatient setting,107.86,Pays at 32.15% of Total Billed charges,268.5,Pays at 80.03% of Total Billed charges,NA,Not Applicable,301.95,Pays at 90% of Total Billed charges,107.86,Pays at 32.15% of Total Billed charges,NA,Not Applicable,107.86,Pays at 32.15% of Total Billed charges,295.24,Pays at 88% of Total Billed charges,111.08,Pays at 33.11% of Total Billed charges,107.86,301.95,201.30
Outpatient Medical Services,EMERGENCY ROOM,13120,"CMPLX LAC 1.1-2.5 CM SCALP,ARMS,LEGS",450,937.75,797.09,Pays at 85% of Billed charges for outpatient setting,301.49,Pays at 32.15% of Total Billed charges,750.48,Pays at 80.03% of Total Billed charges,556.95,Pays at 102% of Medicare OPPS Rate,843.98,Pays at 90% of Total Billed charges,301.49,Pays at 32.15% of Total Billed charges,546.03,Pays at 100% of Medicare OPPS Rate,301.49,Pays at 32.15% of Total Billed charges,825.22,Pays at 88% of Total Billed charges,310.49,Pays at 33.11% of Total Billed charges,301.49,843.98,562.65
Outpatient Medical Services,EMERGENCY ROOM,13121,"CMPLX LAC 2.6-7.5 CM SCLP,ARMS,LEGS",450,937.75,797.09,Pays at 85% of Billed charges for outpatient setting,301.49,Pays at 32.15% of Total Billed charges,750.48,Pays at 80.03% of Total Billed charges,556.95,Pays at 102% of Medicare OPPS Rate,843.98,Pays at 90% of Total Billed charges,301.49,Pays at 32.15% of Total Billed charges,546.03,Pays at 100% of Medicare OPPS Rate,301.49,Pays at 32.15% of Total Billed charges,825.22,Pays at 88% of Total Billed charges,310.49,Pays at 33.11% of Total Billed charges,301.49,843.98,562.65
Outpatient Medical Services,EMERGENCY ROOM,13122,"CMPLX LAC CM SCALP,ARMS,LEGS,EACH ADD 5C",450,335.5,285.18,Pays at 85% of Billed charges for outpatient setting,107.86,Pays at 32.15% of Total Billed charges,268.5,Pays at 80.03% of Total Billed charges,NA,Not Applicable,301.95,Pays at 90% of Total Billed charges,107.86,Pays at 32.15% of Total Billed charges,NA,Not Applicable,107.86,Pays at 32.15% of Total Billed charges,295.24,Pays at 88% of Total Billed charges,111.08,Pays at 33.11% of Total Billed charges,107.86,301.95,201.30
Outpatient Medical Services,EMERGENCY ROOM,13131,CMPLX LAC 1.1-2.5 CM FACE/NECK/HND/FT/AX,450,804.25,683.61,Pays at 85% of Billed charges for outpatient setting,258.57,Pays at 32.15% of Total Billed charges,643.64,Pays at 80.03% of Total Billed charges,357.66,Pays at 102% of Medicare OPPS Rate,723.83,Pays at 90% of Total Billed charges,258.57,Pays at 32.15% of Total Billed charges,350.64,Pays at 100% of Medicare OPPS Rate,258.57,Pays at 32.15% of Total Billed charges,707.74,Pays at 88% of Total Billed charges,266.29,Pays at 33.11% of Total Billed charges,258.57,723.83,482.55
Outpatient Medical Services,EMERGENCY ROOM,13132,"CMPLX LAC 2.6-7.5 CM FACE,H.F",450,937.75,797.09,Pays at 85% of Billed charges for outpatient setting,301.49,Pays at 32.15% of Total Billed charges,750.48,Pays at 80.03% of Total Billed charges,556.95,Pays at 102% of Medicare OPPS Rate,843.98,Pays at 90% of Total Billed charges,301.49,Pays at 32.15% of Total Billed charges,546.03,Pays at 100% of Medicare OPPS Rate,301.49,Pays at 32.15% of Total Billed charges,825.22,Pays at 88% of Total Billed charges,310.49,Pays at 33.11% of Total Billed charges,301.49,843.98,562.65
Outpatient Medical Services,EMERGENCY ROOM,13133,"CMPLX LAC FACE,H,F,EACH ADDITIONAL 5CM O",450,335.5,285.18,Pays at 85% of Billed charges for outpatient setting,107.86,Pays at 32.15% of Total Billed charges,268.5,Pays at 80.03% of Total Billed charges,NA,Not Applicable,301.95,Pays at 90% of Total Billed charges,107.86,Pays at 32.15% of Total Billed charges,NA,Not Applicable,107.86,Pays at 32.15% of Total Billed charges,295.24,Pays at 88% of Total Billed charges,111.08,Pays at 33.11% of Total Billed charges,107.86,301.95,201.30
Outpatient Medical Services,EMERGENCY ROOM,13151,"CMPLX LAC <1.1 CM NOSE,EARS,EYES,LIPS",450,937.75,797.09,Pays at 85% of Billed charges for outpatient setting,301.49,Pays at 32.15% of Total Billed charges,750.48,Pays at 80.03% of Total Billed charges,556.95,Pays at 102% of Medicare OPPS Rate,843.98,Pays at 90% of Total Billed charges,301.49,Pays at 32.15% of Total Billed charges,546.03,Pays at 100% of Medicare OPPS Rate,301.49,Pays at 32.15% of Total Billed charges,825.22,Pays at 88% of Total Billed charges,310.49,Pays at 33.11% of Total Billed charges,301.49,843.98,562.65
Outpatient Medical Services,EMERGENCY ROOM,13151,"CMPLX LAC 1.0-2.5CM  N,E,E,L",450,937.75,797.09,Pays at 85% of Billed charges for outpatient setting,301.49,Pays at 32.15% of Total Billed charges,750.48,Pays at 80.03% of Total Billed charges,556.95,Pays at 102% of Medicare OPPS Rate,843.98,Pays at 90% of Total Billed charges,301.49,Pays at 32.15% of Total Billed charges,546.03,Pays at 100% of Medicare OPPS Rate,301.49,Pays at 32.15% of Total Billed charges,825.22,Pays at 88% of Total Billed charges,310.49,Pays at 33.11% of Total Billed charges,301.49,843.98,562.65
Outpatient Medical Services,EMERGENCY ROOM,13152,"CMPLX LAC 2.6-7.5 CM N,E,E,L",450,937.75,797.09,Pays at 85% of Billed charges for outpatient setting,301.49,Pays at 32.15% of Total Billed charges,750.48,Pays at 80.03% of Total Billed charges,556.95,Pays at 102% of Medicare OPPS Rate,843.98,Pays at 90% of Total Billed charges,301.49,Pays at 32.15% of Total Billed charges,546.03,Pays at 100% of Medicare OPPS Rate,301.49,Pays at 32.15% of Total Billed charges,825.22,Pays at 88% of Total Billed charges,310.49,Pays at 33.11% of Total Billed charges,301.49,843.98,562.65
Outpatient Medical Services,EMERGENCY ROOM,13153,"CMPLX LAC N,E,E,L EA ADD 5CM OR LESS",450,335.5,285.18,Pays at 85% of Billed charges for outpatient setting,107.86,Pays at 32.15% of Total Billed charges,268.5,Pays at 80.03% of Total Billed charges,NA,Not Applicable,301.95,Pays at 90% of Total Billed charges,107.86,Pays at 32.15% of Total Billed charges,NA,Not Applicable,107.86,Pays at 32.15% of Total Billed charges,295.24,Pays at 88% of Total Billed charges,111.08,Pays at 33.11% of Total Billed charges,107.86,301.95,201.30
Outpatient Medical Services,EMERGENCY ROOM,15050,PINCH GRAFT UP TO 2 CM DIAMETER,450,937.75,797.09,Pays at 85% of Billed charges for outpatient setting,301.49,Pays at 32.15% of Total Billed charges,750.48,Pays at 80.03% of Total Billed charges,556.95,Pays at 102% of Medicare OPPS Rate,843.98,Pays at 90% of Total Billed charges,301.49,Pays at 32.15% of Total Billed charges,546.03,Pays at 100% of Medicare OPPS Rate,301.49,Pays at 32.15% of Total Billed charges,825.22,Pays at 88% of Total Billed charges,310.49,Pays at 33.11% of Total Billed charges,301.49,843.98,562.65
Outpatient Medical Services,EMERGENCY ROOM,16000,INITIAL TX BURN 1ST DEGREE LOCAL TX ONLY,450,316.75,269.24,Pays at 85% of Billed charges for outpatient setting,101.84,Pays at 32.15% of Total Billed charges,253.5,Pays at 80.03% of Total Billed charges,173.12,Pays at 102% of Medicare OPPS Rate,285.08,Pays at 90% of Total Billed charges,101.84,Pays at 32.15% of Total Billed charges,169.72,Pays at 100% of Medicare OPPS Rate,101.84,Pays at 32.15% of Total Billed charges,278.74,Pays at 88% of Total Billed charges,104.88,Pays at 33.11% of Total Billed charges,101.84,285.08,190.05
Outpatient Medical Services,EMERGENCY ROOM,16010,CLEAN/DEBR/C ANES SMALL,450,97,82.45,Pays at 85% of Billed charges for outpatient setting,31.19,Pays at 32.15% of Total Billed charges,77.63,Pays at 80.03% of Total Billed charges,97,Not Applicable,87.3,Pays at 90% of Total Billed charges,31.19,Pays at 32.15% of Total Billed charges,97,Not Applicable,31.19,Pays at 32.15% of Total Billed charges,85.36,Pays at 88% of Total Billed charges,32.12,Pays at 33.11% of Total Billed charges,31.19,97,58.20
Outpatient Medical Services,EMERGENCY ROOM,16015,CLEAN/DEBR/C ANES MED/LG,450,538,457.3,Pays at 85% of Billed charges for outpatient setting,172.97,Pays at 32.15% of Total Billed charges,430.56,Pays at 80.03% of Total Billed charges,538,Not Applicable,484.2,Pays at 90% of Total Billed charges,172.97,Pays at 32.15% of Total Billed charges,538,Not Applicable,172.97,Pays at 32.15% of Total Billed charges,473.44,Pays at 88% of Total Billed charges,178.13,Pays at 33.11% of Total Billed charges,172.97,538,322.80
Outpatient Medical Services,EMERGENCY ROOM,16020,DRESS OR DEBRIDE BURN SMALL 1-2 DEGREE,450,316.75,269.24,Pays at 85% of Billed charges for outpatient setting,101.84,Pays at 32.15% of Total Billed charges,253.5,Pays at 80.03% of Total Billed charges,173.12,Pays at 102% of Medicare OPPS Rate,285.08,Pays at 90% of Total Billed charges,101.84,Pays at 32.15% of Total Billed charges,169.72,Pays at 100% of Medicare OPPS Rate,101.84,Pays at 32.15% of Total Billed charges,278.74,Pays at 88% of Total Billed charges,104.88,Pays at 33.11% of Total Billed charges,101.84,285.08,190.05
Outpatient Medical Services,EMERGENCY ROOM,16025,DRESS OR DEBRIDE BURN MED 1-2 DEGREE,450,316.75,269.24,Pays at 85% of Billed charges for outpatient setting,101.84,Pays at 32.15% of Total Billed charges,253.5,Pays at 80.03% of Total Billed charges,173.11,Pays at 102% of Medicare OPPS Rate,285.08,Pays at 90% of Total Billed charges,101.84,Pays at 32.15% of Total Billed charges,169.72,Pays at 100% of Medicare OPPS Rate,101.84,Pays at 32.15% of Total Billed charges,278.74,Pays at 88% of Total Billed charges,104.88,Pays at 33.11% of Total Billed charges,101.84,285.08,190.05
Outpatient Medical Services,EMERGENCY ROOM,16030,DRESS OR DEBRIDE BURN LARGE 9%,450,605.5,514.68,Pays at 85% of Billed charges for outpatient setting,194.67,Pays at 32.15% of Total Billed charges,484.58,Pays at 80.03% of Total Billed charges,357.66,Pays at 102% of Medicare OPPS Rate,544.95,Pays at 90% of Total Billed charges,194.67,Pays at 32.15% of Total Billed charges,350.64,Pays at 100% of Medicare OPPS Rate,194.67,Pays at 32.15% of Total Billed charges,532.84,Pays at 88% of Total Billed charges,200.48,Pays at 33.11% of Total Billed charges,194.67,544.95,363.30
Outpatient Medical Services,EMERGENCY ROOM,20005,"INCISION OF SOFT TISSUE ABSCESS, SUPERFI",450,2558.5,2174.73,Pays at 85% of Billed charges for outpatient setting,822.56,Pays at 32.15% of Total Billed charges,2047.57,Pays at 80.03% of Total Billed charges,2558.5,Not Applicable,2302.65,Pays at 90% of Total Billed charges,822.56,Pays at 32.15% of Total Billed charges,2558.5,Not Applicable,822.56,Pays at 32.15% of Total Billed charges,2251.48,Pays at 88% of Total Billed charges,847.12,Pays at 33.11% of Total Billed charges,822.56,2558.5,1535.10
Outpatient Medical Services,EMERGENCY ROOM,20005,"INCISION OF SOFT TISSUE ABSCESS, DEEP/CO",450,2558.5,2174.73,Pays at 85% of Billed charges for outpatient setting,822.56,Pays at 32.15% of Total Billed charges,2047.57,Pays at 80.03% of Total Billed charges,2558.5,Not Applicable,2302.65,Pays at 90% of Total Billed charges,822.56,Pays at 32.15% of Total Billed charges,2558.5,Not Applicable,822.56,Pays at 32.15% of Total Billed charges,2251.48,Pays at 88% of Total Billed charges,847.12,Pays at 33.11% of Total Billed charges,822.56,2558.5,1535.10
Outpatient Medical Services,EMERGENCY ROOM,20100,EXPLORATION OF PENETRATING WOUND NECK,450,916,778.6,Pays at 85% of Billed charges for outpatient setting,294.49,Pays at 32.15% of Total Billed charges,733.07,Pays at 80.03% of Total Billed charges,437.94,Pays at 102% of Medicare OPPS Rate,824.4,Pays at 90% of Total Billed charges,294.49,Pays at 32.15% of Total Billed charges,429.36,Pays at 100% of Medicare OPPS Rate,294.49,Pays at 32.15% of Total Billed charges,806.08,Pays at 88% of Total Billed charges,303.29,Pays at 33.11% of Total Billed charges,294.49,824.4,549.60
Outpatient Medical Services,EMERGENCY ROOM,20101,EXPLORATION OF PENETRATING WOUND CHEST,450,2954,2510.9,Pays at 85% of Billed charges for outpatient setting,949.71,Pays at 32.15% of Total Billed charges,2364.09,Pays at 80.03% of Total Billed charges,1654.58,Pays at 102% of Medicare OPPS Rate,2658.6,Pays at 90% of Total Billed charges,949.71,Pays at 32.15% of Total Billed charges,1622.14,Pays at 100% of Medicare OPPS Rate,949.71,Pays at 32.15% of Total Billed charges,2599.52,Pays at 88% of Total Billed charges,978.07,Pays at 33.11% of Total Billed charges,949.71,2658.6,1772.40
Outpatient Medical Services,EMERGENCY ROOM,20102,EXPLORATION PENETRATING WOUND ABD/FLANK/,450,2954,2510.9,Pays at 85% of Billed charges for outpatient setting,949.71,Pays at 32.15% of Total Billed charges,2364.09,Pays at 80.03% of Total Billed charges,1654.58,Pays at 102% of Medicare OPPS Rate,2658.6,Pays at 90% of Total Billed charges,949.71,Pays at 32.15% of Total Billed charges,1622.14,Pays at 100% of Medicare OPPS Rate,949.71,Pays at 32.15% of Total Billed charges,2599.52,Pays at 88% of Total Billed charges,978.07,Pays at 33.11% of Total Billed charges,949.71,2658.6,1772.40
Outpatient Medical Services,EMERGENCY ROOM,20103,EXPLORATION OF PENETRATING WOUND EXTREMI,450,1115.75,948.39,Pays at 85% of Billed charges for outpatient setting,358.71,Pays at 32.15% of Total Billed charges,892.93,Pays at 80.03% of Total Billed charges,1437.62,Pays at 102% of Medicare OPPS Rate,1004.18,Pays at 90% of Total Billed charges,358.71,Pays at 32.15% of Total Billed charges,1409.43,Pays at 100% of Medicare OPPS Rate,358.71,Pays at 32.15% of Total Billed charges,981.86,Pays at 88% of Total Billed charges,369.42,Pays at 33.11% of Total Billed charges,358.71,1437.62,669.45
Outpatient Medical Services,EMERGENCY ROOM,20520,FB REM MUSCLE SIMPLE,450,2558.5,2174.73,Pays at 85% of Billed charges for outpatient setting,822.56,Pays at 32.15% of Total Billed charges,2047.57,Pays at 80.03% of Total Billed charges,1437.62,Pays at 102% of Medicare OPPS Rate,2302.65,Pays at 90% of Total Billed charges,822.56,Pays at 32.15% of Total Billed charges,1409.43,Pays at 100% of Medicare OPPS Rate,822.56,Pays at 32.15% of Total Billed charges,2251.48,Pays at 88% of Total Billed charges,847.12,Pays at 33.11% of Total Billed charges,822.56,2302.65,1535.10
Outpatient Medical Services,EMERGENCY ROOM,20525,FB REM MUSCLE COMPLEX,450,4446.25,3779.31,Pays at 85% of Billed charges for outpatient setting,1429.47,Pays at 32.15% of Total Billed charges,3558.33,Pays at 80.03% of Total Billed charges,2476.56,Pays at 102% of Medicare OPPS Rate,4001.63,Pays at 90% of Total Billed charges,1429.47,Pays at 32.15% of Total Billed charges,2428.02,Pays at 100% of Medicare OPPS Rate,1429.47,Pays at 32.15% of Total Billed charges,3912.7,Pays at 88% of Total Billed charges,1472.15,Pays at 33.11% of Total Billed charges,1429.47,4001.63,2667.75
Outpatient Medical Services,EMERGENCY ROOM,20552,INJECT TRIGGER POINT 1-2 MUSCLES,450,633.5,538.48,Pays at 85% of Billed charges for outpatient setting,203.67,Pays at 32.15% of Total Billed charges,506.99,Pays at 80.03% of Total Billed charges,260.64,Pays at 102% of Medicare OPPS Rate,570.15,Pays at 90% of Total Billed charges,203.67,Pays at 32.15% of Total Billed charges,255.55,Pays at 100% of Medicare OPPS Rate,203.67,Pays at 32.15% of Total Billed charges,557.48,Pays at 88% of Total Billed charges,209.75,Pays at 33.11% of Total Billed charges,203.67,570.15,380.10
Outpatient Medical Services,EMERGENCY ROOM,20553,Injection of medication into an area that triggers pain,450,478.25,406.51,Pays at 85% of Billed charges for outpatient setting,153.76,Pays at 32.15% of Total Billed charges,382.74,Pays at 80.03% of Total Billed charges,260.64,Pays at 102% of Medicare OPPS Rate,430.43,Pays at 90% of Total Billed charges,153.76,Pays at 32.15% of Total Billed charges,255.55,Pays at 100% of Medicare OPPS Rate,153.76,Pays at 32.15% of Total Billed charges,420.86,Pays at 88% of Total Billed charges,158.35,Pays at 33.11% of Total Billed charges,153.76,430.43,286.95
Outpatient Medical Services,EMERGENCY ROOM,20600,Draining or injecting medication into a small joint/bursa without ultrasound,450,478.25,406.51,Pays at 85% of Billed charges for outpatient setting,153.76,Pays at 32.15% of Total Billed charges,382.74,Pays at 80.03% of Total Billed charges,260.64,Pays at 102% of Medicare OPPS Rate,430.43,Pays at 90% of Total Billed charges,153.76,Pays at 32.15% of Total Billed charges,255.55,Pays at 100% of Medicare OPPS Rate,153.76,Pays at 32.15% of Total Billed charges,420.86,Pays at 88% of Total Billed charges,158.35,Pays at 33.11% of Total Billed charges,153.76,430.43,286.95
Outpatient Medical Services,EMERGENCY ROOM,20605,Draining or injecting medication into a large joint/bursa without ultrasound,450,478.25,406.51,Pays at 85% of Billed charges for outpatient setting,153.76,Pays at 32.15% of Total Billed charges,382.74,Pays at 80.03% of Total Billed charges,260.64,Pays at 102% of Medicare OPPS Rate,430.43,Pays at 90% of Total Billed charges,153.76,Pays at 32.15% of Total Billed charges,255.55,Pays at 100% of Medicare OPPS Rate,153.76,Pays at 32.15% of Total Billed charges,420.86,Pays at 88% of Total Billed charges,158.35,Pays at 33.11% of Total Billed charges,153.76,430.43,286.95
Outpatient Medical Services,EMERGENCY ROOM,20610,Draining or injecting medication into a major joint/bursa without ultrasound,450,631.25,536.56,Pays at 85% of Billed charges for outpatient setting,202.95,Pays at 32.15% of Total Billed charges,505.19,Pays at 80.03% of Total Billed charges,260.64,Pays at 102% of Medicare OPPS Rate,568.13,Pays at 90% of Total Billed charges,202.95,Pays at 32.15% of Total Billed charges,255.55,Pays at 100% of Medicare OPPS Rate,202.95,Pays at 32.15% of Total Billed charges,555.5,Pays at 88% of Total Billed charges,209.01,Pays at 33.11% of Total Billed charges,202.95,568.13,378.75
Outpatient Medical Services,EMERGENCY ROOM,20950,MONITORING FLUID PRESSURE FOR COMPARTMEN,450,1115.75,948.39,Pays at 85% of Billed charges for outpatient setting,358.71,Pays at 32.15% of Total Billed charges,892.93,Pays at 80.03% of Total Billed charges,622.15,Pays at 102% of Medicare OPPS Rate,1004.18,Pays at 90% of Total Billed charges,358.71,Pays at 32.15% of Total Billed charges,609.96,Pays at 100% of Medicare OPPS Rate,358.71,Pays at 32.15% of Total Billed charges,981.86,Pays at 88% of Total Billed charges,369.42,Pays at 33.11% of Total Billed charges,358.71,1004.18,669.45
Outpatient Medical Services,EMERGENCY ROOM,21310,CLSD TX NASAL FX W/O MANIP,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,414,Not Applicable,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,414,Not Applicable,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,414,248.40
Outpatient Medical Services,EMERGENCY ROOM,21315,CLSD TX NASAL FX W/O STABILIZATION,450,2148.75,1826.44,Pays at 85% of Billed charges for outpatient setting,690.82,Pays at 32.15% of Total Billed charges,1719.64,Pays at 80.03% of Total Billed charges,1330.81,Pays at 102% of Medicare OPPS Rate,1933.88,Pays at 90% of Total Billed charges,690.82,Pays at 32.15% of Total Billed charges,1304.72,Pays at 100% of Medicare OPPS Rate,690.82,Pays at 32.15% of Total Billed charges,1890.9,Pays at 88% of Total Billed charges,711.45,Pays at 33.11% of Total Billed charges,690.82,1933.88,1289.25
Outpatient Medical Services,EMERGENCY ROOM,21320,CLSD TX NASAL FX W/STABILIZATION,450,4498,3823.3,Pays at 85% of Billed charges for outpatient setting,1446.11,Pays at 32.15% of Total Billed charges,3599.75,Pays at 80.03% of Total Billed charges,2727.54,Pays at 102% of Medicare OPPS Rate,4048.2,Pays at 90% of Total Billed charges,1446.11,Pays at 32.15% of Total Billed charges,2674.06,Pays at 100% of Medicare OPPS Rate,1446.11,Pays at 32.15% of Total Billed charges,3958.24,Pays at 88% of Total Billed charges,1489.29,Pays at 33.11% of Total Billed charges,1446.11,4048.2,2698.80
Outpatient Medical Services,EMERGENCY ROOM,21450,TX MANIDIBULAR FX W/O MANIP,450,916,778.6,Pays at 85% of Billed charges for outpatient setting,294.49,Pays at 32.15% of Total Billed charges,733.07,Pays at 80.03% of Total Billed charges,437.94,Pays at 102% of Medicare OPPS Rate,824.4,Pays at 90% of Total Billed charges,294.49,Pays at 32.15% of Total Billed charges,429.36,Pays at 100% of Medicare OPPS Rate,294.49,Pays at 32.15% of Total Billed charges,806.08,Pays at 88% of Total Billed charges,303.29,Pays at 33.11% of Total Billed charges,294.49,824.4,549.60
Outpatient Medical Services,EMERGENCY ROOM,21480,CLSD TX TEMPOROMANIDIBULAR DISLOC,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,21820,CLOSED TX STERNUM FX,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,22899,UNLISTED PROCEDURE SPINE,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,23500,CLSD TX CLAVICLE FX W/O MANIP,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,23505,CLSD TX CLAVICLE FX W/MANIP,450,2519.25,2141.36,Pays at 85% of Billed charges for outpatient setting,809.94,Pays at 32.15% of Total Billed charges,2016.16,Pays at 80.03% of Total Billed charges,1375.28,Pays at 102% of Medicare OPPS Rate,2267.33,Pays at 90% of Total Billed charges,809.94,Pays at 32.15% of Total Billed charges,1348.31,Pays at 100% of Medicare OPPS Rate,809.94,Pays at 32.15% of Total Billed charges,2216.94,Pays at 88% of Total Billed charges,834.12,Pays at 33.11% of Total Billed charges,809.94,2267.33,1511.55
Outpatient Medical Services,EMERGENCY ROOM,23520,CLSD TX CLAVICLE DISLOC W/O MANIP,450,2519.25,2141.36,Pays at 85% of Billed charges for outpatient setting,809.94,Pays at 32.15% of Total Billed charges,2016.16,Pays at 80.03% of Total Billed charges,1375.28,Pays at 102% of Medicare OPPS Rate,2267.33,Pays at 90% of Total Billed charges,809.94,Pays at 32.15% of Total Billed charges,1348.31,Pays at 100% of Medicare OPPS Rate,809.94,Pays at 32.15% of Total Billed charges,2216.94,Pays at 88% of Total Billed charges,834.12,Pays at 33.11% of Total Billed charges,809.94,2267.33,1511.55
Outpatient Medical Services,EMERGENCY ROOM,23525,CLSD TX CLAVICLE DISLOC W/MANIP,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,23540,CLSD TX AC JOINT DISLOCATION W/O MAN,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,23545,CLSD TX AC DISLOCATION W/MAN,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,23570,CLOSED SCAPULAR FRACTURE W/O MAN,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,23600,CLSD TX PROXIMAL HUMERAL FX W/O MANIP,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,23620,CLSD TX PROXIMAL HUMERAL TUBEROSITY FX W,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,23625,CLSD TX PROXIMAL HUMERAL TUBEROSITY FX W,450,2519.25,2141.36,Pays at 85% of Billed charges for outpatient setting,809.94,Pays at 32.15% of Total Billed charges,2016.16,Pays at 80.03% of Total Billed charges,1375.28,Pays at 102% of Medicare OPPS Rate,2267.33,Pays at 90% of Total Billed charges,809.94,Pays at 32.15% of Total Billed charges,1348.31,Pays at 100% of Medicare OPPS Rate,809.94,Pays at 32.15% of Total Billed charges,2216.94,Pays at 88% of Total Billed charges,834.12,Pays at 33.11% of Total Billed charges,809.94,2267.33,1511.55
Outpatient Medical Services,EMERGENCY ROOM,23650,CLSD TX SHOULDER DISLOC W/MANIP W/O ANES,450,555.75,472.39,Pays at 85% of Billed charges for outpatient setting,178.67,Pays at 32.15% of Total Billed charges,444.77,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,500.18,Pays at 90% of Total Billed charges,178.67,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,178.67,Pays at 32.15% of Total Billed charges,489.06,Pays at 88% of Total Billed charges,184.01,Pays at 33.11% of Total Billed charges,178.67,500.18,333.45
Outpatient Medical Services,EMERGENCY ROOM,23655,SHOULDER REDUCTION/C ANES,450,2519.25,2141.36,Pays at 85% of Billed charges for outpatient setting,809.94,Pays at 32.15% of Total Billed charges,2016.16,Pays at 80.03% of Total Billed charges,1375.28,Pays at 102% of Medicare OPPS Rate,2267.33,Pays at 90% of Total Billed charges,809.94,Pays at 32.15% of Total Billed charges,1348.31,Pays at 100% of Medicare OPPS Rate,809.94,Pays at 32.15% of Total Billed charges,2216.94,Pays at 88% of Total Billed charges,834.12,Pays at 33.11% of Total Billed charges,809.94,2267.33,1511.55
Outpatient Medical Services,EMERGENCY ROOM,23665,TX SHOULDER DISLOC W/HUMERAL FX W/O MANI,450,2519.25,2141.36,Pays at 85% of Billed charges for outpatient setting,809.94,Pays at 32.15% of Total Billed charges,2016.16,Pays at 80.03% of Total Billed charges,1375.28,Pays at 102% of Medicare OPPS Rate,2267.33,Pays at 90% of Total Billed charges,809.94,Pays at 32.15% of Total Billed charges,1348.31,Pays at 100% of Medicare OPPS Rate,809.94,Pays at 32.15% of Total Billed charges,2216.94,Pays at 88% of Total Billed charges,834.12,Pays at 33.11% of Total Billed charges,809.94,2267.33,1511.55
Outpatient Medical Services,EMERGENCY ROOM,23675,CLSD TX SHOULDER DISLOC W/SURGICAL NECK,450,2519.25,2141.36,Pays at 85% of Billed charges for outpatient setting,809.94,Pays at 32.15% of Total Billed charges,2016.16,Pays at 80.03% of Total Billed charges,1375.28,Pays at 102% of Medicare OPPS Rate,2267.33,Pays at 90% of Total Billed charges,809.94,Pays at 32.15% of Total Billed charges,1348.31,Pays at 100% of Medicare OPPS Rate,809.94,Pays at 32.15% of Total Billed charges,2216.94,Pays at 88% of Total Billed charges,834.12,Pays at 33.11% of Total Billed charges,809.94,2267.33,1511.55
Outpatient Medical Services,EMERGENCY ROOM,23929,UNLISTED PROCEDURE SHOULDER,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,23930,I & D UPPER ARM OR ELBOW AREA DEEP ABSCE,450,2558.5,2174.73,Pays at 85% of Billed charges for outpatient setting,822.56,Pays at 32.15% of Total Billed charges,2047.57,Pays at 80.03% of Total Billed charges,2476.56,Pays at 102% of Medicare OPPS Rate,2302.65,Pays at 90% of Total Billed charges,822.56,Pays at 32.15% of Total Billed charges,2428.02,Pays at 100% of Medicare OPPS Rate,822.56,Pays at 32.15% of Total Billed charges,2251.48,Pays at 88% of Total Billed charges,847.12,Pays at 33.11% of Total Billed charges,822.56,2476.56,1535.10
Outpatient Medical Services,EMERGENCY ROOM,24500,CLSD TX TREAT HUMERAL FX W/O MAN,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,24530,CLSD TX DISTAL HUMERAL FX W/O MANIP,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,24535,CLSD TX SUPRA OR TRANSCONDYLAR HUMERAL F,450,2519.25,2141.36,Pays at 85% of Billed charges for outpatient setting,809.94,Pays at 32.15% of Total Billed charges,2016.16,Pays at 80.03% of Total Billed charges,1375.28,Pays at 102% of Medicare OPPS Rate,2267.33,Pays at 90% of Total Billed charges,809.94,Pays at 32.15% of Total Billed charges,1348.31,Pays at 100% of Medicare OPPS Rate,809.94,Pays at 32.15% of Total Billed charges,2216.94,Pays at 88% of Total Billed charges,834.12,Pays at 33.11% of Total Billed charges,809.94,2267.33,1511.55
Outpatient Medical Services,EMERGENCY ROOM,24560,TX HUMERAL EPICONDYLAR FX W/O MANIP,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,24565,CLSD TX HUMERAL EPICONDYLAR FX W/MANIP,450,2519.25,2141.36,Pays at 85% of Billed charges for outpatient setting,809.94,Pays at 32.15% of Total Billed charges,2016.16,Pays at 80.03% of Total Billed charges,1375.28,Pays at 102% of Medicare OPPS Rate,2267.33,Pays at 90% of Total Billed charges,809.94,Pays at 32.15% of Total Billed charges,1348.31,Pays at 100% of Medicare OPPS Rate,809.94,Pays at 32.15% of Total Billed charges,2216.94,Pays at 88% of Total Billed charges,834.12,Pays at 33.11% of Total Billed charges,809.94,2267.33,1511.55
Outpatient Medical Services,EMERGENCY ROOM,24576,TX HUMERAL CONDYLAR FX W/O MANIP,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,24577,CLSD TX HUMERAL CONDYLAR FX W/MANIP,450,2519.25,2141.36,Pays at 85% of Billed charges for outpatient setting,809.94,Pays at 32.15% of Total Billed charges,2016.16,Pays at 80.03% of Total Billed charges,1375.28,Pays at 102% of Medicare OPPS Rate,2267.33,Pays at 90% of Total Billed charges,809.94,Pays at 32.15% of Total Billed charges,1348.31,Pays at 100% of Medicare OPPS Rate,809.94,Pays at 32.15% of Total Billed charges,2216.94,Pays at 88% of Total Billed charges,834.12,Pays at 33.11% of Total Billed charges,809.94,2267.33,1511.55
Outpatient Medical Services,EMERGENCY ROOM,24600,TX CLSD ELBOW DISLOC W/O ANEST,450,555.75,472.39,Pays at 85% of Billed charges for outpatient setting,178.67,Pays at 32.15% of Total Billed charges,444.77,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,500.18,Pays at 90% of Total Billed charges,178.67,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,178.67,Pays at 32.15% of Total Billed charges,489.06,Pays at 88% of Total Billed charges,184.01,Pays at 33.11% of Total Billed charges,178.67,500.18,333.45
Outpatient Medical Services,EMERGENCY ROOM,24620,CLSD TX MONTEGGIA TYPE ELBOW FX W/MANIP,450,2519.25,2141.36,Pays at 85% of Billed charges for outpatient setting,809.94,Pays at 32.15% of Total Billed charges,2016.16,Pays at 80.03% of Total Billed charges,1375.28,Pays at 102% of Medicare OPPS Rate,2267.33,Pays at 90% of Total Billed charges,809.94,Pays at 32.15% of Total Billed charges,1348.31,Pays at 100% of Medicare OPPS Rate,809.94,Pays at 32.15% of Total Billed charges,2216.94,Pays at 88% of Total Billed charges,834.12,Pays at 33.11% of Total Billed charges,809.94,2267.33,1511.55
Outpatient Medical Services,EMERGENCY ROOM,24640,CLSD TX NURSEMAID ELBOW W/MANIP,450,555.75,472.39,Pays at 85% of Billed charges for outpatient setting,178.67,Pays at 32.15% of Total Billed charges,444.77,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,500.18,Pays at 90% of Total Billed charges,178.67,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,178.67,Pays at 32.15% of Total Billed charges,489.06,Pays at 88% of Total Billed charges,184.01,Pays at 33.11% of Total Billed charges,178.67,500.18,333.45
Outpatient Medical Services,EMERGENCY ROOM,24650,CLSD TX RADIAL HEADFX W/O MAN,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,24655,CLSD TX FX RADIAL HD W/MANIP,450,2519.25,2141.36,Pays at 85% of Billed charges for outpatient setting,809.94,Pays at 32.15% of Total Billed charges,2016.16,Pays at 80.03% of Total Billed charges,1375.28,Pays at 102% of Medicare OPPS Rate,2267.33,Pays at 90% of Total Billed charges,809.94,Pays at 32.15% of Total Billed charges,1348.31,Pays at 100% of Medicare OPPS Rate,809.94,Pays at 32.15% of Total Billed charges,2216.94,Pays at 88% of Total Billed charges,834.12,Pays at 33.11% of Total Billed charges,809.94,2267.33,1511.55
Outpatient Medical Services,EMERGENCY ROOM,24670,CLSD TX ULNA FX PROXIMAL W/O MANIP,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,24675,CLSD TX ULNA FX PROXIMAL END W/MANIP,450,2519.25,2141.36,Pays at 85% of Billed charges for outpatient setting,809.94,Pays at 32.15% of Total Billed charges,2016.16,Pays at 80.03% of Total Billed charges,1375.28,Pays at 102% of Medicare OPPS Rate,2267.33,Pays at 90% of Total Billed charges,809.94,Pays at 32.15% of Total Billed charges,1348.31,Pays at 100% of Medicare OPPS Rate,809.94,Pays at 32.15% of Total Billed charges,2216.94,Pays at 88% of Total Billed charges,834.12,Pays at 33.11% of Total Billed charges,809.94,2267.33,1511.55
Outpatient Medical Services,EMERGENCY ROOM,24800,ELBOW REDUCTION/S ANES,450,10804.25,9183.61,Pays at 85% of Billed charges for outpatient setting,3473.57,Pays at 32.15% of Total Billed charges,8646.64,Pays at 80.03% of Total Billed charges,6341.48,Pays at 102% of Medicare OPPS Rate,9723.83,Pays at 90% of Total Billed charges,3473.57,Pays at 32.15% of Total Billed charges,6217.15,Pays at 100% of Medicare OPPS Rate,3473.57,Pays at 32.15% of Total Billed charges,9507.74,Pays at 88% of Total Billed charges,3577.29,Pays at 33.11% of Total Billed charges,3473.57,9723.83,6482.55
Outpatient Medical Services,EMERGENCY ROOM,24999,UNLISTED PROCEDURE HUMERUS OR ELBOW,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,25500,CLSD TX RADIAL SHAFT FX W/O MANI,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,25505,CLSD TX RADIAL SHAFT FX W/MANI,450,2519.25,2141.36,Pays at 85% of Billed charges for outpatient setting,809.94,Pays at 32.15% of Total Billed charges,2016.16,Pays at 80.03% of Total Billed charges,1375.28,Pays at 102% of Medicare OPPS Rate,2267.33,Pays at 90% of Total Billed charges,809.94,Pays at 32.15% of Total Billed charges,1348.31,Pays at 100% of Medicare OPPS Rate,809.94,Pays at 32.15% of Total Billed charges,2216.94,Pays at 88% of Total Billed charges,834.12,Pays at 33.11% of Total Billed charges,809.94,2267.33,1511.55
Outpatient Medical Services,EMERGENCY ROOM,25520,CLSD TX RADIAL SHAFT FX W/DISLOC OF RU J,450,2519.25,2141.36,Pays at 85% of Billed charges for outpatient setting,809.94,Pays at 32.15% of Total Billed charges,2016.16,Pays at 80.03% of Total Billed charges,1375.28,Pays at 102% of Medicare OPPS Rate,2267.33,Pays at 90% of Total Billed charges,809.94,Pays at 32.15% of Total Billed charges,1348.31,Pays at 100% of Medicare OPPS Rate,809.94,Pays at 32.15% of Total Billed charges,2216.94,Pays at 88% of Total Billed charges,834.12,Pays at 33.11% of Total Billed charges,809.94,2267.33,1511.55
Outpatient Medical Services,EMERGENCY ROOM,25530,CLSD TX ULNAR SHAFT FX W/O MANIP,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,25535,CLSD TX ULNAR SHAFT FX W/MANIP,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,25560,CLSD TX RADIUS & ULNA W/O MANIP,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,25565,CLSD TX FX RADIUS & ULNA W/MANIP,450,2519.25,2141.36,Pays at 85% of Billed charges for outpatient setting,809.94,Pays at 32.15% of Total Billed charges,2016.16,Pays at 80.03% of Total Billed charges,1375.28,Pays at 102% of Medicare OPPS Rate,2267.33,Pays at 90% of Total Billed charges,809.94,Pays at 32.15% of Total Billed charges,1348.31,Pays at 100% of Medicare OPPS Rate,809.94,Pays at 32.15% of Total Billed charges,2216.94,Pays at 88% of Total Billed charges,834.12,Pays at 33.11% of Total Billed charges,809.94,2267.33,1511.55
Outpatient Medical Services,EMERGENCY ROOM,25600,CLSD TX DISTAL RADIAL FX W/O MAN,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,25605,CLSD TX DISTAL RADIAL FX W/MAN,450,2519.25,2141.36,Pays at 85% of Billed charges for outpatient setting,809.94,Pays at 32.15% of Total Billed charges,2016.16,Pays at 80.03% of Total Billed charges,1375.28,Pays at 102% of Medicare OPPS Rate,2267.33,Pays at 90% of Total Billed charges,809.94,Pays at 32.15% of Total Billed charges,1348.31,Pays at 100% of Medicare OPPS Rate,809.94,Pays at 32.15% of Total Billed charges,2216.94,Pays at 88% of Total Billed charges,834.12,Pays at 33.11% of Total Billed charges,809.94,2267.33,1511.55
Outpatient Medical Services,EMERGENCY ROOM,25622,CLSD TX NAVICULAR FX W/O MANIP,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,25624,CLSD TX CARPAL SCAPOID FX W/MANIPEA,450,2519.25,2141.36,Pays at 85% of Billed charges for outpatient setting,809.94,Pays at 32.15% of Total Billed charges,2016.16,Pays at 80.03% of Total Billed charges,1375.28,Pays at 102% of Medicare OPPS Rate,2267.33,Pays at 90% of Total Billed charges,809.94,Pays at 32.15% of Total Billed charges,1348.31,Pays at 100% of Medicare OPPS Rate,809.94,Pays at 32.15% of Total Billed charges,2216.94,Pays at 88% of Total Billed charges,834.12,Pays at 33.11% of Total Billed charges,809.94,2267.33,1511.55
Outpatient Medical Services,EMERGENCY ROOM,25630,CLSD TX FX CARPAL BONE  W/O MANIP EA,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,25635,CLSD TX CARPAL BONE FX  W/MANIP EA,450,2519.25,2141.36,Pays at 85% of Billed charges for outpatient setting,809.94,Pays at 32.15% of Total Billed charges,2016.16,Pays at 80.03% of Total Billed charges,1375.28,Pays at 102% of Medicare OPPS Rate,2267.33,Pays at 90% of Total Billed charges,809.94,Pays at 32.15% of Total Billed charges,1348.31,Pays at 100% of Medicare OPPS Rate,809.94,Pays at 32.15% of Total Billed charges,2216.94,Pays at 88% of Total Billed charges,834.12,Pays at 33.11% of Total Billed charges,809.94,2267.33,1511.55
Outpatient Medical Services,EMERGENCY ROOM,25650,CLSD TX ULNAR STYLOID FX,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,25660,CLSD TX RADIOCARP DISL ONE OR MORE W/MAN,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,25675,CLSD TX DISTAL RADIOULNAR DISLOC W/MANIP,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,25690,CLSD TX LUNATE DISLOC W/MANIP,450,2519.25,2141.36,Pays at 85% of Billed charges for outpatient setting,809.94,Pays at 32.15% of Total Billed charges,2016.16,Pays at 80.03% of Total Billed charges,1375.28,Pays at 102% of Medicare OPPS Rate,2267.33,Pays at 90% of Total Billed charges,809.94,Pays at 32.15% of Total Billed charges,1348.31,Pays at 100% of Medicare OPPS Rate,809.94,Pays at 32.15% of Total Billed charges,2216.94,Pays at 88% of Total Billed charges,834.12,Pays at 33.11% of Total Billed charges,809.94,2267.33,1511.55
Outpatient Medical Services,EMERGENCY ROOM,25999,UNLISTED PROCEDURE FOREARM OR WRIST,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,26010,I & D FINGER ABSCESS SIMPLE,450,316.75,269.24,Pays at 85% of Billed charges for outpatient setting,101.84,Pays at 32.15% of Total Billed charges,253.5,Pays at 80.03% of Total Billed charges,173.11,Pays at 102% of Medicare OPPS Rate,285.08,Pays at 90% of Total Billed charges,101.84,Pays at 32.15% of Total Billed charges,169.72,Pays at 100% of Medicare OPPS Rate,101.84,Pays at 32.15% of Total Billed charges,278.74,Pays at 88% of Total Billed charges,104.88,Pays at 33.11% of Total Billed charges,101.84,285.08,190.05
Outpatient Medical Services,EMERGENCY ROOM,26011,I & D FINGER ABSCESS COMPLETE,450,2558.5,2174.73,Pays at 85% of Billed charges for outpatient setting,822.56,Pays at 32.15% of Total Billed charges,2047.57,Pays at 80.03% of Total Billed charges,1437.62,Pays at 102% of Medicare OPPS Rate,2302.65,Pays at 90% of Total Billed charges,822.56,Pays at 32.15% of Total Billed charges,1409.43,Pays at 100% of Medicare OPPS Rate,822.56,Pays at 32.15% of Total Billed charges,2251.48,Pays at 88% of Total Billed charges,847.12,Pays at 33.11% of Total Billed charges,822.56,2302.65,1535.10
Outpatient Medical Services,EMERGENCY ROOM,26410,REPAIR EXT TENDON HAND,450,5045.75,4288.89,Pays at 85% of Billed charges for outpatient setting,1622.21,Pays at 32.15% of Total Billed charges,4038.11,Pays at 80.03% of Total Billed charges,1375.28,Pays at 102% of Medicare OPPS Rate,4541.18,Pays at 90% of Total Billed charges,1622.21,Pays at 32.15% of Total Billed charges,1348.31,Pays at 100% of Medicare OPPS Rate,1622.21,Pays at 32.15% of Total Billed charges,4440.26,Pays at 88% of Total Billed charges,1670.65,Pays at 33.11% of Total Billed charges,1348.31,4541.18,3027.45
Outpatient Medical Services,EMERGENCY ROOM,26418,REPAIR EXT TEND FINGER,450,5045.75,4288.89,Pays at 85% of Billed charges for outpatient setting,1622.21,Pays at 32.15% of Total Billed charges,4038.11,Pays at 80.03% of Total Billed charges,1375.28,Pays at 102% of Medicare OPPS Rate,4541.18,Pays at 90% of Total Billed charges,1622.21,Pays at 32.15% of Total Billed charges,1348.31,Pays at 100% of Medicare OPPS Rate,1622.21,Pays at 32.15% of Total Billed charges,4440.26,Pays at 88% of Total Billed charges,1670.65,Pays at 33.11% of Total Billed charges,1348.31,4541.18,3027.45
Outpatient Medical Services,EMERGENCY ROOM,26432,EX TEND REP/SPLINT MALLET FING,450,2519.25,2141.36,Pays at 85% of Billed charges for outpatient setting,809.94,Pays at 32.15% of Total Billed charges,2016.16,Pays at 80.03% of Total Billed charges,1375.28,Pays at 102% of Medicare OPPS Rate,2267.33,Pays at 90% of Total Billed charges,809.94,Pays at 32.15% of Total Billed charges,1348.31,Pays at 100% of Medicare OPPS Rate,809.94,Pays at 32.15% of Total Billed charges,2216.94,Pays at 88% of Total Billed charges,834.12,Pays at 33.11% of Total Billed charges,809.94,2267.33,1511.55
Outpatient Medical Services,EMERGENCY ROOM,26600,CLSD TX METACARPAL FX W/O MANIP EACH,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,26605,CLSD TX METACARPAL FX W/MANIP EACH,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,26641,CLSD TX CARPO-M DISLOC THUMB W/MANIP,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,26645,CLSD TX CARPO-MC DISLOC (THUMB) W/MANIP,450,2519.25,2141.36,Pays at 85% of Billed charges for outpatient setting,809.94,Pays at 32.15% of Total Billed charges,2016.16,Pays at 80.03% of Total Billed charges,1375.28,Pays at 102% of Medicare OPPS Rate,2267.33,Pays at 90% of Total Billed charges,809.94,Pays at 32.15% of Total Billed charges,1348.31,Pays at 100% of Medicare OPPS Rate,809.94,Pays at 32.15% of Total Billed charges,2216.94,Pays at 88% of Total Billed charges,834.12,Pays at 33.11% of Total Billed charges,809.94,2267.33,1511.55
Outpatient Medical Services,EMERGENCY ROOM,26670,CLSD TX CARPO-MC DISLOC (NOT THUMB) W/MA,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,26700,CLSD TX MCP DISLOCATION W/MANIP W/O ANES,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,26705,METACARPAL DISLOC CLOSED/C ANE,450,2519.25,2141.36,Pays at 85% of Billed charges for outpatient setting,809.94,Pays at 32.15% of Total Billed charges,2016.16,Pays at 80.03% of Total Billed charges,1375.28,Pays at 102% of Medicare OPPS Rate,2267.33,Pays at 90% of Total Billed charges,809.94,Pays at 32.15% of Total Billed charges,1348.31,Pays at 100% of Medicare OPPS Rate,809.94,Pays at 32.15% of Total Billed charges,2216.94,Pays at 88% of Total Billed charges,834.12,Pays at 33.11% of Total Billed charges,809.94,2267.33,1511.55
Outpatient Medical Services,EMERGENCY ROOM,26720,"CLSD TX FINGER FRACTURE W/O MANIP, EACH",450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,26725,"CLSD TX FINGER FRACTURE W/ MANIP, EACH",450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,26740,CLSD TX ARTICULAR FX W/O MAN,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,26742,CLSD TX ARTICULAR FX W/ MAN,450,2519.25,2141.36,Pays at 85% of Billed charges for outpatient setting,809.94,Pays at 32.15% of Total Billed charges,2016.16,Pays at 80.03% of Total Billed charges,1375.28,Pays at 102% of Medicare OPPS Rate,2267.33,Pays at 90% of Total Billed charges,809.94,Pays at 32.15% of Total Billed charges,1348.31,Pays at 100% of Medicare OPPS Rate,809.94,Pays at 32.15% of Total Billed charges,2216.94,Pays at 88% of Total Billed charges,834.12,Pays at 33.11% of Total Billed charges,809.94,2267.33,1511.55
Outpatient Medical Services,EMERGENCY ROOM,26750,CLSD TX DISTAL TUFT FX W/O MANIP,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,26755,CLSD TX DISTAL TUFT FX W/ MANIP,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,26770,CLSD TX DIP OR PIP DISLOC W/ MANIP,450,555.75,472.39,Pays at 85% of Billed charges for outpatient setting,178.67,Pays at 32.15% of Total Billed charges,444.77,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,500.18,Pays at 90% of Total Billed charges,178.67,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,178.67,Pays at 32.15% of Total Billed charges,489.06,Pays at 88% of Total Billed charges,184.01,Pays at 33.11% of Total Billed charges,178.67,500.18,333.45
Outpatient Medical Services,EMERGENCY ROOM,26775,CLSD TX DISTAL PHALANGEOAL FRACTURE,450,610.75,519.14,Pays at 85% of Billed charges for outpatient setting,196.36,Pays at 32.15% of Total Billed charges,488.78,Pays at 80.03% of Total Billed charges,229.98,Pays at 102% of Medicare OPPS Rate,549.68,Pays at 90% of Total Billed charges,196.36,Pays at 32.15% of Total Billed charges,225.48,Pays at 100% of Medicare OPPS Rate,196.36,Pays at 32.15% of Total Billed charges,537.46,Pays at 88% of Total Billed charges,202.22,Pays at 33.11% of Total Billed charges,196.36,549.68,366.45
Outpatient Medical Services,EMERGENCY ROOM,26951,SURG AMPUTATION PMALAN/JOINT,450,5045.75,4288.89,Pays at 85% of Billed charges for outpatient setting,1622.21,Pays at 32.15% of Total Billed charges,4038.11,Pays at 80.03% of Total Billed charges,2853.74,Pays at 102% of Medicare OPPS Rate,4541.18,Pays at 90% of Total Billed charges,1622.21,Pays at 32.15% of Total Billed charges,2797.78,Pays at 100% of Medicare OPPS Rate,1622.21,Pays at 32.15% of Total Billed charges,4440.26,Pays at 88% of Total Billed charges,1670.65,Pays at 33.11% of Total Billed charges,1622.21,4541.18,3027.45
Outpatient Medical Services,EMERGENCY ROOM,26989,"UNLISTED PROCEDURE, HANDS OR FINGERS",450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,27197,CLOSED TX PELVIC RING FRACTURE W/O MANIP,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,27200,TX COCCYGEAL FX,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,27220,CLOSED TX HIP SOCKET FRACTURE W/O MANIP,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,27230,CLSD TX FEMORAL FX PROXIMAL END W/O MANI,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,27238,"CLSD TX INTRO, PERTRO, OF SUBTROCHANTERI",450,2519.25,2141.36,Pays at 85% of Billed charges for outpatient setting,809.94,Pays at 32.15% of Total Billed charges,2016.16,Pays at 80.03% of Total Billed charges,1375.28,Pays at 102% of Medicare OPPS Rate,2267.33,Pays at 90% of Total Billed charges,809.94,Pays at 32.15% of Total Billed charges,1348.31,Pays at 100% of Medicare OPPS Rate,809.94,Pays at 32.15% of Total Billed charges,2216.94,Pays at 88% of Total Billed charges,834.12,Pays at 33.11% of Total Billed charges,809.94,2267.33,1511.55
Outpatient Medical Services,EMERGENCY ROOM,27246,TX GREATER TROCHANTERIC FX,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,27250,CLSD TX HIP DISLOCATION W/O ANEST,450,555.75,472.39,Pays at 85% of Billed charges for outpatient setting,178.67,Pays at 32.15% of Total Billed charges,444.77,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,500.18,Pays at 90% of Total Billed charges,178.67,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,178.67,Pays at 32.15% of Total Billed charges,489.06,Pays at 88% of Total Billed charges,184.01,Pays at 33.11% of Total Billed charges,178.67,500.18,333.45
Outpatient Medical Services,EMERGENCY ROOM,27256,TX HIP DISLOCATION BY ABDUCTION W/O ANES,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,27265,CLSD TX POST HIP DISLOC,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,27299,"UNLISTED PROCEDURE, PELVIS OR HIP",450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,27500,CLSD TX FEMORAL SHAFT FX W/O MANIP,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,27501,CLSD TX SUPRA OR TRANSCONDYLAR FEMURAL F,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,27508,CLSD TX FEMORAL FX DISTAL END W/O MANIP,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,27516,CLSD TX DISTAL FEMORAL EPIPHYSEAL SEPERA,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,27520,CLSD TX PATELLAR FX W/O MAN,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,27530,TX TIBAL PLATEAU FX W/O MANIP,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,27538,CLSD TX OF KNEE FRACTURE,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,27550,CLSD TX KNEE DISLOC,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,27552,KNEE DISLOCATION REPAIR,450,2519.25,2141.36,Pays at 85% of Billed charges for outpatient setting,809.94,Pays at 32.15% of Total Billed charges,2016.16,Pays at 80.03% of Total Billed charges,1375.28,Pays at 102% of Medicare OPPS Rate,2267.33,Pays at 90% of Total Billed charges,809.94,Pays at 32.15% of Total Billed charges,1348.31,Pays at 100% of Medicare OPPS Rate,809.94,Pays at 32.15% of Total Billed charges,2216.94,Pays at 88% of Total Billed charges,834.12,Pays at 33.11% of Total Billed charges,809.94,2267.33,1511.55
Outpatient Medical Services,EMERGENCY ROOM,27560,CLSD TX PATELLAR DISLOC W/O ANEST,450,555.75,472.39,Pays at 85% of Billed charges for outpatient setting,178.67,Pays at 32.15% of Total Billed charges,444.77,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,500.18,Pays at 90% of Total Billed charges,178.67,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,178.67,Pays at 32.15% of Total Billed charges,489.06,Pays at 88% of Total Billed charges,184.01,Pays at 33.11% of Total Billed charges,178.67,500.18,333.45
Outpatient Medical Services,EMERGENCY ROOM,27599,"UNLISTED PROCEDURE, FEMUR OR KNEE",450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,27750,CLSD TX TIB FX W/O MAN,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,27752,CLSD TX TIBIAL FX W/ MANIP,450,2519.25,2141.36,Pays at 85% of Billed charges for outpatient setting,809.94,Pays at 32.15% of Total Billed charges,2016.16,Pays at 80.03% of Total Billed charges,1375.28,Pays at 102% of Medicare OPPS Rate,2267.33,Pays at 90% of Total Billed charges,809.94,Pays at 32.15% of Total Billed charges,1348.31,Pays at 100% of Medicare OPPS Rate,809.94,Pays at 32.15% of Total Billed charges,2216.94,Pays at 88% of Total Billed charges,834.12,Pays at 33.11% of Total Billed charges,809.94,2267.33,1511.55
Outpatient Medical Services,EMERGENCY ROOM,27760,CLSD TX FX MED. MALLEOLUS W/O MANIP,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,27762,CLSD TX FX MED. MALLEOLUS W/ MANIP,450,2519.25,2141.36,Pays at 85% of Billed charges for outpatient setting,809.94,Pays at 32.15% of Total Billed charges,2016.16,Pays at 80.03% of Total Billed charges,1375.28,Pays at 102% of Medicare OPPS Rate,2267.33,Pays at 90% of Total Billed charges,809.94,Pays at 32.15% of Total Billed charges,1348.31,Pays at 100% of Medicare OPPS Rate,809.94,Pays at 32.15% of Total Billed charges,2216.94,Pays at 88% of Total Billed charges,834.12,Pays at 33.11% of Total Billed charges,809.94,2267.33,1511.55
Outpatient Medical Services,EMERGENCY ROOM,27780,CLSD TX PROXIMAL FIBULA FX W/O MAN,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,27786,CLSD TX DIS FIBULA W/O MANIP,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,27788,CLSD TX DIS FIBULA W/ MANIP,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,27808,CLSD TX BIMALLEOLAR ANKLE FX W/O MANIP,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,27810,CLSD TX BIMALLEOLAR ANKLE FX W/ MANIP,450,2519.25,2141.36,Pays at 85% of Billed charges for outpatient setting,809.94,Pays at 32.15% of Total Billed charges,2016.16,Pays at 80.03% of Total Billed charges,1375.28,Pays at 102% of Medicare OPPS Rate,2267.33,Pays at 90% of Total Billed charges,809.94,Pays at 32.15% of Total Billed charges,1348.31,Pays at 100% of Medicare OPPS Rate,809.94,Pays at 32.15% of Total Billed charges,2216.94,Pays at 88% of Total Billed charges,834.12,Pays at 33.11% of Total Billed charges,809.94,2267.33,1511.55
Outpatient Medical Services,EMERGENCY ROOM,27816,TREATMENT OF ANKLE FRACTURE,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,27818,CLSD TX TRIMALLEOLAR ANKLE FX W/MANIP,450,2519.25,2141.36,Pays at 85% of Billed charges for outpatient setting,809.94,Pays at 32.15% of Total Billed charges,2016.16,Pays at 80.03% of Total Billed charges,1375.28,Pays at 102% of Medicare OPPS Rate,2267.33,Pays at 90% of Total Billed charges,809.94,Pays at 32.15% of Total Billed charges,1348.31,Pays at 100% of Medicare OPPS Rate,809.94,Pays at 32.15% of Total Billed charges,2216.94,Pays at 88% of Total Billed charges,834.12,Pays at 33.11% of Total Billed charges,809.94,2267.33,1511.55
Outpatient Medical Services,EMERGENCY ROOM,27824,TREAT LOWER LEG FRACTURE,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,27830,TREAT LOWER LEG DISLOCATION,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,27840,CLSD TX ANKLE DISLOC W/O ANEST,450,555.75,472.39,Pays at 85% of Billed charges for outpatient setting,178.67,Pays at 32.15% of Total Billed charges,444.77,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,500.18,Pays at 90% of Total Billed charges,178.67,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,178.67,Pays at 32.15% of Total Billed charges,489.06,Pays at 88% of Total Billed charges,184.01,Pays at 33.11% of Total Billed charges,178.67,500.18,333.45
Outpatient Medical Services,EMERGENCY ROOM,27899,"UNLISTED PROCEDURE, LEG OR ANKLE",450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,28190,"REMOVAL OF F.B. FOOT, SUB",450,1115.75,948.39,Pays at 85% of Billed charges for outpatient setting,358.71,Pays at 32.15% of Total Billed charges,892.93,Pays at 80.03% of Total Billed charges,622.15,Pays at 102% of Medicare OPPS Rate,1004.18,Pays at 90% of Total Billed charges,358.71,Pays at 32.15% of Total Billed charges,609.96,Pays at 100% of Medicare OPPS Rate,358.71,Pays at 32.15% of Total Billed charges,981.86,Pays at 88% of Total Billed charges,369.42,Pays at 33.11% of Total Billed charges,358.71,1004.18,669.45
Outpatient Medical Services,EMERGENCY ROOM,28192,"REMOVAL OF F.B. FOOT, DEEP",450,2558.5,2174.73,Pays at 85% of Billed charges for outpatient setting,822.56,Pays at 32.15% of Total Billed charges,2047.57,Pays at 80.03% of Total Billed charges,1437.62,Pays at 102% of Medicare OPPS Rate,2302.65,Pays at 90% of Total Billed charges,822.56,Pays at 32.15% of Total Billed charges,1409.43,Pays at 100% of Medicare OPPS Rate,822.56,Pays at 32.15% of Total Billed charges,2251.48,Pays at 88% of Total Billed charges,847.12,Pays at 33.11% of Total Billed charges,822.56,2302.65,1535.10
Outpatient Medical Services,EMERGENCY ROOM,28193,"REMOVAL OF F.B. FOOT, COMP",450,2558.5,2174.73,Pays at 85% of Billed charges for outpatient setting,822.56,Pays at 32.15% of Total Billed charges,2047.57,Pays at 80.03% of Total Billed charges,1437.62,Pays at 102% of Medicare OPPS Rate,2302.65,Pays at 90% of Total Billed charges,822.56,Pays at 32.15% of Total Billed charges,1409.43,Pays at 100% of Medicare OPPS Rate,822.56,Pays at 32.15% of Total Billed charges,2251.48,Pays at 88% of Total Billed charges,847.12,Pays at 33.11% of Total Billed charges,822.56,2302.65,1535.10
Outpatient Medical Services,EMERGENCY ROOM,28208,EXT TENDON REPAIR FOOT,450,5045.75,4288.89,Pays at 85% of Billed charges for outpatient setting,1622.21,Pays at 32.15% of Total Billed charges,4038.11,Pays at 80.03% of Total Billed charges,2853.74,Pays at 102% of Medicare OPPS Rate,4541.18,Pays at 90% of Total Billed charges,1622.21,Pays at 32.15% of Total Billed charges,2797.78,Pays at 100% of Medicare OPPS Rate,1622.21,Pays at 32.15% of Total Billed charges,4440.26,Pays at 88% of Total Billed charges,1670.65,Pays at 33.11% of Total Billed charges,1622.21,4541.18,3027.45
Outpatient Medical Services,EMERGENCY ROOM,28400,CLSD TX CALCANEAL FX W/O MAN,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,28405,CLSD TX CALCANEAL FX W/ MANIP,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,28430,CLSD TX TALUS FX W/O MANIP,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,28435,CLSD TX TALUS FX W/ MANIP,450,2519.25,2141.36,Pays at 85% of Billed charges for outpatient setting,809.94,Pays at 32.15% of Total Billed charges,2016.16,Pays at 80.03% of Total Billed charges,1375.28,Pays at 102% of Medicare OPPS Rate,2267.33,Pays at 90% of Total Billed charges,809.94,Pays at 32.15% of Total Billed charges,1348.31,Pays at 100% of Medicare OPPS Rate,809.94,Pays at 32.15% of Total Billed charges,2216.94,Pays at 88% of Total Billed charges,834.12,Pays at 33.11% of Total Billed charges,809.94,2267.33,1511.55
Outpatient Medical Services,EMERGENCY ROOM,28450,"TX TARSAL BONE FX W/O MAN, EACH",450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,28455,TX TARSAL BONE FX W/MAN EA,450,5045.75,4288.89,Pays at 85% of Billed charges for outpatient setting,1622.21,Pays at 32.15% of Total Billed charges,4038.11,Pays at 80.03% of Total Billed charges,1375.28,Pays at 102% of Medicare OPPS Rate,4541.18,Pays at 90% of Total Billed charges,1622.21,Pays at 32.15% of Total Billed charges,1348.31,Pays at 100% of Medicare OPPS Rate,1622.21,Pays at 32.15% of Total Billed charges,4440.26,Pays at 88% of Total Billed charges,1670.65,Pays at 33.11% of Total Billed charges,1348.31,4541.18,3027.45
Outpatient Medical Services,EMERGENCY ROOM,28470,CLSD TX METATARSAL FX W/O MANIP EACH,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,28475,CLSD TX METATARSAL FX W/MANIP EAC,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,28490,CLSD TX BIG TOE FX W/O MANIP,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,28495,CLSD TX BIG TOE FX W/ MANIP,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,28510,CLSD TX TOE FX W/O MANIP,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,28515,CLSD TX TOE FX W/ MANIP,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,28530,CLSD TX SESAMOID FRACTURE,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,28540,CLSD TX TARSAL BONE DISL,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,28570,CLSD TX TARSAL JT DISLOC,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,28600,CLSD TX T-MT JOINT DISL,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,28630,CLSD TX METATARSCOPHA JT DISLOC,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,28660,CLSD TX CLOSED IPJ DICLOC,450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,28899,"UNLISTED PROCEDURE, FOOT OR TOES",450,414,351.9,Pays at 85% of Billed charges for outpatient setting,133.1,Pays at 32.15% of Total Billed charges,331.32,Pays at 80.03% of Total Billed charges,198.45,Pays at 102% of Medicare OPPS Rate,372.6,Pays at 90% of Total Billed charges,133.1,Pays at 32.15% of Total Billed charges,194.56,Pays at 100% of Medicare OPPS Rate,133.1,Pays at 32.15% of Total Billed charges,364.32,Pays at 88% of Total Billed charges,137.08,Pays at 33.11% of Total Billed charges,133.1,372.6,248.40
Outpatient Medical Services,EMERGENCY ROOM,29065,APPLY LONG ARM CAST,450,456.5,388.03,Pays at 85% of Billed charges for outpatient setting,146.76,Pays at 32.15% of Total Billed charges,365.34,Pays at 80.03% of Total Billed charges,229.98,Pays at 102% of Medicare OPPS Rate,410.85,Pays at 90% of Total Billed charges,146.76,Pays at 32.15% of Total Billed charges,225.48,Pays at 100% of Medicare OPPS Rate,146.76,Pays at 32.15% of Total Billed charges,401.72,Pays at 88% of Total Billed charges,151.15,Pays at 33.11% of Total Billed charges,146.76,410.85,273.90
Outpatient Medical Services,EMERGENCY ROOM,29075,APPLY SHORT ARM CAST,450,456.5,388.03,Pays at 85% of Billed charges for outpatient setting,146.76,Pays at 32.15% of Total Billed charges,365.34,Pays at 80.03% of Total Billed charges,229.98,Pays at 102% of Medicare OPPS Rate,410.85,Pays at 90% of Total Billed charges,146.76,Pays at 32.15% of Total Billed charges,225.48,Pays at 100% of Medicare OPPS Rate,146.76,Pays at 32.15% of Total Billed charges,401.72,Pays at 88% of Total Billed charges,151.15,Pays at 33.11% of Total Billed charges,146.76,410.85,273.90
Outpatient Medical Services,EMERGENCY ROOM,29085,APPLY HAND/WRIST CAST (GUANTLET),450,258.75,219.94,Pays at 85% of Billed charges for outpatient setting,83.19,Pays at 32.15% of Total Billed charges,207.08,Pays at 80.03% of Total Billed charges,139.72,Pays at 102% of Medicare OPPS Rate,232.88,Pays at 90% of Total Billed charges,83.19,Pays at 32.15% of Total Billed charges,137,Pays at 100% of Medicare OPPS Rate,83.19,Pays at 32.15% of Total Billed charges,227.7,Pays at 88% of Total Billed charges,85.67,Pays at 33.11% of Total Billed charges,83.19,232.88,155.25
Outpatient Medical Services,EMERGENCY ROOM,29105,APPLY LONG ARM SPLINT,450,350.75,298.14,Pays at 85% of Billed charges for outpatient setting,112.77,Pays at 32.15% of Total Billed charges,280.71,Pays at 80.03% of Total Billed charges,139.72,Pays at 102% of Medicare OPPS Rate,315.68,Pays at 90% of Total Billed charges,112.77,Pays at 32.15% of Total Billed charges,137,Pays at 100% of Medicare OPPS Rate,112.77,Pays at 32.15% of Total Billed charges,308.66,Pays at 88% of Total Billed charges,116.13,Pays at 33.11% of Total Billed charges,112.77,315.68,210.45
Outpatient Medical Services,EMERGENCY ROOM,29125,APPLY SHORT ARM SPLINT,450,340.31,289.26,Pays at 85% of Billed charges for outpatient setting,109.41,Pays at 32.15% of Total Billed charges,272.35,Pays at 80.03% of Total Billed charges,111.31,Pays at 102% of Medicare OPPS Rate,306.28,Pays at 90% of Total Billed charges,109.41,Pays at 32.15% of Total Billed charges,109.13,Pays at 100% of Medicare OPPS Rate,109.41,Pays at 32.15% of Total Billed charges,299.47,Pays at 88% of Total Billed charges,112.68,Pays at 33.11% of Total Billed charges,109.13,306.28,204.19
Outpatient Medical Services,EMERGENCY ROOM,29130,APPLICATION OF FINGER SPLINT;STATIC,450,145,123.25,Pays at 85% of Billed charges for outpatient setting,46.62,Pays at 32.15% of Total Billed charges,116.04,Pays at 80.03% of Total Billed charges,111.31,Pays at 102% of Medicare OPPS Rate,130.5,Pays at 90% of Total Billed charges,46.62,Pays at 32.15% of Total Billed charges,109.13,Pays at 100% of Medicare OPPS Rate,46.62,Pays at 32.15% of Total Billed charges,127.6,Pays at 88% of Total Billed charges,48.01,Pays at 33.11% of Total Billed charges,46.62,130.5,87.00
Outpatient Medical Services,EMERGENCY ROOM,29240,"STRAPPING; SHOULDER (EG, VELPEAU)",450,112.75,95.84,Pays at 85% of Billed charges for outpatient setting,36.25,Pays at 32.15% of Total Billed charges,90.23,Pays at 80.03% of Total Billed charges,111.31,Pays at 102% of Medicare OPPS Rate,101.48,Pays at 90% of Total Billed charges,36.25,Pays at 32.15% of Total Billed charges,109.13,Pays at 100% of Medicare OPPS Rate,36.25,Pays at 32.15% of Total Billed charges,99.22,Pays at 88% of Total Billed charges,37.33,Pays at 33.11% of Total Billed charges,36.25,111.31,67.65
Outpatient Medical Services,EMERGENCY ROOM,29260,STRAPPING; ELBOW OR WRIST,450,59,50.15,Pays at 85% of Billed charges for outpatient setting,18.97,Pays at 32.15% of Total Billed charges,47.22,Pays at 80.03% of Total Billed charges,55.1,Pays at 102% of Medicare OPPS Rate,53.1,Pays at 90% of Total Billed charges,18.97,Pays at 32.15% of Total Billed charges,54.02,Pays at 100% of Medicare OPPS Rate,18.97,Pays at 32.15% of Total Billed charges,51.92,Pays at 88% of Total Billed charges,19.53,Pays at 33.11% of Total Billed charges,18.97,55.1,35.40
Outpatient Medical Services,EMERGENCY ROOM,29280,STRAPPING; HAND OR FINGER,450,59,50.15,Pays at 85% of Billed charges for outpatient setting,18.97,Pays at 32.15% of Total Billed charges,47.22,Pays at 80.03% of Total Billed charges,55.1,Pays at 102% of Medicare OPPS Rate,53.1,Pays at 90% of Total Billed charges,18.97,Pays at 32.15% of Total Billed charges,54.02,Pays at 100% of Medicare OPPS Rate,18.97,Pays at 32.15% of Total Billed charges,51.92,Pays at 88% of Total Billed charges,19.53,Pays at 33.11% of Total Billed charges,18.97,55.1,35.40
Outpatient Medical Services,EMERGENCY ROOM,29405,APPLY SHORT LEG CAST (KNEE TO TOES),450,456.5,388.03,Pays at 85% of Billed charges for outpatient setting,146.76,Pays at 32.15% of Total Billed charges,365.34,Pays at 80.03% of Total Billed charges,229.98,Pays at 102% of Medicare OPPS Rate,410.85,Pays at 90% of Total Billed charges,146.76,Pays at 32.15% of Total Billed charges,225.48,Pays at 100% of Medicare OPPS Rate,146.76,Pays at 32.15% of Total Billed charges,401.72,Pays at 88% of Total Billed charges,151.15,Pays at 33.11% of Total Billed charges,146.76,410.85,273.90
Outpatient Medical Services,EMERGENCY ROOM,29425,APPLY SHORT LEG WALKING CAST,450,456.5,388.03,Pays at 85% of Billed charges for outpatient setting,146.76,Pays at 32.15% of Total Billed charges,365.34,Pays at 80.03% of Total Billed charges,229.98,Pays at 102% of Medicare OPPS Rate,410.85,Pays at 90% of Total Billed charges,146.76,Pays at 32.15% of Total Billed charges,225.48,Pays at 100% of Medicare OPPS Rate,146.76,Pays at 32.15% of Total Billed charges,401.72,Pays at 88% of Total Billed charges,151.15,Pays at 33.11% of Total Billed charges,146.76,410.85,273.90
Outpatient Medical Services,EMERGENCY ROOM,29505,APPLY LONG LEG SPLINT (THIGH TO ANKLE OR,450,287.62,244.48,Pays at 85% of Billed charges for outpatient setting,92.47,Pays at 32.15% of Total Billed charges,230.18,Pays at 80.03% of Total Billed charges,139.72,Pays at 102% of Medicare OPPS Rate,258.86,Pays at 90% of Total Billed charges,92.47,Pays at 32.15% of Total Billed charges,137,Pays at 100% of Medicare OPPS Rate,92.47,Pays at 32.15% of Total Billed charges,253.11,Pays at 88% of Total Billed charges,95.23,Pays at 33.11% of Total Billed charges,92.47,258.86,172.57
Outpatient Medical Services,EMERGENCY ROOM,29515,APPLY SHORT LEG SPLINT (CALF TO FOOT),450,438.44,372.67,Pays at 85% of Billed charges for outpatient setting,140.96,Pays at 32.15% of Total Billed charges,350.88,Pays at 80.03% of Total Billed charges,139.72,Pays at 102% of Medicare OPPS Rate,394.6,Pays at 90% of Total Billed charges,140.96,Pays at 32.15% of Total Billed charges,137,Pays at 100% of Medicare OPPS Rate,140.96,Pays at 32.15% of Total Billed charges,385.83,Pays at 88% of Total Billed charges,145.17,Pays at 33.11% of Total Billed charges,137,394.6,263.06
Outpatient Medical Services,EMERGENCY ROOM,29530,STRAPPING; KNEE,450,112.75,95.84,Pays at 85% of Billed charges for outpatient setting,36.25,Pays at 32.15% of Total Billed charges,90.23,Pays at 80.03% of Total Billed charges,111.31,Pays at 102% of Medicare OPPS Rate,101.48,Pays at 90% of Total Billed charges,36.25,Pays at 32.15% of Total Billed charges,109.13,Pays at 100% of Medicare OPPS Rate,36.25,Pays at 32.15% of Total Billed charges,99.22,Pays at 88% of Total Billed charges,37.33,Pays at 33.11% of Total Billed charges,36.25,111.31,67.65
Outpatient Medical Services,EMERGENCY ROOM,29540,STRAPPING; ANKLE,450,258.75,219.94,Pays at 85% of Billed charges for outpatient setting,83.19,Pays at 32.15% of Total Billed charges,207.08,Pays at 80.03% of Total Billed charges,139.72,Pays at 102% of Medicare OPPS Rate,232.88,Pays at 90% of Total Billed charges,83.19,Pays at 32.15% of Total Billed charges,137,Pays at 100% of Medicare OPPS Rate,83.19,Pays at 32.15% of Total Billed charges,227.7,Pays at 88% of Total Billed charges,85.67,Pays at 33.11% of Total Billed charges,83.19,232.88,155.25
Outpatient Medical Services,EMERGENCY ROOM,29550,STRAPPING; TOES,450,112.75,95.84,Pays at 85% of Billed charges for outpatient setting,36.25,Pays at 32.15% of Total Billed charges,90.23,Pays at 80.03% of Total Billed charges,55.1,Pays at 102% of Medicare OPPS Rate,101.48,Pays at 90% of Total Billed charges,36.25,Pays at 32.15% of Total Billed charges,54.02,Pays at 100% of Medicare OPPS Rate,36.25,Pays at 32.15% of Total Billed charges,99.22,Pays at 88% of Total Billed charges,37.33,Pays at 33.11% of Total Billed charges,36.25,101.48,67.65
Outpatient Medical Services,EMERGENCY ROOM,29580,STRAPPING; UNNA BOOT,450,258.75,219.94,Pays at 85% of Billed charges for outpatient setting,83.19,Pays at 32.15% of Total Billed charges,207.08,Pays at 80.03% of Total Billed charges,139.72,Pays at 102% of Medicare OPPS Rate,232.88,Pays at 90% of Total Billed charges,83.19,Pays at 32.15% of Total Billed charges,137,Pays at 100% of Medicare OPPS Rate,83.19,Pays at 32.15% of Total Billed charges,227.7,Pays at 88% of Total Billed charges,85.67,Pays at 33.11% of Total Billed charges,83.19,232.88,155.25
Outpatient Medical Services,EMERGENCY ROOM,29700,REMOVAL OR BIVALVING CAST,450,456.5,388.03,Pays at 85% of Billed charges for outpatient setting,146.76,Pays at 32.15% of Total Billed charges,365.34,Pays at 80.03% of Total Billed charges,229.98,Pays at 102% of Medicare OPPS Rate,410.85,Pays at 90% of Total Billed charges,146.76,Pays at 32.15% of Total Billed charges,225.48,Pays at 100% of Medicare OPPS Rate,146.76,Pays at 32.15% of Total Billed charges,401.72,Pays at 88% of Total Billed charges,151.15,Pays at 33.11% of Total Billed charges,146.76,410.85,273.90
Outpatient Medical Services,EMERGENCY ROOM,29705,"REMOV/BIVALV LNG A,L CAST",450,456.5,388.03,Pays at 85% of Billed charges for outpatient setting,146.76,Pays at 32.15% of Total Billed charges,365.34,Pays at 80.03% of Total Billed charges,229.98,Pays at 102% of Medicare OPPS Rate,410.85,Pays at 90% of Total Billed charges,146.76,Pays at 32.15% of Total Billed charges,225.48,Pays at 100% of Medicare OPPS Rate,146.76,Pays at 32.15% of Total Billed charges,401.72,Pays at 88% of Total Billed charges,151.15,Pays at 33.11% of Total Billed charges,146.76,410.85,273.90
Outpatient Medical Services,EMERGENCY ROOM,29720,REPAIR SPICA BODY CAST OR JACKET,450,258.75,219.94,Pays at 85% of Billed charges for outpatient setting,83.19,Pays at 32.15% of Total Billed charges,207.08,Pays at 80.03% of Total Billed charges,139.72,Pays at 102% of Medicare OPPS Rate,232.88,Pays at 90% of Total Billed charges,83.19,Pays at 32.15% of Total Billed charges,137,Pays at 100% of Medicare OPPS Rate,83.19,Pays at 32.15% of Total Billed charges,227.7,Pays at 88% of Total Billed charges,85.67,Pays at 33.11% of Total Billed charges,83.19,232.88,155.25
Outpatient Medical Services,EMERGENCY ROOM,29730,WINDOWING OF CAST,450,258.75,219.94,Pays at 85% of Billed charges for outpatient setting,83.19,Pays at 32.15% of Total Billed charges,207.08,Pays at 80.03% of Total Billed charges,139.72,Pays at 102% of Medicare OPPS Rate,232.88,Pays at 90% of Total Billed charges,83.19,Pays at 32.15% of Total Billed charges,137,Pays at 100% of Medicare OPPS Rate,83.19,Pays at 32.15% of Total Billed charges,227.7,Pays at 88% of Total Billed charges,85.67,Pays at 33.11% of Total Billed charges,83.19,232.88,155.25
Outpatient Medical Services,EMERGENCY ROOM,29799,OTHER CASTING  / STRAPPING PROCEDURE,450,349.75,297.29,Pays at 85% of Billed charges for outpatient setting,112.44,Pays at 32.15% of Total Billed charges,279.9,Pays at 80.03% of Total Billed charges,139.72,Pays at 102% of Medicare OPPS Rate,314.78,Pays at 90% of Total Billed charges,112.44,Pays at 32.15% of Total Billed charges,137,Pays at 100% of Medicare OPPS Rate,112.44,Pays at 32.15% of Total Billed charges,307.78,Pays at 88% of Total Billed charges,115.8,Pays at 33.11% of Total Billed charges,112.44,314.78,209.85
Outpatient Medical Services,EMERGENCY ROOM,30300,INTRANASAL-REMOVE F B,450,272.25,231.41,Pays at 85% of Billed charges for outpatient setting,87.53,Pays at 32.15% of Total Billed charges,217.88,Pays at 80.03% of Total Billed charges,111.31,Pays at 102% of Medicare OPPS Rate,245.03,Pays at 90% of Total Billed charges,87.53,Pays at 32.15% of Total Billed charges,109.13,Pays at 100% of Medicare OPPS Rate,87.53,Pays at 32.15% of Total Billed charges,239.58,Pays at 88% of Total Billed charges,90.14,Pays at 33.11% of Total Billed charges,87.53,245.03,163.35
Outpatient Medical Services,EMERGENCY ROOM,30801,NASAL HEMOR/ANT/SIMP/UNI,450,2148.75,1826.44,Pays at 85% of Billed charges for outpatient setting,690.82,Pays at 32.15% of Total Billed charges,1719.64,Pays at 80.03% of Total Billed charges,1330.81,Pays at 102% of Medicare OPPS Rate,1933.88,Pays at 90% of Total Billed charges,690.82,Pays at 32.15% of Total Billed charges,1304.72,Pays at 100% of Medicare OPPS Rate,690.82,Pays at 32.15% of Total Billed charges,1890.9,Pays at 88% of Total Billed charges,711.45,Pays at 33.11% of Total Billed charges,690.82,1933.88,1289.25
Outpatient Medical Services,EMERGENCY ROOM,30802,NASAL HEMOR/ANT/SIMP/BILAT,450,2148.75,1826.44,Pays at 85% of Billed charges for outpatient setting,690.82,Pays at 32.15% of Total Billed charges,1719.64,Pays at 80.03% of Total Billed charges,1330.81,Pays at 102% of Medicare OPPS Rate,1933.88,Pays at 90% of Total Billed charges,690.82,Pays at 32.15% of Total Billed charges,1304.72,Pays at 100% of Medicare OPPS Rate,690.82,Pays at 32.15% of Total Billed charges,1890.9,Pays at 88% of Total Billed charges,711.45,Pays at 33.11% of Total Billed charges,690.82,1933.88,1289.25
Outpatient Medical Services,EMERGENCY ROOM,30901,CONTRL ANT/NASL HEMORR,450,272.25,231.41,Pays at 85% of Billed charges for outpatient setting,87.53,Pays at 32.15% of Total Billed charges,217.88,Pays at 80.03% of Total Billed charges,111.31,Pays at 102% of Medicare OPPS Rate,245.03,Pays at 90% of Total Billed charges,87.53,Pays at 32.15% of Total Billed charges,109.13,Pays at 100% of Medicare OPPS Rate,87.53,Pays at 32.15% of Total Billed charges,239.58,Pays at 88% of Total Billed charges,90.14,Pays at 33.11% of Total Billed charges,87.53,245.03,163.35
Outpatient Medical Services,EMERGENCY ROOM,30903,CONTRL ANT/NASL HEM COMPLEX,450,207,175.95,Pays at 85% of Billed charges for outpatient setting,66.55,Pays at 32.15% of Total Billed charges,165.66,Pays at 80.03% of Total Billed charges,111.3,Pays at 102% of Medicare OPPS Rate,186.3,Pays at 90% of Total Billed charges,66.55,Pays at 32.15% of Total Billed charges,109.12,Pays at 100% of Medicare OPPS Rate,66.55,Pays at 32.15% of Total Billed charges,182.16,Pays at 88% of Total Billed charges,68.54,Pays at 33.11% of Total Billed charges,66.55,186.3,124.20
Outpatient Medical Services,EMERGENCY ROOM,30905,CONTRL POST/NASL HEMORR INIT SAME DAY,450,207,175.95,Pays at 85% of Billed charges for outpatient setting,66.55,Pays at 32.15% of Total Billed charges,165.66,Pays at 80.03% of Total Billed charges,111.3,Pays at 102% of Medicare OPPS Rate,186.3,Pays at 90% of Total Billed charges,66.55,Pays at 32.15% of Total Billed charges,109.12,Pays at 100% of Medicare OPPS Rate,66.55,Pays at 32.15% of Total Billed charges,182.16,Pays at 88% of Total Billed charges,68.54,Pays at 33.11% of Total Billed charges,66.55,186.3,124.20
Outpatient Medical Services,EMERGENCY ROOM,30906,CONTRL POST/NASL HEMORR -SUBSEQUNET,450,366.5,311.53,Pays at 85% of Billed charges for outpatient setting,117.83,Pays at 32.15% of Total Billed charges,293.31,Pays at 80.03% of Total Billed charges,199.23,Pays at 102% of Medicare OPPS Rate,329.85,Pays at 90% of Total Billed charges,117.83,Pays at 32.15% of Total Billed charges,195.33,Pays at 100% of Medicare OPPS Rate,117.83,Pays at 32.15% of Total Billed charges,322.52,Pays at 88% of Total Billed charges,121.35,Pays at 33.11% of Total Billed charges,117.83,329.85,219.90
Outpatient Medical Services,EMERGENCY ROOM,31500,ENDOTRACH INTUBATION,450,461.5,392.28,Pays at 85% of Billed charges for outpatient setting,148.37,Pays at 32.15% of Total Billed charges,369.34,Pays at 80.03% of Total Billed charges,199.23,Pays at 102% of Medicare OPPS Rate,415.35,Pays at 90% of Total Billed charges,148.37,Pays at 32.15% of Total Billed charges,195.33,Pays at 100% of Medicare OPPS Rate,148.37,Pays at 32.15% of Total Billed charges,406.12,Pays at 88% of Total Billed charges,152.8,Pays at 33.11% of Total Billed charges,148.37,415.35,276.90
Outpatient Medical Services,EMERGENCY ROOM,31505,LARYNGOSCOPY DIAGNOSTIC,450,302.25,256.91,Pays at 85% of Billed charges for outpatient setting,97.17,Pays at 32.15% of Total Billed charges,241.89,Pays at 80.03% of Total Billed charges,171.36,Pays at 102% of Medicare OPPS Rate,272.03,Pays at 90% of Total Billed charges,97.17,Pays at 32.15% of Total Billed charges,168,Pays at 100% of Medicare OPPS Rate,97.17,Pays at 32.15% of Total Billed charges,265.98,Pays at 88% of Total Billed charges,100.07,Pays at 33.11% of Total Billed charges,97.17,272.03,181.35
Outpatient Medical Services,EMERGENCY ROOM,31511,LARYNGOSCOPY W/FB REM,450,302.25,256.91,Pays at 85% of Billed charges for outpatient setting,97.17,Pays at 32.15% of Total Billed charges,241.89,Pays at 80.03% of Total Billed charges,171.36,Pays at 102% of Medicare OPPS Rate,272.03,Pays at 90% of Total Billed charges,97.17,Pays at 32.15% of Total Billed charges,168,Pays at 100% of Medicare OPPS Rate,97.17,Pays at 32.15% of Total Billed charges,265.98,Pays at 88% of Total Billed charges,100.07,Pays at 33.11% of Total Billed charges,97.17,272.03,181.35
Outpatient Medical Services,EMERGENCY ROOM,31575,"Flexible, fiberoptic diagnostic laryngoscopy",450,302.25,256.91,Pays at 85% of Billed charges for outpatient setting,97.17,Pays at 32.15% of Total Billed charges,241.89,Pays at 80.03% of Total Billed charges,171.36,Pays at 102% of Medicare OPPS Rate,272.03,Pays at 90% of Total Billed charges,97.17,Pays at 32.15% of Total Billed charges,168,Pays at 100% of Medicare OPPS Rate,97.17,Pays at 32.15% of Total Billed charges,265.98,Pays at 88% of Total Billed charges,100.07,Pays at 33.11% of Total Billed charges,97.17,272.03,181.35
Outpatient Medical Services,EMERGENCY ROOM,31576,"LARYNGOSCOPY, FLEX FIBEROPTIC W/BIOPSY",450,2627.75,2233.59,Pays at 85% of Billed charges for outpatient setting,844.82,Pays at 32.15% of Total Billed charges,2102.99,Pays at 80.03% of Total Billed charges,1532.54,Pays at 102% of Medicare OPPS Rate,2364.98,Pays at 90% of Total Billed charges,844.82,Pays at 32.15% of Total Billed charges,1502.49,Pays at 100% of Medicare OPPS Rate,844.82,Pays at 32.15% of Total Billed charges,2312.42,Pays at 88% of Total Billed charges,870.05,Pays at 33.11% of Total Billed charges,844.82,2364.98,1576.65
Outpatient Medical Services,EMERGENCY ROOM,31577,"LARYNGOSCOPY, FLEX FIBEROPTIC W/FB REMOV",450,749.25,636.86,Pays at 85% of Billed charges for outpatient setting,240.88,Pays at 32.15% of Total Billed charges,599.62,Pays at 80.03% of Total Billed charges,361.55,Pays at 102% of Medicare OPPS Rate,674.33,Pays at 90% of Total Billed charges,240.88,Pays at 32.15% of Total Billed charges,354.46,Pays at 100% of Medicare OPPS Rate,240.88,Pays at 32.15% of Total Billed charges,659.34,Pays at 88% of Total Billed charges,248.08,Pays at 33.11% of Total Billed charges,240.88,674.33,449.55
Outpatient Medical Services,EMERGENCY ROOM,31578,"LARYNGOSCOPY, FLEX FIBEROPTIC W/LESION R",450,5030,4275.5,Pays at 85% of Billed charges for outpatient setting,1617.15,Pays at 32.15% of Total Billed charges,4025.51,Pays at 80.03% of Total Billed charges,3195.99,Pays at 102% of Medicare OPPS Rate,4527,Pays at 90% of Total Billed charges,1617.15,Pays at 32.15% of Total Billed charges,3133.32,Pays at 100% of Medicare OPPS Rate,1617.15,Pays at 32.15% of Total Billed charges,4426.4,Pays at 88% of Total Billed charges,1665.43,Pays at 33.11% of Total Billed charges,1617.15,4527,3018.00
Outpatient Medical Services,EMERGENCY ROOM,31603,TRANSTRACH TRACHEOSTOMY,450,2148.75,1826.44,Pays at 85% of Billed charges for outpatient setting,690.82,Pays at 32.15% of Total Billed charges,1719.64,Pays at 80.03% of Total Billed charges,1330.81,Pays at 102% of Medicare OPPS Rate,1933.88,Pays at 90% of Total Billed charges,690.82,Pays at 32.15% of Total Billed charges,1304.72,Pays at 100% of Medicare OPPS Rate,690.82,Pays at 32.15% of Total Billed charges,1890.9,Pays at 88% of Total Billed charges,711.45,Pays at 33.11% of Total Billed charges,690.82,1933.88,1289.25
Outpatient Medical Services,EMERGENCY ROOM,31605,CRICOTHYROIDOTOMY,450,916,778.6,Pays at 85% of Billed charges for outpatient setting,294.49,Pays at 32.15% of Total Billed charges,733.07,Pays at 80.03% of Total Billed charges,199.23,Pays at 102% of Medicare OPPS Rate,824.4,Pays at 90% of Total Billed charges,294.49,Pays at 32.15% of Total Billed charges,195.33,Pays at 100% of Medicare OPPS Rate,294.49,Pays at 32.15% of Total Billed charges,806.08,Pays at 88% of Total Billed charges,303.29,Pays at 33.11% of Total Billed charges,195.33,824.4,549.60
Outpatient Medical Services,EMERGENCY ROOM,32551,CHEST TUBE,450,2543,2161.55,Pays at 85% of Billed charges for outpatient setting,817.57,Pays at 32.15% of Total Billed charges,2035.16,Pays at 80.03% of Total Billed charges,1426.4,Pays at 102% of Medicare OPPS Rate,2288.7,Pays at 90% of Total Billed charges,817.57,Pays at 32.15% of Total Billed charges,1398.43,Pays at 100% of Medicare OPPS Rate,817.57,Pays at 32.15% of Total Billed charges,2237.84,Pays at 88% of Total Billed charges,841.99,Pays at 33.11% of Total Billed charges,817.57,2288.7,1525.80
Outpatient Medical Services,EMERGENCY ROOM,32554,THORACENTESIS,450,1416,1203.6,Pays at 85% of Billed charges for outpatient setting,455.24,Pays at 32.15% of Total Billed charges,1133.22,Pays at 80.03% of Total Billed charges,554.6,Pays at 102% of Medicare OPPS Rate,1274.4,Pays at 90% of Total Billed charges,455.24,Pays at 32.15% of Total Billed charges,543.73,Pays at 100% of Medicare OPPS Rate,455.24,Pays at 32.15% of Total Billed charges,1246.08,Pays at 88% of Total Billed charges,468.84,Pays at 33.11% of Total Billed charges,455.24,1274.4,849.60
Outpatient Medical Services,EMERGENCY ROOM,32554,THORACENTESIS-PNEUMOTHORAX,450,1416,1203.6,Pays at 85% of Billed charges for outpatient setting,455.24,Pays at 32.15% of Total Billed charges,1133.22,Pays at 80.03% of Total Billed charges,554.6,Pays at 102% of Medicare OPPS Rate,1274.4,Pays at 90% of Total Billed charges,455.24,Pays at 32.15% of Total Billed charges,543.73,Pays at 100% of Medicare OPPS Rate,455.24,Pays at 32.15% of Total Billed charges,1246.08,Pays at 88% of Total Billed charges,468.84,Pays at 33.11% of Total Billed charges,455.24,1274.4,849.60
Outpatient Medical Services,EMERGENCY ROOM,33016,PERICARDIOCENTESIS,450,1416,1203.6,Pays at 85% of Billed charges for outpatient setting,455.24,Pays at 32.15% of Total Billed charges,1133.22,Pays at 80.03% of Total Billed charges,1426.4,Pays at 102% of Medicare OPPS Rate,1274.4,Pays at 90% of Total Billed charges,455.24,Pays at 32.15% of Total Billed charges,1398.43,Pays at 100% of Medicare OPPS Rate,455.24,Pays at 32.15% of Total Billed charges,1246.08,Pays at 88% of Total Billed charges,468.84,Pays at 33.11% of Total Billed charges,455.24,1426.4,849.60
Outpatient Medical Services,EMERGENCY ROOM,33210,INSERTION OF TEMP TRANS PACEMAKER,450,14435.25,12269.96,Pays at 85% of Billed charges for outpatient setting,4640.93,Pays at 32.15% of Total Billed charges,11552.53,Pays at 80.03% of Total Billed charges,7825.7,Pays at 102% of Medicare OPPS Rate,12991.73,Pays at 90% of Total Billed charges,4640.93,Pays at 32.15% of Total Billed charges,7672.25,Pays at 100% of Medicare OPPS Rate,4640.93,Pays at 32.15% of Total Billed charges,12703.02,Pays at 88% of Total Billed charges,4779.51,Pays at 33.11% of Total Billed charges,4640.93,12991.73,8661.15
Outpatient Medical Services,EMERGENCY ROOM,36420,1 Y/O CUTDOWN VENIPUNCTURE,450,112.75,95.84,Pays at 85% of Billed charges for outpatient setting,36.25,Pays at 32.15% of Total Billed charges,90.23,Pays at 80.03% of Total Billed charges,111.31,Pays at 102% of Medicare OPPS Rate,101.48,Pays at 90% of Total Billed charges,36.25,Pays at 32.15% of Total Billed charges,109.13,Pays at 100% of Medicare OPPS Rate,36.25,Pays at 32.15% of Total Billed charges,99.22,Pays at 88% of Total Billed charges,37.33,Pays at 33.11% of Total Billed charges,36.25,111.31,67.65
Outpatient Medical Services,EMERGENCY ROOM,36425,CUTDOWN VENIPUNCTURE > 1 YO,450,545.5,463.68,Pays at 85% of Billed charges for outpatient setting,175.38,Pays at 32.15% of Total Billed charges,436.56,Pays at 80.03% of Total Billed charges,361.97,Pays at 102% of Medicare OPPS Rate,490.95,Pays at 90% of Total Billed charges,175.38,Pays at 32.15% of Total Billed charges,354.88,Pays at 100% of Medicare OPPS Rate,175.38,Pays at 32.15% of Total Billed charges,480.04,Pays at 88% of Total Billed charges,180.62,Pays at 33.11% of Total Billed charges,175.38,490.95,327.30
Outpatient Medical Services,EMERGENCY ROOM,36555,CENTRAL VENOUS CATHETER PERCUTANEOUS <2,450,1416,1203.6,Pays at 85% of Billed charges for outpatient setting,455.24,Pays at 32.15% of Total Billed charges,1133.22,Pays at 80.03% of Total Billed charges,2855.95,Pays at 102% of Medicare OPPS Rate,1274.4,Pays at 90% of Total Billed charges,455.24,Pays at 32.15% of Total Billed charges,2799.95,Pays at 100% of Medicare OPPS Rate,455.24,Pays at 32.15% of Total Billed charges,1246.08,Pays at 88% of Total Billed charges,468.84,Pays at 33.11% of Total Billed charges,455.24,2855.95,849.60
Outpatient Medical Services,EMERGENCY ROOM,36555,CENTRAL VENOUS CATH CUTDOWN < 2YO,450,1416,1203.6,Pays at 85% of Billed charges for outpatient setting,455.24,Pays at 32.15% of Total Billed charges,1133.22,Pays at 80.03% of Total Billed charges,2855.95,Pays at 102% of Medicare OPPS Rate,1274.4,Pays at 90% of Total Billed charges,455.24,Pays at 32.15% of Total Billed charges,2799.95,Pays at 100% of Medicare OPPS Rate,455.24,Pays at 32.15% of Total Billed charges,1246.08,Pays at 88% of Total Billed charges,468.84,Pays at 33.11% of Total Billed charges,455.24,2855.95,849.60
Outpatient Medical Services,EMERGENCY ROOM,36555,CVC PERCUTANEUOS > 2YO,450,2543,2161.55,Pays at 85% of Billed charges for outpatient setting,817.57,Pays at 32.15% of Total Billed charges,2035.16,Pays at 80.03% of Total Billed charges,2855.95,Pays at 102% of Medicare OPPS Rate,2288.7,Pays at 90% of Total Billed charges,817.57,Pays at 32.15% of Total Billed charges,2799.95,Pays at 100% of Medicare OPPS Rate,817.57,Pays at 32.15% of Total Billed charges,2237.84,Pays at 88% of Total Billed charges,841.99,Pays at 33.11% of Total Billed charges,817.57,2855.95,1525.80
Outpatient Medical Services,EMERGENCY ROOM,36556,CVC PERCUTANEOUS BY CUTDOWN > 2YO,450,1416,1203.6,Pays at 85% of Billed charges for outpatient setting,455.24,Pays at 32.15% of Total Billed charges,1133.22,Pays at 80.03% of Total Billed charges,2855.95,Pays at 102% of Medicare OPPS Rate,1274.4,Pays at 90% of Total Billed charges,455.24,Pays at 32.15% of Total Billed charges,2799.95,Pays at 100% of Medicare OPPS Rate,455.24,Pays at 32.15% of Total Billed charges,1246.08,Pays at 88% of Total Billed charges,468.84,Pays at 33.11% of Total Billed charges,455.24,2855.95,849.60
Outpatient Medical Services,EMERGENCY ROOM,36556,CVC PERCUTANEUOS > 5YO,450,2543,2161.55,Pays at 85% of Billed charges for outpatient setting,817.57,Pays at 32.15% of Total Billed charges,2035.16,Pays at 80.03% of Total Billed charges,2855.95,Pays at 102% of Medicare OPPS Rate,2288.7,Pays at 90% of Total Billed charges,817.57,Pays at 32.15% of Total Billed charges,2799.95,Pays at 100% of Medicare OPPS Rate,817.57,Pays at 32.15% of Total Billed charges,2237.84,Pays at 88% of Total Billed charges,841.99,Pays at 33.11% of Total Billed charges,817.57,2855.95,1525.80
Outpatient Medical Services,EMERGENCY ROOM,36680,INTRAOSSEOUS IV,450,545.5,463.68,Pays at 85% of Billed charges for outpatient setting,175.38,Pays at 32.15% of Total Billed charges,436.56,Pays at 80.03% of Total Billed charges,361.97,Pays at 102% of Medicare OPPS Rate,490.95,Pays at 90% of Total Billed charges,175.38,Pays at 32.15% of Total Billed charges,354.88,Pays at 100% of Medicare OPPS Rate,175.38,Pays at 32.15% of Total Billed charges,480.04,Pays at 88% of Total Billed charges,180.62,Pays at 33.11% of Total Billed charges,175.38,490.95,327.30
Outpatient Medical Services,EMERGENCY ROOM,40650,REPAIR LIP FULL THICKNESS VERMILION ONLY,450,1190.25,1011.71,Pays at 85% of Billed charges for outpatient setting,382.67,Pays at 32.15% of Total Billed charges,952.56,Pays at 80.03% of Total Billed charges,437.94,Pays at 102% of Medicare OPPS Rate,1071.23,Pays at 90% of Total Billed charges,382.67,Pays at 32.15% of Total Billed charges,429.36,Pays at 100% of Medicare OPPS Rate,382.67,Pays at 32.15% of Total Billed charges,1047.42,Pays at 88% of Total Billed charges,394.09,Pays at 33.11% of Total Billed charges,382.67,1071.23,714.15
Outpatient Medical Services,EMERGENCY ROOM,40800,"I & D, ABSCESS, CYST, VESTIBULE OF MOUTH",450,1115.75,948.39,Pays at 85% of Billed charges for outpatient setting,358.71,Pays at 32.15% of Total Billed charges,892.93,Pays at 80.03% of Total Billed charges,622.15,Pays at 102% of Medicare OPPS Rate,1004.18,Pays at 90% of Total Billed charges,358.71,Pays at 32.15% of Total Billed charges,609.96,Pays at 100% of Medicare OPPS Rate,358.71,Pays at 32.15% of Total Billed charges,981.86,Pays at 88% of Total Billed charges,369.42,Pays at 33.11% of Total Billed charges,358.71,1004.18,669.45
Outpatient Medical Services,EMERGENCY ROOM,40830,CLSURE LAC VEST < 2.5 CM,450,366.5,311.53,Pays at 85% of Billed charges for outpatient setting,117.83,Pays at 32.15% of Total Billed charges,293.31,Pays at 80.03% of Total Billed charges,199.23,Pays at 102% of Medicare OPPS Rate,329.85,Pays at 90% of Total Billed charges,117.83,Pays at 32.15% of Total Billed charges,195.33,Pays at 100% of Medicare OPPS Rate,117.83,Pays at 32.15% of Total Billed charges,322.52,Pays at 88% of Total Billed charges,121.35,Pays at 33.11% of Total Billed charges,117.83,329.85,219.90
Outpatient Medical Services,EMERGENCY ROOM,40831,CLSURE LAC VEST > 2.5 CM,450,916,778.6,Pays at 85% of Billed charges for outpatient setting,294.49,Pays at 32.15% of Total Billed charges,733.07,Pays at 80.03% of Total Billed charges,437.94,Pays at 102% of Medicare OPPS Rate,824.4,Pays at 90% of Total Billed charges,294.49,Pays at 32.15% of Total Billed charges,429.36,Pays at 100% of Medicare OPPS Rate,294.49,Pays at 32.15% of Total Billed charges,806.08,Pays at 88% of Total Billed charges,303.29,Pays at 33.11% of Total Billed charges,294.49,824.4,549.60
Outpatient Medical Services,EMERGENCY ROOM,41250,MOUTH LAC < 2.5 CM,450,545.5,463.68,Pays at 85% of Billed charges for outpatient setting,175.38,Pays at 32.15% of Total Billed charges,436.56,Pays at 80.03% of Total Billed charges,361.97,Pays at 102% of Medicare OPPS Rate,490.95,Pays at 90% of Total Billed charges,175.38,Pays at 32.15% of Total Billed charges,354.88,Pays at 100% of Medicare OPPS Rate,175.38,Pays at 32.15% of Total Billed charges,480.04,Pays at 88% of Total Billed charges,180.62,Pays at 33.11% of Total Billed charges,175.38,490.95,327.30
Outpatient Medical Services,EMERGENCY ROOM,41252,MOUTH LAC > 2.6 CM,450,916,778.6,Pays at 85% of Billed charges for outpatient setting,294.49,Pays at 32.15% of Total Billed charges,733.07,Pays at 80.03% of Total Billed charges,199.23,Pays at 102% of Medicare OPPS Rate,824.4,Pays at 90% of Total Billed charges,294.49,Pays at 32.15% of Total Billed charges,195.33,Pays at 100% of Medicare OPPS Rate,294.49,Pays at 32.15% of Total Billed charges,806.08,Pays at 88% of Total Billed charges,303.29,Pays at 33.11% of Total Billed charges,195.33,824.4,549.60
Outpatient Medical Services,EMERGENCY ROOM,41800,I & D ABSCESS DENTOALVEOLAR,450,207,175.95,Pays at 85% of Billed charges for outpatient setting,66.55,Pays at 32.15% of Total Billed charges,165.66,Pays at 80.03% of Total Billed charges,111.31,Pays at 102% of Medicare OPPS Rate,186.3,Pays at 90% of Total Billed charges,66.55,Pays at 32.15% of Total Billed charges,109.13,Pays at 100% of Medicare OPPS Rate,66.55,Pays at 32.15% of Total Billed charges,182.16,Pays at 88% of Total Billed charges,68.54,Pays at 33.11% of Total Billed charges,66.55,186.3,124.20
Outpatient Medical Services,EMERGENCY ROOM,42700,I & D ABSCESS PERITONSILLAR ABSCESS,450,366.5,311.53,Pays at 85% of Billed charges for outpatient setting,117.83,Pays at 32.15% of Total Billed charges,293.31,Pays at 80.03% of Total Billed charges,199.23,Pays at 102% of Medicare OPPS Rate,329.85,Pays at 90% of Total Billed charges,117.83,Pays at 32.15% of Total Billed charges,195.33,Pays at 100% of Medicare OPPS Rate,117.83,Pays at 32.15% of Total Billed charges,322.52,Pays at 88% of Total Billed charges,121.35,Pays at 33.11% of Total Billed charges,117.83,329.85,219.90
Outpatient Medical Services,EMERGENCY ROOM,42809,REM PHARYNGEAL FOREIGN BODY,450,545.5,463.68,Pays at 85% of Billed charges for outpatient setting,175.38,Pays at 32.15% of Total Billed charges,436.56,Pays at 80.03% of Total Billed charges,361.97,Pays at 102% of Medicare OPPS Rate,490.95,Pays at 90% of Total Billed charges,175.38,Pays at 32.15% of Total Billed charges,354.88,Pays at 100% of Medicare OPPS Rate,175.38,Pays at 32.15% of Total Billed charges,480.04,Pays at 88% of Total Billed charges,180.62,Pays at 33.11% of Total Billed charges,175.38,490.95,327.30
Outpatient Medical Services,EMERGENCY ROOM,43752,GASTRIC LAVAGE,450,545.5,463.68,Pays at 85% of Billed charges for outpatient setting,175.38,Pays at 32.15% of Total Billed charges,436.56,Pays at 80.03% of Total Billed charges,361.97,Pays at 102% of Medicare OPPS Rate,490.95,Pays at 90% of Total Billed charges,175.38,Pays at 32.15% of Total Billed charges,354.88,Pays at 100% of Medicare OPPS Rate,175.38,Pays at 32.15% of Total Billed charges,480.04,Pays at 88% of Total Billed charges,180.62,Pays at 33.11% of Total Billed charges,175.38,490.95,327.30
Outpatient Medical Services,EMERGENCY ROOM,43752,NG TUBE INSERTION,450,854,725.9,Pays at 85% of Billed charges for outpatient setting,274.56,Pays at 32.15% of Total Billed charges,683.46,Pays at 80.03% of Total Billed charges,361.97,Pays at 102% of Medicare OPPS Rate,768.6,Pays at 90% of Total Billed charges,274.56,Pays at 32.15% of Total Billed charges,354.88,Pays at 100% of Medicare OPPS Rate,274.56,Pays at 32.15% of Total Billed charges,751.52,Pays at 88% of Total Billed charges,282.76,Pays at 33.11% of Total Billed charges,274.56,768.6,512.40
Outpatient Medical Services,EMERGENCY ROOM,43753,GASTRIC INTUBATION,450,925,786.25,Pays at 85% of Billed charges for outpatient setting,297.39,Pays at 32.15% of Total Billed charges,740.28,Pays at 80.03% of Total Billed charges,268.49,Pays at 102% of Medicare OPPS Rate,832.5,Pays at 90% of Total Billed charges,297.39,Pays at 32.15% of Total Billed charges,263.23,Pays at 100% of Medicare OPPS Rate,297.39,Pays at 32.15% of Total Billed charges,814,Pays at 88% of Total Billed charges,306.27,Pays at 33.11% of Total Billed charges,263.23,832.5,555.00
Outpatient Medical Services,EMERGENCY ROOM,43754,"GASTRIC INTUBATION AND ASPIRATION, DIAGN",450,925,786.25,Pays at 85% of Billed charges for outpatient setting,297.39,Pays at 32.15% of Total Billed charges,740.28,Pays at 80.03% of Total Billed charges,268.49,Pays at 102% of Medicare OPPS Rate,832.5,Pays at 90% of Total Billed charges,297.39,Pays at 32.15% of Total Billed charges,263.23,Pays at 100% of Medicare OPPS Rate,297.39,Pays at 32.15% of Total Billed charges,814,Pays at 88% of Total Billed charges,306.27,Pays at 33.11% of Total Billed charges,263.23,832.5,555.00
Outpatient Medical Services,EMERGENCY ROOM,43760,"PROCEDURE, REPLACEMENT G TUBE",450,284.75,242.04,Pays at 85% of Billed charges for outpatient setting,91.55,Pays at 32.15% of Total Billed charges,227.89,Pays at 80.03% of Total Billed charges,284.75,Not Applicable,256.28,Pays at 90% of Total Billed charges,91.55,Pays at 32.15% of Total Billed charges,284.75,Not Applicable,91.55,Pays at 32.15% of Total Billed charges,250.58,Pays at 88% of Total Billed charges,94.28,Pays at 33.11% of Total Billed charges,91.55,284.75,170.85
Outpatient Medical Services,EMERGENCY ROOM,43760,CHANGE GASTROSTOMY TUBE,450,594,504.9,Pays at 85% of Billed charges for outpatient setting,190.97,Pays at 32.15% of Total Billed charges,475.38,Pays at 80.03% of Total Billed charges,594,Not Applicable,534.6,Pays at 90% of Total Billed charges,190.97,Pays at 32.15% of Total Billed charges,594,Not Applicable,190.97,Pays at 32.15% of Total Billed charges,522.72,Pays at 88% of Total Billed charges,196.67,Pays at 33.11% of Total Billed charges,190.97,594,356.40
Outpatient Medical Services,EMERGENCY ROOM,43762,REPLACEMENT G TUBE PERCUTANEOUS,450,930,790.5,Pays at 85% of Billed charges for outpatient setting,299,Pays at 32.15% of Total Billed charges,744.28,Pays at 80.03% of Total Billed charges,205.98,Pays at 102% of Medicare OPPS Rate,837,Pays at 90% of Total Billed charges,299,Pays at 32.15% of Total Billed charges,201.95,Pays at 100% of Medicare OPPS Rate,299,Pays at 32.15% of Total Billed charges,818.4,Pays at 88% of Total Billed charges,307.92,Pays at 33.11% of Total Billed charges,201.95,837,558.00
Outpatient Medical Services,EMERGENCY ROOM,43999,REMOVAL OF GASTRIC RESTRUCTIVE DEVICE,450,1164.4,989.74,Pays at 85% of Billed charges for outpatient setting,374.35,Pays at 32.15% of Total Billed charges,931.87,Pays at 80.03% of Total Billed charges,791.41,Pays at 102% of Medicare OPPS Rate,1047.96,Pays at 90% of Total Billed charges,374.35,Pays at 32.15% of Total Billed charges,775.89,Pays at 100% of Medicare OPPS Rate,374.35,Pays at 32.15% of Total Billed charges,1024.67,Pays at 88% of Total Billed charges,385.53,Pays at 33.11% of Total Billed charges,374.35,1047.96,698.64
Outpatient Medical Services,EMERGENCY ROOM,45100,BIOPSY OF RECTUM,450,4484.75,3812.04,Pays at 85% of Billed charges for outpatient setting,1441.85,Pays at 32.15% of Total Billed charges,3589.15,Pays at 80.03% of Total Billed charges,2463.35,Pays at 102% of Medicare OPPS Rate,4036.28,Pays at 90% of Total Billed charges,1441.85,Pays at 32.15% of Total Billed charges,2415.05,Pays at 100% of Medicare OPPS Rate,1441.85,Pays at 32.15% of Total Billed charges,3946.58,Pays at 88% of Total Billed charges,1484.9,Pays at 33.11% of Total Billed charges,1441.85,4036.28,2690.85
Outpatient Medical Services,EMERGENCY ROOM,45300,PROCTOSIGMOIDOSCOPY,450,1381.75,1174.49,Pays at 85% of Billed charges for outpatient setting,444.23,Pays at 32.15% of Total Billed charges,1105.81,Pays at 80.03% of Total Billed charges,796.71,Pays at 102% of Medicare OPPS Rate,1243.58,Pays at 90% of Total Billed charges,444.23,Pays at 32.15% of Total Billed charges,781.1,Pays at 100% of Medicare OPPS Rate,444.23,Pays at 32.15% of Total Billed charges,1215.94,Pays at 88% of Total Billed charges,457.5,Pays at 33.11% of Total Billed charges,444.23,1243.58,829.05
Outpatient Medical Services,EMERGENCY ROOM,46040,I & D ISCHIORECTAL AND/OR PERIRECTAL ABS,450,1816.5,1544.03,Pays at 85% of Billed charges for outpatient setting,584,Pays at 32.15% of Total Billed charges,1453.74,Pays at 80.03% of Total Billed charges,1038.18,Pays at 102% of Medicare OPPS Rate,1634.85,Pays at 90% of Total Billed charges,584,Pays at 32.15% of Total Billed charges,1017.83,Pays at 100% of Medicare OPPS Rate,584,Pays at 32.15% of Total Billed charges,1598.52,Pays at 88% of Total Billed charges,601.44,Pays at 33.11% of Total Billed charges,584,1634.85,1089.90
Outpatient Medical Services,EMERGENCY ROOM,46050,I & D PERIANAL ABSCESS,450,1381.75,1174.49,Pays at 85% of Billed charges for outpatient setting,444.23,Pays at 32.15% of Total Billed charges,1105.81,Pays at 80.03% of Total Billed charges,796.71,Pays at 102% of Medicare OPPS Rate,1243.58,Pays at 90% of Total Billed charges,444.23,Pays at 32.15% of Total Billed charges,781.1,Pays at 100% of Medicare OPPS Rate,444.23,Pays at 32.15% of Total Billed charges,1215.94,Pays at 88% of Total Billed charges,457.5,Pays at 33.11% of Total Billed charges,444.23,1243.58,829.05
Outpatient Medical Services,EMERGENCY ROOM,46083,INCISION THROMBOSED HEMORRHOID EXT,450,594,504.9,Pays at 85% of Billed charges for outpatient setting,190.97,Pays at 32.15% of Total Billed charges,475.38,Pays at 80.03% of Total Billed charges,205.98,Pays at 102% of Medicare OPPS Rate,534.6,Pays at 90% of Total Billed charges,190.97,Pays at 32.15% of Total Billed charges,201.95,Pays at 100% of Medicare OPPS Rate,190.97,Pays at 32.15% of Total Billed charges,522.72,Pays at 88% of Total Billed charges,196.67,Pays at 33.11% of Total Billed charges,190.97,534.6,356.40
Outpatient Medical Services,EMERGENCY ROOM,46221,LIGATION OF HEMORRHOIDS,450,1381.75,1174.49,Pays at 85% of Billed charges for outpatient setting,444.23,Pays at 32.15% of Total Billed charges,1105.81,Pays at 80.03% of Total Billed charges,796.71,Pays at 102% of Medicare OPPS Rate,1243.58,Pays at 90% of Total Billed charges,444.23,Pays at 32.15% of Total Billed charges,781.1,Pays at 100% of Medicare OPPS Rate,444.23,Pays at 32.15% of Total Billed charges,1215.94,Pays at 88% of Total Billed charges,457.5,Pays at 33.11% of Total Billed charges,444.23,1243.58,829.05
Outpatient Medical Services,EMERGENCY ROOM,46320,ENUC/EXC THROMB. HEMORR,450,1816.5,1544.03,Pays at 85% of Billed charges for outpatient setting,584,Pays at 32.15% of Total Billed charges,1453.74,Pays at 80.03% of Total Billed charges,1038.18,Pays at 102% of Medicare OPPS Rate,1634.85,Pays at 90% of Total Billed charges,584,Pays at 32.15% of Total Billed charges,1017.83,Pays at 100% of Medicare OPPS Rate,584,Pays at 32.15% of Total Billed charges,1598.52,Pays at 88% of Total Billed charges,601.44,Pays at 33.11% of Total Billed charges,584,1634.85,1089.90
Outpatient Medical Services,EMERGENCY ROOM,46608,ANOSCOPY W/ FB REMOVAL,450,1381.75,1174.49,Pays at 85% of Billed charges for outpatient setting,444.23,Pays at 32.15% of Total Billed charges,1105.81,Pays at 80.03% of Total Billed charges,796.71,Pays at 102% of Medicare OPPS Rate,1243.58,Pays at 90% of Total Billed charges,444.23,Pays at 32.15% of Total Billed charges,781.1,Pays at 100% of Medicare OPPS Rate,444.23,Pays at 32.15% of Total Billed charges,1215.94,Pays at 88% of Total Billed charges,457.5,Pays at 33.11% of Total Billed charges,444.23,1243.58,829.05
Outpatient Medical Services,EMERGENCY ROOM,49084,PARACENTESIS INIT PERITON LAVAGE,450,1448,1230.8,Pays at 85% of Billed charges for outpatient setting,465.53,Pays at 32.15% of Total Billed charges,1158.83,Pays at 80.03% of Total Billed charges,791.41,Pays at 102% of Medicare OPPS Rate,1303.2,Pays at 90% of Total Billed charges,465.53,Pays at 32.15% of Total Billed charges,775.89,Pays at 100% of Medicare OPPS Rate,465.53,Pays at 32.15% of Total Billed charges,1274.24,Pays at 88% of Total Billed charges,479.43,Pays at 33.11% of Total Billed charges,465.53,1303.2,868.80
Outpatient Medical Services,EMERGENCY ROOM,49421,INSERT INTRAPERITONEAL CATH FOR DIALYS,450,5923.25,5034.76,Pays at 85% of Billed charges for outpatient setting,1904.32,Pays at 32.15% of Total Billed charges,4740.38,Pays at 80.03% of Total Billed charges,3395.65,Pays at 102% of Medicare OPPS Rate,5330.93,Pays at 90% of Total Billed charges,1904.32,Pays at 32.15% of Total Billed charges,3329.08,Pays at 100% of Medicare OPPS Rate,1904.32,Pays at 32.15% of Total Billed charges,5212.46,Pays at 88% of Total Billed charges,1961.19,Pays at 33.11% of Total Billed charges,1904.32,5330.93,3553.95
Outpatient Medical Services,EMERGENCY ROOM,50432,NEPHROSTOMY TUBE PLACEMENT BILAT,450,514.25,437.11,Pays at 85% of Billed charges for outpatient setting,165.33,Pays at 32.15% of Total Billed charges,411.55,Pays at 80.03% of Total Billed charges,1778.27,Pays at 102% of Medicare OPPS Rate,462.83,Pays at 90% of Total Billed charges,165.33,Pays at 32.15% of Total Billed charges,1743.41,Pays at 100% of Medicare OPPS Rate,165.33,Pays at 32.15% of Total Billed charges,452.54,Pays at 88% of Total Billed charges,170.27,Pays at 33.11% of Total Billed charges,165.33,1778.27,308.55
Outpatient Medical Services,EMERGENCY ROOM,51100,ASPIRATION BLADDER BY NEEDLE,450,1136.5,966.03,Pays at 85% of Billed charges for outpatient setting,365.38,Pays at 32.15% of Total Billed charges,909.54,Pays at 80.03% of Total Billed charges,205.98,Pays at 102% of Medicare OPPS Rate,1022.85,Pays at 90% of Total Billed charges,365.38,Pays at 32.15% of Total Billed charges,201.95,Pays at 100% of Medicare OPPS Rate,365.38,Pays at 32.15% of Total Billed charges,1000.12,Pays at 88% of Total Billed charges,376.3,Pays at 33.11% of Total Billed charges,201.95,1022.85,681.90
Outpatient Medical Services,EMERGENCY ROOM,51700,IRRIGATION OF BLADDER,450,447,379.95,Pays at 85% of Billed charges for outpatient setting,143.71,Pays at 32.15% of Total Billed charges,357.73,Pays at 80.03% of Total Billed charges,205.98,Pays at 102% of Medicare OPPS Rate,402.3,Pays at 90% of Total Billed charges,143.71,Pays at 32.15% of Total Billed charges,201.95,Pays at 100% of Medicare OPPS Rate,143.71,Pays at 32.15% of Total Billed charges,393.36,Pays at 88% of Total Billed charges,148,Pays at 33.11% of Total Billed charges,143.71,402.3,268.20
Outpatient Medical Services,EMERGENCY ROOM,51701,INSERT NON INDWELLING (STRAIGHT) CATH,450,272.25,231.41,Pays at 85% of Billed charges for outpatient setting,87.53,Pays at 32.15% of Total Billed charges,217.88,Pays at 80.03% of Total Billed charges,111.31,Pays at 102% of Medicare OPPS Rate,245.03,Pays at 90% of Total Billed charges,87.53,Pays at 32.15% of Total Billed charges,109.13,Pays at 100% of Medicare OPPS Rate,87.53,Pays at 32.15% of Total Billed charges,239.58,Pays at 88% of Total Billed charges,90.14,Pays at 33.11% of Total Billed charges,87.53,245.03,163.35
Outpatient Medical Services,EMERGENCY ROOM,51702,CATHETER INSERTION,450,267.32,227.22,Pays at 85% of Billed charges for outpatient setting,85.94,Pays at 32.15% of Total Billed charges,213.94,Pays at 80.03% of Total Billed charges,111.31,Pays at 102% of Medicare OPPS Rate,240.59,Pays at 90% of Total Billed charges,85.94,Pays at 32.15% of Total Billed charges,109.13,Pays at 100% of Medicare OPPS Rate,85.94,Pays at 32.15% of Total Billed charges,235.24,Pays at 88% of Total Billed charges,88.51,Pays at 33.11% of Total Billed charges,85.94,240.59,160.39
Outpatient Medical Services,EMERGENCY ROOM,51702,INSERTION OF FOLEY CATH,450,326,277.1,Pays at 85% of Billed charges for outpatient setting,104.81,Pays at 32.15% of Total Billed charges,260.9,Pays at 80.03% of Total Billed charges,111.31,Pays at 102% of Medicare OPPS Rate,293.4,Pays at 90% of Total Billed charges,104.81,Pays at 32.15% of Total Billed charges,109.13,Pays at 100% of Medicare OPPS Rate,104.81,Pays at 32.15% of Total Billed charges,286.88,Pays at 88% of Total Billed charges,107.94,Pays at 33.11% of Total Billed charges,104.81,293.4,195.60
Outpatient Medical Services,EMERGENCY ROOM,51798,Ultrasound of bladder to measure urine capacity,450,139.75,118.79,Pays at 85% of Billed charges for outpatient setting,44.93,Pays at 32.15% of Total Billed charges,111.84,Pays at 80.03% of Total Billed charges,55.1,Pays at 102% of Medicare OPPS Rate,125.78,Pays at 90% of Total Billed charges,44.93,Pays at 32.15% of Total Billed charges,54.02,Pays at 100% of Medicare OPPS Rate,44.93,Pays at 32.15% of Total Billed charges,122.98,Pays at 88% of Total Billed charges,46.27,Pays at 33.11% of Total Billed charges,44.93,125.78,83.85
Outpatient Medical Services,EMERGENCY ROOM,52281,CYSTOSCOPY WITH DIALATION,450,3403,2892.55,Pays at 85% of Billed charges for outpatient setting,1094.06,Pays at 32.15% of Total Billed charges,2723.42,Pays at 80.03% of Total Billed charges,1778.27,Pays at 102% of Medicare OPPS Rate,3062.7,Pays at 90% of Total Billed charges,1094.06,Pays at 32.15% of Total Billed charges,1743.41,Pays at 100% of Medicare OPPS Rate,1094.06,Pays at 32.15% of Total Billed charges,2994.64,Pays at 88% of Total Billed charges,1126.73,Pays at 33.11% of Total Billed charges,1094.06,3062.7,2041.80
Outpatient Medical Services,EMERGENCY ROOM,56405,I & D OF VULVA OR PERINEAL ABSCESS,450,570.25,484.71,Pays at 85% of Billed charges for outpatient setting,183.34,Pays at 32.15% of Total Billed charges,456.37,Pays at 80.03% of Total Billed charges,279.89,Pays at 102% of Medicare OPPS Rate,513.23,Pays at 90% of Total Billed charges,183.34,Pays at 32.15% of Total Billed charges,274.39,Pays at 100% of Medicare OPPS Rate,183.34,Pays at 32.15% of Total Billed charges,501.82,Pays at 88% of Total Billed charges,188.81,Pays at 33.11% of Total Billed charges,183.34,513.23,342.15
Outpatient Medical Services,EMERGENCY ROOM,56420,I & D BARTHOLIN ABSCESS,450,416,353.6,Pays at 85% of Billed charges for outpatient setting,133.74,Pays at 32.15% of Total Billed charges,332.92,Pays at 80.03% of Total Billed charges,170.77,Pays at 102% of Medicare OPPS Rate,374.4,Pays at 90% of Total Billed charges,133.74,Pays at 32.15% of Total Billed charges,167.41,Pays at 100% of Medicare OPPS Rate,133.74,Pays at 32.15% of Total Billed charges,366.08,Pays at 88% of Total Billed charges,137.74,Pays at 33.11% of Total Billed charges,133.74,374.4,249.60
Outpatient Medical Services,EMERGENCY ROOM,56440,MARSUPIALIZATION OF BARTHOLIN'S GLAND CY,450,4315,3667.75,Pays at 85% of Billed charges for outpatient setting,1387.27,Pays at 32.15% of Total Billed charges,3453.29,Pays at 80.03% of Total Billed charges,2710.67,Pays at 102% of Medicare OPPS Rate,3883.5,Pays at 90% of Total Billed charges,1387.27,Pays at 32.15% of Total Billed charges,2657.53,Pays at 100% of Medicare OPPS Rate,1387.27,Pays at 32.15% of Total Billed charges,3797.2,Pays at 88% of Total Billed charges,1428.7,Pays at 33.11% of Total Billed charges,1387.27,3883.5,2589.00
Outpatient Medical Services,EMERGENCY ROOM,57020,CULDOCENTESIS,450,366.5,311.53,Pays at 85% of Billed charges for outpatient setting,117.83,Pays at 32.15% of Total Billed charges,293.31,Pays at 80.03% of Total Billed charges,4443.7,Pays at 102% of Medicare OPPS Rate,329.85,Pays at 90% of Total Billed charges,117.83,Pays at 32.15% of Total Billed charges,4356.57,Pays at 100% of Medicare OPPS Rate,117.83,Pays at 32.15% of Total Billed charges,322.52,Pays at 88% of Total Billed charges,121.35,Pays at 33.11% of Total Billed charges,117.83,4443.7,219.90
Outpatient Medical Services,EMERGENCY ROOM,57020,COLPOCENTESIS,450,4315,3667.75,Pays at 85% of Billed charges for outpatient setting,1387.27,Pays at 32.15% of Total Billed charges,3453.29,Pays at 80.03% of Total Billed charges,4443.7,Pays at 102% of Medicare OPPS Rate,3883.5,Pays at 90% of Total Billed charges,1387.27,Pays at 32.15% of Total Billed charges,4356.57,Pays at 100% of Medicare OPPS Rate,1387.27,Pays at 32.15% of Total Billed charges,3797.2,Pays at 88% of Total Billed charges,1428.7,Pays at 33.11% of Total Billed charges,1387.27,4443.7,2589.00
Outpatient Medical Services,EMERGENCY ROOM,57452,COLPOSCOPY,450,314.75,267.54,Pays at 85% of Billed charges for outpatient setting,101.19,Pays at 32.15% of Total Billed charges,251.89,Pays at 80.03% of Total Billed charges,170.77,Pays at 102% of Medicare OPPS Rate,283.28,Pays at 90% of Total Billed charges,101.19,Pays at 32.15% of Total Billed charges,167.41,Pays at 100% of Medicare OPPS Rate,101.19,Pays at 32.15% of Total Billed charges,276.98,Pays at 88% of Total Billed charges,104.21,Pays at 33.11% of Total Billed charges,101.19,283.28,188.85
Outpatient Medical Services,EMERGENCY ROOM,58301,REMOVAL IUD,450,570.25,484.71,Pays at 85% of Billed charges for outpatient setting,183.34,Pays at 32.15% of Total Billed charges,456.37,Pays at 80.03% of Total Billed charges,279.89,Pays at 102% of Medicare OPPS Rate,513.23,Pays at 90% of Total Billed charges,183.34,Pays at 32.15% of Total Billed charges,274.41,Pays at 100% of Medicare OPPS Rate,183.34,Pays at 32.15% of Total Billed charges,501.82,Pays at 88% of Total Billed charges,188.81,Pays at 33.11% of Total Billed charges,183.34,513.23,342.15
Outpatient Medical Services,EMERGENCY ROOM,59409,Vaginal delivery,450,4315,3667.75,Pays at 85% of Billed charges for outpatient setting,1387.27,Pays at 32.15% of Total Billed charges,3453.29,Pays at 80.03% of Total Billed charges,2710.67,Pays at 102% of Medicare OPPS Rate,3883.5,Pays at 90% of Total Billed charges,1387.27,Pays at 32.15% of Total Billed charges,2657.53,Pays at 100% of Medicare OPPS Rate,1387.27,Pays at 32.15% of Total Billed charges,3797.2,Pays at 88% of Total Billed charges,1428.7,Pays at 33.11% of Total Billed charges,1387.27,3883.5,2589.00
Outpatient Medical Services,EMERGENCY ROOM,59414,Vaginal delivery of placenta,450,4315,3667.75,Pays at 85% of Billed charges for outpatient setting,1387.27,Pays at 32.15% of Total Billed charges,3453.29,Pays at 80.03% of Total Billed charges,2710.67,Pays at 102% of Medicare OPPS Rate,3883.5,Pays at 90% of Total Billed charges,1387.27,Pays at 32.15% of Total Billed charges,2657.53,Pays at 100% of Medicare OPPS Rate,1387.27,Pays at 32.15% of Total Billed charges,3797.2,Pays at 88% of Total Billed charges,1428.7,Pays at 33.11% of Total Billed charges,1387.27,3883.5,2589.00
Outpatient Medical Services,EMERGENCY ROOM,59812,D & C,450,4315,3667.75,Pays at 85% of Billed charges for outpatient setting,1387.27,Pays at 32.15% of Total Billed charges,3453.29,Pays at 80.03% of Total Billed charges,2710.67,Pays at 102% of Medicare OPPS Rate,3883.5,Pays at 90% of Total Billed charges,1387.27,Pays at 32.15% of Total Billed charges,2657.53,Pays at 100% of Medicare OPPS Rate,1387.27,Pays at 32.15% of Total Billed charges,3797.2,Pays at 88% of Total Billed charges,1428.7,Pays at 33.11% of Total Billed charges,1387.27,3883.5,2589.00
Outpatient Medical Services,EMERGENCY ROOM,59812,"TX OF INCOMPLETE ABORTION, SURGICAL",450,4315,3667.75,Pays at 85% of Billed charges for outpatient setting,1387.27,Pays at 32.15% of Total Billed charges,3453.29,Pays at 80.03% of Total Billed charges,2710.67,Pays at 102% of Medicare OPPS Rate,3883.5,Pays at 90% of Total Billed charges,1387.27,Pays at 32.15% of Total Billed charges,2657.53,Pays at 100% of Medicare OPPS Rate,1387.27,Pays at 32.15% of Total Billed charges,3797.2,Pays at 88% of Total Billed charges,1428.7,Pays at 33.11% of Total Billed charges,1387.27,3883.5,2589.00
Outpatient Medical Services,EMERGENCY ROOM,61070,PUNCTURE OF SHUNT TUBING OR RESERVOIR FO,450,1049.5,892.08,Pays at 85% of Billed charges for outpatient setting,337.41,Pays at 32.15% of Total Billed charges,839.91,Pays at 80.03% of Total Billed charges,617.72,Pays at 102% of Medicare OPPS Rate,944.55,Pays at 90% of Total Billed charges,337.41,Pays at 32.15% of Total Billed charges,605.61,Pays at 100% of Medicare OPPS Rate,337.41,Pays at 32.15% of Total Billed charges,923.56,Pays at 88% of Total Billed charges,347.49,Pays at 33.11% of Total Billed charges,337.41,944.55,629.70
Outpatient Medical Services,EMERGENCY ROOM,62270,LUMBAR PUNCTURE,450,1049.5,892.08,Pays at 85% of Billed charges for outpatient setting,337.41,Pays at 32.15% of Total Billed charges,839.91,Pays at 80.03% of Total Billed charges,617.72,Pays at 102% of Medicare OPPS Rate,944.55,Pays at 90% of Total Billed charges,337.41,Pays at 32.15% of Total Billed charges,605.61,Pays at 100% of Medicare OPPS Rate,337.41,Pays at 32.15% of Total Billed charges,923.56,Pays at 88% of Total Billed charges,347.49,Pays at 33.11% of Total Billed charges,337.41,944.55,629.70
Outpatient Medical Services,EMERGENCY ROOM,64400,NERVE BLOCK TRIGEMINAL,450,478.25,406.51,Pays at 85% of Billed charges for outpatient setting,153.76,Pays at 32.15% of Total Billed charges,382.74,Pays at 80.03% of Total Billed charges,260.64,Pays at 102% of Medicare OPPS Rate,430.43,Pays at 90% of Total Billed charges,153.76,Pays at 32.15% of Total Billed charges,255.55,Pays at 100% of Medicare OPPS Rate,153.76,Pays at 32.15% of Total Billed charges,420.86,Pays at 88% of Total Billed charges,158.35,Pays at 33.11% of Total Billed charges,153.76,430.43,286.95
Outpatient Medical Services,EMERGENCY ROOM,64420,INTERCOSTAL NERVE BLOCK SINGLE,450,1049.5,892.08,Pays at 85% of Billed charges for outpatient setting,337.41,Pays at 32.15% of Total Billed charges,839.91,Pays at 80.03% of Total Billed charges,617.72,Pays at 102% of Medicare OPPS Rate,944.55,Pays at 90% of Total Billed charges,337.41,Pays at 32.15% of Total Billed charges,605.61,Pays at 100% of Medicare OPPS Rate,337.41,Pays at 32.15% of Total Billed charges,923.56,Pays at 88% of Total Billed charges,347.49,Pays at 33.11% of Total Billed charges,337.41,944.55,629.70
Outpatient Medical Services,EMERGENCY ROOM,64421,INTERCOSTAL NERVE BLOCK MULTIPLE,450,1321.75,1123.49,Pays at 85% of Billed charges for outpatient setting,424.94,Pays at 32.15% of Total Billed charges,1057.8,Pays at 80.03% of Total Billed charges,816.98,Pays at 102% of Medicare OPPS Rate,1189.58,Pays at 90% of Total Billed charges,424.94,Pays at 32.15% of Total Billed charges,800.96,Pays at 100% of Medicare OPPS Rate,424.94,Pays at 32.15% of Total Billed charges,1163.14,Pays at 88% of Total Billed charges,437.63,Pays at 33.11% of Total Billed charges,424.94,1189.58,793.05
Outpatient Medical Services,EMERGENCY ROOM,64450,NERVE BLOCK ONLY,450,1405.5,1194.68,Pays at 85% of Billed charges for outpatient setting,451.87,Pays at 32.15% of Total Billed charges,1124.82,Pays at 80.03% of Total Billed charges,617.72,Pays at 102% of Medicare OPPS Rate,1264.95,Pays at 90% of Total Billed charges,451.87,Pays at 32.15% of Total Billed charges,605.61,Pays at 100% of Medicare OPPS Rate,451.87,Pays at 32.15% of Total Billed charges,1236.84,Pays at 88% of Total Billed charges,465.36,Pays at 33.11% of Total Billed charges,451.87,1264.95,843.30
Outpatient Medical Services,EMERGENCY ROOM,65205,SPRFICL CONJUNT FB REM,450,207,175.95,Pays at 85% of Billed charges for outpatient setting,66.55,Pays at 32.15% of Total Billed charges,165.66,Pays at 80.03% of Total Billed charges,111.31,Pays at 102% of Medicare OPPS Rate,186.3,Pays at 90% of Total Billed charges,66.55,Pays at 32.15% of Total Billed charges,109.13,Pays at 100% of Medicare OPPS Rate,66.55,Pays at 32.15% of Total Billed charges,182.16,Pays at 88% of Total Billed charges,68.54,Pays at 33.11% of Total Billed charges,66.55,186.3,124.20
Outpatient Medical Services,EMERGENCY ROOM,65210,"EMBED CONJUNCT, FB REM",450,545.5,463.68,Pays at 85% of Billed charges for outpatient setting,175.38,Pays at 32.15% of Total Billed charges,436.56,Pays at 80.03% of Total Billed charges,361.97,Pays at 102% of Medicare OPPS Rate,490.95,Pays at 90% of Total Billed charges,175.38,Pays at 32.15% of Total Billed charges,354.88,Pays at 100% of Medicare OPPS Rate,175.38,Pays at 32.15% of Total Billed charges,480.04,Pays at 88% of Total Billed charges,180.62,Pays at 33.11% of Total Billed charges,175.38,490.95,327.30
Outpatient Medical Services,EMERGENCY ROOM,65220,CORNEAL F.B REMOVAL,450,854,725.9,Pays at 85% of Billed charges for outpatient setting,274.56,Pays at 32.15% of Total Billed charges,683.46,Pays at 80.03% of Total Billed charges,361.97,Pays at 102% of Medicare OPPS Rate,768.6,Pays at 90% of Total Billed charges,274.56,Pays at 32.15% of Total Billed charges,354.88,Pays at 100% of Medicare OPPS Rate,274.56,Pays at 32.15% of Total Billed charges,751.52,Pays at 88% of Total Billed charges,282.76,Pays at 33.11% of Total Billed charges,274.56,768.6,512.40
Outpatient Medical Services,EMERGENCY ROOM,65222,CORNEAL FB REM W/ SL/LP,450,207,175.95,Pays at 85% of Billed charges for outpatient setting,66.55,Pays at 32.15% of Total Billed charges,165.66,Pays at 80.03% of Total Billed charges,111.31,Pays at 102% of Medicare OPPS Rate,186.3,Pays at 90% of Total Billed charges,66.55,Pays at 32.15% of Total Billed charges,109.13,Pays at 100% of Medicare OPPS Rate,66.55,Pays at 32.15% of Total Billed charges,182.16,Pays at 88% of Total Billed charges,68.54,Pays at 33.11% of Total Billed charges,66.55,186.3,124.20
Outpatient Medical Services,EMERGENCY ROOM,65270,REPAIR CONJUNCT LAC,450,3521,2992.85,Pays at 85% of Billed charges for outpatient setting,1132,Pays at 32.15% of Total Billed charges,2817.86,Pays at 80.03% of Total Billed charges,2026.91,Pays at 102% of Medicare OPPS Rate,3168.9,Pays at 90% of Total Billed charges,1132,Pays at 32.15% of Total Billed charges,1987.16,Pays at 100% of Medicare OPPS Rate,1132,Pays at 32.15% of Total Billed charges,3098.48,Pays at 88% of Total Billed charges,1165.8,Pays at 33.11% of Total Billed charges,1132,3168.9,2112.60
Outpatient Medical Services,EMERGENCY ROOM,65435,REMOVAL CORNEAL RUST RING,450,1602.25,1361.91,Pays at 85% of Billed charges for outpatient setting,515.12,Pays at 32.15% of Total Billed charges,1282.28,Pays at 80.03% of Total Billed charges,836.6,Pays at 102% of Medicare OPPS Rate,1442.03,Pays at 90% of Total Billed charges,515.12,Pays at 32.15% of Total Billed charges,820.19,Pays at 100% of Medicare OPPS Rate,515.12,Pays at 32.15% of Total Billed charges,1409.98,Pays at 88% of Total Billed charges,530.5,Pays at 33.11% of Total Billed charges,515.12,1442.03,961.35
Outpatient Medical Services,EMERGENCY ROOM,67700,I & D ABSCESS EYELID,450,555.75,472.39,Pays at 85% of Billed charges for outpatient setting,178.67,Pays at 32.15% of Total Billed charges,444.77,Pays at 80.03% of Total Billed charges,253.77,Pays at 102% of Medicare OPPS Rate,500.18,Pays at 90% of Total Billed charges,178.67,Pays at 32.15% of Total Billed charges,248.79,Pays at 100% of Medicare OPPS Rate,178.67,Pays at 32.15% of Total Billed charges,489.06,Pays at 88% of Total Billed charges,184.01,Pays at 33.11% of Total Billed charges,178.67,500.18,333.45
Outpatient Medical Services,EMERGENCY ROOM,67938,REMOVE EMBED FB-EYELID,450,555.75,472.39,Pays at 85% of Billed charges for outpatient setting,178.67,Pays at 32.15% of Total Billed charges,444.77,Pays at 80.03% of Total Billed charges,253.77,Pays at 102% of Medicare OPPS Rate,500.18,Pays at 90% of Total Billed charges,178.67,Pays at 32.15% of Total Billed charges,248.79,Pays at 100% of Medicare OPPS Rate,178.67,Pays at 32.15% of Total Billed charges,489.06,Pays at 88% of Total Billed charges,184.01,Pays at 33.11% of Total Billed charges,178.67,500.18,333.45
Outpatient Medical Services,EMERGENCY ROOM,69000,I & D EXT EAR,450,1115.75,948.39,Pays at 85% of Billed charges for outpatient setting,358.71,Pays at 32.15% of Total Billed charges,892.93,Pays at 80.03% of Total Billed charges,622.15,Pays at 102% of Medicare OPPS Rate,1004.18,Pays at 90% of Total Billed charges,358.71,Pays at 32.15% of Total Billed charges,609.96,Pays at 100% of Medicare OPPS Rate,358.71,Pays at 32.15% of Total Billed charges,981.86,Pays at 88% of Total Billed charges,369.42,Pays at 33.11% of Total Billed charges,358.71,1004.18,669.45
Outpatient Medical Services,EMERGENCY ROOM,69005,DRAIN EXTERNAL ABSCESS/HEMATOMA-COMPLICA,450,2558.5,2174.73,Pays at 85% of Billed charges for outpatient setting,822.56,Pays at 32.15% of Total Billed charges,2047.57,Pays at 80.03% of Total Billed charges,1437.62,Pays at 102% of Medicare OPPS Rate,2302.65,Pays at 90% of Total Billed charges,822.56,Pays at 32.15% of Total Billed charges,1409.43,Pays at 100% of Medicare OPPS Rate,822.56,Pays at 32.15% of Total Billed charges,2251.48,Pays at 88% of Total Billed charges,847.12,Pays at 33.11% of Total Billed charges,822.56,2302.65,1535.10
Outpatient Medical Services,EMERGENCY ROOM,69020,I & D EX AUDITORY CANAL,450,318,270.3,Pays at 85% of Billed charges for outpatient setting,102.24,Pays at 32.15% of Total Billed charges,254.5,Pays at 80.03% of Total Billed charges,622.15,Pays at 102% of Medicare OPPS Rate,286.2,Pays at 90% of Total Billed charges,102.24,Pays at 32.15% of Total Billed charges,609.96,Pays at 100% of Medicare OPPS Rate,102.24,Pays at 32.15% of Total Billed charges,279.84,Pays at 88% of Total Billed charges,105.29,Pays at 33.11% of Total Billed charges,102.24,622.15,190.80
Outpatient Medical Services,EMERGENCY ROOM,69200,REMOVAL FB-EAR,450,272.25,231.41,Pays at 85% of Billed charges for outpatient setting,87.53,Pays at 32.15% of Total Billed charges,217.88,Pays at 80.03% of Total Billed charges,111.31,Pays at 102% of Medicare OPPS Rate,245.03,Pays at 90% of Total Billed charges,87.53,Pays at 32.15% of Total Billed charges,109.13,Pays at 100% of Medicare OPPS Rate,87.53,Pays at 32.15% of Total Billed charges,239.58,Pays at 88% of Total Billed charges,90.14,Pays at 33.11% of Total Billed charges,87.53,245.03,163.35
Outpatient Medical Services,EMERGENCY ROOM,69209,REMOVAL IMPACTED CERUMEN IRRIGAT/LAVAGE,450,173.75,147.69,Pays at 85% of Billed charges for outpatient setting,55.86,Pays at 32.15% of Total Billed charges,139.05,Pays at 80.03% of Total Billed charges,55.1,Pays at 102% of Medicare OPPS Rate,156.38,Pays at 90% of Total Billed charges,55.86,Pays at 32.15% of Total Billed charges,54.02,Pays at 100% of Medicare OPPS Rate,55.86,Pays at 32.15% of Total Billed charges,152.9,Pays at 88% of Total Billed charges,57.53,Pays at 33.11% of Total Billed charges,54.02,156.38,104.25
Outpatient Medical Services,EMERGENCY ROOM,69210,Removal of ear wax from one or both ears,450,145,123.25,Pays at 85% of Billed charges for outpatient setting,46.62,Pays at 32.15% of Total Billed charges,116.04,Pays at 80.03% of Total Billed charges,55.1,Pays at 102% of Medicare OPPS Rate,130.5,Pays at 90% of Total Billed charges,46.62,Pays at 32.15% of Total Billed charges,54.02,Pays at 100% of Medicare OPPS Rate,46.62,Pays at 32.15% of Total Billed charges,127.6,Pays at 88% of Total Billed charges,48.01,Pays at 33.11% of Total Billed charges,46.62,130.5,87.00
Outpatient Medical Services,EMERGENCY ROOM,69420,MYRINCOTOMY INCLUDING ASP AND/OR INFLATI,450,366.5,311.53,Pays at 85% of Billed charges for outpatient setting,117.83,Pays at 32.15% of Total Billed charges,293.31,Pays at 80.03% of Total Billed charges,199.23,Pays at 102% of Medicare OPPS Rate,329.85,Pays at 90% of Total Billed charges,117.83,Pays at 32.15% of Total Billed charges,195.33,Pays at 100% of Medicare OPPS Rate,117.83,Pays at 32.15% of Total Billed charges,322.52,Pays at 88% of Total Billed charges,121.35,Pays at 33.11% of Total Billed charges,117.83,329.85,219.90
Outpatient Medical Services,EMERGENCY ROOM,74400,IVP,450,387,328.95,Pays at 85% of Billed charges for outpatient setting,124.42,Pays at 32.15% of Total Billed charges,309.72,Pays at 80.03% of Total Billed charges,172.88,Pays at 102% of Medicare OPPS Rate,348.3,Pays at 90% of Total Billed charges,124.42,Pays at 32.15% of Total Billed charges,169.49,Pays at 100% of Medicare OPPS Rate,124.42,Pays at 32.15% of Total Billed charges,340.56,Pays at 88% of Total Billed charges,128.14,Pays at 33.11% of Total Billed charges,124.42,348.3,232.20
Outpatient Medical Services,EMERGENCY ROOM,82962,DEXTROSTICK,450,43.5,36.98,Pays at 85% of Billed charges for outpatient setting,2.94,Pays at 100% of GA Medicaid Fee Schedule,34.81,Pays at 80.03% of Total Billed charges,3.34,Pays at 102% of Medicare OPPS Rate,39.15,Pays at 90% of Total Billed charges,2.94,Pays at 100% of GA Medicaid Fee Schedule,3.28,Pays at 100% of Medicare OPPS Rate,2.94,Pays at 100% of GA Medicaid Fee Schedule,38.28,Pays at 88% of Total Billed charges,3.03,Pays at 103% of GA Medicaid Fee Schedule,2.94,39.15,26.10
Outpatient Medical Services,EMERGENCY ROOM,90702,DIPHTHERIA & TETANUS(DT)CHILD 7 OR UNDER,450,30,25.5,Pays at 85% of Billed charges for outpatient setting,9.65,Pays at 32.15% of Total Billed charges,24.01,Pays at 80.03% of Total Billed charges,30,Not Applicable,27,Pays at 90% of Total Billed charges,9.65,Pays at 32.15% of Total Billed charges,30,Not Applicable,9.65,Pays at 32.15% of Total Billed charges,26.4,Pays at 88% of Total Billed charges,9.93,Pays at 33.11% of Total Billed charges,9.65,30,18.00
Outpatient Medical Services,EMERGENCY ROOM,90782,INTRAMUSCULAR INJECTION,450,83.25,70.76,Pays at 85% of Billed charges for outpatient setting,26.76,Pays at 32.15% of Total Billed charges,66.62,Pays at 80.03% of Total Billed charges,83.25,Not Applicable,74.93,Pays at 90% of Total Billed charges,26.76,Pays at 32.15% of Total Billed charges,83.25,Not Applicable,26.76,Pays at 32.15% of Total Billed charges,73.26,Pays at 88% of Total Billed charges,27.56,Pays at 33.11% of Total Billed charges,26.76,83.25,49.95
Outpatient Medical Services,EMERGENCY ROOM,92511,NASOPHARYNGOSCOPY W/ENDOSCOPE (SEPARATE,450,302.25,256.91,Pays at 85% of Billed charges for outpatient setting,97.17,Pays at 32.15% of Total Billed charges,241.89,Pays at 80.03% of Total Billed charges,171.36,Pays at 102% of Medicare OPPS Rate,272.03,Pays at 90% of Total Billed charges,97.17,Pays at 32.15% of Total Billed charges,168,Pays at 100% of Medicare OPPS Rate,97.17,Pays at 32.15% of Total Billed charges,265.98,Pays at 88% of Total Billed charges,100.07,Pays at 33.11% of Total Billed charges,97.17,272.03,181.35
Outpatient Medical Services,EMERGENCY ROOM,92950,CPR,450,643.75,547.19,Pays at 85% of Billed charges for outpatient setting,206.97,Pays at 32.15% of Total Billed charges,515.19,Pays at 80.03% of Total Billed charges,268.48,Pays at 102% of Medicare OPPS Rate,579.38,Pays at 90% of Total Billed charges,206.97,Pays at 32.15% of Total Billed charges,263.23,Pays at 100% of Medicare OPPS Rate,206.97,Pays at 32.15% of Total Billed charges,566.5,Pays at 88% of Total Billed charges,213.15,Pays at 33.11% of Total Billed charges,206.97,579.38,386.25
Outpatient Medical Services,EMERGENCY ROOM,92953,TEMP TRANSCUT PACING,450,995.75,846.39,Pays at 85% of Billed charges for outpatient setting,320.13,Pays at 32.15% of Total Billed charges,796.9,Pays at 80.03% of Total Billed charges,563.84,Pays at 102% of Medicare OPPS Rate,896.18,Pays at 90% of Total Billed charges,320.13,Pays at 32.15% of Total Billed charges,552.79,Pays at 100% of Medicare OPPS Rate,320.13,Pays at 32.15% of Total Billed charges,876.26,Pays at 88% of Total Billed charges,329.69,Pays at 33.11% of Total Billed charges,320.13,896.18,597.45
Outpatient Medical Services,EMERGENCY ROOM,92960,CARDIOVERSION,450,1326.75,1127.74,Pays at 85% of Billed charges for outpatient setting,426.55,Pays at 32.15% of Total Billed charges,1061.8,Pays at 80.03% of Total Billed charges,563.84,Pays at 102% of Medicare OPPS Rate,1194.08,Pays at 90% of Total Billed charges,426.55,Pays at 32.15% of Total Billed charges,552.79,Pays at 100% of Medicare OPPS Rate,426.55,Pays at 32.15% of Total Billed charges,1167.54,Pays at 88% of Total Billed charges,439.29,Pays at 33.11% of Total Billed charges,426.55,1194.08,796.05
Outpatient Medical Services,EMERGENCY ROOM,93041,RHYTHM ECG 1-3 LEADS TRACING ONLY W/O IN,450,112.75,95.84,Pays at 85% of Billed charges for outpatient setting,36.25,Pays at 32.15% of Total Billed charges,90.23,Pays at 80.03% of Total Billed charges,55.1,Pays at 102% of Medicare OPPS Rate,101.48,Pays at 90% of Total Billed charges,36.25,Pays at 32.15% of Total Billed charges,54.02,Pays at 100% of Medicare OPPS Rate,36.25,Pays at 32.15% of Total Billed charges,99.22,Pays at 88% of Total Billed charges,37.33,Pays at 33.11% of Total Billed charges,36.25,101.48,67.65
Outpatient Medical Services,EMERGENCY ROOM,94060,Test to determine if wheezing is present,450,480.25,408.21,Pays at 85% of Billed charges for outpatient setting,154.4,Pays at 32.15% of Total Billed charges,384.34,Pays at 80.03% of Total Billed charges,268.48,Pays at 102% of Medicare OPPS Rate,432.23,Pays at 90% of Total Billed charges,154.4,Pays at 32.15% of Total Billed charges,263.23,Pays at 100% of Medicare OPPS Rate,154.4,Pays at 32.15% of Total Billed charges,422.62,Pays at 88% of Total Billed charges,159.01,Pays at 33.11% of Total Billed charges,154.4,432.23,288.15
Outpatient Medical Services,EMERGENCY ROOM,94664,AEROSOL OR VAPOR INHALATION BREATHING TX,450,335.25,284.96,Pays at 85% of Billed charges for outpatient setting,107.78,Pays at 32.15% of Total Billed charges,268.3,Pays at 80.03% of Total Billed charges,183.59,Pays at 102% of Medicare OPPS Rate,301.73,Pays at 90% of Total Billed charges,107.78,Pays at 32.15% of Total Billed charges,179.99,Pays at 100% of Medicare OPPS Rate,107.78,Pays at 32.15% of Total Billed charges,295.02,Pays at 88% of Total Billed charges,111,Pays at 33.11% of Total Billed charges,107.78,301.73,201.15
Outpatient Medical Services,EMERGENCY ROOM,99152,MOD SEDATION SAME MD/QHP INITIAL 15 MIN.,450,408.5,347.23,Pays at 85% of Billed charges for outpatient setting,131.33,Pays at 32.15% of Total Billed charges,326.92,Pays at 80.03% of Total Billed charges,408.5,Not Applicable,367.65,Pays at 90% of Total Billed charges,131.33,Pays at 32.15% of Total Billed charges,408.5,Not Applicable,131.33,Pays at 32.15% of Total Billed charges,359.48,Pays at 88% of Total Billed charges,135.25,Pays at 33.11% of Total Billed charges,131.33,408.5,245.10
Outpatient Medical Services,EMERGENCY ROOM,99195,PHLEBOTOMY,450,112.75,95.84,Pays at 85% of Billed charges for outpatient setting,36.25,Pays at 32.15% of Total Billed charges,90.23,Pays at 80.03% of Total Billed charges,111.31,Pays at 102% of Medicare OPPS Rate,101.48,Pays at 90% of Total Billed charges,36.25,Pays at 32.15% of Total Billed charges,109.13,Pays at 100% of Medicare OPPS Rate,36.25,Pays at 32.15% of Total Billed charges,99.22,Pays at 88% of Total Billed charges,37.33,Pays at 33.11% of Total Billed charges,36.25,111.31,67.65
Outpatient Medical Services,EMERGENCY ROOM,99201,ER INJECTION FEE,450,54.5,46.33,Pays at 85% of Billed charges for outpatient setting,17.52,Pays at 32.15% of Total Billed charges,43.62,Pays at 80.03% of Total Billed charges,54.5,Not Applicable,49.05,Pays at 90% of Total Billed charges,17.52,Pays at 32.15% of Total Billed charges,54.5,Not Applicable,17.52,Pays at 32.15% of Total Billed charges,47.96,Pays at 88% of Total Billed charges,18.04,Pays at 33.11% of Total Billed charges,17.52,54.5,32.70
Outpatient Medical Services,EMERGENCY ROOM,99211,Outpatient visit of established patient not requiring a physician,450,145.96,124.07,Pays at 85% of Billed charges for outpatient setting,46.93,Pays at 32.15% of Total Billed charges,116.81,Pays at 80.03% of Total Billed charges,145.96,Not Applicable,131.36,Pays at 90% of Total Billed charges,46.93,Pays at 32.15% of Total Billed charges,145.96,Not Applicable,46.93,Pays at 32.15% of Total Billed charges,128.44,Pays at 88% of Total Billed charges,48.33,Pays at 33.11% of Total Billed charges,46.93,145.96,87.58
Outpatient Medical Services,EMERGENCY ROOM,99281,OB OBSERVATION TRIAGE PER HR.,450,105.5,89.68,Pays at 85% of Billed charges for outpatient setting,385,Pays based on per visit rate,84.43,Pays at 80.03% of Total Billed charges,71.98,Pays at 102% of Medicare OPPS Rate,94.95,Pays at 90% of Total Billed charges,385,Pays based on per visit rate,70.56,Pays at 100% of Medicare OPPS Rate,385,Pays based on per visit rate,92.84,Pays at 88% of Total Billed charges,396.55,Pays based on per visit rate,70.56,396.55,63.30
Outpatient Medical Services,EMERGENCY ROOM,99281,LEVEL 1 ED VISIT,450,145.96,124.07,Pays at 85% of Billed charges for outpatient setting,385,Pays based on per visit rate,116.81,Pays at 80.03% of Total Billed charges,71.98,Pays at 102% of Medicare OPPS Rate,131.36,Pays at 90% of Total Billed charges,385,Pays based on per visit rate,70.56,Pays at 100% of Medicare OPPS Rate,385,Pays based on per visit rate,128.44,Pays at 88% of Total Billed charges,396.55,Pays based on per visit rate,70.56,396.55,87.58
Outpatient Medical Services,EMERGENCY ROOM,99281,SUTURE REMOVAL/WOUND RECHECK,450,178,151.3,Pays at 85% of Billed charges for outpatient setting,385,Pays based on per visit rate,142.45,Pays at 80.03% of Total Billed charges,71.98,Pays at 102% of Medicare OPPS Rate,160.2,Pays at 90% of Total Billed charges,385,Pays based on per visit rate,70.56,Pays at 100% of Medicare OPPS Rate,385,Pays based on per visit rate,156.64,Pays at 88% of Total Billed charges,396.55,Pays based on per visit rate,70.56,396.55,106.80
Outpatient Medical Services,EMERGENCY ROOM,99282,EMERGENCY ROOM/EXTENSIVE,450,155.25,131.96,Pays at 85% of Billed charges for outpatient setting,385,Pays based on per visit rate,124.25,Pays at 80.03% of Total Billed charges,133.91,Pays at 102% of Medicare OPPS Rate,139.73,Pays at 90% of Total Billed charges,385,Pays based on per visit rate,131.29,Pays at 100% of Medicare OPPS Rate,385,Pays based on per visit rate,136.62,Pays at 88% of Total Billed charges,396.55,Pays based on per visit rate,124.25,396.55,93.15
Outpatient Medical Services,EMERGENCY ROOM,99282,LEVEL 2 ED VISIT,450,264.86,225.13,Pays at 85% of Billed charges for outpatient setting,385,Pays based on per visit rate,211.97,Pays at 80.03% of Total Billed charges,133.91,Pays at 102% of Medicare OPPS Rate,238.37,Pays at 90% of Total Billed charges,385,Pays based on per visit rate,131.29,Pays at 100% of Medicare OPPS Rate,385,Pays based on per visit rate,233.08,Pays at 88% of Total Billed charges,396.55,Pays based on per visit rate,131.29,396.55,158.92
Outpatient Medical Services,EMERGENCY ROOM,99283,"Emergency department visit, moderately severe problem",450,465.15,395.38,Pays at 85% of Billed charges for outpatient setting,385,Pays based on per visit rate,372.26,Pays at 80.03% of Total Billed charges,234.91,Pays at 102% of Medicare OPPS Rate,418.64,Pays at 90% of Total Billed charges,385,Pays based on per visit rate,230.29,Pays at 100% of Medicare OPPS Rate,385,Pays based on per visit rate,409.33,Pays at 88% of Total Billed charges,396.55,Pays based on per visit rate,230.29,418.64,279.09
Outpatient Medical Services,EMERGENCY ROOM,99284,"Emergency department visit, problem of high severity",450,1150,977.5,Pays at 85% of Billed charges for outpatient setting,385,Pays based on per visit rate,920.35,Pays at 80.03% of Total Billed charges,365.84,Pays at 102% of Medicare OPPS Rate,1035,Pays at 90% of Total Billed charges,385,Pays based on per visit rate,358.67,Pays at 100% of Medicare OPPS Rate,385,Pays based on per visit rate,1012,Pays at 88% of Total Billed charges,396.55,Pays based on per visit rate,358.67,1035,690.00
Outpatient Medical Services,EMERGENCY ROOM,99285,"Emergency department visit, problem with significant threat to life or function",450,1347.5,1145.38,Pays at 85% of Billed charges for outpatient setting,385,Pays based on per visit rate,1078.4,Pays at 80.03% of Total Billed charges,525.47,Pays at 102% of Medicare OPPS Rate,1212.75,Pays at 90% of Total Billed charges,385,Pays based on per visit rate,515.16,Pays at 100% of Medicare OPPS Rate,385,Pays based on per visit rate,1185.8,Pays at 88% of Total Billed charges,396.55,Pays based on per visit rate,385,1212.75,808.50
Outpatient Medical Services,EMERGENCY ROOM,99291,LEVEL 6 CRITICAL CARE ED,450,1898.25,1613.51,Pays at 85% of Billed charges for outpatient setting,610.29,Pays at 32.15% of Total Billed charges,1519.17,Pays at 80.03% of Total Billed charges,736.01,Pays at 102% of Medicare OPPS Rate,1708.43,Pays at 90% of Total Billed charges,610.29,Pays at 32.15% of Total Billed charges,721.58,Pays at 100% of Medicare OPPS Rate,610.29,Pays at 32.15% of Total Billed charges,1670.46,Pays at 88% of Total Billed charges,628.51,Pays at 33.11% of Total Billed charges,610.29,1708.43,1138.95
Outpatient Medical Services,EMERGENCY ROOM,99291,CRITICIAL CARE 1ST HR W PROC,450,1898.25,1613.51,Pays at 85% of Billed charges for outpatient setting,610.29,Pays at 32.15% of Total Billed charges,1519.17,Pays at 80.03% of Total Billed charges,736.01,Pays at 102% of Medicare OPPS Rate,1708.43,Pays at 90% of Total Billed charges,610.29,Pays at 32.15% of Total Billed charges,721.58,Pays at 100% of Medicare OPPS Rate,610.29,Pays at 32.15% of Total Billed charges,1670.46,Pays at 88% of Total Billed charges,628.51,Pays at 33.11% of Total Billed charges,610.29,1708.43,1138.95
Outpatient Medical Services,EMERGENCY ROOM,99292,ADDITIONAL 1/2HR CRITICAL CARE,450,302,256.7,Pays at 85% of Billed charges for outpatient setting,97.09,Pays at 32.15% of Total Billed charges,241.69,Pays at 80.03% of Total Billed charges,302,Not Applicable,271.8,Pays at 90% of Total Billed charges,97.09,Pays at 32.15% of Total Billed charges,302,Not Applicable,97.09,Pays at 32.15% of Total Billed charges,265.76,Pays at 88% of Total Billed charges,99.99,Pays at 33.11% of Total Billed charges,97.09,302,181.20
Outpatient Medical Services,EMERGENCY ROOM,30901,NASAL PACKING BILATERAL,450,475,403.75,Pays at 85% of Billed charges for outpatient setting,152.71,Pays at 32.15% of Total Billed charges,380.14,Pays at 80.03% of Total Billed charges,111.31,Pays at 102% of Medicare OPPS Rate,427.5,Pays at 90% of Total Billed charges,152.71,Pays at 32.15% of Total Billed charges,109.13,Pays at 100% of Medicare OPPS Rate,152.71,Pays at 32.15% of Total Billed charges,418,Pays at 88% of Total Billed charges,157.27,Pays at 33.11% of Total Billed charges,109.13,427.5,285.00
Outpatient Medical Services,EMERGENCY ROOM,30903,NASAL HEMOR/ANT/COMPL/BILAT,450,207,175.95,Pays at 85% of Billed charges for outpatient setting,66.55,Pays at 32.15% of Total Billed charges,165.66,Pays at 80.03% of Total Billed charges,111.3,Pays at 102% of Medicare OPPS Rate,186.3,Pays at 90% of Total Billed charges,66.55,Pays at 32.15% of Total Billed charges,109.12,Pays at 100% of Medicare OPPS Rate,66.55,Pays at 32.15% of Total Billed charges,182.16,Pays at 88% of Total Billed charges,68.54,Pays at 33.11% of Total Billed charges,66.55,186.3,124.20
Outpatient Medical Services,EMERGENCY ROOM,99281,LEVEL 1 WITH PROCEDURE,450,178,151.3,Pays at 85% of Billed charges for outpatient setting,385,Pays based on per visit rate,142.45,Pays at 80.03% of Total Billed charges,71.98,Pays at 102% of Medicare OPPS Rate,160.2,Pays at 90% of Total Billed charges,385,Pays based on per visit rate,70.56,Pays at 100% of Medicare OPPS Rate,385,Pays based on per visit rate,156.64,Pays at 88% of Total Billed charges,396.55,Pays based on per visit rate,70.56,396.55,106.80
Outpatient Medical Services,EMERGENCY ROOM,99282,LEVEL 2 WITH PROCEDURE,450,264.86,225.13,Pays at 85% of Billed charges for outpatient setting,385,Pays based on per visit rate,211.97,Pays at 80.03% of Total Billed charges,133.91,Pays at 102% of Medicare OPPS Rate,238.37,Pays at 90% of Total Billed charges,385,Pays based on per visit rate,131.29,Pays at 100% of Medicare OPPS Rate,385,Pays based on per visit rate,233.08,Pays at 88% of Total Billed charges,396.55,Pays based on per visit rate,131.29,396.55,158.92
Outpatient Medical Services,EMERGENCY ROOM,99283,"Emergency department visit, moderately severe problem",450,465.15,395.38,Pays at 85% of Billed charges for outpatient setting,385,Pays based on per visit rate,372.26,Pays at 80.03% of Total Billed charges,234.91,Pays at 102% of Medicare OPPS Rate,418.64,Pays at 90% of Total Billed charges,385,Pays based on per visit rate,230.29,Pays at 100% of Medicare OPPS Rate,385,Pays based on per visit rate,409.33,Pays at 88% of Total Billed charges,396.55,Pays based on per visit rate,230.29,418.64,279.09
Outpatient Medical Services,EMERGENCY ROOM,99284,"Emergency department visit, problem of high severity",450,1150,977.5,Pays at 85% of Billed charges for outpatient setting,385,Pays based on per visit rate,920.35,Pays at 80.03% of Total Billed charges,365.84,Pays at 102% of Medicare OPPS Rate,1035,Pays at 90% of Total Billed charges,385,Pays based on per visit rate,358.67,Pays at 100% of Medicare OPPS Rate,385,Pays based on per visit rate,1012,Pays at 88% of Total Billed charges,396.55,Pays based on per visit rate,358.67,1035,690.00
Outpatient Medical Services,EMERGENCY ROOM,99285,"Emergency department visit, problem with significant threat to life or function",450,1104.95,939.21,Pays at 85% of Billed charges for outpatient setting,385,Pays based on per visit rate,884.29,Pays at 80.03% of Total Billed charges,525.47,Pays at 102% of Medicare OPPS Rate,994.46,Pays at 90% of Total Billed charges,385,Pays based on per visit rate,515.16,Pays at 100% of Medicare OPPS Rate,385,Pays based on per visit rate,972.36,Pays at 88% of Total Billed charges,396.55,Pays based on per visit rate,385,994.46,662.97
Outpatient Medical Services,EMERGENCY ROOM,G0168,WOUND ADHESIVE,450,108,91.8,Pays at 85% of Billed charges for outpatient setting,34.72,Pays at 32.15% of Total Billed charges,86.43,Pays at 80.03% of Total Billed charges,108,Not Applicable,97.2,Pays at 90% of Total Billed charges,34.72,Pays at 32.15% of Total Billed charges,108,Not Applicable,34.72,Pays at 32.15% of Total Billed charges,95.04,Pays at 88% of Total Billed charges,35.76,Pays at 33.11% of Total Billed charges,34.72,108,64.80
Outpatient Medical Services,EMERGENCY ROOM,Q0081,INFUSION THERAPY OTHER THAN CHEMO,450,263.75,224.19,Pays at 85% of Billed charges for outpatient setting,84.8,Pays at 32.15% of Total Billed charges,211.08,Pays at 80.03% of Total Billed charges,NA,Not Applicable,237.38,Pays at 90% of Total Billed charges,84.8,Pays at 32.15% of Total Billed charges,NA,Not Applicable,84.8,Pays at 32.15% of Total Billed charges,232.1,Pays at 88% of Total Billed charges,87.33,Pays at 33.11% of Total Billed charges,84.8,237.38,158.25
Outpatient Medical Services,CARDIAC,92551,HEARING/SCREENING NEWBORN,479,61.91,52.62,Pays at 85% of Billed charges for outpatient setting,19.9,Pays at 32.15% of Total Billed charges,49.55,Pays at 80.03% of Total Billed charges,NA,Not Applicable,55.72,Pays at 90% of Total Billed charges,19.9,Pays at 32.15% of Total Billed charges,NA,Not Applicable,19.9,Pays at 32.15% of Total Billed charges,54.48,Pays at 88% of Total Billed charges,20.5,Pays at 33.11% of Total Billed charges,19.9,55.72,37.15
Outpatient Medical Services,CARDIAC,92551,HEARING/SCREENING OUTPATIENT,471,75.5,64.18,Pays at 85% of Billed charges for outpatient setting,24.27,Pays at 32.15% of Total Billed charges,60.42,Pays at 80.03% of Total Billed charges,NA,Not Applicable,67.95,Pays at 90% of Total Billed charges,24.27,Pays at 32.15% of Total Billed charges,NA,Not Applicable,24.27,Pays at 32.15% of Total Billed charges,66.44,Pays at 88% of Total Billed charges,25,Pays at 33.11% of Total Billed charges,24.27,67.95,45.30
Outpatient Medical Services,CARDIAC,92551,OUTPATIENT HEARING/SCREENING,479,75.5,64.18,Pays at 85% of Billed charges for outpatient setting,24.27,Pays at 32.15% of Total Billed charges,60.42,Pays at 80.03% of Total Billed charges,NA,Not Applicable,67.95,Pays at 90% of Total Billed charges,24.27,Pays at 32.15% of Total Billed charges,NA,Not Applicable,24.27,Pays at 32.15% of Total Billed charges,66.44,Pays at 88% of Total Billed charges,25,Pays at 33.11% of Total Billed charges,24.27,67.95,45.30
Outpatient Medical Services,CARDIAC,92557,HEARING SCREENING,471,50,42.5,Pays at 85% of Billed charges for outpatient setting,16.08,Pays at 32.15% of Total Billed charges,40.02,Pays at 80.03% of Total Billed charges,139.41,Pays at 102% of Medicare OPPS Rate,45,Pays at 90% of Total Billed charges,16.08,Pays at 32.15% of Total Billed charges,136.69,Pays at 100% of Medicare OPPS Rate,16.08,Pays at 32.15% of Total Billed charges,44,Pays at 88% of Total Billed charges,16.56,Pays at 33.11% of Total Billed charges,16.08,139.41,30.00
Outpatient Medical Services,CARDIAC,92586,HEARING/SCREENING,479,424.25,360.61,Pays at 85% of Billed charges for outpatient setting,136.4,Pays at 32.15% of Total Billed charges,339.53,Pays at 80.03% of Total Billed charges,NA,Not Applicable,381.83,Pays at 90% of Total Billed charges,136.4,Pays at 32.15% of Total Billed charges,NA,Not Applicable,136.4,Pays at 32.15% of Total Billed charges,373.34,Pays at 88% of Total Billed charges,140.47,Pays at 33.11% of Total Billed charges,136.4,381.83,254.55
Outpatient Medical Services,CARDIAC,92950,CARDIO/PULM RESUSCITATION,480,189.25,160.86,Pays at 85% of Billed charges for outpatient setting,60.84,Pays at 32.15% of Total Billed charges,151.46,Pays at 80.03% of Total Billed charges,268.48,Pays at 102% of Medicare OPPS Rate,170.33,Pays at 90% of Total Billed charges,60.84,Pays at 32.15% of Total Billed charges,263.23,Pays at 100% of Medicare OPPS Rate,60.84,Pays at 32.15% of Total Billed charges,166.54,Pays at 88% of Total Billed charges,62.66,Pays at 33.11% of Total Billed charges,60.84,268.48,113.55
Outpatient Medical Services,CARDIAC,92960,CARDIOVERSION,480,1326.75,1127.74,Pays at 85% of Billed charges for outpatient setting,426.55,Pays at 32.15% of Total Billed charges,1061.8,Pays at 80.03% of Total Billed charges,563.84,Pays at 102% of Medicare OPPS Rate,1194.08,Pays at 90% of Total Billed charges,426.55,Pays at 32.15% of Total Billed charges,552.79,Pays at 100% of Medicare OPPS Rate,426.55,Pays at 32.15% of Total Billed charges,1167.54,Pays at 88% of Total Billed charges,439.29,Pays at 33.11% of Total Billed charges,426.55,1194.08,796.05
Outpatient Medical Services,CARDIAC,92961,OUTPATIENT CARDIOVERSION,480,636.5,541.03,Pays at 85% of Billed charges for outpatient setting,204.63,Pays at 32.15% of Total Billed charges,509.39,Pays at 80.03% of Total Billed charges,563.84,Pays at 102% of Medicare OPPS Rate,572.85,Pays at 90% of Total Billed charges,204.63,Pays at 32.15% of Total Billed charges,552.79,Pays at 100% of Medicare OPPS Rate,204.63,Pays at 32.15% of Total Billed charges,560.12,Pays at 88% of Total Billed charges,210.75,Pays at 33.11% of Total Billed charges,204.63,572.85,381.90
Outpatient Medical Services,CARDIAC,93005,EKG,730,193.73,164.67,Pays at 85% of Billed charges for outpatient setting,62.28,Pays at 32.15% of Total Billed charges,155.04,Pays at 80.03% of Total Billed charges,55.1,Pays at 102% of Medicare OPPS Rate,174.36,Pays at 90% of Total Billed charges,62.28,Pays at 32.15% of Total Billed charges,54.02,Pays at 100% of Medicare OPPS Rate,62.28,Pays at 32.15% of Total Billed charges,170.48,Pays at 88% of Total Billed charges,64.14,Pays at 33.11% of Total Billed charges,54.02,174.36,116.24
Outpatient Medical Services,CARDIAC,93005,EKG 12 LEADS TRACING ONLY,730,236.25,200.81,Pays at 85% of Billed charges for outpatient setting,75.95,Pays at 32.15% of Total Billed charges,189.07,Pays at 80.03% of Total Billed charges,55.1,Pays at 102% of Medicare OPPS Rate,212.63,Pays at 90% of Total Billed charges,75.95,Pays at 32.15% of Total Billed charges,54.02,Pays at 100% of Medicare OPPS Rate,75.95,Pays at 32.15% of Total Billed charges,207.9,Pays at 88% of Total Billed charges,78.22,Pays at 33.11% of Total Billed charges,54.02,212.63,141.75
Outpatient Medical Services,CARDIAC,93012,RECTAL TEMPERATURE CABLE,732,90,76.5,Pays at 85% of Billed charges for outpatient setting,28.94,Pays at 32.15% of Total Billed charges,72.03,Pays at 80.03% of Total Billed charges,NA,Not Applicable,81,Pays at 90% of Total Billed charges,28.94,Pays at 32.15% of Total Billed charges,NA,Not Applicable,28.94,Pays at 32.15% of Total Billed charges,79.2,Pays at 88% of Total Billed charges,29.8,Pays at 33.11% of Total Billed charges,28.94,81,54.00
Outpatient Medical Services,CARDIAC,93012,EXTERNAL PACEMAKER (ER),732,209.75,178.29,Pays at 85% of Billed charges for outpatient setting,67.43,Pays at 32.15% of Total Billed charges,167.86,Pays at 80.03% of Total Billed charges,NA,Not Applicable,188.78,Pays at 90% of Total Billed charges,67.43,Pays at 32.15% of Total Billed charges,NA,Not Applicable,67.43,Pays at 32.15% of Total Billed charges,184.58,Pays at 88% of Total Billed charges,69.45,Pays at 33.11% of Total Billed charges,67.43,188.78,125.85
Outpatient Medical Services,CARDIAC,93012,PACEMAKER DAILY CHARGE,732,936,795.6,Pays at 85% of Billed charges for outpatient setting,300.92,Pays at 32.15% of Total Billed charges,749.08,Pays at 80.03% of Total Billed charges,NA,Not Applicable,842.4,Pays at 90% of Total Billed charges,300.92,Pays at 32.15% of Total Billed charges,NA,Not Applicable,300.92,Pays at 32.15% of Total Billed charges,823.68,Pays at 88% of Total Billed charges,309.91,Pays at 33.11% of Total Billed charges,300.92,842.4,561.60
Outpatient Medical Services,CARDIAC,93012,ARTERIAL LINE (DAILY),732,936,795.6,Pays at 85% of Billed charges for outpatient setting,300.92,Pays at 32.15% of Total Billed charges,749.08,Pays at 80.03% of Total Billed charges,NA,Not Applicable,842.4,Pays at 90% of Total Billed charges,300.92,Pays at 32.15% of Total Billed charges,NA,Not Applicable,300.92,Pays at 32.15% of Total Billed charges,823.68,Pays at 88% of Total Billed charges,309.91,Pays at 33.11% of Total Billed charges,300.92,842.4,561.60
Outpatient Medical Services,CARDIAC,93017,NM TREADMILL (ONLY),482,269.75,229.29,Pays at 85% of Billed charges for outpatient setting,86.72,Pays at 32.15% of Total Billed charges,215.88,Pays at 80.03% of Total Billed charges,268.49,Pays at 102% of Medicare OPPS Rate,242.78,Pays at 90% of Total Billed charges,86.72,Pays at 32.15% of Total Billed charges,263.23,Pays at 100% of Medicare OPPS Rate,86.72,Pays at 32.15% of Total Billed charges,237.38,Pays at 88% of Total Billed charges,89.31,Pays at 33.11% of Total Billed charges,86.72,268.49,161.85
Outpatient Medical Services,CARDIAC,93017,STRESS THALLIUM (SPECT),482,2368.75,2013.44,Pays at 85% of Billed charges for outpatient setting,761.55,Pays at 32.15% of Total Billed charges,1895.71,Pays at 80.03% of Total Billed charges,268.49,Pays at 102% of Medicare OPPS Rate,2131.88,Pays at 90% of Total Billed charges,761.55,Pays at 32.15% of Total Billed charges,263.23,Pays at 100% of Medicare OPPS Rate,761.55,Pays at 32.15% of Total Billed charges,2084.5,Pays at 88% of Total Billed charges,784.29,Pays at 33.11% of Total Billed charges,263.23,2131.88,1421.25
Outpatient Medical Services,CARDIAC,93231,SWAN GANZ MTR DAILY CHG,731,1413,1201.05,Pays at 85% of Billed charges for outpatient setting,454.28,Pays at 32.15% of Total Billed charges,1130.82,Pays at 80.03% of Total Billed charges,NA,Not Applicable,1271.7,Pays at 90% of Total Billed charges,454.28,Pays at 32.15% of Total Billed charges,NA,Not Applicable,454.28,Pays at 32.15% of Total Billed charges,1243.44,Pays at 88% of Total Billed charges,467.84,Pays at 33.11% of Total Billed charges,454.28,1271.7,847.80
Outpatient Medical Services,CARDIAC,93307,Echo without doppler study,480,604.5,513.83,Pays at 85% of Billed charges for outpatient setting,194.35,Pays at 32.15% of Total Billed charges,483.78,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,544.05,Pays at 90% of Total Billed charges,194.35,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,194.35,Pays at 32.15% of Total Billed charges,531.96,Pays at 88% of Total Billed charges,200.15,Pays at 33.11% of Total Billed charges,194.35,544.05,362.70
Outpatient Medical Services,CARDIAC,93307,Echo without doppler study,480,604.5,513.83,Pays at 85% of Billed charges for outpatient setting,194.35,Pays at 32.15% of Total Billed charges,483.78,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,544.05,Pays at 90% of Total Billed charges,194.35,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,194.35,Pays at 32.15% of Total Billed charges,531.96,Pays at 88% of Total Billed charges,200.15,Pays at 33.11% of Total Billed charges,194.35,544.05,362.70
Outpatient Medical Services,CARDIAC,93307,Echo without doppler study,480,604.5,513.83,Pays at 85% of Billed charges for outpatient setting,194.35,Pays at 32.15% of Total Billed charges,483.78,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,544.05,Pays at 90% of Total Billed charges,194.35,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,194.35,Pays at 32.15% of Total Billed charges,531.96,Pays at 88% of Total Billed charges,200.15,Pays at 33.11% of Total Billed charges,194.35,544.05,362.70
Outpatient Medical Services,CARDIAC,93320,Echo with doppler,480,193.5,164.48,Pays at 85% of Billed charges for outpatient setting,62.21,Pays at 32.15% of Total Billed charges,154.86,Pays at 80.03% of Total Billed charges,NA,Not Applicable,174.15,Pays at 90% of Total Billed charges,62.21,Pays at 32.15% of Total Billed charges,NA,Not Applicable,62.21,Pays at 32.15% of Total Billed charges,170.28,Pays at 88% of Total Billed charges,64.07,Pays at 33.11% of Total Billed charges,62.21,174.15,116.10
Outpatient Medical Services,CARDIAC,93320,Echo with doppler,480,193.5,164.48,Pays at 85% of Billed charges for outpatient setting,62.21,Pays at 32.15% of Total Billed charges,154.86,Pays at 80.03% of Total Billed charges,NA,Not Applicable,174.15,Pays at 90% of Total Billed charges,62.21,Pays at 32.15% of Total Billed charges,NA,Not Applicable,62.21,Pays at 32.15% of Total Billed charges,170.28,Pays at 88% of Total Billed charges,64.07,Pays at 33.11% of Total Billed charges,62.21,174.15,116.10
Outpatient Medical Services,CARDIAC,93320,Echo with doppler,480,193.5,164.48,Pays at 85% of Billed charges for outpatient setting,62.21,Pays at 32.15% of Total Billed charges,154.86,Pays at 80.03% of Total Billed charges,NA,Not Applicable,174.15,Pays at 90% of Total Billed charges,62.21,Pays at 32.15% of Total Billed charges,NA,Not Applicable,62.21,Pays at 32.15% of Total Billed charges,170.28,Pays at 88% of Total Billed charges,64.07,Pays at 33.11% of Total Billed charges,62.21,174.15,116.10
Outpatient Medical Services,CARDIAC,93325,DOPPLER ECHO COLOR FLOW,480,193.5,164.48,Pays at 85% of Billed charges for outpatient setting,62.21,Pays at 32.15% of Total Billed charges,154.86,Pays at 80.03% of Total Billed charges,NA,Not Applicable,174.15,Pays at 90% of Total Billed charges,62.21,Pays at 32.15% of Total Billed charges,NA,Not Applicable,62.21,Pays at 32.15% of Total Billed charges,170.28,Pays at 88% of Total Billed charges,64.07,Pays at 33.11% of Total Billed charges,62.21,174.15,116.10
Outpatient Medical Services,CARDIAC,93325,DOPPLER ECHO COLOR FLOW,480,193.5,164.48,Pays at 85% of Billed charges for outpatient setting,62.21,Pays at 32.15% of Total Billed charges,154.86,Pays at 80.03% of Total Billed charges,NA,Not Applicable,174.15,Pays at 90% of Total Billed charges,62.21,Pays at 32.15% of Total Billed charges,NA,Not Applicable,62.21,Pays at 32.15% of Total Billed charges,170.28,Pays at 88% of Total Billed charges,64.07,Pays at 33.11% of Total Billed charges,62.21,174.15,116.10
Outpatient Medical Services,CARDIAC,93325,DOPPLER ECHO COLOR FLOW STEP DOWN/ICU,480,193.5,164.48,Pays at 85% of Billed charges for outpatient setting,62.21,Pays at 32.15% of Total Billed charges,154.86,Pays at 80.03% of Total Billed charges,NA,Not Applicable,174.15,Pays at 90% of Total Billed charges,62.21,Pays at 32.15% of Total Billed charges,NA,Not Applicable,62.21,Pays at 32.15% of Total Billed charges,170.28,Pays at 88% of Total Billed charges,64.07,Pays at 33.11% of Total Billed charges,62.21,174.15,116.10
Outpatient Medical Services,CARDIAC,93668,SET PAD,480,140,119,Pays at 85% of Billed charges for outpatient setting,45.01,Pays at 32.15% of Total Billed charges,112.04,Pays at 80.03% of Total Billed charges,55.09,Pays at 102% of Medicare OPPS Rate,126,Pays at 90% of Total Billed charges,45.01,Pays at 32.15% of Total Billed charges,54.02,Pays at 100% of Medicare OPPS Rate,45.01,Pays at 32.15% of Total Billed charges,123.2,Pays at 88% of Total Billed charges,46.35,Pays at 33.11% of Total Billed charges,45.01,126,84.00
Outpatient Medical Services,CARDIAC,93798,Use of EKG to monitor cardiac rehabilitation,943,30,25.5,Pays at 85% of Billed charges for outpatient setting,9.65,Pays at 32.15% of Total Billed charges,24.01,Pays at 80.03% of Total Billed charges,115.11,Pays at 102% of Medicare OPPS Rate,27,Pays at 90% of Total Billed charges,9.65,Pays at 32.15% of Total Billed charges,112.85,Pays at 100% of Medicare OPPS Rate,9.65,Pays at 32.15% of Total Billed charges,26.4,Pays at 88% of Total Billed charges,9.93,Pays at 33.11% of Total Billed charges,9.65,115.11,18.00
Outpatient Medical Services,CARDIAC,93798,Use of EKG to monitor cardiac rehabilitation,943,239.44,203.52,Pays at 85% of Billed charges for outpatient setting,76.98,Pays at 32.15% of Total Billed charges,191.62,Pays at 80.03% of Total Billed charges,115.11,Pays at 102% of Medicare OPPS Rate,215.5,Pays at 90% of Total Billed charges,76.98,Pays at 32.15% of Total Billed charges,112.85,Pays at 100% of Medicare OPPS Rate,76.98,Pays at 32.15% of Total Billed charges,210.71,Pays at 88% of Total Billed charges,79.28,Pays at 33.11% of Total Billed charges,76.98,215.5,143.66
Outpatient Medical Services,CARDIAC,93798,Use of EKG to monitor cardiac rehabilitation,943,297.69,253.04,Pays at 85% of Billed charges for outpatient setting,95.71,Pays at 32.15% of Total Billed charges,238.24,Pays at 80.03% of Total Billed charges,115.11,Pays at 102% of Medicare OPPS Rate,267.92,Pays at 90% of Total Billed charges,95.71,Pays at 32.15% of Total Billed charges,112.85,Pays at 100% of Medicare OPPS Rate,95.71,Pays at 32.15% of Total Billed charges,261.97,Pays at 88% of Total Billed charges,98.57,Pays at 33.11% of Total Billed charges,95.71,267.92,178.61
Outpatient Medical Services,CARDIAC,93799,NICO CARDIAC OUTPUT,730,102.5,87.13,Pays at 85% of Billed charges for outpatient setting,32.95,Pays at 32.15% of Total Billed charges,82.03,Pays at 80.03% of Total Billed charges,139.41,Pays at 102% of Medicare OPPS Rate,92.25,Pays at 90% of Total Billed charges,32.95,Pays at 32.15% of Total Billed charges,136.69,Pays at 100% of Medicare OPPS Rate,32.95,Pays at 32.15% of Total Billed charges,90.2,Pays at 88% of Total Billed charges,33.94,Pays at 33.11% of Total Billed charges,32.95,139.41,61.50
Outpatient Medical Services,CARDIAC,93880,Study of vessels on both sides of the head and neck,921,936,795.6,Pays at 85% of Billed charges for outpatient setting,300.92,Pays at 32.15% of Total Billed charges,749.08,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,842.4,Pays at 90% of Total Billed charges,300.92,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,300.92,Pays at 32.15% of Total Billed charges,823.68,Pays at 88% of Total Billed charges,309.91,Pays at 33.11% of Total Billed charges,219.48,842.4,561.60
Outpatient Medical Services,CARDIAC,93922,Limited bilateral noninvasive physiologic studies of upper or lower extremity arteries,921,231.75,196.99,Pays at 85% of Billed charges for outpatient setting,74.51,Pays at 32.15% of Total Billed charges,185.47,Pays at 80.03% of Total Billed charges,111.31,Pays at 102% of Medicare OPPS Rate,208.58,Pays at 90% of Total Billed charges,74.51,Pays at 32.15% of Total Billed charges,109.13,Pays at 100% of Medicare OPPS Rate,74.51,Pays at 32.15% of Total Billed charges,203.94,Pays at 88% of Total Billed charges,76.73,Pays at 33.11% of Total Billed charges,74.51,208.58,139.05
Outpatient Medical Services,CARDIAC,93923,COMPLETE BILATERAL PHYSIOLOGIC STUDY,921,433.5,368.48,Pays at 85% of Billed charges for outpatient setting,139.37,Pays at 32.15% of Total Billed charges,346.93,Pays at 80.03% of Total Billed charges,139.41,Pays at 102% of Medicare OPPS Rate,390.15,Pays at 90% of Total Billed charges,139.37,Pays at 32.15% of Total Billed charges,136.69,Pays at 100% of Medicare OPPS Rate,139.37,Pays at 32.15% of Total Billed charges,381.48,Pays at 88% of Total Billed charges,143.53,Pays at 33.11% of Total Billed charges,136.69,390.15,260.10
Outpatient Medical Services,CARDIAC,93970,Complete bilateral study of the extremities,921,1473.5,1252.48,Pays at 85% of Billed charges for outpatient setting,473.73,Pays at 32.15% of Total Billed charges,1179.24,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,1326.15,Pays at 90% of Total Billed charges,473.73,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,473.73,Pays at 32.15% of Total Billed charges,1296.68,Pays at 88% of Total Billed charges,487.88,Pays at 33.11% of Total Billed charges,219.48,1326.15,884.10
Outpatient Medical Services,CARDIAC,93971,One sided or limited bilateral study,921,736.75,626.24,Pays at 85% of Billed charges for outpatient setting,236.87,Pays at 32.15% of Total Billed charges,589.62,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,663.08,Pays at 90% of Total Billed charges,236.87,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,236.87,Pays at 32.15% of Total Billed charges,648.34,Pays at 88% of Total Billed charges,243.94,Pays at 33.11% of Total Billed charges,100.44,663.08,442.05
Outpatient Medical Services,CARDIAC,94010,Test to determine how well oxygen moves from the lungs to the blood stream,460,219.25,186.36,Pays at 85% of Billed charges for outpatient setting,70.49,Pays at 32.15% of Total Billed charges,175.47,Pays at 80.03% of Total Billed charges,139.41,Pays at 102% of Medicare OPPS Rate,197.33,Pays at 90% of Total Billed charges,70.49,Pays at 32.15% of Total Billed charges,136.69,Pays at 100% of Medicare OPPS Rate,70.49,Pays at 32.15% of Total Billed charges,192.94,Pays at 88% of Total Billed charges,72.59,Pays at 33.11% of Total Billed charges,70.49,197.33,131.55
Outpatient Medical Services,CARDIAC,94010,Test to determine how well oxygen moves from the lungs to the blood stream,460,353,300.05,Pays at 85% of Billed charges for outpatient setting,113.49,Pays at 32.15% of Total Billed charges,282.51,Pays at 80.03% of Total Billed charges,139.41,Pays at 102% of Medicare OPPS Rate,317.7,Pays at 90% of Total Billed charges,113.49,Pays at 32.15% of Total Billed charges,136.69,Pays at 100% of Medicare OPPS Rate,113.49,Pays at 32.15% of Total Billed charges,310.64,Pays at 88% of Total Billed charges,116.88,Pays at 33.11% of Total Billed charges,113.49,317.7,211.80
Outpatient Medical Services,CARDIAC,94010,Test to determine how well oxygen moves from the lungs to the blood stream,460,353,300.05,Pays at 85% of Billed charges for outpatient setting,113.49,Pays at 32.15% of Total Billed charges,282.51,Pays at 80.03% of Total Billed charges,139.41,Pays at 102% of Medicare OPPS Rate,317.7,Pays at 90% of Total Billed charges,113.49,Pays at 32.15% of Total Billed charges,136.69,Pays at 100% of Medicare OPPS Rate,113.49,Pays at 32.15% of Total Billed charges,310.64,Pays at 88% of Total Billed charges,116.88,Pays at 33.11% of Total Billed charges,113.49,317.7,211.80
Outpatient Medical Services,CARDIAC,94060,Test to determine if wheezing is present,460,643.75,547.19,Pays at 85% of Billed charges for outpatient setting,206.97,Pays at 32.15% of Total Billed charges,515.19,Pays at 80.03% of Total Billed charges,268.48,Pays at 102% of Medicare OPPS Rate,579.38,Pays at 90% of Total Billed charges,206.97,Pays at 32.15% of Total Billed charges,263.23,Pays at 100% of Medicare OPPS Rate,206.97,Pays at 32.15% of Total Billed charges,566.5,Pays at 88% of Total Billed charges,213.15,Pays at 33.11% of Total Billed charges,206.97,579.38,386.25
Outpatient Medical Services,CARDIAC,94150,VITAL CAPACITY,460,80.25,68.21,Pays at 85% of Billed charges for outpatient setting,25.8,Pays at 32.15% of Total Billed charges,64.22,Pays at 80.03% of Total Billed charges,139.41,Pays at 102% of Medicare OPPS Rate,72.23,Pays at 90% of Total Billed charges,25.8,Pays at 32.15% of Total Billed charges,136.69,Pays at 100% of Medicare OPPS Rate,25.8,Pays at 32.15% of Total Billed charges,70.62,Pays at 88% of Total Billed charges,26.57,Pays at 33.11% of Total Billed charges,25.8,139.41,48.15
Outpatient Medical Services,CARDIAC,94618,SIX MINUTE WALK,460,146,124.1,Pays at 85% of Billed charges for outpatient setting,46.94,Pays at 32.15% of Total Billed charges,116.84,Pays at 80.03% of Total Billed charges,111.31,Pays at 102% of Medicare OPPS Rate,131.4,Pays at 90% of Total Billed charges,46.94,Pays at 32.15% of Total Billed charges,109.13,Pays at 100% of Medicare OPPS Rate,46.94,Pays at 32.15% of Total Billed charges,128.48,Pays at 88% of Total Billed charges,48.34,Pays at 33.11% of Total Billed charges,46.94,131.4,87.60
Outpatient Medical Services,CARDIAC,94726,Measures how much air is in the lungs after taking a deep breath,460,643.75,547.19,Pays at 85% of Billed charges for outpatient setting,206.97,Pays at 32.15% of Total Billed charges,515.19,Pays at 80.03% of Total Billed charges,268.49,Pays at 102% of Medicare OPPS Rate,579.38,Pays at 90% of Total Billed charges,206.97,Pays at 32.15% of Total Billed charges,263.23,Pays at 100% of Medicare OPPS Rate,206.97,Pays at 32.15% of Total Billed charges,566.5,Pays at 88% of Total Billed charges,213.15,Pays at 33.11% of Total Billed charges,206.97,579.38,386.25
Outpatient Medical Services,CARDIAC,94728,PULM FUNCT TST OSCILLOMETRY,460,643.75,547.19,Pays at 85% of Billed charges for outpatient setting,206.97,Pays at 32.15% of Total Billed charges,515.19,Pays at 80.03% of Total Billed charges,268.49,Pays at 102% of Medicare OPPS Rate,579.38,Pays at 90% of Total Billed charges,206.97,Pays at 32.15% of Total Billed charges,263.23,Pays at 100% of Medicare OPPS Rate,206.97,Pays at 32.15% of Total Billed charges,566.5,Pays at 88% of Total Billed charges,213.15,Pays at 33.11% of Total Billed charges,206.97,579.38,386.25
Outpatient Medical Services,CARDIAC,94729,Test to measure how well gases diffuse across lung surfaces,460,294,249.9,Pays at 85% of Billed charges for outpatient setting,94.52,Pays at 32.15% of Total Billed charges,235.29,Pays at 80.03% of Total Billed charges,NA,Not Applicable,264.6,Pays at 90% of Total Billed charges,94.52,Pays at 32.15% of Total Billed charges,NA,Not Applicable,94.52,Pays at 32.15% of Total Billed charges,258.72,Pays at 88% of Total Billed charges,97.34,Pays at 33.11% of Total Billed charges,94.52,264.6,176.40
Outpatient Medical Services,CARDIAC,94760,PULSE OXIMETRY,460,18.25,15.51,Pays at 85% of Billed charges for outpatient setting,5.87,Pays at 32.15% of Total Billed charges,14.61,Pays at 80.03% of Total Billed charges,NA,Not Applicable,16.43,Pays at 90% of Total Billed charges,5.87,Pays at 32.15% of Total Billed charges,NA,Not Applicable,5.87,Pays at 32.15% of Total Billed charges,16.06,Pays at 88% of Total Billed charges,6.04,Pays at 33.11% of Total Billed charges,5.87,16.43,10.95
Outpatient Medical Services,CARDIAC,94761,"EAR, PULSE OXIMETRY MULTI DETERMINATIONS",460,18.25,15.51,Pays at 85% of Billed charges for outpatient setting,5.87,Pays at 32.15% of Total Billed charges,14.61,Pays at 80.03% of Total Billed charges,NA,Not Applicable,16.43,Pays at 90% of Total Billed charges,5.87,Pays at 32.15% of Total Billed charges,NA,Not Applicable,5.87,Pays at 32.15% of Total Billed charges,16.06,Pays at 88% of Total Billed charges,6.04,Pays at 33.11% of Total Billed charges,5.87,16.43,10.95
Outpatient Medical Services,CARDIAC,94762,PULSE OX CONTINUOUS,460,22.25,18.91,Pays at 85% of Billed charges for outpatient setting,7.15,Pays at 32.15% of Total Billed charges,17.81,Pays at 80.03% of Total Billed charges,139.41,Pays at 102% of Medicare OPPS Rate,20.03,Pays at 90% of Total Billed charges,7.15,Pays at 32.15% of Total Billed charges,136.69,Pays at 100% of Medicare OPPS Rate,7.15,Pays at 32.15% of Total Billed charges,19.58,Pays at 88% of Total Billed charges,7.37,Pays at 33.11% of Total Billed charges,7.15,139.41,13.35
Outpatient Medical Services,CARDIAC,94780,"CAR SEAT EVALUATION, NEONATE, 60 MIN",460,88,74.8,Pays at 85% of Billed charges for outpatient setting,28.29,Pays at 32.15% of Total Billed charges,70.43,Pays at 80.03% of Total Billed charges,32.54,Pays at 102% of Medicare OPPS Rate,79.2,Pays at 90% of Total Billed charges,28.29,Pays at 32.15% of Total Billed charges,31.91,Pays at 100% of Medicare OPPS Rate,28.29,Pays at 32.15% of Total Billed charges,77.44,Pays at 88% of Total Billed charges,29.14,Pays at 33.11% of Total Billed charges,28.29,79.2,52.80
Outpatient Medical Services,CARDIAC,94781,"CAR SEAT EVALUATION, NEONATE, ADD 30 MIN",460,82.75,70.34,Pays at 85% of Billed charges for outpatient setting,26.6,Pays at 32.15% of Total Billed charges,66.22,Pays at 80.03% of Total Billed charges,NA,Not Applicable,74.48,Pays at 90% of Total Billed charges,26.6,Pays at 32.15% of Total Billed charges,NA,Not Applicable,26.6,Pays at 32.15% of Total Billed charges,72.82,Pays at 88% of Total Billed charges,27.4,Pays at 33.11% of Total Billed charges,26.6,74.48,49.65
Outpatient Medical Services,CARDIAC,94799,CAPNOGRAPHY CONT.P,460,173.44,147.42,Pays at 85% of Billed charges for outpatient setting,55.76,Pays at 32.15% of Total Billed charges,138.8,Pays at 80.03% of Total Billed charges,139.41,Pays at 102% of Medicare OPPS Rate,156.1,Pays at 90% of Total Billed charges,55.76,Pays at 32.15% of Total Billed charges,136.69,Pays at 100% of Medicare OPPS Rate,55.76,Pays at 32.15% of Total Billed charges,152.63,Pays at 88% of Total Billed charges,57.43,Pays at 33.11% of Total Billed charges,55.76,156.1,104.06
Outpatient Medical Services,CARDIAC,95819,EEG (AWAKE & ASLEEP),740,647.75,550.59,Pays at 85% of Billed charges for outpatient setting,208.25,Pays at 32.15% of Total Billed charges,518.39,Pays at 80.03% of Total Billed charges,268.48,Pays at 102% of Medicare OPPS Rate,582.98,Pays at 90% of Total Billed charges,208.25,Pays at 32.15% of Total Billed charges,263.23,Pays at 100% of Medicare OPPS Rate,208.25,Pays at 32.15% of Total Billed charges,570.02,Pays at 88% of Total Billed charges,214.47,Pays at 33.11% of Total Billed charges,208.25,582.98,388.65
Outpatient Medical Services,CARDIAC,93307,Echo without doppler study,480,604.5,513.83,Pays at 85% of Billed charges for outpatient setting,194.35,Pays at 32.15% of Total Billed charges,483.78,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,544.05,Pays at 90% of Total Billed charges,194.35,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,194.35,Pays at 32.15% of Total Billed charges,531.96,Pays at 88% of Total Billed charges,200.15,Pays at 33.11% of Total Billed charges,194.35,544.05,362.70
Outpatient Medical Services,CARDIAC,93307,Echo without doppler study,480,604.5,513.83,Pays at 85% of Billed charges for outpatient setting,194.35,Pays at 32.15% of Total Billed charges,483.78,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,544.05,Pays at 90% of Total Billed charges,194.35,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,194.35,Pays at 32.15% of Total Billed charges,531.96,Pays at 88% of Total Billed charges,200.15,Pays at 33.11% of Total Billed charges,194.35,544.05,362.70
Outpatient Medical Services,CARDIAC,93307,Echo without doppler study,480,604.5,513.83,Pays at 85% of Billed charges for outpatient setting,194.35,Pays at 32.15% of Total Billed charges,483.78,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,544.05,Pays at 90% of Total Billed charges,194.35,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,194.35,Pays at 32.15% of Total Billed charges,531.96,Pays at 88% of Total Billed charges,200.15,Pays at 33.11% of Total Billed charges,194.35,544.05,362.70
Outpatient Medical Services,CARDIAC,93320,Echo with doppler,480,46.25,39.31,Pays at 85% of Billed charges for outpatient setting,14.87,Pays at 32.15% of Total Billed charges,37.01,Pays at 80.03% of Total Billed charges,NA,Not Applicable,41.63,Pays at 90% of Total Billed charges,14.87,Pays at 32.15% of Total Billed charges,NA,Not Applicable,14.87,Pays at 32.15% of Total Billed charges,40.7,Pays at 88% of Total Billed charges,15.31,Pays at 33.11% of Total Billed charges,14.87,41.63,27.75
Outpatient Medical Services,CARDIAC,93320,Echo with doppler,480,46.25,39.31,Pays at 85% of Billed charges for outpatient setting,14.87,Pays at 32.15% of Total Billed charges,37.01,Pays at 80.03% of Total Billed charges,NA,Not Applicable,41.63,Pays at 90% of Total Billed charges,14.87,Pays at 32.15% of Total Billed charges,NA,Not Applicable,14.87,Pays at 32.15% of Total Billed charges,40.7,Pays at 88% of Total Billed charges,15.31,Pays at 33.11% of Total Billed charges,14.87,41.63,27.75
Outpatient Medical Services,CARDIAC,93320,Echo with doppler,480,46.25,39.31,Pays at 85% of Billed charges for outpatient setting,14.87,Pays at 32.15% of Total Billed charges,37.01,Pays at 80.03% of Total Billed charges,NA,Not Applicable,41.63,Pays at 90% of Total Billed charges,14.87,Pays at 32.15% of Total Billed charges,NA,Not Applicable,14.87,Pays at 32.15% of Total Billed charges,40.7,Pays at 88% of Total Billed charges,15.31,Pays at 33.11% of Total Billed charges,14.87,41.63,27.75
Outpatient Medical Services,CARDIAC,93325,DOPPLER ECHO COLOR FLOW INTERPRETATION,480,16.25,13.81,Pays at 85% of Billed charges for outpatient setting,5.22,Pays at 32.15% of Total Billed charges,13,Pays at 80.03% of Total Billed charges,NA,Not Applicable,14.63,Pays at 90% of Total Billed charges,5.22,Pays at 32.15% of Total Billed charges,NA,Not Applicable,5.22,Pays at 32.15% of Total Billed charges,14.3,Pays at 88% of Total Billed charges,5.38,Pays at 33.11% of Total Billed charges,5.22,14.63,9.75
Outpatient Medical Services,CARDIAC,93325,DOPPLER ECHO COLOR FLOW INTERPRETATION,480,16.25,13.81,Pays at 85% of Billed charges for outpatient setting,5.22,Pays at 32.15% of Total Billed charges,13,Pays at 80.03% of Total Billed charges,NA,Not Applicable,14.63,Pays at 90% of Total Billed charges,5.22,Pays at 32.15% of Total Billed charges,NA,Not Applicable,5.22,Pays at 32.15% of Total Billed charges,14.3,Pays at 88% of Total Billed charges,5.38,Pays at 33.11% of Total Billed charges,5.22,14.63,9.75
Outpatient Medical Services,CARDIAC,93325,DOPPLER ECHO FLOW INTREPRE STEP DOWN/ICU,480,16.25,13.81,Pays at 85% of Billed charges for outpatient setting,5.22,Pays at 32.15% of Total Billed charges,13,Pays at 80.03% of Total Billed charges,NA,Not Applicable,14.63,Pays at 90% of Total Billed charges,5.22,Pays at 32.15% of Total Billed charges,NA,Not Applicable,5.22,Pays at 32.15% of Total Billed charges,14.3,Pays at 88% of Total Billed charges,5.38,Pays at 33.11% of Total Billed charges,5.22,14.63,9.75
Outpatient Medical Services,CARDIAC,93922,Limited bilateral noninvasive physiologic studies of upper or lower extremity arteries,921,116.5,99.03,Pays at 85% of Billed charges for outpatient setting,37.45,Pays at 32.15% of Total Billed charges,93.23,Pays at 80.03% of Total Billed charges,111.31,Pays at 102% of Medicare OPPS Rate,104.85,Pays at 90% of Total Billed charges,37.45,Pays at 32.15% of Total Billed charges,109.13,Pays at 100% of Medicare OPPS Rate,37.45,Pays at 32.15% of Total Billed charges,102.52,Pays at 88% of Total Billed charges,38.57,Pays at 33.11% of Total Billed charges,37.45,111.31,69.90
Outpatient Medical Services,CARDIAC,0399T,CARDIAC STRAIN,480,67.25,57.16,Pays at 85% of Billed charges for outpatient setting,21.62,Pays at 32.15% of Total Billed charges,53.82,Pays at 80.03% of Total Billed charges,NA,Not Applicable,60.53,Pays at 90% of Total Billed charges,21.62,Pays at 32.15% of Total Billed charges,NA,Not Applicable,21.62,Pays at 32.15% of Total Billed charges,59.18,Pays at 88% of Total Billed charges,22.27,Pays at 33.11% of Total Billed charges,21.62,60.53,40.35
Outpatient Medical Services,CARDIAC,93017,NM STRESS,482,534.38,454.22,Pays at 85% of Billed charges for outpatient setting,171.8,Pays at 32.15% of Total Billed charges,427.66,Pays at 80.03% of Total Billed charges,268.49,Pays at 102% of Medicare OPPS Rate,480.94,Pays at 90% of Total Billed charges,171.8,Pays at 32.15% of Total Billed charges,263.23,Pays at 100% of Medicare OPPS Rate,171.8,Pays at 32.15% of Total Billed charges,470.25,Pays at 88% of Total Billed charges,176.93,Pays at 33.11% of Total Billed charges,171.8,480.94,320.63
Outpatient Medical Services,CARDIAC,93306,"Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function",483,1363.46,1158.94,Pays at 85% of Billed charges for outpatient setting,438.35,Pays at 32.15% of Total Billed charges,1091.18,Pays at 80.03% of Total Billed charges,482.34,Pays at 102% of Medicare OPPS Rate,1227.11,Pays at 90% of Total Billed charges,438.35,Pays at 32.15% of Total Billed charges,472.88,Pays at 100% of Medicare OPPS Rate,438.35,Pays at 32.15% of Total Billed charges,1199.84,Pays at 88% of Total Billed charges,451.44,Pays at 33.11% of Total Billed charges,438.35,1227.11,818.08
Outpatient Medical Services,CARDIAC,93320,Echo with doppler,480,369.75,314.29,Pays at 85% of Billed charges for outpatient setting,118.87,Pays at 32.15% of Total Billed charges,295.91,Pays at 80.03% of Total Billed charges,NA,Not Applicable,332.78,Pays at 90% of Total Billed charges,118.87,Pays at 32.15% of Total Billed charges,NA,Not Applicable,118.87,Pays at 32.15% of Total Billed charges,325.38,Pays at 88% of Total Billed charges,122.42,Pays at 33.11% of Total Billed charges,118.87,332.78,221.85
Outpatient Medical Services,CARDIAC,93325,US COLOR FLOW ECHO,480,421.5,358.28,Pays at 85% of Billed charges for outpatient setting,135.51,Pays at 32.15% of Total Billed charges,337.33,Pays at 80.03% of Total Billed charges,NA,Not Applicable,379.35,Pays at 90% of Total Billed charges,135.51,Pays at 32.15% of Total Billed charges,NA,Not Applicable,135.51,Pays at 32.15% of Total Billed charges,370.92,Pays at 88% of Total Billed charges,139.56,Pays at 33.11% of Total Billed charges,135.51,379.35,252.90
Outpatient Medical Services,CARDIAC,93880,Study of vessels on both sides of the head and neck,921,776.13,659.71,Pays at 85% of Billed charges for outpatient setting,249.53,Pays at 32.15% of Total Billed charges,621.14,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,698.52,Pays at 90% of Total Billed charges,249.53,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,249.53,Pays at 32.15% of Total Billed charges,682.99,Pays at 88% of Total Billed charges,256.98,Pays at 33.11% of Total Billed charges,219.48,698.52,465.68
Outpatient Medical Services,CARDIAC,93880,Study of vessels on both sides of the head and neck,921,994.75,845.54,Pays at 85% of Billed charges for outpatient setting,319.81,Pays at 32.15% of Total Billed charges,796.1,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,895.28,Pays at 90% of Total Billed charges,319.81,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,319.81,Pays at 32.15% of Total Billed charges,875.38,Pays at 88% of Total Billed charges,329.36,Pays at 33.11% of Total Billed charges,219.48,895.28,596.85
Outpatient Medical Services,CARDIAC,93923,US PVR SINGLE,921,353,300.05,Pays at 85% of Billed charges for outpatient setting,113.49,Pays at 32.15% of Total Billed charges,282.51,Pays at 80.03% of Total Billed charges,139.41,Pays at 102% of Medicare OPPS Rate,317.7,Pays at 90% of Total Billed charges,113.49,Pays at 32.15% of Total Billed charges,136.69,Pays at 100% of Medicare OPPS Rate,113.49,Pays at 32.15% of Total Billed charges,310.64,Pays at 88% of Total Billed charges,116.88,Pays at 33.11% of Total Billed charges,113.49,317.7,211.80
Outpatient Medical Services,CARDIAC,93923,US PVR MULTI ARTERIAL,921,353,300.05,Pays at 85% of Billed charges for outpatient setting,113.49,Pays at 32.15% of Total Billed charges,282.51,Pays at 80.03% of Total Billed charges,139.41,Pays at 102% of Medicare OPPS Rate,317.7,Pays at 90% of Total Billed charges,113.49,Pays at 32.15% of Total Billed charges,136.69,Pays at 100% of Medicare OPPS Rate,113.49,Pays at 32.15% of Total Billed charges,310.64,Pays at 88% of Total Billed charges,116.88,Pays at 33.11% of Total Billed charges,113.49,317.7,211.80
Outpatient Medical Services,CARDIAC,93923,US ABI MULTI,921,353,300.05,Pays at 85% of Billed charges for outpatient setting,113.49,Pays at 32.15% of Total Billed charges,282.51,Pays at 80.03% of Total Billed charges,139.41,Pays at 102% of Medicare OPPS Rate,317.7,Pays at 90% of Total Billed charges,113.49,Pays at 32.15% of Total Billed charges,136.69,Pays at 100% of Medicare OPPS Rate,113.49,Pays at 32.15% of Total Billed charges,310.64,Pays at 88% of Total Billed charges,116.88,Pays at 33.11% of Total Billed charges,113.49,317.7,211.80
Outpatient Medical Services,CARDIAC,93923,US ABI SINGLE,921,353,300.05,Pays at 85% of Billed charges for outpatient setting,113.49,Pays at 32.15% of Total Billed charges,282.51,Pays at 80.03% of Total Billed charges,139.41,Pays at 102% of Medicare OPPS Rate,317.7,Pays at 90% of Total Billed charges,113.49,Pays at 32.15% of Total Billed charges,136.69,Pays at 100% of Medicare OPPS Rate,113.49,Pays at 32.15% of Total Billed charges,310.64,Pays at 88% of Total Billed charges,116.88,Pays at 33.11% of Total Billed charges,113.49,317.7,211.80
Outpatient Medical Services,CARDIAC,93925,PORT US EXTREMITY VASCULAR,921,776.75,660.24,Pays at 85% of Billed charges for outpatient setting,249.73,Pays at 32.15% of Total Billed charges,621.63,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,699.08,Pays at 90% of Total Billed charges,249.73,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,249.73,Pays at 32.15% of Total Billed charges,683.54,Pays at 88% of Total Billed charges,257.18,Pays at 33.11% of Total Billed charges,219.48,699.08,466.05
Outpatient Medical Services,CARDIAC,93925,US EXTREMITY BILATERAL ARTERIAL,921,1202.75,1022.34,Pays at 85% of Billed charges for outpatient setting,386.68,Pays at 32.15% of Total Billed charges,962.56,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,1082.48,Pays at 90% of Total Billed charges,386.68,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,386.68,Pays at 32.15% of Total Billed charges,1058.42,Pays at 88% of Total Billed charges,398.23,Pays at 33.11% of Total Billed charges,219.48,1082.48,721.65
Outpatient Medical Services,CARDIAC,93925,PORT US EXTREMITY BILAT VASCULAR,921,1493.25,1269.26,Pays at 85% of Billed charges for outpatient setting,480.08,Pays at 32.15% of Total Billed charges,1195.05,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,1343.93,Pays at 90% of Total Billed charges,480.08,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,480.08,Pays at 32.15% of Total Billed charges,1314.06,Pays at 88% of Total Billed charges,494.42,Pays at 33.11% of Total Billed charges,219.48,1343.93,895.95
Outpatient Medical Services,CARDIAC,93926,US EXTREMITY UNILATERAL ARTERIAL,921,474,402.9,Pays at 85% of Billed charges for outpatient setting,152.39,Pays at 32.15% of Total Billed charges,379.34,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,426.6,Pays at 90% of Total Billed charges,152.39,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,152.39,Pays at 32.15% of Total Billed charges,417.12,Pays at 88% of Total Billed charges,156.94,Pays at 33.11% of Total Billed charges,100.44,426.6,284.40
Outpatient Medical Services,CARDIAC,93930,US DUPLEX UPPER ARTERIAL,921,601.25,511.06,Pays at 85% of Billed charges for outpatient setting,193.3,Pays at 32.15% of Total Billed charges,481.18,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,541.13,Pays at 90% of Total Billed charges,193.3,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,193.3,Pays at 32.15% of Total Billed charges,529.1,Pays at 88% of Total Billed charges,199.07,Pays at 33.11% of Total Billed charges,193.3,541.13,360.75
Outpatient Medical Services,CARDIAC,93970,Complete bilateral study of the extremities,921,1183.67,1006.12,Pays at 85% of Billed charges for outpatient setting,380.55,Pays at 32.15% of Total Billed charges,947.29,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,1065.3,Pays at 90% of Total Billed charges,380.55,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,380.55,Pays at 32.15% of Total Billed charges,1041.63,Pays at 88% of Total Billed charges,391.91,Pays at 33.11% of Total Billed charges,219.48,1065.3,710.20
Outpatient Medical Services,CARDIAC,93971,One sided or limited bilateral study,921,592,503.2,Pays at 85% of Billed charges for outpatient setting,190.33,Pays at 32.15% of Total Billed charges,473.78,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,532.8,Pays at 90% of Total Billed charges,190.33,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,190.33,Pays at 32.15% of Total Billed charges,520.96,Pays at 88% of Total Billed charges,196.01,Pays at 33.11% of Total Billed charges,100.44,532.8,355.20
Outpatient Medical Services,CARDIAC,93975,US RENAL ARTERIES,921,751.56,638.83,Pays at 85% of Billed charges for outpatient setting,241.63,Pays at 32.15% of Total Billed charges,601.47,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,676.4,Pays at 90% of Total Billed charges,241.63,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,241.63,Pays at 32.15% of Total Billed charges,661.37,Pays at 88% of Total Billed charges,248.84,Pays at 33.11% of Total Billed charges,219.48,676.4,450.94
Outpatient Medical Services,CARDIAC,93976,US MESENTARY,921,457.25,388.66,Pays at 85% of Billed charges for outpatient setting,147.01,Pays at 32.15% of Total Billed charges,365.94,Pays at 80.03% of Total Billed charges,102.45,Pays at 102% of Medicare OPPS Rate,411.53,Pays at 90% of Total Billed charges,147.01,Pays at 32.15% of Total Billed charges,100.44,Pays at 100% of Medicare OPPS Rate,147.01,Pays at 32.15% of Total Billed charges,402.38,Pays at 88% of Total Billed charges,151.4,Pays at 33.11% of Total Billed charges,100.44,411.53,274.35
Outpatient Medical Services,CARDIAC,93978,US AORTA/IVC GRAFTS,921,766.25,651.31,Pays at 85% of Billed charges for outpatient setting,246.35,Pays at 32.15% of Total Billed charges,613.23,Pays at 80.03% of Total Billed charges,223.87,Pays at 102% of Medicare OPPS Rate,689.63,Pays at 90% of Total Billed charges,246.35,Pays at 32.15% of Total Billed charges,219.48,Pays at 100% of Medicare OPPS Rate,246.35,Pays at 32.15% of Total Billed charges,674.3,Pays at 88% of Total Billed charges,253.71,Pays at 33.11% of Total Billed charges,219.48,689.63,459.75
Outpatient Medical Services,CARDIAC,93990,US DUPLEX HEMODIALYSIS,921,519.25,441.36,Pays at 85% of Billed charges for outpatient setting,166.94,Pays at 32.15% of Total Billed charges,415.56,Pays at 80.03% of Total Billed charges,102.46,Pays at 102% of Medicare OPPS Rate,467.33,Pays at 90% of Total Billed charges,166.94,Pays at 32.15% of Total Billed charges,100.45,Pays at 100% of Medicare OPPS Rate,166.94,Pays at 32.15% of Total Billed charges,456.94,Pays at 88% of Total Billed charges,171.92,Pays at 33.11% of Total Billed charges,100.45,467.33,311.55
Outpatient Medical Services,RADIOLOGY,47531,XRAY BILE DUCTS/PANCREAS THRU CATH,972,64,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,38.40
Outpatient Medical Services,RADIOLOGY,70100,XRAY EXAM OF MANDIBLE,972,74,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,44.40
Outpatient Medical Services,RADIOLOGY,70110,XRAY EXAM OF JAW,972,74,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,44.40
Outpatient Medical Services,RADIOLOGY,70130,MM XRAY EXAM OF MASTOIDS,972,84,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,50.40
Outpatient Medical Services,RADIOLOGY,70134,XRAY EXAM OF MIDDLE EAR,972,84,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,50.40
Outpatient Medical Services,RADIOLOGY,70140,XRAY EXAM FACIAL BONES<3 VIEWS,972,57,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,34.20
Outpatient Medical Services,RADIOLOGY,70150,XRAY EXAM FACIAL BONES >3 VIEWS,972,67,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,40.20
Outpatient Medical Services,RADIOLOGY,70160,XRAY EXAM OF NASAL BONE,972,53,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,31.80
Outpatient Medical Services,RADIOLOGY,70190,XRAY EXAM OF EYE SOCKETS,972,66,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,39.60
Outpatient Medical Services,RADIOLOGY,70200,"XRAY EXAM OF EYE SOCKETS, MIN 4 VIEWS",972,72,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,43.20
Outpatient Medical Services,RADIOLOGY,70210,XRAY EXAM OF SINUSES <3 VIEWS,972,53,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,31.80
Outpatient Medical Services,RADIOLOGY,70220,"XRAY EXAM OF SINUSES, > 3 VIEWS",972,74,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,44.40
Outpatient Medical Services,RADIOLOGY,70240,XRAY EXAM OF PITUITARY SADDLE,972,58,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,34.80
Outpatient Medical Services,RADIOLOGY,70250,XRAY EXAM OF SKULL < 4 VIEWS,972,72,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,43.20
Outpatient Medical Services,RADIOLOGY,70260,XRAY EXAM OF SKULL > 4 VIEWS,972,84,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,50.40
Outpatient Medical Services,RADIOLOGY,70336,MRI JAW JOINT,972,360,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,216.00
Outpatient Medical Services,RADIOLOGY,70360,XRAY EXAM OF NECK,972,53,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,31.80
Outpatient Medical Services,RADIOLOGY,70390,XRAY EXAM OF SALIVARY DUCT,972,96,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,57.60
Outpatient Medical Services,RADIOLOGY,70450,CT scan head or brain without dye,972,284,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,170.40
Outpatient Medical Services,RADIOLOGY,70460,CT OF HEAD/BRAIN W/DYE,972,281,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,168.60
Outpatient Medical Services,RADIOLOGY,70470,CT OF HEAD/BRAIN W/ & W/O DYE,972,326,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,195.60
Outpatient Medical Services,RADIOLOGY,70480,CT ORBIT/EAR/FOSSA W/O DYE,972,319,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,191.40
Outpatient Medical Services,RADIOLOGY,70481,CT ORBIT/EAR/FOSSA W/DYE,972,343,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,205.80
Outpatient Medical Services,RADIOLOGY,70482,CT ORBIT/EAR/FOSSA W/ & W/O DYE,972,358,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,214.80
Outpatient Medical Services,RADIOLOGY,70486,CT Scan of the face and jaw without dye,972,284,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,170.40
Outpatient Medical Services,RADIOLOGY,70487,CT MAXILLOFACIAL  W /DYE,972,323,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,193.80
Outpatient Medical Services,RADIOLOGY,70488,CT MAXILLOFACIAL BONES W AND WO CONTRAST,972,358,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,214.80
Outpatient Medical Services,RADIOLOGY,70490,CT SOFT TISSUE NECK W/O DYE,972,382,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,229.20
Outpatient Medical Services,RADIOLOGY,70491,CT scan of neck with dye,972,343,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,205.80
Outpatient Medical Services,RADIOLOGY,70492,CT SOFT TISSUE NECK W/ & W/O DYE,972,358,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,214.80
Outpatient Medical Services,RADIOLOGY,70496,CTA HEAD W/ & W/O CONTRAST,972,394,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,236.40
Outpatient Medical Services,RADIOLOGY,70498,CTA OF NECK,972,394,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,236.40
Outpatient Medical Services,RADIOLOGY,70540,MRI HEAD WO DYE,972,332,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,199.20
Outpatient Medical Services,RADIOLOGY,70542,MRI HEAD W DYE,972,360,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,216.00
Outpatient Medical Services,RADIOLOGY,70543,MRI NECK SOFT TISSUE WWO,972,479,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,287.40
Outpatient Medical Services,RADIOLOGY,70544,MRA  HEAD W/O CONTRAST,972,268,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,160.80
Outpatient Medical Services,RADIOLOGY,70546,MRA  HEAD W &  W/O CONTRAST,972,424,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,254.40
Outpatient Medical Services,RADIOLOGY,70547,MRA  OF NECK W/O CONTRAST,972,269,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,161.40
Outpatient Medical Services,RADIOLOGY,70548,MRA  OF NECK WITH CONTRAST,972,269,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,161.40
Outpatient Medical Services,RADIOLOGY,70549,MRA  CAROTIDS W/ & W/O CONTRAST,972,416,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,249.60
Outpatient Medical Services,RADIOLOGY,70551,MRI of brain stem without dye,972,368,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,220.80
Outpatient Medical Services,RADIOLOGY,70552,MRI BRAIN W/  CONTRAST,972,333,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,199.80
Outpatient Medical Services,RADIOLOGY,70553,MRI scan of brain before and after contrast,972,441,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,264.60
Outpatient Medical Services,RADIOLOGY,71022,"CHEST XRAY 2 VIEWS FRO &  LAT, W/OBLIQUE",972,78,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,46.80
Outpatient Medical Services,RADIOLOGY,71045,Single view,972,54,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,32.40
Outpatient Medical Services,RADIOLOGY,71045,Single view,972,54,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,32.40
Outpatient Medical Services,RADIOLOGY,71046,"2 views, front and back",972,61,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,36.60
Outpatient Medical Services,RADIOLOGY,71047,3 views,972,67,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,40.20
Outpatient Medical Services,RADIOLOGY,71048,4 or more views,972,50,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,30.00
Outpatient Medical Services,RADIOLOGY,71090,XRAY OF PACEMAKER INSERTION,972,138,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,82.80
Outpatient Medical Services,RADIOLOGY,71100,XRAY EXAM OF RIBS UNILATERAL 2 VIEW,972,56,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,33.60
Outpatient Medical Services,RADIOLOGY,71101,Radiologic examination of one side of the chest/ribs,972,58,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,34.80
Outpatient Medical Services,RADIOLOGY,71111,XRAY EXAM OF RIBS BILATERAL 4 VIEW,972,80,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,48.00
Outpatient Medical Services,RADIOLOGY,71120,XRAY EXAM OF BREASTBONE 2 VIEWS,972,60,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,36.00
Outpatient Medical Services,RADIOLOGY,71130,XRAY OF STERNOCLAVICULAR JOINT 3 VIEW,972,53,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,31.80
Outpatient Medical Services,RADIOLOGY,71250,CT scan of the thorax without dye,972,442,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,265.20
Outpatient Medical Services,RADIOLOGY,71260,CT scan of the thorax with dye,972,327,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,196.20
Outpatient Medical Services,RADIOLOGY,71270,CT THORAX WITH AND  W/O DYE,972,768,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,460.80
Outpatient Medical Services,RADIOLOGY,71270,CT THORAX  WWO DYE,972,343,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,205.80
Outpatient Medical Services,RADIOLOGY,71275,Diagnostic Radiology (Diagnostic Imaging) Procedures of the Chest,972,389,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,233.40
Outpatient Medical Services,RADIOLOGY,71551,MRI CHEST W/ DYE,972,320,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,192.00
Outpatient Medical Services,RADIOLOGY,72020,XRAY EXAM OF SPINE SINGLE VIEW,972,46,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,27.60
Outpatient Medical Services,RADIOLOGY,72040,"Radiologic examination of the neck/spine, 2-3 views",972,66,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,39.60
Outpatient Medical Services,RADIOLOGY,72050,"Radiologic examination of the neck/spine, 4-5 views",972,75,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,45.00
Outpatient Medical Services,RADIOLOGY,72050,"Radiologic examination of the neck/spine, 4-5 views",972,75,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,45.00
Outpatient Medical Services,RADIOLOGY,72052,XRAY EXAM OF C-SPINE (NECK) COMPLETE,972,91,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,54.60
Outpatient Medical Services,RADIOLOGY,72070,"Radiologic examination of the middle spine, 2 views",972,46,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,27.60
Outpatient Medical Services,RADIOLOGY,72072,"Radiologic examination of the middle spine, 3 views",972,53,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,31.80
Outpatient Medical Services,RADIOLOGY,72074,XRAY EXAM OF THORACIC SPINE 4 VIEW,972,66,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,39.60
Outpatient Medical Services,RADIOLOGY,72080,XRAY EXAM OF THORACOLUMBAR AP/LAT 2 VIEW,972,72,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,43.20
Outpatient Medical Services,RADIOLOGY,72100,X-ray of the lower spine 2-3 views,972,67,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,40.20
Outpatient Medical Services,RADIOLOGY,72110,"X-ray of lower and sacral spine, minimum of 4 views",972,78,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,46.80
Outpatient Medical Services,RADIOLOGY,72114,XRAY EXAM L-SPINE COMPLETE W/BENDING,972,95,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,57.00
Outpatient Medical Services,RADIOLOGY,72114,XRAY EXAM L-SPINE COMPLETE W/BENDING,972,95,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,57.00
Outpatient Medical Services,RADIOLOGY,72125,CT CERVICAL WO CONTRAST,972,288,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,172.80
Outpatient Medical Services,RADIOLOGY,72126,CT C-SPINE W/DYE,972,301,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,180.60
Outpatient Medical Services,RADIOLOGY,72127,CT C-SPINE  W/ & W/O DYE,972,471,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,282.60
Outpatient Medical Services,RADIOLOGY,72128,CT CHEST  SPINE W/O DYE,972,288,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,172.80
Outpatient Medical Services,RADIOLOGY,72130,CT SPINE  THORACIC WWO DYE,972,471,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,282.60
Outpatient Medical Services,RADIOLOGY,72131,CT scan of lower spine without dye,972,327,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,196.20
Outpatient Medical Services,RADIOLOGY,72132,CT L-SPINE  W/DYE,972,305,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,183.00
Outpatient Medical Services,RADIOLOGY,72132,CT L-SPINE  W/DYE,972,305,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,183.00
Outpatient Medical Services,RADIOLOGY,72141,MRI of the neck or spine without dye,972,362,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,217.20
Outpatient Medical Services,RADIOLOGY,72142,MRI C-SPINE W/  CONTRAST,972,362,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,217.20
Outpatient Medical Services,RADIOLOGY,72146,MRI of chest and spine without dye,972,337,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,202.20
Outpatient Medical Services,RADIOLOGY,72147,MRI THORACIC  SPINE W DYE,972,360,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,216.00
Outpatient Medical Services,RADIOLOGY,72148,MRI scan of lower spinal canal,972,336,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,201.60
Outpatient Medical Services,RADIOLOGY,72149,MRI LUMBAR W/ DYE,972,336,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,201.60
Outpatient Medical Services,RADIOLOGY,72156,MRI of neck/spine with and without dye,972,479,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,287.40
Outpatient Medical Services,RADIOLOGY,72157,MRI of chest and spine with and without dye,972,479,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,287.40
Outpatient Medical Services,RADIOLOGY,72158,MRI of lower back with and without dye,972,442,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,265.20
Outpatient Medical Services,RADIOLOGY,72170,Radiologic examination of the pelvis,972,57,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,34.20
Outpatient Medical Services,RADIOLOGY,72191,CTA PELVIS W/ W/O CONTRAST,972,408,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,244.80
Outpatient Medical Services,RADIOLOGY,72192,CT of pelvis without dye,972,327,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,196.20
Outpatient Medical Services,RADIOLOGY,72193,"CT scan, pelvis, with contrast",972,327,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,196.20
Outpatient Medical Services,RADIOLOGY,72194,CT PELVIS W &  W/O DYE,972,303,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,181.80
Outpatient Medical Services,RADIOLOGY,72195,MRI of pelvis without dye,972,360,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,216.00
Outpatient Medical Services,RADIOLOGY,72196,MRI PELVIS W/ DYE,972,319,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,191.40
Outpatient Medical Services,RADIOLOGY,72197,MRI of pelvis before and after dye,972,419,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,251.40
Outpatient Medical Services,RADIOLOGY,72198,MRA  PELVIS W/ OR WO DYE,972,419,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,251.40
Outpatient Medical Services,RADIOLOGY,72200,XRAY EXAM OF SACROILIAC JOINTS <3 VIEWS,972,50.97,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,30.58
Outpatient Medical Services,RADIOLOGY,72200,XRAY EXAM OF SACROILIAC JOINTS <3 VIEWS,972,53,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,31.80
Outpatient Medical Services,RADIOLOGY,72202,XRAY EXAM OF SACROILIAC JOINTS 3 VIEWS,972,53,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,31.80
Outpatient Medical Services,RADIOLOGY,72220,XRAY EXAM OF TAILBONE,972,53,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,31.80
Outpatient Medical Services,RADIOLOGY,73000,Radiologic examination of the collar bone,972,101,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,60.60
Outpatient Medical Services,RADIOLOGY,73010,XRAY EXAM OF SHOULDER BLADE,972,53,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,31.80
Outpatient Medical Services,RADIOLOGY,73020,XRAY EXAM OF SHOULDER 1 VIEW,972,46,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,27.60
Outpatient Medical Services,RADIOLOGY,73030,Radiologic examination of the shoulder,972,57,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,34.20
Outpatient Medical Services,RADIOLOGY,73040,CONTRAST XRAY OF SHOULDER,972,137,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,82.20
Outpatient Medical Services,RADIOLOGY,73050,XRAY EXAM OF SHOULDERS,972,64,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,38.40
Outpatient Medical Services,RADIOLOGY,73060,XRAY EXAM OF HUMERUS 2 VIEWS,972,54,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,32.40
Outpatient Medical Services,RADIOLOGY,73070,"Radiologic examination, elbow; 2 views",972,46,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,27.60
Outpatient Medical Services,RADIOLOGY,73080,"Radiologic examination, elbow; 3 or more views",972,53,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,31.80
Outpatient Medical Services,RADIOLOGY,73090,Radiologic examination of the forearm,972,48,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,28.80
Outpatient Medical Services,RADIOLOGY,73100,3 or more views,972,56.25,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,33.75
Outpatient Medical Services,RADIOLOGY,73100,3 or more views,972,67,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,40.20
Outpatient Medical Services,RADIOLOGY,73110,Up to 3 views,972,64.43,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,38.66
Outpatient Medical Services,RADIOLOGY,73115,CONTRAST XRAY OF WRIST,972,139,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,83.40
Outpatient Medical Services,RADIOLOGY,73120,X-ray of the hand with 2 views,972,67,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,40.20
Outpatient Medical Services,RADIOLOGY,73130,X-ray of the hand with 3 or more views,972,67,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,40.20
Outpatient Medical Services,RADIOLOGY,73140,Radiologic examination of the finger(s),972,46,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,27.60
Outpatient Medical Services,RADIOLOGY,73200,CT EXTREMITY UPPER,972,301,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,180.60
Outpatient Medical Services,RADIOLOGY,73200,CT UPPER  EXTREMITY  W/O DYE,972,272,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,163.20
Outpatient Medical Services,RADIOLOGY,73201,CT UPPER  EXTREMITY  W/ DYE,972,288,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,172.80
Outpatient Medical Services,RADIOLOGY,73201,CT UPPER  EXTREMITY  W/ WO,972,441.4,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,264.84
Outpatient Medical Services,RADIOLOGY,73206,CTA UPPER  EXTREMITY  W/ DYE,972,272,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,163.20
Outpatient Medical Services,RADIOLOGY,73218,MRI UPPER EXTREMITY WO DYE,972,400,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,240.00
Outpatient Medical Services,RADIOLOGY,73220,MRI UPPER EXTREMITY W & WO DYE,972,509,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,305.40
Outpatient Medical Services,RADIOLOGY,73221,MRI of upper extremity without dye,972,332,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,199.20
Outpatient Medical Services,RADIOLOGY,73222,MRI UPPER EXTREMITY W DYE,972,364,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,218.40
Outpatient Medical Services,RADIOLOGY,73222,MRI UPPER EXTREMITY JOINT W DYE,972,364,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,218.40
Outpatient Medical Services,RADIOLOGY,73223,MRI UPPER JOINT W & WO DYE,972,398,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,238.80
Outpatient Medical Services,RADIOLOGY,73501,"XRAY EXAM OF HIP UNILATERAL, 1 VIEW",972,54,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,32.40
Outpatient Medical Services,RADIOLOGY,73502,XRAY EXAM HIP UNILATERAL 2 VIEWS,972,67,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,40.20
Outpatient Medical Services,RADIOLOGY,73502,XRAY EXAM OF HIP DURING SURGERY,972,72,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,43.20
Outpatient Medical Services,RADIOLOGY,73502,XRAY EXAM OF PELVIS OR HIPS INFANT/CHILD,972,64,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,38.40
Outpatient Medical Services,RADIOLOGY,73521,XRAY EXAM HIP BILATERAL 2 VIEWS,972,67,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,40.20
Outpatient Medical Services,RADIOLOGY,73525,CONTRAST XRAY OF HIP,972,137,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,82.20
Outpatient Medical Services,RADIOLOGY,73552,XRAY EXAM OF THIGH,972,54,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,32.40
Outpatient Medical Services,RADIOLOGY,73560,Radiologic examination of the knee with 1 or 2 views,972,57,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,34.20
Outpatient Medical Services,RADIOLOGY,73562,Radiologic examination of the knee with 3 views,972,78,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,46.80
Outpatient Medical Services,RADIOLOGY,73564,Radiologic examination of the knee with 4 or more views,972,70,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,42.00
Outpatient Medical Services,RADIOLOGY,73580,CONTRAST XRAY OF KNEE JOINT,972,137,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,82.20
Outpatient Medical Services,RADIOLOGY,73590,Radiologic examination of the lower leg,972,90,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,54.00
Outpatient Medical Services,RADIOLOGY,73600,Radiologic examination of the ankle with 2 views,972,41,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,24.60
Outpatient Medical Services,RADIOLOGY,73610,Radiologic examination of the ankle with 3 views,972,48,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,28.80
Outpatient Medical Services,RADIOLOGY,73620,"Radiologic examination, foot; 2 views",972,46,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,27.60
Outpatient Medical Services,RADIOLOGY,73630,Radiologic examination of the foot with 3 or more views,972,48,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,28.80
Outpatient Medical Services,RADIOLOGY,73650,Radiologic examination of the heel,972,57,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,34.20
Outpatient Medical Services,RADIOLOGY,73660,Radiologic examination of the toe(s),972,48,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,28.80
Outpatient Medical Services,RADIOLOGY,73700,CT scan of leg without dye,972,273,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,163.80
Outpatient Medical Services,RADIOLOGY,73701,CT LOWER EXTREMITY W/  DYE,972,272,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,163.20
Outpatient Medical Services,RADIOLOGY,73702,CT LWR  EXTREMITY  W/ & W/O DYE,972,288,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,172.80
Outpatient Medical Services,RADIOLOGY,73706,CTA OF LOWER EXTREMITY W/&W/O CONTRAST,972,428,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,256.80
Outpatient Medical Services,RADIOLOGY,73718,MRI of leg without dye,972,284,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,170.40
Outpatient Medical Services,RADIOLOGY,73720,MRI LOWER EXTREMITY  W&WO DYE,972,299,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,179.40
Outpatient Medical Services,RADIOLOGY,73721,MRI of lower extremity joint (knee/ankle) without dye,972,284,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,170.40
Outpatient Medical Services,RADIOLOGY,73722,MRI of lower extremity joint (knee/ankle) with dye,972,300,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,180.00
Outpatient Medical Services,RADIOLOGY,73723,MRI of lower extremity joint (knee/ankle) with and without dye,972,300,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,180.00
Outpatient Medical Services,RADIOLOGY,73725,MRA  LOWER EXTREMITY WITH OR W/O CONTRAS,972,423,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,253.80
Outpatient Medical Services,RADIOLOGY,74018,XRAY EXAM OF ABDOMEN,972,66,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,39.60
Outpatient Medical Services,RADIOLOGY,74021,XRAY EXAM  ABDOMEN DECUBITUS &/DR ERECT,972,70,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,42.00
Outpatient Medical Services,RADIOLOGY,74022,Serial radiologic examination of the abdomen,972,67,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,40.20
Outpatient Medical Services,RADIOLOGY,74150,CT of abdomen without dye,972,301,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,180.60
Outpatient Medical Services,RADIOLOGY,74160,CT of abdomen with dye,972,327,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,196.20
Outpatient Medical Services,RADIOLOGY,74170,CT of abdomen with and without dye,972,301,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,180.60
Outpatient Medical Services,RADIOLOGY,74175,MM CTA ABDOMEN W/ W/O CONTRAST,972,427,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,256.20
Outpatient Medical Services,RADIOLOGY,74176,CT of abdomen and pelvis without dye,972,610,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,366.00
Outpatient Medical Services,RADIOLOGY,74177,CT scan of abdomen and pelvis with contrast,972,655,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,393.00
Outpatient Medical Services,RADIOLOGY,74178,"Computed tomography, abdomen and pelvis; without contrast material in one or both body regions, followed by contrast material(s) and further sections ",972,610,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,366.00
Outpatient Medical Services,RADIOLOGY,74181,MRI of abdomen without dye,972,350,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,210.00
Outpatient Medical Services,RADIOLOGY,74182,MRI ABDOMEN W/  CONTRAST,972,350,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,210.00
Outpatient Medical Services,RADIOLOGY,74183,MRI of abdomen without and with dye,972,509,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,305.40
Outpatient Medical Services,RADIOLOGY,74185,MRA  ABDOMEN W/ OR  W/O CONTRAST,972,406,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,243.60
Outpatient Medical Services,RADIOLOGY,74220,CONTRAST XRAY ESOPHAGUS,972,90,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,54.00
Outpatient Medical Services,RADIOLOGY,74230,MODIFIED BARIUM SWALLOW,972,88,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,52.80
Outpatient Medical Services,RADIOLOGY,74240,XRAY UPR GI TRACT W/OR W/O DELAYED FILM,972,246,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,147.60
Outpatient Medical Services,RADIOLOGY,74245,XRAY UPR GI TRACT W/SMALL INTESTINE,972,228,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,136.80
Outpatient Medical Services,RADIOLOGY,74250,XRAY EXAM OF SMALL BOWEL,972,221,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,132.60
Outpatient Medical Services,RADIOLOGY,74270,"XRAY EXAM OF COLON, BE, W/ DR W/O KUB",972,149,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,89.40
Outpatient Medical Services,RADIOLOGY,74280,XRAY OF COLON AIR CONT W/ DR W/O GLUCAG,972,172,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,103.20
Outpatient Medical Services,RADIOLOGY,74290,CONTRAST XRAY GALLBLADDER,972,377,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,226.20
Outpatient Medical Services,RADIOLOGY,74290,CHOLECYSTOGRAPHY,972,80,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,48.00
Outpatient Medical Services,RADIOLOGY,74300,XRAY BILE DUCTS/PANCREAS,972,101,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,60.60
Outpatient Medical Services,RADIOLOGY,74400,CONTRAST XRAY URINARY TRACT W WO KUB,972,221,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,132.60
Outpatient Medical Services,RADIOLOGY,74415,IVP W/NEPHROTOMOGRAPHY,972,224,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,134.40
Outpatient Medical Services,RADIOLOGY,74420,CONTRAST XRAY URINARY TRACT RETROGRADE,972,121,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,72.60
Outpatient Medical Services,RADIOLOGY,74425,CONTRAST XRAY URINARY TRACT ANTEGRADE,972,91,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,54.60
Outpatient Medical Services,RADIOLOGY,74430,CONTRAST XRAY BLADDER 3 VIEWS,972,90,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,54.00
Outpatient Medical Services,RADIOLOGY,74455,XRAY URETHRA/BLADDER,972,84,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,50.40
Outpatient Medical Services,RADIOLOGY,74740,XRAY FEMALE GENITAL TRACT,972,85,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,51.00
Outpatient Medical Services,RADIOLOGY,75635,CTA ABDOMINAL AORTA W/ W/O CONTRAST,972,541,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,324.60
Outpatient Medical Services,RADIOLOGY,75820,VENOGRAM EXTREMITY UNILATERAL,972,232,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,139.20
Outpatient Medical Services,RADIOLOGY,75822,VENOGRAM EXTREMITY BILATERAL,972,178,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,106.80
Outpatient Medical Services,RADIOLOGY,76000,"Flouroscopy, or x-ray ""movie"" that takes less than an hour",972,37,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,22.20
Outpatient Medical Services,RADIOLOGY,76001,FLUROSCOPE EXAM OVER 1 HOUR,972,150,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,90.00
Outpatient Medical Services,RADIOLOGY,76080,XRAY EXAM OF FISTULA,972,62,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,37.20
Outpatient Medical Services,RADIOLOGY,76098,MM XRAY EXAM OF BREAST SPECIMEN,972,66,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,39.60
Outpatient Medical Services,RADIOLOGY,76376,HOLOGRAPH (3D) RECONSTRUCTION TOMOGRA,972,102,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,61.20
Outpatient Medical Services,RADIOLOGY,76536,Ultrasound of head and neck,972,148,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,88.80
Outpatient Medical Services,RADIOLOGY,76604,US CHEST B-SCAN,972,148,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,88.80
Outpatient Medical Services,RADIOLOGY,76641,US EXAM BREAST,972,136,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,81.60
Outpatient Medical Services,RADIOLOGY,76700,Ultrasound of abdomen with all areas scanned,972,327,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,196.20
Outpatient Medical Services,RADIOLOGY,76700,Ultrasound of abdomen with all areas scanned,972,191,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,114.60
Outpatient Medical Services,RADIOLOGY,76705,A diagnostic procedure that allows a provider to see the organs and other structures in the abdomen,972,192,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,115.20
Outpatient Medical Services,RADIOLOGY,76705,A diagnostic procedure that allows a provider to see the organs and other structures in the abdomen,972,148,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,88.80
Outpatient Medical Services,RADIOLOGY,76706,US ABDOMINAL AORTA,972,338.5,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,203.10
Outpatient Medical Services,RADIOLOGY,76775,Ultrasound of back wall of the abdomen with limited areas viewed,972,191,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,114.60
Outpatient Medical Services,RADIOLOGY,76801,Abdominal ultrasound of pregnant uterus (less than 14 weeks) single or first fetus,972,214,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,128.40
Outpatient Medical Services,RADIOLOGY,76801,Abdominal ultrasound of pregnant uterus (less than 14 weeks) single or first fetus,972,214,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,128.40
Outpatient Medical Services,RADIOLOGY,76805,Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus,972,214,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,128.40
Outpatient Medical Services,RADIOLOGY,76810,US PREGNANT UTEREUS ADD'L FETUS,972,244,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,146.40
Outpatient Medical Services,RADIOLOGY,76815,Ultrasound of fetus with limited views,972,86.3,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,51.78
Outpatient Medical Services,RADIOLOGY,76816,US OB FOLLOW-UP PER FETUS,972,130,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,78.00
Outpatient Medical Services,RADIOLOGY,76817,Transvaginal ultrasound of uterus,972,214,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,128.40
Outpatient Medical Services,RADIOLOGY,76819,Fetal biophysical profile without non-stress test,972,134.5,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,80.70
Outpatient Medical Services,RADIOLOGY,76830,Ultrasound of the pelvis through vagina,972,214,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,128.40
Outpatient Medical Services,RADIOLOGY,76856,Complete ultrasound of the pelvis,972,191,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,114.60
Outpatient Medical Services,RADIOLOGY,76856,Complete ultrasound of the pelvis,972,191,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,114.60
Outpatient Medical Services,RADIOLOGY,76870,Ultrasound of the scrotum,972,148,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,88.80
Outpatient Medical Services,RADIOLOGY,76872,Transrectal ultrasound,972,232,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,139.20
Outpatient Medical Services,RADIOLOGY,76881,US EXTREMEMITY NON-VASCULAR,972,232,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,139.20
Outpatient Medical Services,RADIOLOGY,76881,US GROIN,972,232,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,139.20
Outpatient Medical Services,RADIOLOGY,76882,"Diagnostic ultrasound of an extremity excluding the bone, joints or vessels",972,232,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,139.20
Outpatient Medical Services,RADIOLOGY,76942,US GUIDANCE,972,210,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,126.00
Outpatient Medical Services,RADIOLOGY,76946,US AMNIOCENTESIS,972,173,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,103.80
Outpatient Medical Services,RADIOLOGY,77002,NEEDLE LOCALIZATION BY XRAY,972,168,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,100.80
Outpatient Medical Services,RADIOLOGY,77021,MRI BREAST,972,441,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,264.60
Outpatient Medical Services,RADIOLOGY,77049,MRI BREAST SCREENING,972,441,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,264.60
Outpatient Medical Services,RADIOLOGY,77058,MRI BREAST WITH OR W/O UNILATERIAL,972,441,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,264.60
Outpatient Medical Services,RADIOLOGY,77065,"Diagnostic mammography, including computer-aided detection (cad) when performed; unilateral",972,102,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,61.20
Outpatient Medical Services,RADIOLOGY,77066,"Diagnostic mammography, including computer-aided detection (cad) when performed; bilateral",972,90,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,54.00
Outpatient Medical Services,RADIOLOGY,77066,"Diagnostic mammography, including computer-aided detection (cad) when performed; bilateral",972,108,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,64.80
Outpatient Medical Services,RADIOLOGY,77067,Mammography of both breasts-2 or more views,972,102,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,61.20
Outpatient Medical Services,RADIOLOGY,77072,XRAYS FOR BONE AGE,972,326,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,195.60
Outpatient Medical Services,RADIOLOGY,77075,XRAY EXAM SKELETAL SURVEY FOR METASTASES,972,254.87,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,152.92
Outpatient Medical Services,RADIOLOGY,77075,XRAY EXAM SKELETAL SURVEY,972,264,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,158.40
Outpatient Medical Services,RADIOLOGY,77076,XRAY EXAM SKELETAL SURVEY INFANT,972,264,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,158.40
Outpatient Medical Services,RADIOLOGY,77078,CT BONE DENSITY SPINE,972,215,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,129.00
Outpatient Medical Services,RADIOLOGY,77084,MRI BONE MARROW,972,788,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,472.80
Outpatient Medical Services,RADIOLOGY,93880,Study of vessels on both sides of the head and neck,972,112,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,67.20
Outpatient Medical Services,RADIOLOGY,93923,US PVR MULTI ARTERIAL,972,108,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,64.80
Outpatient Medical Services,RADIOLOGY,93925,US EXTREMITY BILAT ARTERIAL,972,108,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,64.80
Outpatient Medical Services,RADIOLOGY,93926,US EXTREMITY UNILATERAL ARTERIAL,972,108,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,64.80
Outpatient Medical Services,RADIOLOGY,93970,Complete bilateral study of the extremities,972,108,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,64.80
Outpatient Medical Services,RADIOLOGY,93971,One sided or limited bilateral study,972,108,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,64.80
Outpatient Medical Services,RADIOLOGY,93975,US RENAL  ARTERIAL,972,108,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,64.80
Outpatient Medical Services,RADIOLOGY,70330,XRAY EXAM OF JOINTS BILATERAL,972,72,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,43.20
Outpatient Medical Services,RADIOLOGY,71110,XRAY EXAM OF RIBS BILATERAL 3 VIEW,972,77.11,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,46.27
Outpatient Medical Services,RADIOLOGY,78012,NM THYROID IMAGING,974,98,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,58.80
Outpatient Medical Services,RADIOLOGY,78070,NM PARATHYROID NUCLEAR IMAGING,974,205,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,123.00
Outpatient Medical Services,RADIOLOGY,78140,NM RED CELL SEQUESTRATION,974,154,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,92.40
Outpatient Medical Services,RADIOLOGY,78195,NM LYMPH SYSTEM IMAGING,974,309,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,185.40
Outpatient Medical Services,RADIOLOGY,78215,NM LIVER AND SPLEEN IMAGING,974,124,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,74.40
Outpatient Medical Services,RADIOLOGY,78227,NM HEPATOBILIARY IMAGING,974,211,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,126.60
Outpatient Medical Services,RADIOLOGY,78264,NM GASTRIC EMPTYING STUDY,974,197,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,118.20
Outpatient Medical Services,RADIOLOGY,78290,NM MECKEL'S DIVERT EXAM,974,179,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,107.40
Outpatient Medical Services,RADIOLOGY,78300,NM BONE IMAGING LTD AREA,974,197,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,118.20
Outpatient Medical Services,RADIOLOGY,78306,"A procedure most commonly ordered to detect areas of abnormal bone growth due to fractures, tumors, infection, or other bone issues",974,216,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,129.60
Outpatient Medical Services,RADIOLOGY,78315,NM BONE IMAGING 3 PHRASE STUDY,974,256,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,153.60
Outpatient Medical Services,RADIOLOGY,78320,NM BONE IMAGING 3 D,974,263,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,157.80
Outpatient Medical Services,RADIOLOGY,78451,"NM HEART MUSCLE BLOOD, SINGLE",974,216,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,129.60
Outpatient Medical Services,RADIOLOGY,78452,Image of the heart to assess perfusion,974,309,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,185.40
Outpatient Medical Services,RADIOLOGY,78452,Image of the heart to assess perfusion,974,545,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,327.00
Outpatient Medical Services,RADIOLOGY,78457,NM VENOUS THROMBOSIS IMAGING,974,197,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,118.20
Outpatient Medical Services,RADIOLOGY,78458,NM VENOUS THROMBOSIS IMAGING BILATERAL,974,197,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,118.20
Outpatient Medical Services,RADIOLOGY,78466,NM HEART INFARCT IMAGE,974,179,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,107.40
Outpatient Medical Services,RADIOLOGY,78472,"NM GATED HEART, PLANAR, SINGLE",974,238.83,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,143.30
Outpatient Medical Services,RADIOLOGY,78478,NM HEART WALL MOTION,974,90,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,54.00
Outpatient Medical Services,RADIOLOGY,78480,NM HEART EF,974,90,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,54.00
Outpatient Medical Services,RADIOLOGY,78579,"NM LUNG AEROSOL IMAGE, MULTIPLE",974,124,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,74.40
Outpatient Medical Services,RADIOLOGY,78580,NM LUNG PERFUSION IMAGING,974,197,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,118.20
Outpatient Medical Services,RADIOLOGY,78582,NM LUNG V/Q IMAGE SINGLE BREATH,974,247,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,148.20
Outpatient Medical Services,RADIOLOGY,78701,NM KIDNEY IMAGING W/ FLOW,974,154,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,92.40
Outpatient Medical Services,RADIOLOGY,78708,NM RENAL FLOW W/ PHARMACOLOGIC,974,159.5,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,95.70
Outpatient Medical Services,RADIOLOGY,78709,NM RENAL FLOW WITH AND W/O PHARMACOLOGIC,974,207,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,124.20
Outpatient Medical Services,RADIOLOGY,78805,NM ABSCESS IMAGING LTD AREA,974,216,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,129.60
Outpatient Medical Services,RADIOLOGY,78806,"NM ABSCESS IMAGING, WHOLE BODY",974,216,NA,Not Applicable. Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,NA,Not Applicable.Service not offered,,,129.60
Outpatient Medical Services,BEHAVIORAL,90832,"Psychotherapy, 30 minute",900,SERVICE NOT OFFERED,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,NA,NA
Outpatient Medical Services,BEHAVIORAL,90834,"Psychotherapy, 45 minutes",900,SERVICE NOT OFFERED,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,NA,NA
Outpatient Medical Services,BEHAVIORAL,90837,"Psychotherapy, 60 minutes",900,SERVICE NOT OFFERED,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,NA,NA
Outpatient Medical Services,BEHAVIORAL,90846,"Family psychotherapy, not including patient, 50 minutes",900,SERVICE NOT OFFERED,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,NA,NA
Outpatient Medical Services,BEHAVIORAL,90847,"Family psychotherapy, including patient, 50 min",900,SERVICE NOT OFFERED,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,NA,NA
Outpatient Medical Services,BEHAVIORAL,90853,Group psychotherapy,900,SERVICE NOT OFFERED,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,NA,NA
Outpatient Medical Services,OFFICE VISIT,99243,"Patient office consultation, typically 40 min",761,SERVICE NOT OFFERED,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,NA,NA
Outpatient Medical Services,OFFICE VISIT,99244,"Patient office consultation, typically 60 min",761,SERVICE NOT OFFERED,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,NA,NA
Outpatient Medical Services,OFFICE VISIT,99385,"Initial new patient preventive medicine evaluation, for those ages 18 to 39",761,SERVICE NOT OFFERED,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,NA,NA
Outpatient Medical Services,OFFICE VISIT,99386,"Initial new patient preventive medicine evaluation, for those ages 40 to 64",761,SERVICE NOT OFFERED,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,NA,NA
Outpatient Medical Services,LAB,81000,Manual urinalysis test with examination using microscope,300,SERVICE NOT OFFERED,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,NA,NA
Outpatient Medical Services,RADIOLOGY,19120,"Removal of 1 or more breast growth, open procedure",360,SERVICE NOT OFFERED,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,NA,NA
Outpatient Medical Services,OUTPATIENT SERVICES,29826,Shaving of shoulder bone using an endoscope,360,SERVICE NOT OFFERED,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,NA,NA
Outpatient Medical Services,OUTPATIENT SERVICES,29881,Removal of one knee cartilage using an endoscope,360,SERVICE NOT OFFERED,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,NA,NA
Outpatient Medical Services,OUTPATIENT SERVICES,42820,Removal of tonsils and adenoid glands patient younger than age 12,360,SERVICE NOT OFFERED,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,NA,NA
Outpatient Medical Services,OUTPATIENT SERVICES,43235,"Diagnostic examination of esophagus, stomach, and/or upper small bowel using an endoscop",360,SERVICE NOT OFFERED,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,NA,NA
Outpatient Medical Services,OUTPATIENT SERVICES,43239,"Biopsy of the esophagus, stomach, and/or upper small bowel using an endoscope",360,SERVICE NOT OFFERED,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,NA,NA
Outpatient Medical Services,OUTPATIENT SERVICES,45378,Diagnostic examination of large bowel using an endoscope,360,SERVICE NOT OFFERED,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,NA,NA
Outpatient Medical Services,OUTPATIENT SERVICES,45380,Biopsy of large bowel using an endoscope,360,SERVICE NOT OFFERED,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,NA,NA
Outpatient Medical Services,OUTPATIENT SERVICES,45385,Removal of polyps or growths of large bowel using an endoscope,360,SERVICE NOT OFFERED,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,NA,NA
Outpatient Medical Services,OUTPATIENT SERVICES,45391,Ultrasound examination of lower large bowel using an endoscope,360,SERVICE NOT OFFERED,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,NA,NA
Outpatient Medical Services,OUTPATIENT SERVICES,47562,Removal of gallbladder using an endoscope,360,SERVICE NOT OFFERED,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,NA,NA
Outpatient Medical Services,OUTPATIENT SERVICES,49505,Repair of groin hernia patient age 5 or older,360,SERVICE NOT OFFERED,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,NA,NA
Outpatient Medical Services,OUTPATIENT SERVICES,55866,Surgical removal of prostate and surrounding lymph nodes using an endoscope,360,SERVICE NOT OFFERED,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,NA,NA
Outpatient Medical Services,OUTPATIENT SERVICES,59400,"Routine obstetric care for vaginal delivery, including pre-and post-delivery care",720,SERVICE NOT OFFERED,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,NA,NA
Outpatient Medical Services,OUTPATIENT SERVICES,59510,"Routine obstetric care for cesarean delivery, including pre-and post-delivery care",720,SERVICE NOT OFFERED,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,NA,NA
Outpatient Medical Services,OUTPATIENT SERVICES,59610,Routine obstetric care for vaginal delivery after prior cesarean delivery including pre-and post-delivery care,720,SERVICE NOT OFFERED,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,NA,NA
Outpatient Medical Services,OUTPATIENT SERVICES,62323,Injection of substance into spinal canal of lower back or sacrum using imaging guidanc,360,SERVICE NOT OFFERED,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,NA,NA
Outpatient Medical Services,OUTPATIENT SERVICES,66821,Removal of recurring cataract in lens capsule using laser,360,SERVICE NOT OFFERED,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,NA,NA
Outpatient Medical Services,ECCG,93000,"Electrocardiogram, routine, with interpretation and report",730,SERVICE NOT OFFERED,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,NA,NA
Outpatient Medical Services,CARDIOLOGY,93452,Insertion of catheter into left heart for diagnosis,480,SERVICE NOT OFFERED,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,NA,NA
Inpatient Medical Services,INPATIENT PROCEDURES,216,Cardiac valve and other major cardiothoracic procedures with cardiac catheterization with major complications or comorbidities,100,SERVICE NOT OFFERED,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,NA,NA
Inpatient Medical Services,INPATIENT PROCEDURES,460,Spinal fusion except cervical without major comorbid conditions or complications,100,SERVICE NOT OFFERED,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,NA,NA
Inpatient Medical Services,INPATIENT PROCEDURES,470,Major joint replacement or reattachment of lower extremity without major comorbid conditions or complications,100,SERVICE NOT OFFERED,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,NA,NA
Inpatient Medical Services,INPATIENT PROCEDURES,473,Cervical spinal fusion without comorbid conditions or major comorbid conditions or complications,100,SERVICE NOT OFFERED,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,NA,NA
Inpatient Medical Services,INPATIENT PROCEDURES,743,Uterine and adnexa procedures for non-malignancy without comorbid conditions or major comorbid conditions or complications,100,SERVICE NOT OFFERED,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,Service not offered,NA,NA,NA