hospital_name,last_updated_on,version,hospital_location,hospital_address,license_number|MO,"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.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Ste. Genevieve County Memorial Hospital,3/5/2025,2.0.0,Ste. Genevieve County Memorial Hospital,"800 Ste Genevieve Dr, Ste. Genevieve, MO 63670",282NC0060X,TRUE,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SERVICE DESCRIPTION,CATEGORY,BILLING MSDRG | CPT | HCPCS,ITEM/SERVICE DESCRIPTION,BILLING REVENUE CODE,GROSS CHARGES,AETNA PLAN,AETNA REMIBURSEMENT METHOD,AETNA MEDICARE PLAN,AETNA MEDICARE REMIBURSEMENT METHOD,ALLWELL PLAN,ALLWELL REMIBURSEMENT METHOD,AMBETTER PLAN,AMBETTER REMIBURSEMENT METHOD,BCBS BLUE ACCESS PLAN,BCBS BLUE ACCESS REMIBURSEMENT METHOD,BCBS BLUE ACCESS CHOICE PLAN,BCBS BLUE ACCESS CHOICE REMIBURSEMENT METHOD,BCBS BLUE PREFERRED PLAN,BCBS BLUE PREFERRED REMIBURSEMENT METHOD,BCBS MEDICARE PLAN,BCBS MEDICARE REMIBURSEMENT METHOD,BCBS PATHWAY PLAN,BCBS PATHWAY REMIBURSEMENT METHOD,BCBS PATHWAY X PLAN,BCBS PATHWAY X REMIBURSEMENT METHOD,BCBS TRADITIONAL PLAN,BCBS TRADITIONAL REMIBURSEMENT METHOD,CIGNA PLAN,CIGNA REMIBURSEMENT METHOD,HEALTHLINK COMPMANAGEMENT PLAN,HEALTHLINK COMPMANAGEMENT REMIBURSEMENT METHOD,HEALTHLINK HMO PLAN,HEALTHLINK HMO REMIBURSEMENT METHOD,HEALTHLINK PPO PLAN,HEALTHLINK PPO REMIBURSEMENT METHOD,HEALTHY BLUE PLAN,HEALTHY BLUE REMIBURSEMENT METHOD,HOMESTATE PLAN,HOMESTATE REMIBURSEMENT METHOD,MEDICAID PLAN,MEDICAID REMIBURSEMENT METHOD,MERITAIN PLAN,MERITAIN REMIBURSEMENT METHOD,MULTIPLAN/PHCS PLAN,MULTIPLAN/PHCS REMIBURSEMENT METHOD,PPHP PLAN,PPHP REMIBURSEMENT METHOD,UHC PLAN,UHC REMIBURSEMENT METHOD,UHC COMMUNITY PLAN PLAN,UHC COMMUNITY PLAN REMIBURSEMENT METHOD,UHC MEDICARE PLAN,UHC MEDICARE PLAN,UMR PLAN,UMR REMIBURSEMENT METHOD,VA PLAN,VA REMIBURSEMENT METHOD,De-Identified Minimum Negotiated Rate,De-Identified Maximum Negotiated Rate,DISCOUNTED CASH PRICE
Inpatient Medical Services,INPATIENT,470,Major joint replacement or reattachment of lower extremity without major comorbid conditions or complications (MCC).,120,"$50,595.17 ","$38,958.28 ",77% of total billed charges,"$2,811.12 ",pays based on per day rate,"$2,811.12 ",pays based on per day rate,"$3,445.00 ",pays based on per day rate,"$2,472.00 ",pays based on per day rate,"$2,350.00 ",pays based on per day rate,"$2,350.00 ",pays based on per day rate,"$2,756.00 ",pays based on per day rate,"$2,350.00 ",pays based on per day rate,"$2,350.00 ",pays based on per day rate,"$2,429.00 ",pays based on per day rate,"$2,020.00 ",pays based on per day rate,"$2,751.00 ",pays based on per day rate,"$2,719.00 ",pays based on per day rate,"$2,751.00 ",pays based on per day rate,"$2,494.66 ",pays based on per day rate,"$2,494.66 ",pays based on per day rate,"$2,494.66 ",pays based on per day rate,"$38,958.28 ",77% of total billed charges,"$43,005.89 ",85% of total billed charges,"$3,169.40 ",pays based on per day rate,"$3,180.00 ",pays based on per day rate,"$2,494.66 ",pays based on per day rate,"$2,756.00 ",pays based on per day rate,"$2,563.00 ",pays based on per day rate,"$2,756.00 ",pays based on per day rate,"$2,020.00 ","$43,005.89 ","$25,297.59 "
Inpatient Medical Services,INPATIENT,743,Uterine and adnexa procedures for non-malignancy without comorbid conditions (CC) or major comorbid conditions or complications (MCC),120,"$34,791.64 ","$26,789.56 ",77% of total billed charges,"$2,811.12 ",pays based on per day rate,"$2,811.12 ",pays based on per day rate,"$3,445.00 ",pays based on per day rate,"$2,472.00 ",pays based on per day rate,"$2,350.00 ",pays based on per day rate,"$2,350.00 ",pays based on per day rate,"$2,756.00 ",pays based on per day rate,"$2,350.00 ",pays based on per day rate,"$2,350.00 ",pays based on per day rate,"$2,429.00 ",pays based on per day rate,"$2,020.00 ",pays based on per day rate,"$2,751.00 ",pays based on per day rate,"$2,719.00 ",pays based on per day rate,"$2,751.00 ",pays based on per day rate,"$2,494.66 ",pays based on per day rate,"$2,494.66 ",pays based on per day rate,"$2,494.66 ",pays based on per day rate,"$26,789.56 ",77% of total billed charges,"$29,572.89 ",85% of total billed charges,"$3,169.40 ",pays based on per day rate,"$3,180.00 ",pays based on per day rate,"$2,494.66 ",pays based on per day rate,"$2,756.00 ",pays based on per day rate,"$2,563.00 ",pays based on per day rate,"$2,756.00 ",pays based on per day rate,"$2,020.00 ","$29,572.89 ","$17,395.82 "
Inpatient Medical Services,INPATIENT,795,Normal Newborn Birth,120,"$3,392.20 ","$2,611.99 ",77% of total billed charges,"$2,811.12 ",pays based on per day rate,"$2,811.12 ",pays based on per day rate,"$3,445.00 ",pays based on per day rate,"$1,644.00 ",pays based on per day rate,"$1,562.00 ",pays based on per day rate,"$1,562.00 ",pays based on per day rate,"$2,756.00 ",pays based on per day rate,"$1,562.00 ",pays based on per day rate,"$1,562.00 ",pays based on per day rate,"$1,614.00 ",pays based on per day rate,"$1,460.00 ",pays based on per day rate,"$1,989.00 ",pays based on per day rate,"$1,890.00 ",pays based on per day rate,"$1,989.00 ",pays based on per day rate,"$2,494.66 ",pays based on per day rate,"$2,494.66 ",pays based on per day rate,"$2,494.66 ",pays based on per day rate,"$2,611.99 ",77% of total billed charges,"$2,883.37 ",85% of total billed charges,"$3,169.40 ",pays based on per day rate,"$1,272.00 ",pays based on per day rate,"$2,494.66 ",pays based on per day rate,"$2,756.00 ",pays based on per day rate,"$1,024.00 ",pays based on per day rate,"$2,756.00 ",pays based on per day rate,"$1,024.00 ","$3,445.00 ","$1,696.10 "
Inpatient Medical Services,INPATIENT,177,Respiratory Infections and inflammations with MCC,120,"$28,782.69 ","$22,162.67 ",77% of total billed charges,"$2,811.12 ",pays based on per day rate,"$2,811.12 ",pays based on per day rate,"$3,445.00 ",pays based on per day rate,"$1,644.00 ",pays based on per day rate,"$1,562.00 ",pays based on per day rate,"$1,562.00 ",pays based on per day rate,"$2,756.00 ",pays based on per day rate,"$1,562.00 ",pays based on per day rate,"$1,562.00 ",pays based on per day rate,"$1,614.00 ",pays based on per day rate,"$1,460.00 ",pays based on per day rate,"$1,989.00 ",pays based on per day rate,"$1,890.00 ",pays based on per day rate,"$1,989.00 ",pays based on per day rate,"$2,494.66 ",pays based on per day rate,"$2,494.66 ",pays based on per day rate,"$2,494.66 ",pays based on per day rate,"$22,162.67 ",77% of total billed charges,"$24,465.29 ",85% of total billed charges,"$3,169.40 ",pays based on per day rate,"$3,180.00 ",pays based on per day rate,"$2,494.66 ",pays based on per day rate,"$2,756.00 ",pays based on per day rate,"$2,563.00 ",pays based on per day rate,"$2,756.00 ",pays based on per day rate,"$1,460.00 ","$24,465.29 ","$14,391.35 "
Inpatient Medical Services,INPATIENT,807,Vaginal delivery without sterilization or D&C without CC/MCC,120,"$12,334.71 ","$9,497.73 ",77% of total billed charges,"$2,811.12 ",pays based on per day rate,"$2,811.12 ",pays based on per day rate,"$3,445.00 ",pays based on per day rate,"$2,369.00 ",pays based on per visit rate,"$2,252.00 ",pays based on per visit rate,"$2,252.00 ",pays based on per visit rate,"$2,756.00 ",pays based on per day rate,"$2,252.00 ",pays based on per visit rate,"$2,252.00 ",pays based on per visit rate,"$2,330.00 ",pays based on per visit rate,"$2,369.00 ",pays based on per visit rate,"$2,795.00 ",pays based on per visit rate,"$2,719.00 ",pays based on per visit rate,"$2,795.00 ",pays based on per visit rate,"$2,494.66 ",pays based on per day rate,"$2,494.66 ",pays based on per day rate,"$2,494.66 ",pays based on per day rate,"$9,497.73 ",77% of total billed charges,"$10,484.50 ",85% of total billed charges,"$3,169.40 ",pays based on per day rate,"$5,930.00 ",pays based on per day rate,"$2,494.66 ",pays based on per day rate,"$2,756.00 ",pays based on per day rate,"$4,774.00 ",pays based on per visit rate,"$2,756.00 ",pays based on per day rate,"$2,252.00 ","$10,484.50 ","$6,167.36 "
Inpatient Medical Services,INPATIENT,897,"Alcohol, Drug Abuse or dependence without Rehabilitation therapy, without MCC",120,"$9,225.00 ","$7,103.25 ",77% of total billed charges,"$2,811.12 ",pays based on per day rate,"$2,811.12 ",pays based on per day rate,"$3,445.00 ",pays based on per day rate,"$1,644.00 ",pays based on per day rate,"$1,562.00 ",pays based on per day rate,"$1,562.00 ",pays based on per day rate,"$2,756.00 ",pays based on per day rate,"$1,562.00 ",pays based on per day rate,"$1,562.00 ",pays based on per day rate,"$1,614.00 ",pays based on per day rate,"$1,460.00 ",pays based on per day rate,"$1,989.00 ",pays based on per day rate,"$1,890.00 ",pays based on per day rate,"$1,989.00 ",pays based on per day rate,"$2,494.66 ",pays based on per day rate,"$2,494.66 ",pays based on per day rate,"$2,494.66 ",pays based on per day rate,"$7,103.25 ",77% of total billed charges,"$7,841.25 ",85% of total billed charges,"$3,169.40 ",pays based on per day rate,"$3,180.00 ",pays based on per day rate,"$2,494.66 ",pays based on per day rate,"$2,756.00 ",pays based on per day rate,"$2,563.00 ",pays based on per day rate,"$2,756.00 ",pays based on per day rate,"$1,460.00 ","$7,841.25 ","$4,612.50 "
Inpatient Medical Services,INPATIENT,194,Simple pneumonia and pleurisy with CC,120,"$12,209.40 ","$9,401.24 ",77% of total billed charges,"$2,811.12 ",pays based on per day rate,"$2,811.12 ",pays based on per day rate,"$3,445.00 ",pays based on per day rate,"$1,644.00 ",pays based on per day rate,"$1,562.00 ",pays based on per day rate,"$1,562.00 ",pays based on per day rate,"$2,756.00 ",pays based on per day rate,"$1,562.00 ",pays based on per day rate,"$1,562.00 ",pays based on per day rate,"$1,614.00 ",pays based on per day rate,"$1,460.00 ",pays based on per day rate,"$1,989.00 ",pays based on per day rate,"$1,890.00 ",pays based on per day rate,"$1,989.00 ",pays based on per day rate,"$2,494.66 ",pays based on per day rate,"$2,494.66 ",pays based on per day rate,"$2,494.66 ",pays based on per day rate,"$9,401.24 ",77% of total billed charges,"$10,377.99 ",85% of total billed charges,"$3,169.40 ",pays based on per day rate,"$3,180.00 ",pays based on per day rate,"$2,494.66 ",pays based on per day rate,"$2,756.00 ",pays based on per day rate,"$2,563.00 ",pays based on per day rate,"$2,756.00 ",pays based on per day rate,"$1,460.00 ","$10,377.99 ","$6,104.70 "
Inpatient Medical Services,INPATIENT,794,Neonate with other significant problems,120,"$3,207.17 ","$2,469.52 ",77% of total billed charges,"$2,811.12 ",pays based on per day rate,"$2,811.12 ",pays based on per day rate,"$3,445.00 ",pays based on per day rate,"$1,644.00 ",pays based on per day rate,"$1,562.00 ",pays based on per day rate,"$1,562.00 ",pays based on per day rate,"$2,756.00 ",pays based on per day rate,"$1,562.00 ",pays based on per day rate,"$1,562.00 ",pays based on per day rate,"$1,614.00 ",pays based on per day rate,"$1,460.00 ",pays based on per day rate,"$1,989.00 ",pays based on per day rate,"$1,890.00 ",pays based on per day rate,"$1,989.00 ",pays based on per day rate,"$2,494.66 ",pays based on per day rate,"$2,494.66 ",pays based on per day rate,"$2,494.66 ",pays based on per day rate,"$2,469.52 ",77% of total billed charges,"$2,726.09 ",85% of total billed charges,"$3,169.40 ",pays based on per day rate,"$1,272.00 ",pays based on per day rate,"$2,494.66 ",pays based on per day rate,"$2,756.00 ",pays based on per day rate,"$1,024.00 ",pays based on per day rate,"$2,756.00 ",pays based on per day rate,"$1,024.00 ","$3,445.00 ","$1,603.59 "
Inpatient Medical Services,INPATIENT,190,Chronic obstructive pulmonary disease with CC,120,"$19,395.39 ","$14,934.45 ",77% of total billed charges,"$2,811.12 ",pays based on per day rate,"$2,811.12 ",pays based on per day rate,"$3,445.00 ",pays based on per day rate,"$1,644.00 ",pays based on per day rate,"$1,562.00 ",pays based on per day rate,"$1,562.00 ",pays based on per day rate,"$2,756.00 ",pays based on per day rate,"$1,562.00 ",pays based on per day rate,"$1,562.00 ",pays based on per day rate,"$1,614.00 ",pays based on per day rate,"$1,460.00 ",pays based on per day rate,"$1,989.00 ",pays based on per day rate,"$1,890.00 ",pays based on per day rate,"$1,989.00 ",pays based on per day rate,"$2,494.66 ",pays based on per day rate,"$2,494.66 ",pays based on per day rate,"$2,494.66 ",pays based on per day rate,"$14,934.45 ",77% of total billed charges,"$16,486.08 ",85% of total billed charges,"$3,169.40 ",pays based on per day rate,"$3,180.00 ",pays based on per day rate,"$2,494.66 ",pays based on per day rate,"$2,756.00 ",pays based on per day rate,"$2,563.00 ",pays based on per day rate,"$2,756.00 ",pays based on per day rate,"$1,460.00 ","$16,486.08 ","$9,697.70 "
Inpatient Medical Services,INPATIENT,603,Cellulitis without MCC,120,"$19,373.31 ","$14,917.45 ",77% of total billed charges,"$2,811.12 ",pays based on per day rate,"$2,811.12 ",pays based on per day rate,"$3,445.00 ",pays based on per day rate,"$1,644.00 ",pays based on per day rate,"$1,562.00 ",pays based on per day rate,"$1,562.00 ",pays based on per day rate,"$2,756.00 ",pays based on per day rate,"$1,562.00 ",pays based on per day rate,"$1,562.00 ",pays based on per day rate,"$1,614.00 ",pays based on per day rate,"$1,460.00 ",pays based on per day rate,"$1,989.00 ",pays based on per day rate,"$1,890.00 ",pays based on per day rate,"$1,989.00 ",pays based on per day rate,"$2,494.66 ",pays based on per day rate,"$2,494.66 ",pays based on per day rate,"$2,494.66 ",pays based on per day rate,"$14,917.45 ",77% of total billed charges,"$16,467.31 ",85% of total billed charges,"$3,169.40 ",pays based on per day rate,"$3,180.00 ",pays based on per day rate,"$2,494.66 ",pays based on per day rate,"$2,756.00 ",pays based on per day rate,"$2,563.00 ",pays based on per day rate,"$2,756.00 ",pays based on per day rate,"$1,460.00 ","$16,467.31 ","$9,686.66 "
Outpatient Medical Services,SURGICAL CARE,19120,"Removal of 1 or more breast growth, open procedure",360,"$8,997.43 ","$6,928.02 ",77% of total billed charges,"$2,294.34 ",25.5% of total billed charges,"$2,294.34 ",25.5% of total billed charges,"$2,811.70 ",31.25% of total billed charges,"$1,495.00 ",pays based on per visit rate,"$1,334.00 ",pays based on per visit rate,"$1,334.00 ",pays based on per visit rate,"$2,249.36 ",25% of total billed charges,"$1,334.00 ",pays based on per visit rate,"$1,334.00 ",pays based on per visit rate,"$7,557.84 ",84% of total billed charges,"$7,377.89 ",82% of total billed charges,"$4,592.00 ",89% of total billed charges,"$4,458.00 ",pays based on per visit rate,"$4,592.00 ",89% of total billed charges,"$3,670.95 ",40.8% of total billed charges,"$3,670.95 ",40.8% of total billed charges,"$3,670.95 ",40.8% of total billed charges,"$6,928.02 ",77% of total billed charges,"$7,647.82 ",85% of total billed charges,"$2,586.76 ",28.75% of total billed charges,"$4,498.72 ",50% of total billed charges,"$3,670.95 ",40.8% of total billed charges,"$2,249.36 ",25% of total billed charges,"$2,291.00 ",100% of CMS ASC tier groupins rate,"$2,249.36 ",25% of total billed charges,"$1,334.00 ","$7,647.82 ","$4,498.72 "
Outpatient Medical Services,SURGICAL CARE,29826,Shaving of shoulder bone using an endoscope,360,"$5,778.49 ","$4,449.44 ",77% of total billed charges,"$1,473.51 ",25.5% of total billed charges,"$1,473.51 ",25.5% of total billed charges,"$1,805.78 ",31.25% of total billed charges,"$3,645.00 ",pays based on per visit rate,"$3,620.00 ",pays based on per visit rate,"$3,620.00 ",pays based on per visit rate,"$1,444.62 ",25% of total billed charges,"$3,620.00 ",pays based on per visit rate,"$3,620.00 ",pays based on per visit rate,"$3,583.00 ",pays based on per visit rate,"$4,738.36 ",82% of total billed charges,"$4,592.00 ",89% of total billed charges,"$4,458.00 ",pays based on per visit rate,"$4,592.00 ",89% of total billed charges,"$2,357.62 ",40.8% of total billed charges,"$2,357.62 ",40.8% of total billed charges,"$2,357.62 ",40.8% of total billed charges,"$4,449.44 ",77% of total billed charges,"$4,911.72 ",85% of total billed charges,"$1,661.32 ",28.75% of total billed charges,"$2,889.25 ",50% of total billed charges,"$2,357.62 ",40.8% of total billed charges,"$1,444.62 ",25% of total billed charges,$377.00 ,100% of CMS ASC tier groupins rate,"$1,444.62 ",25% of total billed charges,$377.00 ,"$4,911.72 ","$2,889.25 "
Outpatient Medical Services,SURGICAL CARE,29881,Removal of one knee cartilage using an endoscope,360,"$9,089.96 ","$6,999.27 ",77% of total billed charges,"$2,317.94 ",25.5% of total billed charges,"$2,317.94 ",25.5% of total billed charges,"$2,840.61 ",31.25% of total billed charges,"$3,775.00 ",pays based on per visit rate,"$3,662.00 ",pays based on per visit rate,"$3,662.00 ",pays based on per visit rate,"$2,272.49 ",25% of total billed charges,"$3,662.00 ",pays based on per visit rate,"$3,662.00 ",pays based on per visit rate,"$3,798.00 ",pays based on per visit rate,"$7,453.77 ",82% of total billed charges,"$4,592.00 ",89% of total billed charges,"$4,458.00 ",pays based on per visit rate,"$4,592.00 ",89% of total billed charges,"$3,708.70 ",40.8% of total billed charges,"$3,708.70 ",40.8% of total billed charges,"$3,708.70 ",40.8% of total billed charges,"$6,999.27 ",77% of total billed charges,"$7,726.47 ",85% of total billed charges,"$2,613.36 ",28.75% of total billed charges,"$4,544.98 ",50% of total billed charges,"$3,708.70 ",40.8% of total billed charges,"$2,272.49 ",25% of total billed charges,"$2,711.00 ",100% of CMS ASC tier groupins rate,"$2,272.49 ",25% of total billed charges,"$2,272.49 ","$7,726.47 ","$4,544.98 "
Outpatient Medical Services,SURGICAL CARE,42820,Removal of tonsils and adenoid glands patient younger than age 12,360,"$8,288.85 ","$6,382.41 ",77% of total billed charges,"$2,113.66 ",25.5% of total billed charges,"$2,113.66 ",25.5% of total billed charges,"$2,590.27 ",31.25% of total billed charges,"$2,212.00 ",pays based on per visit rate,"$2,102.00 ",pays based on per visit rate,"$2,102.00 ",pays based on per visit rate,"$2,072.21 ",25% of total billed charges,"$2,102.00 ",pays based on per visit rate,"$2,102.00 ",pays based on per visit rate,"$2,173.00 ",pays based on per visit rate,"$6,796.86 ",82% of total billed charges,"$4,592.00 ",89% of total billed charges,"$4,458.00 ",pays based on per visit rate,"$4,592.00 ",89% of total billed charges,"$3,381.85 ",40.8% of total billed charges,"$3,381.85 ",40.8% of total billed charges,"$3,381.85 ",40.8% of total billed charges,"$6,382.41 ",77% of total billed charges,"$7,045.52 ",85% of total billed charges,"$2,383.04 ",28.75% of total billed charges,"$4,144.43 ",50% of total billed charges,"$3,381.85 ",40.8% of total billed charges,"$2,072.21 ",25% of total billed charges,"$2,291.00 ",100% of CMS ASC tier groupins rate,"$2,072.21 ",25% of total billed charges,"$2,072.21 ","$7,045.52 ","$4,144.43 "
Outpatient Medical Services,SURGICAL CARE,43235,"Diagnostic examination of esophagus, stomach, and/or upper small bowel using an endoscope",360,"$4,642.10 ","$3,574.42 ",77% of total billed charges,"$1,183.74 ",25.5% of total billed charges,"$1,183.74 ",25.5% of total billed charges,"$1,450.66 ",31.25% of total billed charges,"$1,614.00 ",69% of total billed charges,"$1,606.00 ",69% of total billed charges,"$1,606.00 ",69% of total billed charges,"$1,160.53 ",25% of total billed charges,"$1,606.00 ",69% of total billed charges,"$1,606.00 ",69% of total billed charges,"$3,899.36 ",84% of total billed charges,"$3,806.52 ",82% of total billed charges,"$4,131.47 ",89% of total billed charges,"$3,899.36 ",pays based on per visit rate,"$4,131.47 ",89% of total billed charges,"$1,893.98 ",40.8% of total billed charges,"$1,893.98 ",40.8% of total billed charges,"$1,893.98 ",40.8% of total billed charges,"$3,574.42 ",77% of total billed charges,"$3,945.79 ",85% of total billed charges,"$1,334.60 ",28.75% of total billed charges,"$2,321.05 ",50% of total billed charges,"$1,893.98 ",40.8% of total billed charges,"$1,160.53 ",25% of total billed charges,"$2,034.00 ",100% of CMS ASC tier groupins rate,"$1,160.53 ",25% of total billed charges,"$1,160.53 ","$4,131.47 ","$2,321.05 "
Outpatient Medical Services,SURGICAL CARE,43239,"Biopsy of the esophagus, stomach, and/or upper small bowel using an endoscope",360,"$5,618.89 ","$4,326.55 ",77% of total billed charges,"$1,432.82 ",25.5% of total billed charges,"$1,432.82 ",25.5% of total billed charges,"$1,755.90 ",31.25% of total billed charges,"$2,668.00 ",pays based on per visit rate,"$2,589.00 ",pays based on per visit rate,"$2,589.00 ",pays based on per visit rate,"$1,404.72 ",25% of total billed charges,"$2,589.00 ",pays based on per visit rate,"$2,589.00 ",pays based on per visit rate,"$2,676.00 ",pays based on per visit rate,"$4,607.49 ",82% of total billed charges,"$4,592.00 ",89% of total billed charges,"$4,458.00 ",pays based on per visit rate,"$4,592.00 ",89% of total billed charges,"$2,292.51 ",40.8% of total billed charges,"$2,292.51 ",40.8% of total billed charges,"$2,292.51 ",40.8% of total billed charges,"$4,326.55 ",77% of total billed charges,"$4,776.06 ",85% of total billed charges,"$1,615.43 ",28.75% of total billed charges,"$2,809.45 ",50% of total billed charges,"$2,292.51 ",40.8% of total billed charges,"$1,404.72 ",25% of total billed charges,"$2,034.00 ",100% of CMS ASC tier groupins rate,"$1,404.72 ",25% of total billed charges,"$1,404.72 ","$4,776.06 ","$2,809.45 "
Outpatient Medical Services,SURGICAL CARE,45378,Diagnostic examination of large bowel using an endoscope,360,"$4,442.81 ","$3,420.96 ",77% of total billed charges,"$1,132.92 ",25.5% of total billed charges,"$1,132.92 ",25.5% of total billed charges,"$1,388.38 ",31.25% of total billed charges,"$2,472.00 ",pays based on per visit rate,"$2,400.00 ",pays based on per visit rate,"$2,400.00 ",pays based on per visit rate,"$1,110.70 ",25% of total billed charges,"$2,400.00 ",pays based on per visit rate,"$2,400.00 ",pays based on per visit rate,"$2,490.00 ",pays based on per visit rate,"$3,643.10 ",82% of total billed charges,"$3,954.10 ",89% of total billed charges,"$3,731.96 ",pays based on per visit rate,"$3,954.10 ",89% of total billed charges,"$1,812.67 ",40.8% of total billed charges,"$1,812.67 ",40.8% of total billed charges,"$1,812.67 ",40.8% of total billed charges,"$3,420.96 ",77% of total billed charges,"$3,776.39 ",85% of total billed charges,"$1,277.31 ",28.75% of total billed charges,"$2,221.41 ",50% of total billed charges,"$1,812.67 ",40.8% of total billed charges,"$1,110.70 ",25% of total billed charges,"$2,034.00 ",100% of CMS ASC tier groupins rate,"$1,110.70 ",25% of total billed charges,"$1,110.70 ","$3,954.10 ","$2,221.41 "
Outpatient Medical Services,SURGICAL CARE,45380,Biopsy of large bowel using an endoscope,360,"$4,922.75 ","$3,790.52 ",77% of total billed charges,"$1,255.30 ",25.5% of total billed charges,"$1,255.30 ",25.5% of total billed charges,"$1,538.36 ",31.25% of total billed charges,"$2,572.00 ",pays based on per visit rate,"$2,496.00 ",pays based on per visit rate,"$2,496.00 ",pays based on per visit rate,"$1,230.69 ",25% of total billed charges,"$2,496.00 ",pays based on per visit rate,"$2,496.00 ",pays based on per visit rate,"$2,586.00 ",pays based on per visit rate,"$4,036.66 ",82% of total billed charges,"$4,381.25 ",89% of total billed charges,"$4,135.11 ",pays based on per visit rate,"$4,381.25 ",89% of total billed charges,"$2,008.48 ",40.8% of total billed charges,"$2,008.48 ",40.8% of total billed charges,"$2,008.48 ",40.8% of total billed charges,"$3,790.52 ",77% of total billed charges,"$4,184.34 ",85% of total billed charges,"$1,415.29 ",28.75% of total billed charges,"$2,461.38 ",50% of total billed charges,"$2,008.48 ",40.8% of total billed charges,"$1,230.69 ",25% of total billed charges,"$2,034.00 ",100% of CMS ASC tier groupins rate,"$1,230.69 ",25% of total billed charges,"$1,230.69 ","$4,381.25 ","$2,461.38 "
Outpatient Medical Services,SURGICAL CARE,45385,Removal of polyps or growths of large bowel using an endoscope,360,"$5,401.69 ","$4,159.30 ",77% of total billed charges,"$1,377.43 ",25.5% of total billed charges,"$1,377.43 ",25.5% of total billed charges,"$1,688.03 ",31.25% of total billed charges,"$1,614.00 ",69% of total billed charges,"$1,606.00 ",69% of total billed charges,"$1,606.00 ",69% of total billed charges,"$1,350.42 ",25% of total billed charges,"$1,606.00 ",69% of total billed charges,"$1,606.00 ",69% of total billed charges,"$4,537.42 ",84% of total billed charges,"$4,429.39 ",82% of total billed charges,"$4,592.00 ",89% of total billed charges,"$4,458.00 ",pays based on per visit rate,"$4,592.00 ",89% of total billed charges,"$2,203.89 ",40.8% of total billed charges,"$2,203.89 ",40.8% of total billed charges,"$2,203.89 ",40.8% of total billed charges,"$4,159.30 ",77% of total billed charges,"$4,591.44 ",85% of total billed charges,"$1,552.99 ",28.75% of total billed charges,"$2,700.85 ",50% of total billed charges,"$2,203.89 ",40.8% of total billed charges,"$1,350.42 ",25% of total billed charges,"$2,034.00 ",100% of CMS ASC tier groupins rate,"$1,350.42 ",25% of total billed charges,"$1,350.42 ","$4,592.00 ","$2,700.85 "
Outpatient Medical Services,SURGICAL CARE,46221,Excision Procedures on the Anus,360,"$4,942.27 ","$3,805.55 ",77% of total billed charges,"$1,260.28 ",25.5% of total billed charges,"$1,260.28 ",25.5% of total billed charges,"$1,544.46 ",31.25% of total billed charges,"$1,495.00 ",pays based on per visit rate,"$1,334.00 ",pays based on per visit rate,"$1,334.00 ",pays based on per visit rate,"$1,235.57 ",25% of total billed charges,"$1,334.00 ",pays based on per visit rate,"$1,334.00 ",pays based on per visit rate,"$4,151.51 ",84% of total billed charges,"$4,052.66 ",82% of total billed charges,"$4,398.62 ",89% of total billed charges,"$4,151.51 ",pays based on per visit rate,"$4,398.62 ",89% of total billed charges,"$2,016.45 ",40.8% of total billed charges,"$2,016.45 ",40.8% of total billed charges,"$2,016.45 ",40.8% of total billed charges,"$3,805.55 ",77% of total billed charges,"$4,200.93 ",85% of total billed charges,"$1,420.90 ",28.75% of total billed charges,"$2,471.14 ",50% of total billed charges,"$2,016.45 ",40.8% of total billed charges,"$1,235.57 ",25% of total billed charges,"$1,092.00 ",100% of CMS ASC tier groupins rate,"$1,235.57 ",25% of total billed charges,"$1,092.00 ","$4,398.62 ","$2,471.14 "
Outpatient Medical Services,SURGICAL CARE,47562,Removal of gallbladder using an endoscope,360,"$18,942.73 ","$14,585.90 ",77% of total billed charges,"$4,830.40 ",25.5% of total billed charges,"$4,830.40 ",25.5% of total billed charges,"$5,919.60 ",31.25% of total billed charges,"$2,212.00 ",pays based on per visit rate,"$2,102.00 ",pays based on per visit rate,"$2,102.00 ",pays based on per visit rate,"$4,735.68 ",25% of total billed charges,"$2,102.00 ",pays based on per visit rate,"$2,102.00 ",pays based on per visit rate,"$2,173.00 ",pays based on per visit rate,"$15,533.04 ",82% of total billed charges,"$4,592.00 ",89% of total billed charges,"$4,458.00 ",pays based on per visit rate,"$4,592.00 ",89% of total billed charges,"$7,728.63 ",40.8% of total billed charges,"$7,728.63 ",40.8% of total billed charges,"$7,728.63 ",40.8% of total billed charges,"$14,585.90 ",77% of total billed charges,"$16,101.32 ",85% of total billed charges,"$5,446.03 ",28.75% of total billed charges,"$9,471.37 ",50% of total billed charges,"$7,728.63 ",40.8% of total billed charges,"$4,735.68 ",25% of total billed charges,"$3,842.00 ",100% of CMS ASC tier groupins rate,"$4,735.68 ",25% of total billed charges,"$2,102.00 ","$16,101.32 ","$9,471.37 "
Outpatient Medical Services,SURGICAL CARE,49505,Repair of groin hernia patient age 5 years or older,360,"$11,385.38 ","$8,766.74 ",77% of total billed charges,"$2,903.27 ",25.5% of total billed charges,"$2,903.27 ",25.5% of total billed charges,"$3,557.93 ",31.25% of total billed charges,"$2,212.00 ",pays based on per visit rate,"$2,102.00 ",pays based on per visit rate,"$2,102.00 ",pays based on per visit rate,"$2,846.35 ",25% of total billed charges,"$2,102.00 ",pays based on per visit rate,"$2,102.00 ",pays based on per visit rate,"$2,173.00 ",pays based on per visit rate,"$9,336.01 ",82% of total billed charges,"$4,592.00 ",89% of total billed charges,"$4,458.00 ",pays based on per visit rate,"$4,592.00 ",89% of total billed charges,"$4,645.24 ",40.8% of total billed charges,"$4,645.24 ",40.8% of total billed charges,"$4,645.24 ",40.8% of total billed charges,"$8,766.74 ",77% of total billed charges,"$9,677.57 ",85% of total billed charges,"$3,273.30 ",28.75% of total billed charges,"$5,692.69 ",50% of total billed charges,"$4,645.24 ",40.8% of total billed charges,"$2,846.35 ",25% of total billed charges,"$2,711.00 ",100% of CMS ASC tier groupins rate,"$2,846.35 ",25% of total billed charges,"$2,102.00 ","$9,677.57 ","$5,692.69 "
Outpatient Medical Services,SURGICAL CARE,51700,Bladder irrigation and/or instillation,761,$343.95 ,$264.84 ,77% of total billed charges,$87.71 ,25.5% of total billed charges,$87.71 ,25.5% of total billed charges,$107.48 ,31.25% of total billed charges,$254.52 ,74% of total billed charges,$237.33 ,69% of total billed charges,$237.33 ,69% of total billed charges,$85.99 ,25% of total billed charges,$237.33 ,69% of total billed charges,$237.33 ,69% of total billed charges,$288.92 ,84% of total billed charges,$282.04 ,82% of total billed charges,$306.12 ,89% of total billed charges,$306.12 ,89% of total billed charges,$306.12 ,89% of total billed charges,$140.33 ,40.8% of total billed charges,$140.33 ,40.8% of total billed charges,$140.33 ,40.8% of total billed charges,$264.84 ,77% of total billed charges,$292.36 ,85% of total billed charges,$98.89 ,28.75% of total billed charges,$171.98 ,50% of total billed charges,$140.33 ,40.8% of total billed charges,$85.99 ,25% of total billed charges,$306.12 ,89% of total billed charges,$85.99 ,25% of total billed charges,$85.99 ,$306.12 ,$171.98 
Outpatient Medical Services,SURGICAL CARE,51702,Insertion of temporary indwelling bladder catheter.,981,$222.27 ,$52.20 ,175% of AETNA fee schedule,$26.47 ,115% of CMS fee schedule,$27.00 ,117.3% of CMS fee schedule,$33.09 ,143.75% of CMS fee schedule,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$26.47 ,115% of CMS fee schedule,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$29.93 ,100% of CIGNA fee schedule,$29.42 ,100% of HEALTHLINK fee schedule,$28.14 ,100% of HEALTHLINK fee schedule,$29.42 ,100% of HEALTHLINK fee schedule,$200.04 ,40.8% of total billed charges,$200.04 ,90% of total billed charges,$200.04 ,40.8% of total billed charges,$52.20 ,175% of CMS fee schedule,$41.03 ,178.25% of CMS fee schedule,$30.44 ,132.25% of CMS fee schedule,$52.54 ,100% of UHC fee schedule,$200.04 ,40.8% of total billed charges,$26.47 ,100% of CMS fee schedule,$47.29 ,100% of CMS fee schedule,$26.47 ,115% of CMS fee schedule,$26.47 ,$200.04 ,$111.14 
Outpatient Medical Services,SURGICAL CARE,51741,Uroflowmetry,360,"$2,498.50 ","$1,923.85 ",77% of total billed charges,$637.12 ,25.5% of total billed charges,$637.12 ,25.5% of total billed charges,$780.78 ,31.25% of total billed charges,"$1,474.12 ",pays based on per visit rate,"$1,334.00 ",pays based on per visit rate,"$1,334.00 ",pays based on per visit rate,$624.63 ,25% of total billed charges,"$1,334.00 ",pays based on per visit rate,"$1,334.00 ",pays based on per visit rate,"$2,098.74 ",84% of total billed charges,"$2,048.77 ",82% of total billed charges,"$2,223.67 ",89% of total billed charges,"$2,098.74 ",pays based on per visit rate,"$2,223.67 ",89% of total billed charges,$17.27 ,120% of MO fee schedule,$17.27 ,120% of MO fee schedule,$17.27 ,120% of MO fee schedule,"$1,923.85 ",77% of total billed charges,"$2,123.73 ",85% of total billed charges,$718.32 ,28.75% of total billed charges,"$1,249.25 ",50% of total billed charges,$17.27 ,120% of MO fee schedule,$624.63 ,25% of total billed charges,$377.00 ,100% of CMS ASC tier groupins rate,$624.63 ,25% of total billed charges,$17.27 ,"$2,223.67 ","$1,249.25 "
Outpatient Medical Services,SURGICAL CARE,51798,"Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging",360,"$2,498.50 ","$1,923.85 ",77% of total billed charges,$637.12 ,25.5% of total billed charges,$637.12 ,25.5% of total billed charges,$780.78 ,31.25% of total billed charges,"$1,474.12 ",pays based on per visit rate,"$1,334.00 ",pays based on per visit rate,"$1,334.00 ",pays based on per visit rate,$624.63 ,25% of total billed charges,"$1,334.00 ",pays based on per visit rate,"$1,334.00 ",pays based on per visit rate,"$2,098.74 ",84% of total billed charges,"$2,048.77 ",82% of total billed charges,"$2,223.67 ",89% of total billed charges,"$2,098.74 ",pays based on per visit rate,"$2,223.67 ",89% of total billed charges,"$1,019.39 ",40.8% of total billed charges,"$1,019.39 ",40.8% of total billed charges,"$1,019.39 ",40.8% of total billed charges,"$1,923.85 ",77% of total billed charges,"$2,123.73 ",85% of total billed charges,$718.32 ,28.75% of total billed charges,"$1,249.25 ",50% of total billed charges,"$1,019.39 ",40.8% of total billed charges,$624.63 ,25% of total billed charges,$377.00 ,100% of CMS ASC tier groupins rate,$624.63 ,25% of total billed charges,$377.00 ,"$2,223.67 ","$1,249.25 "
Outpatient Medical Services,SURGICAL CARE,52000,cystourethroscopy,360,"$4,995.42 ","$3,846.47 ",77% of total billed charges,"$1,273.83 ",25.5% of total billed charges,"$1,273.83 ",25.5% of total billed charges,"$1,561.07 ",31.25% of total billed charges,"$1,205.00 ",pays based on per visit rate,"$1,168.00 ",pays based on per visit rate,"$1,168.00 ",pays based on per visit rate,"$1,248.86 ",25% of total billed charges,"$1,168.00 ",pays based on per visit rate,"$1,168.00 ",pays based on per visit rate,"$1,210.00 ",pays based on per visit rate,"$4,096.24 ",82% of total billed charges,"$4,445.92 ",89% of total billed charges,"$4,196.15 ",pays based on per visit rate,"$4,445.92 ",89% of total billed charges,"$2,038.13 ",40.8% of total billed charges,"$2,038.13 ",40.8% of total billed charges,"$2,038.13 ",40.8% of total billed charges,"$3,846.47 ",77% of total billed charges,"$4,246.11 ",85% of total billed charges,"$1,436.18 ",28.75% of total billed charges,"$2,497.71 ",50% of total billed charges,"$2,038.13 ",40.8% of total billed charges,"$1,248.86 ",25% of total billed charges,"$1,092.00 ",100% of CMS ASC tier groupins rate,"$1,248.86 ",25% of total billed charges,"$1,092.00 ","$4,445.92 ","$2,497.71 "
Outpatient Medical Services,SURGICAL CARE,53661,Dilation of female urethra including suppository and/or instillation.,360,$120.00 ,$92.40 ,77% of total billed charges,$30.60 ,25.5% of total billed charges,$30.60 ,25.5% of total billed charges,$37.50 ,31.25% of total billed charges,$70.80 ,pays based on per visit rate,$70.80 ,pays based on per visit rate,$70.80 ,pays based on per visit rate,$30.00 ,25% of total billed charges,$70.80 ,pays based on per visit rate,$70.80 ,pays based on per visit rate,$100.80 ,84% of total billed charges,$98.40 ,82% of total billed charges,$106.80 ,89% of total billed charges,$100.80 ,pays based on per visit rate,$106.80 ,89% of total billed charges,$48.96 ,40.8% of total billed charges,$48.96 ,40.8% of total billed charges,$48.96 ,40.8% of total billed charges,$92.40 ,77% of total billed charges,$102.00 ,85% of total billed charges,$34.50 ,28.75% of total billed charges,$60.00 ,50% of total billed charges,$48.96 ,40.8% of total billed charges,$30.00 ,25% of total billed charges,$377.00 ,100% of CMS ASC tier groupins rate,$30.00 ,25% of total billed charges,$30.00 ,$377.00 ,$60.00 
Outpatient Medical Services,SURGICAL CARE,55700,Biopsy of prostate gland,360,"$7,754.22 ","$5,970.75 ",77% of total billed charges,"$1,977.33 ",25.5% of total billed charges,"$1,977.33 ",25.5% of total billed charges,"$2,423.19 ",31.25% of total billed charges,"$1,495.00 ",pays based on per visit rate,"$1,334.00 ",pays based on per visit rate,"$1,334.00 ",pays based on per visit rate,"$1,938.56 ",25% of total billed charges,"$1,334.00 ",pays based on per visit rate,"$1,334.00 ",pays based on per visit rate,"$6,513.54 ",84% of total billed charges,"$6,358.46 ",82% of total billed charges,"$4,592.00 ",89% of total billed charges,"$4,458.00 ",pays based on per visit rate,"$4,592.00 ",89% of total billed charges,"$3,163.72 ",40.8% of total billed charges,"$3,163.72 ",40.8% of total billed charges,"$3,163.72 ",40.8% of total billed charges,"$5,970.75 ",77% of total billed charges,"$6,591.09 ",85% of total billed charges,"$2,229.34 ",28.75% of total billed charges,"$3,877.11 ",50% of total billed charges,"$3,163.72 ",40.8% of total billed charges,"$1,938.56 ",25% of total billed charges,"$2,034.00 ",100% of CMS ASC tier groupins rate,"$1,938.56 ",25% of total billed charges,"$1,334.00 ","$6,591.09 ","$3,877.11 "
Outpatient Medical Services,SURGICAL CARE,62322,Injection of substance into spinal canal of lower back or sacrum using imaging guidance,360,$188.00 ,$144.76 ,77% of total billed charges,$47.94 ,25.5% of total billed charges,$47.94 ,25.5% of total billed charges,$58.75 ,31.25% of total billed charges,$110.92 ,pays based on per visit rate,$110.92 ,pays based on per visit rate,$110.92 ,pays based on per visit rate,$47.00 ,25% of total billed charges,$110.92 ,pays based on per visit rate,$110.92 ,pays based on per visit rate,$157.92 ,84% of total billed charges,$154.16 ,82% of total billed charges,$167.32 ,89% of total billed charges,$157.92 ,pays based on per visit rate,$167.32 ,89% of total billed charges,$76.70 ,40.8% of total billed charges,$76.70 ,40.8% of total billed charges,$76.70 ,40.8% of total billed charges,$144.76 ,77% of total billed charges,$159.80 ,85% of total billed charges,$54.05 ,28.75% of total billed charges,$94.00 ,50% of total billed charges,$76.70 ,40.8% of total billed charges,$47.00 ,25% of total billed charges,"$1,092.00 ",100% of CMS ASC tier groupins rate,$47.00 ,25% of total billed charges,$47.00 ,"$1,092.00 ",$94.00 
Outpatient Medical Services,SURGICAL CARE,62323,"INJ, DX OR THERAP SUB LMBR/SAC W/IMG",360,"$1,359.85 ","$1,047.08 ",77% of total billed charges,$346.76 ,25.5% of total billed charges,$346.76 ,25.5% of total billed charges,$424.95 ,31.25% of total billed charges,$802.31 ,pays based on per visit rate,$802.31 ,pays based on per visit rate,$802.31 ,pays based on per visit rate,$339.96 ,25% of total billed charges,$802.31 ,pays based on per visit rate,$802.31 ,pays based on per visit rate,"$1,142.27 ",84% of total billed charges,"$1,115.08 ",82% of total billed charges,"$1,210.27 ",89% of total billed charges,"$1,142.27 ",pays based on per visit rate,"$1,210.27 ",89% of total billed charges,$554.82 ,40.8% of total billed charges,$554.82 ,40.8% of total billed charges,$554.82 ,40.8% of total billed charges,"$1,047.08 ",77% of total billed charges,"$1,155.87 ",85% of total billed charges,$390.96 ,28.75% of total billed charges,$679.93 ,50% of total billed charges,$554.82 ,40.8% of total billed charges,$339.96 ,25% of total billed charges,"$1,092.00 ",100% of CMS ASC tier groupins rate,$339.96 ,25% of total billed charges,$339.96 ,"$1,210.27 ",$679.93 
Outpatient Medical Services,SURGICAL CARE,64483,Injections of anesthetic and/or steroid drug into lower or sacral spine nerve root using imaging guidance,360,"$1,292.49 ",$995.22 ,77% of total billed charges,$329.58 ,25.5% of total billed charges,$329.58 ,25.5% of total billed charges,$403.90 ,31.25% of total billed charges,$762.57 ,pays based on per visit rate,$762.57 ,pays based on per visit rate,$762.57 ,pays based on per visit rate,$323.12 ,25% of total billed charges,$762.57 ,pays based on per visit rate,$762.57 ,pays based on per visit rate,"$1,085.69 ",84% of total billed charges,"$1,059.84 ",82% of total billed charges,"$1,150.32 ",89% of total billed charges,"$1,085.69 ",pays based on per visit rate,"$1,150.32 ",89% of total billed charges,$527.34 ,40.8% of total billed charges,$527.34 ,40.8% of total billed charges,$527.34 ,40.8% of total billed charges,$995.22 ,77% of total billed charges,"$1,098.62 ",85% of total billed charges,$371.59 ,28.75% of total billed charges,$646.25 ,50% of total billed charges,$527.34 ,40.8% of total billed charges,$323.12 ,25% of total billed charges,"$1,092.00 ",100% of CMS ASC tier groupins rate,$323.12 ,25% of total billed charges,$323.12 ,"$1,150.32 ",$646.25 
Outpatient Medical Services,SURGICAL CARE,66821,Removal of recurring cataract in lens capsule using laser,490,"$1,513.16 ","$1,165.13 ",77% of total billed charges,$385.86 ,25.5% of total billed charges,$385.86 ,25.5% of total billed charges,$472.86 ,31.25% of total billed charges,$892.76 ,pays based on per visit rate,$892.76 ,pays based on per visit rate,$892.76 ,pays based on per visit rate,$378.29 ,25% of total billed charges,$892.76 ,pays based on per visit rate,$892.76 ,pays based on per visit rate,"$1,271.05 ",84% of total billed charges,"$1,240.79 ",82% of total billed charges,"$1,346.71 ",89% of total billed charges,"$1,271.05 ",pays based on per visit rate,"$1,346.71 ",89% of total billed charges,$617.37 ,40.8% of total billed charges,$617.37 ,40.8% of total billed charges,$617.37 ,40.8% of total billed charges,"$1,165.13 ",77% of total billed charges,"$1,286.19 ",85% of total billed charges,$435.03 ,28.75% of total billed charges,$756.58 ,50% of total billed charges,$617.37 ,40.8% of total billed charges,$378.29 ,25% of total billed charges,"$1,092.00 ",100% of CMS ASC tier groupins rate,$378.29 ,25% of total billed charges,$378.29 ,"$1,346.71 ",$756.58 
Outpatient Medical Services,SURGICAL CARE,66984,Removal of cataract with insertion of lens,360,"$12,912.23 ","$9,942.42 ",77% of total billed charges,"$3,292.62 ",25.5% of total billed charges,"$3,292.62 ",25.5% of total billed charges,"$4,035.07 ",31.25% of total billed charges,"$2,212.00 ",pays based on per visit rate,"$2,102.00 ",pays based on per visit rate,"$2,102.00 ",pays based on per visit rate,"$3,228.06 ",25% of total billed charges,"$2,102.00 ",pays based on per visit rate,"$2,102.00 ",pays based on per visit rate,"$2,173.00 ",pays based on per visit rate,"$10,588.03 ",82% of total billed charges,"$4,592.00 ",89% of total billed charges,"$4,458.00 ",pays based on per visit rate,"$4,592.00 ",89% of total billed charges,"$5,268.19 ",40.8% of total billed charges,"$5,268.19 ",40.8% of total billed charges,"$5,268.19 ",40.8% of total billed charges,"$9,942.42 ",77% of total billed charges,"$10,975.40 ",85% of total billed charges,"$3,712.27 ",28.75% of total billed charges,"$6,456.12 ",50% of total billed charges,"$5,268.19 ",40.8% of total billed charges,"$3,228.06 ",25% of total billed charges,"$2,291.00 ",100% of CMS ASC tier groupins rate,"$3,228.06 ",25% of total billed charges,"$2,102.00 ","$10,975.40 ","$6,456.12 "
Outpatient Medical Services,DIAGNOSTIC IMAGING,70450,"CT scan, head or brain, without contrast",351,"$2,209.50 ","$1,701.32 ",77% of total billed charges,$563.42 ,25.5% of total billed charges,$563.42 ,25.5% of total billed charges,$690.47 ,31.25% of total billed charges,"$2,116.52 ",350% of BCBS fee schedule,"$1,524.56 ",69% of total billed charges,"$1,524.56 ",69% of total billed charges,$552.38 ,25% of total billed charges,"$1,524.56 ",69% of total billed charges,"$1,524.56 ",69% of total billed charges,$631.81 ,100% of BCBS fee schedule,"$1,811.79 ",82% of total billed charges,$741.12 ,400% of HEALTHLINK fee schedule,$694.80 ,375% of HEALTHLINK fee schedule,$741.12 ,400% of HEALTHLINK fee schedule,$159.72 ,120% of MO fee schedule,$159.72 ,120% of MO fee schedule,$159.72 ,120% of MO fee schedule,"$1,701.32 ",77% of total billed charges,"$1,878.08 ",85% of total billed charges,$635.23 ,28.75% of total billed charges,"$2,209.50 ",100% of UHC fee schedule,$159.72 ,120% of MO fee schedule,$552.38 ,25% of total billed charges,$770.00 ,pays based on per visit rate,$552.38 ,25% of total billed charges,$159.72 ,"$2,209.50 ","$1,104.75 "
Outpatient Medical Services,DIAGNOSTIC IMAGING,70551,Brain MRI,611,"$2,787.00 ","$2,145.99 ",77% of total billed charges,$710.69 ,25.5% of total billed charges,$710.69 ,25.5% of total billed charges,$870.94 ,31.25% of total billed charges,"$3,385.18 ",295% of BCBS fee schedule,"$3,159.62 ",285% of BCBS fee schedule,"$3,159.62 ",285% of BCBS fee schedule,$696.75 ,25% of total billed charges,"$3,159.62 ",285% of BCBS fee schedule,"$3,159.62 ",285% of BCBS fee schedule,"$1,176.78 ",100% of BCBS fee schedule,"$2,285.34 ",82% of total billed charges,"$1,999.80 ",400% of HEALTHLINK fee schedule,"$1,874.81 ",375% of HEALTHLINK fee schedule,"$1,999.80 ",400% of HEALTHLINK fee schedule,$294.14 ,120% of MO fee schedule,$294.14 ,120% of MO fee schedule,$294.14 ,120% of MO fee schedule,"$2,145.99 ",77% of total billed charges,"$2,368.95 ",85% of total billed charges,$801.26 ,28.75% of total billed charges,"$2,787.00 ",100% of UHC fee schedule,$294.14 ,120% of MO fee schedule,$696.75 ,25% of total billed charges,"$1,280.00 ",pays based on per visit rate,$696.75 ,25% of total billed charges,$294.14 ,"$3,385.18 ","$1,393.50 "
Outpatient Medical Services,DIAGNOSTIC IMAGING,70553,MRI scan of brain before and after contrast,611,"$3,968.00 ","$3,055.36 ",77% of total billed charges,"$1,011.84 ",25.5% of total billed charges,"$1,011.84 ",25.5% of total billed charges,"$1,240.00 ",31.25% of total billed charges,"$5,265.34 ",295% of BCBS fee schedule,"$4,914.40 ",285% of BCBS fee schedule,"$4,914.40 ",285% of BCBS fee schedule,$992.00 ,25% of total billed charges,"$4,914.40 ",285% of BCBS fee schedule,"$4,914.40 ",285% of BCBS fee schedule,"$1,830.37 ",100% of BCBS fee schedule,"$3,253.76 ",82% of total billed charges,"$2,659.84 ",400% of HEALTHLINK fee schedule,"$2,493.60 ",375% of HEALTHLINK fee schedule,"$2,659.84 ",400% of HEALTHLINK fee schedule,$575.05 ,120% of MO fee schedule,$575.05 ,120% of MO fee schedule,$575.05 ,120% of MO fee schedule,"$3,055.36 ",77% of total billed charges,"$3,372.80 ",85% of total billed charges,"$1,140.80 ",28.75% of total billed charges,"$3,968.00 ",100% of UHC fee schedule,$575.05 ,120% of MO fee schedule,$992.00 ,25% of total billed charges,"$1,280.00 ",pays based on per visit rate,$992.00 ,25% of total billed charges,$575.05 ,"$5,265.34 ","$1,984.00 "
Outpatient Medical Services,DIAGNOSTIC IMAGING,71045,Diagnostic Radiology (Diagnostic Imaging) Procedures of the Chest,324,$392.00 ,$301.84 ,77% of total billed charges,$99.96 ,25.5% of total billed charges,$99.96 ,25.5% of total billed charges,$122.50 ,31.25% of total billed charges,$290.08 ,74% of total billed charges,$270.48 ,69% of total billed charges,$270.48 ,69% of total billed charges,$98.00 ,25% of total billed charges,$270.48 ,69% of total billed charges,$270.48 ,69% of total billed charges,$50.50 ,100% of BCBS fee schedule,$321.44 ,82% of total billed charges,$348.88 ,89% of total billed charges,$348.88 ,89% of total billed charges,$348.88 ,89% of total billed charges,$15.48 ,120% of MO fee schedule,$15.48 ,120% of MO fee schedule,$15.48 ,120% of MO fee schedule,$301.84 ,77% of total billed charges,$333.20 ,85% of total billed charges,$112.70 ,28.75% of total billed charges,$392.00 ,100% of UHC fee schedule,$15.48 ,120% of MO fee schedule,$98.00 ,25% of total billed charges,$235.00 ,pays based on per visit rate,$98.00 ,25% of total billed charges,$15.48 ,$392.00 ,$196.00 
Outpatient Medical Services,DIAGNOSTIC IMAGING,71046,Chest XRAY,324,$406.50 ,$313.01 ,77% of total billed charges,$103.66 ,25.5% of total billed charges,$103.66 ,25.5% of total billed charges,$127.03 ,31.25% of total billed charges,$300.81 ,74% of total billed charges,$280.49 ,69% of total billed charges,$280.49 ,69% of total billed charges,$101.63 ,25% of total billed charges,$280.49 ,69% of total billed charges,$280.49 ,69% of total billed charges,$68.83 ,100% of BCBS fee schedule,$333.33 ,82% of total billed charges,$361.79 ,89% of total billed charges,$361.79 ,89% of total billed charges,$361.79 ,89% of total billed charges,$20.95 ,120% of MO fee schedule,$20.95 ,120% of MO fee schedule,$20.95 ,120% of MO fee schedule,$313.01 ,77% of total billed charges,$345.53 ,85% of total billed charges,$116.87 ,28.75% of total billed charges,$406.50 ,100% of UHC fee schedule,$20.95 ,120% of MO fee schedule,$101.63 ,25% of total billed charges,$235.00 ,pays based on per visit rate,$101.63 ,25% of total billed charges,$20.95 ,$406.50 ,$203.25 
Outpatient Medical Services,DIAGNOSTIC IMAGING,71101,"Radiologic examination, ribs, unilateral",320,$426.50 ,$328.41 ,77% of total billed charges,$108.76 ,25.5% of total billed charges,$108.76 ,25.5% of total billed charges,$133.28 ,31.25% of total billed charges,$315.61 ,74% of total billed charges,$294.29 ,69% of total billed charges,$294.29 ,69% of total billed charges,$106.63 ,25% of total billed charges,$294.29 ,69% of total billed charges,$294.29 ,69% of total billed charges,$89.46 ,100% of BCBS fee schedule,$349.73 ,82% of total billed charges,$136.16 ,400% of HEALTHLINK fee schedule,$127.65 ,375% of HEALTHLINK fee schedule,$136.16 ,400% of HEALTHLINK fee schedule,$26.76 ,120% of MO fee schedule,$26.76 ,120% of MO fee schedule,$26.76 ,120% of MO fee schedule,$328.41 ,77% of total billed charges,$362.53 ,85% of total billed charges,$122.62 ,28.75% of total billed charges,$426.50 ,100% of UHC fee schedule,$26.76 ,120% of MO fee schedule,$106.63 ,25% of total billed charges,$235.00 ,pays based on per visit rate,$106.63 ,25% of total billed charges,$26.76 ,$426.50 ,$213.25 
Outpatient Medical Services,DIAGNOSTIC IMAGING,71250,"CT, thorax; without contrast material",352,"$2,209.00 ","$1,700.93 ",77% of total billed charges,$563.30 ,25.5% of total billed charges,$563.30 ,25.5% of total billed charges,$690.31 ,31.25% of total billed charges,"$2,644.50 ",350% of BCBS fee schedule,"$1,524.21 ",69% of total billed charges,"$1,524.21 ",69% of total billed charges,$552.25 ,25% of total billed charges,"$1,524.21 ",69% of total billed charges,"$1,524.21 ",69% of total billed charges,$789.40 ,100% of BCBS fee schedule,"$1,811.38 ",82% of total billed charges,$977.16 ,400% of HEALTHLINK fee schedule,$916.09 ,375% of HEALTHLINK fee schedule,$977.16 ,400% of HEALTHLINK fee schedule,$179.52 ,120% of MO fee schedule,$179.52 ,120% of MO fee schedule,$179.52 ,120% of MO fee schedule,"$1,700.93 ",77% of total billed charges,"$1,877.65 ",85% of total billed charges,$635.09 ,28.75% of total billed charges,"$2,209.00 ",100% of UHC fee schedule,$179.52 ,120% of MO fee schedule,$552.25 ,25% of total billed charges,$770.00 ,pays based on per visit rate,$552.25 ,25% of total billed charges,$179.52 ,"$2,644.50 ","$1,104.50 "
Outpatient Medical Services,DIAGNOSTIC IMAGING,71260,CT Chest with contrast material,352,$400.50 ,$308.39 ,77% of total billed charges,$102.13 ,25.5% of total billed charges,$102.13 ,25.5% of total billed charges,$125.16 ,31.25% of total billed charges,"$3,408.44 ",350% of BCBS fee schedule,$276.35 ,69% of total billed charges,$276.35 ,69% of total billed charges,$100.13 ,25% of total billed charges,$276.35 ,69% of total billed charges,$276.35 ,69% of total billed charges,"$1,017.45 ",100% of BCBS fee schedule,$328.41 ,82% of total billed charges,"$1,177.36 ",400% of HEALTHLINK fee schedule,"$1,103.78 ",375% of HEALTHLINK fee schedule,"$1,177.36 ",400% of HEALTHLINK fee schedule,$258.72 ,120% of MO fee schedule,$258.72 ,120% of MO fee schedule,$258.72 ,120% of MO fee schedule,$308.39 ,77% of total billed charges,$340.43 ,85% of total billed charges,$115.14 ,28.75% of total billed charges,$400.50 ,100% of UHC fee schedule,$258.72 ,120% of MO fee schedule,$100.13 ,25% of total billed charges,$770.00 ,pays based on per visit rate,$100.13 ,25% of total billed charges,$100.13 ,"$3,408.44 ",$200.25 
Outpatient Medical Services,DIAGNOSTIC IMAGING,71271,"Computed tomography, thorax, low dose for lung cancer screening, without contrast",352,"$2,145.00 ","$1,651.65 ",77% of total billed charges,$546.98 ,25.5% of total billed charges,$546.98 ,25.5% of total billed charges,$670.31 ,31.25% of total billed charges,"$1,026.27 ",350% of BCBS fee schedule,"$1,480.05 ",69% of total billed charges,"$1,480.05 ",69% of total billed charges,$536.25 ,25% of total billed charges,"$1,480.05 ",69% of total billed charges,"$1,480.05 ",69% of total billed charges,$306.36 ,100% of BCBS fee schedule,"$1,758.90 ",82% of total billed charges,"$1,909.05 ",89% of total billed charges,"$1,909.05 ",89% of total billed charges,"$1,909.05 ",89% of total billed charges,$136.48 ,120% of MO fee schedule,$136.48 ,120% of MO fee schedule,$136.48 ,120% of MO fee schedule,"$1,651.65 ",77% of total billed charges,"$1,823.25 ",85% of total billed charges,$616.69 ,28.75% of total billed charges,"$2,145.00 ",100% of UHC fee schedule,$136.48 ,120% of MO fee schedule,$536.25 ,25% of total billed charges,$770.00 ,pays based on per visit rate,$536.25 ,25% of total billed charges,$136.48 ,"$2,145.00 ","$1,072.50 "
Outpatient Medical Services,DIAGNOSTIC IMAGING,71275,CTA of noncoronary chest vessels such as the aorta and pulmonary arteries.,352,"$2,936.00 ","$2,260.72 ",77% of total billed charges,$748.68 ,25.5% of total billed charges,$748.68 ,25.5% of total billed charges,$917.50 ,31.25% of total billed charges,"$4,612.34 ",350% of BCBS fee schedule,"$2,025.84 ",69% of total billed charges,"$2,025.84 ",69% of total billed charges,$734.00 ,25% of total billed charges,"$2,025.84 ",69% of total billed charges,"$2,025.84 ",69% of total billed charges,"$1,376.83 ",100% of BCBS fee schedule,"$2,407.52 ",82% of total billed charges,"$1,721.12 ",400% of HEALTHLINK fee schedule,"$1,613.55 ",375% of HEALTHLINK fee schedule,"$1,721.12 ",400% of HEALTHLINK fee schedule,$298.48 ,120% of MO fee schedule,$298.48 ,120% of MO fee schedule,$298.48 ,120% of MO fee schedule,"$2,260.72 ",77% of total billed charges,"$2,495.60 ",85% of total billed charges,$844.10 ,28.75% of total billed charges,"$2,936.00 ",100% of UHC fee schedule,$298.48 ,120% of MO fee schedule,$734.00 ,25% of total billed charges,$770.00 ,pays based on per visit rate,$734.00 ,25% of total billed charges,$298.48 ,"$4,612.34 ","$1,468.00 "
Outpatient Medical Services,DIAGNOSTIC IMAGING,72040,"Radiologic examination, spine, cervical; two or three views",320,$464.50 ,$357.67 ,77% of total billed charges,$118.45 ,25.5% of total billed charges,$118.45 ,25.5% of total billed charges,$145.16 ,31.25% of total billed charges,$343.73 ,74% of total billed charges,$320.51 ,69% of total billed charges,$320.51 ,69% of total billed charges,$116.13 ,25% of total billed charges,$320.51 ,69% of total billed charges,$320.51 ,69% of total billed charges,$92.89 ,100% of BCBS fee schedule,$380.89 ,82% of total billed charges,$128.92 ,400% of HEALTHLINK fee schedule,$120.86 ,375% of HEALTHLINK fee schedule,$128.92 ,400% of HEALTHLINK fee schedule,$26.12 ,120% of MO fee schedule,$26.12 ,120% of MO fee schedule,$26.12 ,120% of MO fee schedule,$357.67 ,77% of total billed charges,$394.83 ,85% of total billed charges,$133.54 ,28.75% of total billed charges,$464.50 ,100% of UHC fee schedule,$26.12 ,120% of MO fee schedule,$116.13 ,25% of total billed charges,$235.00 ,pays based on per visit rate,$116.13 ,25% of total billed charges,$26.12 ,$464.50 ,$232.25 
Outpatient Medical Services,DIAGNOSTIC IMAGING,72050,"Radiologic examination, spine, cervical; minimum of four views",320,$680.50 ,$523.99 ,77% of total billed charges,$173.53 ,25.5% of total billed charges,$173.53 ,25.5% of total billed charges,$212.66 ,31.25% of total billed charges,$503.57 ,74% of total billed charges,$469.55 ,69% of total billed charges,$469.55 ,69% of total billed charges,$170.13 ,25% of total billed charges,$469.55 ,69% of total billed charges,$469.55 ,69% of total billed charges,$126.10 ,100% of BCBS fee schedule,$558.01 ,82% of total billed charges,$181.52 ,400% of HEALTHLINK fee schedule,$170.18 ,375% of HEALTHLINK fee schedule,$181.52 ,400% of HEALTHLINK fee schedule,$36.46 ,120% of MO fee schedule,$36.46 ,120% of MO fee schedule,$36.46 ,120% of MO fee schedule,$523.99 ,77% of total billed charges,$578.43 ,85% of total billed charges,$195.64 ,28.75% of total billed charges,$680.50 ,100% of UHC fee schedule,$36.46 ,120% of MO fee schedule,$170.13 ,25% of total billed charges,$235.00 ,pays based on per visit rate,$170.13 ,25% of total billed charges,$36.46 ,$680.50 ,$340.25 
Outpatient Medical Services,DIAGNOSTIC IMAGING,72100,"Radiologic examination, spine, lumbosacral",320,$495.00 ,$381.15 ,77% of total billed charges,$126.23 ,25.5% of total billed charges,$126.23 ,25.5% of total billed charges,$154.69 ,31.25% of total billed charges,$366.30 ,74% of total billed charges,$341.55 ,69% of total billed charges,$341.55 ,69% of total billed charges,$123.75 ,25% of total billed charges,$341.55 ,69% of total billed charges,$341.55 ,69% of total billed charges,$98.61 ,100% of BCBS fee schedule,$405.90 ,82% of total billed charges,$133.68 ,400% of HEALTHLINK fee schedule,$125.33 ,375% of HEALTHLINK fee schedule,$133.68 ,400% of HEALTHLINK fee schedule,$26.41 ,120% of MO fee schedule,$26.41 ,120% of MO fee schedule,$26.41 ,120% of MO fee schedule,$381.15 ,77% of total billed charges,$420.75 ,85% of total billed charges,$142.31 ,28.75% of total billed charges,$495.00 ,100% of UHC fee schedule,$26.41 ,120% of MO fee schedule,$123.75 ,25% of total billed charges,$235.00 ,pays based on per visit rate,$123.75 ,25% of total billed charges,$26.41 ,$495.00 ,$247.50 
Outpatient Medical Services,DIAGNOSTIC IMAGING,72110,"X-Ray, lower back, minimum four views",320,$600.50 ,$462.39 ,77% of total billed charges,$153.13 ,25.5% of total billed charges,$153.13 ,25.5% of total billed charges,$187.66 ,31.25% of total billed charges,$444.37 ,74% of total billed charges,$414.35 ,69% of total billed charges,$414.35 ,69% of total billed charges,$150.13 ,25% of total billed charges,$414.35 ,69% of total billed charges,$414.35 ,69% of total billed charges,$135.27 ,100% of BCBS fee schedule,$492.41 ,82% of total billed charges,$189.80 ,400% of HEALTHLINK fee schedule,$177.94 ,375% of HEALTHLINK fee schedule,$189.80 ,400% of HEALTHLINK fee schedule,$35.23 ,120% of MO fee schedule,$35.23 ,120% of MO fee schedule,$35.23 ,120% of MO fee schedule,$462.39 ,77% of total billed charges,$510.43 ,85% of total billed charges,$172.64 ,28.75% of total billed charges,$600.50 ,100% of UHC fee schedule,$35.23 ,120% of MO fee schedule,$150.13 ,25% of total billed charges,$235.00 ,pays based on per visit rate,$150.13 ,25% of total billed charges,$35.23 ,$600.50 ,$300.25 
Outpatient Medical Services,DIAGNOSTIC IMAGING,72131,CT Lumbar Spine,352,"$2,216.00 ","$1,706.32 ",77% of total billed charges,$565.08 ,25.5% of total billed charges,$565.08 ,25.5% of total billed charges,$692.50 ,31.25% of total billed charges,"$2,644.50 ",350% of BCBS fee schedule,"$1,529.04 ",69% of total billed charges,"$1,529.04 ",69% of total billed charges,$554.00 ,25% of total billed charges,"$1,529.04 ",69% of total billed charges,"$1,529.04 ",69% of total billed charges,$789.40 ,100% of BCBS fee schedule,"$1,817.12 ",82% of total billed charges,$973.60 ,400% of HEALTHLINK fee schedule,$912.75 ,375% of HEALTHLINK fee schedule,$973.60 ,400% of HEALTHLINK fee schedule,$180.88 ,120% of MO fee schedule,$180.88 ,120% of MO fee schedule,$180.88 ,120% of MO fee schedule,"$1,706.32 ",77% of total billed charges,"$1,883.60 ",85% of total billed charges,$637.10 ,28.75% of total billed charges,"$2,216.00 ",100% of UHC fee schedule,$180.88 ,120% of MO fee schedule,$554.00 ,25% of total billed charges,$770.00 ,pays based on per visit rate,$554.00 ,25% of total billed charges,$180.88 ,"$2,644.50 ","$1,108.00 "
Outpatient Medical Services,DIAGNOSTIC IMAGING,72141,MRI cervical spine,612,"$3,016.50 ","$2,322.71 ",77% of total billed charges,$769.21 ,25.5% of total billed charges,$769.21 ,25.5% of total billed charges,$942.66 ,31.25% of total billed charges,"$3,381.88 ",295% of BCBS fee schedule,"$3,156.52 ",285% of BCBS fee schedule,"$3,156.52 ",285% of BCBS fee schedule,$754.13 ,25% of total billed charges,"$3,156.52 ",285% of BCBS fee schedule,"$3,156.52 ",285% of BCBS fee schedule,"$1,175.63 ",100% of BCBS fee schedule,"$2,473.53 ",82% of total billed charges,"$1,784.96 ",400% of HEALTHLINK fee schedule,"$1,673.40 ",375% of HEALTHLINK fee schedule,"$1,784.96 ",400% of HEALTHLINK fee schedule,$282.67 ,120% of MO fee schedule,$282.67 ,120% of MO fee schedule,$282.67 ,120% of MO fee schedule,"$2,322.71 ",77% of total billed charges,"$2,564.03 ",85% of total billed charges,$867.24 ,28.75% of total billed charges,"$3,016.50 ",100% of UHC fee schedule,$282.67 ,120% of MO fee schedule,$754.13 ,25% of total billed charges,"$1,280.00 ",pays based on per visit rate,$754.13 ,25% of total billed charges,$282.67 ,"$3,381.88 ","$1,508.25 "
Outpatient Medical Services,DIAGNOSTIC IMAGING,72148,MRI scan of lower spinal canal,612,"$3,063.50 ","$2,358.90 ",77% of total billed charges,$781.19 ,25.5% of total billed charges,$781.19 ,25.5% of total billed charges,$957.34 ,31.25% of total billed charges,"$3,381.88 ",295% of BCBS fee schedule,"$3,156.52 ",285% of BCBS fee schedule,"$3,156.52 ",285% of BCBS fee schedule,$765.88 ,25% of total billed charges,"$3,156.52 ",285% of BCBS fee schedule,"$3,156.52 ",285% of BCBS fee schedule,"$1,175.63 ",100% of BCBS fee schedule,"$2,512.07 ",82% of total billed charges,"$1,768.92 ",400% of HEALTHLINK fee schedule,"$1,658.36 ",375% of HEALTHLINK fee schedule,"$1,768.92 ",400% of HEALTHLINK fee schedule,$306.07 ,120% of MO fee schedule,$306.07 ,120% of MO fee schedule,$306.07 ,120% of MO fee schedule,"$2,358.90 ",77% of total billed charges,"$2,603.98 ",85% of total billed charges,$880.76 ,28.75% of total billed charges,"$3,063.50 ",100% of UHC fee schedule,$306.07 ,120% of MO fee schedule,$765.88 ,25% of total billed charges,"$1,280.00 ",pays based on per visit rate,$765.88 ,25% of total billed charges,$306.07 ,"$3,381.88 ","$1,531.75 "
Outpatient Medical Services,DIAGNOSTIC IMAGING,72193,"CT scan, pelvis, with contrast",350,"$2,552.50 ","$1,965.43 ",77% of total billed charges,$650.89 ,25.5% of total billed charges,$650.89 ,25.5% of total billed charges,$797.66 ,31.25% of total billed charges,"$3,237.08 ",350% of BCBS fee schedule,"$1,761.23 ",69% of total billed charges,"$1,761.23 ",69% of total billed charges,$638.13 ,25% of total billed charges,"$1,761.23 ",69% of total billed charges,"$1,761.23 ",69% of total billed charges,$966.32 ,100% of BCBS fee schedule,"$2,093.05 ",82% of total billed charges,"$1,112.24 ",400% of HEALTHLINK fee schedule,"$1,042.73 ",375% of HEALTHLINK fee schedule,"$1,112.24 ",400% of HEALTHLINK fee schedule,$268.92 ,120% of MO fee schedule,$268.92 ,120% of MO fee schedule,$268.92 ,120% of MO fee schedule,"$1,965.43 ",77% of total billed charges,"$2,169.63 ",85% of total billed charges,$733.84 ,28.75% of total billed charges,"$2,552.50 ",100% of UHC fee schedule,$268.92 ,120% of MO fee schedule,$638.13 ,25% of total billed charges,$770.00 ,pays based on per visit rate,$638.13 ,25% of total billed charges,$268.92 ,"$3,237.08 ","$1,276.25 "
Outpatient Medical Services,DIAGNOSTIC IMAGING,73030,"Radiologic examination, shoulder",320,$333.50 ,$256.80 ,77% of total billed charges,$85.04 ,25.5% of total billed charges,$85.04 ,25.5% of total billed charges,$104.22 ,31.25% of total billed charges,$246.79 ,74% of total billed charges,$230.12 ,69% of total billed charges,$230.12 ,69% of total billed charges,$83.38 ,25% of total billed charges,$230.12 ,69% of total billed charges,$230.12 ,69% of total billed charges,$71.10 ,100% of BCBS fee schedule,$273.47 ,82% of total billed charges,$100.64 ,400% of HEALTHLINK fee schedule,$94.35 ,375% of HEALTHLINK fee schedule,$100.64 ,400% of HEALTHLINK fee schedule,$23.08 ,120% of MO fee schedule,$23.08 ,120% of MO fee schedule,$23.08 ,120% of MO fee schedule,$256.80 ,77% of total billed charges,$283.48 ,85% of total billed charges,$95.88 ,28.75% of total billed charges,$333.50 ,100% of UHC fee schedule,$23.08 ,120% of MO fee schedule,$83.38 ,25% of total billed charges,$235.00 ,pays based on per visit rate,$83.38 ,25% of total billed charges,$23.08 ,$333.50 ,$166.75 
Outpatient Medical Services,DIAGNOSTIC IMAGING,73080,"Radiologic examination, elbow",320,$308.50 ,$237.55 ,77% of total billed charges,$78.67 ,25.5% of total billed charges,$78.67 ,25.5% of total billed charges,$96.41 ,31.25% of total billed charges,$228.29 ,74% of total billed charges,$212.87 ,69% of total billed charges,$212.87 ,69% of total billed charges,$77.13 ,25% of total billed charges,$212.87 ,69% of total billed charges,$212.87 ,69% of total billed charges,$87.18 ,100% of BCBS fee schedule,$252.97 ,82% of total billed charges,$120.52 ,400% of HEALTHLINK fee schedule,$112.99 ,375% of HEALTHLINK fee schedule,$120.52 ,400% of HEALTHLINK fee schedule,$21.86 ,120% of MO fee schedule,$21.86 ,120% of MO fee schedule,$21.86 ,120% of MO fee schedule,$237.55 ,77% of total billed charges,$262.23 ,85% of total billed charges,$88.69 ,28.75% of total billed charges,$308.50 ,100% of UHC fee schedule,$21.86 ,120% of MO fee schedule,$77.13 ,25% of total billed charges,$235.00 ,pays based on per visit rate,$77.13 ,25% of total billed charges,$21.86 ,$308.50 ,$154.25 
Outpatient Medical Services,DIAGNOSTIC IMAGING,73110,"Radiologic examination, wrist",320,$341.50 ,$262.96 ,77% of total billed charges,$87.08 ,25.5% of total billed charges,$87.08 ,25.5% of total billed charges,$106.72 ,31.25% of total billed charges,$252.71 ,74% of total billed charges,$235.64 ,69% of total billed charges,$235.64 ,69% of total billed charges,$85.38 ,25% of total billed charges,$235.64 ,69% of total billed charges,$235.64 ,69% of total billed charges,$94.03 ,100% of BCBS fee schedule,$280.03 ,82% of total billed charges,$118.84 ,400% of HEALTHLINK fee schedule,$111.41 ,375% of HEALTHLINK fee schedule,$118.84 ,400% of HEALTHLINK fee schedule,$29.46 ,120% of MO fee schedule,$29.46 ,120% of MO fee schedule,$29.46 ,120% of MO fee schedule,$262.96 ,77% of total billed charges,$290.28 ,85% of total billed charges,$98.18 ,28.75% of total billed charges,$341.50 ,100% of UHC fee schedule,$29.46 ,120% of MO fee schedule,$85.38 ,25% of total billed charges,$235.00 ,pays based on per visit rate,$85.38 ,25% of total billed charges,$29.46 ,$341.50 ,$170.75 
Outpatient Medical Services,DIAGNOSTIC IMAGING,73130,Diagnostic Radiology (Diagnostic Imaging) Procedures of the Upper Extremities,320,$308.50 ,$237.55 ,77% of total billed charges,$78.67 ,25.5% of total billed charges,$78.67 ,25.5% of total billed charges,$96.41 ,31.25% of total billed charges,$228.29 ,74% of total billed charges,$212.87 ,69% of total billed charges,$212.87 ,69% of total billed charges,$77.13 ,25% of total billed charges,$212.87 ,69% of total billed charges,$212.87 ,69% of total billed charges,$80.30 ,100% of BCBS fee schedule,$252.97 ,82% of total billed charges,$105.80 ,400% of HEALTHLINK fee schedule,$99.19 ,375% of HEALTHLINK fee schedule,$105.80 ,400% of HEALTHLINK fee schedule,$25.51 ,120% of MO fee schedule,$25.51 ,120% of MO fee schedule,$25.51 ,120% of MO fee schedule,$237.55 ,77% of total billed charges,$262.23 ,85% of total billed charges,$88.69 ,28.75% of total billed charges,$308.50 ,100% of UHC fee schedule,$25.51 ,120% of MO fee schedule,$77.13 ,25% of total billed charges,$235.00 ,pays based on per visit rate,$77.13 ,25% of total billed charges,$25.51 ,$308.50 ,$154.25 
Outpatient Medical Services,DIAGNOSTIC IMAGING,73221,"Magnetic resonance (eg, proton) imaging, any joint of upper extremity; without contrast material(s)",614,"$3,159.00 ","$2,432.43 ",77% of total billed charges,$805.55 ,25.5% of total billed charges,$805.55 ,25.5% of total billed charges,$987.19 ,31.25% of total billed charges,"$3,385.18 ",295% of BCBS fee schedule,"$3,159.62 ",285% of BCBS fee schedule,"$3,159.62 ",285% of BCBS fee schedule,$789.75 ,25% of total billed charges,"$3,159.62 ",285% of BCBS fee schedule,"$3,159.62 ",285% of BCBS fee schedule,"$1,176.78 ",100% of BCBS fee schedule,"$2,590.38 ",82% of total billed charges,"$1,843.04 ",400% of HEALTHLINK fee schedule,"$1,727.85 ",375% of HEALTHLINK fee schedule,"$1,843.04 ",400% of HEALTHLINK fee schedule,$285.22 ,120% of MO fee schedule,$285.22 ,120% of MO fee schedule,$285.22 ,120% of MO fee schedule,"$2,432.43 ",77% of total billed charges,"$2,685.15 ",85% of total billed charges,$908.21 ,28.75% of total billed charges,"$3,159.00 ",100% of UHC fee schedule,$285.22 ,120% of MO fee schedule,$789.75 ,25% of total billed charges,"$1,280.00 ",pays based on per visit rate,$789.75 ,25% of total billed charges,$285.22 ,"$3,385.18 ","$1,579.50 "
Outpatient Medical Services,DIAGNOSTIC IMAGING,73501,"Radiologic examination, hip, unilateral.",320,$385.50 ,$296.84 ,77% of total billed charges,$98.30 ,25.5% of total billed charges,$98.30 ,25.5% of total billed charges,$120.47 ,31.25% of total billed charges,$285.27 ,74% of total billed charges,$266.00 ,69% of total billed charges,$266.00 ,69% of total billed charges,$96.38 ,25% of total billed charges,$266.00 ,69% of total billed charges,$266.00 ,69% of total billed charges,$58.80 ,100% of BCBS fee schedule,$316.11 ,82% of total billed charges,$343.10 ,89% of total billed charges,$343.10 ,89% of total billed charges,$343.10 ,89% of total billed charges,$21.25 ,120% of MO fee schedule,$21.25 ,120% of MO fee schedule,$21.25 ,120% of MO fee schedule,$296.84 ,77% of total billed charges,$327.68 ,85% of total billed charges,$110.83 ,28.75% of total billed charges,$385.50 ,100% of UHC fee schedule,$21.25 ,120% of MO fee schedule,$96.38 ,25% of total billed charges,$235.00 ,pays based on per visit rate,$96.38 ,25% of total billed charges,$21.25 ,$385.50 ,$192.75 
Outpatient Medical Services,DIAGNOSTIC IMAGING,73502,"Radiologic examination, hip, unilateral.",320,$554.00 ,$426.58 ,77% of total billed charges,$141.27 ,25.5% of total billed charges,$141.27 ,25.5% of total billed charges,$173.13 ,31.25% of total billed charges,$409.96 ,74% of total billed charges,$382.26 ,69% of total billed charges,$382.26 ,69% of total billed charges,$138.50 ,25% of total billed charges,$382.26 ,69% of total billed charges,$382.26 ,69% of total billed charges,$86.62 ,100% of BCBS fee schedule,$454.28 ,82% of total billed charges,$493.06 ,89% of total billed charges,$493.06 ,89% of total billed charges,$493.06 ,89% of total billed charges,$32.81 ,120% of MO fee schedule,$32.81 ,120% of MO fee schedule,$32.81 ,120% of MO fee schedule,$426.58 ,77% of total billed charges,$470.90 ,85% of total billed charges,$159.28 ,28.75% of total billed charges,$554.00 ,100% of UHC fee schedule,$32.81 ,120% of MO fee schedule,$138.50 ,25% of total billed charges,$235.00 ,pays based on per visit rate,$138.50 ,25% of total billed charges,$32.81 ,$554.00 ,$277.00 
Outpatient Medical Services,DIAGNOSTIC IMAGING,73523,"Radiologic examination, hips, bilateral.",320,$535.00 ,$411.95 ,77% of total billed charges,$136.43 ,25.5% of total billed charges,$136.43 ,25.5% of total billed charges,$167.19 ,31.25% of total billed charges,$395.90 ,74% of total billed charges,$369.15 ,69% of total billed charges,$369.15 ,69% of total billed charges,$133.75 ,25% of total billed charges,$369.15 ,69% of total billed charges,$369.15 ,69% of total billed charges,$116.46 ,100% of BCBS fee schedule,$438.70 ,82% of total billed charges,$476.15 ,89% of total billed charges,$476.15 ,89% of total billed charges,$476.15 ,89% of total billed charges,$42.23 ,120% of MO fee schedule,$42.23 ,120% of MO fee schedule,$42.23 ,120% of MO fee schedule,$411.95 ,77% of total billed charges,$454.75 ,85% of total billed charges,$153.81 ,28.75% of total billed charges,$535.00 ,100% of UHC fee schedule,$42.23 ,120% of MO fee schedule,$133.75 ,25% of total billed charges,$235.00 ,pays based on per visit rate,$133.75 ,25% of total billed charges,$42.23 ,$535.00 ,$267.50 
Outpatient Medical Services,DIAGNOSTIC IMAGING,73564,complete radiological knee exam with four or more views,320,$414.00 ,$318.78 ,77% of total billed charges,$105.57 ,25.5% of total billed charges,$105.57 ,25.5% of total billed charges,$129.38 ,31.25% of total billed charges,$306.36 ,74% of total billed charges,$285.66 ,69% of total billed charges,$285.66 ,69% of total billed charges,$103.50 ,25% of total billed charges,$285.66 ,69% of total billed charges,$285.66 ,69% of total billed charges,$103.20 ,100% of BCBS fee schedule,$339.48 ,82% of total billed charges,$139.60 ,400% of HEALTHLINK fee schedule,$130.88 ,375% of HEALTHLINK fee schedule,$139.60 ,400% of HEALTHLINK fee schedule,$32.20 ,120% of MO fee schedule,$32.20 ,120% of MO fee schedule,$32.20 ,120% of MO fee schedule,$318.78 ,77% of total billed charges,$351.90 ,85% of total billed charges,$119.03 ,28.75% of total billed charges,$414.00 ,100% of UHC fee schedule,$32.20 ,120% of MO fee schedule,$103.50 ,25% of total billed charges,$235.00 ,pays based on per visit rate,$103.50 ,25% of total billed charges,$32.20 ,$414.00 ,$207.00 
Outpatient Medical Services,DIAGNOSTIC IMAGING,73590,Xray of lower leg,320,$302.00 ,$232.54 ,77% of total billed charges,$77.01 ,25.5% of total billed charges,$77.01 ,25.5% of total billed charges,$94.38 ,31.25% of total billed charges,$223.48 ,74% of total billed charges,$208.38 ,69% of total billed charges,$208.38 ,69% of total billed charges,$75.50 ,25% of total billed charges,$208.38 ,69% of total billed charges,$208.38 ,69% of total billed charges,$65.39 ,100% of BCBS fee schedule,$247.64 ,82% of total billed charges,$91.60 ,400% of HEALTHLINK fee schedule,$85.88 ,375% of HEALTHLINK fee schedule,$91.60 ,400% of HEALTHLINK fee schedule,$21.55 ,120% of MO fee schedule,$21.55 ,120% of MO fee schedule,$21.55 ,120% of MO fee schedule,$232.54 ,77% of total billed charges,$256.70 ,85% of total billed charges,$86.83 ,28.75% of total billed charges,$302.00 ,100% of UHC fee schedule,$21.55 ,120% of MO fee schedule,$75.50 ,25% of total billed charges,$235.00 ,pays based on per visit rate,$75.50 ,25% of total billed charges,$21.55 ,$302.00 ,$151.00 
Outpatient Medical Services,DIAGNOSTIC IMAGING,73610,"Radiologic examination, ankle",320,$308.50 ,$237.55 ,77% of total billed charges,$78.67 ,25.5% of total billed charges,$78.67 ,25.5% of total billed charges,$96.41 ,31.25% of total billed charges,$228.29 ,74% of total billed charges,$212.87 ,69% of total billed charges,$212.87 ,69% of total billed charges,$77.13 ,25% of total billed charges,$212.87 ,69% of total billed charges,$212.87 ,69% of total billed charges,$81.43 ,100% of BCBS fee schedule,$252.97 ,82% of total billed charges,$107.00 ,400% of HEALTHLINK fee schedule,$100.31 ,375% of HEALTHLINK fee schedule,$107.00 ,400% of HEALTHLINK fee schedule,$25.81 ,120% of MO fee schedule,$25.81 ,120% of MO fee schedule,$25.81 ,120% of MO fee schedule,$237.55 ,77% of total billed charges,$262.23 ,85% of total billed charges,$88.69 ,28.75% of total billed charges,$308.50 ,100% of UHC fee schedule,$25.81 ,120% of MO fee schedule,$77.13 ,25% of total billed charges,$235.00 ,pays based on per visit rate,$77.13 ,25% of total billed charges,$25.81 ,$308.50 ,$154.25 
Outpatient Medical Services,DIAGNOSTIC IMAGING,73630,Diagnostic Radiology (Diagnostic Imaging) Procedures of the Lower Extremities,320,$308.50 ,$237.55 ,77% of total billed charges,$78.67 ,25.5% of total billed charges,$78.67 ,25.5% of total billed charges,$96.41 ,31.25% of total billed charges,$228.29 ,74% of total billed charges,$212.87 ,69% of total billed charges,$212.87 ,69% of total billed charges,$77.13 ,25% of total billed charges,$212.87 ,69% of total billed charges,$212.87 ,69% of total billed charges,$79.16 ,100% of BCBS fee schedule,$252.97 ,82% of total billed charges,$104.64 ,400% of HEALTHLINK fee schedule,$98.10 ,375% of HEALTHLINK fee schedule,$104.64 ,400% of HEALTHLINK fee schedule,$23.99 ,120% of MO fee schedule,$23.99 ,120% of MO fee schedule,$23.99 ,120% of MO fee schedule,$237.55 ,77% of total billed charges,$262.23 ,85% of total billed charges,$88.69 ,28.75% of total billed charges,$308.50 ,100% of UHC fee schedule,$23.99 ,120% of MO fee schedule,$77.13 ,25% of total billed charges,$235.00 ,pays based on per visit rate,$77.13 ,25% of total billed charges,$23.99 ,$308.50 ,$154.25 
Outpatient Medical Services,DIAGNOSTIC IMAGING,73721,MRI scan of leg joint,614,"$3,159.00 ","$2,432.43 ",77% of total billed charges,$805.55 ,25.5% of total billed charges,$805.55 ,25.5% of total billed charges,$987.19 ,31.25% of total billed charges,"$3,385.18 ",295% of BCBS fee schedule,"$3,159.62 ",285% of BCBS fee schedule,"$3,159.62 ",285% of BCBS fee schedule,$789.75 ,25% of total billed charges,"$3,159.62 ",285% of BCBS fee schedule,"$3,159.62 ",285% of BCBS fee schedule,"$1,176.78 ",100% of BCBS fee schedule,"$2,590.38 ",82% of total billed charges,"$1,880.96 ",400% of HEALTHLINK fee schedule,"$1,763.40 ",375% of HEALTHLINK fee schedule,"$1,880.96 ",400% of HEALTHLINK fee schedule,$286.88 ,120% of MO fee schedule,$286.88 ,120% of MO fee schedule,$286.88 ,120% of MO fee schedule,"$2,432.43 ",77% of total billed charges,"$2,685.15 ",85% of total billed charges,$908.21 ,28.75% of total billed charges,"$3,159.00 ",100% of UHC fee schedule,$286.88 ,120% of MO fee schedule,$789.75 ,25% of total billed charges,"$1,280.00 ",pays based on per visit rate,$789.75 ,25% of total billed charges,$286.88 ,"$3,385.18 ","$1,579.50 "
Outpatient Medical Services,DIAGNOSTIC IMAGING,74018,"Radiologic examination, abdomen",320,$287.00 ,$220.99 ,77% of total billed charges,$73.19 ,25.5% of total billed charges,$73.19 ,25.5% of total billed charges,$89.69 ,31.25% of total billed charges,$212.38 ,74% of total billed charges,$198.03 ,69% of total billed charges,$198.03 ,69% of total billed charges,$71.75 ,25% of total billed charges,$198.03 ,69% of total billed charges,$198.03 ,69% of total billed charges,$55.09 ,100% of BCBS fee schedule,$235.34 ,82% of total billed charges,$255.43 ,89% of total billed charges,$255.43 ,89% of total billed charges,$255.43 ,89% of total billed charges,$19.43 ,120% of MO fee schedule,$19.43 ,120% of MO fee schedule,$19.43 ,120% of MO fee schedule,$220.99 ,77% of total billed charges,$243.95 ,85% of total billed charges,$82.51 ,28.75% of total billed charges,$287.00 ,100% of UHC fee schedule,$19.43 ,120% of MO fee schedule,$71.75 ,25% of total billed charges,$235.00 ,pays based on per visit rate,$71.75 ,25% of total billed charges,$19.43 ,$287.00 ,$143.50 
Outpatient Medical Services,DIAGNOSTIC IMAGING,74022,"Radiologic examination, abdomen",320,$488.00 ,$375.76 ,77% of total billed charges,$124.44 ,25.5% of total billed charges,$124.44 ,25.5% of total billed charges,$152.50 ,31.25% of total billed charges,$361.12 ,74% of total billed charges,$336.72 ,69% of total billed charges,$336.72 ,69% of total billed charges,$122.00 ,25% of total billed charges,$336.72 ,69% of total billed charges,$336.72 ,69% of total billed charges,$111.21 ,100% of BCBS fee schedule,$400.16 ,82% of total billed charges,$170.84 ,400% of HEALTHLINK fee schedule,$160.16 ,375% of HEALTHLINK fee schedule,$170.84 ,400% of HEALTHLINK fee schedule,$33.17 ,120% of MO fee schedule,$33.17 ,120% of MO fee schedule,$33.17 ,120% of MO fee schedule,$375.76 ,77% of total billed charges,$414.80 ,85% of total billed charges,$140.30 ,28.75% of total billed charges,$488.00 ,100% of UHC fee schedule,$33.17 ,120% of MO fee schedule,$122.00 ,25% of total billed charges,$235.00 ,pays based on per visit rate,$122.00 ,25% of total billed charges,$33.17 ,$488.00 ,$244.00 
Outpatient Medical Services,DIAGNOSTIC IMAGING,74176,CT Abdoment Pelvis without contrast,352,"$4,677.00 ","$3,601.29 ",77% of total billed charges,"$1,192.64 ",25.5% of total billed charges,"$1,192.64 ",25.5% of total billed charges,"$1,461.56 ",31.25% of total billed charges,"$1,797.18 ",350% of BCBS fee schedule,"$3,227.13 ",69% of total billed charges,"$3,227.13 ",69% of total billed charges,"$1,169.25 ",25% of total billed charges,"$3,227.13 ",69% of total billed charges,"$3,227.13 ",69% of total billed charges,$536.46 ,100% of BCBS fee schedule,"$3,835.14 ",82% of total billed charges,"$4,162.53 ",89% of total billed charges,"$4,162.53 ",89% of total billed charges,"$4,162.53 ",89% of total billed charges,$98.63 ,120% of MO fee schedule,$98.63 ,120% of MO fee schedule,$98.63 ,120% of MO fee schedule,"$3,601.29 ",77% of total billed charges,"$3,975.45 ",85% of total billed charges,"$1,344.64 ",28.75% of total billed charges,"$4,677.00 ",100% of UHC fee schedule,$98.63 ,120% of MO fee schedule,"$1,169.25 ",25% of total billed charges,$770.00 ,pays based on per visit rate,"$1,169.25 ",25% of total billed charges,$98.63 ,"$4,677.00 ","$2,338.50 "
Outpatient Medical Services,DIAGNOSTIC IMAGING,74177,CT scan of abdomen and pelvis with contrast,352,"$4,890.50 ","$3,765.69 ",77% of total billed charges,"$1,247.08 ",25.5% of total billed charges,"$1,247.08 ",25.5% of total billed charges,"$1,528.28 ",31.25% of total billed charges,"$3,427.03 ",350% of BCBS fee schedule,"$3,374.45 ",69% of total billed charges,"$3,374.45 ",69% of total billed charges,"$1,222.63 ",25% of total billed charges,"$3,374.45 ",69% of total billed charges,"$3,374.45 ",69% of total billed charges,"$1,023.01 ",100% of BCBS fee schedule,"$4,010.21 ",82% of total billed charges,"$4,352.55 ",89% of total billed charges,"$4,352.55 ",89% of total billed charges,"$4,352.55 ",89% of total billed charges,$214.56 ,120% of MO fee schedule,$214.56 ,120% of MO fee schedule,$214.56 ,120% of MO fee schedule,"$3,765.69 ",77% of total billed charges,"$4,156.93 ",85% of total billed charges,"$1,406.02 ",28.75% of total billed charges,"$4,890.50 ",100% of UHC fee schedule,$214.56 ,120% of MO fee schedule,"$1,222.63 ",25% of total billed charges,$770.00 ,pays based on per visit rate,"$1,222.63 ",25% of total billed charges,$214.56 ,"$4,890.50 ","$2,445.25 "
Outpatient Medical Services,DIAGNOSTIC IMAGING,76000,Cholesterol Lab Test,320,$335.00 ,$257.95 ,77% of total billed charges,$85.43 ,25.5% of total billed charges,$85.43 ,25.5% of total billed charges,$104.69 ,31.25% of total billed charges,$247.90 ,74% of total billed charges,$231.15 ,69% of total billed charges,$231.15 ,69% of total billed charges,$83.75 ,25% of total billed charges,$231.15 ,69% of total billed charges,$231.15 ,69% of total billed charges,$233.75 ,100% of BCBS fee schedule,$274.70 ,82% of total billed charges,$358.16 ,400% of HEALTHLINK fee schedule,$335.78 ,375% of HEALTHLINK fee schedule,$358.16 ,400% of HEALTHLINK fee schedule,$56.15 ,120% of MO fee schedule,$56.15 ,120% of MO fee schedule,$56.15 ,120% of MO fee schedule,$257.95 ,77% of total billed charges,$284.75 ,85% of total billed charges,$96.31 ,28.75% of total billed charges,$335.00 ,100% of UHC fee schedule,$56.15 ,120% of MO fee schedule,$83.75 ,25% of total billed charges,$235.00 ,pays based on per visit rate,$83.75 ,25% of total billed charges,$56.15 ,$358.16 ,$167.50 
Outpatient Medical Services,DIAGNOSTIC IMAGING,76536,Diagnostic Ultrasound Procedures of the Head and Neck,402,$751.50 ,$578.66 ,77% of total billed charges,$191.63 ,25.5% of total billed charges,$191.63 ,25.5% of total billed charges,$234.84 ,31.25% of total billed charges,$556.11 ,74% of total billed charges,$518.54 ,69% of total billed charges,$518.54 ,69% of total billed charges,$187.88 ,25% of total billed charges,$518.54 ,69% of total billed charges,$518.54 ,69% of total billed charges,$307.06 ,100% of BCBS fee schedule,$616.23 ,82% of total billed charges,$409.04 ,400% of HEALTHLINK fee schedule,$383.48 ,375% of HEALTHLINK fee schedule,$409.04 ,400% of HEALTHLINK fee schedule,$77.80 ,120% of MO fee schedule,$77.80 ,120% of MO fee schedule,$77.80 ,120% of MO fee schedule,$578.66 ,77% of total billed charges,$638.78 ,85% of total billed charges,$216.06 ,28.75% of total billed charges,$751.50 ,100% of UHC fee schedule,$77.80 ,120% of MO fee schedule,$187.88 ,25% of total billed charges,$386.00 ,pays based on per visit rate,$187.88 ,25% of total billed charges,$77.80 ,$751.50 ,$375.75 
Outpatient Medical Services,DIAGNOSTIC IMAGING,76641,"Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete",402,$828.50 ,$637.95 ,77% of total billed charges,$211.27 ,25.5% of total billed charges,$211.27 ,25.5% of total billed charges,$258.91 ,31.25% of total billed charges,$613.09 ,74% of total billed charges,$571.67 ,69% of total billed charges,$571.67 ,69% of total billed charges,$207.13 ,25% of total billed charges,$571.67 ,69% of total billed charges,$571.67 ,69% of total billed charges,$212.04 ,100% of BCBS fee schedule,$679.37 ,82% of total billed charges,$737.37 ,89% of total billed charges,$737.37 ,89% of total billed charges,$737.37 ,89% of total billed charges,$62.90 ,120% of MO fee schedule,$62.90 ,120% of MO fee schedule,$62.90 ,120% of MO fee schedule,$637.95 ,77% of total billed charges,$704.23 ,85% of total billed charges,$238.19 ,28.75% of total billed charges,$828.50 ,100% of UHC fee schedule,$62.90 ,120% of MO fee schedule,$207.13 ,25% of total billed charges,$386.00 ,pays based on per visit rate,$207.13 ,25% of total billed charges,$62.90 ,$828.50 ,$414.25 
Outpatient Medical Services,DIAGNOSTIC IMAGING,76642,"Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed",402,$621.50 ,$478.56 ,77% of total billed charges,$158.48 ,25.5% of total billed charges,$158.48 ,25.5% of total billed charges,$194.22 ,31.25% of total billed charges,$459.91 ,74% of total billed charges,$428.84 ,69% of total billed charges,$428.84 ,69% of total billed charges,$155.38 ,25% of total billed charges,$428.84 ,69% of total billed charges,$428.84 ,69% of total billed charges,$162.25 ,100% of BCBS fee schedule,$509.63 ,82% of total billed charges,$553.14 ,89% of total billed charges,$553.14 ,89% of total billed charges,$553.14 ,89% of total billed charges,$48.01 ,120% of MO fee schedule,$48.01 ,120% of MO fee schedule,$48.01 ,120% of MO fee schedule,$478.56 ,77% of total billed charges,$528.28 ,85% of total billed charges,$178.68 ,28.75% of total billed charges,$621.50 ,100% of UHC fee schedule,$48.01 ,120% of MO fee schedule,$155.38 ,25% of total billed charges,$386.00 ,pays based on per visit rate,$155.38 ,25% of total billed charges,$48.01 ,$621.50 ,$310.75 
Outpatient Medical Services,DIAGNOSTIC IMAGING,76700,Ultrasound of abdomen,402,$814.50 ,$627.17 ,77% of total billed charges,$207.70 ,25.5% of total billed charges,$207.70 ,25.5% of total billed charges,$254.53 ,31.25% of total billed charges,$602.73 ,74% of total billed charges,$562.01 ,69% of total billed charges,$562.01 ,69% of total billed charges,$203.63 ,25% of total billed charges,$562.01 ,69% of total billed charges,$562.01 ,69% of total billed charges,$324.23 ,100% of BCBS fee schedule,$667.89 ,82% of total billed charges,$493.72 ,400% of HEALTHLINK fee schedule,$462.86 ,375% of HEALTHLINK fee schedule,$493.72 ,400% of HEALTHLINK fee schedule,$72.62 ,120% of MO fee schedule,$72.62 ,120% of MO fee schedule,$72.62 ,120% of MO fee schedule,$627.17 ,77% of total billed charges,$692.33 ,85% of total billed charges,$234.17 ,28.75% of total billed charges,$814.50 ,100% of UHC fee schedule,$72.62 ,120% of MO fee schedule,$203.63 ,25% of total billed charges,$386.00 ,pays based on per visit rate,$203.63 ,25% of total billed charges,$72.62 ,$814.50 ,$407.25 
Outpatient Medical Services,DIAGNOSTIC IMAGING,76705,"Ultrasound, abdominal",402,$694.50 ,$534.77 ,77% of total billed charges,$177.10 ,25.5% of total billed charges,$177.10 ,25.5% of total billed charges,$217.03 ,31.25% of total billed charges,$513.93 ,74% of total billed charges,$479.21 ,69% of total billed charges,$479.21 ,69% of total billed charges,$173.63 ,25% of total billed charges,$479.21 ,69% of total billed charges,$479.21 ,69% of total billed charges,$263.54 ,100% of BCBS fee schedule,$569.49 ,82% of total billed charges,$378.08 ,400% of HEALTHLINK fee schedule,$354.45 ,375% of HEALTHLINK fee schedule,$378.08 ,400% of HEALTHLINK fee schedule,$54.70 ,120% of MO fee schedule,$54.70 ,120% of MO fee schedule,$54.70 ,120% of MO fee schedule,$534.77 ,77% of total billed charges,$590.33 ,85% of total billed charges,$199.67 ,28.75% of total billed charges,$694.50 ,100% of UHC fee schedule,$54.70 ,120% of MO fee schedule,$173.63 ,25% of total billed charges,$386.00 ,pays based on per visit rate,$173.63 ,25% of total billed charges,$54.70 ,$694.50 ,$347.25 
Outpatient Medical Services,DIAGNOSTIC IMAGING,76770,"Ultrasound, retroperitoneal",402,$954.00 ,$734.58 ,77% of total billed charges,$243.27 ,25.5% of total billed charges,$243.27 ,25.5% of total billed charges,$298.13 ,31.25% of total billed charges,$705.96 ,74% of total billed charges,$658.26 ,69% of total billed charges,$658.26 ,69% of total billed charges,$238.50 ,25% of total billed charges,$658.26 ,69% of total billed charges,$658.26 ,69% of total billed charges,$324.23 ,100% of BCBS fee schedule,$782.28 ,82% of total billed charges,$470.36 ,400% of HEALTHLINK fee schedule,$440.96 ,375% of HEALTHLINK fee schedule,$470.36 ,400% of HEALTHLINK fee schedule,$67.76 ,120% of MO fee schedule,$67.76 ,120% of MO fee schedule,$67.76 ,120% of MO fee schedule,$734.58 ,77% of total billed charges,$810.90 ,85% of total billed charges,$274.28 ,28.75% of total billed charges,$954.00 ,100% of UHC fee schedule,$67.76 ,120% of MO fee schedule,$238.50 ,25% of total billed charges,$386.00 ,pays based on per visit rate,$238.50 ,25% of total billed charges,$67.76 ,$954.00 ,$477.00 
Outpatient Medical Services,DIAGNOSTIC IMAGING,76775,"Ultrasound, retroperitoneal (",402,$849.00 ,$653.73 ,77% of total billed charges,$216.50 ,25.5% of total billed charges,$216.50 ,25.5% of total billed charges,$265.31 ,31.25% of total billed charges,$628.26 ,74% of total billed charges,$585.81 ,69% of total billed charges,$585.81 ,69% of total billed charges,$212.25 ,25% of total billed charges,$585.81 ,69% of total billed charges,$585.81 ,69% of total billed charges,$279.57 ,100% of BCBS fee schedule,$696.18 ,82% of total billed charges,$382.56 ,400% of HEALTHLINK fee schedule,$358.65 ,375% of HEALTHLINK fee schedule,$382.56 ,400% of HEALTHLINK fee schedule,$51.05 ,120% of MO fee schedule,$51.05 ,120% of MO fee schedule,$51.05 ,120% of MO fee schedule,$653.73 ,77% of total billed charges,$721.65 ,85% of total billed charges,$244.09 ,28.75% of total billed charges,$849.00 ,100% of UHC fee schedule,$51.05 ,120% of MO fee schedule,$212.25 ,25% of total billed charges,$386.00 ,pays based on per visit rate,$212.25 ,25% of total billed charges,$51.05 ,$849.00 ,$424.50 
Outpatient Medical Services,DIAGNOSTIC IMAGING,76801,"Ultrasound, pregnant uterus, real time image documentation, fetal and maternal evaluation",402,$748.50 ,$576.35 ,77% of total billed charges,$190.87 ,25.5% of total billed charges,$190.87 ,25.5% of total billed charges,$233.91 ,31.25% of total billed charges,$553.89 ,74% of total billed charges,$516.47 ,69% of total billed charges,$516.47 ,69% of total billed charges,$187.13 ,25% of total billed charges,$516.47 ,69% of total billed charges,$516.47 ,69% of total billed charges,$276.13 ,100% of BCBS fee schedule,$613.77 ,82% of total billed charges,$457.20 ,400% of HEALTHLINK fee schedule,$428.63 ,375% of HEALTHLINK fee schedule,$457.20 ,400% of HEALTHLINK fee schedule,$64.72 ,120% of MO fee schedule,$64.72 ,120% of MO fee schedule,$64.72 ,120% of MO fee schedule,$576.35 ,77% of total billed charges,$636.23 ,85% of total billed charges,$215.19 ,28.75% of total billed charges,$748.50 ,100% of UHC fee schedule,$64.72 ,120% of MO fee schedule,$187.13 ,25% of total billed charges,$386.00 ,pays based on per visit rate,$187.13 ,25% of total billed charges,$64.72 ,$748.50 ,$374.25 
Outpatient Medical Services,DIAGNOSTIC IMAGING,76805,Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus,402,$753.00 ,$579.81 ,77% of total billed charges,$192.02 ,25.5% of total billed charges,$192.02 ,25.5% of total billed charges,$235.31 ,31.25% of total billed charges,$557.22 ,74% of total billed charges,$519.57 ,69% of total billed charges,$519.57 ,69% of total billed charges,$188.25 ,25% of total billed charges,$519.57 ,69% of total billed charges,$519.57 ,69% of total billed charges,$324.23 ,100% of BCBS fee schedule,$617.46 ,82% of total billed charges,$522.32 ,400% of HEALTHLINK fee schedule,$489.68 ,375% of HEALTHLINK fee schedule,$522.32 ,400% of HEALTHLINK fee schedule,$80.53 ,120% of MO fee schedule,$80.53 ,120% of MO fee schedule,$80.53 ,120% of MO fee schedule,$579.81 ,77% of total billed charges,$640.05 ,85% of total billed charges,$216.49 ,28.75% of total billed charges,$753.00 ,100% of UHC fee schedule,$80.53 ,120% of MO fee schedule,$188.25 ,25% of total billed charges,$386.00 ,pays based on per visit rate,$188.25 ,25% of total billed charges,$80.53 ,$753.00 ,$376.50 
Outpatient Medical Services,DIAGNOSTIC IMAGING,76816,"Ultrasound, pregnant uterus, real time with image documentation",402,$962.50 ,$741.13 ,77% of total billed charges,$245.44 ,25.5% of total billed charges,$245.44 ,25.5% of total billed charges,$300.78 ,31.25% of total billed charges,$712.25 ,74% of total billed charges,$664.13 ,69% of total billed charges,$664.13 ,69% of total billed charges,$240.63 ,25% of total billed charges,$664.13 ,69% of total billed charges,$664.13 ,69% of total billed charges,$209.73 ,100% of BCBS fee schedule,$789.25 ,82% of total billed charges,$414.16 ,400% of HEALTHLINK fee schedule,$388.28 ,375% of HEALTHLINK fee schedule,$414.16 ,400% of HEALTHLINK fee schedule,$63.20 ,120% of MO fee schedule,$63.20 ,120% of MO fee schedule,$63.20 ,120% of MO fee schedule,$741.13 ,77% of total billed charges,$818.13 ,85% of total billed charges,$276.72 ,28.75% of total billed charges,$962.50 ,100% of UHC fee schedule,$63.20 ,120% of MO fee schedule,$240.63 ,25% of total billed charges,$386.00 ,pays based on per visit rate,$240.63 ,25% of total billed charges,$63.20 ,$962.50 ,$481.25 
Outpatient Medical Services,DIAGNOSTIC IMAGING,76817,"ultrasound, pregnant uterus, real time with image documentation, transvaginal",40,$860.50 ,$662.59 ,77% of total billed charges,$219.43 ,25.5% of total billed charges,$219.43 ,25.5% of total billed charges,$268.91 ,31.25% of total billed charges,$636.77 ,74% of total billed charges,$593.75 ,69% of total billed charges,$593.75 ,69% of total billed charges,$215.13 ,25% of total billed charges,$593.75 ,69% of total billed charges,$593.75 ,69% of total billed charges,$722.82 ,84% of total billed charges,$705.61 ,82% of total billed charges,$358.00 ,400% of HEALTHLINK fee schedule,$335.63 ,375% of HEALTHLINK fee schedule,$358.00 ,400% of HEALTHLINK fee schedule,$52.26 ,120% of MO fee schedule,$52.26 ,120% of MO fee schedule,$52.26 ,120% of MO fee schedule,$662.59 ,77% of total billed charges,$731.43 ,85% of total billed charges,$247.39 ,28.75% of total billed charges,$430.25 ,50% of total billed charges,$52.26 ,120% of MO fee schedule,$215.13 ,25% of total billed charges,$765.85 ,89% of total billed charges,$215.13 ,25% of total billed charges,$52.26 ,$765.85 ,$430.25 
Outpatient Medical Services,DIAGNOSTIC IMAGING,76830,Ultrasound pelvis through vagina,402,$791.50 ,$609.46 ,77% of total billed charges,$201.83 ,25.5% of total billed charges,$201.83 ,25.5% of total billed charges,$247.34 ,31.25% of total billed charges,$585.71 ,74% of total billed charges,$546.14 ,69% of total billed charges,$546.14 ,69% of total billed charges,$197.88 ,25% of total billed charges,$546.14 ,69% of total billed charges,$546.14 ,69% of total billed charges,$308.21 ,100% of BCBS fee schedule,$649.03 ,82% of total billed charges,$441.56 ,400% of HEALTHLINK fee schedule,$413.96 ,375% of HEALTHLINK fee schedule,$441.56 ,400% of HEALTHLINK fee schedule,$79.92 ,120% of MO fee schedule,$79.92 ,120% of MO fee schedule,$79.92 ,120% of MO fee schedule,$609.46 ,77% of total billed charges,$672.78 ,85% of total billed charges,$227.56 ,28.75% of total billed charges,$791.50 ,100% of UHC fee schedule,$79.92 ,120% of MO fee schedule,$197.88 ,25% of total billed charges,$386.00 ,pays based on per visit rate,$197.88 ,25% of total billed charges,$79.92 ,$791.50 ,$395.75 
Outpatient Medical Services,DIAGNOSTIC IMAGING,76882,"Ultrasound, limited, joint or other nonvascular extremity structure(s) (eg, joint space, peri-articular tendon[s], muscle[s], nerve[s], other soft tis",402,$677.00 ,$521.29 ,77% of total billed charges,$172.64 ,25.5% of total billed charges,$172.64 ,25.5% of total billed charges,$211.56 ,31.25% of total billed charges,$500.98 ,74% of total billed charges,$467.13 ,69% of total billed charges,$467.13 ,69% of total billed charges,$169.25 ,25% of total billed charges,$467.13 ,69% of total billed charges,$467.13 ,69% of total billed charges,$34.49 ,100% of BCBS fee schedule,$555.14 ,82% of total billed charges,$602.53 ,89% of total billed charges,$602.53 ,89% of total billed charges,$602.53 ,89% of total billed charges,$30.07 ,120% of MO fee schedule,$30.07 ,120% of MO fee schedule,$30.07 ,120% of MO fee schedule,$521.29 ,77% of total billed charges,$575.45 ,85% of total billed charges,$194.64 ,28.75% of total billed charges,$677.00 ,100% of UHC fee schedule,$30.07 ,120% of MO fee schedule,$169.25 ,25% of total billed charges,$386.00 ,pays based on per visit rate,$169.25 ,25% of total billed charges,$30.07 ,$677.00 ,$338.50 
Outpatient Medical Services,DIAGNOSTIC IMAGING,77049,"Magnetic resonance imaging, breast, without and/or with contrast material(s)",614,"$2,868.00 ","$2,208.36 ",77% of total billed charges,$731.34 ,25.5% of total billed charges,$731.34 ,25.5% of total billed charges,$896.25 ,31.25% of total billed charges,"$2,360.06 ",295% of BCBS fee schedule,"$2,202.79 ",285% of BCBS fee schedule,"$2,202.79 ",285% of BCBS fee schedule,$717.00 ,25% of total billed charges,"$2,202.79 ",285% of BCBS fee schedule,"$2,202.79 ",285% of BCBS fee schedule,$820.42 ,100% of BCBS fee schedule,"$2,351.76 ",82% of total billed charges,"$2,552.52 ",89% of total billed charges,"$2,552.52 ",89% of total billed charges,"$2,552.52 ",89% of total billed charges,$231.28 ,120% of MO fee schedule,$231.28 ,120% of MO fee schedule,$231.28 ,120% of MO fee schedule,"$2,208.36 ",77% of total billed charges,"$2,437.80 ",85% of total billed charges,$824.55 ,28.75% of total billed charges,"$2,868.00 ",100% of UHC fee schedule,$231.28 ,120% of MO fee schedule,$717.00 ,25% of total billed charges,"$1,280.00 ",pays based on per visit rate,$717.00 ,25% of total billed charges,$231.28 ,"$2,868.00 ","$1,434.00 "
Outpatient Medical Services,DIAGNOSTIC IMAGING,77063,"Screening digital breast tomosynthesis, bilateral",403,$74.00 ,$56.98 ,77% of total billed charges,$18.87 ,25.5% of total billed charges,$18.87 ,25.5% of total billed charges,$23.13 ,31.25% of total billed charges,$54.76 ,74% of total billed charges,$51.06 ,69% of total billed charges,$51.06 ,69% of total billed charges,$18.50 ,25% of total billed charges,$51.06 ,69% of total billed charges,$51.06 ,69% of total billed charges,$76.39 ,100% of BCBS fee schedule,$60.68 ,82% of total billed charges,$65.86 ,89% of total billed charges,$65.86 ,89% of total billed charges,$65.86 ,89% of total billed charges,$23.54 ,120% of MO fee schedule,$23.54 ,120% of MO fee schedule,$23.54 ,120% of MO fee schedule,$56.98 ,77% of total billed charges,$62.90 ,85% of total billed charges,$21.28 ,28.75% of total billed charges,$74.00 ,100% of UHC fee schedule,$23.54 ,120% of MO fee schedule,$18.50 ,25% of total billed charges,$153.00 ,pays based on per visit rate,$18.50 ,25% of total billed charges,$18.50 ,$153.00 ,$37.00 
Outpatient Medical Services,DIAGNOSTIC IMAGING,77065,Mammography of one breast,401,$518.50 ,$399.25 ,77% of total billed charges,$132.22 ,25.5% of total billed charges,$132.22 ,25.5% of total billed charges,$162.03 ,31.25% of total billed charges,$383.69 ,74% of total billed charges,$357.77 ,69% of total billed charges,$357.77 ,69% of total billed charges,$129.63 ,25% of total billed charges,$357.77 ,69% of total billed charges,$357.77 ,69% of total billed charges,$202.96 ,100% of BCBS fee schedule,$425.17 ,82% of total billed charges,$461.47 ,89% of total billed charges,$461.47 ,89% of total billed charges,$461.47 ,89% of total billed charges,$88.10 ,120% of MO fee schedule,$88.10 ,120% of MO fee schedule,$88.10 ,120% of MO fee schedule,$399.25 ,77% of total billed charges,$440.73 ,85% of total billed charges,$149.07 ,28.75% of total billed charges,$518.50 ,100% of UHC fee schedule,$88.10 ,120% of MO fee schedule,$129.63 ,25% of total billed charges,$153.00 ,pays based on per visit rate,$129.63 ,25% of total billed charges,$88.10 ,$518.50 ,$259.25 
Outpatient Medical Services,DIAGNOSTIC IMAGING,77066,Mammography of both breasts,401,$627.50 ,$483.18 ,77% of total billed charges,$160.01 ,25.5% of total billed charges,$160.01 ,25.5% of total billed charges,$196.09 ,31.25% of total billed charges,$464.35 ,74% of total billed charges,$432.98 ,69% of total billed charges,$432.98 ,69% of total billed charges,$156.88 ,25% of total billed charges,$432.98 ,69% of total billed charges,$432.98 ,69% of total billed charges,$255.67 ,100% of BCBS fee schedule,$514.55 ,82% of total billed charges,$558.48 ,89% of total billed charges,$558.48 ,89% of total billed charges,$558.48 ,89% of total billed charges,$112.33 ,120% of MO fee schedule,$112.33 ,120% of MO fee schedule,$112.33 ,120% of MO fee schedule,$483.18 ,77% of total billed charges,$533.38 ,85% of total billed charges,$180.41 ,28.75% of total billed charges,$627.50 ,100% of UHC fee schedule,$112.33 ,120% of MO fee schedule,$156.88 ,25% of total billed charges,$153.00 ,pays based on per visit rate,$156.88 ,25% of total billed charges,$112.33 ,$627.50 ,$313.75 
Outpatient Medical Services,DIAGNOSTIC IMAGING,77067,"Mammography, screening, bilateral",403,$556.00 ,$428.12 ,77% of total billed charges,$141.78 ,25.5% of total billed charges,$141.78 ,25.5% of total billed charges,$173.75 ,31.25% of total billed charges,$411.44 ,74% of total billed charges,$383.64 ,69% of total billed charges,$383.64 ,69% of total billed charges,$139.00 ,25% of total billed charges,$383.64 ,69% of total billed charges,$383.64 ,69% of total billed charges,$184.66 ,100% of BCBS fee schedule,$455.92 ,82% of total billed charges,$494.84 ,89% of total billed charges,$494.84 ,89% of total billed charges,$494.84 ,89% of total billed charges,$92.82 ,120% of MO fee schedule,$92.82 ,120% of MO fee schedule,$92.82 ,120% of MO fee schedule,$428.12 ,77% of total billed charges,$472.60 ,85% of total billed charges,$159.85 ,28.75% of total billed charges,$556.00 ,100% of UHC fee schedule,$92.82 ,120% of MO fee schedule,$139.00 ,25% of total billed charges,$153.00 ,pays based on per visit rate,$139.00 ,25% of total billed charges,$92.82 ,$556.00 ,$278.00 
Outpatient Medical Services,DIAGNOSTIC IMAGING,77080,"bone density scan of axial bones like hip, pelvis and spine",320,$588.50 ,$453.15 ,77% of total billed charges,$150.07 ,25.5% of total billed charges,$150.07 ,25.5% of total billed charges,$183.91 ,31.25% of total billed charges,$435.49 ,74% of total billed charges,$406.07 ,69% of total billed charges,$406.07 ,69% of total billed charges,$147.13 ,25% of total billed charges,$406.07 ,69% of total billed charges,$406.07 ,69% of total billed charges,$293.51 ,100% of BCBS fee schedule,$482.57 ,82% of total billed charges,$183.84 ,400% of HEALTHLINK fee schedule,$172.35 ,375% of HEALTHLINK fee schedule,$183.84 ,400% of HEALTHLINK fee schedule,$62.96 ,120% of MO fee schedule,$62.96 ,120% of MO fee schedule,$62.96 ,120% of MO fee schedule,$453.15 ,77% of total billed charges,$500.23 ,85% of total billed charges,$169.19 ,28.75% of total billed charges,$588.50 ,100% of UHC fee schedule,$62.96 ,120% of MO fee schedule,$147.13 ,25% of total billed charges,$235.00 ,pays based on per visit rate,$147.13 ,25% of total billed charges,$62.96 ,$588.50 ,$294.25 
Outpatient Medical Services,DIAGNOSTIC IMAGING,78452,"Myocardial perfusion imaging, tomographic (SPECT); multiple studies, at rest and/or stress and/or redistribution and/or rest reinjectio",340,"$3,458.00 ","$2,662.66 ",77% of total billed charges,$881.79 ,25.5% of total billed charges,$881.79 ,25.5% of total billed charges,"$1,080.63 ",31.25% of total billed charges,"$2,558.92 ",74% of total billed charges,"$2,386.02 ",69% of total billed charges,"$2,386.02 ",69% of total billed charges,$864.50 ,25% of total billed charges,"$2,386.02 ",69% of total billed charges,"$2,386.02 ",69% of total billed charges,"$1,348.44 ",100% of BCBS fee schedule,"$2,835.56 ",82% of total billed charges,"$3,077.62 ",89% of total billed charges,"$3,077.62 ",89% of total billed charges,"$3,077.62 ",89% of total billed charges,$339.32 ,120% of MO fee schedule,$339.32 ,120% of MO fee schedule,$339.32 ,120% of MO fee schedule,"$2,662.66 ",77% of total billed charges,"$2,939.30 ",85% of total billed charges,$994.18 ,28.75% of total billed charges,"$3,458.00 ",100% of UHC fee schedule,$339.32 ,120% of MO fee schedule,$864.50 ,25% of total billed charges,$733.00 ,pays based on per visit rate,$864.50 ,25% of total billed charges,$339.32 ,"$3,458.00 ","$1,729.00 "
Outpatient Medical Services,LABORATORY,36415,Collection of venous blood by venipuncture,300,$47.00 ,$36.19 ,77% of total billed charges,$11.99 ,25.5% of total billed charges,$11.99 ,25.5% of total billed charges,$14.69 ,31.25% of total billed charges,$34.78 ,74% of total billed charges,$32.43 ,69% of total billed charges,$32.43 ,69% of total billed charges,$11.75 ,25% of total billed charges,$32.43 ,69% of total billed charges,$32.43 ,69% of total billed charges,$13.36 ,100% of BCBS fee schedule,$38.54 ,82% of total billed charges,$15.00 ,500% of HEALTHLINK fee schedule,$15.00 ,500% of HEALTHLINK fee schedule,$15.00 ,500% of HEALTHLINK fee schedule,$19.18 ,40.8% of total billed charges,$19.18 ,40.8% of total billed charges,$19.18 ,40.8% of total billed charges,$36.19 ,77% of total billed charges,$39.95 ,85% of total billed charges,$13.51 ,28.75% of total billed charges,$47.00 ,100% of UHC fee schedule,$19.18 ,40.8% of total billed charges,$11.75 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$11.75 ,25% of total billed charges,$11.75 ,$55.00 ,$23.50 
Outpatient Medical Services,LABORATORY,36416,Collection of capillary blood specimen,300,$27.50 ,$21.18 ,77% of total billed charges,$7.01 ,25.5% of total billed charges,$7.01 ,25.5% of total billed charges,$8.59 ,31.25% of total billed charges,$20.35 ,74% of total billed charges,$18.98 ,69% of total billed charges,$18.98 ,69% of total billed charges,$6.88 ,25% of total billed charges,$18.98 ,69% of total billed charges,$18.98 ,69% of total billed charges,$13.36 ,100% of BCBS fee schedule,$22.55 ,82% of total billed charges,$24.48 ,89% of total billed charges,$24.48 ,89% of total billed charges,$24.48 ,89% of total billed charges,$11.22 ,40.8% of total billed charges,$11.22 ,40.8% of total billed charges,$11.22 ,40.8% of total billed charges,$21.18 ,77% of total billed charges,$23.38 ,85% of total billed charges,$7.91 ,28.75% of total billed charges,$27.50 ,100% of UHC fee schedule,$11.22 ,40.8% of total billed charges,$6.88 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$6.88 ,25% of total billed charges,$6.88 ,$55.00 ,$13.75 
Outpatient Medical Services,LABORATORY,80048,Basic metabolic panel,301,$155.50 ,$119.74 ,77% of total billed charges,$39.65 ,25.5% of total billed charges,$39.65 ,25.5% of total billed charges,$48.59 ,31.25% of total billed charges,$115.07 ,74% of total billed charges,$107.30 ,69% of total billed charges,$107.30 ,69% of total billed charges,$38.88 ,25% of total billed charges,$107.30 ,69% of total billed charges,$107.30 ,69% of total billed charges,$53.07 ,100% of BCBS fee schedule,$127.51 ,82% of total billed charges,$61.80 ,500% of HEALTHLINK fee schedule,$61.80 ,500% of HEALTHLINK fee schedule,$61.80 ,500% of HEALTHLINK fee schedule,$8.11 ,120% of MO fee schedule,$8.11 ,120% of MO fee schedule,$8.11 ,120% of MO fee schedule,$119.74 ,77% of total billed charges,$132.18 ,85% of total billed charges,$44.71 ,28.75% of total billed charges,$155.50 ,100% of UHC fee schedule,$8.11 ,120% of MO fee schedule,$38.88 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$38.88 ,25% of total billed charges,$8.11 ,$155.50 ,$77.75 
Outpatient Medical Services,LABORATORY,80050,Complete Blood Count w/Differential,301,$576.00 ,$443.52 ,77% of total billed charges,$146.88 ,25.5% of total billed charges,$146.88 ,25.5% of total billed charges,$180.00 ,31.25% of total billed charges,$426.24 ,74% of total billed charges,$397.44 ,69% of total billed charges,$397.44 ,69% of total billed charges,$144.00 ,25% of total billed charges,$397.44 ,69% of total billed charges,$397.44 ,69% of total billed charges,$164.48 ,100% of BCBS fee schedule,$472.32 ,82% of total billed charges,$512.64 ,89% of total billed charges,$512.64 ,89% of total billed charges,$512.64 ,89% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$443.52 ,77% of total billed charges,$489.60 ,85% of total billed charges,$165.60 ,28.75% of total billed charges,$576.00 ,100% of UHC fee schedule,N/A,not seperately reimbursable,$144.00 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$144.00 ,25% of total billed charges,$55.00 ,$576.00 ,$288.00 
Outpatient Medical Services,LABORATORY,80053,"Blood test, comprehensive group of blood chemicals",301,$164.50 ,$126.67 ,77% of total billed charges,$41.95 ,25.5% of total billed charges,$41.95 ,25.5% of total billed charges,$51.41 ,31.25% of total billed charges,$121.73 ,74% of total billed charges,$113.51 ,69% of total billed charges,$113.51 ,69% of total billed charges,$41.13 ,25% of total billed charges,$113.51 ,69% of total billed charges,$113.51 ,69% of total billed charges,$66.27 ,100% of BCBS fee schedule,$134.89 ,82% of total billed charges,$77.20 ,500% of HEALTHLINK fee schedule,$77.20 ,500% of HEALTHLINK fee schedule,$77.20 ,500% of HEALTHLINK fee schedule,$10.13 ,120% of MO fee schedule,$10.13 ,120% of MO fee schedule,$10.13 ,120% of MO fee schedule,$126.67 ,77% of total billed charges,$139.83 ,85% of total billed charges,$47.29 ,28.75% of total billed charges,$164.50 ,100% of UHC fee schedule,$10.13 ,120% of MO fee schedule,$41.13 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$41.13 ,25% of total billed charges,$10.13 ,$164.50 ,$82.25 
Outpatient Medical Services,LABORATORY,80055,Obstetric blood test panel,301,$524.50 ,$403.87 ,77% of total billed charges,$133.75 ,25.5% of total billed charges,$133.75 ,25.5% of total billed charges,$163.91 ,31.25% of total billed charges,$388.13 ,74% of total billed charges,$361.91 ,69% of total billed charges,$361.91 ,69% of total billed charges,$131.13 ,25% of total billed charges,$361.91 ,69% of total billed charges,$361.91 ,69% of total billed charges,$240.52 ,100% of BCBS fee schedule,$430.09 ,82% of total billed charges,$466.81 ,89% of total billed charges,$466.81 ,89% of total billed charges,$466.81 ,89% of total billed charges,$45.89 ,120% of MO fee schedule,$45.89 ,120% of MO fee schedule,$45.89 ,120% of MO fee schedule,$403.87 ,77% of total billed charges,$445.83 ,85% of total billed charges,$150.79 ,28.75% of total billed charges,$524.50 ,100% of UHC fee schedule,$45.89 ,120% of MO fee schedule,$131.13 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$131.13 ,25% of total billed charges,$45.89 ,$524.50 ,$262.25 
Outpatient Medical Services,LABORATORY,80061,"Blood test, lipids (cholesterol and triglycerides)",301,$455.00 ,$350.35 ,77% of total billed charges,$116.03 ,25.5% of total billed charges,$116.03 ,25.5% of total billed charges,$142.19 ,31.25% of total billed charges,$336.70 ,74% of total billed charges,$313.95 ,69% of total billed charges,$313.95 ,69% of total billed charges,$113.75 ,25% of total billed charges,$313.95 ,69% of total billed charges,$313.95 ,69% of total billed charges,$84.00 ,100% of BCBS fee schedule,$373.10 ,82% of total billed charges,$97.85 ,500% of HEALTHLINK fee schedule,$97.85 ,500% of HEALTHLINK fee schedule,$97.85 ,500% of HEALTHLINK fee schedule,$12.85 ,120% of MO fee schedule,$12.85 ,120% of MO fee schedule,$12.85 ,120% of MO fee schedule,$350.35 ,77% of total billed charges,$386.75 ,85% of total billed charges,$130.81 ,28.75% of total billed charges,$455.00 ,100% of UHC fee schedule,$12.85 ,120% of MO fee schedule,$113.75 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$113.75 ,25% of total billed charges,$12.85 ,$455.00 ,$227.50 
Outpatient Medical Services,LABORATORY,80069,Kidney function panel test,301,$196.00 ,$150.92 ,77% of total billed charges,$49.98 ,25.5% of total billed charges,$49.98 ,25.5% of total billed charges,$61.25 ,31.25% of total billed charges,$145.04 ,74% of total billed charges,$135.24 ,69% of total billed charges,$135.24 ,69% of total billed charges,$49.00 ,25% of total billed charges,$135.24 ,69% of total billed charges,$135.24 ,69% of total billed charges,$54.45 ,100% of BCBS fee schedule,$160.72 ,82% of total billed charges,$63.40 ,500% of HEALTHLINK fee schedule,$63.40 ,500% of HEALTHLINK fee schedule,$63.40 ,500% of HEALTHLINK fee schedule,$8.33 ,120% of MO fee schedule,$8.33 ,120% of MO fee schedule,$8.33 ,120% of MO fee schedule,$150.92 ,77% of total billed charges,$166.60 ,85% of total billed charges,$56.35 ,28.75% of total billed charges,$196.00 ,100% of UHC fee schedule,$8.33 ,120% of MO fee schedule,$49.00 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$49.00 ,25% of total billed charges,$8.33 ,$196.00 ,$98.00 
Outpatient Medical Services,LABORATORY,80074,"Hepatitis A, IgM Hepatitis B Core Antibody, IgM Hepatitis B Surface Antigen Hepatitis C Antibody with Confirmation",301,$465.50 ,$358.44 ,77% of total billed charges,$118.70 ,25.5% of total billed charges,$118.70 ,25.5% of total billed charges,$145.47 ,31.25% of total billed charges,$344.47 ,74% of total billed charges,$321.20 ,69% of total billed charges,$321.20 ,69% of total billed charges,$116.38 ,25% of total billed charges,$321.20 ,69% of total billed charges,$321.20 ,69% of total billed charges,$297.49 ,100% of BCBS fee schedule,$381.71 ,82% of total billed charges,$346.35 ,500% of HEALTHLINK fee schedule,$346.35 ,500% of HEALTHLINK fee schedule,$346.35 ,500% of HEALTHLINK fee schedule,$45.72 ,120% of MO fee schedule,$45.72 ,120% of MO fee schedule,$45.72 ,120% of MO fee schedule,$358.44 ,77% of total billed charges,$395.68 ,85% of total billed charges,$133.83 ,28.75% of total billed charges,$465.50 ,100% of UHC fee schedule,$45.72 ,120% of MO fee schedule,$116.38 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$116.38 ,25% of total billed charges,$45.72 ,$465.50 ,$232.75 
Outpatient Medical Services,LABORATORY,80076,Liver function blood test panel,301,$112.50 ,$86.63 ,77% of total billed charges,$28.69 ,25.5% of total billed charges,$28.69 ,25.5% of total billed charges,$35.16 ,31.25% of total billed charges,$83.25 ,74% of total billed charges,$77.63 ,69% of total billed charges,$77.63 ,69% of total billed charges,$28.13 ,25% of total billed charges,$77.63 ,69% of total billed charges,$77.63 ,69% of total billed charges,$51.21 ,100% of BCBS fee schedule,$92.25 ,82% of total billed charges,$59.65 ,500% of HEALTHLINK fee schedule,$59.65 ,500% of HEALTHLINK fee schedule,$59.65 ,500% of HEALTHLINK fee schedule,$7.84 ,120% of MO fee schedule,$7.84 ,120% of MO fee schedule,$7.84 ,120% of MO fee schedule,$86.63 ,77% of total billed charges,$95.63 ,85% of total billed charges,$32.34 ,28.75% of total billed charges,$112.50 ,100% of UHC fee schedule,$7.84 ,120% of MO fee schedule,$28.13 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$28.13 ,25% of total billed charges,$7.84 ,$112.50 ,$56.25 
Outpatient Medical Services,LABORATORY,80306,"drug test(s), presumptive, any number of drug classes, any number of devices or procedures (eg, immunoassay",301,$228.00 ,$175.56 ,77% of total billed charges,$58.14 ,25.5% of total billed charges,$58.14 ,25.5% of total billed charges,$71.25 ,31.25% of total billed charges,$168.72 ,74% of total billed charges,$157.32 ,69% of total billed charges,$157.32 ,69% of total billed charges,$57.00 ,25% of total billed charges,$157.32 ,69% of total billed charges,$157.32 ,69% of total billed charges,$78.96 ,100% of BCBS fee schedule,$186.96 ,82% of total billed charges,$202.92 ,89% of total billed charges,$202.92 ,89% of total billed charges,$202.92 ,89% of total billed charges,$16.45 ,120% of MO fee schedule,$16.45 ,120% of MO fee schedule,$16.45 ,120% of MO fee schedule,$175.56 ,77% of total billed charges,$193.80 ,85% of total billed charges,$65.55 ,28.75% of total billed charges,$228.00 ,100% of UHC fee schedule,$16.45 ,120% of MO fee schedule,$57.00 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$57.00 ,25% of total billed charges,$16.45 ,$228.00 ,$114.00 
Outpatient Medical Services,LABORATORY,80320,Drug Test,301,$134.50 ,$103.57 ,77% of total billed charges,$34.30 ,25.5% of total billed charges,$34.30 ,25.5% of total billed charges,$42.03 ,31.25% of total billed charges,$99.53 ,74% of total billed charges,$92.81 ,69% of total billed charges,$92.81 ,69% of total billed charges,$33.63 ,25% of total billed charges,$92.81 ,69% of total billed charges,$92.81 ,69% of total billed charges,$112.98 ,84% of total billed charges,$110.29 ,82% of total billed charges,$119.71 ,89% of total billed charges,$119.71 ,89% of total billed charges,$119.71 ,89% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$103.57 ,77% of total billed charges,$114.33 ,85% of total billed charges,$38.67 ,28.75% of total billed charges,$134.50 ,100% of UHC fee schedule,N/A,not seperately reimbursable,$33.63 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$33.63 ,25% of total billed charges,$33.63 ,$134.50 ,$67.25 
Outpatient Medical Services,LABORATORY,81000,Manual urinalysis test with examination using microscope,521,$24.00 ,$18.48 ,77% of total billed charges,$6.12 ,25.5% of total billed charges,$6.12 ,25.5% of total billed charges,$7.50 ,31.25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$6.00 ,25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$23.15 ,500% of HEALTHLINK fee schedule,$23.15 ,500% of HEALTHLINK fee schedule,$23.15 ,500% of HEALTHLINK fee schedule,$3.85 ,120% of MO fee schedule,$3.85 ,120% of MO fee schedule,$3.85 ,120% of MO fee schedule,$18.48 ,77% of total billed charges,$20.40 ,85% of total billed charges,$6.90 ,28.75% of total billed charges,$24.00 ,100% of UHC fee schedule,$3.85 ,120% of MO fee schedule,$6.00 ,25% of total billed charges,N/A,not seperately reimbursable,$6.00 ,25% of total billed charges,$3.85 ,$24.00 ,$12.00 
Outpatient Medical Services,LABORATORY,81001,Manual urinalysis test with examination using microscope,307,$51.50 ,$39.66 ,77% of total billed charges,$13.13 ,25.5% of total billed charges,$13.13 ,25.5% of total billed charges,$16.09 ,31.25% of total billed charges,$38.11 ,74% of total billed charges,$35.54 ,69% of total billed charges,$35.54 ,69% of total billed charges,$12.88 ,25% of total billed charges,$35.54 ,69% of total billed charges,$35.54 ,69% of total billed charges,$19.83 ,100% of BCBS fee schedule,$42.23 ,82% of total billed charges,$23.15 ,500% of HEALTHLINK fee schedule,$23.15 ,500% of HEALTHLINK fee schedule,$23.15 ,500% of HEALTHLINK fee schedule,$3.04 ,120% of MO fee schedule,$3.04 ,120% of MO fee schedule,$3.04 ,120% of MO fee schedule,$39.66 ,77% of total billed charges,$43.78 ,85% of total billed charges,$14.81 ,28.75% of total billed charges,$51.50 ,100% of UHC fee schedule,$3.04 ,120% of MO fee schedule,$12.88 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$12.88 ,25% of total billed charges,$3.04 ,$55.00 ,$25.75 
Outpatient Medical Services,LABORATORY,81002,Automated urinalysis test,300,$49.00 ,$37.73 ,77% of total billed charges,$12.50 ,25.5% of total billed charges,$12.50 ,25.5% of total billed charges,$15.31 ,31.25% of total billed charges,$36.26 ,74% of total billed charges,$33.81 ,69% of total billed charges,$33.81 ,69% of total billed charges,$12.25 ,25% of total billed charges,$33.81 ,69% of total billed charges,$33.81 ,69% of total billed charges,$13.12 ,100% of BCBS fee schedule,$40.18 ,82% of total billed charges,$15.25 ,500% of HEALTHLINK fee schedule,$15.25 ,500% of HEALTHLINK fee schedule,$15.25 ,500% of HEALTHLINK fee schedule,$3.34 ,120% of MO fee schedule,$3.34 ,120% of MO fee schedule,$3.34 ,120% of MO fee schedule,$37.73 ,77% of total billed charges,$41.65 ,85% of total billed charges,$14.09 ,28.75% of total billed charges,$49.00 ,100% of UHC fee schedule,$3.34 ,120% of MO fee schedule,$12.25 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$12.25 ,25% of total billed charges,$3.34 ,$55.00 ,$24.50 
Outpatient Medical Services,LABORATORY,81003,"Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH,",307,$50.00 ,$38.50 ,77% of total billed charges,$12.75 ,25.5% of total billed charges,$12.75 ,25.5% of total billed charges,$15.63 ,31.25% of total billed charges,$37.00 ,74% of total billed charges,$34.50 ,69% of total billed charges,$34.50 ,69% of total billed charges,$12.50 ,25% of total billed charges,$34.50 ,69% of total billed charges,$34.50 ,69% of total billed charges,$13.12 ,100% of BCBS fee schedule,$41.00 ,82% of total billed charges,$15.25 ,500% of HEALTHLINK fee schedule,$15.25 ,500% of HEALTHLINK fee schedule,$15.25 ,500% of HEALTHLINK fee schedule,$2.16 ,120% of MO fee schedule,$2.16 ,120% of MO fee schedule,$2.16 ,120% of MO fee schedule,$38.50 ,77% of total billed charges,$42.50 ,85% of total billed charges,$14.38 ,28.75% of total billed charges,$50.00 ,100% of UHC fee schedule,$2.16 ,120% of MO fee schedule,$12.50 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$12.50 ,25% of total billed charges,$2.16 ,$55.00 ,$25.00 
Outpatient Medical Services,LABORATORY,81015,"Urinalysis, microscopic only",307,$47.50 ,$36.58 ,77% of total billed charges,$12.11 ,25.5% of total billed charges,$12.11 ,25.5% of total billed charges,$14.84 ,31.25% of total billed charges,$35.15 ,74% of total billed charges,$32.78 ,69% of total billed charges,$32.78 ,69% of total billed charges,$11.88 ,25% of total billed charges,$32.78 ,69% of total billed charges,$32.78 ,69% of total billed charges,$18.06 ,100% of BCBS fee schedule,$38.95 ,82% of total billed charges,$21.00 ,500% of HEALTHLINK fee schedule,$21.00 ,500% of HEALTHLINK fee schedule,$21.00 ,500% of HEALTHLINK fee schedule,$2.93 ,120% of MO fee schedule,$2.93 ,120% of MO fee schedule,$2.93 ,120% of MO fee schedule,$36.58 ,77% of total billed charges,$40.38 ,85% of total billed charges,$13.66 ,28.75% of total billed charges,$47.50 ,100% of UHC fee schedule,$2.93 ,120% of MO fee schedule,$11.88 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$11.88 ,25% of total billed charges,$2.93 ,$55.00 ,$23.75 
Outpatient Medical Services,LABORATORY,81025,"urine pregnancy test, by visual color comparison methods",521,$43.00 ,$33.11 ,77% of total billed charges,$10.97 ,25.5% of total billed charges,$10.97 ,25.5% of total billed charges,$13.44 ,31.25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$10.75 ,25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$46.20 ,500% of HEALTHLINK fee schedule,$46.20 ,500% of HEALTHLINK fee schedule,$46.20 ,500% of HEALTHLINK fee schedule,$8.26 ,120% of MO fee schedule,$8.26 ,120% of MO fee schedule,$8.26 ,120% of MO fee schedule,$33.11 ,77% of total billed charges,$36.55 ,85% of total billed charges,$12.36 ,28.75% of total billed charges,$43.00 ,100% of UHC fee schedule,$8.26 ,120% of MO fee schedule,$10.75 ,25% of total billed charges,N/A,not seperately reimbursable,$10.75 ,25% of total billed charges,$8.26 ,$46.20 ,$21.50 
Outpatient Medical Services,LABORATORY,82043,Microalbumin Creatinine Microalbumin/creatinine ratio,301,$110.00 ,$84.70 ,77% of total billed charges,$28.05 ,25.5% of total billed charges,$28.05 ,25.5% of total billed charges,$34.38 ,31.25% of total billed charges,$81.40 ,74% of total billed charges,$75.90 ,69% of total billed charges,$75.90 ,69% of total billed charges,$27.50 ,25% of total billed charges,$75.90 ,69% of total billed charges,$75.90 ,69% of total billed charges,$36.27 ,100% of BCBS fee schedule,$90.20 ,82% of total billed charges,$42.25 ,500% of HEALTHLINK fee schedule,$42.25 ,500% of HEALTHLINK fee schedule,$42.25 ,500% of HEALTHLINK fee schedule,$5.54 ,120% of MO fee schedule,$5.54 ,120% of MO fee schedule,$5.54 ,120% of MO fee schedule,$84.70 ,77% of total billed charges,$93.50 ,85% of total billed charges,$31.63 ,28.75% of total billed charges,$110.00 ,100% of UHC fee schedule,$5.54 ,120% of MO fee schedule,$27.50 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$27.50 ,25% of total billed charges,$5.54 ,$110.00 ,$55.00 
Outpatient Medical Services,LABORATORY,82150,Amylase,301,$133.00 ,$102.41 ,77% of total billed charges,$33.92 ,25.5% of total billed charges,$33.92 ,25.5% of total billed charges,$41.56 ,31.25% of total billed charges,$98.42 ,74% of total billed charges,$91.77 ,69% of total billed charges,$91.77 ,69% of total billed charges,$33.25 ,25% of total billed charges,$91.77 ,69% of total billed charges,$91.77 ,69% of total billed charges,$40.63 ,100% of BCBS fee schedule,$109.06 ,82% of total billed charges,$47.30 ,500% of HEALTHLINK fee schedule,$47.30 ,500% of HEALTHLINK fee schedule,$47.30 ,500% of HEALTHLINK fee schedule,$6.22 ,120% of MO fee schedule,$6.22 ,120% of MO fee schedule,$6.22 ,120% of MO fee schedule,$102.41 ,77% of total billed charges,$113.05 ,85% of total billed charges,$38.24 ,28.75% of total billed charges,$133.00 ,100% of UHC fee schedule,$6.22 ,120% of MO fee schedule,$33.25 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$33.25 ,25% of total billed charges,$6.22 ,$133.00 ,$66.50 
Outpatient Medical Services,LABORATORY,82248,Total Bilirubin Direct Bilirubin Indirect Bilirubin,301,$112.00 ,$86.24 ,77% of total billed charges,$28.56 ,25.5% of total billed charges,$28.56 ,25.5% of total billed charges,$35.00 ,31.25% of total billed charges,$82.88 ,74% of total billed charges,$77.28 ,69% of total billed charges,$77.28 ,69% of total billed charges,$28.00 ,25% of total billed charges,$77.28 ,69% of total billed charges,$77.28 ,69% of total billed charges,$31.47 ,100% of BCBS fee schedule,$91.84 ,82% of total billed charges,$36.65 ,500% of HEALTHLINK fee schedule,$36.65 ,500% of HEALTHLINK fee schedule,$36.65 ,500% of HEALTHLINK fee schedule,$4.81 ,120% of MO fee schedule,$4.81 ,120% of MO fee schedule,$4.81 ,120% of MO fee schedule,$86.24 ,77% of total billed charges,$95.20 ,85% of total billed charges,$32.20 ,28.75% of total billed charges,$112.00 ,100% of UHC fee schedule,$4.81 ,120% of MO fee schedule,$28.00 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$28.00 ,25% of total billed charges,$4.81 ,$112.00 ,$56.00 
Outpatient Medical Services,LABORATORY,82306,Vitamin D testing,301,$273.00 ,$210.21 ,77% of total billed charges,$69.62 ,25.5% of total billed charges,$69.62 ,25.5% of total billed charges,$85.31 ,31.25% of total billed charges,$202.02 ,74% of total billed charges,$188.37 ,69% of total billed charges,$188.37 ,69% of total billed charges,$68.25 ,25% of total billed charges,$188.37 ,69% of total billed charges,$188.37 ,69% of total billed charges,$185.64 ,100% of BCBS fee schedule,$223.86 ,82% of total billed charges,$216.10 ,500% of HEALTHLINK fee schedule,$216.10 ,500% of HEALTHLINK fee schedule,$216.10 ,500% of HEALTHLINK fee schedule,$28.42 ,120% of MO fee schedule,$28.42 ,120% of MO fee schedule,$28.42 ,120% of MO fee schedule,$210.21 ,77% of total billed charges,$232.05 ,85% of total billed charges,$78.49 ,28.75% of total billed charges,$273.00 ,100% of UHC fee schedule,$28.42 ,120% of MO fee schedule,$68.25 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$68.25 ,25% of total billed charges,$28.42 ,$273.00 ,$136.50 
Outpatient Medical Services,LABORATORY,82550,Creatine Kinase,301,$92.50 ,$71.23 ,77% of total billed charges,$23.59 ,25.5% of total billed charges,$23.59 ,25.5% of total billed charges,$28.91 ,31.25% of total billed charges,$68.45 ,74% of total billed charges,$63.83 ,69% of total billed charges,$63.83 ,69% of total billed charges,$23.13 ,25% of total billed charges,$63.83 ,69% of total billed charges,$63.83 ,69% of total billed charges,$40.87 ,100% of BCBS fee schedule,$75.85 ,82% of total billed charges,$47.55 ,500% of HEALTHLINK fee schedule,$47.55 ,500% of HEALTHLINK fee schedule,$47.55 ,500% of HEALTHLINK fee schedule,$6.24 ,120% of MO fee schedule,$6.24 ,120% of MO fee schedule,$6.24 ,120% of MO fee schedule,$71.23 ,77% of total billed charges,$78.63 ,85% of total billed charges,$26.59 ,28.75% of total billed charges,$92.50 ,100% of UHC fee schedule,$6.24 ,120% of MO fee schedule,$23.13 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$23.13 ,25% of total billed charges,$6.24 ,$92.50 ,$46.25 
Outpatient Medical Services,LABORATORY,82565,Copper Level Test,301,$68.50 ,$52.75 ,77% of total billed charges,$17.47 ,25.5% of total billed charges,$17.47 ,25.5% of total billed charges,$21.41 ,31.25% of total billed charges,$50.69 ,74% of total billed charges,$47.27 ,69% of total billed charges,$47.27 ,69% of total billed charges,$17.13 ,25% of total billed charges,$47.27 ,69% of total billed charges,$47.27 ,69% of total billed charges,$32.17 ,100% of BCBS fee schedule,$56.17 ,82% of total billed charges,$37.40 ,500% of HEALTHLINK fee schedule,$37.40 ,500% of HEALTHLINK fee schedule,$37.40 ,500% of HEALTHLINK fee schedule,$4.91 ,120% of MO fee schedule,$4.91 ,120% of MO fee schedule,$4.91 ,120% of MO fee schedule,$52.75 ,77% of total billed charges,$58.23 ,85% of total billed charges,$19.69 ,28.75% of total billed charges,$68.50 ,100% of UHC fee schedule,$4.91 ,120% of MO fee schedule,$17.13 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$17.13 ,25% of total billed charges,$4.91 ,$68.50 ,$34.25 
Outpatient Medical Services,LABORATORY,82570,"Albumin:Creatinine ratio, random urine",301,$62.00 ,$47.74 ,77% of total billed charges,$15.81 ,25.5% of total billed charges,$15.81 ,25.5% of total billed charges,$19.38 ,31.25% of total billed charges,$45.88 ,74% of total billed charges,$42.78 ,69% of total billed charges,$42.78 ,69% of total billed charges,$15.50 ,25% of total billed charges,$42.78 ,69% of total billed charges,$42.78 ,69% of total billed charges,$32.45 ,100% of BCBS fee schedule,$50.84 ,82% of total billed charges,$37.80 ,500% of HEALTHLINK fee schedule,$37.80 ,500% of HEALTHLINK fee schedule,$37.80 ,500% of HEALTHLINK fee schedule,$4.97 ,120% of MO fee schedule,$4.97 ,120% of MO fee schedule,$4.97 ,120% of MO fee schedule,$47.74 ,77% of total billed charges,$52.70 ,85% of total billed charges,$17.83 ,28.75% of total billed charges,$62.00 ,100% of UHC fee schedule,$4.97 ,120% of MO fee schedule,$15.50 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$15.50 ,25% of total billed charges,$4.97 ,$62.00 ,$31.00 
Outpatient Medical Services,LABORATORY,82607,Vitamin B-12 Testing,301,$176.00 ,$135.52 ,77% of total billed charges,$44.88 ,25.5% of total billed charges,$44.88 ,25.5% of total billed charges,$55.00 ,31.25% of total billed charges,$130.24 ,74% of total billed charges,$121.44 ,69% of total billed charges,$121.44 ,69% of total billed charges,$44.00 ,25% of total billed charges,$121.44 ,69% of total billed charges,$121.44 ,69% of total billed charges,$94.52 ,100% of BCBS fee schedule,$144.32 ,82% of total billed charges,$110.05 ,500% of HEALTHLINK fee schedule,$110.05 ,500% of HEALTHLINK fee schedule,$110.05 ,500% of HEALTHLINK fee schedule,$14.47 ,120% of MO fee schedule,$14.47 ,120% of MO fee schedule,$14.47 ,120% of MO fee schedule,$135.52 ,77% of total billed charges,$149.60 ,85% of total billed charges,$50.60 ,28.75% of total billed charges,$176.00 ,100% of UHC fee schedule,$14.47 ,120% of MO fee schedule,$44.00 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$44.00 ,25% of total billed charges,$14.47 ,$176.00 ,$88.00 
Outpatient Medical Services,LABORATORY,82672,estrogen analysis,301,$235.00 ,$180.95 ,77% of total billed charges,$59.93 ,25.5% of total billed charges,$59.93 ,25.5% of total billed charges,$73.44 ,31.25% of total billed charges,$173.90 ,74% of total billed charges,$162.15 ,69% of total billed charges,$162.15 ,69% of total billed charges,$58.75 ,25% of total billed charges,$162.15 ,69% of total billed charges,$162.15 ,69% of total billed charges,$136.06 ,100% of BCBS fee schedule,$192.70 ,82% of total billed charges,$158.30 ,500% of HEALTHLINK fee schedule,$158.30 ,500% of HEALTHLINK fee schedule,$158.30 ,500% of HEALTHLINK fee schedule,$20.83 ,120% of MO fee schedule,$20.83 ,120% of MO fee schedule,$20.83 ,120% of MO fee schedule,$180.95 ,77% of total billed charges,$199.75 ,85% of total billed charges,$67.56 ,28.75% of total billed charges,$235.00 ,100% of UHC fee schedule,$20.83 ,120% of MO fee schedule,$58.75 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$58.75 ,25% of total billed charges,$20.83 ,$235.00 ,$117.50 
Outpatient Medical Services,LABORATORY,82728,Ferritin Iron Transferrin Calculated total iron binding capacity (TIBC) % Saturation,301,$185.50 ,$142.84 ,77% of total billed charges,$47.30 ,25.5% of total billed charges,$47.30 ,25.5% of total billed charges,$57.97 ,31.25% of total billed charges,$137.27 ,74% of total billed charges,$128.00 ,69% of total billed charges,$128.00 ,69% of total billed charges,$46.38 ,25% of total billed charges,$128.00 ,69% of total billed charges,$128.00 ,69% of total billed charges,$85.43 ,100% of BCBS fee schedule,$152.11 ,82% of total billed charges,$99.45 ,500% of HEALTHLINK fee schedule,$99.45 ,500% of HEALTHLINK fee schedule,$99.45 ,500% of HEALTHLINK fee schedule,$13.08 ,120% of MO fee schedule,$13.08 ,120% of MO fee schedule,$13.08 ,120% of MO fee schedule,$142.84 ,77% of total billed charges,$157.68 ,85% of total billed charges,$53.33 ,28.75% of total billed charges,$185.50 ,100% of UHC fee schedule,$13.08 ,120% of MO fee schedule,$46.38 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$46.38 ,25% of total billed charges,$13.08 ,$185.50 ,$92.75 
Outpatient Medical Services,LABORATORY,82746,"Vitamin B12 Folate, Serum",301,$157.00 ,$120.89 ,77% of total billed charges,$40.04 ,25.5% of total billed charges,$40.04 ,25.5% of total billed charges,$49.06 ,31.25% of total billed charges,$116.18 ,74% of total billed charges,$108.33 ,69% of total billed charges,$108.33 ,69% of total billed charges,$39.25 ,25% of total billed charges,$108.33 ,69% of total billed charges,$108.33 ,69% of total billed charges,$92.20 ,100% of BCBS fee schedule,$128.74 ,82% of total billed charges,$107.35 ,500% of HEALTHLINK fee schedule,$107.35 ,500% of HEALTHLINK fee schedule,$107.35 ,500% of HEALTHLINK fee schedule,$14.11 ,120% of MO fee schedule,$14.11 ,120% of MO fee schedule,$14.11 ,120% of MO fee schedule,$120.89 ,77% of total billed charges,$133.45 ,85% of total billed charges,$45.14 ,28.75% of total billed charges,$157.00 ,100% of UHC fee schedule,$14.11 ,120% of MO fee schedule,$39.25 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$39.25 ,25% of total billed charges,$14.11 ,$157.00 ,$78.50 
Outpatient Medical Services,LABORATORY,82784,Gammaglobulin (immunoglobulin),301,$122.00 ,$93.94 ,77% of total billed charges,$31.11 ,25.5% of total billed charges,$31.11 ,25.5% of total billed charges,$38.13 ,31.25% of total billed charges,$90.28 ,74% of total billed charges,$84.18 ,69% of total billed charges,$84.18 ,69% of total billed charges,$30.50 ,25% of total billed charges,$84.18 ,69% of total billed charges,$84.18 ,69% of total billed charges,$34.95 ,100% of BCBS fee schedule,$100.04 ,82% of total billed charges,$40.65 ,500% of HEALTHLINK fee schedule,$40.65 ,500% of HEALTHLINK fee schedule,$40.65 ,500% of HEALTHLINK fee schedule,$8.93 ,120% of MO fee schedule,$8.93 ,120% of MO fee schedule,$8.93 ,120% of MO fee schedule,$93.94 ,77% of total billed charges,$103.70 ,85% of total billed charges,$35.08 ,28.75% of total billed charges,$122.00 ,100% of UHC fee schedule,$8.93 ,120% of MO fee schedule,$30.50 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$30.50 ,25% of total billed charges,$8.93 ,$122.00 ,$61.00 
Outpatient Medical Services,LABORATORY,82805,"Gases, blood, any combination of pH, pCO2, pO2, CO2, HCO3",301,$280.00 ,$215.60 ,77% of total billed charges,$71.40 ,25.5% of total billed charges,$71.40 ,25.5% of total billed charges,$87.50 ,31.25% of total billed charges,$207.20 ,74% of total billed charges,$193.20 ,69% of total billed charges,$193.20 ,69% of total billed charges,$70.00 ,25% of total billed charges,$193.20 ,69% of total billed charges,$193.20 ,69% of total billed charges,$177.98 ,100% of BCBS fee schedule,$229.60 ,82% of total billed charges,$207.15 ,500% of HEALTHLINK fee schedule,$207.15 ,500% of HEALTHLINK fee schedule,$207.15 ,500% of HEALTHLINK fee schedule,$75.61 ,120% of MO fee schedule,$75.61 ,120% of MO fee schedule,$75.61 ,120% of MO fee schedule,$215.60 ,77% of total billed charges,$238.00 ,85% of total billed charges,$80.50 ,28.75% of total billed charges,$280.00 ,100% of UHC fee schedule,$75.61 ,120% of MO fee schedule,$70.00 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$70.00 ,25% of total billed charges,$55.00 ,$280.00 ,$140.00 
Outpatient Medical Services,LABORATORY,82947,"Glucose; quantitative, blood (except reagent strip)",300,$81.50 ,$62.76 ,77% of total billed charges,$20.78 ,25.5% of total billed charges,$20.78 ,25.5% of total billed charges,$25.47 ,31.25% of total billed charges,$60.31 ,74% of total billed charges,$56.24 ,69% of total billed charges,$56.24 ,69% of total billed charges,$20.38 ,25% of total billed charges,$56.24 ,69% of total billed charges,$56.24 ,69% of total billed charges,$24.60 ,100% of BCBS fee schedule,$66.83 ,82% of total billed charges,$28.65 ,500% of HEALTHLINK fee schedule,$28.65 ,500% of HEALTHLINK fee schedule,$28.65 ,500% of HEALTHLINK fee schedule,$3.77 ,120% of MO fee schedule,$3.77 ,120% of MO fee schedule,$3.77 ,120% of MO fee schedule,$62.76 ,77% of total billed charges,$69.28 ,85% of total billed charges,$23.43 ,28.75% of total billed charges,$81.50 ,100% of UHC fee schedule,$3.77 ,120% of MO fee schedule,$20.38 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$20.38 ,25% of total billed charges,$3.77 ,$81.50 ,$40.75 
Outpatient Medical Services,LABORATORY,82950,Glucose; post glucose dose (includes glucose),310,$68.50 ,$52.75 ,77% of total billed charges,$17.47 ,25.5% of total billed charges,$17.47 ,25.5% of total billed charges,$21.41 ,31.25% of total billed charges,$50.69 ,74% of total billed charges,$47.27 ,69% of total billed charges,$47.27 ,69% of total billed charges,$17.13 ,25% of total billed charges,$47.27 ,69% of total billed charges,$47.27 ,69% of total billed charges,$29.76 ,100% of BCBS fee schedule,$56.17 ,82% of total billed charges,$34.65 ,500% of HEALTHLINK fee schedule,$34.65 ,500% of HEALTHLINK fee schedule,$34.65 ,500% of HEALTHLINK fee schedule,$4.56 ,120% of MO fee schedule,$4.56 ,120% of MO fee schedule,$4.56 ,120% of MO fee schedule,$52.75 ,77% of total billed charges,$58.23 ,85% of total billed charges,$19.69 ,28.75% of total billed charges,$68.50 ,100% of UHC fee schedule,$4.56 ,120% of MO fee schedule,$17.13 ,25% of total billed charges,$70.00 ,pays based on per visit rate,$17.13 ,25% of total billed charges,$4.56 ,$70.00 ,$34.25 
Outpatient Medical Services,LABORATORY,83001,Gonadotropin; follicle stimulating hormone. Test,301,$182.00 ,$140.14 ,77% of total billed charges,$46.41 ,25.5% of total billed charges,$46.41 ,25.5% of total billed charges,$56.88 ,31.25% of total billed charges,$134.68 ,74% of total billed charges,$125.58 ,69% of total billed charges,$125.58 ,69% of total billed charges,$45.50 ,25% of total billed charges,$125.58 ,69% of total billed charges,$125.58 ,69% of total billed charges,$116.53 ,100% of BCBS fee schedule,$149.24 ,82% of total billed charges,$135.70 ,500% of HEALTHLINK fee schedule,$135.70 ,500% of HEALTHLINK fee schedule,$135.70 ,500% of HEALTHLINK fee schedule,$17.83 ,120% of MO fee schedule,$17.83 ,120% of MO fee schedule,$17.83 ,120% of MO fee schedule,$140.14 ,77% of total billed charges,$154.70 ,85% of total billed charges,$52.33 ,28.75% of total billed charges,$182.00 ,100% of UHC fee schedule,$17.83 ,120% of MO fee schedule,$45.50 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$45.50 ,25% of total billed charges,$17.83 ,$182.00 ,$91.00 
Outpatient Medical Services,LABORATORY,83036,Hemoglobin; glycosylated,301,$131.00 ,$100.87 ,77% of total billed charges,$33.41 ,25.5% of total billed charges,$33.41 ,25.5% of total billed charges,$40.94 ,31.25% of total billed charges,$96.94 ,74% of total billed charges,$90.39 ,69% of total billed charges,$90.39 ,69% of total billed charges,$32.75 ,25% of total billed charges,$90.39 ,69% of total billed charges,$90.39 ,69% of total billed charges,$60.87 ,100% of BCBS fee schedule,$107.42 ,82% of total billed charges,$70.85 ,500% of HEALTHLINK fee schedule,$70.85 ,500% of HEALTHLINK fee schedule,$70.85 ,500% of HEALTHLINK fee schedule,$9.31 ,120% of MO fee schedule,$9.31 ,120% of MO fee schedule,$9.31 ,120% of MO fee schedule,$100.87 ,77% of total billed charges,$111.35 ,85% of total billed charges,$37.66 ,28.75% of total billed charges,$131.00 ,100% of UHC fee schedule,$9.31 ,120% of MO fee schedule,$32.75 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$32.75 ,25% of total billed charges,$9.31 ,$131.00 ,$65.50 
Outpatient Medical Services,LABORATORY,83516,Immunoassay for analyte other than infectious agent antibody or infectious agent antigen.,301,$184.50 ,$142.07 ,77% of total billed charges,$47.05 ,25.5% of total billed charges,$47.05 ,25.5% of total billed charges,$57.66 ,31.25% of total billed charges,$136.53 ,74% of total billed charges,$127.31 ,69% of total billed charges,$127.31 ,69% of total billed charges,$46.13 ,25% of total billed charges,$127.31 ,69% of total billed charges,$127.31 ,69% of total billed charges,$72.35 ,100% of BCBS fee schedule,$151.29 ,82% of total billed charges,$84.25 ,500% of HEALTHLINK fee schedule,$84.25 ,500% of HEALTHLINK fee schedule,$84.25 ,500% of HEALTHLINK fee schedule,$11.06 ,120% of MO fee schedule,$11.06 ,120% of MO fee schedule,$11.06 ,120% of MO fee schedule,$142.07 ,77% of total billed charges,$156.83 ,85% of total billed charges,$53.04 ,28.75% of total billed charges,$184.50 ,100% of UHC fee schedule,$11.06 ,120% of MO fee schedule,$46.13 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$46.13 ,25% of total billed charges,$11.06 ,$184.50 ,$92.25 
Outpatient Medical Services,LABORATORY,83525,Insulin,301,$123.50 ,$95.10 ,77% of total billed charges,$31.49 ,25.5% of total billed charges,$31.49 ,25.5% of total billed charges,$38.59 ,31.25% of total billed charges,$91.39 ,74% of total billed charges,$85.22 ,69% of total billed charges,$85.22 ,69% of total billed charges,$30.88 ,25% of total billed charges,$85.22 ,69% of total billed charges,$85.22 ,69% of total billed charges,$71.71 ,100% of BCBS fee schedule,$101.27 ,82% of total billed charges,$83.45 ,500% of HEALTHLINK fee schedule,$83.45 ,500% of HEALTHLINK fee schedule,$83.45 ,500% of HEALTHLINK fee schedule,$10.97 ,120% of MO fee schedule,$10.97 ,120% of MO fee schedule,$10.97 ,120% of MO fee schedule,$95.10 ,77% of total billed charges,$104.98 ,85% of total billed charges,$35.51 ,28.75% of total billed charges,$123.50 ,100% of UHC fee schedule,$10.97 ,120% of MO fee schedule,$30.88 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$30.88 ,25% of total billed charges,$10.97 ,$123.50 ,$61.75 
Outpatient Medical Services,LABORATORY,83540,Iron Transferrin Calculated TIBC % Saturation,301,$91.00 ,$70.07 ,77% of total billed charges,$23.21 ,25.5% of total billed charges,$23.21 ,25.5% of total billed charges,$28.44 ,31.25% of total billed charges,$67.34 ,74% of total billed charges,$62.79 ,69% of total billed charges,$62.79 ,69% of total billed charges,$22.75 ,25% of total billed charges,$62.79 ,69% of total billed charges,$62.79 ,69% of total billed charges,$40.63 ,100% of BCBS fee schedule,$74.62 ,82% of total billed charges,$47.30 ,500% of HEALTHLINK fee schedule,$47.30 ,500% of HEALTHLINK fee schedule,$47.30 ,500% of HEALTHLINK fee schedule,$6.20 ,120% of MO fee schedule,$6.20 ,120% of MO fee schedule,$6.20 ,120% of MO fee schedule,$70.07 ,77% of total billed charges,$77.35 ,85% of total billed charges,$26.16 ,28.75% of total billed charges,$91.00 ,100% of UHC fee schedule,$6.20 ,120% of MO fee schedule,$22.75 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$22.75 ,25% of total billed charges,$6.20 ,$91.00 ,$45.50 
Outpatient Medical Services,LABORATORY,83550,Iron Binding Capacity,301,$101.00 ,$77.77 ,77% of total billed charges,$25.76 ,25.5% of total billed charges,$25.76 ,25.5% of total billed charges,$31.56 ,31.25% of total billed charges,$74.74 ,74% of total billed charges,$69.69 ,69% of total billed charges,$69.69 ,69% of total billed charges,$25.25 ,25% of total billed charges,$69.69 ,69% of total billed charges,$69.69 ,69% of total billed charges,$54.82 ,100% of BCBS fee schedule,$82.82 ,82% of total billed charges,$63.85 ,500% of HEALTHLINK fee schedule,$63.85 ,500% of HEALTHLINK fee schedule,$63.85 ,500% of HEALTHLINK fee schedule,$8.39 ,120% of MO fee schedule,$8.39 ,120% of MO fee schedule,$8.39 ,120% of MO fee schedule,$77.77 ,77% of total billed charges,$85.85 ,85% of total billed charges,$29.04 ,28.75% of total billed charges,$101.00 ,100% of UHC fee schedule,$8.39 ,120% of MO fee schedule,$25.25 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$25.25 ,25% of total billed charges,$8.39 ,$101.00 ,$50.50 
Outpatient Medical Services,LABORATORY,83605,lactic acid test,301,$142.50 ,$109.73 ,77% of total billed charges,$36.34 ,25.5% of total billed charges,$36.34 ,25.5% of total billed charges,$44.53 ,31.25% of total billed charges,$105.45 ,74% of total billed charges,$98.33 ,69% of total billed charges,$98.33 ,69% of total billed charges,$35.63 ,25% of total billed charges,$98.33 ,69% of total billed charges,$98.33 ,69% of total billed charges,$66.97 ,100% of BCBS fee schedule,$116.85 ,82% of total billed charges,$77.95 ,500% of HEALTHLINK fee schedule,$77.95 ,500% of HEALTHLINK fee schedule,$77.95 ,500% of HEALTHLINK fee schedule,$11.10 ,120% of MO fee schedule,$11.10 ,120% of MO fee schedule,$11.10 ,120% of MO fee schedule,$109.73 ,77% of total billed charges,$121.13 ,85% of total billed charges,$40.97 ,28.75% of total billed charges,$142.50 ,100% of UHC fee schedule,$11.10 ,120% of MO fee schedule,$35.63 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$35.63 ,25% of total billed charges,$11.10 ,$142.50 ,$71.25 
Outpatient Medical Services,LABORATORY,83615,complete examination of all four quadrants of the breast and the retroareolar region;,301,$97.00 ,$74.69 ,77% of total billed charges,$24.74 ,25.5% of total billed charges,$24.74 ,25.5% of total billed charges,$30.31 ,31.25% of total billed charges,$71.78 ,74% of total billed charges,$66.93 ,69% of total billed charges,$66.93 ,69% of total billed charges,$24.25 ,25% of total billed charges,$66.93 ,69% of total billed charges,$66.93 ,69% of total billed charges,$37.87 ,100% of BCBS fee schedule,$79.54 ,82% of total billed charges,$44.05 ,500% of HEALTHLINK fee schedule,$44.05 ,500% of HEALTHLINK fee schedule,$44.05 ,500% of HEALTHLINK fee schedule,$5.80 ,120% of MO fee schedule,$5.80 ,120% of MO fee schedule,$5.80 ,120% of MO fee schedule,$74.69 ,77% of total billed charges,$82.45 ,85% of total billed charges,$27.89 ,28.75% of total billed charges,$97.00 ,100% of UHC fee schedule,$5.80 ,120% of MO fee schedule,$24.25 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$24.25 ,25% of total billed charges,$5.80 ,$97.00 ,$48.50 
Outpatient Medical Services,LABORATORY,83690,Lipase (fat enzyme) level,301,$164.50 ,$126.67 ,77% of total billed charges,$41.95 ,25.5% of total billed charges,$41.95 ,25.5% of total billed charges,$51.41 ,31.25% of total billed charges,$121.73 ,74% of total billed charges,$113.51 ,69% of total billed charges,$113.51 ,69% of total billed charges,$41.13 ,25% of total billed charges,$113.51 ,69% of total billed charges,$113.51 ,69% of total billed charges,$43.21 ,100% of BCBS fee schedule,$134.89 ,82% of total billed charges,$50.30 ,500% of HEALTHLINK fee schedule,$50.30 ,500% of HEALTHLINK fee schedule,$50.30 ,500% of HEALTHLINK fee schedule,$6.61 ,120% of MO fee schedule,$6.61 ,120% of MO fee schedule,$6.61 ,120% of MO fee schedule,$126.67 ,77% of total billed charges,$139.83 ,85% of total billed charges,$47.29 ,28.75% of total billed charges,$164.50 ,100% of UHC fee schedule,$6.61 ,120% of MO fee schedule,$41.13 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$41.13 ,25% of total billed charges,$6.61 ,$164.50 ,$82.25 
Outpatient Medical Services,LABORATORY,83735,Serum Magnesium,301,$87.50 ,$67.38 ,77% of total billed charges,$22.31 ,25.5% of total billed charges,$22.31 ,25.5% of total billed charges,$27.34 ,31.25% of total billed charges,$64.75 ,74% of total billed charges,$60.38 ,69% of total billed charges,$60.38 ,69% of total billed charges,$21.88 ,25% of total billed charges,$60.38 ,69% of total billed charges,$60.38 ,69% of total billed charges,$42.05 ,100% of BCBS fee schedule,$71.75 ,82% of total billed charges,$48.90 ,500% of HEALTHLINK fee schedule,$48.90 ,500% of HEALTHLINK fee schedule,$48.90 ,500% of HEALTHLINK fee schedule,$6.43 ,120% of MO fee schedule,$6.43 ,120% of MO fee schedule,$6.43 ,120% of MO fee schedule,$67.38 ,77% of total billed charges,$74.38 ,85% of total billed charges,$25.16 ,28.75% of total billed charges,$87.50 ,100% of UHC fee schedule,$6.43 ,120% of MO fee schedule,$21.88 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$21.88 ,25% of total billed charges,$6.43 ,$87.50 ,$43.75 
Outpatient Medical Services,LABORATORY,83880,Assay of natriuretic peptide,301,$298.50 ,$229.85 ,77% of total billed charges,$76.12 ,25.5% of total billed charges,$76.12 ,25.5% of total billed charges,$93.28 ,31.25% of total billed charges,$220.89 ,74% of total billed charges,$205.97 ,69% of total billed charges,$205.97 ,69% of total billed charges,$74.63 ,25% of total billed charges,$205.97 ,69% of total billed charges,$205.97 ,69% of total billed charges,$174.97 ,100% of BCBS fee schedule,$244.77 ,82% of total billed charges,$203.70 ,500% of HEALTHLINK fee schedule,$203.70 ,500% of HEALTHLINK fee schedule,$203.70 ,500% of HEALTHLINK fee schedule,$37.68 ,120% of MO fee schedule,$37.68 ,120% of MO fee schedule,$37.68 ,120% of MO fee schedule,$229.85 ,77% of total billed charges,$253.73 ,85% of total billed charges,$85.82 ,28.75% of total billed charges,$298.50 ,100% of UHC fee schedule,$37.68 ,120% of MO fee schedule,$74.63 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$74.63 ,25% of total billed charges,$37.68 ,$298.50 ,$149.25 
Outpatient Medical Services,LABORATORY,84144,Progerstone,301,$132.00 ,$101.64 ,77% of total billed charges,$33.66 ,25.5% of total billed charges,$33.66 ,25.5% of total billed charges,$41.25 ,31.25% of total billed charges,$97.68 ,74% of total billed charges,$91.08 ,69% of total billed charges,$91.08 ,69% of total billed charges,$33.00 ,25% of total billed charges,$91.08 ,69% of total billed charges,$91.08 ,69% of total billed charges,$130.82 ,100% of BCBS fee schedule,$108.24 ,82% of total billed charges,$152.30 ,500% of HEALTHLINK fee schedule,$152.30 ,500% of HEALTHLINK fee schedule,$152.30 ,500% of HEALTHLINK fee schedule,$20.02 ,120% of MO fee schedule,$20.02 ,120% of MO fee schedule,$20.02 ,120% of MO fee schedule,$101.64 ,77% of total billed charges,$112.20 ,85% of total billed charges,$37.95 ,28.75% of total billed charges,$132.00 ,100% of UHC fee schedule,$20.02 ,120% of MO fee schedule,$33.00 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$33.00 ,25% of total billed charges,$20.02 ,$152.30 ,$66.00 
Outpatient Medical Services,LABORATORY,84145,procalcitonin (hormone) level,301,$235.50 ,$181.34 ,77% of total billed charges,$60.05 ,25.5% of total billed charges,$60.05 ,25.5% of total billed charges,$73.59 ,31.25% of total billed charges,$174.27 ,74% of total billed charges,$162.50 ,69% of total billed charges,$162.50 ,69% of total billed charges,$58.88 ,25% of total billed charges,$162.50 ,69% of total billed charges,$162.50 ,69% of total billed charges,$167.94 ,100% of BCBS fee schedule,$193.11 ,82% of total billed charges,$209.60 ,89% of total billed charges,$209.60 ,89% of total billed charges,$209.60 ,89% of total billed charges,$26.12 ,120% of MO fee schedule,$26.12 ,120% of MO fee schedule,$26.12 ,120% of MO fee schedule,$181.34 ,77% of total billed charges,$200.18 ,85% of total billed charges,$67.71 ,28.75% of total billed charges,$235.50 ,100% of UHC fee schedule,$26.12 ,120% of MO fee schedule,$58.88 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$58.88 ,25% of total billed charges,$26.12 ,$235.50 ,$117.75 
Outpatient Medical Services,LABORATORY,84146,Prolactin lab,301,$152.00 ,$117.04 ,77% of total billed charges,$38.76 ,25.5% of total billed charges,$38.76 ,25.5% of total billed charges,$47.50 ,31.25% of total billed charges,$112.48 ,74% of total billed charges,$104.88 ,69% of total billed charges,$104.88 ,69% of total billed charges,$38.00 ,25% of total billed charges,$104.88 ,69% of total billed charges,$104.88 ,69% of total billed charges,$121.52 ,100% of BCBS fee schedule,$124.64 ,82% of total billed charges,$141.50 ,500% of HEALTHLINK fee schedule,$141.50 ,500% of HEALTHLINK fee schedule,$141.50 ,500% of HEALTHLINK fee schedule,$18.60 ,120% of MO fee schedule,$18.60 ,120% of MO fee schedule,$18.60 ,120% of MO fee schedule,$117.04 ,77% of total billed charges,$129.20 ,85% of total billed charges,$43.70 ,28.75% of total billed charges,$152.00 ,100% of UHC fee schedule,$18.60 ,120% of MO fee schedule,$38.00 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$38.00 ,25% of total billed charges,$18.60 ,$152.00 ,$76.00 
Outpatient Medical Services,LABORATORY,84153,PSA (prostate specific antigen),301,$167.00 ,$128.59 ,77% of total billed charges,$42.59 ,25.5% of total billed charges,$42.59 ,25.5% of total billed charges,$52.19 ,31.25% of total billed charges,$123.58 ,74% of total billed charges,$115.23 ,69% of total billed charges,$115.23 ,69% of total billed charges,$41.75 ,25% of total billed charges,$115.23 ,69% of total billed charges,$115.23 ,69% of total billed charges,$115.38 ,100% of BCBS fee schedule,$136.94 ,82% of total billed charges,$134.25 ,500% of HEALTHLINK fee schedule,$134.25 ,500% of HEALTHLINK fee schedule,$134.25 ,500% of HEALTHLINK fee schedule,$17.65 ,120% of MO fee schedule,$17.65 ,120% of MO fee schedule,$17.65 ,120% of MO fee schedule,$128.59 ,77% of total billed charges,$141.95 ,85% of total billed charges,$48.01 ,28.75% of total billed charges,$167.00 ,100% of UHC fee schedule,$17.65 ,120% of MO fee schedule,$41.75 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$41.75 ,25% of total billed charges,$17.65 ,$167.00 ,$83.50 
Outpatient Medical Services,LABORATORY,84154,PSA (prostate specific antigen) measurement,301,$245.00 ,$188.65 ,77% of total billed charges,$62.48 ,25.5% of total billed charges,$62.48 ,25.5% of total billed charges,$76.56 ,31.25% of total billed charges,$181.30 ,74% of total billed charges,$169.05 ,69% of total billed charges,$169.05 ,69% of total billed charges,$61.25 ,25% of total billed charges,$169.05 ,69% of total billed charges,$169.05 ,69% of total billed charges,$115.38 ,100% of BCBS fee schedule,$200.90 ,82% of total billed charges,$134.25 ,500% of HEALTHLINK fee schedule,$134.25 ,500% of HEALTHLINK fee schedule,$134.25 ,500% of HEALTHLINK fee schedule,$17.65 ,120% of MO fee schedule,$17.65 ,120% of MO fee schedule,$17.65 ,120% of MO fee schedule,$188.65 ,77% of total billed charges,$208.25 ,85% of total billed charges,$70.44 ,28.75% of total billed charges,$245.00 ,100% of UHC fee schedule,$17.65 ,120% of MO fee schedule,$61.25 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$61.25 ,25% of total billed charges,$17.65 ,$245.00 ,$122.50 
Outpatient Medical Services,LABORATORY,84156,"Protein, total, except by refractometry",301,$118.50 ,$91.25 ,77% of total billed charges,$30.22 ,25.5% of total billed charges,$30.22 ,25.5% of total billed charges,$37.03 ,31.25% of total billed charges,$87.69 ,74% of total billed charges,$81.77 ,69% of total billed charges,$81.77 ,69% of total billed charges,$29.63 ,25% of total billed charges,$81.77 ,69% of total billed charges,$81.77 ,69% of total billed charges,$22.99 ,100% of BCBS fee schedule,$97.17 ,82% of total billed charges,$26.75 ,500% of HEALTHLINK fee schedule,$26.75 ,500% of HEALTHLINK fee schedule,$26.75 ,500% of HEALTHLINK fee schedule,$3.52 ,120% of MO fee schedule,$3.52 ,120% of MO fee schedule,$3.52 ,120% of MO fee schedule,$91.25 ,77% of total billed charges,$100.73 ,85% of total billed charges,$34.07 ,28.75% of total billed charges,$118.50 ,100% of UHC fee schedule,$3.52 ,120% of MO fee schedule,$29.63 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$29.63 ,25% of total billed charges,$3.52 ,$118.50 ,$59.25 
Outpatient Medical Services,LABORATORY,84402,"Testosterone, Free and Total",301,$235.00 ,$180.95 ,77% of total billed charges,$59.93 ,25.5% of total billed charges,$59.93 ,25.5% of total billed charges,$73.44 ,31.25% of total billed charges,$173.90 ,74% of total billed charges,$162.15 ,69% of total billed charges,$162.15 ,69% of total billed charges,$58.75 ,25% of total billed charges,$162.15 ,69% of total billed charges,$162.15 ,69% of total billed charges,$159.69 ,100% of BCBS fee schedule,$192.70 ,82% of total billed charges,$185.90 ,500% of HEALTHLINK fee schedule,$185.90 ,500% of HEALTHLINK fee schedule,$185.90 ,500% of HEALTHLINK fee schedule,$24.44 ,120% of MO fee schedule,$24.44 ,120% of MO fee schedule,$24.44 ,120% of MO fee schedule,$180.95 ,77% of total billed charges,$199.75 ,85% of total billed charges,$67.56 ,28.75% of total billed charges,$235.00 ,100% of UHC fee schedule,$24.44 ,120% of MO fee schedule,$58.75 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$58.75 ,25% of total billed charges,$24.44 ,$235.00 ,$117.50 
Outpatient Medical Services,LABORATORY,84403,Testosterone Total,301,$291.00 ,$224.07 ,77% of total billed charges,$74.21 ,25.5% of total billed charges,$74.21 ,25.5% of total billed charges,$90.94 ,31.25% of total billed charges,$215.34 ,74% of total billed charges,$200.79 ,69% of total billed charges,$200.79 ,69% of total billed charges,$72.75 ,25% of total billed charges,$200.79 ,69% of total billed charges,$200.79 ,69% of total billed charges,$161.91 ,100% of BCBS fee schedule,$238.62 ,82% of total billed charges,$188.50 ,500% of HEALTHLINK fee schedule,$188.50 ,500% of HEALTHLINK fee schedule,$188.50 ,500% of HEALTHLINK fee schedule,$24.77 ,120% of MO fee schedule,$24.77 ,120% of MO fee schedule,$24.77 ,120% of MO fee schedule,$224.07 ,77% of total billed charges,$247.35 ,85% of total billed charges,$83.66 ,28.75% of total billed charges,$291.00 ,100% of UHC fee schedule,$24.77 ,120% of MO fee schedule,$72.75 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$72.75 ,25% of total billed charges,$24.77 ,$291.00 ,$145.50 
Outpatient Medical Services,LABORATORY,84439,Thyroid Funtion Test,301,$153.00 ,$117.81 ,77% of total billed charges,$39.02 ,25.5% of total billed charges,$39.02 ,25.5% of total billed charges,$47.81 ,31.25% of total billed charges,$113.22 ,74% of total billed charges,$105.57 ,69% of total billed charges,$105.57 ,69% of total billed charges,$38.25 ,25% of total billed charges,$105.57 ,69% of total billed charges,$105.57 ,69% of total billed charges,$56.56 ,100% of BCBS fee schedule,$125.46 ,82% of total billed charges,$65.85 ,500% of HEALTHLINK fee schedule,$65.85 ,500% of HEALTHLINK fee schedule,$65.85 ,500% of HEALTHLINK fee schedule,$8.65 ,120% of MO fee schedule,$8.65 ,120% of MO fee schedule,$8.65 ,120% of MO fee schedule,$117.81 ,77% of total billed charges,$130.05 ,85% of total billed charges,$43.99 ,28.75% of total billed charges,$153.00 ,100% of UHC fee schedule,$8.65 ,120% of MO fee schedule,$38.25 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$38.25 ,25% of total billed charges,$8.65 ,$153.00 ,$76.50 
Outpatient Medical Services,LABORATORY,84443,"Blood test, thyroid stimulating hormone (TSH)",301,$152.00 ,$117.04 ,77% of total billed charges,$38.76 ,25.5% of total billed charges,$38.76 ,25.5% of total billed charges,$47.50 ,31.25% of total billed charges,$112.48 ,74% of total billed charges,$104.88 ,69% of total billed charges,$104.88 ,69% of total billed charges,$38.00 ,25% of total billed charges,$104.88 ,69% of total billed charges,$104.88 ,69% of total billed charges,$105.33 ,100% of BCBS fee schedule,$124.64 ,82% of total billed charges,$122.65 ,500% of HEALTHLINK fee schedule,$122.65 ,500% of HEALTHLINK fee schedule,$122.65 ,500% of HEALTHLINK fee schedule,$16.13 ,120% of MO fee schedule,$16.13 ,120% of MO fee schedule,$16.13 ,120% of MO fee schedule,$117.04 ,77% of total billed charges,$129.20 ,85% of total billed charges,$43.70 ,28.75% of total billed charges,$152.00 ,100% of UHC fee schedule,$16.13 ,120% of MO fee schedule,$38.00 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$38.00 ,25% of total billed charges,$16.13 ,$152.00 ,$76.00 
Outpatient Medical Services,LABORATORY,84480,T3 test,301,$124.00 ,$95.48 ,77% of total billed charges,$31.62 ,25.5% of total billed charges,$31.62 ,25.5% of total billed charges,$38.75 ,31.25% of total billed charges,$91.76 ,74% of total billed charges,$85.56 ,69% of total billed charges,$85.56 ,69% of total billed charges,$31.00 ,25% of total billed charges,$85.56 ,69% of total billed charges,$85.56 ,69% of total billed charges,$88.90 ,100% of BCBS fee schedule,$101.68 ,82% of total billed charges,$103.50 ,500% of HEALTHLINK fee schedule,$103.50 ,500% of HEALTHLINK fee schedule,$103.50 ,500% of HEALTHLINK fee schedule,$13.61 ,120% of MO fee schedule,$13.61 ,120% of MO fee schedule,$13.61 ,120% of MO fee schedule,$95.48 ,77% of total billed charges,$105.40 ,85% of total billed charges,$35.65 ,28.75% of total billed charges,$124.00 ,100% of UHC fee schedule,$13.61 ,120% of MO fee schedule,$31.00 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$31.00 ,25% of total billed charges,$13.61 ,$124.00 ,$62.00 
Outpatient Medical Services,LABORATORY,84481,Triiodothyronine Unbound T3,301,$124.00 ,$95.48 ,77% of total billed charges,$31.62 ,25.5% of total billed charges,$31.62 ,25.5% of total billed charges,$38.75 ,31.25% of total billed charges,$91.76 ,74% of total billed charges,$85.56 ,69% of total billed charges,$85.56 ,69% of total billed charges,$31.00 ,25% of total billed charges,$85.56 ,69% of total billed charges,$85.56 ,69% of total billed charges,$106.23 ,100% of BCBS fee schedule,$101.68 ,82% of total billed charges,$123.70 ,500% of HEALTHLINK fee schedule,$123.70 ,500% of HEALTHLINK fee schedule,$123.70 ,500% of HEALTHLINK fee schedule,$16.26 ,120% of MO fee schedule,$16.26 ,120% of MO fee schedule,$16.26 ,120% of MO fee schedule,$95.48 ,77% of total billed charges,$105.40 ,85% of total billed charges,$35.65 ,28.75% of total billed charges,$124.00 ,100% of UHC fee schedule,$16.26 ,120% of MO fee schedule,$31.00 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$31.00 ,25% of total billed charges,$16.26 ,$124.00 ,$62.00 
Outpatient Medical Services,LABORATORY,84484,"Troponin, quantitative",301,$179.50 ,$138.22 ,77% of total billed charges,$45.77 ,25.5% of total billed charges,$45.77 ,25.5% of total billed charges,$56.09 ,31.25% of total billed charges,$132.83 ,74% of total billed charges,$123.86 ,69% of total billed charges,$123.86 ,69% of total billed charges,$44.88 ,25% of total billed charges,$123.86 ,69% of total billed charges,$123.86 ,69% of total billed charges,$61.71 ,100% of BCBS fee schedule,$147.19 ,82% of total billed charges,$71.85 ,500% of HEALTHLINK fee schedule,$71.85 ,500% of HEALTHLINK fee schedule,$71.85 ,500% of HEALTHLINK fee schedule,$11.96 ,120% of MO fee schedule,$11.96 ,120% of MO fee schedule,$11.96 ,120% of MO fee schedule,$138.22 ,77% of total billed charges,$152.58 ,85% of total billed charges,$51.61 ,28.75% of total billed charges,$179.50 ,100% of UHC fee schedule,$11.96 ,120% of MO fee schedule,$44.88 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$44.88 ,25% of total billed charges,$11.96 ,$179.50 ,$89.75 
Outpatient Medical Services,LABORATORY,84520,Urea nitrogen,301,$68.50 ,$52.75 ,77% of total billed charges,$17.47 ,25.5% of total billed charges,$17.47 ,25.5% of total billed charges,$21.41 ,31.25% of total billed charges,$50.69 ,74% of total billed charges,$47.27 ,69% of total billed charges,$47.27 ,69% of total billed charges,$17.13 ,25% of total billed charges,$47.27 ,69% of total billed charges,$47.27 ,69% of total billed charges,$24.78 ,100% of BCBS fee schedule,$56.17 ,82% of total billed charges,$28.80 ,500% of HEALTHLINK fee schedule,$28.80 ,500% of HEALTHLINK fee schedule,$28.80 ,500% of HEALTHLINK fee schedule,$3.79 ,120% of MO fee schedule,$3.79 ,120% of MO fee schedule,$3.79 ,120% of MO fee schedule,$52.75 ,77% of total billed charges,$58.23 ,85% of total billed charges,$19.69 ,28.75% of total billed charges,$68.50 ,100% of UHC fee schedule,$3.79 ,120% of MO fee schedule,$17.13 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$17.13 ,25% of total billed charges,$3.79 ,$68.50 ,$34.25 
Outpatient Medical Services,LABORATORY,84550,Uric Acid,301,$84.00 ,$64.68 ,77% of total billed charges,$21.42 ,25.5% of total billed charges,$21.42 ,25.5% of total billed charges,$26.25 ,31.25% of total billed charges,$62.16 ,74% of total billed charges,$57.96 ,69% of total billed charges,$57.96 ,69% of total billed charges,$21.00 ,25% of total billed charges,$57.96 ,69% of total billed charges,$57.96 ,69% of total billed charges,$28.34 ,100% of BCBS fee schedule,$68.88 ,82% of total billed charges,$32.95 ,500% of HEALTHLINK fee schedule,$32.95 ,500% of HEALTHLINK fee schedule,$32.95 ,500% of HEALTHLINK fee schedule,$4.33 ,120% of MO fee schedule,$4.33 ,120% of MO fee schedule,$4.33 ,120% of MO fee schedule,$64.68 ,77% of total billed charges,$71.40 ,85% of total billed charges,$24.15 ,28.75% of total billed charges,$84.00 ,100% of UHC fee schedule,$4.33 ,120% of MO fee schedule,$21.00 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$21.00 ,25% of total billed charges,$4.33 ,$84.00 ,$42.00 
Outpatient Medical Services,LABORATORY,84702,"Gonadotropin, chorionic (hCG)",301,$210.00 ,$161.70 ,77% of total billed charges,$53.55 ,25.5% of total billed charges,$53.55 ,25.5% of total billed charges,$65.63 ,31.25% of total billed charges,$155.40 ,74% of total billed charges,$144.90 ,69% of total billed charges,$144.90 ,69% of total billed charges,$52.50 ,25% of total billed charges,$144.90 ,69% of total billed charges,$144.90 ,69% of total billed charges,$43.82 ,100% of BCBS fee schedule,$172.20 ,82% of total billed charges,$51.00 ,500% of HEALTHLINK fee schedule,$51.00 ,500% of HEALTHLINK fee schedule,$51.00 ,500% of HEALTHLINK fee schedule,$14.45 ,120% of MO fee schedule,$14.45 ,120% of MO fee schedule,$14.45 ,120% of MO fee schedule,$161.70 ,77% of total billed charges,$178.50 ,85% of total billed charges,$60.38 ,28.75% of total billed charges,$210.00 ,100% of UHC fee schedule,$14.45 ,120% of MO fee schedule,$52.50 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$52.50 ,25% of total billed charges,$14.45 ,$210.00 ,$105.00 
Outpatient Medical Services,LABORATORY,84703,"Gonadotropin, chorionic (hCG)",301,$101.40 ,$78.08 ,77% of total billed charges,$25.86 ,25.5% of total billed charges,$25.86 ,25.5% of total billed charges,$31.69 ,31.25% of total billed charges,$75.04 ,74% of total billed charges,$69.97 ,69% of total billed charges,$69.97 ,69% of total billed charges,$25.35 ,25% of total billed charges,$69.97 ,69% of total billed charges,$69.97 ,69% of total billed charges,$47.10 ,100% of BCBS fee schedule,$83.15 ,82% of total billed charges,$54.85 ,500% of HEALTHLINK fee schedule,$54.85 ,500% of HEALTHLINK fee schedule,$54.85 ,500% of HEALTHLINK fee schedule,$7.21 ,120% of MO fee schedule,$7.21 ,120% of MO fee schedule,$7.21 ,120% of MO fee schedule,$78.08 ,77% of total billed charges,$86.19 ,85% of total billed charges,$29.15 ,28.75% of total billed charges,$101.40 ,100% of UHC fee schedule,$7.21 ,120% of MO fee schedule,$25.35 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$25.35 ,25% of total billed charges,$7.21 ,$101.40 ,$50.70 
Outpatient Medical Services,LABORATORY,85007,"blood smear, with differential WBC count",305,$52.00 ,$40.04 ,77% of total billed charges,$13.26 ,25.5% of total billed charges,$13.26 ,25.5% of total billed charges,$16.25 ,31.25% of total billed charges,$38.48 ,74% of total billed charges,$35.88 ,69% of total billed charges,$35.88 ,69% of total billed charges,$13.00 ,25% of total billed charges,$35.88 ,69% of total billed charges,$35.88 ,69% of total billed charges,$18.06 ,100% of BCBS fee schedule,$42.64 ,82% of total billed charges,$21.00 ,500% of HEALTHLINK fee schedule,$21.00 ,500% of HEALTHLINK fee schedule,$21.00 ,500% of HEALTHLINK fee schedule,$3.65 ,120% of MO fee schedule,$3.65 ,120% of MO fee schedule,$3.65 ,120% of MO fee schedule,$40.04 ,77% of total billed charges,$44.20 ,85% of total billed charges,$14.95 ,28.75% of total billed charges,$52.00 ,100% of UHC fee schedule,$3.65 ,120% of MO fee schedule,$13.00 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$13.00 ,25% of total billed charges,$3.65 ,$55.00 ,$26.00 
Outpatient Medical Services,LABORATORY,85018,hemoglobin and hematocrit,305,$50.00 ,$38.50 ,77% of total billed charges,$12.75 ,25.5% of total billed charges,$12.75 ,25.5% of total billed charges,$15.63 ,31.25% of total billed charges,$37.00 ,74% of total billed charges,$34.50 ,69% of total billed charges,$34.50 ,69% of total billed charges,$12.50 ,25% of total billed charges,$34.50 ,69% of total billed charges,$34.50 ,69% of total billed charges,$14.84 ,100% of BCBS fee schedule,$41.00 ,82% of total billed charges,$17.30 ,500% of HEALTHLINK fee schedule,$17.30 ,500% of HEALTHLINK fee schedule,$17.30 ,500% of HEALTHLINK fee schedule,$2.27 ,120% of MO fee schedule,$2.27 ,120% of MO fee schedule,$2.27 ,120% of MO fee schedule,$38.50 ,77% of total billed charges,$42.50 ,85% of total billed charges,$14.38 ,28.75% of total billed charges,$50.00 ,100% of UHC fee schedule,$2.27 ,120% of MO fee schedule,$12.50 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$12.50 ,25% of total billed charges,$2.27 ,$55.00 ,$25.00 
Outpatient Medical Services,LABORATORY,85025,"Complete blood cell count, with differential white blood cells, automated",300,$113.00 ,$87.01 ,77% of total billed charges,$28.82 ,25.5% of total billed charges,$28.82 ,25.5% of total billed charges,$35.31 ,31.25% of total billed charges,$83.62 ,74% of total billed charges,$77.97 ,69% of total billed charges,$77.97 ,69% of total billed charges,$28.25 ,25% of total billed charges,$77.97 ,69% of total billed charges,$77.97 ,69% of total billed charges,$48.74 ,100% of BCBS fee schedule,$92.66 ,82% of total billed charges,$56.75 ,500% of HEALTHLINK fee schedule,$56.75 ,500% of HEALTHLINK fee schedule,$56.75 ,500% of HEALTHLINK fee schedule,$7.45 ,120% of MO fee schedule,$7.45 ,120% of MO fee schedule,$7.45 ,120% of MO fee schedule,$87.01 ,77% of total billed charges,$96.05 ,85% of total billed charges,$32.49 ,28.75% of total billed charges,$113.00 ,100% of UHC fee schedule,$7.45 ,120% of MO fee schedule,$28.25 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$28.25 ,25% of total billed charges,$7.45 ,$113.00 ,$56.50 
Outpatient Medical Services,LABORATORY,85027,"Complete blood count, automated",305,$95.50 ,$73.54 ,77% of total billed charges,$24.35 ,25.5% of total billed charges,$24.35 ,25.5% of total billed charges,$29.84 ,31.25% of total billed charges,$70.67 ,74% of total billed charges,$65.90 ,69% of total billed charges,$65.90 ,69% of total billed charges,$23.88 ,25% of total billed charges,$65.90 ,69% of total billed charges,$65.90 ,69% of total billed charges,$40.59 ,100% of BCBS fee schedule,$78.31 ,82% of total billed charges,$47.25 ,500% of HEALTHLINK fee schedule,$47.25 ,500% of HEALTHLINK fee schedule,$47.25 ,500% of HEALTHLINK fee schedule,$6.20 ,120% of MO fee schedule,$6.20 ,120% of MO fee schedule,$6.20 ,120% of MO fee schedule,$73.54 ,77% of total billed charges,$81.18 ,85% of total billed charges,$27.46 ,28.75% of total billed charges,$95.50 ,100% of UHC fee schedule,$6.20 ,120% of MO fee schedule,$23.88 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$23.88 ,25% of total billed charges,$6.20 ,$95.50 ,$47.75 
Outpatient Medical Services,LABORATORY,85379,D-dimer; quantitative (fibrin degradation products),305,$258.50 ,$199.05 ,77% of total billed charges,$65.92 ,25.5% of total billed charges,$65.92 ,25.5% of total billed charges,$80.78 ,31.25% of total billed charges,$191.29 ,74% of total billed charges,$178.37 ,69% of total billed charges,$178.37 ,69% of total billed charges,$64.63 ,25% of total billed charges,$178.37 ,69% of total billed charges,$178.37 ,69% of total billed charges,$63.80 ,100% of BCBS fee schedule,$211.97 ,82% of total billed charges,$74.25 ,500% of HEALTHLINK fee schedule,$74.25 ,500% of HEALTHLINK fee schedule,$74.25 ,500% of HEALTHLINK fee schedule,$9.77 ,120% of MO fee schedule,$9.77 ,120% of MO fee schedule,$9.77 ,120% of MO fee schedule,$199.05 ,77% of total billed charges,$219.73 ,85% of total billed charges,$74.32 ,28.75% of total billed charges,$258.50 ,100% of UHC fee schedule,$9.77 ,120% of MO fee schedule,$64.63 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$64.63 ,25% of total billed charges,$9.77 ,$258.50 ,$129.25 
Outpatient Medical Services,LABORATORY,85610,"Blood test, clotting time",305,$65.00 ,$50.05 ,77% of total billed charges,$16.58 ,25.5% of total billed charges,$16.58 ,25.5% of total billed charges,$20.31 ,31.25% of total billed charges,$48.10 ,74% of total billed charges,$44.85 ,69% of total billed charges,$44.85 ,69% of total billed charges,$16.25 ,25% of total billed charges,$44.85 ,69% of total billed charges,$44.85 ,69% of total billed charges,$24.64 ,100% of BCBS fee schedule,$53.30 ,82% of total billed charges,$28.70 ,500% of HEALTHLINK fee schedule,$28.70 ,500% of HEALTHLINK fee schedule,$28.70 ,500% of HEALTHLINK fee schedule,$4.12 ,120% of MO fee schedule,$4.12 ,120% of MO fee schedule,$4.12 ,120% of MO fee schedule,$50.05 ,77% of total billed charges,$55.25 ,85% of total billed charges,$18.69 ,28.75% of total billed charges,$65.00 ,100% of UHC fee schedule,$4.12 ,120% of MO fee schedule,$16.25 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$16.25 ,25% of total billed charges,$4.12 ,$65.00 ,$32.50 
Outpatient Medical Services,LABORATORY,85651,"Sedimentation Rate, Erythrocyte",305,$81.50 ,$62.76 ,77% of total billed charges,$20.78 ,25.5% of total billed charges,$20.78 ,25.5% of total billed charges,$25.47 ,31.25% of total billed charges,$60.31 ,74% of total billed charges,$56.24 ,69% of total billed charges,$56.24 ,69% of total billed charges,$20.38 ,25% of total billed charges,$56.24 ,69% of total billed charges,$56.24 ,69% of total billed charges,$22.28 ,100% of BCBS fee schedule,$66.83 ,82% of total billed charges,$25.90 ,500% of HEALTHLINK fee schedule,$25.90 ,500% of HEALTHLINK fee schedule,$25.90 ,500% of HEALTHLINK fee schedule,$4.09 ,120% of MO fee schedule,$4.09 ,120% of MO fee schedule,$4.09 ,120% of MO fee schedule,$62.76 ,77% of total billed charges,$69.28 ,85% of total billed charges,$23.43 ,28.75% of total billed charges,$81.50 ,100% of UHC fee schedule,$4.09 ,120% of MO fee schedule,$20.38 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$20.38 ,25% of total billed charges,$4.09 ,$81.50 ,$40.75 
Outpatient Medical Services,LABORATORY,85730,Coagulation assessment blood test,305,$98.00 ,$75.46 ,77% of total billed charges,$24.99 ,25.5% of total billed charges,$24.99 ,25.5% of total billed charges,$30.63 ,31.25% of total billed charges,$72.52 ,74% of total billed charges,$67.62 ,69% of total billed charges,$67.62 ,69% of total billed charges,$24.50 ,25% of total billed charges,$67.62 ,69% of total billed charges,$67.62 ,69% of total billed charges,$37.66 ,100% of BCBS fee schedule,$80.36 ,82% of total billed charges,$43.80 ,500% of HEALTHLINK fee schedule,$43.80 ,500% of HEALTHLINK fee schedule,$43.80 ,500% of HEALTHLINK fee schedule,$5.76 ,120% of MO fee schedule,$5.76 ,120% of MO fee schedule,$5.76 ,120% of MO fee schedule,$75.46 ,77% of total billed charges,$83.30 ,85% of total billed charges,$28.18 ,28.75% of total billed charges,$98.00 ,100% of UHC fee schedule,$5.76 ,120% of MO fee schedule,$24.50 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$24.50 ,25% of total billed charges,$5.76 ,$98.00 ,$49.00 
Outpatient Medical Services,LABORATORY,86003,"Herpes Simplex Virus 1/2 Antibody (IgM), IFA with Reflex to Titer, CSF",302,"$1,073.50 ",$826.60 ,77% of total billed charges,$273.74 ,25.5% of total billed charges,$273.74 ,25.5% of total billed charges,$335.47 ,31.25% of total billed charges,$794.39 ,74% of total billed charges,$740.72 ,69% of total billed charges,$740.72 ,69% of total billed charges,$268.38 ,25% of total billed charges,$740.72 ,69% of total billed charges,$740.72 ,69% of total billed charges,$32.70 ,100% of BCBS fee schedule,$880.27 ,82% of total billed charges,$38.10 ,500% of HEALTHLINK fee schedule,$38.10 ,500% of HEALTHLINK fee schedule,$38.10 ,500% of HEALTHLINK fee schedule,$5.00 ,120% of MO fee schedule,$5.00 ,120% of MO fee schedule,$5.00 ,120% of MO fee schedule,$826.60 ,77% of total billed charges,$912.48 ,85% of total billed charges,$308.63 ,28.75% of total billed charges,"$1,073.50 ",100% of UHC fee schedule,$5.00 ,120% of MO fee schedule,$268.38 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$268.38 ,25% of total billed charges,$5.00 ,"$1,073.50 ",$536.75 
Outpatient Medical Services,LABORATORY,86038,Antinuclear antibodies (ANA),302,$157.00 ,$120.89 ,77% of total billed charges,$40.04 ,25.5% of total billed charges,$40.04 ,25.5% of total billed charges,$49.06 ,31.25% of total billed charges,$116.18 ,74% of total billed charges,$108.33 ,69% of total billed charges,$108.33 ,69% of total billed charges,$39.25 ,25% of total billed charges,$108.33 ,69% of total billed charges,$108.33 ,69% of total billed charges,$75.79 ,100% of BCBS fee schedule,$128.74 ,82% of total billed charges,$88.25 ,500% of HEALTHLINK fee schedule,$88.25 ,500% of HEALTHLINK fee schedule,$88.25 ,500% of HEALTHLINK fee schedule,$11.60 ,120% of MO fee schedule,$11.60 ,120% of MO fee schedule,$11.60 ,120% of MO fee schedule,$120.89 ,77% of total billed charges,$133.45 ,85% of total billed charges,$45.14 ,28.75% of total billed charges,$157.00 ,100% of UHC fee schedule,$11.60 ,120% of MO fee schedule,$39.25 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$39.25 ,25% of total billed charges,$11.60 ,$157.00 ,$78.50 
Outpatient Medical Services,LABORATORY,86039,Antinuclear antibodies (ANA),302,$153.00 ,$117.81 ,77% of total billed charges,$39.02 ,25.5% of total billed charges,$39.02 ,25.5% of total billed charges,$47.81 ,31.25% of total billed charges,$113.22 ,74% of total billed charges,$105.57 ,69% of total billed charges,$105.57 ,69% of total billed charges,$38.25 ,25% of total billed charges,$105.57 ,69% of total billed charges,$105.57 ,69% of total billed charges,$69.99 ,100% of BCBS fee schedule,$125.46 ,82% of total billed charges,$81.50 ,500% of HEALTHLINK fee schedule,$81.50 ,500% of HEALTHLINK fee schedule,$81.50 ,500% of HEALTHLINK fee schedule,$10.70 ,120% of MO fee schedule,$10.70 ,120% of MO fee schedule,$10.70 ,120% of MO fee schedule,$117.81 ,77% of total billed charges,$130.05 ,85% of total billed charges,$43.99 ,28.75% of total billed charges,$153.00 ,100% of UHC fee schedule,$10.70 ,120% of MO fee schedule,$38.25 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$38.25 ,25% of total billed charges,$10.70 ,$153.00 ,$76.50 
Outpatient Medical Services,LABORATORY,86140,Qualitative or Semiquantitative Immunoassays.,302,$139.50 ,$107.42 ,77% of total billed charges,$35.57 ,25.5% of total billed charges,$35.57 ,25.5% of total billed charges,$43.59 ,31.25% of total billed charges,$103.23 ,74% of total billed charges,$96.26 ,69% of total billed charges,$96.26 ,69% of total billed charges,$34.88 ,25% of total billed charges,$96.26 ,69% of total billed charges,$96.26 ,69% of total billed charges,$32.45 ,100% of BCBS fee schedule,$114.39 ,82% of total billed charges,$37.80 ,500% of HEALTHLINK fee schedule,$37.80 ,500% of HEALTHLINK fee schedule,$37.80 ,500% of HEALTHLINK fee schedule,$4.97 ,120% of MO fee schedule,$4.97 ,120% of MO fee schedule,$4.97 ,120% of MO fee schedule,$107.42 ,77% of total billed charges,$118.58 ,85% of total billed charges,$40.11 ,28.75% of total billed charges,$139.50 ,100% of UHC fee schedule,$4.97 ,120% of MO fee schedule,$34.88 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$34.88 ,25% of total billed charges,$4.97 ,$139.50 ,$69.75 
Outpatient Medical Services,LABORATORY,86200,Cyclic Citrullinated Peptide (CCP) Antibody (IgG),302,$287.00 ,$220.99 ,77% of total billed charges,$73.19 ,25.5% of total billed charges,$73.19 ,25.5% of total billed charges,$89.69 ,31.25% of total billed charges,$212.38 ,74% of total billed charges,$198.03 ,69% of total billed charges,$198.03 ,69% of total billed charges,$71.75 ,25% of total billed charges,$198.03 ,69% of total billed charges,$198.03 ,69% of total billed charges,$81.17 ,100% of BCBS fee schedule,$235.34 ,82% of total billed charges,$94.55 ,500% of HEALTHLINK fee schedule,$94.55 ,500% of HEALTHLINK fee schedule,$94.55 ,500% of HEALTHLINK fee schedule,$12.43 ,120% of MO fee schedule,$12.43 ,120% of MO fee schedule,$12.43 ,120% of MO fee schedule,$220.99 ,77% of total billed charges,$243.95 ,85% of total billed charges,$82.51 ,28.75% of total billed charges,$287.00 ,100% of UHC fee schedule,$12.43 ,120% of MO fee schedule,$71.75 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$71.75 ,25% of total billed charges,$12.43 ,$287.00 ,$143.50 
Outpatient Medical Services,LABORATORY,86225,Deoxyribonucleic acid (DNA) antibody; native or double stranded,302,$182.00 ,$140.14 ,77% of total billed charges,$46.41 ,25.5% of total billed charges,$46.41 ,25.5% of total billed charges,$56.88 ,31.25% of total billed charges,$134.68 ,74% of total billed charges,$125.58 ,69% of total billed charges,$125.58 ,69% of total billed charges,$45.50 ,25% of total billed charges,$125.58 ,69% of total billed charges,$125.58 ,69% of total billed charges,$86.14 ,100% of BCBS fee schedule,$149.24 ,82% of total billed charges,$100.30 ,500% of HEALTHLINK fee schedule,$100.30 ,500% of HEALTHLINK fee schedule,$100.30 ,500% of HEALTHLINK fee schedule,$13.19 ,120% of MO fee schedule,$13.19 ,120% of MO fee schedule,$13.19 ,120% of MO fee schedule,$140.14 ,77% of total billed charges,$154.70 ,85% of total billed charges,$52.33 ,28.75% of total billed charges,$182.00 ,100% of UHC fee schedule,$13.19 ,120% of MO fee schedule,$45.50 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$45.50 ,25% of total billed charges,$13.19 ,$182.00 ,$91.00 
Outpatient Medical Services,LABORATORY,86235,Nuclear antigen antibody,301,$747.50 ,$575.58 ,77% of total billed charges,$190.61 ,25.5% of total billed charges,$190.61 ,25.5% of total billed charges,$233.59 ,31.25% of total billed charges,$553.15 ,74% of total billed charges,$515.78 ,69% of total billed charges,$515.78 ,69% of total billed charges,$186.88 ,25% of total billed charges,$515.78 ,69% of total billed charges,$515.78 ,69% of total billed charges,$112.43 ,100% of BCBS fee schedule,$612.95 ,82% of total billed charges,$130.90 ,500% of HEALTHLINK fee schedule,$130.90 ,500% of HEALTHLINK fee schedule,$130.90 ,500% of HEALTHLINK fee schedule,$17.21 ,120% of MO fee schedule,$17.21 ,120% of MO fee schedule,$17.21 ,120% of MO fee schedule,$575.58 ,77% of total billed charges,$635.38 ,85% of total billed charges,$214.91 ,28.75% of total billed charges,$747.50 ,100% of UHC fee schedule,$17.21 ,120% of MO fee schedule,$186.88 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$186.88 ,25% of total billed charges,$17.21 ,$747.50 ,$373.75 
Outpatient Medical Services,LABORATORY,86376,Thyroid Antibody Panel,302,$158.50 ,$122.05 ,77% of total billed charges,$40.42 ,25.5% of total billed charges,$40.42 ,25.5% of total billed charges,$49.53 ,31.25% of total billed charges,$117.29 ,74% of total billed charges,$109.37 ,69% of total billed charges,$109.37 ,69% of total billed charges,$39.63 ,25% of total billed charges,$109.37 ,69% of total billed charges,$109.37 ,69% of total billed charges,$91.26 ,100% of BCBS fee schedule,$129.97 ,82% of total billed charges,$106.25 ,500% of HEALTHLINK fee schedule,$106.25 ,500% of HEALTHLINK fee schedule,$106.25 ,500% of HEALTHLINK fee schedule,$13.97 ,120% of MO fee schedule,$13.97 ,120% of MO fee schedule,$13.97 ,120% of MO fee schedule,$122.05 ,77% of total billed charges,$134.73 ,85% of total billed charges,$45.57 ,28.75% of total billed charges,$158.50 ,100% of UHC fee schedule,$13.97 ,120% of MO fee schedule,$39.63 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$39.63 ,25% of total billed charges,$13.97 ,$158.50 ,$79.25 
Outpatient Medical Services,LABORATORY,86430,RA RF with reflex titer Rheumatoid Arthritis Factor with reflex titer,302,$90.00 ,$69.30 ,77% of total billed charges,$22.95 ,25.5% of total billed charges,$22.95 ,25.5% of total billed charges,$28.13 ,31.25% of total billed charges,$66.60 ,74% of total billed charges,$62.10 ,69% of total billed charges,$62.10 ,69% of total billed charges,$22.50 ,25% of total billed charges,$62.10 ,69% of total billed charges,$62.10 ,69% of total billed charges,$35.56 ,100% of BCBS fee schedule,$73.80 ,82% of total billed charges,$41.45 ,500% of HEALTHLINK fee schedule,$41.45 ,500% of HEALTHLINK fee schedule,$41.45 ,500% of HEALTHLINK fee schedule,$5.89 ,120% of MO fee schedule,$5.89 ,120% of MO fee schedule,$5.89 ,120% of MO fee schedule,$69.30 ,77% of total billed charges,$76.50 ,85% of total billed charges,$25.88 ,28.75% of total billed charges,$90.00 ,100% of UHC fee schedule,$5.89 ,120% of MO fee schedule,$22.50 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$22.50 ,25% of total billed charges,$5.89 ,$90.00 ,$45.00 
Outpatient Medical Services,LABORATORY,86592,"Syphilis test, non-treponemal antibody",302,$71.50 ,$55.06 ,77% of total billed charges,$18.23 ,25.5% of total billed charges,$18.23 ,25.5% of total billed charges,$22.34 ,31.25% of total billed charges,$52.91 ,74% of total billed charges,$49.34 ,69% of total billed charges,$49.34 ,69% of total billed charges,$17.88 ,25% of total billed charges,$49.34 ,69% of total billed charges,$49.34 ,69% of total billed charges,$26.79 ,100% of BCBS fee schedule,$58.63 ,82% of total billed charges,$31.15 ,500% of HEALTHLINK fee schedule,$31.15 ,500% of HEALTHLINK fee schedule,$31.15 ,500% of HEALTHLINK fee schedule,$4.09 ,120% of MO fee schedule,$4.09 ,120% of MO fee schedule,$4.09 ,120% of MO fee schedule,$55.06 ,77% of total billed charges,$60.78 ,85% of total billed charges,$20.56 ,28.75% of total billed charges,$71.50 ,100% of UHC fee schedule,$4.09 ,120% of MO fee schedule,$17.88 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$17.88 ,25% of total billed charges,$4.09 ,$71.50 ,$35.75 
Outpatient Medical Services,LABORATORY,86696,Test panel that detects the flu and respiratory syncytial virus (RSV) infections,302,$200.00 ,$154.00 ,77% of total billed charges,$51.00 ,25.5% of total billed charges,$51.00 ,25.5% of total billed charges,$62.50 ,31.25% of total billed charges,$148.00 ,74% of total billed charges,$138.00 ,69% of total billed charges,$138.00 ,69% of total billed charges,$50.00 ,25% of total billed charges,$138.00 ,69% of total billed charges,$138.00 ,69% of total billed charges,$121.34 ,100% of BCBS fee schedule,$164.00 ,82% of total billed charges,$141.30 ,500% of HEALTHLINK fee schedule,$141.30 ,500% of HEALTHLINK fee schedule,$141.30 ,500% of HEALTHLINK fee schedule,$18.58 ,120% of MO fee schedule,$18.58 ,120% of MO fee schedule,$18.58 ,120% of MO fee schedule,$154.00 ,77% of total billed charges,$170.00 ,85% of total billed charges,$57.50 ,28.75% of total billed charges,$200.00 ,100% of UHC fee schedule,$18.58 ,120% of MO fee schedule,$50.00 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$50.00 ,25% of total billed charges,$18.58 ,$200.00 ,$100.00 
Outpatient Medical Services,LABORATORY,86710,antibody serum test for influenza,302,$112.00 ,$86.24 ,77% of total billed charges,$28.56 ,25.5% of total billed charges,$28.56 ,25.5% of total billed charges,$35.00 ,31.25% of total billed charges,$82.88 ,74% of total billed charges,$77.28 ,69% of total billed charges,$77.28 ,69% of total billed charges,$28.00 ,25% of total billed charges,$77.28 ,69% of total billed charges,$77.28 ,69% of total billed charges,$47.95 ,100% of BCBS fee schedule,$91.84 ,82% of total billed charges,$55.80 ,500% of HEALTHLINK fee schedule,$55.80 ,500% of HEALTHLINK fee schedule,$55.80 ,500% of HEALTHLINK fee schedule,$13.01 ,120% of MO fee schedule,$13.01 ,120% of MO fee schedule,$13.01 ,120% of MO fee schedule,$86.24 ,77% of total billed charges,$95.20 ,85% of total billed charges,$32.20 ,28.75% of total billed charges,$112.00 ,100% of UHC fee schedule,$13.01 ,120% of MO fee schedule,$28.00 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$28.00 ,25% of total billed charges,$13.01 ,$112.00 ,$56.00 
Outpatient Medical Services,LABORATORY,86769,Antibody; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]),300,$225.50 ,$173.64 ,77% of total billed charges,$57.50 ,25.5% of total billed charges,$57.50 ,25.5% of total billed charges,$70.47 ,31.25% of total billed charges,$166.87 ,74% of total billed charges,$155.60 ,69% of total billed charges,$155.60 ,69% of total billed charges,$56.38 ,25% of total billed charges,$155.60 ,69% of total billed charges,$155.60 ,69% of total billed charges,$151.22 ,100% of BCBS fee schedule,$184.91 ,82% of total billed charges,$200.70 ,89% of total billed charges,$200.70 ,89% of total billed charges,$200.70 ,89% of total billed charges,$36.40 ,120% of MO fee schedule,$36.40 ,120% of MO fee schedule,$36.40 ,120% of MO fee schedule,$173.64 ,77% of total billed charges,$191.68 ,85% of total billed charges,$64.83 ,28.75% of total billed charges,$225.50 ,100% of UHC fee schedule,$36.40 ,120% of MO fee schedule,$56.38 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$56.38 ,25% of total billed charges,$36.40 ,$225.50 ,$112.75 
Outpatient Medical Services,LABORATORY,86787,Varicella-Zoster Virus Antibody,302,$232.00 ,$178.64 ,77% of total billed charges,$59.16 ,25.5% of total billed charges,$59.16 ,25.5% of total billed charges,$72.50 ,31.25% of total billed charges,$171.68 ,74% of total billed charges,$160.08 ,69% of total billed charges,$160.08 ,69% of total billed charges,$58.00 ,25% of total billed charges,$160.08 ,69% of total billed charges,$160.08 ,69% of total billed charges,$80.79 ,100% of BCBS fee schedule,$190.24 ,82% of total billed charges,$94.05 ,500% of HEALTHLINK fee schedule,$94.05 ,500% of HEALTHLINK fee schedule,$94.05 ,500% of HEALTHLINK fee schedule,$12.36 ,120% of MO fee schedule,$12.36 ,120% of MO fee schedule,$12.36 ,120% of MO fee schedule,$178.64 ,77% of total billed charges,$197.20 ,85% of total billed charges,$66.70 ,28.75% of total billed charges,$232.00 ,100% of UHC fee schedule,$12.36 ,120% of MO fee schedule,$58.00 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$58.00 ,25% of total billed charges,$12.36 ,$232.00 ,$116.00 
Outpatient Medical Services,LABORATORY,86800,TPO Antibody Thyroglobulin Antibody (Anti-Tg),301,$279.00 ,$214.83 ,77% of total billed charges,$71.15 ,25.5% of total billed charges,$71.15 ,25.5% of total billed charges,$87.19 ,31.25% of total billed charges,$206.46 ,74% of total billed charges,$192.51 ,69% of total billed charges,$192.51 ,69% of total billed charges,$69.75 ,25% of total billed charges,$192.51 ,69% of total billed charges,$192.51 ,69% of total billed charges,$99.72 ,100% of BCBS fee schedule,$228.78 ,82% of total billed charges,$116.10 ,500% of HEALTHLINK fee schedule,$116.10 ,500% of HEALTHLINK fee schedule,$116.10 ,500% of HEALTHLINK fee schedule,$15.26 ,120% of MO fee schedule,$15.26 ,120% of MO fee schedule,$15.26 ,120% of MO fee schedule,$214.83 ,77% of total billed charges,$237.15 ,85% of total billed charges,$80.21 ,28.75% of total billed charges,$279.00 ,100% of UHC fee schedule,$15.26 ,120% of MO fee schedule,$69.75 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$69.75 ,25% of total billed charges,$15.26 ,$279.00 ,$139.50 
Outpatient Medical Services,LABORATORY,86803,Hepatitis C antibody.,302,$54.00 ,$41.58 ,77% of total billed charges,$13.77 ,25.5% of total billed charges,$13.77 ,25.5% of total billed charges,$16.88 ,31.25% of total billed charges,$39.96 ,74% of total billed charges,$37.26 ,69% of total billed charges,$37.26 ,69% of total billed charges,$13.50 ,25% of total billed charges,$37.26 ,69% of total billed charges,$37.26 ,69% of total billed charges,$89.47 ,100% of BCBS fee schedule,$44.28 ,82% of total billed charges,$104.20 ,500% of HEALTHLINK fee schedule,$104.20 ,500% of HEALTHLINK fee schedule,$104.20 ,500% of HEALTHLINK fee schedule,$13.69 ,120% of MO fee schedule,$13.69 ,120% of MO fee schedule,$13.69 ,120% of MO fee schedule,$41.58 ,77% of total billed charges,$45.90 ,85% of total billed charges,$15.53 ,28.75% of total billed charges,$54.00 ,100% of UHC fee schedule,$13.69 ,120% of MO fee schedule,$13.50 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$13.50 ,25% of total billed charges,$13.50 ,$104.20 ,$27.00 
Outpatient Medical Services,LABORATORY,86812,HLA-B27 Antigen,302,$562.50 ,$433.13 ,77% of total billed charges,$143.44 ,25.5% of total billed charges,$143.44 ,25.5% of total billed charges,$175.78 ,31.25% of total billed charges,$416.25 ,74% of total billed charges,$388.13 ,69% of total billed charges,$388.13 ,69% of total billed charges,$140.63 ,25% of total billed charges,$388.13 ,69% of total billed charges,$388.13 ,69% of total billed charges,$161.84 ,100% of BCBS fee schedule,$461.25 ,82% of total billed charges,$188.40 ,500% of HEALTHLINK fee schedule,$188.40 ,500% of HEALTHLINK fee schedule,$188.40 ,500% of HEALTHLINK fee schedule,$24.77 ,120% of MO fee schedule,$24.77 ,120% of MO fee schedule,$24.77 ,120% of MO fee schedule,$433.13 ,77% of total billed charges,$478.13 ,85% of total billed charges,$161.72 ,28.75% of total billed charges,$562.50 ,100% of UHC fee schedule,$24.77 ,120% of MO fee schedule,$140.63 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$140.63 ,25% of total billed charges,$24.77 ,$562.50 ,$281.25 
Outpatient Medical Services,LABORATORY,86886,Antihuman globulin test,300,$241.00 ,$185.57 ,77% of total billed charges,$61.46 ,25.5% of total billed charges,$61.46 ,25.5% of total billed charges,$75.31 ,31.25% of total billed charges,$178.34 ,74% of total billed charges,$166.29 ,69% of total billed charges,$166.29 ,69% of total billed charges,$60.25 ,25% of total billed charges,$166.29 ,69% of total billed charges,$166.29 ,69% of total billed charges,$32.45 ,100% of BCBS fee schedule,$197.62 ,82% of total billed charges,$37.80 ,500% of HEALTHLINK fee schedule,$37.80 ,500% of HEALTHLINK fee schedule,$37.80 ,500% of HEALTHLINK fee schedule,$4.97 ,120% of MO fee schedule,$4.97 ,120% of MO fee schedule,$4.97 ,120% of MO fee schedule,$185.57 ,77% of total billed charges,$204.85 ,85% of total billed charges,$69.29 ,28.75% of total billed charges,$241.00 ,100% of UHC fee schedule,$4.97 ,120% of MO fee schedule,$60.25 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$60.25 ,25% of total billed charges,$4.97 ,$241.00 ,$120.50 
Outpatient Medical Services,LABORATORY,86900,Blood Typing Test,300,$108.50 ,$83.55 ,77% of total billed charges,$27.67 ,25.5% of total billed charges,$27.67 ,25.5% of total billed charges,$33.91 ,31.25% of total billed charges,$80.29 ,74% of total billed charges,$74.87 ,69% of total billed charges,$74.87 ,69% of total billed charges,$27.13 ,25% of total billed charges,$74.87 ,69% of total billed charges,$74.87 ,69% of total billed charges,$18.73 ,100% of BCBS fee schedule,$88.97 ,82% of total billed charges,$21.75 ,500% of HEALTHLINK fee schedule,$21.75 ,500% of HEALTHLINK fee schedule,$21.75 ,500% of HEALTHLINK fee schedule,$2.87 ,120% of MO fee schedule,$2.87 ,120% of MO fee schedule,$2.87 ,120% of MO fee schedule,$83.55 ,77% of total billed charges,$92.23 ,85% of total billed charges,$31.19 ,28.75% of total billed charges,$108.50 ,100% of UHC fee schedule,$2.87 ,120% of MO fee schedule,$27.13 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$27.13 ,25% of total billed charges,$2.87 ,$108.50 ,$54.25 
Outpatient Medical Services,LABORATORY,86901,RH Blood Typing Test,309,$108.50 ,$83.55 ,77% of total billed charges,$27.67 ,25.5% of total billed charges,$27.67 ,25.5% of total billed charges,$33.91 ,31.25% of total billed charges,$80.29 ,74% of total billed charges,$74.87 ,69% of total billed charges,$74.87 ,69% of total billed charges,$27.13 ,25% of total billed charges,$74.87 ,69% of total billed charges,$74.87 ,69% of total billed charges,$18.73 ,100% of BCBS fee schedule,$88.97 ,82% of total billed charges,$21.75 ,500% of HEALTHLINK fee schedule,$21.75 ,500% of HEALTHLINK fee schedule,$21.75 ,500% of HEALTHLINK fee schedule,$2.87 ,120% of MO fee schedule,$2.87 ,120% of MO fee schedule,$2.87 ,120% of MO fee schedule,$83.55 ,77% of total billed charges,$92.23 ,85% of total billed charges,$31.19 ,28.75% of total billed charges,$108.50 ,100% of UHC fee schedule,$2.87 ,120% of MO fee schedule,$27.13 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$27.13 ,25% of total billed charges,$2.87 ,$108.50 ,$54.25 
Outpatient Medical Services,LABORATORY,86920,Compatibility test each unit,300,$189.00 ,$145.53 ,77% of total billed charges,$48.20 ,25.5% of total billed charges,$48.20 ,25.5% of total billed charges,$59.06 ,31.25% of total billed charges,$139.86 ,74% of total billed charges,$130.41 ,69% of total billed charges,$130.41 ,69% of total billed charges,$47.25 ,25% of total billed charges,$130.41 ,69% of total billed charges,$130.41 ,69% of total billed charges,$95.34 ,100% of BCBS fee schedule,$154.98 ,82% of total billed charges,$168.21 ,89% of total billed charges,$168.21 ,89% of total billed charges,$168.21 ,89% of total billed charges,$143.18 ,120% of MO fee schedule,$143.18 ,120% of MO fee schedule,$143.18 ,120% of MO fee schedule,$145.53 ,77% of total billed charges,$160.65 ,85% of total billed charges,$54.34 ,28.75% of total billed charges,$189.00 ,100% of UHC fee schedule,$143.18 ,120% of MO fee schedule,$47.25 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$47.25 ,25% of total billed charges,$47.25 ,$189.00 ,$94.50 
Outpatient Medical Services,LABORATORY,86922,Compatibility test each unit,300,$470.50 ,$362.29 ,77% of total billed charges,$119.98 ,25.5% of total billed charges,$119.98 ,25.5% of total billed charges,$147.03 ,31.25% of total billed charges,$348.17 ,74% of total billed charges,$324.65 ,69% of total billed charges,$324.65 ,69% of total billed charges,$117.63 ,25% of total billed charges,$324.65 ,69% of total billed charges,$324.65 ,69% of total billed charges,$102.30 ,100% of BCBS fee schedule,$385.81 ,82% of total billed charges,$418.75 ,89% of total billed charges,$418.75 ,89% of total billed charges,$418.75 ,89% of total billed charges,$143.18 ,120% of MO fee schedule,$143.18 ,120% of MO fee schedule,$143.18 ,120% of MO fee schedule,$362.29 ,77% of total billed charges,$399.93 ,85% of total billed charges,$135.27 ,28.75% of total billed charges,$470.50 ,100% of UHC fee schedule,$143.18 ,120% of MO fee schedule,$117.63 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$117.63 ,25% of total billed charges,$55.00 ,$470.50 ,$235.25 
Outpatient Medical Services,LABORATORY,87040,"Culture, bacterial; blood aerobic with isolation and presumptive identification of isolates.",306,$183.50 ,$141.30 ,77% of total billed charges,$46.79 ,25.5% of total billed charges,$46.79 ,25.5% of total billed charges,$57.34 ,31.25% of total billed charges,$135.79 ,74% of total billed charges,$126.62 ,69% of total billed charges,$126.62 ,69% of total billed charges,$45.88 ,25% of total billed charges,$126.62 ,69% of total billed charges,$126.62 ,69% of total billed charges,$64.74 ,100% of BCBS fee schedule,$150.47 ,82% of total billed charges,$75.35 ,500% of HEALTHLINK fee schedule,$75.35 ,500% of HEALTHLINK fee schedule,$75.35 ,500% of HEALTHLINK fee schedule,$9.90 ,120% of MO fee schedule,$9.90 ,120% of MO fee schedule,$9.90 ,120% of MO fee schedule,$141.30 ,77% of total billed charges,$155.98 ,85% of total billed charges,$52.76 ,28.75% of total billed charges,$183.50 ,100% of UHC fee schedule,$9.90 ,120% of MO fee schedule,$45.88 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$45.88 ,25% of total billed charges,$9.90 ,$183.50 ,$91.75 
Outpatient Medical Services,LABORATORY,87070,"Culture, bacterial; any other source but urine, blood or stool, with isolation and presumptive identification of isolates",306,$171.50 ,$132.06 ,77% of total billed charges,$43.73 ,25.5% of total billed charges,$43.73 ,25.5% of total billed charges,$53.59 ,31.25% of total billed charges,$126.91 ,74% of total billed charges,$118.34 ,69% of total billed charges,$118.34 ,69% of total billed charges,$42.88 ,25% of total billed charges,$118.34 ,69% of total billed charges,$118.34 ,69% of total billed charges,$54.01 ,100% of BCBS fee schedule,$140.63 ,82% of total billed charges,$62.85 ,500% of HEALTHLINK fee schedule,$62.85 ,500% of HEALTHLINK fee schedule,$62.85 ,500% of HEALTHLINK fee schedule,$8.27 ,120% of MO fee schedule,$8.27 ,120% of MO fee schedule,$8.27 ,120% of MO fee schedule,$132.06 ,77% of total billed charges,$145.78 ,85% of total billed charges,$49.31 ,28.75% of total billed charges,$171.50 ,100% of UHC fee schedule,$8.27 ,120% of MO fee schedule,$42.88 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$42.88 ,25% of total billed charges,$8.27 ,$171.50 ,$85.75 
Outpatient Medical Services,LABORATORY,87075,Bacterial Culture,306,$148.50 ,$114.35 ,77% of total billed charges,$37.87 ,25.5% of total billed charges,$37.87 ,25.5% of total billed charges,$46.41 ,31.25% of total billed charges,$109.89 ,74% of total billed charges,$102.47 ,69% of total billed charges,$102.47 ,69% of total billed charges,$37.13 ,25% of total billed charges,$102.47 ,69% of total billed charges,$102.47 ,69% of total billed charges,$43.85 ,100% of BCBS fee schedule,$121.77 ,82% of total billed charges,$51.05 ,500% of HEALTHLINK fee schedule,$51.05 ,500% of HEALTHLINK fee schedule,$51.05 ,500% of HEALTHLINK fee schedule,$9.08 ,120% of MO fee schedule,$9.08 ,120% of MO fee schedule,$9.08 ,120% of MO fee schedule,$114.35 ,77% of total billed charges,$126.23 ,85% of total billed charges,$42.69 ,28.75% of total billed charges,$148.50 ,100% of UHC fee schedule,$9.08 ,120% of MO fee schedule,$37.13 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$37.13 ,25% of total billed charges,$9.08 ,$148.50 ,$74.25 
Outpatient Medical Services,LABORATORY,87077,"Culture, bacterial; aerobic isolate, additional. methods required for definitive identification, each isolate.",306,$157.00 ,$120.89 ,77% of total billed charges,$40.04 ,25.5% of total billed charges,$40.04 ,25.5% of total billed charges,$49.06 ,31.25% of total billed charges,$116.18 ,74% of total billed charges,$108.33 ,69% of total billed charges,$108.33 ,69% of total billed charges,$39.25 ,25% of total billed charges,$108.33 ,69% of total billed charges,$108.33 ,69% of total billed charges,$50.66 ,100% of BCBS fee schedule,$128.74 ,82% of total billed charges,$59.00 ,500% of HEALTHLINK fee schedule,$59.00 ,500% of HEALTHLINK fee schedule,$59.00 ,500% of HEALTHLINK fee schedule,$7.75 ,120% of MO fee schedule,$7.75 ,120% of MO fee schedule,$7.75 ,120% of MO fee schedule,$120.89 ,77% of total billed charges,$133.45 ,85% of total billed charges,$45.14 ,28.75% of total billed charges,$157.00 ,100% of UHC fee schedule,$7.75 ,120% of MO fee schedule,$39.25 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$39.25 ,25% of total billed charges,$7.75 ,$157.00 ,$78.50 
Outpatient Medical Services,LABORATORY,87086,"Urine Culture, Bacteria",306,$148.50 ,$114.35 ,77% of total billed charges,$37.87 ,25.5% of total billed charges,$37.87 ,25.5% of total billed charges,$46.41 ,31.25% of total billed charges,$109.89 ,74% of total billed charges,$102.47 ,69% of total billed charges,$102.47 ,69% of total billed charges,$37.13 ,25% of total billed charges,$102.47 ,69% of total billed charges,$102.47 ,69% of total billed charges,$43.85 ,100% of BCBS fee schedule,$121.77 ,82% of total billed charges,$51.05 ,500% of HEALTHLINK fee schedule,$51.05 ,500% of HEALTHLINK fee schedule,$51.05 ,500% of HEALTHLINK fee schedule,$7.74 ,120% of MO fee schedule,$7.74 ,120% of MO fee schedule,$7.74 ,120% of MO fee schedule,$114.35 ,77% of total billed charges,$126.23 ,85% of total billed charges,$42.69 ,28.75% of total billed charges,$148.50 ,100% of UHC fee schedule,$7.74 ,120% of MO fee schedule,$37.13 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$37.13 ,25% of total billed charges,$7.74 ,$148.50 ,$74.25 
Outpatient Medical Services,LABORATORY,87088,bacterial urine culture with isolation,306,$98.00 ,$75.46 ,77% of total billed charges,$24.99 ,25.5% of total billed charges,$24.99 ,25.5% of total billed charges,$30.63 ,31.25% of total billed charges,$72.52 ,74% of total billed charges,$67.62 ,69% of total billed charges,$67.62 ,69% of total billed charges,$24.50 ,25% of total billed charges,$67.62 ,69% of total billed charges,$67.62 ,69% of total billed charges,$34.95 ,100% of BCBS fee schedule,$80.36 ,82% of total billed charges,$40.65 ,500% of HEALTHLINK fee schedule,$40.65 ,500% of HEALTHLINK fee schedule,$40.65 ,500% of HEALTHLINK fee schedule,$7.76 ,120% of MO fee schedule,$7.76 ,120% of MO fee schedule,$7.76 ,120% of MO fee schedule,$75.46 ,77% of total billed charges,$83.30 ,85% of total billed charges,$28.18 ,28.75% of total billed charges,$98.00 ,100% of UHC fee schedule,$7.76 ,120% of MO fee schedule,$24.50 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$24.50 ,25% of total billed charges,$7.76 ,$98.00 ,$49.00 
Outpatient Medical Services,LABORATORY,87147,Bordetella LAB9442 Pertussis Whooping Cough,306,$79.00 ,$60.83 ,77% of total billed charges,$20.15 ,25.5% of total billed charges,$20.15 ,25.5% of total billed charges,$24.69 ,31.25% of total billed charges,$58.46 ,74% of total billed charges,$54.51 ,69% of total billed charges,$54.51 ,69% of total billed charges,$19.75 ,25% of total billed charges,$54.51 ,69% of total billed charges,$54.51 ,69% of total billed charges,$26.20 ,100% of BCBS fee schedule,$64.78 ,82% of total billed charges,$30.50 ,500% of HEALTHLINK fee schedule,$30.50 ,500% of HEALTHLINK fee schedule,$30.50 ,500% of HEALTHLINK fee schedule,$4.97 ,120% of MO fee schedule,$4.97 ,120% of MO fee schedule,$4.97 ,120% of MO fee schedule,$60.83 ,77% of total billed charges,$67.15 ,85% of total billed charges,$22.71 ,28.75% of total billed charges,$79.00 ,100% of UHC fee schedule,$4.97 ,120% of MO fee schedule,$19.75 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$19.75 ,25% of total billed charges,$4.97 ,$79.00 ,$39.50 
Outpatient Medical Services,LABORATORY,87186,"Susceptibility studies, antimicrobial agent.",306,$193.50 ,$149.00 ,77% of total billed charges,$49.34 ,25.5% of total billed charges,$49.34 ,25.5% of total billed charges,$60.47 ,31.25% of total billed charges,$143.19 ,74% of total billed charges,$133.52 ,69% of total billed charges,$133.52 ,69% of total billed charges,$48.38 ,25% of total billed charges,$133.52 ,69% of total billed charges,$133.52 ,69% of total billed charges,$54.22 ,100% of BCBS fee schedule,$158.67 ,82% of total billed charges,$63.10 ,500% of HEALTHLINK fee schedule,$63.10 ,500% of HEALTHLINK fee schedule,$63.10 ,500% of HEALTHLINK fee schedule,$8.30 ,120% of MO fee schedule,$8.30 ,120% of MO fee schedule,$8.30 ,120% of MO fee schedule,$149.00 ,77% of total billed charges,$164.48 ,85% of total billed charges,$55.63 ,28.75% of total billed charges,$193.50 ,100% of UHC fee schedule,$8.30 ,120% of MO fee schedule,$48.38 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$48.38 ,25% of total billed charges,$8.30 ,$193.50 ,$96.75 
Outpatient Medical Services,LABORATORY,87205,"Smear, primary source with interpretation",306,$63.00 ,$48.51 ,77% of total billed charges,$16.07 ,25.5% of total billed charges,$16.07 ,25.5% of total billed charges,$19.69 ,31.25% of total billed charges,$46.62 ,74% of total billed charges,$43.47 ,69% of total billed charges,$43.47 ,69% of total billed charges,$15.75 ,25% of total billed charges,$43.47 ,69% of total billed charges,$43.47 ,69% of total billed charges,$26.20 ,100% of BCBS fee schedule,$51.66 ,82% of total billed charges,$30.50 ,500% of HEALTHLINK fee schedule,$30.50 ,500% of HEALTHLINK fee schedule,$30.50 ,500% of HEALTHLINK fee schedule,$4.09 ,120% of MO fee schedule,$4.09 ,120% of MO fee schedule,$4.09 ,120% of MO fee schedule,$48.51 ,77% of total billed charges,$53.55 ,85% of total billed charges,$18.11 ,28.75% of total billed charges,$63.00 ,100% of UHC fee schedule,$4.09 ,120% of MO fee schedule,$15.75 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$15.75 ,25% of total billed charges,$4.09 ,$63.00 ,$31.50 
Outpatient Medical Services,LABORATORY,87340,"Infectious agent antigen detection by immunoassay technique, [e.g., enzyme immunoassay (EIA), enzyme-linked immunosorbent assay",306,$118.50 ,$91.25 ,77% of total billed charges,$30.22 ,25.5% of total billed charges,$30.22 ,25.5% of total billed charges,$37.03 ,31.25% of total billed charges,$87.69 ,74% of total billed charges,$81.77 ,69% of total billed charges,$81.77 ,69% of total billed charges,$29.63 ,25% of total billed charges,$81.77 ,69% of total billed charges,$81.77 ,69% of total billed charges,$63.62 ,100% of BCBS fee schedule,$97.17 ,82% of total billed charges,$74.05 ,500% of HEALTHLINK fee schedule,$74.05 ,500% of HEALTHLINK fee schedule,$74.05 ,500% of HEALTHLINK fee schedule,$9.91 ,120% of MO fee schedule,$9.91 ,120% of MO fee schedule,$9.91 ,120% of MO fee schedule,$91.25 ,77% of total billed charges,$100.73 ,85% of total billed charges,$34.07 ,28.75% of total billed charges,$118.50 ,100% of UHC fee schedule,$9.91 ,120% of MO fee schedule,$29.63 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$29.63 ,25% of total billed charges,$9.91 ,$118.50 ,$59.25 
Outpatient Medical Services,LABORATORY,87389,HIV antigen test,306,$160.50 ,$123.59 ,77% of total billed charges,$40.93 ,25.5% of total billed charges,$40.93 ,25.5% of total billed charges,$50.16 ,31.25% of total billed charges,$118.77 ,74% of total billed charges,$110.75 ,69% of total billed charges,$110.75 ,69% of total billed charges,$40.13 ,25% of total billed charges,$110.75 ,69% of total billed charges,$110.75 ,69% of total billed charges,$152.03 ,100% of BCBS fee schedule,$131.61 ,82% of total billed charges,$142.85 ,89% of total billed charges,$142.85 ,89% of total billed charges,$142.85 ,89% of total billed charges,$23.11 ,120% of MO fee schedule,$23.11 ,120% of MO fee schedule,$23.11 ,120% of MO fee schedule,$123.59 ,77% of total billed charges,$136.43 ,85% of total billed charges,$46.14 ,28.75% of total billed charges,$160.50 ,100% of UHC fee schedule,$23.11 ,120% of MO fee schedule,$40.13 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$40.13 ,25% of total billed charges,$23.11 ,$160.50 ,$80.25 
Outpatient Medical Services,LABORATORY,87486,Infectious Agent Antigen Detection.,306,$438.00 ,$337.26 ,77% of total billed charges,$111.69 ,25.5% of total billed charges,$111.69 ,25.5% of total billed charges,$136.88 ,31.25% of total billed charges,$324.12 ,74% of total billed charges,$302.22 ,69% of total billed charges,$302.22 ,69% of total billed charges,$109.50 ,25% of total billed charges,$302.22 ,69% of total billed charges,$302.22 ,69% of total billed charges,$220.11 ,100% of BCBS fee schedule,$359.16 ,82% of total billed charges,$256.25 ,500% of HEALTHLINK fee schedule,$256.25 ,500% of HEALTHLINK fee schedule,$256.25 ,500% of HEALTHLINK fee schedule,$33.68 ,120% of MO fee schedule,$33.68 ,120% of MO fee schedule,$33.68 ,120% of MO fee schedule,$337.26 ,77% of total billed charges,$372.30 ,85% of total billed charges,$125.93 ,28.75% of total billed charges,$438.00 ,100% of UHC fee schedule,$33.68 ,120% of MO fee schedule,$109.50 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$109.50 ,25% of total billed charges,$33.68 ,$438.00 ,$219.00 
Outpatient Medical Services,LABORATORY,87491,Routine screening for chlamydia infection,306,$62.00 ,$47.74 ,77% of total billed charges,$15.81 ,25.5% of total billed charges,$15.81 ,25.5% of total billed charges,$19.38 ,31.25% of total billed charges,$45.88 ,74% of total billed charges,$42.78 ,69% of total billed charges,$42.78 ,69% of total billed charges,$15.50 ,25% of total billed charges,$42.78 ,69% of total billed charges,$42.78 ,69% of total billed charges,$220.11 ,100% of BCBS fee schedule,$50.84 ,82% of total billed charges,$256.25 ,500% of HEALTHLINK fee schedule,$256.25 ,500% of HEALTHLINK fee schedule,$256.25 ,500% of HEALTHLINK fee schedule,$33.68 ,120% of MO fee schedule,$33.68 ,120% of MO fee schedule,$33.68 ,120% of MO fee schedule,$47.74 ,77% of total billed charges,$52.70 ,85% of total billed charges,$17.83 ,28.75% of total billed charges,$62.00 ,100% of UHC fee schedule,$33.68 ,120% of MO fee schedule,$15.50 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$15.50 ,25% of total billed charges,$15.50 ,$256.25 ,$31.00 
Outpatient Medical Services,LABORATORY,87493,Infectious agent detection by nucleic acid (DNA or RNA),306,$302.50 ,$232.93 ,77% of total billed charges,$77.14 ,25.5% of total billed charges,$77.14 ,25.5% of total billed charges,$94.53 ,31.25% of total billed charges,$223.85 ,74% of total billed charges,$208.73 ,69% of total billed charges,$208.73 ,69% of total billed charges,$75.63 ,25% of total billed charges,$208.73 ,69% of total billed charges,$208.73 ,69% of total billed charges,$220.11 ,100% of BCBS fee schedule,$248.05 ,82% of total billed charges,$269.23 ,89% of total billed charges,$269.23 ,89% of total billed charges,$269.23 ,89% of total billed charges,$35.77 ,120% of MO fee schedule,$35.77 ,120% of MO fee schedule,$35.77 ,120% of MO fee schedule,$232.93 ,77% of total billed charges,$257.13 ,85% of total billed charges,$86.97 ,28.75% of total billed charges,$302.50 ,100% of UHC fee schedule,$35.77 ,120% of MO fee schedule,$75.63 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$75.63 ,25% of total billed charges,$35.77 ,$302.50 ,$151.25 
Outpatient Medical Services,LABORATORY,87581,Infectious agent detection by nucleic acid (DNA or RNA,306,$438.00 ,$337.26 ,77% of total billed charges,$111.69 ,25.5% of total billed charges,$111.69 ,25.5% of total billed charges,$136.88 ,31.25% of total billed charges,$324.12 ,74% of total billed charges,$302.22 ,69% of total billed charges,$302.22 ,69% of total billed charges,$109.50 ,25% of total billed charges,$302.22 ,69% of total billed charges,$302.22 ,69% of total billed charges,$220.11 ,100% of BCBS fee schedule,$359.16 ,82% of total billed charges,$256.25 ,500% of HEALTHLINK fee schedule,$256.25 ,500% of HEALTHLINK fee schedule,$256.25 ,500% of HEALTHLINK fee schedule,$33.68 ,120% of MO fee schedule,$33.68 ,120% of MO fee schedule,$33.68 ,120% of MO fee schedule,$337.26 ,77% of total billed charges,$372.30 ,85% of total billed charges,$125.93 ,28.75% of total billed charges,$438.00 ,100% of UHC fee schedule,$33.68 ,120% of MO fee schedule,$109.50 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$109.50 ,25% of total billed charges,$33.68 ,$438.00 ,$219.00 
Outpatient Medical Services,LABORATORY,87591,Infectious agent detection by nucleic acid,306,$62.00 ,$47.74 ,77% of total billed charges,$15.81 ,25.5% of total billed charges,$15.81 ,25.5% of total billed charges,$19.38 ,31.25% of total billed charges,$45.88 ,74% of total billed charges,$42.78 ,69% of total billed charges,$42.78 ,69% of total billed charges,$15.50 ,25% of total billed charges,$42.78 ,69% of total billed charges,$42.78 ,69% of total billed charges,$220.11 ,100% of BCBS fee schedule,$50.84 ,82% of total billed charges,$256.25 ,500% of HEALTHLINK fee schedule,$256.25 ,500% of HEALTHLINK fee schedule,$256.25 ,500% of HEALTHLINK fee schedule,$33.68 ,120% of MO fee schedule,$33.68 ,120% of MO fee schedule,$33.68 ,120% of MO fee schedule,$47.74 ,77% of total billed charges,$52.70 ,85% of total billed charges,$17.83 ,28.75% of total billed charges,$62.00 ,100% of UHC fee schedule,$33.68 ,120% of MO fee schedule,$15.50 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$15.50 ,25% of total billed charges,$15.50 ,$256.25 ,$31.00 
Outpatient Medical Services,LABORATORY,87624,Infectious Agent Antigen Detection,306,$92.00 ,$70.84 ,77% of total billed charges,$23.46 ,25.5% of total billed charges,$23.46 ,25.5% of total billed charges,$28.75 ,31.25% of total billed charges,$68.08 ,74% of total billed charges,$63.48 ,69% of total billed charges,$63.48 ,69% of total billed charges,$23.00 ,25% of total billed charges,$63.48 ,69% of total billed charges,$63.48 ,69% of total billed charges,$201.18 ,100% of BCBS fee schedule,$75.44 ,82% of total billed charges,$81.88 ,89% of total billed charges,$81.88 ,89% of total billed charges,$81.88 ,89% of total billed charges,$33.68 ,120% of MO fee schedule,$33.68 ,120% of MO fee schedule,$33.68 ,120% of MO fee schedule,$70.84 ,77% of total billed charges,$78.20 ,85% of total billed charges,$26.45 ,28.75% of total billed charges,$92.00 ,100% of UHC fee schedule,$33.68 ,120% of MO fee schedule,$23.00 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$23.00 ,25% of total billed charges,$23.00 ,$201.18 ,$46.00 
Outpatient Medical Services,LABORATORY,87631,test panel that detects the flu and respiratory syncytial virus (RSV) infections,300,$563.00 ,$433.51 ,77% of total billed charges,$143.57 ,25.5% of total billed charges,$143.57 ,25.5% of total billed charges,$175.94 ,31.25% of total billed charges,$416.62 ,74% of total billed charges,$388.47 ,69% of total billed charges,$388.47 ,69% of total billed charges,$140.75 ,25% of total billed charges,$388.47 ,69% of total billed charges,$388.47 ,69% of total billed charges,$785.76 ,100% of BCBS fee schedule,$461.66 ,82% of total billed charges,$501.07 ,89% of total billed charges,$501.07 ,89% of total billed charges,$501.07 ,89% of total billed charges,$136.92 ,120% of MO fee schedule,$136.92 ,120% of MO fee schedule,$136.92 ,120% of MO fee schedule,$433.51 ,77% of total billed charges,$478.55 ,85% of total billed charges,$161.86 ,28.75% of total billed charges,$563.00 ,100% of UHC fee schedule,$136.92 ,120% of MO fee schedule,$140.75 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$140.75 ,25% of total billed charges,$55.00 ,$785.76 ,$281.50 
Outpatient Medical Services,LABORATORY,87633,Infectious agent detection by nucleic acid (DNA or RNA),300,$670.00 ,$515.90 ,77% of total billed charges,$170.85 ,25.5% of total billed charges,$170.85 ,25.5% of total billed charges,$209.38 ,31.25% of total billed charges,$495.80 ,74% of total billed charges,$462.30 ,69% of total billed charges,$462.30 ,69% of total billed charges,$167.50 ,25% of total billed charges,$462.30 ,69% of total billed charges,$462.30 ,69% of total billed charges,"$2,552.83 ",100% of BCBS fee schedule,$549.40 ,82% of total billed charges,$596.30 ,89% of total billed charges,$596.30 ,89% of total billed charges,$596.30 ,89% of total billed charges,$400.10 ,120% of MO fee schedule,$400.10 ,120% of MO fee schedule,$400.10 ,120% of MO fee schedule,$515.90 ,77% of total billed charges,$569.50 ,85% of total billed charges,$192.63 ,28.75% of total billed charges,$670.00 ,100% of UHC fee schedule,$400.10 ,120% of MO fee schedule,$167.50 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$167.50 ,25% of total billed charges,$55.00 ,"$2,552.83 ",$335.00 
Outpatient Medical Services,LABORATORY,87651,Infectious agent detection by nucleic acid (DNA or RNA),306,$139.00 ,$107.03 ,77% of total billed charges,$35.45 ,25.5% of total billed charges,$35.45 ,25.5% of total billed charges,$43.44 ,31.25% of total billed charges,$102.86 ,74% of total billed charges,$95.91 ,69% of total billed charges,$95.91 ,69% of total billed charges,$34.75 ,25% of total billed charges,$95.91 ,69% of total billed charges,$95.91 ,69% of total billed charges,$220.11 ,100% of BCBS fee schedule,$113.98 ,82% of total billed charges,$256.25 ,500% of HEALTHLINK fee schedule,$256.25 ,500% of HEALTHLINK fee schedule,$256.25 ,500% of HEALTHLINK fee schedule,$33.68 ,120% of MO fee schedule,$33.68 ,120% of MO fee schedule,$33.68 ,120% of MO fee schedule,$107.03 ,77% of total billed charges,$118.15 ,85% of total billed charges,$39.96 ,28.75% of total billed charges,$139.00 ,100% of UHC fee schedule,$33.68 ,120% of MO fee schedule,$34.75 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$34.75 ,25% of total billed charges,$33.68 ,$256.25 ,$69.50 
Outpatient Medical Services,LABORATORY,87798,"Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified",306,"$1,517.00 ","$1,168.09 ",77% of total billed charges,$386.84 ,25.5% of total billed charges,$386.84 ,25.5% of total billed charges,$474.06 ,31.25% of total billed charges,"$1,122.58 ",74% of total billed charges,"$1,046.73 ",69% of total billed charges,"$1,046.73 ",69% of total billed charges,$379.25 ,25% of total billed charges,"$1,046.73 ",69% of total billed charges,"$1,046.73 ",69% of total billed charges,$220.11 ,100% of BCBS fee schedule,"$1,243.94 ",82% of total billed charges,$256.25 ,500% of HEALTHLINK fee schedule,$256.25 ,500% of HEALTHLINK fee schedule,$256.25 ,500% of HEALTHLINK fee schedule,$33.68 ,120% of MO fee schedule,$33.68 ,120% of MO fee schedule,$33.68 ,120% of MO fee schedule,"$1,168.09 ",77% of total billed charges,"$1,289.45 ",85% of total billed charges,$436.14 ,28.75% of total billed charges,"$1,517.00 ",100% of UHC fee schedule,$33.68 ,120% of MO fee schedule,$379.25 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$379.25 ,25% of total billed charges,$33.68 ,"$1,517.00 ",$758.50 
Outpatient Medical Services,LABORATORY,87807,"Infectious agent antigen detection by immunoassay with direct optical observation; respiratory syncytial
virus",306,$138.00 ,$106.26 ,77% of total billed charges,$35.19 ,25.5% of total billed charges,$35.19 ,25.5% of total billed charges,$43.13 ,31.25% of total billed charges,$102.12 ,74% of total billed charges,$95.22 ,69% of total billed charges,$95.22 ,69% of total billed charges,$34.50 ,25% of total billed charges,$95.22 ,69% of total billed charges,$95.22 ,69% of total billed charges,$75.22 ,100% of BCBS fee schedule,$113.16 ,82% of total billed charges,$87.60 ,500% of HEALTHLINK fee schedule,$87.60 ,500% of HEALTHLINK fee schedule,$87.60 ,500% of HEALTHLINK fee schedule,$12.58 ,120% of MO fee schedule,$12.58 ,120% of MO fee schedule,$12.58 ,120% of MO fee schedule,$106.26 ,77% of total billed charges,$117.30 ,85% of total billed charges,$39.68 ,28.75% of total billed charges,$138.00 ,100% of UHC fee schedule,$12.58 ,120% of MO fee schedule,$34.50 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$34.50 ,25% of total billed charges,$12.58 ,$138.00 ,$69.00 
Outpatient Medical Services,LABORATORY,87880,"Infectious agent detection by immunoassay with direct optical observation; Streptococcus, group A",521,$68.00 ,$52.36 ,77% of total billed charges,$17.34 ,25.5% of total billed charges,$17.34 ,25.5% of total billed charges,$21.25 ,31.25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$17.00 ,25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$87.60 ,500% of HEALTHLINK fee schedule,$87.60 ,500% of HEALTHLINK fee schedule,$87.60 ,500% of HEALTHLINK fee schedule,$15.86 ,120% of MO fee schedule,$15.86 ,120% of MO fee schedule,$15.86 ,120% of MO fee schedule,$52.36 ,77% of total billed charges,$57.80 ,85% of total billed charges,$19.55 ,28.75% of total billed charges,$68.00 ,100% of UHC fee schedule,$15.86 ,120% of MO fee schedule,$17.00 ,25% of total billed charges,N/A,not seperately reimbursable,$17.00 ,25% of total billed charges,$15.86 ,$87.60 ,$34.00 
Outpatient Medical Services,LABORATORY,88142,"Cytopathology, cervical or vaginal",311,$145.50 ,$112.04 ,77% of total billed charges,$37.10 ,25.5% of total billed charges,$37.10 ,25.5% of total billed charges,$45.47 ,31.25% of total billed charges,$107.67 ,74% of total billed charges,$100.40 ,69% of total billed charges,$100.40 ,69% of total billed charges,$36.38 ,25% of total billed charges,$100.40 ,69% of total billed charges,$100.40 ,69% of total billed charges,$94.68 ,100% of BCBS fee schedule,$119.31 ,82% of total billed charges,$110.25 ,500% of HEALTHLINK fee schedule,$110.25 ,500% of HEALTHLINK fee schedule,$110.25 ,500% of HEALTHLINK fee schedule,$19.44 ,120% of MO fee schedule,$19.44 ,120% of MO fee schedule,$19.44 ,120% of MO fee schedule,$112.04 ,77% of total billed charges,$123.68 ,85% of total billed charges,$41.83 ,28.75% of total billed charges,$145.50 ,100% of UHC fee schedule,$19.44 ,120% of MO fee schedule,$36.38 ,25% of total billed charges,$70.00 ,pays based on per visit rate,$36.38 ,25% of total billed charges,$19.44 ,$145.50 ,$72.75 
Outpatient Medical Services,LABORATORY,88175,"Cytopathology, cervical or vaginal",311,$182.00 ,$140.14 ,77% of total billed charges,$46.41 ,25.5% of total billed charges,$46.41 ,25.5% of total billed charges,$56.88 ,31.25% of total billed charges,$134.68 ,74% of total billed charges,$125.58 ,69% of total billed charges,$125.58 ,69% of total billed charges,$45.50 ,25% of total billed charges,$125.58 ,69% of total billed charges,$125.58 ,69% of total billed charges,$115.38 ,100% of BCBS fee schedule,$149.24 ,82% of total billed charges,$134.30 ,500% of HEALTHLINK fee schedule,$134.30 ,500% of HEALTHLINK fee schedule,$134.30 ,500% of HEALTHLINK fee schedule,$25.54 ,120% of MO fee schedule,$25.54 ,120% of MO fee schedule,$25.54 ,120% of MO fee schedule,$140.14 ,77% of total billed charges,$154.70 ,85% of total billed charges,$52.33 ,28.75% of total billed charges,$182.00 ,100% of UHC fee schedule,$25.54 ,120% of MO fee schedule,$45.50 ,25% of total billed charges,$70.00 ,pays based on per visit rate,$45.50 ,25% of total billed charges,$25.54 ,$182.00 ,$91.00 
Outpatient Medical Services,LABORATORY,88305,"surgical pathology, gross and microscopic examination",310,$189.50 ,$145.92 ,77% of total billed charges,$48.32 ,25.5% of total billed charges,$48.32 ,25.5% of total billed charges,$59.22 ,31.25% of total billed charges,$140.23 ,74% of total billed charges,$130.76 ,69% of total billed charges,$130.76 ,69% of total billed charges,$47.38 ,25% of total billed charges,$130.76 ,69% of total billed charges,$130.76 ,69% of total billed charges,$283.48 ,100% of BCBS fee schedule,$155.39 ,82% of total billed charges,$168.66 ,89% of total billed charges,$168.66 ,89% of total billed charges,$168.66 ,89% of total billed charges,$32.62 ,120% of MO fee schedule,$32.62 ,120% of MO fee schedule,$32.62 ,120% of MO fee schedule,$145.92 ,77% of total billed charges,$161.08 ,85% of total billed charges,$54.48 ,28.75% of total billed charges,$189.50 ,100% of UHC fee schedule,$32.62 ,120% of MO fee schedule,$47.38 ,25% of total billed charges,$70.00 ,pays based on per visit rate,$47.38 ,25% of total billed charges,$32.62 ,$283.48 ,$94.75 
Outpatient Medical Services,LABORATORY,0240U,"Oncology (thyroid), mRNA, gene expression analysis of 593 genes.",300,$541.00 ,$416.57 ,77% of total billed charges,$137.96 ,25.5% of total billed charges,$137.96 ,25.5% of total billed charges,$169.06 ,31.25% of total billed charges,$400.34 ,74% of total billed charges,$373.29 ,69% of total billed charges,$373.29 ,69% of total billed charges,$135.25 ,25% of total billed charges,$373.29 ,69% of total billed charges,$373.29 ,69% of total billed charges,$511.94 ,100% of BCBS fee schedule,$443.62 ,82% of total billed charges,$481.49 ,89% of total billed charges,$481.49 ,89% of total billed charges,$481.49 ,89% of total billed charges,$123.23 ,120% of MO fee schedule,$123.23 ,120% of MO fee schedule,$123.23 ,120% of MO fee schedule,$416.57 ,77% of total billed charges,$459.85 ,85% of total billed charges,$155.54 ,28.75% of total billed charges,$541.00 ,100% of UHC fee schedule,$123.23 ,120% of MO fee schedule,$135.25 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$135.25 ,25% of total billed charges,$55.00 ,$541.00 ,$270.50 
Outpatient Medical Services,LABORATORY,0241U,"Infectious disease (viral respiratory tract infection), pathogen-specific RNA, 4 targets.",300,$585.50 ,$450.84 ,77% of total billed charges,$149.30 ,25.5% of total billed charges,$149.30 ,25.5% of total billed charges,$182.97 ,31.25% of total billed charges,$433.27 ,74% of total billed charges,$404.00 ,69% of total billed charges,$404.00 ,69% of total billed charges,$146.38 ,25% of total billed charges,$404.00 ,69% of total billed charges,$404.00 ,69% of total billed charges,$511.94 ,100% of BCBS fee schedule,$480.11 ,82% of total billed charges,$521.10 ,89% of total billed charges,$521.10 ,89% of total billed charges,$521.10 ,89% of total billed charges,$123.23 ,120% of MO fee schedule,$123.23 ,120% of MO fee schedule,$123.23 ,120% of MO fee schedule,$450.84 ,77% of total billed charges,$497.68 ,85% of total billed charges,$168.33 ,28.75% of total billed charges,$585.50 ,100% of UHC fee schedule,$123.23 ,120% of MO fee schedule,$146.38 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$146.38 ,25% of total billed charges,$55.00 ,$585.50 ,$292.75 
Outpatient Medical Services,LABORATORY,C9803,symptom assessment and specimen collection performed by hospital outpatient departments,300,$78.00 ,$60.06 ,77% of total billed charges,$19.89 ,25.5% of total billed charges,$19.89 ,25.5% of total billed charges,$24.38 ,31.25% of total billed charges,$57.72 ,74% of total billed charges,$53.82 ,69% of total billed charges,$53.82 ,69% of total billed charges,$19.50 ,25% of total billed charges,$53.82 ,69% of total billed charges,$53.82 ,69% of total billed charges,$65.52 ,84% of total billed charges,$63.96 ,82% of total billed charges,$69.42 ,89% of total billed charges,$69.42 ,89% of total billed charges,$69.42 ,89% of total billed charges,$31.82 ,40.8% of total billed charges,$31.82 ,40.8% of total billed charges,$31.82 ,40.8% of total billed charges,$60.06 ,77% of total billed charges,$66.30 ,85% of total billed charges,$22.43 ,28.75% of total billed charges,$78.00 ,100% of UHC fee schedule,$31.82 ,40.8% of total billed charges,$19.50 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$19.50 ,25% of total billed charges,$19.50 ,$78.00 ,$39.00 
Outpatient Medical Services,LABORATORY,U0002,: CDC 2019 Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic Panel,300,$278.50 ,$214.45 ,77% of total billed charges,$71.02 ,25.5% of total billed charges,$71.02 ,25.5% of total billed charges,$87.03 ,31.25% of total billed charges,$206.09 ,74% of total billed charges,$192.17 ,69% of total billed charges,$192.17 ,69% of total billed charges,$69.63 ,25% of total billed charges,$192.17 ,69% of total billed charges,$192.17 ,69% of total billed charges,$184.17 ,100% of BCBS fee schedule,$228.37 ,82% of total billed charges,$247.87 ,89% of total billed charges,$247.87 ,89% of total billed charges,$247.87 ,89% of total billed charges,$43.85 ,120% of MO fee schedule,$43.85 ,120% of MO fee schedule,$43.85 ,120% of MO fee schedule,$214.45 ,77% of total billed charges,$236.73 ,85% of total billed charges,$80.07 ,28.75% of total billed charges,$278.50 ,100% of UHC fee schedule,$43.85 ,120% of MO fee schedule,$69.63 ,25% of total billed charges,$55.00 ,pays based on per visit rate,$69.63 ,25% of total billed charges,$43.85 ,$278.50 ,$139.25 
Outpatient Medical Services,RESPIRATORY THERAPY SLEEP,94010,Pulmonary Function Testing—no bronchodilator,460,$534.50 ,$411.57 ,77% of total billed charges,$136.30 ,25.5% of total billed charges,$136.30 ,25.5% of total billed charges,$167.03 ,31.25% of total billed charges,$395.53 ,74% of total billed charges,$368.81 ,69% of total billed charges,$368.81 ,69% of total billed charges,$133.63 ,25% of total billed charges,$368.81 ,69% of total billed charges,$368.81 ,69% of total billed charges,$448.98 ,84% of total billed charges,$438.29 ,82% of total billed charges,$475.71 ,89% of total billed charges,$475.71 ,89% of total billed charges,$475.71 ,89% of total billed charges,$18.90 ,120% of MO fee schedule,$18.90 ,120% of MO fee schedule,$18.90 ,120% of MO fee schedule,$411.57 ,77% of total billed charges,$454.33 ,85% of total billed charges,$153.67 ,28.75% of total billed charges,$534.50 ,100% of UHC fee schedule,$18.90 ,120% of MO fee schedule,$133.63 ,25% of total billed charges,$562.00 ,pays based on per visit rate,$133.63 ,25% of total billed charges,$18.90 ,$562.00 ,$267.25 
Outpatient Medical Services,RESPIRATORY THERAPY SLEEP,94375,Respiratory Flow Volume Loop,460,$146.00 ,$112.42 ,77% of total billed charges,$37.23 ,25.5% of total billed charges,$37.23 ,25.5% of total billed charges,$45.63 ,31.25% of total billed charges,$108.04 ,74% of total billed charges,$100.74 ,69% of total billed charges,$100.74 ,69% of total billed charges,$36.50 ,25% of total billed charges,$100.74 ,69% of total billed charges,$100.74 ,69% of total billed charges,$122.64 ,84% of total billed charges,$119.72 ,82% of total billed charges,$129.94 ,89% of total billed charges,$129.94 ,89% of total billed charges,$129.94 ,89% of total billed charges,$21.55 ,120% of MO fee schedule,$21.55 ,120% of MO fee schedule,$21.55 ,120% of MO fee schedule,$112.42 ,77% of total billed charges,$124.10 ,85% of total billed charges,$41.98 ,28.75% of total billed charges,$146.00 ,100% of UHC fee schedule,$21.55 ,120% of MO fee schedule,$36.50 ,25% of total billed charges,$562.00 ,pays based on per visit rate,$36.50 ,25% of total billed charges,$21.55 ,$562.00 ,$73.00 
Outpatient Medical Services,RESPIRATORY THERAPY SLEEP,94640,Treatment of acute airway obstruction with inhaled medication,410,$246.00 ,$189.42 ,77% of total billed charges,$62.73 ,25.5% of total billed charges,$62.73 ,25.5% of total billed charges,$76.88 ,31.25% of total billed charges,$182.04 ,74% of total billed charges,$169.74 ,69% of total billed charges,$169.74 ,69% of total billed charges,$61.50 ,25% of total billed charges,$169.74 ,69% of total billed charges,$169.74 ,69% of total billed charges,$206.64 ,84% of total billed charges,$201.72 ,82% of total billed charges,$218.94 ,89% of total billed charges,$218.94 ,89% of total billed charges,$218.94 ,89% of total billed charges,$10.02 ,120% of MO fee schedule,$10.02 ,120% of MO fee schedule,$10.02 ,120% of MO fee schedule,$189.42 ,77% of total billed charges,$209.10 ,85% of total billed charges,$70.73 ,28.75% of total billed charges,$246.00 ,100% of UHC fee schedule,$10.02 ,120% of MO fee schedule,$61.50 ,25% of total billed charges,$141.00 ,pays based on per visit rate,$61.50 ,25% of total billed charges,$10.02 ,$246.00 ,$123.00 
Outpatient Medical Services,RESPIRATORY THERAPY SLEEP,94726,"Determination of lung volumes, residual volume, functional residual capacity (FRC), and airway resistance",460,$238.00 ,$183.26 ,77% of total billed charges,$60.69 ,25.5% of total billed charges,$60.69 ,25.5% of total billed charges,$74.38 ,31.25% of total billed charges,$176.12 ,74% of total billed charges,$164.22 ,69% of total billed charges,$164.22 ,69% of total billed charges,$59.50 ,25% of total billed charges,$164.22 ,69% of total billed charges,$164.22 ,69% of total billed charges,$199.92 ,84% of total billed charges,$195.16 ,82% of total billed charges,$211.82 ,89% of total billed charges,$211.82 ,89% of total billed charges,$211.82 ,89% of total billed charges,$38.26 ,120% of MO fee schedule,$38.26 ,120% of MO fee schedule,$38.26 ,120% of MO fee schedule,$183.26 ,77% of total billed charges,$202.30 ,85% of total billed charges,$68.43 ,28.75% of total billed charges,$238.00 ,100% of UHC fee schedule,$38.26 ,120% of MO fee schedule,$59.50 ,25% of total billed charges,$562.00 ,pays based on per visit rate,$59.50 ,25% of total billed charges,$38.26 ,$562.00 ,$119.00 
Outpatient Medical Services,RESPIRATORY THERAPY SLEEP,94727,Gas dilution or washout for determination of lung volumes,460,$394.00 ,$303.38 ,77% of total billed charges,$100.47 ,25.5% of total billed charges,$100.47 ,25.5% of total billed charges,$123.13 ,31.25% of total billed charges,$291.56 ,74% of total billed charges,$271.86 ,69% of total billed charges,$271.86 ,69% of total billed charges,$98.50 ,25% of total billed charges,$271.86 ,69% of total billed charges,$271.86 ,69% of total billed charges,$330.96 ,84% of total billed charges,$323.08 ,82% of total billed charges,$350.66 ,89% of total billed charges,$350.66 ,89% of total billed charges,$350.66 ,89% of total billed charges,$28.55 ,120% of MO fee schedule,$28.55 ,120% of MO fee schedule,$28.55 ,120% of MO fee schedule,$303.38 ,77% of total billed charges,$334.90 ,85% of total billed charges,$113.28 ,28.75% of total billed charges,$394.00 ,100% of UHC fee schedule,$28.55 ,120% of MO fee schedule,$98.50 ,25% of total billed charges,$562.00 ,pays based on per visit rate,$98.50 ,25% of total billed charges,$28.55 ,$562.00 ,$197.00 
Outpatient Medical Services,RESPIRATORY THERAPY SLEEP,94729,Pulmonary stress testing,460,$394.00 ,$303.38 ,77% of total billed charges,$100.47 ,25.5% of total billed charges,$100.47 ,25.5% of total billed charges,$123.13 ,31.25% of total billed charges,$291.56 ,74% of total billed charges,$271.86 ,69% of total billed charges,$271.86 ,69% of total billed charges,$98.50 ,25% of total billed charges,$271.86 ,69% of total billed charges,$271.86 ,69% of total billed charges,$330.96 ,84% of total billed charges,$323.08 ,82% of total billed charges,$350.66 ,89% of total billed charges,$350.66 ,89% of total billed charges,$350.66 ,89% of total billed charges,$44.66 ,120% of MO fee schedule,$44.66 ,120% of MO fee schedule,$44.66 ,120% of MO fee schedule,$303.38 ,77% of total billed charges,$334.90 ,85% of total billed charges,$113.28 ,28.75% of total billed charges,$394.00 ,100% of UHC fee schedule,$44.66 ,120% of MO fee schedule,$98.50 ,25% of total billed charges,$562.00 ,pays based on per visit rate,$98.50 ,25% of total billed charges,$44.66 ,$562.00 ,$197.00 
Outpatient Medical Services,RESPIRATORY THERAPY SLEEP,95806,Sleep Study,920,"$2,352.00 ","$1,811.04 ",77% of total billed charges,$599.76 ,25.5% of total billed charges,$599.76 ,25.5% of total billed charges,$735.00 ,31.25% of total billed charges,"$1,433.00 ",69% of total billed charges,"$1,389.00 ",69% of total billed charges,"$1,389.00 ",69% of total billed charges,$588.00 ,25% of total billed charges,"$1,389.00 ",69% of total billed charges,"$1,389.00 ",69% of total billed charges,"$1,407.00 ",84% of total billed charges,"$1,928.64 ",82% of total billed charges,"$2,093.28 ",89% of total billed charges,"$2,093.28 ",89% of total billed charges,"$2,093.28 ",89% of total billed charges,$52.93 ,120% of MO fee schedule,$52.93 ,120% of MO fee schedule,$52.93 ,120% of MO fee schedule,"$1,811.04 ",77% of total billed charges,"$1,999.20 ",85% of total billed charges,$676.20 ,28.75% of total billed charges,"$2,352.00 ",100% of UHC fee schedule,$52.93 ,120% of MO fee schedule,$588.00 ,25% of total billed charges,"$1,827.00 ",pays based on per visit rate,$588.00 ,25% of total billed charges,$52.93 ,"$2,352.00 ","$1,176.00 "
Outpatient Medical Services,RESPIRATORY THERAPY SLEEP,95810,Sleep study,920,"$3,972.00 ","$3,058.44 ",77% of total billed charges,"$1,012.86 ",25.5% of total billed charges,"$1,012.86 ",25.5% of total billed charges,"$1,241.25 ",31.25% of total billed charges,"$1,433.00 ",69% of total billed charges,"$1,389.00 ",69% of total billed charges,"$1,389.00 ",69% of total billed charges,$993.00 ,25% of total billed charges,"$1,389.00 ",69% of total billed charges,"$1,389.00 ",69% of total billed charges,"$1,407.00 ",84% of total billed charges,"$3,257.04 ",82% of total billed charges,"$3,535.08 ",89% of total billed charges,"$3,535.08 ",89% of total billed charges,"$3,535.08 ",89% of total billed charges,$464.96 ,120% of MO fee schedule,$464.96 ,120% of MO fee schedule,$464.96 ,120% of MO fee schedule,"$3,058.44 ",77% of total billed charges,"$3,376.20 ",85% of total billed charges,"$1,141.95 ",28.75% of total billed charges,"$3,972.00 ",100% of UHC fee schedule,$464.96 ,120% of MO fee schedule,$993.00 ,25% of total billed charges,"$2,050.00 ",pays based on per visit rate,$993.00 ,25% of total billed charges,$464.96 ,"$3,972.00 ","$1,986.00 "
Outpatient Medical Services,PROVIDER SERVICES,59400,"Routine obstetric care for vaginal delivery, including pre-and post-delivery care",521,"$4,532.00 ","$3,489.64 ",77% of total billed charges,"$1,155.66 ",25.5% of total billed charges,"$1,155.66 ",25.5% of total billed charges,"$1,416.25 ",31.25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,"$1,133.00 ",25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,"$4,033.48 ",89% of total billed charges,"$4,033.48 ",89% of total billed charges,"$4,033.48 ",89% of total billed charges,"$1,849.06 ",40.8% of total billed charges,"$1,849.06 ",40.8% of total billed charges,"$1,849.06 ",40.8% of total billed charges,"$3,489.64 ",77% of total billed charges,"$3,852.20 ",85% of total billed charges,"$1,302.95 ",28.75% of total billed charges,"$4,532.00 ",100% of UHC fee schedule,"$1,849.06 ",40.8% of total billed charges,"$1,133.00 ",25% of total billed charges,N/A,not seperately reimbursable,"$1,133.00 ",25% of total billed charges,"$1,133.00 ","$4,532.00 ","$2,266.00 "
Outpatient Medical Services,PROVIDER SERVICES,59510,"Routine obstetric care for cesarean delivery, including pre-and post-delivery care",521,"$5,030.00 ","$3,873.10 ",77% of total billed charges,"$1,282.65 ",25.5% of total billed charges,"$1,282.65 ",25.5% of total billed charges,"$1,571.88 ",31.25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,"$1,257.50 ",25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,"$4,476.70 ",89% of total billed charges,"$4,476.70 ",89% of total billed charges,"$4,476.70 ",89% of total billed charges,"$2,052.24 ",40.8% of total billed charges,"$2,052.24 ",40.8% of total billed charges,"$2,052.24 ",40.8% of total billed charges,"$3,873.10 ",77% of total billed charges,"$4,275.50 ",85% of total billed charges,"$1,446.13 ",28.75% of total billed charges,"$5,030.00 ",100% of UHC fee schedule,"$2,052.24 ",40.8% of total billed charges,"$1,257.50 ",25% of total billed charges,N/A,not seperately reimbursable,"$1,257.50 ",25% of total billed charges,"$1,257.50 ","$5,030.00 ","$2,515.00 "
Outpatient Medical Services,PROVIDER SERVICES,59610,Routine obstetric care for vaginal delivery after prior cesarean delivery including pre-and post-delivery care,521,"$3,958.00 ","$3,047.66 ",77% of total billed charges,"$1,009.29 ",25.5% of total billed charges,"$1,009.29 ",25.5% of total billed charges,"$1,236.88 ",31.25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$989.50 ,25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,"$3,522.62 ",89% of total billed charges,"$3,522.62 ",89% of total billed charges,"$3,522.62 ",89% of total billed charges,"$1,614.86 ",40.8% of total billed charges,"$1,614.86 ",40.8% of total billed charges,"$1,614.86 ",40.8% of total billed charges,"$3,047.66 ",77% of total billed charges,"$3,364.30 ",85% of total billed charges,"$1,137.93 ",28.75% of total billed charges,"$3,958.00 ",100% of UHC fee schedule,"$1,614.86 ",40.8% of total billed charges,$989.50 ,25% of total billed charges,N/A,not seperately reimbursable,$989.50 ,25% of total billed charges,$989.50 ,"$3,958.00 ","$1,979.00 "
Outpatient Medical Services,PROVIDER SERVICES,90832,"Psychotherapy, 30 min",521,$135.00 ,$103.95 ,77% of total billed charges,$34.43 ,25.5% of total billed charges,$34.43 ,25.5% of total billed charges,$42.19 ,31.25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$33.75 ,25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$120.15 ,89% of total billed charges,$120.15 ,89% of total billed charges,$120.15 ,89% of total billed charges,$55.08 ,40.8% of total billed charges,$55.08 ,40.8% of total billed charges,$55.08 ,40.8% of total billed charges,$103.95 ,77% of total billed charges,$114.75 ,85% of total billed charges,$38.81 ,28.75% of total billed charges,$135.00 ,100% of UHC fee schedule,$55.08 ,40.8% of total billed charges,$33.75 ,25% of total billed charges,N/A,not seperately reimbursable,$33.75 ,25% of total billed charges,$33.75 ,$135.00 ,$67.50 
Outpatient Medical Services,PROVIDER SERVICES,90834,"Psychotherapy, 45 min",521,$178.00 ,$137.06 ,77% of total billed charges,$45.39 ,25.5% of total billed charges,$45.39 ,25.5% of total billed charges,$55.63 ,31.25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$44.50 ,25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$158.42 ,89% of total billed charges,$158.42 ,89% of total billed charges,$158.42 ,89% of total billed charges,$72.62 ,40.8% of total billed charges,$72.62 ,40.8% of total billed charges,$72.62 ,40.8% of total billed charges,$137.06 ,77% of total billed charges,$151.30 ,85% of total billed charges,$51.18 ,28.75% of total billed charges,$178.00 ,100% of UHC fee schedule,$72.62 ,40.8% of total billed charges,$44.50 ,25% of total billed charges,N/A,not seperately reimbursable,$44.50 ,25% of total billed charges,$44.50 ,$178.00 ,$89.00 
Outpatient Medical Services,PROVIDER SERVICES,90837,"Psychotherapy, 60 min",521,$215.00 ,$165.55 ,77% of total billed charges,$54.83 ,25.5% of total billed charges,$54.83 ,25.5% of total billed charges,$67.19 ,31.25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$53.75 ,25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$191.35 ,89% of total billed charges,$191.35 ,89% of total billed charges,$191.35 ,89% of total billed charges,$87.72 ,40.8% of total billed charges,$87.72 ,40.8% of total billed charges,$87.72 ,40.8% of total billed charges,$165.55 ,77% of total billed charges,$182.75 ,85% of total billed charges,$61.81 ,28.75% of total billed charges,$215.00 ,100% of UHC fee schedule,$87.72 ,40.8% of total billed charges,$53.75 ,25% of total billed charges,N/A,not seperately reimbursable,$53.75 ,25% of total billed charges,$53.75 ,$215.00 ,$107.50 
Outpatient Medical Services,PROVIDER SERVICES,90846,"Family psychotherapy, not including patient, 50 min",521,$132.00 ,$101.64 ,77% of total billed charges,$33.66 ,25.5% of total billed charges,$33.66 ,25.5% of total billed charges,$41.25 ,31.25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$33.00 ,25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$117.48 ,89% of total billed charges,$117.48 ,89% of total billed charges,$117.48 ,89% of total billed charges,$53.86 ,40.8% of total billed charges,$53.86 ,40.8% of total billed charges,$53.86 ,40.8% of total billed charges,$101.64 ,77% of total billed charges,$112.20 ,85% of total billed charges,$37.95 ,28.75% of total billed charges,$132.00 ,100% of UHC fee schedule,$53.86 ,40.8% of total billed charges,$33.00 ,25% of total billed charges,N/A,not seperately reimbursable,$33.00 ,25% of total billed charges,$33.00 ,$132.00 ,$66.00 
Outpatient Medical Services,PROVIDER SERVICES,90847,"Family psychotherapy, including patient, 50 min",521,$165.00 ,$127.05 ,77% of total billed charges,$42.08 ,25.5% of total billed charges,$42.08 ,25.5% of total billed charges,$51.56 ,31.25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$41.25 ,25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$146.85 ,89% of total billed charges,$146.85 ,89% of total billed charges,$146.85 ,89% of total billed charges,$67.32 ,40.8% of total billed charges,$67.32 ,40.8% of total billed charges,$67.32 ,40.8% of total billed charges,$127.05 ,77% of total billed charges,$140.25 ,85% of total billed charges,$47.44 ,28.75% of total billed charges,$165.00 ,100% of UHC fee schedule,$67.32 ,40.8% of total billed charges,$41.25 ,25% of total billed charges,N/A,not seperately reimbursable,$41.25 ,25% of total billed charges,$41.25 ,$165.00 ,$82.50 
Outpatient Medical Services,PROVIDER SERVICES,90853,Group psychotherapy,521,$206.00 ,$158.62 ,77% of total billed charges,$52.53 ,25.5% of total billed charges,$52.53 ,25.5% of total billed charges,$64.38 ,31.25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$51.50 ,25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$183.34 ,89% of total billed charges,$183.34 ,89% of total billed charges,$183.34 ,89% of total billed charges,$84.05 ,40.8% of total billed charges,$84.05 ,40.8% of total billed charges,$84.05 ,40.8% of total billed charges,$158.62 ,77% of total billed charges,$175.10 ,85% of total billed charges,$59.23 ,28.75% of total billed charges,$206.00 ,100% of UHC fee schedule,$84.05 ,40.8% of total billed charges,$51.50 ,25% of total billed charges,N/A,not seperately reimbursable,$51.50 ,25% of total billed charges,$51.50 ,$206.00 ,$103.00 
Outpatient Medical Services,PROVIDER SERVICES,99203,"New patient office or other outpatient visit, typically 30 min",510,$640.00 ,$492.80 ,77% of total billed charges,$163.20 ,25.5% of total billed charges,$163.20 ,25.5% of total billed charges,$200.00 ,31.25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$160.00 ,25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$261.12 ,40.8% of total billed charges,$261.12 ,40.8% of total billed charges,$261.12 ,40.8% of total billed charges,$492.80 ,77% of total billed charges,$544.00 ,85% of total billed charges,$184.00 ,28.75% of total billed charges,$320.00 ,50% of total billed charges,$261.12 ,40.8% of total billed charges,$160.00 ,25% of total billed charges,$569.60 ,89% of total billed charges,$160.00 ,25% of total billed charges,$160.00 ,$569.60 ,$320.00 
Outpatient Medical Services,PROVIDER SERVICES,99204,Office visit or other outpatient consultation to evaluate and treat a new patient that requires a medically appropriate medical history,510,$867.50 ,$667.98 ,77% of total billed charges,$221.21 ,25.5% of total billed charges,$221.21 ,25.5% of total billed charges,$271.09 ,31.25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$216.88 ,25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$353.94 ,40.8% of total billed charges,$353.94 ,40.8% of total billed charges,$353.94 ,40.8% of total billed charges,$667.98 ,77% of total billed charges,$737.38 ,85% of total billed charges,$249.41 ,28.75% of total billed charges,$433.75 ,50% of total billed charges,$353.94 ,40.8% of total billed charges,$216.88 ,25% of total billed charges,$772.08 ,89% of total billed charges,$216.88 ,25% of total billed charges,$216.88 ,$772.08 ,$433.75 
Outpatient Medical Services,PROVIDER SERVICES,99205,"New patient office of other outpatient visit, typically 60 min",510,$867.50 ,$667.98 ,77% of total billed charges,$221.21 ,25.5% of total billed charges,$221.21 ,25.5% of total billed charges,$271.09 ,31.25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$216.88 ,25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$353.94 ,40.8% of total billed charges,$353.94 ,40.8% of total billed charges,$353.94 ,40.8% of total billed charges,$667.98 ,77% of total billed charges,$737.38 ,85% of total billed charges,$249.41 ,28.75% of total billed charges,$433.75 ,50% of total billed charges,$353.94 ,40.8% of total billed charges,$216.88 ,25% of total billed charges,$772.08 ,89% of total billed charges,$216.88 ,25% of total billed charges,$216.88 ,$772.08 ,$433.75 
Outpatient Medical Services,PROVIDER SERVICES,99211,Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician,510,$510.50 ,$393.09 ,77% of total billed charges,$130.18 ,25.5% of total billed charges,$130.18 ,25.5% of total billed charges,$159.53 ,31.25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$127.63 ,25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$208.28 ,40.8% of total billed charges,$208.28 ,40.8% of total billed charges,$208.28 ,40.8% of total billed charges,$393.09 ,77% of total billed charges,$433.93 ,85% of total billed charges,$146.77 ,28.75% of total billed charges,$255.25 ,50% of total billed charges,$208.28 ,40.8% of total billed charges,$127.63 ,25% of total billed charges,$454.35 ,89% of total billed charges,$127.63 ,25% of total billed charges,$127.63 ,$454.35 ,$255.25 
Outpatient Medical Services,PROVIDER SERVICES,99212,An evaluation and management appointment for an established patient,510,$510.50 ,$393.09 ,77% of total billed charges,$130.18 ,25.5% of total billed charges,$130.18 ,25.5% of total billed charges,$159.53 ,31.25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$127.63 ,25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$208.28 ,40.8% of total billed charges,$208.28 ,40.8% of total billed charges,$208.28 ,40.8% of total billed charges,$393.09 ,77% of total billed charges,$433.93 ,85% of total billed charges,$146.77 ,28.75% of total billed charges,$255.25 ,50% of total billed charges,$208.28 ,40.8% of total billed charges,$127.63 ,25% of total billed charges,$454.35 ,89% of total billed charges,$127.63 ,25% of total billed charges,$127.63 ,$454.35 ,$255.25 
Outpatient Medical Services,PROVIDER SERVICES,99213,Office or other outpatient visit for the evaluation and management of an established patient,510,$586.00 ,$451.22 ,77% of total billed charges,$149.43 ,25.5% of total billed charges,$149.43 ,25.5% of total billed charges,$183.13 ,31.25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$146.50 ,25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$239.09 ,40.8% of total billed charges,$239.09 ,40.8% of total billed charges,$239.09 ,40.8% of total billed charges,$451.22 ,77% of total billed charges,$498.10 ,85% of total billed charges,$168.48 ,28.75% of total billed charges,$293.00 ,50% of total billed charges,$239.09 ,40.8% of total billed charges,$146.50 ,25% of total billed charges,$521.54 ,89% of total billed charges,$146.50 ,25% of total billed charges,$146.50 ,$521.54 ,$293.00 
Outpatient Medical Services,PROVIDER SERVICES,99214,Office or other outpatient visit for the evaluation and management of an established patient,510,$851.00 ,$655.27 ,77% of total billed charges,$217.01 ,25.5% of total billed charges,$217.01 ,25.5% of total billed charges,$265.94 ,31.25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$212.75 ,25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$347.21 ,40.8% of total billed charges,$347.21 ,40.8% of total billed charges,$347.21 ,40.8% of total billed charges,$655.27 ,77% of total billed charges,$723.35 ,85% of total billed charges,$244.66 ,28.75% of total billed charges,$425.50 ,50% of total billed charges,$347.21 ,40.8% of total billed charges,$212.75 ,25% of total billed charges,$757.39 ,89% of total billed charges,$212.75 ,25% of total billed charges,$212.75 ,$757.39 ,$425.50 
Outpatient Medical Services,PROVIDER SERVICES,99215,Office or other outpatient visit for the evaluation and management of an established patient,510,$851.00 ,$655.27 ,77% of total billed charges,$217.01 ,25.5% of total billed charges,$217.01 ,25.5% of total billed charges,$265.94 ,31.25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$212.75 ,25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$347.21 ,40.8% of total billed charges,$347.21 ,40.8% of total billed charges,$347.21 ,40.8% of total billed charges,$655.27 ,77% of total billed charges,$723.35 ,85% of total billed charges,$244.66 ,28.75% of total billed charges,$425.50 ,50% of total billed charges,$347.21 ,40.8% of total billed charges,$212.75 ,25% of total billed charges,$757.39 ,89% of total billed charges,$212.75 ,25% of total billed charges,$212.75 ,$757.39 ,$425.50 
Outpatient Medical Services,PROVIDER SERVICES,99217,Observation care discharge day management,762,$256.50 ,$197.51 ,77% of total billed charges,$65.41 ,25.5% of total billed charges,$65.41 ,25.5% of total billed charges,$80.16 ,31.25% of total billed charges,$176.99 ,69% of total billed charges,$176.99 ,69% of total billed charges,$176.99 ,69% of total billed charges,$64.13 ,25% of total billed charges,$176.99 ,69% of total billed charges,$176.99 ,69% of total billed charges,$215.46 ,84% of total billed charges,$210.33 ,82% of total billed charges,$228.29 ,89% of total billed charges,$215.46 ,pays based on per visit rate,$228.29 ,89% of total billed charges,$104.65 ,40.8% of total billed charges,$104.65 ,40.8% of total billed charges,$104.65 ,40.8% of total billed charges,$197.51 ,77% of total billed charges,$218.03 ,85% of total billed charges,$73.74 ,28.75% of total billed charges,$256.50 ,100% of UHC fee schedule,$104.65 ,40.8% of total billed charges,$64.13 ,25% of total billed charges,"$1,978.00 ",pays based on per visit rate,$64.13 ,25% of total billed charges,$64.13 ,"$1,978.00 ",$128.25 
Outpatient Medical Services,PROVIDER SERVICES,99243,"Patient office consultation, typically 40 min",982,$318.00 ,$126.23 ,175% of AETNA fee schedule,$93.99 ,115% of CMS fee schedule,$95.87 ,117.3% of CMS fee schedule,$117.49 ,143.75% of CMS fee schedule,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$93.99 ,115% of CMS fee schedule,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$110.84 ,100% of CIGNA fee schedule,$106.10 ,100% of HEALTHLINK fee schedule,$96.62 ,100% of HEALTHLINK fee schedule,$106.10 ,100% of HEALTHLINK fee schedule,$286.20 ,40.8% of total billed charges,$286.20 ,90% of total billed charges,$286.20 ,40.8% of total billed charges,$126.23 ,175% of CMS fee schedule,$145.68 ,178.25% of CMS fee schedule,$108.09 ,132.25% of CMS fee schedule,$93.58 ,100% of UHC fee schedule,$286.20 ,40.8% of total billed charges,$93.99 ,100% of CMS fee schedule,$82.39 ,100% of CMS fee schedule,$93.99 ,115% of CMS fee schedule,$82.39 ,$286.20 ,$159.00 
Outpatient Medical Services,PROVIDER SERVICES,99244,"Patient office consultation, typically 60 min",510,$459.00 ,$353.43 ,77% of total billed charges,$117.05 ,25.5% of total billed charges,$117.05 ,25.5% of total billed charges,$143.44 ,31.25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$114.75 ,25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$187.27 ,40.8% of total billed charges,$187.27 ,40.8% of total billed charges,$187.27 ,40.8% of total billed charges,$353.43 ,77% of total billed charges,$390.15 ,85% of total billed charges,$131.96 ,28.75% of total billed charges,$229.50 ,50% of total billed charges,$187.27 ,40.8% of total billed charges,$114.75 ,25% of total billed charges,$408.51 ,89% of total billed charges,$114.75 ,25% of total billed charges,$114.75 ,$408.51 ,$229.50 
Outpatient Medical Services,PROVIDER SERVICES,99281,"Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A problem focused history; A problem",450,$367.50 ,$282.98 ,77% of total billed charges,$93.71 ,25.5% of total billed charges,$93.71 ,25.5% of total billed charges,$114.84 ,31.25% of total billed charges,$216.83 ,pays based on per visit rate,$216.83 ,pays based on per visit rate,$216.83 ,pays based on per visit rate,$91.88 ,25% of total billed charges,$216.83 ,pays based on per visit rate,$216.83 ,pays based on per visit rate,$308.70 ,84% of total billed charges,$301.35 ,82% of total billed charges,$327.08 ,89% of total billed charges,$308.70 ,pays based on per visit rate,$327.08 ,89% of total billed charges,$149.94 ,40.8% of total billed charges,$149.94 ,40.8% of total billed charges,$149.94 ,40.8% of total billed charges,$282.98 ,77% of total billed charges,$312.38 ,85% of total billed charges,$105.66 ,28.75% of total billed charges,$367.50 ,100% of UHC fee schedule,$149.94 ,40.8% of total billed charges,$91.88 ,25% of total billed charges,$476.00 ,pays based on per visit rate,$91.88 ,25% of total billed charges,$91.88 ,$476.00 ,$183.75 
Outpatient Medical Services,PROVIDER SERVICES,99282,Emergency department visit for the evaluation and management of a patient,450,$539.00 ,$415.03 ,77% of total billed charges,$137.45 ,25.5% of total billed charges,$137.45 ,25.5% of total billed charges,$168.44 ,31.25% of total billed charges,$318.01 ,pays based on per visit rate,$318.01 ,pays based on per visit rate,$318.01 ,pays based on per visit rate,$134.75 ,25% of total billed charges,$318.01 ,pays based on per visit rate,$318.01 ,pays based on per visit rate,$452.76 ,84% of total billed charges,$441.98 ,82% of total billed charges,$479.71 ,89% of total billed charges,$452.76 ,pays based on per visit rate,$479.71 ,89% of total billed charges,$219.91 ,40.8% of total billed charges,$219.91 ,40.8% of total billed charges,$219.91 ,40.8% of total billed charges,$415.03 ,77% of total billed charges,$458.15 ,85% of total billed charges,$154.96 ,28.75% of total billed charges,$539.00 ,100% of UHC fee schedule,$219.91 ,40.8% of total billed charges,$134.75 ,25% of total billed charges,$637.00 ,pays based on per visit rate,$134.75 ,25% of total billed charges,$134.75 ,$637.00 ,$269.50 
Outpatient Medical Services,PROVIDER SERVICES,99283,"Emergency department visit for the evaluation and management of a patient,",450,$775.00 ,$596.75 ,77% of total billed charges,$197.63 ,25.5% of total billed charges,$197.63 ,25.5% of total billed charges,$242.19 ,31.25% of total billed charges,$457.25 ,pays based on per visit rate,$457.25 ,pays based on per visit rate,$457.25 ,pays based on per visit rate,$193.75 ,25% of total billed charges,$457.25 ,pays based on per visit rate,$457.25 ,pays based on per visit rate,$651.00 ,84% of total billed charges,$635.50 ,82% of total billed charges,$689.75 ,89% of total billed charges,$651.00 ,pays based on per visit rate,$689.75 ,89% of total billed charges,$316.20 ,40.8% of total billed charges,$316.20 ,40.8% of total billed charges,$316.20 ,40.8% of total billed charges,$596.75 ,77% of total billed charges,$658.75 ,85% of total billed charges,$222.81 ,28.75% of total billed charges,$775.00 ,100% of UHC fee schedule,$316.20 ,40.8% of total billed charges,$193.75 ,25% of total billed charges,$864.00 ,pays based on per visit rate,$193.75 ,25% of total billed charges,$193.75 ,$864.00 ,$387.50 
Outpatient Medical Services,PROVIDER SERVICES,99284,ER Dept visit detailed problem/decision,450,"$1,226.50 ",$944.41 ,77% of total billed charges,$312.76 ,25.5% of total billed charges,$312.76 ,25.5% of total billed charges,$383.28 ,31.25% of total billed charges,$723.64 ,pays based on per visit rate,$723.64 ,pays based on per visit rate,$723.64 ,pays based on per visit rate,$306.63 ,25% of total billed charges,$723.64 ,pays based on per visit rate,$723.64 ,pays based on per visit rate,"$1,030.26 ",84% of total billed charges,"$1,005.73 ",82% of total billed charges,"$1,091.59 ",89% of total billed charges,"$1,030.26 ",pays based on per visit rate,"$1,091.59 ",89% of total billed charges,$500.41 ,40.8% of total billed charges,$500.41 ,40.8% of total billed charges,$500.41 ,40.8% of total billed charges,$944.41 ,77% of total billed charges,"$1,042.53 ",85% of total billed charges,$352.62 ,28.75% of total billed charges,"$1,226.50 ",100% of UHC fee schedule,$500.41 ,40.8% of total billed charges,$306.63 ,25% of total billed charges,"$1,368.00 ",pays based on per visit rate,$306.63 ,25% of total billed charges,$306.63 ,"$1,368.00 ",$613.25 
Outpatient Medical Services,PROVIDER SERVICES,99285,Emergency department visit for the evaluation and management of a patient,450,"$1,668.50 ","$1,284.75 ",77% of total billed charges,$425.47 ,25.5% of total billed charges,$425.47 ,25.5% of total billed charges,$521.41 ,31.25% of total billed charges,$984.42 ,pays based on per visit rate,$984.42 ,pays based on per visit rate,$984.42 ,pays based on per visit rate,$417.13 ,25% of total billed charges,$984.42 ,pays based on per visit rate,$984.42 ,pays based on per visit rate,"$1,401.54 ",84% of total billed charges,"$1,368.17 ",82% of total billed charges,"$1,484.97 ",89% of total billed charges,"$1,401.54 ",pays based on per visit rate,"$1,484.97 ",89% of total billed charges,$680.75 ,40.8% of total billed charges,$680.75 ,40.8% of total billed charges,$680.75 ,40.8% of total billed charges,"$1,284.75 ",77% of total billed charges,"$1,418.23 ",85% of total billed charges,$479.69 ,28.75% of total billed charges,"$1,668.50 ",100% of UHC fee schedule,$680.75 ,40.8% of total billed charges,$417.13 ,25% of total billed charges,"$3,662.00 ",pays based on per visit rate,$417.13 ,25% of total billed charges,$417.13 ,"$3,662.00 ",$834.25 
Outpatient Medical Services,PROVIDER SERVICES,99308,"Subsequent nursing facility care, per day",521,$158.00 ,$121.66 ,77% of total billed charges,$40.29 ,25.5% of total billed charges,$40.29 ,25.5% of total billed charges,$49.38 ,31.25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$39.50 ,25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$140.62 ,89% of total billed charges,$140.62 ,89% of total billed charges,$140.62 ,89% of total billed charges,$64.46 ,40.8% of total billed charges,$64.46 ,40.8% of total billed charges,$64.46 ,40.8% of total billed charges,$121.66 ,77% of total billed charges,$134.30 ,85% of total billed charges,$45.43 ,28.75% of total billed charges,$158.00 ,100% of UHC fee schedule,$64.46 ,40.8% of total billed charges,$39.50 ,25% of total billed charges,N/A,not seperately reimbursable,$39.50 ,25% of total billed charges,$39.50 ,$158.00 ,$79.00 
Outpatient Medical Services,PROVIDER SERVICES,99309,"Subsequent nursing facility care, per day,",521,$193.00 ,$148.61 ,77% of total billed charges,$49.22 ,25.5% of total billed charges,$49.22 ,25.5% of total billed charges,$60.31 ,31.25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$48.25 ,25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$171.77 ,89% of total billed charges,$171.77 ,89% of total billed charges,$171.77 ,89% of total billed charges,$78.74 ,40.8% of total billed charges,$78.74 ,40.8% of total billed charges,$78.74 ,40.8% of total billed charges,$148.61 ,77% of total billed charges,$164.05 ,85% of total billed charges,$55.49 ,28.75% of total billed charges,$193.00 ,100% of UHC fee schedule,$78.74 ,40.8% of total billed charges,$48.25 ,25% of total billed charges,N/A,not seperately reimbursable,$48.25 ,25% of total billed charges,$48.25 ,$193.00 ,$96.50 
Outpatient Medical Services,PROVIDER SERVICES,99310,Subsequent Nursing Facility Care,521,$286.00 ,$220.22 ,77% of total billed charges,$72.93 ,25.5% of total billed charges,$72.93 ,25.5% of total billed charges,$89.38 ,31.25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$71.50 ,25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$254.54 ,89% of total billed charges,$254.54 ,89% of total billed charges,$254.54 ,89% of total billed charges,$116.69 ,40.8% of total billed charges,$116.69 ,40.8% of total billed charges,$116.69 ,40.8% of total billed charges,$220.22 ,77% of total billed charges,$243.10 ,85% of total billed charges,$82.23 ,28.75% of total billed charges,$286.00 ,100% of UHC fee schedule,$116.69 ,40.8% of total billed charges,$71.50 ,25% of total billed charges,N/A,not seperately reimbursable,$71.50 ,25% of total billed charges,$71.50 ,$286.00 ,$143.00 
Outpatient Medical Services,PROVIDER SERVICES,99336,"Evaluation and Management / Domiciliary, rest home (boarding home) or custodial care services.",521,$287.00 ,$220.99 ,77% of total billed charges,$73.19 ,25.5% of total billed charges,$73.19 ,25.5% of total billed charges,$89.69 ,31.25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$71.75 ,25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$255.43 ,89% of total billed charges,$255.43 ,89% of total billed charges,$255.43 ,89% of total billed charges,$117.10 ,40.8% of total billed charges,$117.10 ,40.8% of total billed charges,$117.10 ,40.8% of total billed charges,$220.99 ,77% of total billed charges,$243.95 ,85% of total billed charges,$82.51 ,28.75% of total billed charges,$287.00 ,100% of UHC fee schedule,$117.10 ,40.8% of total billed charges,$71.75 ,25% of total billed charges,N/A,not seperately reimbursable,$71.75 ,25% of total billed charges,$71.75 ,$287.00 ,$143.50 
Outpatient Medical Services,PROVIDER SERVICES,99350,Level 4 established patient home visit,521,$338.00 ,$260.26 ,77% of total billed charges,$86.19 ,25.5% of total billed charges,$86.19 ,25.5% of total billed charges,$105.63 ,31.25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$84.50 ,25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$300.82 ,89% of total billed charges,$300.82 ,89% of total billed charges,$300.82 ,89% of total billed charges,$137.90 ,40.8% of total billed charges,$137.90 ,40.8% of total billed charges,$137.90 ,40.8% of total billed charges,$260.26 ,77% of total billed charges,$287.30 ,85% of total billed charges,$97.18 ,28.75% of total billed charges,$338.00 ,100% of UHC fee schedule,$137.90 ,40.8% of total billed charges,$84.50 ,25% of total billed charges,N/A,not seperately reimbursable,$84.50 ,25% of total billed charges,$84.50 ,$338.00 ,$169.00 
Outpatient Medical Services,PROVIDER SERVICES,99385,Initial new patient preventive medicine evaluation (18-39 years),521,$303.00 ,$233.31 ,77% of total billed charges,$77.27 ,25.5% of total billed charges,$77.27 ,25.5% of total billed charges,$94.69 ,31.25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$75.75 ,25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$269.67 ,89% of total billed charges,$269.67 ,89% of total billed charges,$269.67 ,89% of total billed charges,$123.62 ,40.8% of total billed charges,$123.62 ,40.8% of total billed charges,$123.62 ,40.8% of total billed charges,$233.31 ,77% of total billed charges,$257.55 ,85% of total billed charges,$87.11 ,28.75% of total billed charges,$303.00 ,100% of UHC fee schedule,$123.62 ,40.8% of total billed charges,$75.75 ,25% of total billed charges,N/A,not seperately reimbursable,$75.75 ,25% of total billed charges,$75.75 ,$303.00 ,$151.50 
Outpatient Medical Services,PROVIDER SERVICES,99386,Initial new patient preventive medicine evaluation (40-64 years),521,$330.00 ,$254.10 ,77% of total billed charges,$84.15 ,25.5% of total billed charges,$84.15 ,25.5% of total billed charges,$103.13 ,31.25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$82.50 ,25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$293.70 ,89% of total billed charges,$293.70 ,89% of total billed charges,$293.70 ,89% of total billed charges,$134.64 ,40.8% of total billed charges,$134.64 ,40.8% of total billed charges,$134.64 ,40.8% of total billed charges,$254.10 ,77% of total billed charges,$280.50 ,85% of total billed charges,$94.88 ,28.75% of total billed charges,$330.00 ,100% of UHC fee schedule,$134.64 ,40.8% of total billed charges,$82.50 ,25% of total billed charges,N/A,not seperately reimbursable,$82.50 ,25% of total billed charges,$82.50 ,$330.00 ,$165.00 
Outpatient Medical Services,PROVIDER SERVICES,99391,Wellcare visit for infant under 1 year,521,$151.00 ,$116.27 ,77% of total billed charges,$38.51 ,25.5% of total billed charges,$38.51 ,25.5% of total billed charges,$47.19 ,31.25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$37.75 ,25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$134.39 ,89% of total billed charges,$134.39 ,89% of total billed charges,$134.39 ,89% of total billed charges,$61.61 ,40.8% of total billed charges,$61.61 ,40.8% of total billed charges,$61.61 ,40.8% of total billed charges,$116.27 ,77% of total billed charges,$128.35 ,85% of total billed charges,$43.41 ,28.75% of total billed charges,$151.00 ,100% of UHC fee schedule,$61.61 ,40.8% of total billed charges,$37.75 ,25% of total billed charges,N/A,not seperately reimbursable,$37.75 ,25% of total billed charges,$37.75 ,$151.00 ,$75.50 
Outpatient Medical Services,PROVIDER SERVICES,99392,Established patient well age 1-4 years,521,$158.00 ,$121.66 ,77% of total billed charges,$40.29 ,25.5% of total billed charges,$40.29 ,25.5% of total billed charges,$49.38 ,31.25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$39.50 ,25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$140.62 ,89% of total billed charges,$140.62 ,89% of total billed charges,$140.62 ,89% of total billed charges,$64.46 ,40.8% of total billed charges,$64.46 ,40.8% of total billed charges,$64.46 ,40.8% of total billed charges,$121.66 ,77% of total billed charges,$134.30 ,85% of total billed charges,$45.43 ,28.75% of total billed charges,$158.00 ,100% of UHC fee schedule,$64.46 ,40.8% of total billed charges,$39.50 ,25% of total billed charges,N/A,not seperately reimbursable,$39.50 ,25% of total billed charges,$39.50 ,$158.00 ,$79.00 
Outpatient Medical Services,PROVIDER SERVICES,99393,Established patient well age 5-11 yeas,521,$173.00 ,$133.21 ,77% of total billed charges,$44.12 ,25.5% of total billed charges,$44.12 ,25.5% of total billed charges,$54.06 ,31.25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$43.25 ,25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$153.97 ,89% of total billed charges,$153.97 ,89% of total billed charges,$153.97 ,89% of total billed charges,$70.58 ,40.8% of total billed charges,$70.58 ,40.8% of total billed charges,$70.58 ,40.8% of total billed charges,$133.21 ,77% of total billed charges,$147.05 ,85% of total billed charges,$49.74 ,28.75% of total billed charges,$173.00 ,100% of UHC fee schedule,$70.58 ,40.8% of total billed charges,$43.25 ,25% of total billed charges,N/A,not seperately reimbursable,$43.25 ,25% of total billed charges,$43.25 ,$173.00 ,$86.50 
Outpatient Medical Services,PROVIDER SERVICES,99394,Established patient well age 12-17 years,521,$186.00 ,$143.22 ,77% of total billed charges,$47.43 ,25.5% of total billed charges,$47.43 ,25.5% of total billed charges,$58.13 ,31.25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$46.50 ,25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$165.54 ,89% of total billed charges,$165.54 ,89% of total billed charges,$165.54 ,89% of total billed charges,$75.89 ,40.8% of total billed charges,$75.89 ,40.8% of total billed charges,$75.89 ,40.8% of total billed charges,$143.22 ,77% of total billed charges,$158.10 ,85% of total billed charges,$53.48 ,28.75% of total billed charges,$186.00 ,100% of UHC fee schedule,$75.89 ,40.8% of total billed charges,$46.50 ,25% of total billed charges,N/A,not seperately reimbursable,$46.50 ,25% of total billed charges,$46.50 ,$186.00 ,$93.00 
Outpatient Medical Services,PROVIDER SERVICES,G0009,Pneumonia vaccine administration,771,$65.00 ,$50.05 ,77% of total billed charges,$16.58 ,25.5% of total billed charges,$16.58 ,25.5% of total billed charges,$20.31 ,31.25% of total billed charges,$48.10 ,74% of total billed charges,$44.85 ,69% of total billed charges,$44.85 ,69% of total billed charges,$16.25 ,25% of total billed charges,$44.85 ,69% of total billed charges,$44.85 ,69% of total billed charges,$54.60 ,84% of total billed charges,$53.30 ,82% of total billed charges,$57.85 ,89% of total billed charges,$57.85 ,89% of total billed charges,$57.85 ,89% of total billed charges,$26.52 ,40.8% of total billed charges,$26.52 ,40.8% of total billed charges,$26.52 ,40.8% of total billed charges,$50.05 ,77% of total billed charges,$55.25 ,85% of total billed charges,$18.69 ,28.75% of total billed charges,$65.00 ,100% of UHC fee schedule,$26.52 ,40.8% of total billed charges,$16.25 ,25% of total billed charges,N/A,not seperately reimbursable,$16.25 ,25% of total billed charges,$16.25 ,$65.00 ,$32.50 
Outpatient Medical Services,PROVIDER SERVICES,G0101,Cervical or vaginal cancer screening; pelvic and clinical breast examination.,521,$129.00 ,$99.33 ,77% of total billed charges,$32.90 ,25.5% of total billed charges,$32.90 ,25.5% of total billed charges,$40.31 ,31.25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$32.25 ,25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$114.81 ,89% of total billed charges,$114.81 ,89% of total billed charges,$114.81 ,89% of total billed charges,$52.63 ,40.8% of total billed charges,$52.63 ,40.8% of total billed charges,$52.63 ,40.8% of total billed charges,$99.33 ,77% of total billed charges,$109.65 ,85% of total billed charges,$37.09 ,28.75% of total billed charges,$129.00 ,100% of UHC fee schedule,$52.63 ,40.8% of total billed charges,$32.25 ,25% of total billed charges,N/A,not seperately reimbursable,$32.25 ,25% of total billed charges,$32.25 ,$129.00 ,$64.50 
Outpatient Medical Services,OUTPATIENT THERAPY,92507,"Therapy services that pertain to auditory rehabilitation, voice prosthetics, and communication and/or cognitive impairments",440,$470.50 ,$362.29 ,77% of total billed charges,$119.98 ,25.5% of total billed charges,$119.98 ,25.5% of total billed charges,$147.03 ,31.25% of total billed charges,$102.00 ,pays based on per visit rate,$96.00 ,pays based on per visit rate,$96.00 ,pays based on per visit rate,$117.63 ,25% of total billed charges,$96.00 ,pays based on per visit rate,$96.00 ,pays based on per visit rate,$108.00 ,pays based on per visit rate,$385.81 ,82% of total billed charges,$418.75 ,89% of total billed charges,$418.75 ,89% of total billed charges,$418.75 ,89% of total billed charges,$191.96 ,40.8% of total billed charges,$191.96 ,40.8% of total billed charges,$191.96 ,40.8% of total billed charges,$362.29 ,77% of total billed charges,$399.93 ,85% of total billed charges,$135.27 ,28.75% of total billed charges,$470.50 ,100% of UHC fee schedule,$191.96 ,40.8% of total billed charges,$117.63 ,25% of total billed charges,$192.00 ,pays based on per visit rate,$117.63 ,25% of total billed charges,$96.00 ,$470.50 ,$235.25 
Outpatient Medical Services,OUTPATIENT THERAPY,97010,Any physical agent applied to produce therapeutic changes to biologic tissue,440,$47.50 ,$36.58 ,77% of total billed charges,$12.11 ,25.5% of total billed charges,$12.11 ,25.5% of total billed charges,$14.84 ,31.25% of total billed charges,$102.00 ,pays based on per visit rate,$96.00 ,pays based on per visit rate,$96.00 ,pays based on per visit rate,$11.88 ,25% of total billed charges,$96.00 ,pays based on per visit rate,$96.00 ,pays based on per visit rate,$108.00 ,pays based on per visit rate,$38.95 ,82% of total billed charges,$42.28 ,89% of total billed charges,$42.28 ,89% of total billed charges,$42.28 ,89% of total billed charges,$19.38 ,40.8% of total billed charges,$19.38 ,40.8% of total billed charges,$19.38 ,40.8% of total billed charges,$36.58 ,77% of total billed charges,$40.38 ,85% of total billed charges,$13.66 ,28.75% of total billed charges,$47.50 ,100% of UHC fee schedule,$19.38 ,40.8% of total billed charges,$11.88 ,25% of total billed charges,$192.00 ,pays based on per visit rate,$11.88 ,25% of total billed charges,$11.88 ,$192.00 ,$23.75 
Outpatient Medical Services,OUTPATIENT THERAPY,97012,Mechanical Traction,420,$94.00 ,$72.38 ,77% of total billed charges,$23.97 ,25.5% of total billed charges,$23.97 ,25.5% of total billed charges,$29.38 ,31.25% of total billed charges,$155.00 ,pays based on per visit rate,$146.00 ,pays based on per visit rate,$146.00 ,pays based on per visit rate,$23.50 ,25% of total billed charges,$146.00 ,pays based on per visit rate,$146.00 ,pays based on per visit rate,$152.00 ,pays based on per visit rate,$77.08 ,82% of total billed charges,$83.66 ,89% of total billed charges,$83.66 ,89% of total billed charges,$83.66 ,89% of total billed charges,$38.35 ,40.8% of total billed charges,$38.35 ,40.8% of total billed charges,$38.35 ,40.8% of total billed charges,$72.38 ,77% of total billed charges,$79.90 ,85% of total billed charges,$27.03 ,28.75% of total billed charges,$94.00 ,100% of UHC fee schedule,$38.35 ,40.8% of total billed charges,$23.50 ,25% of total billed charges,$192.00 ,pays based on per visit rate,$23.50 ,25% of total billed charges,$23.50 ,$192.00 ,$47.00 
Outpatient Medical Services,OUTPATIENT THERAPY,97014,electrical muscle stimulation,420,$124.50 ,$95.87 ,77% of total billed charges,$31.75 ,25.5% of total billed charges,$31.75 ,25.5% of total billed charges,$38.91 ,31.25% of total billed charges,$155.00 ,pays based on per visit rate,$146.00 ,pays based on per visit rate,$146.00 ,pays based on per visit rate,$31.13 ,25% of total billed charges,$146.00 ,pays based on per visit rate,$146.00 ,pays based on per visit rate,$152.00 ,pays based on per visit rate,$102.09 ,82% of total billed charges,$110.81 ,89% of total billed charges,$110.81 ,89% of total billed charges,$110.81 ,89% of total billed charges,$50.80 ,40.8% of total billed charges,$50.80 ,40.8% of total billed charges,$50.80 ,40.8% of total billed charges,$95.87 ,77% of total billed charges,$105.83 ,85% of total billed charges,$35.79 ,28.75% of total billed charges,$124.50 ,100% of UHC fee schedule,$50.80 ,40.8% of total billed charges,$31.13 ,25% of total billed charges,$192.00 ,pays based on per visit rate,$31.13 ,25% of total billed charges,$31.13 ,$192.00 ,$62.25 
Outpatient Medical Services,OUTPATIENT THERAPY,97035,Therapeutic Ultrasound,420,$70.50 ,$54.29 ,77% of total billed charges,$17.98 ,25.5% of total billed charges,$17.98 ,25.5% of total billed charges,$22.03 ,31.25% of total billed charges,$155.00 ,pays based on per visit rate,$146.00 ,pays based on per visit rate,$146.00 ,pays based on per visit rate,$17.63 ,25% of total billed charges,$146.00 ,pays based on per visit rate,$146.00 ,pays based on per visit rate,$152.00 ,pays based on per visit rate,$57.81 ,82% of total billed charges,$62.75 ,89% of total billed charges,$62.75 ,89% of total billed charges,$62.75 ,89% of total billed charges,$28.76 ,40.8% of total billed charges,$28.76 ,40.8% of total billed charges,$28.76 ,40.8% of total billed charges,$54.29 ,77% of total billed charges,$59.93 ,85% of total billed charges,$20.27 ,28.75% of total billed charges,$70.50 ,100% of UHC fee schedule,$28.76 ,40.8% of total billed charges,$17.63 ,25% of total billed charges,$192.00 ,pays based on per visit rate,$17.63 ,25% of total billed charges,$17.63 ,$192.00 ,$35.25 
Outpatient Medical Services,OUTPATIENT THERAPY,97110,"Physical therapy, therapeutic exercise",420,$96.00 ,$73.92 ,77% of total billed charges,$24.48 ,25.5% of total billed charges,$24.48 ,25.5% of total billed charges,$30.00 ,31.25% of total billed charges,$155.00 ,pays based on per visit rate,$146.00 ,pays based on per visit rate,$146.00 ,pays based on per visit rate,$24.00 ,25% of total billed charges,$146.00 ,pays based on per visit rate,$146.00 ,pays based on per visit rate,$152.00 ,pays based on per visit rate,$78.72 ,82% of total billed charges,$85.44 ,89% of total billed charges,$85.44 ,89% of total billed charges,$85.44 ,89% of total billed charges,$39.17 ,40.8% of total billed charges,$39.17 ,40.8% of total billed charges,$39.17 ,40.8% of total billed charges,$73.92 ,77% of total billed charges,$81.60 ,85% of total billed charges,$27.60 ,28.75% of total billed charges,$96.00 ,100% of UHC fee schedule,$39.17 ,40.8% of total billed charges,$24.00 ,25% of total billed charges,$192.00 ,pays based on per visit rate,$24.00 ,25% of total billed charges,$24.00 ,$192.00 ,$48.00 
Outpatient Medical Services,OUTPATIENT THERAPY,97112,"neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities",420,$105.50 ,$81.24 ,77% of total billed charges,$26.90 ,25.5% of total billed charges,$26.90 ,25.5% of total billed charges,$32.97 ,31.25% of total billed charges,$155.00 ,pays based on per visit rate,$146.00 ,pays based on per visit rate,$146.00 ,pays based on per visit rate,$26.38 ,25% of total billed charges,$146.00 ,pays based on per visit rate,$146.00 ,pays based on per visit rate,$152.00 ,pays based on per visit rate,$86.51 ,82% of total billed charges,$93.90 ,89% of total billed charges,$93.90 ,89% of total billed charges,$93.90 ,89% of total billed charges,$43.04 ,40.8% of total billed charges,$43.04 ,40.8% of total billed charges,$43.04 ,40.8% of total billed charges,$81.24 ,77% of total billed charges,$89.68 ,85% of total billed charges,$30.33 ,28.75% of total billed charges,$105.50 ,100% of UHC fee schedule,$43.04 ,40.8% of total billed charges,$26.38 ,25% of total billed charges,$192.00 ,pays based on per visit rate,$26.38 ,25% of total billed charges,$26.38 ,$192.00 ,$52.75 
Outpatient Medical Services,OUTPATIENT THERAPY,97113,aquatic physical therapy,420,$151.00 ,$116.27 ,77% of total billed charges,$38.51 ,25.5% of total billed charges,$38.51 ,25.5% of total billed charges,$47.19 ,31.25% of total billed charges,$155.00 ,pays based on per visit rate,$146.00 ,pays based on per visit rate,$146.00 ,pays based on per visit rate,$37.75 ,25% of total billed charges,$146.00 ,pays based on per visit rate,$146.00 ,pays based on per visit rate,$152.00 ,pays based on per visit rate,$123.82 ,82% of total billed charges,$134.39 ,89% of total billed charges,$134.39 ,89% of total billed charges,$134.39 ,89% of total billed charges,$61.61 ,40.8% of total billed charges,$61.61 ,40.8% of total billed charges,$61.61 ,40.8% of total billed charges,$116.27 ,77% of total billed charges,$128.35 ,85% of total billed charges,$43.41 ,28.75% of total billed charges,$151.00 ,100% of UHC fee schedule,$61.61 ,40.8% of total billed charges,$37.75 ,25% of total billed charges,$192.00 ,pays based on per visit rate,$37.75 ,25% of total billed charges,$37.75 ,$192.00 ,$75.50 
Outpatient Medical Services,OUTPATIENT THERAPY,97140,Manual therapy,420,$117.50 ,$90.48 ,77% of total billed charges,$29.96 ,25.5% of total billed charges,$29.96 ,25.5% of total billed charges,$36.72 ,31.25% of total billed charges,$155.00 ,pays based on per visit rate,$146.00 ,pays based on per visit rate,$146.00 ,pays based on per visit rate,$29.38 ,25% of total billed charges,$146.00 ,pays based on per visit rate,$146.00 ,pays based on per visit rate,$152.00 ,pays based on per visit rate,$96.35 ,82% of total billed charges,$104.58 ,89% of total billed charges,$104.58 ,89% of total billed charges,$104.58 ,89% of total billed charges,$47.94 ,40.8% of total billed charges,$47.94 ,40.8% of total billed charges,$47.94 ,40.8% of total billed charges,$90.48 ,77% of total billed charges,$99.88 ,85% of total billed charges,$33.78 ,28.75% of total billed charges,$117.50 ,100% of UHC fee schedule,$47.94 ,40.8% of total billed charges,$29.38 ,25% of total billed charges,$192.00 ,pays based on per visit rate,$29.38 ,25% of total billed charges,$29.38 ,$192.00 ,$58.75 
Outpatient Medical Services,OUTPATIENT THERAPY,97161,Physical therapy evaluation,424,$112.00 ,$86.24 ,77% of total billed charges,$28.56 ,25.5% of total billed charges,$28.56 ,25.5% of total billed charges,$35.00 ,31.25% of total billed charges,$155.00 ,pays based on per visit rate,$146.00 ,pays based on per visit rate,$146.00 ,pays based on per visit rate,$28.00 ,25% of total billed charges,$146.00 ,pays based on per visit rate,$146.00 ,pays based on per visit rate,$152.00 ,pays based on per visit rate,$91.84 ,82% of total billed charges,$99.68 ,89% of total billed charges,$99.68 ,89% of total billed charges,$99.68 ,89% of total billed charges,$45.70 ,40.8% of total billed charges,$45.70 ,40.8% of total billed charges,$45.70 ,40.8% of total billed charges,$86.24 ,77% of total billed charges,$95.20 ,85% of total billed charges,$32.20 ,28.75% of total billed charges,$112.00 ,100% of UHC fee schedule,$45.70 ,40.8% of total billed charges,$28.00 ,25% of total billed charges,$192.00 ,pays based on per visit rate,$28.00 ,25% of total billed charges,$28.00 ,$192.00 ,$56.00 
Outpatient Medical Services,OUTPATIENT THERAPY,97530,Theraputic Activities,420,$114.00 ,$87.78 ,77% of total billed charges,$29.07 ,25.5% of total billed charges,$29.07 ,25.5% of total billed charges,$35.63 ,31.25% of total billed charges,$155.00 ,pays based on per visit rate,$146.00 ,pays based on per visit rate,$146.00 ,pays based on per visit rate,$28.50 ,25% of total billed charges,$146.00 ,pays based on per visit rate,$146.00 ,pays based on per visit rate,$152.00 ,pays based on per visit rate,$93.48 ,82% of total billed charges,$101.46 ,89% of total billed charges,$101.46 ,89% of total billed charges,$101.46 ,89% of total billed charges,$46.51 ,40.8% of total billed charges,$46.51 ,40.8% of total billed charges,$46.51 ,40.8% of total billed charges,$87.78 ,77% of total billed charges,$96.90 ,85% of total billed charges,$32.78 ,28.75% of total billed charges,$114.00 ,100% of UHC fee schedule,$46.51 ,40.8% of total billed charges,$28.50 ,25% of total billed charges,$192.00 ,pays based on per visit rate,$28.50 ,25% of total billed charges,$28.50 ,$192.00 ,$57.00 
Outpatient Medical Services,OUTPATIENT THERAPY,97535,self-care/home management training,420,$120.50 ,$92.79 ,77% of total billed charges,$30.73 ,25.5% of total billed charges,$30.73 ,25.5% of total billed charges,$37.66 ,31.25% of total billed charges,$155.00 ,pays based on per visit rate,$146.00 ,pays based on per visit rate,$146.00 ,pays based on per visit rate,$30.13 ,25% of total billed charges,$146.00 ,pays based on per visit rate,$146.00 ,pays based on per visit rate,$152.00 ,pays based on per visit rate,$98.81 ,82% of total billed charges,$107.25 ,89% of total billed charges,$107.25 ,89% of total billed charges,$107.25 ,89% of total billed charges,$49.16 ,40.8% of total billed charges,$49.16 ,40.8% of total billed charges,$49.16 ,40.8% of total billed charges,$92.79 ,77% of total billed charges,$102.43 ,85% of total billed charges,$34.64 ,28.75% of total billed charges,$120.50 ,100% of UHC fee schedule,$49.16 ,40.8% of total billed charges,$30.13 ,25% of total billed charges,$192.00 ,pays based on per visit rate,$30.13 ,25% of total billed charges,$30.13 ,$192.00 ,$60.25 
Outpatient Medical Services,CARDIAC TESTING,93000,"Electrocardiogram, routine, with interpretation and report",521,$28.00 ,$21.56 ,77% of total billed charges,$7.14 ,25.5% of total billed charges,$7.14 ,25.5% of total billed charges,$8.75 ,31.25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$7.00 ,25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$24.92 ,89% of total billed charges,$24.92 ,89% of total billed charges,$24.92 ,89% of total billed charges,$11.42 ,40.8% of total billed charges,$11.42 ,40.8% of total billed charges,$11.42 ,40.8% of total billed charges,$21.56 ,77% of total billed charges,$23.80 ,85% of total billed charges,$8.05 ,28.75% of total billed charges,$28.00 ,100% of UHC fee schedule,$11.42 ,40.8% of total billed charges,$7.00 ,25% of total billed charges,N/A,not seperately reimbursable,$7.00 ,25% of total billed charges,$7.00 ,$28.00 ,$14.00 
Outpatient Medical Services,CARDIAC TESTING,93005,"Electrocardiogram, routine ECG with at least 12 leads; tracing only",730,$296.00 ,$227.92 ,77% of total billed charges,$75.48 ,25.5% of total billed charges,$75.48 ,25.5% of total billed charges,$92.50 ,31.25% of total billed charges,$160.00 ,pays based on per visit rate,$155.00 ,pays based on per visit rate,$155.00 ,pays based on per visit rate,$74.00 ,25% of total billed charges,$155.00 ,pays based on per visit rate,$155.00 ,pays based on per visit rate,$156.00 ,pays based on per visit rate,$242.72 ,82% of total billed charges,$263.44 ,89% of total billed charges,$263.44 ,89% of total billed charges,$263.44 ,89% of total billed charges,$12.43 ,120% of MO fee schedule,$12.43 ,120% of MO fee schedule,$12.43 ,120% of MO fee schedule,$227.92 ,77% of total billed charges,$251.60 ,85% of total billed charges,$85.10 ,28.75% of total billed charges,$296.00 ,100% of UHC fee schedule,$12.43 ,120% of MO fee schedule,$74.00 ,25% of total billed charges,$256.00 ,pays based on per visit rate,$74.00 ,25% of total billed charges,$12.43 ,$296.00 ,$148.00 
Outpatient Medical Services,CARDIAC TESTING,93010,"ECG, INTERPRETATION AND REPORT",521,$16.00 ,$12.32 ,77% of total billed charges,$4.08 ,25.5% of total billed charges,$4.08 ,25.5% of total billed charges,$5.00 ,31.25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$4.00 ,25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$14.24 ,89% of total billed charges,$14.24 ,89% of total billed charges,$14.24 ,89% of total billed charges,$6.53 ,40.8% of total billed charges,$6.53 ,40.8% of total billed charges,$6.53 ,40.8% of total billed charges,$12.32 ,77% of total billed charges,$13.60 ,85% of total billed charges,$4.60 ,28.75% of total billed charges,$16.00 ,100% of UHC fee schedule,$6.53 ,40.8% of total billed charges,$4.00 ,25% of total billed charges,N/A,not seperately reimbursable,$4.00 ,25% of total billed charges,$4.00 ,$16.00 ,$8.00 
Outpatient Medical Services,CARDIAC TESTING,93017,Cardiovascular stress test,482,$745.00 ,$573.65 ,77% of total billed charges,$189.98 ,25.5% of total billed charges,$189.98 ,25.5% of total billed charges,$232.81 ,31.25% of total billed charges,$291.00 ,pays based on per visit rate,$284.00 ,pays based on per visit rate,$284.00 ,pays based on per visit rate,$186.25 ,25% of total billed charges,$284.00 ,pays based on per visit rate,$284.00 ,pays based on per visit rate,$297.00 ,pays based on per visit rate,$610.90 ,82% of total billed charges,$663.05 ,89% of total billed charges,$663.05 ,89% of total billed charges,$663.05 ,89% of total billed charges,$62.29 ,120% of MO fee schedule,$62.29 ,120% of MO fee schedule,$62.29 ,120% of MO fee schedule,$573.65 ,77% of total billed charges,$633.25 ,85% of total billed charges,$214.19 ,28.75% of total billed charges,$745.00 ,100% of UHC fee schedule,$62.29 ,120% of MO fee schedule,$186.25 ,25% of total billed charges,$386.00 ,pays based on per visit rate,$186.25 ,25% of total billed charges,$62.29 ,$745.00 ,$372.50 
Outpatient Medical Services,CARDIAC TESTING,93270,Cardiovascular Monitoring Services,731,$773.00 ,$595.21 ,77% of total billed charges,$197.12 ,25.5% of total billed charges,$197.12 ,25.5% of total billed charges,$241.56 ,31.25% of total billed charges,$572.02 ,74% of total billed charges,$533.37 ,69% of total billed charges,$533.37 ,69% of total billed charges,$193.25 ,25% of total billed charges,$533.37 ,69% of total billed charges,$533.37 ,69% of total billed charges,$649.32 ,84% of total billed charges,$633.86 ,82% of total billed charges,$687.97 ,89% of total billed charges,$687.97 ,89% of total billed charges,$687.97 ,89% of total billed charges,$22.87 ,120% of MO fee schedule,$22.87 ,120% of MO fee schedule,$22.87 ,120% of MO fee schedule,$595.21 ,77% of total billed charges,$657.05 ,85% of total billed charges,$222.24 ,28.75% of total billed charges,$773.00 ,100% of UHC fee schedule,$22.87 ,120% of MO fee schedule,$193.25 ,25% of total billed charges,$439.00 ,pays based on per visit rate,$193.25 ,25% of total billed charges,$22.87 ,$773.00 ,$386.50 
Outpatient Medical Services,CARDIAC TESTING,93306,"Echocardiography, transthoracic, real-time with image documentation",480,"$3,053.00 ","$2,350.81 ",77% of total billed charges,$778.52 ,25.5% of total billed charges,$778.52 ,25.5% of total billed charges,$954.06 ,31.25% of total billed charges,"$2,259.22 ",74% of total billed charges,"$2,106.57 ",69% of total billed charges,"$2,106.57 ",69% of total billed charges,$763.25 ,25% of total billed charges,"$2,106.57 ",69% of total billed charges,"$2,106.57 ",69% of total billed charges,"$2,564.52 ",84% of total billed charges,"$2,503.46 ",82% of total billed charges,"$2,717.17 ",89% of total billed charges,"$2,717.17 ",89% of total billed charges,"$2,717.17 ",89% of total billed charges,$142.21 ,120% of MO fee schedule,$142.21 ,120% of MO fee schedule,$142.21 ,120% of MO fee schedule,"$2,350.81 ",77% of total billed charges,"$2,595.05 ",85% of total billed charges,$877.74 ,28.75% of total billed charges,"$3,053.00 ",100% of UHC fee schedule,$142.21 ,120% of MO fee schedule,$763.25 ,25% of total billed charges,$777.00 ,pays based on per visit rate,$763.25 ,25% of total billed charges,$142.21 ,"$3,053.00 ","$1,526.50 "
Outpatient Medical Services,CARDIAC TESTING,93798,CARDIAC REHAB MONITORED,943,$354.50 ,$272.97 ,77% of total billed charges,$90.40 ,25.5% of total billed charges,$90.40 ,25.5% of total billed charges,$110.78 ,31.25% of total billed charges,$262.33 ,74% of total billed charges,$244.61 ,69% of total billed charges,$244.61 ,69% of total billed charges,$88.63 ,25% of total billed charges,$244.61 ,69% of total billed charges,$244.61 ,69% of total billed charges,$297.78 ,84% of total billed charges,$290.69 ,82% of total billed charges,$315.51 ,89% of total billed charges,$315.51 ,89% of total billed charges,$315.51 ,89% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$272.97 ,77% of total billed charges,$301.33 ,85% of total billed charges,$101.92 ,28.75% of total billed charges,$354.50 ,100% of UHC fee schedule,N/A,not seperately reimbursable,$88.63 ,25% of total billed charges,$140.00 ,pays based on per visit rate,$88.63 ,25% of total billed charges,$88.63 ,$354.50 ,$177.25 
Outpatient Medical Services,CARDIAC TESTING,93880,Duplex scan of extracranial arteries; complete bilateral study,921,"$1,589.00 ","$1,223.53 ",77% of total billed charges,$405.20 ,25.5% of total billed charges,$405.20 ,25.5% of total billed charges,$496.56 ,31.25% of total billed charges,"$1,175.86 ",74% of total billed charges,"$1,096.41 ",69% of total billed charges,"$1,096.41 ",69% of total billed charges,$397.25 ,25% of total billed charges,"$1,096.41 ",69% of total billed charges,"$1,096.41 ",69% of total billed charges,"$1,334.76 ",84% of total billed charges,"$1,302.98 ",82% of total billed charges,"$1,414.21 ",89% of total billed charges,"$1,414.21 ",89% of total billed charges,"$1,414.21 ",89% of total billed charges,$181.34 ,120% of MO fee schedule,$181.34 ,120% of MO fee schedule,$181.34 ,120% of MO fee schedule,"$1,223.53 ",77% of total billed charges,"$1,350.65 ",85% of total billed charges,$456.84 ,28.75% of total billed charges,"$1,589.00 ",100% of UHC fee schedule,$181.34 ,120% of MO fee schedule,$397.25 ,25% of total billed charges,$630.00 ,pays based on per visit rate,$397.25 ,25% of total billed charges,$181.34 ,"$1,589.00 ",$794.50 
Outpatient Medical Services,CARDIAC TESTING,93971,Duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited study,921,"$1,297.50 ",$999.08 ,77% of total billed charges,$330.86 ,25.5% of total billed charges,$330.86 ,25.5% of total billed charges,$405.47 ,31.25% of total billed charges,$960.15 ,74% of total billed charges,$895.28 ,69% of total billed charges,$895.28 ,69% of total billed charges,$324.38 ,25% of total billed charges,$895.28 ,69% of total billed charges,$895.28 ,69% of total billed charges,"$1,089.90 ",84% of total billed charges,"$1,063.95 ",82% of total billed charges,"$1,154.78 ",89% of total billed charges,"$1,154.78 ",89% of total billed charges,"$1,154.78 ",89% of total billed charges,$93.16 ,120% of MO fee schedule,$93.16 ,120% of MO fee schedule,$93.16 ,120% of MO fee schedule,$999.08 ,77% of total billed charges,"$1,102.88 ",85% of total billed charges,$373.03 ,28.75% of total billed charges,"$1,297.50 ",100% of UHC fee schedule,$93.16 ,120% of MO fee schedule,$324.38 ,25% of total billed charges,$630.00 ,pays based on per visit rate,$324.38 ,25% of total billed charges,$93.16 ,"$1,297.50 ",$648.75 
Outpatient Medical Services,OTHER SERVICES,36430,"Transfusion, blood or blood components",391,N/A,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,N/A,N/A
Outpatient Medical Services,OTHER SERVICES,36591,collection of blood specimen from a completely implantable venous access device,300,N/A,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$55.00 ,pays based on per visit rate,N/A,not seperately reimbursable,$55.00 ,$55.00 ,N/A
Outpatient Medical Services,OTHER SERVICES,36600,"catheter ""placement.",920,N/A,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$103.00 ,pays based on per visit rate,N/A,not seperately reimbursable,$103.00 ,$103.00 ,N/A
Outpatient Medical Services,OTHER SERVICES,59025,Fetal non-stress test,920,$90.00 ,$69.30 ,77% of total billed charges,$22.95 ,25.5% of total billed charges,$22.95 ,25.5% of total billed charges,$28.13 ,31.25% of total billed charges,$66.60 ,74% of total billed charges,$62.10 ,69% of total billed charges,$62.10 ,69% of total billed charges,$22.50 ,25% of total billed charges,$62.10 ,69% of total billed charges,$62.10 ,69% of total billed charges,$75.60 ,84% of total billed charges,$73.80 ,82% of total billed charges,$80.10 ,89% of total billed charges,$80.10 ,89% of total billed charges,$80.10 ,89% of total billed charges,$17.60 ,120% of MO fee schedule,$17.60 ,120% of MO fee schedule,$17.60 ,120% of MO fee schedule,$69.30 ,77% of total billed charges,$76.50 ,85% of total billed charges,$25.88 ,28.75% of total billed charges,$45.00 ,50% of total billed charges,$17.60 ,120% of MO fee schedule,$22.50 ,25% of total billed charges,$103.00 ,pays based on per visit rate,$22.50 ,25% of total billed charges,$17.60 ,$103.00 ,$45.00 
Outpatient Medical Services,OTHER SERVICES,59050,"fetal monitoring during labor by consulting physician (i.e., non-attending physician",920,N/A,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$103.00 ,pays based on per visit rate,N/A,not seperately reimbursable,$103.00 ,$103.00 ,N/A
Outpatient Medical Services,OTHER SERVICES,90471,"Immunization administration for percutaneous, intra-dermal, subcutaneous or intramuscular injections, initial",771,$28.00 ,$21.56 ,77% of total billed charges,$7.14 ,25.5% of total billed charges,$7.14 ,25.5% of total billed charges,$8.75 ,31.25% of total billed charges,$20.72 ,74% of total billed charges,$19.32 ,69% of total billed charges,$19.32 ,69% of total billed charges,$7.00 ,25% of total billed charges,$19.32 ,69% of total billed charges,$19.32 ,69% of total billed charges,$23.52 ,84% of total billed charges,$22.96 ,82% of total billed charges,$24.92 ,89% of total billed charges,$24.92 ,89% of total billed charges,$24.92 ,89% of total billed charges,$11.42 ,40.8% of total billed charges,$11.42 ,40.8% of total billed charges,$11.42 ,40.8% of total billed charges,$21.56 ,77% of total billed charges,$23.80 ,85% of total billed charges,$8.05 ,28.75% of total billed charges,$28.00 ,100% of UHC fee schedule,$11.42 ,40.8% of total billed charges,$7.00 ,25% of total billed charges,N/A,not seperately reimbursable,$7.00 ,25% of total billed charges,$7.00 ,$28.00 ,$14.00 
Outpatient Medical Services,OTHER SERVICES,90620,"Meningococcal recombinant protein and outer membrane vesicle vaccine, serogroup B, 2 dose schedule, for intramuscular use",521,$284.00 ,$218.68 ,77% of total billed charges,$72.42 ,25.5% of total billed charges,$72.42 ,25.5% of total billed charges,$88.75 ,31.25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$71.00 ,25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$252.76 ,89% of total billed charges,$252.76 ,89% of total billed charges,$252.76 ,89% of total billed charges,$115.87 ,40.8% of total billed charges,$115.87 ,40.8% of total billed charges,$115.87 ,40.8% of total billed charges,$218.68 ,77% of total billed charges,$241.40 ,85% of total billed charges,$81.65 ,28.75% of total billed charges,$284.00 ,100% of UHC fee schedule,$115.87 ,40.8% of total billed charges,$71.00 ,25% of total billed charges,N/A,not seperately reimbursable,$71.00 ,25% of total billed charges,$71.00 ,$284.00 ,$142.00 
Outpatient Medical Services,OTHER SERVICES,90633,Hepatitis A vaccine,521,$50.00 ,$38.50 ,77% of total billed charges,$12.75 ,25.5% of total billed charges,$12.75 ,25.5% of total billed charges,$15.63 ,31.25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$12.50 ,25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$44.50 ,89% of total billed charges,$44.50 ,89% of total billed charges,$44.50 ,89% of total billed charges,$20.40 ,40.8% of total billed charges,$20.40 ,40.8% of total billed charges,$20.40 ,40.8% of total billed charges,$38.50 ,77% of total billed charges,$42.50 ,85% of total billed charges,$14.38 ,28.75% of total billed charges,$50.00 ,100% of UHC fee schedule,$20.40 ,40.8% of total billed charges,$12.50 ,25% of total billed charges,N/A,not seperately reimbursable,$12.50 ,25% of total billed charges,$12.50 ,$50.00 ,$25.00 
Outpatient Medical Services,OTHER SERVICES,90649,"HPV vaccine,",521,$315.00 ,$242.55 ,77% of total billed charges,$80.33 ,25.5% of total billed charges,$80.33 ,25.5% of total billed charges,$98.44 ,31.25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$78.75 ,25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$280.35 ,89% of total billed charges,$280.35 ,89% of total billed charges,$280.35 ,89% of total billed charges,$128.52 ,40.8% of total billed charges,$128.52 ,40.8% of total billed charges,$128.52 ,40.8% of total billed charges,$242.55 ,77% of total billed charges,$267.75 ,85% of total billed charges,$90.56 ,28.75% of total billed charges,$315.00 ,100% of UHC fee schedule,$128.52 ,40.8% of total billed charges,$78.75 ,25% of total billed charges,N/A,not seperately reimbursable,$78.75 ,25% of total billed charges,$78.75 ,$315.00 ,$157.50 
Outpatient Medical Services,OTHER SERVICES,90670,"Pneumococcal conjugate vaccine, 13 valent, for intramuscular use",636,$307.00 ,$236.39 ,77% of total billed charges,$78.29 ,25.5% of total billed charges,$78.29 ,25.5% of total billed charges,$95.94 ,31.25% of total billed charges,$211.83 ,69% of total billed charges,$211.83 ,69% of total billed charges,$211.83 ,69% of total billed charges,$76.75 ,25% of total billed charges,$211.83 ,69% of total billed charges,$211.83 ,69% of total billed charges,$211.83 ,69% of total billed charges,$138.15 ,45% of total billed charges,$273.23 ,89% of total billed charges,$273.23 ,89% of total billed charges,$273.23 ,89% of total billed charges,$125.26 ,40.8% of total billed charges,$125.26 ,40.8% of total billed charges,$125.26 ,40.8% of total billed charges,$236.39 ,77% of total billed charges,$260.95 ,85% of total billed charges,$88.26 ,28.75% of total billed charges,N/A,not seperately reimbursable,$125.26 ,40.8% of total billed charges,$76.75 ,25% of total billed charges,N/A,not seperately reimbursable,$76.75 ,25% of total billed charges,$76.75 ,$273.23 ,$153.50 
Outpatient Medical Services,OTHER SERVICES,90734,"Meningicoccal conjugate vaccine, serogoups A, C, Y and W-135",521,$200.00 ,$154.00 ,77% of total billed charges,$51.00 ,25.5% of total billed charges,$51.00 ,25.5% of total billed charges,$62.50 ,31.25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$50.00 ,25% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$178.00 ,89% of total billed charges,$178.00 ,89% of total billed charges,$178.00 ,89% of total billed charges,$81.60 ,40.8% of total billed charges,$81.60 ,40.8% of total billed charges,$81.60 ,40.8% of total billed charges,$154.00 ,77% of total billed charges,$170.00 ,85% of total billed charges,$57.50 ,28.75% of total billed charges,$200.00 ,100% of UHC fee schedule,$81.60 ,40.8% of total billed charges,$50.00 ,25% of total billed charges,N/A,not seperately reimbursable,$50.00 ,25% of total billed charges,$50.00 ,$200.00 ,$100.00 
Outpatient Medical Services,OTHER SERVICES,96360,"Intravenous Infusion, hydration; initial, 31 minutes to 1 hour",940,$95.00 ,$73.15 ,77% of total billed charges,$24.23 ,25.5% of total billed charges,$24.23 ,25.5% of total billed charges,$29.69 ,31.25% of total billed charges,$70.30 ,74% of total billed charges,$65.55 ,69% of total billed charges,$65.55 ,69% of total billed charges,$23.75 ,25% of total billed charges,$65.55 ,69% of total billed charges,$65.55 ,69% of total billed charges,$79.80 ,84% of total billed charges,$77.90 ,82% of total billed charges,$84.55 ,89% of total billed charges,$84.55 ,89% of total billed charges,$84.55 ,89% of total billed charges,$38.76 ,40.8% of total billed charges,$38.76 ,40.8% of total billed charges,$38.76 ,40.8% of total billed charges,$73.15 ,77% of total billed charges,$80.75 ,85% of total billed charges,$27.31 ,28.75% of total billed charges,$95.00 ,100% of UHC fee schedule,$38.76 ,40.8% of total billed charges,$23.75 ,25% of total billed charges,$117.00 ,pays based on per visit rate,$23.75 ,25% of total billed charges,$23.75 ,$117.00 ,$47.50 
Outpatient Medical Services,OTHER SERVICES,96361,"Intravenous Infusion, hydration; each additional hour",940,N/A,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$117.00 ,pays based on per visit rate,N/A,not seperately reimbursable,$117.00 ,$117.00 ,N/A
Outpatient Medical Services,OTHER SERVICES,96365,"Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to one hour) on the same day.",940,$122.30 ,$94.17 ,77% of total billed charges,$31.19 ,25.5% of total billed charges,$31.19 ,25.5% of total billed charges,$38.22 ,31.25% of total billed charges,$90.50 ,74% of total billed charges,$84.39 ,69% of total billed charges,$84.39 ,69% of total billed charges,$30.58 ,25% of total billed charges,$84.39 ,69% of total billed charges,$84.39 ,69% of total billed charges,$102.73 ,84% of total billed charges,$100.29 ,82% of total billed charges,$108.85 ,89% of total billed charges,$108.85 ,89% of total billed charges,$108.85 ,89% of total billed charges,$49.90 ,40.8% of total billed charges,$49.90 ,40.8% of total billed charges,$49.90 ,40.8% of total billed charges,$94.17 ,77% of total billed charges,$103.96 ,85% of total billed charges,$35.16 ,28.75% of total billed charges,$122.30 ,100% of UHC fee schedule,$49.90 ,40.8% of total billed charges,$30.58 ,25% of total billed charges,$117.00 ,pays based on per visit rate,$30.58 ,25% of total billed charges,$30.58 ,$122.30 ,$61.15 
Outpatient Medical Services,OTHER SERVICES,96366,additional hours code associated with the sequential therapeutic infusion,940,N/A,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$117.00 ,pays based on per visit rate,N/A,not seperately reimbursable,$117.00 ,$117.00 ,N/A
Outpatient Medical Services,OTHER SERVICES,96367,"Therapeutic, Prophylactic, and Diagnostic Injections and Infusions",940,N/A,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$117.00 ,pays based on per visit rate,N/A,not seperately reimbursable,$117.00 ,$117.00 ,N/A
Outpatient Medical Services,OTHER SERVICES,96372,"Therapeutic, Prophylactic, and Diagnostic Injections and Infusions",940,$26.00 ,$20.02 ,77% of total billed charges,$6.63 ,25.5% of total billed charges,$6.63 ,25.5% of total billed charges,$8.13 ,31.25% of total billed charges,$19.24 ,74% of total billed charges,$17.94 ,69% of total billed charges,$17.94 ,69% of total billed charges,$6.50 ,25% of total billed charges,$17.94 ,69% of total billed charges,$17.94 ,69% of total billed charges,$21.84 ,84% of total billed charges,$21.32 ,82% of total billed charges,$23.14 ,89% of total billed charges,$23.14 ,89% of total billed charges,$23.14 ,89% of total billed charges,$10.61 ,40.8% of total billed charges,$10.61 ,40.8% of total billed charges,$10.61 ,40.8% of total billed charges,$20.02 ,77% of total billed charges,$22.10 ,85% of total billed charges,$7.48 ,28.75% of total billed charges,$26.00 ,100% of UHC fee schedule,$10.61 ,40.8% of total billed charges,$6.50 ,25% of total billed charges,$117.00 ,pays based on per visit rate,$6.50 ,25% of total billed charges,$6.50 ,$117.00 ,$13.00 
Outpatient Medical Services,OTHER SERVICES,96374,"Hydration, Therapeutic, Prophylactic, Diagnostic Injections and Infusions, and Chemotherapy and Other Highly Complex Drug",940,N/A,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$117.00 ,pays based on per visit rate,N/A,not seperately reimbursable,$117.00 ,$117.00 ,N/A
Outpatient Medical Services,OTHER SERVICES,96375,"Therapeutic, Prophylactic, and Diagnostic Injections and Infusions",940,N/A,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$117.00 ,pays based on per visit rate,N/A,not seperately reimbursable,$117.00 ,$117.00 ,N/A
Outpatient Medical Services,OTHER SERVICES,96376,"Therapeutic, prophylactic, or diagnostic injection",940,N/A,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$117.00 ,pays based on per visit rate,N/A,not seperately reimbursable,$117.00 ,$117.00 ,N/A
Outpatient Medical Services,OTHER SERVICES,96401,Injection and Intravenous Infusion Chemotherapy and Other Highly Complex Drug or Highly Complex Biologic Agent Administration,331,N/A,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$182.00 ,pays based on per visit rate,N/A,not seperately reimbursable,$182.00 ,$182.00 ,N/A
Outpatient Medical Services,OTHER SERVICES,96413,"chemotherapy administration, intravenous infusion technique; up to one hour",940,"$1,237.00 ",$952.49 ,77% of total billed charges,$315.44 ,25.5% of total billed charges,$315.44 ,25.5% of total billed charges,$386.56 ,31.25% of total billed charges,$915.38 ,74% of total billed charges,$853.53 ,69% of total billed charges,$853.53 ,69% of total billed charges,$309.25 ,25% of total billed charges,$853.53 ,69% of total billed charges,$853.53 ,69% of total billed charges,"$1,039.08 ",84% of total billed charges,"$1,014.34 ",82% of total billed charges,"$1,100.93 ",89% of total billed charges,"$1,100.93 ",89% of total billed charges,"$1,100.93 ",89% of total billed charges,$504.70 ,40.8% of total billed charges,$504.70 ,40.8% of total billed charges,$504.70 ,40.8% of total billed charges,$952.49 ,77% of total billed charges,"$1,051.45 ",85% of total billed charges,$355.64 ,28.75% of total billed charges,"$1,237.00 ",100% of UHC fee schedule,$504.70 ,40.8% of total billed charges,$309.25 ,25% of total billed charges,$117.00 ,pays based on per visit rate,$309.25 ,25% of total billed charges,$117.00 ,"$1,237.00 ",$618.50 
Outpatient Medical Services,OTHER SERVICES,96415,Injection and Intravenous Infusion Chemotherapy and Other Highly Complex Drug or Highly Complex Biologic Agent Administration,335,$155.50 ,$119.74 ,77% of total billed charges,$39.65 ,25.5% of total billed charges,$39.65 ,25.5% of total billed charges,$48.59 ,31.25% of total billed charges,$115.07 ,74% of total billed charges,$107.30 ,69% of total billed charges,$107.30 ,69% of total billed charges,$38.88 ,25% of total billed charges,$107.30 ,69% of total billed charges,$107.30 ,69% of total billed charges,$130.62 ,84% of total billed charges,$127.51 ,82% of total billed charges,$138.40 ,89% of total billed charges,$138.40 ,89% of total billed charges,$138.40 ,89% of total billed charges,$63.44 ,40.8% of total billed charges,$63.44 ,40.8% of total billed charges,$63.44 ,40.8% of total billed charges,$119.74 ,77% of total billed charges,$132.18 ,85% of total billed charges,$44.71 ,28.75% of total billed charges,$155.50 ,100% of UHC fee schedule,$63.44 ,40.8% of total billed charges,$38.88 ,25% of total billed charges,$182.00 ,pays based on per visit rate,$38.88 ,25% of total billed charges,$38.88 ,$182.00 ,$77.75 
Outpatient Medical Services,OTHER SERVICES,96417,Injection and Intravenous Infusion Chemotherapy and Other Highly Complex Drug or Highly Complex Biologic Agent Administration,335,$316.50 ,$243.71 ,77% of total billed charges,$80.71 ,25.5% of total billed charges,$80.71 ,25.5% of total billed charges,$98.91 ,31.25% of total billed charges,$234.21 ,74% of total billed charges,$218.39 ,69% of total billed charges,$218.39 ,69% of total billed charges,$79.13 ,25% of total billed charges,$218.39 ,69% of total billed charges,$218.39 ,69% of total billed charges,$265.86 ,84% of total billed charges,$259.53 ,82% of total billed charges,$281.69 ,89% of total billed charges,$281.69 ,89% of total billed charges,$281.69 ,89% of total billed charges,$129.13 ,40.8% of total billed charges,$129.13 ,40.8% of total billed charges,$129.13 ,40.8% of total billed charges,$243.71 ,77% of total billed charges,$269.03 ,85% of total billed charges,$90.99 ,28.75% of total billed charges,$316.50 ,100% of UHC fee schedule,$129.13 ,40.8% of total billed charges,$79.13 ,25% of total billed charges,$182.00 ,pays based on per visit rate,$79.13 ,25% of total billed charges,$79.13 ,$316.50 ,$158.25 
Outpatient Medical Services,OTHER SERVICES,96523,Irrigation of implanted venous access device for drug delivery system,940,$466.50 ,$359.21 ,77% of total billed charges,$118.96 ,25.5% of total billed charges,$118.96 ,25.5% of total billed charges,$145.78 ,31.25% of total billed charges,$345.21 ,74% of total billed charges,$321.89 ,69% of total billed charges,$321.89 ,69% of total billed charges,$116.63 ,25% of total billed charges,$321.89 ,69% of total billed charges,$321.89 ,69% of total billed charges,$391.86 ,84% of total billed charges,$382.53 ,82% of total billed charges,$415.19 ,89% of total billed charges,$415.19 ,89% of total billed charges,$415.19 ,89% of total billed charges,$190.33 ,40.8% of total billed charges,$190.33 ,40.8% of total billed charges,$190.33 ,40.8% of total billed charges,$359.21 ,77% of total billed charges,$396.53 ,85% of total billed charges,$134.12 ,28.75% of total billed charges,$466.50 ,100% of UHC fee schedule,$190.33 ,40.8% of total billed charges,$116.63 ,25% of total billed charges,$117.00 ,pays based on per visit rate,$116.63 ,25% of total billed charges,$116.63 ,$466.50 ,$233.25 
Outpatient Medical Services,OTHER SERVICES,A9502,"Technetium tc-99m tetrofosmin, diagnostic, per study dose",343,$265.00 ,$204.05 ,77% of total billed charges,$67.58 ,25.5% of total billed charges,$67.58 ,25.5% of total billed charges,$82.81 ,31.25% of total billed charges,$196.10 ,74% of total billed charges,$182.85 ,69% of total billed charges,$182.85 ,69% of total billed charges,$66.25 ,25% of total billed charges,$182.85 ,69% of total billed charges,$182.85 ,69% of total billed charges,$222.60 ,84% of total billed charges,$217.30 ,82% of total billed charges,$235.85 ,89% of total billed charges,$235.85 ,89% of total billed charges,$235.85 ,89% of total billed charges,$108.12 ,40.8% of total billed charges,$108.12 ,40.8% of total billed charges,$108.12 ,40.8% of total billed charges,$204.05 ,77% of total billed charges,$225.25 ,85% of total billed charges,$76.19 ,28.75% of total billed charges,$265.00 ,100% of UHC fee schedule,$108.12 ,40.8% of total billed charges,$66.25 ,25% of total billed charges,$235.85 ,89% of total billed charges,$66.25 ,25% of total billed charges,$66.25 ,$265.00 ,$132.50 
Outpatient Medical Services,OTHER SERVICES,M0243,Monoclonal Antibody COVID-19 Infusion,771,"$1,924.00 ","$1,481.48 ",77% of total billed charges,$490.62 ,25.5% of total billed charges,$490.62 ,25.5% of total billed charges,$601.25 ,31.25% of total billed charges,"$1,423.76 ",74% of total billed charges,"$1,327.56 ",69% of total billed charges,"$1,327.56 ",69% of total billed charges,$481.00 ,25% of total billed charges,"$1,327.56 ",69% of total billed charges,"$1,327.56 ",69% of total billed charges,"$1,616.16 ",84% of total billed charges,"$1,577.68 ",82% of total billed charges,"$1,712.36 ",89% of total billed charges,"$1,712.36 ",89% of total billed charges,"$1,712.36 ",89% of total billed charges,$784.99 ,40.8% of total billed charges,$784.99 ,40.8% of total billed charges,$784.99 ,40.8% of total billed charges,"$1,481.48 ",77% of total billed charges,"$1,635.40 ",85% of total billed charges,$553.15 ,28.75% of total billed charges,"$1,924.00 ",100% of UHC fee schedule,$784.99 ,40.8% of total billed charges,$481.00 ,25% of total billed charges,N/A,not seperately reimbursable,$481.00 ,25% of total billed charges,$481.00 ,"$1,924.00 ",$962.00 
Outpatient Medical Services,OTHER SERVICES,P9016,"Red blood cells, leukocytes reduced, each unit Short description: Rbc leukocytes reduced",390,$611.50 ,$470.86 ,77% of total billed charges,$155.93 ,25.5% of total billed charges,$155.93 ,25.5% of total billed charges,$191.09 ,31.25% of total billed charges,$452.51 ,74% of total billed charges,$421.94 ,69% of total billed charges,$421.94 ,69% of total billed charges,$152.88 ,25% of total billed charges,$421.94 ,69% of total billed charges,$421.94 ,69% of total billed charges,$513.66 ,84% of total billed charges,$501.43 ,82% of total billed charges,$544.24 ,89% of total billed charges,$544.24 ,89% of total billed charges,$544.24 ,89% of total billed charges,N/A,not seperately reimbursable,N/A,not seperately reimbursable,N/A,not seperately reimbursable,$470.86 ,77% of total billed charges,$519.78 ,85% of total billed charges,$175.81 ,28.75% of total billed charges,$611.50 ,100% of UHC fee schedule,N/A,not seperately reimbursable,$152.88 ,25% of total billed charges,N/A,not seperately reimbursable,$152.88 ,25% of total billed charges,$152.88 ,$611.50 ,$305.75 
Outpatient Medical Services,OTHER SERVICES,Q3014,Telehealth originating site facility fee,780,$111.50 ,$85.86 ,77% of total billed charges,$28.43 ,25.5% of total billed charges,$28.43 ,25.5% of total billed charges,$34.84 ,31.25% of total billed charges,$82.51 ,74% of total billed charges,$76.94 ,69% of total billed charges,$76.94 ,69% of total billed charges,$27.88 ,25% of total billed charges,$76.94 ,69% of total billed charges,$76.94 ,69% of total billed charges,$93.66 ,84% of total billed charges,$91.43 ,82% of total billed charges,$99.24 ,89% of total billed charges,$99.24 ,89% of total billed charges,$99.24 ,89% of total billed charges,$45.49 ,40.8% of total billed charges,$45.49 ,40.8% of total billed charges,$45.49 ,40.8% of total billed charges,$85.86 ,77% of total billed charges,$94.78 ,85% of total billed charges,$32.06 ,28.75% of total billed charges,$55.75 ,50% of total billed charges,$45.49 ,40.8% of total billed charges,$27.88 ,25% of total billed charges,$99.24 ,89% of total billed charges,$27.88 ,25% of total billed charges,$27.88 ,$99.24 ,$55.75 
Outpatient Medical Services,OUTPATIENT SERVICES,45391,Ultrasound examination of lower large bowel using an endoscope,360,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,OUTPATIENT SERVICES,55866,Surgical removal of prostate and surrounding lymph nodes using an endoscope,360,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,CARDIOLOGY,93452,Insertion of catheter into left heart for diagnosis,480,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
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,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Inpatient Medical Services,INPATIENT PROCEDURES,460,Spinal fusion except cervical without major comorbid conditions or complications,100,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Inpatient Medical Services,INPATIENT PROCEDURES,473,Cervical spinal fusion without comorbid conditions or major comorbid conditions or complications,100,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A