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,11/25/2024,2.0.0,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 REIMBURSEMENT METHOD,AETNA MEDICARE PLAN,AETNA MEDICARE REIMBURSEMENT METHOD,ALLWELL PLAN,ALLWELL REIMBURSEMENT METHOD,AMBETTER PLAN,AMBETTER REIMBURSEMENT METHOD,BCBS BLUE ACCESS PLAN,BCBS BLUE ACCESS REIMBURSEMENT METHOD,BCBS BLUE ACCESS CHOICE PLAN,BCBS BLUE ACCESS CHOICE REIMBURSEMENT METHOD,BCBS BLUE PREFERRED PLAN,BCBS BLUE PREFERRED REIMBURSEMENT METHOD,BCBS MEDICARE PLAN,BCBS MEDICARE REIMBURSEMENT METHOD,BCBS PATHWAY PLAN,BCBS PATHWAY REIMBURSEMENT METHOD,BCBS PATHWAY X PLAN,BCBS PATHWAY X REIMBURSEMENT METHOD,BCBS TRADITIONAL PLAN,BCBS TRADITIONAL REIMBURSEMENT METHOD,CIGNA PLAN,CIGNA REIMBURSEMENT METHOD,HEALTHLINK COMPMANAGEMENT PLAN,HEALTHLINK COMPMANAGEMENT REIMBURSEMENT METHOD,HEALTHLINK HMO PLAN,HEALTHLINK HMO REIMBURSEMENT METHOD,HEALTHLINK PPO PLAN,HEALTHLINK PPO REIMBURSEMENT METHOD,HEALTHY BLUE PLAN,HEALTHY BLUE REIMBURSEMENT METHOD,HOMESTATE PLAN,HOMESTATE REIMBURSEMENT METHOD,MEDICAID PLAN,MEDICAID REIMBURSEMENT METHOD,MEDICARE PLAN,MEDICARE REIMBURSEMENT METHOD,MERITAIN PLAN,MERITAIN REIMBURSEMENT METHOD,MULTIPLAN/PHCS PLAN,MULTIPLAN/PHCS REIMBURSEMENT METHOD,PPHP PLAN,PPHP REIMBURSEMENT METHOD,UHC PLAN,UHC REIMBURSEMENT METHOD,UHC COMMUNITY PLAN PLAN,UHC COMMUNITY PLAN REIMBURSEMENT METHOD,UHC MEDICARE PLAN,UHC MEDICARE REIMBURSEMENT METHOD,UMR PLAN,UMR REIMBURSEMENT METHOD,VA PLAN,VA REIMBURSEMENT 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).,120,50595.17,38958.28,77% of Billed Charges,2811.12,PER DIEM,2811.12,PER DIEM,3445,PER DIEM,2472,PER DIEM,2350,PER DIEM,2350,PER DIEM,2756,PER DIEM,2350,PER DIEM,2252,PER DIEM,2547,PER DIEM,2020,PER DIEM,2751,PER DIEM,2719,PER DIEM,2751,PER DIEM,2494.66,PER DIEM,2494.66,PER DIEM,2494.66,PER DIEM,2756,PER DIEM,38958.28,77% of Billed Charges,43005.89,85% of Billed Charges,3169.4,PER DIEM,2962,PER DIEM,2494.66,PER DIEM,2756,PER DIEM,2291,100% of Asc Tier Groupings Fee Schedule,2756,PER DIEM,2020,43005.89,25297.59
Inpatient Medical Services,INPATIENT,743,Uterine and adnexa procedures for non-malignancy without comorbid conditions (CC) or major comorbid conditions or complications (MCC),120,34791.64,26789.56,77% of Billed Charges,2811.12,PER DIEM,2811.12,PER DIEM,3445,PER DIEM,2472,PER DIEM,2350,PER DIEM,2350,PER DIEM,2756,PER DIEM,2350,PER DIEM,3662,PER DIEM,2547,PER DIEM,2020,PER DIEM,2751,PER DIEM,2719,PER DIEM,2751,PER DIEM,2494.66,PER DIEM,2494.66,PER DIEM,2494.66,PER DIEM,2756,PER DIEM,26789.56,77% of Billed Charges,29572.89,85% of Billed Charges,3169.4,PER DIEM,2962,PER DIEM,2494.66,PER DIEM,2756,PER DIEM,377,100% of Asc Tier Groupings Fee Schedule,2756,PER DIEM,377,29572.89,17395.82
Inpatient Medical Services,INPATIENT,795,Normal Newborn Birth,120,3392.2,2611.99,77% of Billed Charges,2811.12,PER DIEM,2811.12,PER DIEM,3445,PER DIEM,1644,PER DIEM,1562,PER DIEM,1562,PER DIEM,2756,PER DIEM,1562,PER DIEM,3620,PER DIEM,1692,PER DIEM,1460,PER DIEM,1989,PER DIEM,1890,PER DIEM,1989,PER DIEM,2494.66,PER DIEM,2494.66,PER DIEM,2494.66,PER DIEM,2756,PER DIEM,2611.99,77% of Billed Charges,2883.37,85% of Billed Charges,3169.4,PER DIEM,1183,PER DIEM,2494.66,PER DIEM,2756,PER DIEM,2711,100% of Asc Tier Groupings Fee Schedule,2756,PER DIEM,1183,3620,1696.1
Inpatient Medical Services,INPATIENT,177,Respiratory Infections and inflammations with MCC,120,28782.69,22162.67,77% of Billed Charges,2811.12,PER DIEM,2811.12,PER DIEM,3445,PER DIEM,1644,PER DIEM,1562,PER DIEM,1562,PER DIEM,2756,PER DIEM,1562,PER DIEM,107.3,PER DIEM,1692,PER DIEM,1460,PER DIEM,1989,PER DIEM,1890,PER DIEM,1989,PER DIEM,2494.66,PER DIEM,2494.66,PER DIEM,2494.66,PER DIEM,2756,PER DIEM,22162.67,77% of Billed Charges,24465.29,85% of Billed Charges,3169.4,PER DIEM,2962,PER DIEM,2494.66,PER DIEM,2756,PER DIEM,2291,100% of Asc Tier Groupings Fee Schedule,2756,PER DIEM,107.3,24465.29,14391.35
Inpatient Medical Services,INPATIENT,807,Vaginal delivery without sterilization or D&C without CC/MCC,120,12334.71,9497.73,77% of Billed Charges,2811.12,PER DIEM,2811.12,PER DIEM,3445,PER DIEM,2369,Pays Based On Per Visit,2252,Pays Based On Per Visit,2252,Pays Based On Per Visit,2756,PER DIEM,2252,PER DIEM,218.39,PER DIEM,2443,Pays Based On Per Visit,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,2494.66,PER DIEM,2494.66,PER DIEM,2494.66,PER DIEM,2756,PER DIEM,9497.73,77% of Billed Charges,10484.5,85% of Billed Charges,3169.4,PER DIEM,5516,Pays Based On Per Visit,2494.66,PER DIEM,2756,PER DIEM,2034,100% of Asc Tier Groupings Fee Schedule,2756,PER DIEM,218.39,10484.5,6167.36
Inpatient Medical Services,INPATIENT,897,"Alcohol, Drug Abuse or dependence without Rehabilitation therapy, without MCC",120,9225,7103.25,77% of Billed Charges,2811.12,PER DIEM,2811.12,PER DIEM,3445,PER DIEM,1644,PER DIEM,1562,PER DIEM,1562,PER DIEM,2756,PER DIEM,1562,PER DIEM,2496,PER DIEM,1692,PER DIEM,1460,PER DIEM,1989,PER DIEM,1890,PER DIEM,1989,PER DIEM,2494.66,PER DIEM,2494.66,PER DIEM,2494.66,PER DIEM,2756,PER DIEM,7103.25,77% of Billed Charges,7841.25,85% of Billed Charges,3169.4,PER DIEM,2962,PER DIEM,2494.66,PER DIEM,2756,PER DIEM,2034,100% of Asc Tier Groupings Fee Schedule,2756,PER DIEM,1460,7841.25,4612.5
Inpatient Medical Services,INPATIENT,194,Simple pneumonia and pleurisy with CC,120,12209.4,9401.24,77% of Billed Charges,2811.12,PER DIEM,2811.12,PER DIEM,3445,PER DIEM,1644,PER DIEM,1562,PER DIEM,1562,PER DIEM,2756,PER DIEM,1562,PER DIEM,2400,PER DIEM,1692,PER DIEM,1460,PER DIEM,1989,PER DIEM,1890,PER DIEM,1989,PER DIEM,2494.66,PER DIEM,2494.66,PER DIEM,2494.66,PER DIEM,2756,PER DIEM,9401.24,77% of Billed Charges,10377.99,85% of Billed Charges,3169.4,PER DIEM,2962,PER DIEM,2494.66,PER DIEM,2756,PER DIEM,2034,100% of Asc Tier Groupings Fee Schedule,2756,PER DIEM,1460,10377.99,6104.7
Inpatient Medical Services,INPATIENT,794,Neonate with other significant problems,120,3207.17,2469.52,77% of Billed Charges,2811.12,PER DIEM,2811.12,PER DIEM,3445,PER DIEM,1644,PER DIEM,1562,PER DIEM,1562,PER DIEM,2756,PER DIEM,1562,PER DIEM,1168,PER DIEM,1692,PER DIEM,1460,PER DIEM,1989,PER DIEM,1890,PER DIEM,1989,PER DIEM,2494.66,PER DIEM,2494.66,PER DIEM,2494.66,PER DIEM,2756,PER DIEM,2469.52,77% of Billed Charges,2726.09,85% of Billed Charges,3169.4,PER DIEM,1183,PER DIEM,2494.66,PER DIEM,2756,PER DIEM,2034,100% of Asc Tier Groupings Fee Schedule,2756,PER DIEM,1168,3445,1603.59
Inpatient Medical Services,INPATIENT,190,Chronic obstructive pulmonary disease with CC,120,19395.39,14934.45,77% of Billed Charges,2811.12,PER DIEM,2811.12,PER DIEM,3445,PER DIEM,1644,PER DIEM,1562,PER DIEM,1562,PER DIEM,2756,PER DIEM,1562,PER DIEM,155,PER DIEM,1692,PER DIEM,1460,PER DIEM,1989,PER DIEM,1890,PER DIEM,1989,PER DIEM,2494.66,PER DIEM,2494.66,PER DIEM,2494.66,PER DIEM,2756,PER DIEM,14934.45,77% of Billed Charges,16486.08,85% of Billed Charges,3169.4,PER DIEM,2962,PER DIEM,2494.66,PER DIEM,2756,PER DIEM,2034,100% of Asc Tier Groupings Fee Schedule,2756,PER DIEM,155,16486.08,9697.7
Inpatient Medical Services,INPATIENT,603,Cellulitis without MCC,120,19373.31,14917.45,77% of Billed Charges,2811.12,PER DIEM,2811.12,PER DIEM,3445,PER DIEM,1644,PER DIEM,1562,PER DIEM,1562,PER DIEM,2756,PER DIEM,1562,PER DIEM,2589,PER DIEM,1692,PER DIEM,1460,PER DIEM,1989,PER DIEM,1890,PER DIEM,1989,PER DIEM,2494.66,PER DIEM,2494.66,PER DIEM,2494.66,PER DIEM,2756,PER DIEM,14917.45,77% of Billed Charges,16467.31,85% of Billed Charges,3169.4,PER DIEM,2962,PER DIEM,2494.66,PER DIEM,2756,PER DIEM,1092,100% of Asc Tier Groupings Fee Schedule,2756,PER DIEM,1092,16467.31,9686.66
Outpatient Medical Services,SURGICAL CARE,19120,"Removal of 1 or more breast growth, open procedure",360,8997.43,6928.02,77% of Billed Charges,2294.34,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,2294.34,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,2811.7,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,1495,Pays Based On Per Visit,1334,Pays Based On Per Visit,1334,Pays Based On Per Visit,2249.36,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,1334,PER DIEM,1606,PER DIEM,7557.84,Pays Based On Per Visit,7377.89,Pays Based On Per Visit,4592,Pays Based On Per Visit,4458,Pays Based On Per Visit,4592,Pays Based On Per Visit,3670.95,40.8% of Billed Charges,3670.95,40.8% of Billed Charges,3670.95,40.8% of Billed Charges,2249.36,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,6928.02,77% of Billed Charges,7647.82,85% of Billed Charges,2586.76,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,2647,100% of Asc Tier Groupings,3670.95,40.8% of Billed Charges,2249.36,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,3842,100% of Asc Tier Groupings Fee Schedule,2249.36,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,1334,7647.82,4498.72
Outpatient Medical Services,SURGICAL CARE,29826,Shaving of shoulder bone using an endoscope,360,5778.49,4449.44,77% of Billed Charges,1473.51,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,1473.51,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,1805.78,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,3645,Pays Based On Per Visit,3620,Pays Based On Per Visit,3620,Pays Based On Per Visit,1444.62,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,3620,PER DIEM,1606,PER DIEM,3757,Pays Based On Per Visit,4738.36,Pays Based On Per Visit,4592,Pays Based On Per Visit,4458,Pays Based On Per Visit,4592,Pays Based On Per Visit,2357.62,40.8% of Billed Charges,2357.62,40.8% of Billed Charges,2357.62,40.8% of Billed Charges,1444.62,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,4449.44,77% of Billed Charges,4911.72,85% of Billed Charges,1661.32,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,436,100% of Asc Tier Groupings,2357.62,40.8% of Billed Charges,1444.62,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,2711,100% of Asc Tier Groupings Fee Schedule,1444.62,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,436,4911.72,2889.25
Outpatient Medical Services,SURGICAL CARE,29881,Removal of one knee cartilage using an endoscope,360,9089.96,6999.27,77% of Billed Charges,2317.94,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,2317.94,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,2840.61,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,3775,Pays Based On Per Visit,3662,Pays Based On Per Visit,3662,Pays Based On Per Visit,2272.49,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,3662,PER DIEM,723.64,PER DIEM,3983,Pays Based On Per Visit,7453.77,Pays Based On Per Visit,4592,Pays Based On Per Visit,4458,Pays Based On Per Visit,4592,Pays Based On Per Visit,3708.7,40.8% of Billed Charges,3708.7,40.8% of Billed Charges,3708.7,40.8% of Billed Charges,2272.49,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,6999.27,77% of Billed Charges,7726.47,85% of Billed Charges,2613.36,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,3132,100% of Asc Tier Groupings,3708.7,40.8% of Billed Charges,2272.49,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,377,100% of Asc Tier Groupings Fee Schedule,2272.49,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,377,7726.47,4544.98
Outpatient Medical Services,SURGICAL CARE,42820,Removal of tonsils and adenoid glands patient younger than age 12,360,8288.85,6382.41,77% of Billed Charges,2113.66,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,2113.66,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,2590.27,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,2212,Pays Based On Per Visit,2102,Pays Based On Per Visit,2102,Pays Based On Per Visit,2072.21,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,2102,PER DIEM,984.42,PER DIEM,2278,Pays Based On Per Visit,6796.86,Pays Based On Per Visit,4592,Pays Based On Per Visit,4458,Pays Based On Per Visit,4592,Pays Based On Per Visit,3381.85,40.8% of Billed Charges,3381.85,40.8% of Billed Charges,3381.85,40.8% of Billed Charges,2072.21,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,6382.41,77% of Billed Charges,7045.52,85% of Billed Charges,2383.04,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,2647,100% of Asc Tier Groupings,3381.85,40.8% of Billed Charges,2072.21,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,377,100% of Asc Tier Groupings Fee Schedule,2072.21,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,377,7045.52,4144.43
Outpatient Medical Services,SURGICAL CARE,43235,"Diagnostic examination of esophagus, stomach, and/or upper small bowel using an endoscope",360,4642.1,3574.42,77% of Billed Charges,1183.74,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,1183.74,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,1450.66,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,1614,Pays Based On Per Visit,1606,Pays Based On Per Visit,1606,Pays Based On Per Visit,1160.53,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,1606,PER DIEM,216.83,PER DIEM,1606,Pays Based On Per Visit,3806.52,Pays Based On Per Visit,4131.47,Pays Based On Per Visit,3899.36,Pays Based On Per Visit,4131.47,Pays Based On Per Visit,1893.98,40.8% of Billed Charges,1893.98,40.8% of Billed Charges,1893.98,40.8% of Billed Charges,1160.53,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,3574.42,77% of Billed Charges,3945.79,85% of Billed Charges,1334.6,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,2350,100% of Asc Tier Groupings,1893.98,40.8% of Billed Charges,1160.53,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,1092,100% of Asc Tier Groupings Fee Schedule,1160.53,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,216.83,4131.47,2321.05
Outpatient Medical Services,SURGICAL CARE,43239,"Biopsy of the esophagus, stomach, and/or upper small bowel using an endoscope",360,5618.89,4326.55,77% of Billed Charges,1432.82,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,1432.82,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,1755.9,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,2668,Pays Based On Per Visit,2589,Pays Based On Per Visit,2589,Pays Based On Per Visit,1404.72,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,2589,PER DIEM,318.01,PER DIEM,2806,Pays Based On Per Visit,4607.49,Pays Based On Per Visit,4592,Pays Based On Per Visit,4458,Pays Based On Per Visit,4592,Pays Based On Per Visit,2292.51,40.8% of Billed Charges,2292.51,40.8% of Billed Charges,2292.51,40.8% of Billed Charges,1404.72,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,4326.55,77% of Billed Charges,4776.06,85% of Billed Charges,1615.43,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,2350,100% of Asc Tier Groupings,2292.51,40.8% of Billed Charges,1404.72,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,377,100% of Asc Tier Groupings Fee Schedule,1404.72,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,318.01,4776.06,2809.45
Outpatient Medical Services,SURGICAL CARE,45378,Diagnostic examination of large bowel using an endoscope,360,4442.81,3420.96,77% of Billed Charges,1132.92,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,1132.92,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,1388.38,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,2472,Pays Based On Per Visit,2400,Pays Based On Per Visit,2400,Pays Based On Per Visit,1110.7,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,2400,PER DIEM,457.25,PER DIEM,2610,Pays Based On Per Visit,3643.1,Pays Based On Per Visit,3954.1,Pays Based On Per Visit,3731.96,Pays Based On Per Visit,3954.1,Pays Based On Per Visit,1812.67,40.8% of Billed Charges,1812.67,40.8% of Billed Charges,1812.67,40.8% of Billed Charges,1110.7,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,3420.96,77% of Billed Charges,3776.39,85% of Billed Charges,1277.31,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,2350,100% of Asc Tier Groupings,1812.67,40.8% of Billed Charges,1110.7,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,2034,100% of Asc Tier Groupings Fee Schedule,1110.7,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,457.25,3954.1,2221.41
Outpatient Medical Services,SURGICAL CARE,45380,Biopsy of large bowel using an endoscope,360,4922.75,3790.52,77% of Billed Charges,1255.3,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,1255.3,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,1538.36,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,2572,Pays Based On Per Visit,2496,Pays Based On Per Visit,2496,Pays Based On Per Visit,1230.69,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,2496,PER DIEM,1334,PER DIEM,2712,Pays Based On Per Visit,4036.66,Pays Based On Per Visit,4381.25,Pays Based On Per Visit,4135.11,Pays Based On Per Visit,4381.25,Pays Based On Per Visit,2008.48,40.8% of Billed Charges,2008.48,40.8% of Billed Charges,2008.48,40.8% of Billed Charges,1230.69,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,3790.52,77% of Billed Charges,4184.34,85% of Billed Charges,1415.29,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,2350,100% of Asc Tier Groupings,2008.48,40.8% of Billed Charges,1230.69,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,1092,100% of Asc Tier Groupings Fee Schedule,1230.69,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,1092,4381.25,2461.38
Outpatient Medical Services,SURGICAL CARE,45385,Removal of polyps or growths of large bowel using an endoscope,360,5401.69,4159.3,77% of Billed Charges,1377.43,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,1377.43,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,1688.03,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,1614,Pays Based On Per Visit,1606,Pays Based On Per Visit,1606,Pays Based On Per Visit,1350.42,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,1606,PER DIEM,1334,PER DIEM,1606,Pays Based On Per Visit,4429.39,Pays Based On Per Visit,4592,Pays Based On Per Visit,4458,Pays Based On Per Visit,4592,Pays Based On Per Visit,2203.89,40.8% of Billed Charges,2203.89,40.8% of Billed Charges,2203.89,40.8% of Billed Charges,1350.42,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,4159.3,77% of Billed Charges,4591.44,85% of Billed Charges,1552.99,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,2350,100% of Asc Tier Groupings,2203.89,40.8% of Billed Charges,1350.42,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,1092,100% of Asc Tier Groupings Fee Schedule,1350.42,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,1092,4592,2700.85
Outpatient Medical Services,SURGICAL CARE,46221,Excision Procedures on the Anus,360,4942.27,3805.55,77% of Billed Charges,1260.28,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,1260.28,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,1544.46,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,1495,Pays Based On Per Visit,1334,Pays Based On Per Visit,1334,Pays Based On Per Visit,1235.57,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,1334,PER DIEM,1334,PER DIEM,4151.51,Pays Based On Per Visit,4052.66,Pays Based On Per Visit,4398.62,Pays Based On Per Visit,4151.51,Pays Based On Per Visit,4398.62,Pays Based On Per Visit,2016.45,40.8% of Billed Charges,2016.45,40.8% of Billed Charges,2016.45,40.8% of Billed Charges,1235.57,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,3805.55,77% of Billed Charges,4200.93,85% of Billed Charges,1420.9,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,1261,100% of Asc Tier Groupings,2016.45,40.8% of Billed Charges,1235.57,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,1092,100% of Asc Tier Groupings Fee Schedule,1235.57,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,1092,4398.62,2471.14
Outpatient Medical Services,SURGICAL CARE,47562,Removal of gallbladder using an endoscope,360,18942.73,14585.9,77% of Billed Charges,4830.4,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,4830.4,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,5919.6,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,2212,Pays Based On Per Visit,2102,Pays Based On Per Visit,2102,Pays Based On Per Visit,4735.68,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,2102,PER DIEM,1334,PER DIEM,2278,Pays Based On Per Visit,15533.04,Pays Based On Per Visit,4592,Pays Based On Per Visit,4458,Pays Based On Per Visit,4592,Pays Based On Per Visit,7728.63,40.8% of Billed Charges,7728.63,40.8% of Billed Charges,7728.63,40.8% of Billed Charges,4735.68,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,14585.9,77% of Billed Charges,16101.32,85% of Billed Charges,5446.03,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,4439,100% of Asc Tier Groupings,7728.63,40.8% of Billed Charges,4735.68,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,1092,100% of Asc Tier Groupings Fee Schedule,4735.68,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,1092,16101.32,9471.37
Outpatient Medical Services,SURGICAL CARE,49505,Repair of groin hernia patient age 5 years or older,360,11385.38,8766.74,77% of Billed Charges,2903.27,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,2903.27,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,3557.93,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,2212,Pays Based On Per Visit,2102,Pays Based On Per Visit,2102,Pays Based On Per Visit,2846.35,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,2102,PER DIEM,70.8,PER DIEM,2278,Pays Based On Per Visit,9336.01,Pays Based On Per Visit,4592,Pays Based On Per Visit,4458,Pays Based On Per Visit,4592,Pays Based On Per Visit,4645.24,40.8% of Billed Charges,4645.24,40.8% of Billed Charges,4645.24,40.8% of Billed Charges,2846.35,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,8766.74,77% of Billed Charges,9677.57,85% of Billed Charges,3273.3,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,3132,100% of Asc Tier Groupings,4645.24,40.8% of Billed Charges,2846.35,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,2291,100% of Asc Tier Groupings Fee Schedule,2846.35,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,70.8,9677.57,5692.69
Outpatient Medical Services,SURGICAL CARE,51700,Bladder irrigation and/or instillation,761,343.95,264.84,77% of Billed Charges,87.71,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,87.71,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,107.48,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,254.52,74% OF Billed Charges,237.33,69% of Billed Charges,237.33,69% of Billed charges,85.99,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,237.33,69% of Billed Charges,237.33,69% of Billed Charges,288.92,84% of Billed Charges,282.04,82% of Billed Charges,306.12,89% of Billed Charges,306.12,89% of Billed Charges,306.12,89% of Billed Charges,140.33,40.8% of Billed Charges,140.33,40.8% of Billed Charges,140.33,40.8% of Billed Charges,85.99,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,264.84,77% of Billed Charges,292.36,85% of Billed Charges,98.89,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,171.98,50% of Billed Charges,140.33,40.8% of Billed Charges,85.99,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,306.12,89% of Billed Charges,85.99,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,85.99,306.12,171.98
Outpatient Medical Services,SURGICAL CARE,51702,Insertion of temporary indwelling bladder catheter.,981,222.27,52.2,175% OF AETNA Fees Schedule,27.43,115% OF CMS Fees Schedule,27.98,117.3% OF ALLWELL Fees Schedule,34.28,143.75 OF AMBETTER Fees Schedule,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,27.43,115% of CMS Fees Schedule,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,29.93,100% of CIGNA Fees Schedule,29.42,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,28.14,100% of HEALTHLINK HMO  Fees Schedule,29.42,100% of HEALTHLINK PPO Fees Schedule,200.04,40.8% of Billed Charges,200.04,40.8% of Billed Charges,200.04,40.8% of Billed Charges,27.43,115% of CMS Fees Schedule,52.2,175% of MERITAIN Fee Schedule,42.51,178.25%  of MULTIPLAN/PHCS  Fee Schedule,31.54,132.25% of PPHP Fee schedule,52.54,100% of UHC Fee Schedule,200.04,40.8% of Billed Charges,27.43,115% of CMS Fee Schedule,4774,Pays Based On Per Visit,27.43,115% of VA Fee Schedule,27.43,4774,111.14
Outpatient Medical Services,SURGICAL CARE,51741,Uroflowmetry,360,2498.5,1923.85,77% of Billed Charges,637.12,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,637.12,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,780.78,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,1474.12,Pays Based On Per Visit,1334,Pays Based On Per Visit,1334,Pays Based On Per Visit,624.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,1334,PER DIEM,1334,PER DIEM,2098.74,Pays Based On Per Visit,2048.77,Pays Based On Per Visit,2223.67,Pays Based On Per Visit,2098.74,Pays Based On Per Visit,2223.67,Pays Based On Per Visit,17.27,120% of HEALTHY BLUE Fees Schedule,17.27,120% of HOMESTATE Fees Schedule,17.27,120% of MO Fee Schedule,624.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,1923.85,77% of Billed Charges,2123.73,85% of Billed Charges,718.32,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,436,100% of Asc Tier Groupings,17.27,120% of UHC COMMUNITY PLAN fee Schedule,624.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,140,Pays Based On Per Visit,624.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,17.27,2223.67,1249.25
Outpatient Medical Services,SURGICAL CARE,51798,"Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging",360,2498.5,1923.85,77% of Billed Charges,637.12,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,637.12,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,780.78,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,1474.12,Pays Based On Per Visit,1334,Pays Based On Per Visit,1334,Pays Based On Per Visit,624.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,1334,PER DIEM,110.92,PER DIEM,2098.74,Pays Based On Per Visit,2048.77,Pays Based On Per Visit,2223.67,Pays Based On Per Visit,2098.74,Pays Based On Per Visit,2223.67,Pays Based On Per Visit,1019.39,40.8% of Billed Charges,1019.39,40.8% of Billed Charges,1019.39,40.8% of Billed Charges,624.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,1923.85,77% of Billed Charges,2123.73,85% of Billed Charges,718.32,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,436,100% of Asc Tier Groupings,1019.39,40.8% of Billed Charges,624.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,386,Pays Based On Per Visit,624.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,110.92,2223.67,1249.25
Outpatient Medical Services,SURGICAL CARE,52000,cystourethroscopy,360,4995.42,3846.47,77% of Billed Charges,1273.83,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,1273.83,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,1561.07,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,1205,Pays Based On Per Visit,1168,Pays Based On Per Visit,1168,Pays Based On Per Visit,1248.86,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,1168,PER DIEM,802.31,PER DIEM,1269,Pays Based On Per Visit,4096.24,Pays Based On Per Visit,4445.92,Pays Based On Per Visit,4196.15,Pays Based On Per Visit,4445.92,Pays Based On Per Visit,2038.13,40.8% of Billed Charges,2038.13,40.8% of Billed Charges,2038.13,40.8% of Billed Charges,1248.86,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,3846.47,77% of Billed Charges,4246.11,85% of Billed Charges,1436.18,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,1261,100% of Asc Tier Groupings,2038.13,40.8% of Billed Charges,1248.86,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,777,Pays Based On Per Visit,1248.86,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,777,4445.92,2497.71
Outpatient Medical Services,SURGICAL CARE,53661,Dilation of female urethra including suppository and/or instillation.,360,120,92.4,77% of Billed Charges,30.6,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,30.6,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,37.5,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,70.8,Pays Based On Per Visit,70.8,Pays Based On Per Visit,70.8,Pays Based On Per Visit,30,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,70.8,PER DIEM,762.57,PER DIEM,100.8,Pays Based On Per Visit,98.4,Pays Based On Per Visit,106.8,Pays Based On Per Visit,100.8,Pays Based On Per Visit,106.8,Pays Based On Per Visit,48.96,40.8% of Billed Charges,48.96,40.8% of Billed Charges,48.96,40.8% of Billed Charges,30,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,92.4,77% of Billed Charges,102,85% of Billed Charges,34.5,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,436,100% of Asc Tier Groupings,48.96,40.8% of Billed Charges,30,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,182,Pays Based On Per Visit,30,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,30,762.57,60
Outpatient Medical Services,SURGICAL CARE,55700,Biopsy of prostate gland,360,7754.22,5970.75,77% of Billed Charges,1977.33,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,1977.33,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,2423.19,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,1495,Pays Based On Per Visit,1334,Pays Based On Per Visit,1334,Pays Based On Per Visit,1938.56,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,1334,PER DIEM,892.76,PER DIEM,6513.54,Pays Based On Per Visit,6358.46,Pays Based On Per Visit,4592,Pays Based On Per Visit,4458,Pays Based On Per Visit,4592,Pays Based On Per Visit,3163.72,40.8% of Billed Charges,3163.72,40.8% of Billed Charges,3163.72,40.8% of Billed Charges,1938.56,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,5970.75,77% of Billed Charges,6591.09,85% of Billed Charges,2229.34,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,2350,100% of Asc Tier Groupings,3163.72,40.8% of Billed Charges,1938.56,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,182,Pays Based On Per Visit,1938.56,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,182,6591.09,3877.11
Outpatient Medical Services,SURGICAL CARE,62322,Injection of substance into spinal canal of lower back or sacrum using imaging guidance,360,188,144.76,77% of Billed Charges,47.94,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,47.94,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,58.75,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,110.92,Pays Based On Per Visit,110.92,Pays Based On Per Visit,110.92,Pays Based On Per Visit,47,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,110.92,PER DIEM,176.99,PER DIEM,157.92,Pays Based On Per Visit,154.16,Pays Based On Per Visit,167.32,Pays Based On Per Visit,157.92,Pays Based On Per Visit,167.32,Pays Based On Per Visit,76.7,40.8% of Billed Charges,76.7,40.8% of Billed Charges,76.7,40.8% of Billed Charges,47,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,144.76,77% of Billed Charges,159.8,85% of Billed Charges,54.05,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,1261,100% of Asc Tier Groupings,76.7,40.8% of Billed Charges,47,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,182,Pays Based On Per Visit,47,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,47,1261,94
Outpatient Medical Services,SURGICAL CARE,62323,"INJ, DX OR THERAP SUB LMBR/SAC W/IMG",360,1359.85,1047.08,77% of Billed Charges,346.76,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,346.76,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,424.95,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,802.31,Pays Based On Per Visit,802.31,Pays Based On Per Visit,802.31,Pays Based On Per Visit,339.96,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,802.31,PER DIEM,146,PER DIEM,1142.27,Pays Based On Per Visit,1115.08,Pays Based On Per Visit,1210.27,Pays Based On Per Visit,1142.27,Pays Based On Per Visit,1210.27,Pays Based On Per Visit,554.82,40.8% of Billed Charges,554.82,40.8% of Billed Charges,554.82,40.8% of Billed Charges,339.96,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,1047.08,77% of Billed Charges,1155.87,85% of Billed Charges,390.96,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,1261,100% of Asc Tier Groupings,554.82,40.8% of Billed Charges,339.96,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,770,Pays Based On Per Visit,339.96,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,146,1261,679.93
Outpatient Medical Services,SURGICAL CARE,64483,Injections of anesthetic and/or steroid drug into lower or sacral spine nerve root using imaging guidance,360,1292.49,995.22,77% of Billed Charges,329.58,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,329.58,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,403.9,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,762.57,Pays Based On Per Visit,762.57,Pays Based On Per Visit,762.57,Pays Based On Per Visit,323.12,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,762.57,PER DIEM,146,PER DIEM,1085.69,Pays Based On Per Visit,1059.84,Pays Based On Per Visit,1150.32,Pays Based On Per Visit,1085.69,Pays Based On Per Visit,1150.32,Pays Based On Per Visit,527.34,40.8% of Billed Charges,527.34,40.8% of Billed Charges,527.34,40.8% of Billed Charges,323.12,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,995.22,77% of Billed Charges,1098.62,85% of Billed Charges,371.59,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,1261,100% of Asc Tier Groupings,527.34,40.8% of Billed Charges,323.12,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,770,Pays Based On Per Visit,323.12,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,146,1261,646.25
Outpatient Medical Services,SURGICAL CARE,66821,Removal of recurring cataract in lens capsule using laser,490,1513.16,1165.13,77% of Billed Charges,385.86,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,385.86,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,472.86,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,892.76,Pays Based On Per Visit,892.76,Pays Based On Per Visit,892.76,Pays Based On Per Visit,378.29,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,892.76,PER DIEM,146,PER DIEM,1271.05,Pays Based On Per Visit,1240.79,Pays Based On Per Visit,1346.71,Pays Based On Per Visit,1271.05,Pays Based On Per Visit,1346.71,Pays Based On Per Visit,617.37,40.8% of Billed Charges,617.37,40.8% of Billed Charges,617.37,40.8% of Billed Charges,378.29,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,1165.13,77% of Billed Charges,1286.19,85% of Billed Charges,435.03,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,1261,100% of Asc Tier Groupings,617.37,40.8% of Billed Charges,378.29,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,770,Pays Based On Per Visit,378.29,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,146,1346.71,756.58
Outpatient Medical Services,SURGICAL CARE,66984,Removal of cataract with insertion of lens,360,12912.23,9942.42,77% of Billed Charges,3292.62,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,3292.62,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,4035.07,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,2212,Pays Based On Per Visit,2102,Pays Based On Per Visit,2102,Pays Based On Per Visit,3228.06,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,2102,PER DIEM,146,PER DIEM,2278,Pays Based On Per Visit,10588.03,Pays Based On Per Visit,4592,Pays Based On Per Visit,4458,Pays Based On Per Visit,4592,Pays Based On Per Visit,5268.19,40.8% of Billed Charges,5268.19,40.8% of Billed Charges,5268.19,40.8% of Billed Charges,3228.06,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,9942.42,77% of Billed Charges,10975.4,85% of Billed Charges,3712.27,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,2647,100% of Asc Tier Groupings,5268.19,40.8% of Billed Charges,3228.06,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,770,Pays Based On Per Visit,3228.06,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,146,10975.4,6456.12
Outpatient Medical Services,DIAGNOSTIC IMAGING,70450,"CT scan, head or brain, without contrast",351,2209.5,1701.32,77% of Billed Charges,563.42,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,563.42,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,690.47,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,2116.52,350% of BCBS BLUE ACCESS Fees Schedule,1524.56,69% of Billed Charges,1524.56,69% of Billed charges,552.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,1524.56,69% of Billed Charges,1524.56,69% of Billed Charges,1855.98,84% of Billed Charges,1811.79,Pays Based On Per Visit,741.12,400% of HEALTHLINK COMPMANAGEMENT Fees Schedule,694.8,375% of HEALTHLINK HMO Fees Schedule,741.12,400% HEALTHLINK PPO Fees Schedule,159.72,120% of HEALTHY BLUE Fees Schedule,159.72,120% of HOMESTATE Fees Schedule,159.72,120% of MO Fee Schedule,552.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,1701.32,77% of Billed Charges,1878.08,85% of Billed Charges,635.23,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,889,Pays Based On Per Visit,159.72,120% of UHC COMMUNITY PLAN fee Schedule,552.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,770,Pays Based On Per Visit,552.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,159.72,2116.52,1104.75
Outpatient Medical Services,DIAGNOSTIC IMAGING,70551,Brain MRI,611,2787,2145.99,77% of Billed Charges,710.69,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,710.69,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,870.94,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,3385.18,295% of BCBS BLUE ACCESS Fees Schedule,3159.62,285% of BCBS BLUE ACCESS CHOICE Fees Schedule ,3159.62,285% of BCBS BLUE PREFFERED Fees Schedule,696.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,3159.62,285% of BCBS PATHWAY Fees Schedule,146,PER DIEM,3270.49,295% of BCBS TRADITIONAL Fees Schedule,2285.34,Pays Based On Per Visit,1999.8,400% of HEALTHLINK COMPMANAGEMENT Fees Schedule,1874.81,375% of HEALTHLINK HMO Fees Schedule,1999.8,400% HEALTHLINK PPO Fees Schedule,294.14,120% of HEALTHY BLUE Fees Schedule,294.14,120% of HOMESTATE Fees Schedule,294.14,120% of MO Fee Schedule,696.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,2145.99,77% of Billed Charges,2368.95,85% of Billed Charges,801.26,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,1479,Pays Based On Per Visit,294.14,120% of UHC COMMUNITY PLAN fee Schedule,696.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,770,Pays Based On Per Visit,696.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,146,3385.18,1393.5
Outpatient Medical Services,DIAGNOSTIC IMAGING,70553,MRI scan of brain before and after contrast,611,3968,3055.36,77% of Billed Charges,1011.84,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,1011.84,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,1240,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,5265.34,295% of BCBS BLUE ACCESS Fees Schedule,4914.4,285% of BCBS BLUE ACCESS CHOICE Fees Schedule ,4914.4,285% of BCBS BLUE PREFFERED Fees Schedule,992,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,4914.4,285% of BCBS PATHWAY Fees Schedule,146,PER DIEM,5086.83,295% of BCBS TRADITIONAL Fees Schedule,3253.76,Pays Based On Per Visit,2659.84,400% of HEALTHLINK COMPMANAGEMENT Fees Schedule,2493.6,375% of HEALTHLINK HMO Fees Schedule,2659.84,400% HEALTHLINK PPO Fees Schedule,575.05,120% of HEALTHY BLUE Fees Schedule,575.05,120% of HOMESTATE Fees Schedule,575.05,120% of MO Fee Schedule,992,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,3055.36,77% of Billed Charges,3372.8,85% of Billed Charges,1140.8,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,1479,Pays Based On Per Visit,575.05,120% of UHC COMMUNITY PLAN fee Schedule,992,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,770,Pays Based On Per Visit,992,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,146,5265.34,1984
Outpatient Medical Services,DIAGNOSTIC IMAGING,71045,Diagnostic Radiology (Diagnostic Imaging) Procedures of the Chest,324,392,301.84,77% of Billed Charges,99.96,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,99.96,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,122.5,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,290.08,74% OF Billed Charges,270.48,69% of Billed Charges,270.48,69% of Billed charges,98,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,270.48,69% of Billed Charges,270.48,69% of Billed Charges,329.28,84% of Billed Charges,321.44,Pays Based On Per Visit,348.88,89% of Billed Charges,348.88,89% of Billed Charges,348.88,89% of Billed Charges,15.48,120% of HEALTHY BLUE Fees Schedule,15.48,120% of HOMESTATE Fees Schedule,15.48,120% of MO Fee Schedule,98,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,301.84,77% of Billed Charges,333.2,85% of Billed Charges,112.7,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,271,Pays Based On Per Visit,15.48,120% of UHC COMMUNITY PLAN fee Schedule,98,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,770,Pays Based On Per Visit,98,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,15.48,770,196
Outpatient Medical Services,DIAGNOSTIC IMAGING,71046,Chest XRAY,324,406.5,313.01,77% of Billed Charges,103.66,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,103.66,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,127.03,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,300.81,74% OF Billed Charges,280.49,69% of Billed Charges,280.49,69% of Billed charges,101.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,280.49,69% of Billed Charges,280.49,69% of Billed Charges,341.46,84% of Billed Charges,333.33,Pays Based On Per Visit,361.79,89% of Billed Charges,361.79,89% of Billed Charges,361.79,89% of Billed Charges,20.95,120% of HEALTHY BLUE Fees Schedule,20.95,120% of HOMESTATE Fees Schedule,20.95,120% of MO Fee Schedule,101.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,313.01,77% of Billed Charges,345.53,85% of Billed Charges,116.87,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,271,Pays Based On Per Visit,20.95,120% of UHC COMMUNITY PLAN fee Schedule,101.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,770,Pays Based On Per Visit,101.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,20.95,770,203.25
Outpatient Medical Services,DIAGNOSTIC IMAGING,71101,"Radiologic examination, ribs, unilateral",320,426.5,328.41,77% of Billed Charges,108.76,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,108.76,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,133.28,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,315.61,74% OF Billed Charges,294.29,69% of Billed Charges,294.29,69% of Billed charges,106.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,294.29,69% of Billed Charges,294.29,69% of Billed Charges,358.26,84% of Billed Charges,349.73,Pays Based On Per Visit,136.16,400% of HEALTHLINK COMPMANAGEMENT Fees Schedule,127.65,375% of HEALTHLINK HMO Fees Schedule,136.16,400% HEALTHLINK PPO Fees Schedule,26.76,120% of HEALTHY BLUE Fees Schedule,26.76,120% of HOMESTATE Fees Schedule,26.76,120% of MO Fee Schedule,106.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,328.41,77% of Billed Charges,362.53,85% of Billed Charges,122.62,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,271,Pays Based On Per Visit,26.76,120% of UHC COMMUNITY PLAN fee Schedule,106.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,256,Pays Based On Per Visit,106.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,26.76,362.53,213.25
Outpatient Medical Services,DIAGNOSTIC IMAGING,71250,"CT, thorax; without contrast material",352,2209,1700.93,77% of Billed Charges,563.3,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,563.3,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,690.31,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,2644.5,350% of BCBS BLUE ACCESS Fees Schedule,1524.21,69% of Billed Charges,1524.21,69% of Billed charges,552.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,1524.21,69% of Billed Charges,1524.21,69% of Billed Charges,1855.56,84% of Billed Charges,1811.38,Pays Based On Per Visit,977.16,400% of HEALTHLINK COMPMANAGEMENT Fees Schedule,916.09,375% of HEALTHLINK HMO Fees Schedule,977.16,400% HEALTHLINK PPO Fees Schedule,179.52,120% of HEALTHY BLUE Fees Schedule,179.52,120% of HOMESTATE Fees Schedule,179.52,120% of MO Fee Schedule,552.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,1700.93,77% of Billed Charges,1877.65,85% of Billed Charges,635.09,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,889,Pays Based On Per Visit,179.52,120% of UHC COMMUNITY PLAN fee Schedule,552.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,476,Pays Based On Per Visit,552.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,179.52,2644.5,1104.5
Outpatient Medical Services,DIAGNOSTIC IMAGING,71260,CT Chest with contrast material,352,400.5,308.39,77% of Billed Charges,102.13,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,102.13,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,125.16,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,3408.44,350% of BCBS BLUE ACCESS Fees Schedule,276.35,69% of Billed Charges,276.35,69% of Billed charges,100.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,276.35,69% of Billed Charges,276.35,69% of Billed Charges,336.42,84% of Billed Charges,328.41,Pays Based On Per Visit,1177.36,400% of HEALTHLINK COMPMANAGEMENT Fees Schedule,1103.78,375% of HEALTHLINK HMO Fees Schedule,1177.36,400% HEALTHLINK PPO Fees Schedule,258.72,120% of HEALTHY BLUE Fees Schedule,258.72,120% of HOMESTATE Fees Schedule,258.72,120% of MO Fee Schedule,100.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,308.39,77% of Billed Charges,340.43,85% of Billed Charges,115.14,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,889,Pays Based On Per Visit,258.72,120% of UHC COMMUNITY PLAN fee Schedule,100.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,637,Pays Based On Per Visit,100.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,100.13,3408.44,200.25
Outpatient Medical Services,DIAGNOSTIC IMAGING,71271,"Computed tomography, thorax, low dose for lung cancer screening, without contrast",352,2145,1651.65,77% of Billed Charges,546.98,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,546.98,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,670.31,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,1026.27,350% of BCBS BLUE ACCESS Fees Schedule,1480.05,69% of Billed Charges,1480.05,69% of Billed charges,536.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,1480.05,69% of Billed Charges,1480.05,69% of Billed Charges,1801.8,84% of Billed Charges,1758.9,Pays Based On Per Visit,1909.05,89% of Billed Charges,1909.05,89% of Billed Charges,1909.05,89% of Billed Charges,136.48,120% of HEALTHY BLUE Fees Schedule,136.48,120% of HOMESTATE Fees Schedule,136.48,120% of MO Fee Schedule,536.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,1651.65,77% of Billed Charges,1823.25,85% of Billed Charges,616.69,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,889,Pays Based On Per Visit,136.48,120% of UHC COMMUNITY PLAN fee Schedule,536.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,864,Pays Based On Per Visit,536.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,136.48,1909.05,1072.5
Outpatient Medical Services,DIAGNOSTIC IMAGING,71275,CTA of noncoronary chest vessels such as the aorta and pulmonary arteries.,352,2936,2260.72,77% of Billed Charges,748.68,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,748.68,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,917.5,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,4612.34,350% of BCBS BLUE ACCESS Fees Schedule,2025.84,69% of Billed Charges,2025.84,69% of Billed charges,734,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,2025.84,69% of Billed Charges,2025.84,69% of Billed Charges,2466.24,84% of Billed Charges,2407.52,Pays Based On Per Visit,1721.12,400% of HEALTHLINK COMPMANAGEMENT Fees Schedule,1613.55,375% of HEALTHLINK HMO Fees Schedule,1721.12,400% HEALTHLINK PPO Fees Schedule,298.48,120% of HEALTHY BLUE Fees Schedule,298.48,120% of HOMESTATE Fees Schedule,298.48,120% of MO Fee Schedule,734,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,2260.72,77% of Billed Charges,2495.6,85% of Billed Charges,844.1,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,889,Pays Based On Per Visit,298.48,120% of UHC COMMUNITY PLAN fee Schedule,734,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,1368,Pays Based On Per Visit,734,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,298.48,4612.34,1468
Outpatient Medical Services,DIAGNOSTIC IMAGING,72040,"Radiologic examination, spine, cervical; two or three views",320,464.5,357.67,77% of Billed Charges,118.45,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,118.45,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,145.16,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,343.73,74% OF Billed Charges,320.51,69% of Billed Charges,320.51,69% of Billed charges,116.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,320.51,69% of Billed Charges,320.51,69% of Billed Charges,390.18,84% of Billed Charges,380.89,Pays Based On Per Visit,128.92,400% of HEALTHLINK COMPMANAGEMENT Fees Schedule,120.86,375% of HEALTHLINK HMO Fees Schedule,128.92,400% HEALTHLINK PPO Fees Schedule,26.12,120% of HEALTHY BLUE Fees Schedule,26.12,120% of HOMESTATE Fees Schedule,26.12,120% of MO Fee Schedule,116.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,357.67,77% of Billed Charges,394.83,85% of Billed Charges,133.54,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,271,Pays Based On Per Visit,26.12,120% of UHC COMMUNITY PLAN fee Schedule,116.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,3662,Pays Based On Per Visit,116.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,26.12,3662,232.25
Outpatient Medical Services,DIAGNOSTIC IMAGING,72050,"Radiologic examination, spine, cervical; minimum of four views",320,680.5,523.99,77% of Billed Charges,173.53,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,173.53,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,212.66,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,503.57,74% OF Billed Charges,469.55,69% of Billed Charges,469.55,69% of Billed charges,170.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,469.55,69% of Billed Charges,469.55,69% of Billed Charges,571.62,84% of Billed Charges,558.01,Pays Based On Per Visit,181.52,400% of HEALTHLINK COMPMANAGEMENT Fees Schedule,170.18,375% of HEALTHLINK HMO Fees Schedule,181.52,400% HEALTHLINK PPO Fees Schedule,36.46,120% of HEALTHY BLUE Fees Schedule,36.46,120% of HOMESTATE Fees Schedule,36.46,120% of MO Fee Schedule,170.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,523.99,77% of Billed Charges,578.43,85% of Billed Charges,195.64,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,271,Pays Based On Per Visit,36.46,120% of UHC COMMUNITY PLAN fee Schedule,170.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,439,Pays Based On Per Visit,170.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,36.46,578.43,340.25
Outpatient Medical Services,DIAGNOSTIC IMAGING,72100,"Radiologic examination, spine, lumbosacral",320,495,381.15,77% of Billed Charges,126.23,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,126.23,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,154.69,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,366.3,74% OF Billed Charges,341.55,69% of Billed Charges,341.55,69% of Billed charges,123.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,341.55,69% of Billed Charges,341.55,69% of Billed Charges,415.8,84% of Billed Charges,405.9,Pays Based On Per Visit,133.68,400% of HEALTHLINK COMPMANAGEMENT Fees Schedule,125.33,375% of HEALTHLINK HMO Fees Schedule,133.68,400% HEALTHLINK PPO Fees Schedule,26.41,120% of HEALTHY BLUE Fees Schedule,26.41,120% of HOMESTATE Fees Schedule,26.41,120% of MO Fee Schedule,123.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,381.15,77% of Billed Charges,420.75,85% of Billed Charges,142.31,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,271,Pays Based On Per Visit,26.41,120% of UHC COMMUNITY PLAN fee Schedule,123.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,123.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,26.41,420.75,247.5
Outpatient Medical Services,DIAGNOSTIC IMAGING,72110,"X-Ray, lower back, minimum four views",320,600.5,462.39,77% of Billed Charges,153.13,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,153.13,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,187.66,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,444.37,74% OF Billed Charges,414.35,69% of Billed Charges,414.35,69% of Billed charges,150.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,414.35,69% of Billed Charges,414.35,69% of Billed Charges,504.42,84% of Billed Charges,492.41,Pays Based On Per Visit,189.8,400% of HEALTHLINK COMPMANAGEMENT Fees Schedule,177.94,375% of HEALTHLINK HMO Fees Schedule,189.8,400% HEALTHLINK PPO Fees Schedule,35.23,120% of HEALTHY BLUE Fees Schedule,35.23,120% of HOMESTATE Fees Schedule,35.23,120% of MO Fee Schedule,150.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,462.39,77% of Billed Charges,510.43,85% of Billed Charges,172.64,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,271,Pays Based On Per Visit,35.23,120% of UHC COMMUNITY PLAN fee Schedule,150.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,150.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,35.23,510.43,300.25
Outpatient Medical Services,DIAGNOSTIC IMAGING,72131,CT Lumbar Spine,352,2216,1706.32,77% of Billed Charges,565.08,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,565.08,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,692.5,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,2644.5,350% of BCBS BLUE ACCESS Fees Schedule,1529.04,69% of Billed Charges,1529.04,69% of Billed charges,554,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,1529.04,69% of Billed Charges,1529.04,69% of Billed Charges,1861.44,84% of Billed Charges,1817.12,Pays Based On Per Visit,973.6,400% of HEALTHLINK COMPMANAGEMENT Fees Schedule,912.75,375% of HEALTHLINK HMO Fees Schedule,973.6,400% HEALTHLINK PPO Fees Schedule,180.88,120% of HEALTHY BLUE Fees Schedule,180.88,120% of HOMESTATE Fees Schedule,180.88,120% of MO Fee Schedule,554,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,1706.32,77% of Billed Charges,1883.6,85% of Billed Charges,637.1,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,889,Pays Based On Per Visit,180.88,120% of UHC COMMUNITY PLAN fee Schedule,554,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,554,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,2644.5,1108
Outpatient Medical Services,DIAGNOSTIC IMAGING,72141,MRI cervical spine,612,3016.5,2322.71,77% of Billed Charges,769.21,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,769.21,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,942.66,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,3381.88,295% of BCBS BLUE ACCESS Fees Schedule,3156.52,285% of BCBS BLUE ACCESS CHOICE Fees Schedule ,3156.52,285% of BCBS BLUE PREFFERED Fees Schedule,754.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,3156.52,285% of BCBS PATHWAY Fees Schedule,146,PER DIEM,3267.27,295% of BCBS TRADITIONAL Fees Schedule,2473.53,Pays Based On Per Visit,1784.96,400% of HEALTHLINK COMPMANAGEMENT Fees Schedule,1673.4,375% of HEALTHLINK HMO Fees Schedule,1784.96,400% HEALTHLINK PPO Fees Schedule,282.67,120% of HEALTHY BLUE Fees Schedule,282.67,120% of HOMESTATE Fees Schedule,282.67,120% of MO Fee Schedule,754.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,2322.71,77% of Billed Charges,2564.03,85% of Billed Charges,867.24,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,1479,Pays Based On Per Visit,282.67,120% of UHC COMMUNITY PLAN fee Schedule,754.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,754.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,3381.88,1508.25
Outpatient Medical Services,DIAGNOSTIC IMAGING,72148,MRI scan of lower spinal canal,612,3063.5,2358.9,77% of Billed Charges,781.19,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,781.19,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,957.34,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,3381.88,295% of BCBS BLUE ACCESS Fees Schedule,3156.52,285% of BCBS BLUE ACCESS CHOICE Fees Schedule ,3156.52,285% of BCBS BLUE PREFFERED Fees Schedule,765.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,3156.52,285% of BCBS PATHWAY Fees Schedule,146,PER DIEM,3267.27,295% of BCBS TRADITIONAL Fees Schedule,2512.07,Pays Based On Per Visit,1768.92,400% of HEALTHLINK COMPMANAGEMENT Fees Schedule,1658.36,375% of HEALTHLINK HMO Fees Schedule,1768.92,400% HEALTHLINK PPO Fees Schedule,306.07,120% of HEALTHY BLUE Fees Schedule,306.07,120% of HOMESTATE Fees Schedule,306.07,120% of MO Fee Schedule,765.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,2358.9,77% of Billed Charges,2603.98,85% of Billed Charges,880.76,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,1479,Pays Based On Per Visit,306.07,120% of UHC COMMUNITY PLAN fee Schedule,765.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,765.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,3381.88,1531.75
Outpatient Medical Services,DIAGNOSTIC IMAGING,72193,"CT scan, pelvis, with contrast",350,2552.5,1965.43,77% of Billed Charges,650.89,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,650.89,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,797.66,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,3237.08,350% of BCBS BLUE ACCESS Fees Schedule,1761.23,69% of Billed Charges,1761.23,69% of Billed charges,638.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,1761.23,69% of Billed Charges,1761.23,69% of Billed Charges,2144.1,84% of Billed Charges,2093.05,Pays Based On Per Visit,1112.24,400% of HEALTHLINK COMPMANAGEMENT Fees Schedule,1042.73,375% of HEALTHLINK HMO Fees Schedule,1112.24,400% HEALTHLINK PPO Fees Schedule,268.92,120% of HEALTHY BLUE Fees Schedule,268.92,120% of HOMESTATE Fees Schedule,268.92,120% of MO Fee Schedule,638.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,1965.43,77% of Billed Charges,2169.63,85% of Billed Charges,733.84,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,889,Pays Based On Per Visit,268.92,120% of UHC COMMUNITY PLAN fee Schedule,638.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,638.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,3237.08,1276.25
Outpatient Medical Services,DIAGNOSTIC IMAGING,73030,"Radiologic examination, shoulder",320,333.5,256.8,77% of Billed Charges,85.04,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,85.04,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,104.22,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,246.79,74% OF Billed Charges,230.12,69% of Billed Charges,230.12,69% of Billed charges,83.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,230.12,69% of Billed Charges,230.12,69% of Billed Charges,280.14,84% of Billed Charges,273.47,Pays Based On Per Visit,100.64,400% of HEALTHLINK COMPMANAGEMENT Fees Schedule,94.35,375% of HEALTHLINK HMO Fees Schedule,100.64,400% HEALTHLINK PPO Fees Schedule,23.08,120% of HEALTHY BLUE Fees Schedule,23.08,120% of HOMESTATE Fees Schedule,23.08,120% of MO Fee Schedule,83.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,256.8,77% of Billed Charges,283.48,85% of Billed Charges,95.88,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,271,Pays Based On Per Visit,23.08,120% of UHC COMMUNITY PLAN fee Schedule,83.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,83.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,23.08,283.48,166.75
Outpatient Medical Services,DIAGNOSTIC IMAGING,73080,"Radiologic examination, elbow",320,308.5,237.55,77% of Billed Charges,78.67,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,78.67,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,96.41,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,228.29,74% OF Billed Charges,212.87,69% of Billed Charges,212.87,69% of Billed charges,77.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,212.87,69% of Billed Charges,212.87,69% of Billed Charges,259.14,84% of Billed Charges,252.97,Pays Based On Per Visit,120.52,400% of HEALTHLINK COMPMANAGEMENT Fees Schedule,112.99,375% of HEALTHLINK HMO Fees Schedule,120.52,400% HEALTHLINK PPO Fees Schedule,21.86,120% of HEALTHY BLUE Fees Schedule,21.86,120% of HOMESTATE Fees Schedule,21.86,120% of MO Fee Schedule,77.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,237.55,77% of Billed Charges,262.23,85% of Billed Charges,88.69,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,271,Pays Based On Per Visit,21.86,120% of UHC COMMUNITY PLAN fee Schedule,77.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,77.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,21.86,271,154.25
Outpatient Medical Services,DIAGNOSTIC IMAGING,73110,"Radiologic examination, wrist",320,341.5,262.96,77% of Billed Charges,87.08,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,87.08,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,106.72,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,252.71,74% OF Billed Charges,235.64,69% of Billed Charges,235.64,69% of Billed charges,85.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,235.64,69% of Billed Charges,235.64,69% of Billed Charges,286.86,84% of Billed Charges,280.03,Pays Based On Per Visit,118.84,400% of HEALTHLINK COMPMANAGEMENT Fees Schedule,111.41,375% of HEALTHLINK HMO Fees Schedule,118.84,400% HEALTHLINK PPO Fees Schedule,29.46,120% of HEALTHY BLUE Fees Schedule,29.46,120% of HOMESTATE Fees Schedule,29.46,120% of MO Fee Schedule,85.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,262.96,77% of Billed Charges,290.28,85% of Billed Charges,98.18,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,271,Pays Based On Per Visit,29.46,120% of UHC COMMUNITY PLAN fee Schedule,85.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,85.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,29.46,290.28,170.75
Outpatient Medical Services,DIAGNOSTIC IMAGING,73130,Diagnostic Radiology (Diagnostic Imaging) Procedures of the Upper Extremities,320,308.5,237.55,77% of Billed Charges,78.67,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,78.67,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,96.41,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,228.29,74% OF Billed Charges,212.87,69% of Billed Charges,212.87,69% of Billed charges,77.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,212.87,69% of Billed Charges,212.87,69% of Billed Charges,259.14,84% of Billed Charges,252.97,Pays Based On Per Visit,105.8,400% of HEALTHLINK COMPMANAGEMENT Fees Schedule,99.19,375% of HEALTHLINK HMO Fees Schedule,105.8,400% HEALTHLINK PPO Fees Schedule,25.51,120% of HEALTHY BLUE Fees Schedule,25.51,120% of HOMESTATE Fees Schedule,25.51,120% of MO Fee Schedule,77.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,237.55,77% of Billed Charges,262.23,85% of Billed Charges,88.69,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,271,Pays Based On Per Visit,25.51,120% of UHC COMMUNITY PLAN fee Schedule,77.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,77.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,25.51,271,154.25
Outpatient Medical Services,DIAGNOSTIC IMAGING,73221,"Magnetic resonance (eg, proton) imaging, any joint of upper extremity; without contrast material(s)",614,3159,2432.43,77% of Billed Charges,805.55,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,805.55,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,987.19,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,3385.18,295% of BCBS BLUE ACCESS Fees Schedule,3159.62,285% of BCBS BLUE ACCESS CHOICE Fees Schedule ,3159.62,285% of BCBS BLUE PREFFERED Fees Schedule,789.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,3159.62,285% of BCBS PATHWAY Fees Schedule,146,PER DIEM,3270.49,295% of BCBS TRADITIONAL Fees Schedule,2590.38,Pays Based On Per Visit,1843.04,400% of HEALTHLINK COMPMANAGEMENT Fees Schedule,1727.85,375% of HEALTHLINK HMO Fees Schedule,1843.04,400% HEALTHLINK PPO Fees Schedule,285.22,120% of HEALTHY BLUE Fees Schedule,285.22,120% of HOMESTATE Fees Schedule,285.22,120% of MO Fee Schedule,789.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,2432.43,77% of Billed Charges,2685.15,85% of Billed Charges,908.21,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,1479,Pays Based On Per Visit,285.22,120% of UHC COMMUNITY PLAN fee Schedule,789.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,789.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,3385.18,1579.5
Outpatient Medical Services,DIAGNOSTIC IMAGING,73501,"Radiologic examination, hip, unilateral.",320,385.5,296.84,77% of Billed Charges,98.3,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,98.3,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,120.47,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,285.27,74% OF Billed Charges,266,69% of Billed Charges,266,69% of Billed charges,96.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,266,69% of Billed Charges,266,69% of Billed Charges,323.82,84% of Billed Charges,316.11,Pays Based On Per Visit,343.1,89% of Billed Charges,343.1,89% of Billed Charges,343.1,89% of Billed Charges,21.25,120% of HEALTHY BLUE Fees Schedule,21.25,120% of HOMESTATE Fees Schedule,21.25,120% of MO Fee Schedule,96.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,296.84,77% of Billed Charges,327.68,85% of Billed Charges,110.83,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,271,Pays Based On Per Visit,21.25,120% of UHC COMMUNITY PLAN fee Schedule,96.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,96.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,21.25,343.1,192.75
Outpatient Medical Services,DIAGNOSTIC IMAGING,73502,"Radiologic examination, hip, unilateral.",320,554,426.58,77% of Billed Charges,141.27,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,141.27,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,173.13,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,409.96,74% OF Billed Charges,382.26,69% of Billed Charges,382.26,69% of Billed charges,138.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,382.26,69% of Billed Charges,382.26,69% of Billed Charges,465.36,84% of Billed Charges,454.28,Pays Based On Per Visit,493.06,89% of Billed Charges,493.06,89% of Billed Charges,493.06,89% of Billed Charges,32.81,120% of HEALTHY BLUE Fees Schedule,32.81,120% of HOMESTATE Fees Schedule,32.81,120% of MO Fee Schedule,138.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,426.58,77% of Billed Charges,470.9,85% of Billed Charges,159.28,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,271,Pays Based On Per Visit,32.81,120% of UHC COMMUNITY PLAN fee Schedule,138.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,138.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,32.81,493.06,277
Outpatient Medical Services,DIAGNOSTIC IMAGING,73523,"Radiologic examination, hips, bilateral.",320,535,411.95,77% of Billed Charges,136.43,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,136.43,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,167.19,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,395.9,74% OF Billed Charges,369.15,69% of Billed Charges,369.15,69% of Billed charges,133.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,369.15,69% of Billed Charges,369.15,69% of Billed Charges,449.4,84% of Billed Charges,438.7,Pays Based On Per Visit,476.15,89% of Billed Charges,476.15,89% of Billed Charges,476.15,89% of Billed Charges,42.23,120% of HEALTHY BLUE Fees Schedule,42.23,120% of HOMESTATE Fees Schedule,42.23,120% of MO Fee Schedule,133.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,411.95,77% of Billed Charges,454.75,85% of Billed Charges,153.81,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,271,Pays Based On Per Visit,42.23,120% of UHC COMMUNITY PLAN fee Schedule,133.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,133.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,42.23,476.15,267.5
Outpatient Medical Services,DIAGNOSTIC IMAGING,73564,complete radiological knee exam with four or more views,320,414,318.78,77% of Billed Charges,105.57,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,105.57,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,129.38,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,306.36,74% OF Billed Charges,285.66,69% of Billed Charges,285.66,69% of Billed charges,103.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,285.66,69% of Billed Charges,285.66,69% of Billed Charges,347.76,84% of Billed Charges,339.48,Pays Based On Per Visit,139.6,400% of HEALTHLINK COMPMANAGEMENT Fees Schedule,130.88,375% of HEALTHLINK HMO Fees Schedule,139.6,400% HEALTHLINK PPO Fees Schedule,32.2,120% of HEALTHY BLUE Fees Schedule,32.2,120% of HOMESTATE Fees Schedule,32.2,120% of MO Fee Schedule,103.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,318.78,77% of Billed Charges,351.9,85% of Billed Charges,119.03,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,271,Pays Based On Per Visit,32.2,120% of UHC COMMUNITY PLAN fee Schedule,103.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,103.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,32.2,351.9,207
Outpatient Medical Services,DIAGNOSTIC IMAGING,73590,Xray of lower leg,320,302,232.54,77% of Billed Charges,77.01,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,77.01,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,94.38,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,223.48,74% OF Billed Charges,208.38,69% of Billed Charges,208.38,69% of Billed charges,75.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,208.38,69% of Billed Charges,208.38,69% of Billed Charges,253.68,84% of Billed Charges,247.64,Pays Based On Per Visit,91.6,400% of HEALTHLINK COMPMANAGEMENT Fees Schedule,85.88,375% of HEALTHLINK HMO Fees Schedule,91.6,400% HEALTHLINK PPO Fees Schedule,21.55,120% of HEALTHY BLUE Fees Schedule,21.55,120% of HOMESTATE Fees Schedule,21.55,120% of MO Fee Schedule,75.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,232.54,77% of Billed Charges,256.7,85% of Billed Charges,86.83,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,271,Pays Based On Per Visit,21.55,120% of UHC COMMUNITY PLAN fee Schedule,75.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,75.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,21.55,271,151
Outpatient Medical Services,DIAGNOSTIC IMAGING,73610,"Radiologic examination, ankle",320,308.5,237.55,77% of Billed Charges,78.67,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,78.67,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,96.41,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,228.29,74% OF Billed Charges,212.87,69% of Billed Charges,212.87,69% of Billed charges,77.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,212.87,69% of Billed Charges,212.87,69% of Billed Charges,259.14,84% of Billed Charges,252.97,Pays Based On Per Visit,107,400% of HEALTHLINK COMPMANAGEMENT Fees Schedule,100.31,375% of HEALTHLINK HMO Fees Schedule,107,400% HEALTHLINK PPO Fees Schedule,25.81,120% of HEALTHY BLUE Fees Schedule,25.81,120% of HOMESTATE Fees Schedule,25.81,120% of MO Fee Schedule,77.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,237.55,77% of Billed Charges,262.23,85% of Billed Charges,88.69,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,271,Pays Based On Per Visit,25.81,120% of UHC COMMUNITY PLAN fee Schedule,77.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,77.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,25.81,271,154.25
Outpatient Medical Services,DIAGNOSTIC IMAGING,73630,Diagnostic Radiology (Diagnostic Imaging) Procedures of the Lower Extremities,320,308.5,237.55,77% of Billed Charges,78.67,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,78.67,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,96.41,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,228.29,74% OF Billed Charges,212.87,69% of Billed Charges,212.87,69% of Billed charges,77.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,212.87,69% of Billed Charges,212.87,69% of Billed Charges,259.14,84% of Billed Charges,252.97,Pays Based On Per Visit,104.64,400% of HEALTHLINK COMPMANAGEMENT Fees Schedule,98.1,375% of HEALTHLINK HMO Fees Schedule,104.64,400% HEALTHLINK PPO Fees Schedule,23.99,120% of HEALTHY BLUE Fees Schedule,23.99,120% of HOMESTATE Fees Schedule,23.99,120% of MO Fee Schedule,77.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,237.55,77% of Billed Charges,262.23,85% of Billed Charges,88.69,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,271,Pays Based On Per Visit,23.99,120% of UHC COMMUNITY PLAN fee Schedule,77.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,77.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,23.99,271,154.25
Outpatient Medical Services,DIAGNOSTIC IMAGING,73721,MRI scan of leg joint,614,3159,2432.43,77% of Billed Charges,805.55,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,805.55,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,987.19,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,3385.18,295% of BCBS BLUE ACCESS Fees Schedule,3159.62,285% of BCBS BLUE ACCESS CHOICE Fees Schedule ,3159.62,285% of BCBS BLUE PREFFERED Fees Schedule,789.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,3159.62,285% of BCBS PATHWAY Fees Schedule,146,PER DIEM,3270.49,295% of BCBS TRADITIONAL Fees Schedule,2590.38,Pays Based On Per Visit,1880.96,400% of HEALTHLINK COMPMANAGEMENT Fees Schedule,1763.4,375% of HEALTHLINK HMO Fees Schedule,1880.96,400% HEALTHLINK PPO Fees Schedule,286.88,120% of HEALTHY BLUE Fees Schedule,286.88,120% of HOMESTATE Fees Schedule,286.88,120% of MO Fee Schedule,789.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,2432.43,77% of Billed Charges,2685.15,85% of Billed Charges,908.21,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,1479,Pays Based On Per Visit,286.88,120% of UHC COMMUNITY PLAN fee Schedule,789.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,789.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,3385.18,1579.5
Outpatient Medical Services,DIAGNOSTIC IMAGING,74018,"Radiologic examination, abdomen",320,287,220.99,77% of Billed Charges,73.19,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,73.19,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,89.69,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,212.38,74% OF Billed Charges,198.03,69% of Billed Charges,198.03,69% of Billed charges,71.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,198.03,69% of Billed Charges,198.03,69% of Billed Charges,241.08,84% of Billed Charges,235.34,Pays Based On Per Visit,255.43,89% of Billed Charges,255.43,89% of Billed Charges,255.43,89% of Billed Charges,19.43,120% of HEALTHY BLUE Fees Schedule,19.43,120% of HOMESTATE Fees Schedule,19.43,120% of MO Fee Schedule,71.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,220.99,77% of Billed Charges,243.95,85% of Billed Charges,82.51,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,271,Pays Based On Per Visit,19.43,120% of UHC COMMUNITY PLAN fee Schedule,71.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,71.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,19.43,271,143.5
Outpatient Medical Services,DIAGNOSTIC IMAGING,74022,"Radiologic examination, abdomen",320,488,375.76,77% of Billed Charges,124.44,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,124.44,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,152.5,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,361.12,74% OF Billed Charges,336.72,69% of Billed Charges,336.72,69% of Billed charges,122,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,336.72,69% of Billed Charges,336.72,69% of Billed Charges,409.92,84% of Billed Charges,400.16,Pays Based On Per Visit,170.84,400% of HEALTHLINK COMPMANAGEMENT Fees Schedule,160.16,375% of HEALTHLINK HMO Fees Schedule,170.84,400% HEALTHLINK PPO Fees Schedule,33.17,120% of HEALTHY BLUE Fees Schedule,33.17,120% of HOMESTATE Fees Schedule,33.17,120% of MO Fee Schedule,122,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,375.76,77% of Billed Charges,414.8,85% of Billed Charges,140.3,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,271,Pays Based On Per Visit,33.17,120% of UHC COMMUNITY PLAN fee Schedule,122,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,122,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,33.17,414.8,244
Outpatient Medical Services,DIAGNOSTIC IMAGING,74176,CT Abdoment Pelvis without contrast,352,4677,3601.29,77% of Billed Charges,1192.64,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,1192.64,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,1461.56,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,1797.18,350% of BCBS BLUE ACCESS Fees Schedule,3227.13,69% of Billed Charges,3227.13,69% of Billed charges,1169.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,3227.13,69% of Billed Charges,3227.13,69% of Billed Charges,3928.68,84% of Billed Charges,3835.14,Pays Based On Per Visit,4162.53,89% of Billed Charges,4162.53,89% of Billed Charges,4162.53,89% of Billed Charges,98.63,120% of HEALTHY BLUE Fees Schedule,98.63,120% of HOMESTATE Fees Schedule,98.63,120% of MO Fee Schedule,1169.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,3601.29,77% of Billed Charges,3975.45,85% of Billed Charges,1344.64,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,889,Pays Based On Per Visit,98.63,120% of UHC COMMUNITY PLAN fee Schedule,1169.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,1169.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,4162.53,2338.5
Outpatient Medical Services,DIAGNOSTIC IMAGING,74177,CT scan of abdomen and pelvis with contrast,352,4890.5,3765.69,77% of Billed Charges,1247.08,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,1247.08,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,1528.28,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,3427.03,350% of BCBS BLUE ACCESS Fees Schedule,3374.45,69% of Billed Charges,3374.45,69% of Billed charges,1222.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,3374.45,69% of Billed Charges,3374.45,69% of Billed Charges,4108.02,84% of Billed Charges,4010.21,Pays Based On Per Visit,4352.55,89% of Billed Charges,4352.55,89% of Billed Charges,4352.55,89% of Billed Charges,214.56,120% of HEALTHY BLUE Fees Schedule,214.56,120% of HOMESTATE Fees Schedule,214.56,120% of MO Fee Schedule,1222.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,3765.69,77% of Billed Charges,4156.93,85% of Billed Charges,1406.02,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,889,Pays Based On Per Visit,214.56,120% of UHC COMMUNITY PLAN fee Schedule,1222.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,1222.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,4352.55,2445.25
Outpatient Medical Services,DIAGNOSTIC IMAGING,76000,Cholesterol Lab Test,320,335,257.95,77% of Billed Charges,85.43,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,85.43,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,104.69,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,247.9,74% OF Billed Charges,231.15,69% of Billed Charges,231.15,69% of Billed charges,83.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,231.15,69% of Billed Charges,231.15,69% of Billed Charges,281.4,84% of Billed Charges,274.7,Pays Based On Per Visit,358.16,400% of HEALTHLINK COMPMANAGEMENT Fees Schedule,335.78,375% of HEALTHLINK HMO Fees Schedule,358.16,400% HEALTHLINK PPO Fees Schedule,56.15,120% of HEALTHY BLUE Fees Schedule,56.15,120% of HOMESTATE Fees Schedule,56.15,120% of MO Fee Schedule,83.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,257.95,77% of Billed Charges,284.75,85% of Billed Charges,96.31,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,271,Pays Based On Per Visit,56.15,120% of UHC COMMUNITY PLAN fee Schedule,83.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,83.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,358.16,167.5
Outpatient Medical Services,DIAGNOSTIC IMAGING,76536,Diagnostic Ultrasound Procedures of the Head and Neck,402,751.5,578.66,77% of Billed Charges,191.63,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,191.63,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,234.84,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,556.11,74% OF Billed Charges,518.54,69% of Billed Charges,518.54,69% of Billed charges,187.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,518.54,69% of Billed Charges,518.54,69% of Billed Charges,631.26,84% of Billed Charges,616.23,Pays Based On Per Visit,409.04,400% of HEALTHLINK COMPMANAGEMENT Fees Schedule,383.48,375% of HEALTHLINK HMO Fees Schedule,409.04,400% HEALTHLINK PPO Fees Schedule,77.8,120% of HEALTHY BLUE Fees Schedule,77.8,120% of HOMESTATE Fees Schedule,77.8,120% of MO Fee Schedule,187.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,578.66,77% of Billed Charges,638.78,85% of Billed Charges,216.06,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,446,Pays Based On Per Visit,77.8,120% of UHC COMMUNITY PLAN fee Schedule,187.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,187.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,638.78,375.75
Outpatient Medical Services,DIAGNOSTIC IMAGING,76641,"Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete",402,828.5,637.95,77% of Billed Charges,211.27,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,211.27,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,258.91,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,613.09,74% OF Billed Charges,571.67,69% of Billed Charges,571.67,69% of Billed charges,207.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,571.67,69% of Billed Charges,571.67,69% of Billed Charges,695.94,84% of Billed Charges,679.37,Pays Based On Per Visit,737.37,89% of Billed Charges,737.37,89% of Billed Charges,737.37,89% of Billed Charges,62.9,120% of HEALTHY BLUE Fees Schedule,62.9,120% of HOMESTATE Fees Schedule,62.9,120% of MO Fee Schedule,207.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,637.95,77% of Billed Charges,704.23,85% of Billed Charges,238.19,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,446,Pays Based On Per Visit,62.9,120% of UHC COMMUNITY PLAN fee Schedule,207.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,207.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,737.37,414.25
Outpatient Medical Services,DIAGNOSTIC IMAGING,76642,"Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed",402,621.5,478.56,77% of Billed Charges,158.48,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,158.48,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,194.22,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,459.91,74% OF Billed Charges,428.84,69% of Billed Charges,428.84,69% of Billed charges,155.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,428.84,69% of Billed Charges,428.84,69% of Billed Charges,522.06,84% of Billed Charges,509.63,Pays Based On Per Visit,553.14,89% of Billed Charges,553.14,89% of Billed Charges,553.14,89% of Billed Charges,48.01,120% of HEALTHY BLUE Fees Schedule,48.01,120% of HOMESTATE Fees Schedule,48.01,120% of MO Fee Schedule,155.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,478.56,77% of Billed Charges,528.28,85% of Billed Charges,178.68,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,446,Pays Based On Per Visit,48.01,120% of UHC COMMUNITY PLAN fee Schedule,155.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,155.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,48.01,553.14,310.75
Outpatient Medical Services,DIAGNOSTIC IMAGING,76700,Ultrasound of abdomen,402,814.5,627.17,77% of Billed Charges,207.7,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,207.7,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,254.53,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,602.73,74% OF Billed Charges,562.01,69% of Billed Charges,562.01,69% of Billed charges,203.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,562.01,69% of Billed Charges,562.01,69% of Billed Charges,684.18,84% of Billed Charges,667.89,Pays Based On Per Visit,493.72,400% of HEALTHLINK COMPMANAGEMENT Fees Schedule,462.86,375% of HEALTHLINK HMO Fees Schedule,493.72,400% HEALTHLINK PPO Fees Schedule,72.62,120% of HEALTHY BLUE Fees Schedule,72.62,120% of HOMESTATE Fees Schedule,72.62,120% of MO Fee Schedule,203.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,627.17,77% of Billed Charges,692.33,85% of Billed Charges,234.17,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,446,Pays Based On Per Visit,72.62,120% of UHC COMMUNITY PLAN fee Schedule,203.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,203.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,692.33,407.25
Outpatient Medical Services,DIAGNOSTIC IMAGING,76705,"Ultrasound, abdominal",402,694.5,534.77,77% of Billed Charges,177.1,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,177.1,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,217.03,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,513.93,74% OF Billed Charges,479.21,69% of Billed Charges,479.21,69% of Billed charges,173.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,479.21,69% of Billed Charges,479.21,69% of Billed Charges,583.38,84% of Billed Charges,569.49,Pays Based On Per Visit,378.08,400% of HEALTHLINK COMPMANAGEMENT Fees Schedule,354.45,375% of HEALTHLINK HMO Fees Schedule,378.08,400% HEALTHLINK PPO Fees Schedule,54.7,120% of HEALTHY BLUE Fees Schedule,54.7,120% of HOMESTATE Fees Schedule,54.7,120% of MO Fee Schedule,173.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,534.77,77% of Billed Charges,590.33,85% of Billed Charges,199.67,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,446,Pays Based On Per Visit,54.7,120% of UHC COMMUNITY PLAN fee Schedule,173.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,173.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,54.7,590.33,347.25
Outpatient Medical Services,DIAGNOSTIC IMAGING,76770,"Ultrasound, retroperitoneal",402,954,734.58,77% of Billed Charges,243.27,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,243.27,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,298.13,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,705.96,74% OF Billed Charges,658.26,69% of Billed Charges,658.26,69% of Billed charges,238.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,658.26,69% of Billed Charges,658.26,69% of Billed Charges,801.36,84% of Billed Charges,782.28,Pays Based On Per Visit,470.36,400% of HEALTHLINK COMPMANAGEMENT Fees Schedule,440.96,375% of HEALTHLINK HMO Fees Schedule,470.36,400% HEALTHLINK PPO Fees Schedule,67.76,120% of HEALTHY BLUE Fees Schedule,67.76,120% of HOMESTATE Fees Schedule,67.76,120% of MO Fee Schedule,238.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,734.58,77% of Billed Charges,810.9,85% of Billed Charges,274.28,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,446,Pays Based On Per Visit,67.76,120% of UHC COMMUNITY PLAN fee Schedule,238.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,238.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,810.9,477
Outpatient Medical Services,DIAGNOSTIC IMAGING,76775,"Ultrasound, retroperitoneal (",402,849,653.73,77% of Billed Charges,216.5,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,216.5,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,265.31,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,628.26,74% OF Billed Charges,585.81,69% of Billed Charges,585.81,69% of Billed charges,212.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,585.81,69% of Billed Charges,585.81,69% of Billed Charges,713.16,84% of Billed Charges,696.18,Pays Based On Per Visit,382.56,400% of HEALTHLINK COMPMANAGEMENT Fees Schedule,358.65,375% of HEALTHLINK HMO Fees Schedule,382.56,400% HEALTHLINK PPO Fees Schedule,51.05,120% of HEALTHY BLUE Fees Schedule,51.05,120% of HOMESTATE Fees Schedule,51.05,120% of MO Fee Schedule,212.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,653.73,77% of Billed Charges,721.65,85% of Billed Charges,244.09,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,446,Pays Based On Per Visit,51.05,120% of UHC COMMUNITY PLAN fee Schedule,212.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,212.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,51.05,721.65,424.5
Outpatient Medical Services,DIAGNOSTIC IMAGING,76801,"Ultrasound, pregnant uterus, real time image documentation, fetal and maternal evaluation",402,748.5,576.35,77% of Billed Charges,190.87,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,190.87,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,233.91,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,553.89,74% OF Billed Charges,516.47,69% of Billed Charges,516.47,69% of Billed charges,187.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,516.47,69% of Billed Charges,516.47,69% of Billed Charges,628.74,84% of Billed Charges,613.77,Pays Based On Per Visit,457.2,400% of HEALTHLINK COMPMANAGEMENT Fees Schedule,428.63,375% of HEALTHLINK HMO Fees Schedule,457.2,400% HEALTHLINK PPO Fees Schedule,64.72,120% of HEALTHY BLUE Fees Schedule,64.72,120% of HOMESTATE Fees Schedule,64.72,120% of MO Fee Schedule,187.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,576.35,77% of Billed Charges,636.23,85% of Billed Charges,215.19,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,446,Pays Based On Per Visit,64.72,120% of UHC COMMUNITY PLAN fee Schedule,187.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,187.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,636.23,374.25
Outpatient Medical Services,DIAGNOSTIC IMAGING,76805,Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus,402,753,579.81,77% of Billed Charges,192.02,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,192.02,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,235.31,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,557.22,74% OF Billed Charges,519.57,69% of Billed Charges,519.57,69% of Billed charges,188.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,519.57,69% of Billed Charges,519.57,69% of Billed Charges,632.52,84% of Billed Charges,617.46,Pays Based On Per Visit,522.32,400% of HEALTHLINK COMPMANAGEMENT Fees Schedule,489.68,375% of HEALTHLINK HMO Fees Schedule,522.32,400% HEALTHLINK PPO Fees Schedule,80.53,120% of HEALTHY BLUE Fees Schedule,80.53,120% of HOMESTATE Fees Schedule,80.53,120% of MO Fee Schedule,188.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,579.81,77% of Billed Charges,640.05,85% of Billed Charges,216.49,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,446,Pays Based On Per Visit,80.53,120% of UHC COMMUNITY PLAN fee Schedule,188.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,188.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,640.05,376.5
Outpatient Medical Services,DIAGNOSTIC IMAGING,76816,"Ultrasound, pregnant uterus, real time with image documentation",402,962.5,741.13,77% of Billed Charges,245.44,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,245.44,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,300.78,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,712.25,74% OF Billed Charges,664.13,69% of Billed Charges,664.13,69% of Billed charges,240.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,664.13,69% of Billed Charges,664.13,69% of Billed Charges,808.5,84% of Billed Charges,789.25,Pays Based On Per Visit,414.16,400% of HEALTHLINK COMPMANAGEMENT Fees Schedule,388.28,375% of HEALTHLINK HMO Fees Schedule,414.16,400% HEALTHLINK PPO Fees Schedule,63.2,120% of HEALTHY BLUE Fees Schedule,63.2,120% of HOMESTATE Fees Schedule,63.2,120% of MO Fee Schedule,240.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,741.13,77% of Billed Charges,818.13,85% of Billed Charges,276.72,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,446,Pays Based On Per Visit,63.2,120% of UHC COMMUNITY PLAN fee Schedule,240.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,240.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,818.13,481.25
Outpatient Medical Services,DIAGNOSTIC IMAGING,76817,"ultrasound, pregnant uterus, real time with image documentation, transvaginal",40,860.5,662.59,77% of Billed Charges,219.43,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,219.43,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,268.91,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,636.77,74% OF Billed Charges,593.75,69% of Billed Charges,593.75,69% of Billed charges,215.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,593.75,69% of Billed Charges,593.75,69% of Billed Charges,722.82,84% of Billed Charges,705.61,82% of Billed Charges,358,400% of HEALTHLINK COMPMANAGEMENT Fees Schedule,335.63,375% of HEALTHLINK HMO Fees Schedule,358,400% HEALTHLINK PPO Fees Schedule,52.26,120% of HEALTHY BLUE Fees Schedule,52.26,120% of HOMESTATE Fees Schedule,52.26,120% of MO Fee Schedule,215.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,662.59,77% of Billed Charges,731.43,85% of Billed Charges,247.39,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,430.25,50% of Billed Charges,52.26,120% of UHC COMMUNITY PLAN fee Schedule,215.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,765.85,89% of Billed Charges,215.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,52.26,765.85,430.25
Outpatient Medical Services,DIAGNOSTIC IMAGING,76830,Ultrasound pelvis through vagina,402,791.5,609.46,77% of Billed Charges,201.83,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,201.83,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,247.34,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,585.71,74% OF Billed Charges,546.14,69% of Billed Charges,546.14,69% of Billed charges,197.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,546.14,69% of Billed Charges,546.14,69% of Billed Charges,664.86,84% of Billed Charges,649.03,Pays Based On Per Visit,441.56,400% of HEALTHLINK COMPMANAGEMENT Fees Schedule,413.96,375% of HEALTHLINK HMO Fees Schedule,441.56,400% HEALTHLINK PPO Fees Schedule,79.92,120% of HEALTHY BLUE Fees Schedule,79.92,120% of HOMESTATE Fees Schedule,79.92,120% of MO Fee Schedule,197.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,609.46,77% of Billed Charges,672.78,85% of Billed Charges,227.56,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,446,Pays Based On Per Visit,79.92,120% of UHC COMMUNITY PLAN fee Schedule,197.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,197.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,672.78,395.75
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",402,677,521.29,77% of Billed Charges,172.64,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,172.64,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,211.56,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,500.98,74% OF Billed Charges,467.13,69% of Billed Charges,467.13,69% of Billed charges,169.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,467.13,69% of Billed Charges,467.13,69% of Billed Charges,568.68,84% of Billed Charges,555.14,Pays Based On Per Visit,602.53,89% of Billed Charges,602.53,89% of Billed Charges,602.53,89% of Billed Charges,30.07,120% of HEALTHY BLUE Fees Schedule,30.07,120% of HOMESTATE Fees Schedule,30.07,120% of MO Fee Schedule,169.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,521.29,77% of Billed Charges,575.45,85% of Billed Charges,194.64,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,446,Pays Based On Per Visit,30.07,120% of UHC COMMUNITY PLAN fee Schedule,169.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,169.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,30.07,602.53,338.5
Outpatient Medical Services,DIAGNOSTIC IMAGING,77049,"Magnetic resonance imaging, breast, without and/or with contrast material(s)",614,2868,2208.36,77% of Billed Charges,731.34,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,731.34,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,896.25,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,2360.06,295% of BCBS BLUE ACCESS Fees Schedule,2202.79,285% of BCBS BLUE ACCESS CHOICE Fees Schedule ,2202.79,285% of BCBS BLUE PREFFERED Fees Schedule,717,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,2202.79,285% of BCBS PATHWAY Fees Schedule,1389,PER DIEM,2280.08,295% of BCBS TRADITIONAL Fees Schedule,2351.76,Pays Based On Per Visit,2552.52,89% of Billed Charges,2552.52,89% of Billed Charges,2552.52,89% of Billed Charges,231.28,120% of HEALTHY BLUE Fees Schedule,231.28,120% of HOMESTATE Fees Schedule,231.28,120% of MO Fee Schedule,717,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,2208.36,77% of Billed Charges,2437.8,85% of Billed Charges,824.55,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,1479,Pays Based On Per Visit,231.28,120% of UHC COMMUNITY PLAN fee Schedule,717,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,717,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,2552.52,1434
Outpatient Medical Services,DIAGNOSTIC IMAGING,77063,"Screening digital breast tomosynthesis, bilateral",403,74,56.98,77% of Billed Charges,18.87,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,18.87,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,23.13,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,54.76,74% OF Billed Charges,51.06,69% of Billed Charges,51.06,69% of Billed charges,18.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,51.06,69% of Billed Charges,51.06,69% of Billed Charges,62.16,84% of Billed Charges,60.68,Pays Based On Per Visit,65.86,89% of Billed Charges,65.86,89% of Billed Charges,65.86,89% of Billed Charges,23.54,120% of HEALTHY BLUE Fees Schedule,23.54,120% of HOMESTATE Fees Schedule,23.54,120% of MO Fee Schedule,18.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,56.98,77% of Billed Charges,62.9,85% of Billed Charges,21.28,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,177,Pays Based On Per Visit,23.54,120% of UHC COMMUNITY PLAN fee Schedule,18.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,18.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,18.5,177,37
Outpatient Medical Services,DIAGNOSTIC IMAGING,77065,Mammography of one breast,401,518.5,399.25,77% of Billed Charges,132.22,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,132.22,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,162.03,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,383.69,74% OF Billed Charges,357.77,69% of Billed Charges,357.77,69% of Billed charges,129.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,357.77,69% of Billed Charges,357.77,69% of Billed Charges,435.54,84% of Billed Charges,425.17,Pays Based On Per Visit,461.47,89% of Billed Charges,461.47,89% of Billed Charges,461.47,89% of Billed Charges,88.1,120% of HEALTHY BLUE Fees Schedule,88.1,120% of HOMESTATE Fees Schedule,88.1,120% of MO Fee Schedule,129.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,399.25,77% of Billed Charges,440.73,85% of Billed Charges,149.07,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,177,Pays Based On Per Visit,88.1,120% of UHC COMMUNITY PLAN fee Schedule,129.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,129.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,461.47,259.25
Outpatient Medical Services,DIAGNOSTIC IMAGING,77066,Mammography of both breasts,401,627.5,483.18,77% of Billed Charges,160.01,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,160.01,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,196.09,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,464.35,74% OF Billed Charges,432.98,69% of Billed Charges,432.98,69% of Billed charges,156.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,432.98,69% of Billed Charges,432.98,69% of Billed Charges,527.1,84% of Billed Charges,514.55,Pays Based On Per Visit,558.48,89% of Billed Charges,558.48,89% of Billed Charges,558.48,89% of Billed Charges,112.33,120% of HEALTHY BLUE Fees Schedule,112.33,120% of HOMESTATE Fees Schedule,112.33,120% of MO Fee Schedule,156.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,483.18,77% of Billed Charges,533.38,85% of Billed Charges,180.41,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,177,Pays Based On Per Visit,112.33,120% of UHC COMMUNITY PLAN fee Schedule,156.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,156.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,558.48,313.75
Outpatient Medical Services,DIAGNOSTIC IMAGING,77067,"Mammography, screening, bilateral",403,556,428.12,77% of Billed Charges,141.78,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,141.78,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,173.75,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,411.44,74% OF Billed Charges,383.64,69% of Billed Charges,383.64,69% of Billed charges,139,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,383.64,69% of Billed Charges,383.64,69% of Billed Charges,467.04,84% of Billed Charges,455.92,Pays Based On Per Visit,494.84,89% of Billed Charges,494.84,89% of Billed Charges,494.84,89% of Billed Charges,92.82,120% of HEALTHY BLUE Fees Schedule,92.82,120% of HOMESTATE Fees Schedule,92.82,120% of MO Fee Schedule,139,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,428.12,77% of Billed Charges,472.6,85% of Billed Charges,159.85,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,177,Pays Based On Per Visit,92.82,120% of UHC COMMUNITY PLAN fee Schedule,139,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,139,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,494.84,278
Outpatient Medical Services,DIAGNOSTIC IMAGING,77080,"bone density scan of axial bones like hip, pelvis and spine",320,588.5,453.15,77% of Billed Charges,150.07,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,150.07,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,183.91,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,435.49,74% OF Billed Charges,406.07,69% of Billed Charges,406.07,69% of Billed charges,147.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,406.07,69% of Billed Charges,406.07,69% of Billed Charges,494.34,84% of Billed Charges,482.57,Pays Based On Per Visit,183.84,400% of HEALTHLINK COMPMANAGEMENT Fees Schedule,172.35,375% of HEALTHLINK HMO Fees Schedule,183.84,400% HEALTHLINK PPO Fees Schedule,62.96,120% of HEALTHY BLUE Fees Schedule,62.96,120% of HOMESTATE Fees Schedule,62.96,120% of MO Fee Schedule,147.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,453.15,77% of Billed Charges,500.23,85% of Billed Charges,169.19,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,271,Pays Based On Per Visit,62.96,120% of UHC COMMUNITY PLAN fee Schedule,147.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,147.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,500.23,294.25
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",340,3458,2662.66,77% of Billed Charges,881.79,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,881.79,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,1080.63,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,2558.92,74% OF Billed Charges,2386.02,69% of Billed Charges,2386.02,69% of Billed charges,864.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,2386.02,69% of Billed Charges,2386.02,69% of Billed Charges,2904.72,84% of Billed Charges,2835.56,Pays Based On Per Visit,3077.62,89% of Billed Charges,3077.62,89% of Billed Charges,3077.62,89% of Billed Charges,339.32,120% of HEALTHY BLUE Fees Schedule,339.32,120% of HOMESTATE Fees Schedule,339.32,120% of MO Fee Schedule,864.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,2662.66,77% of Billed Charges,2939.3,85% of Billed Charges,994.18,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,847,Pays Based On Per Visit,339.32,120% of UHC COMMUNITY PLAN fee Schedule,864.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,864.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,3077.62,1729
Outpatient Medical Services,LABORATORY,36415,Collection of venous blood by venipuncture,300,47,36.19,77% of Billed Charges,11.99,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,11.99,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,14.69,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,34.78,74% OF Billed Charges,32.43,69% of Billed Charges,32.43,69% of Billed charges,11.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,32.43,69% of Billed Charges,32.43,69% of Billed Charges,39.48,84% of Billed Charges,38.54,Pays Based On Per Visit,15,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,15,500% of HEALTHLINK HMO Fees Schedule,15,500% of HEALTHLINK PPO Fees Schedule,19.18,40.8% of Billed Charges,19.18,40.8% of Billed Charges,19.18,40.8% of Billed Charges,11.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,36.19,77% of Billed Charges,39.95,85% of Billed Charges,13.51,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,19.18,40.8% of Billed Charges,11.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,11.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,11.75,64,23.5
Outpatient Medical Services,LABORATORY,36416,Collection of capillary blood specimen,300,27.5,21.18,77% of Billed Charges,7.01,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,7.01,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,8.59,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,20.35,74% OF Billed Charges,18.98,69% of Billed Charges,18.98,69% of Billed charges,6.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,18.98,69% of Billed Charges,18.98,69% of Billed Charges,23.1,84% of Billed Charges,22.55,Pays Based On Per Visit,24.48,89% of Billed Charges,24.48,89% of Billed Charges,24.48,89% of Billed Charges,11.22,40.8% of Billed Charges,11.22,40.8% of Billed Charges,11.22,40.8% of Billed Charges,6.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,21.18,77% of Billed Charges,23.38,85% of Billed Charges,7.91,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,11.22,40.8% of Billed Charges,6.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,6.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,6.88,64,13.75
Outpatient Medical Services,LABORATORY,80048,Basic metabolic panel,301,155.5,119.74,77% of Billed Charges,39.65,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,39.65,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,48.59,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,115.07,74% OF Billed Charges,107.3,69% of Billed Charges,107.3,69% of Billed charges,38.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,107.3,69% of Billed Charges,107.3,69% of Billed Charges,130.62,84% of Billed Charges,127.51,Pays Based On Per Visit,61.8,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,61.8,500% of HEALTHLINK HMO Fees Schedule,61.8,500% of HEALTHLINK PPO Fees Schedule,8.11,120% of HEALTHY BLUE Fees Schedule,8.11,120% of HOMESTATE Fees Schedule,8.11,120% of MO Fee Schedule,38.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,119.74,77% of Billed Charges,132.18,85% of Billed Charges,44.71,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,8.11,120% of UHC COMMUNITY PLAN fee Schedule,38.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,38.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,8.11,132.18,77.75
Outpatient Medical Services,LABORATORY,80050,Complete Blood Count w/Differential,301,576,443.52,77% of Billed Charges,146.88,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,146.88,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,180,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,426.24,74% OF Billed Charges,397.44,69% of Billed Charges,397.44,69% of Billed charges,144,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,397.44,69% of Billed Charges,397.44,69% of Billed Charges,483.84,84% of Billed Charges,472.32,Pays Based On Per Visit,512.64,89% of Billed Charges,512.64,89% of Billed Charges,512.64,89% of Billed Charges,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,144,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,443.52,77% of Billed Charges,489.6,85% of Billed Charges,165.6,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,N/A,NOT REIMBURSABLE,144,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,144,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,512.64,288
Outpatient Medical Services,LABORATORY,80053,"Blood test, comprehensive group of blood chemicals",301,164.5,126.67,77% of Billed Charges,41.95,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,41.95,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,51.41,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,121.73,74% OF Billed Charges,113.51,69% of Billed Charges,113.51,69% of Billed charges,41.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,113.51,69% of Billed Charges,113.51,69% of Billed Charges,138.18,84% of Billed Charges,134.89,Pays Based On Per Visit,77.2,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,77.2,500% of HEALTHLINK HMO Fees Schedule,77.2,500% of HEALTHLINK PPO Fees Schedule,10.13,120% of HEALTHY BLUE Fees Schedule,10.13,120% of HOMESTATE Fees Schedule,10.13,120% of MO Fee Schedule,41.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,126.67,77% of Billed Charges,139.83,85% of Billed Charges,47.29,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,10.13,120% of UHC COMMUNITY PLAN fee Schedule,41.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,41.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,10.13,139.83,82.25
Outpatient Medical Services,LABORATORY,80055,Obstetric blood test panel,301,524.5,403.87,77% of Billed Charges,133.75,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,133.75,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,163.91,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,388.13,74% OF Billed Charges,361.91,69% of Billed Charges,361.91,69% of Billed charges,131.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,361.91,69% of Billed Charges,361.91,69% of Billed Charges,440.58,84% of Billed Charges,430.09,Pays Based On Per Visit,466.81,89% of Billed Charges,466.81,89% of Billed Charges,466.81,89% of Billed Charges,45.89,120% of HEALTHY BLUE Fees Schedule,45.89,120% of HOMESTATE Fees Schedule,45.89,120% of MO Fee Schedule,131.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,403.87,77% of Billed Charges,445.83,85% of Billed Charges,150.79,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,45.89,120% of UHC COMMUNITY PLAN fee Schedule,131.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,131.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,45.89,466.81,262.25
Outpatient Medical Services,LABORATORY,80061,"Blood test, lipids (cholesterol and triglycerides)",301,455,350.35,77% of Billed Charges,116.03,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,116.03,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,142.19,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,336.7,74% OF Billed Charges,313.95,69% of Billed Charges,313.95,69% of Billed charges,113.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,313.95,69% of Billed Charges,313.95,69% of Billed Charges,382.2,84% of Billed Charges,373.1,Pays Based On Per Visit,97.85,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,97.85,500% of HEALTHLINK HMO Fees Schedule,97.85,500% of HEALTHLINK PPO Fees Schedule,12.85,120% of HEALTHY BLUE Fees Schedule,12.85,120% of HOMESTATE Fees Schedule,12.85,120% of MO Fee Schedule,113.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,350.35,77% of Billed Charges,386.75,85% of Billed Charges,130.81,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,12.85,120% of UHC COMMUNITY PLAN fee Schedule,113.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,113.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,12.85,386.75,227.5
Outpatient Medical Services,LABORATORY,80069,Kidney function panel test,301,196,150.92,77% of Billed Charges,49.98,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,49.98,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,61.25,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,145.04,74% OF Billed Charges,135.24,69% of Billed Charges,135.24,69% of Billed charges,49,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,135.24,69% of Billed Charges,135.24,69% of Billed Charges,164.64,84% of Billed Charges,160.72,Pays Based On Per Visit,63.4,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,63.4,500% of HEALTHLINK HMO Fees Schedule,63.4,500% of HEALTHLINK PPO Fees Schedule,8.33,120% of HEALTHY BLUE Fees Schedule,8.33,120% of HOMESTATE Fees Schedule,8.33,120% of MO Fee Schedule,49,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,150.92,77% of Billed Charges,166.6,85% of Billed Charges,56.35,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,8.33,120% of UHC COMMUNITY PLAN fee Schedule,49,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,49,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,8.33,166.6,98
Outpatient Medical Services,LABORATORY,80074,"Hepatitis A, IgM Hepatitis B Core Antibody, IgM Hepatitis B Surface Antigen Hepatitis C Antibody with Confirmation",301,465.5,358.44,77% of Billed Charges,118.7,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,118.7,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,145.47,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,344.47,74% OF Billed Charges,321.2,69% of Billed Charges,321.2,69% of Billed charges,116.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,321.2,69% of Billed Charges,321.2,69% of Billed Charges,391.02,84% of Billed Charges,381.71,Pays Based On Per Visit,346.35,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,346.35,500% of HEALTHLINK HMO Fees Schedule,346.35,500% of HEALTHLINK PPO Fees Schedule,45.72,120% of HEALTHY BLUE Fees Schedule,45.72,120% of HOMESTATE Fees Schedule,45.72,120% of MO Fee Schedule,116.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,358.44,77% of Billed Charges,395.68,85% of Billed Charges,133.83,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,45.72,120% of UHC COMMUNITY PLAN fee Schedule,116.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,116.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,45.72,395.68,232.75
Outpatient Medical Services,LABORATORY,80076,Liver function blood test panel,301,112.5,86.63,77% of Billed Charges,28.69,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,28.69,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,35.16,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,83.25,74% OF Billed Charges,77.63,69% of Billed Charges,77.63,69% of Billed charges,28.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,77.63,69% of Billed Charges,77.63,69% of Billed Charges,94.5,84% of Billed Charges,92.25,Pays Based On Per Visit,59.65,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,59.65,500% of HEALTHLINK HMO Fees Schedule,59.65,500% of HEALTHLINK PPO Fees Schedule,7.84,120% of HEALTHY BLUE Fees Schedule,7.84,120% of HOMESTATE Fees Schedule,7.84,120% of MO Fee Schedule,28.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,86.63,77% of Billed Charges,95.63,85% of Billed Charges,32.34,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,7.84,120% of UHC COMMUNITY PLAN fee Schedule,28.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,28.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,7.84,95.63,56.25
Outpatient Medical Services,LABORATORY,80306,"drug test(s), presumptive, any number of drug classes, any number of devices or procedures (eg, immunoassay",301,228,175.56,77% of Billed Charges,58.14,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,58.14,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,71.25,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,168.72,74% OF Billed Charges,157.32,69% of Billed Charges,157.32,69% of Billed charges,57,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,157.32,69% of Billed Charges,157.32,69% of Billed Charges,191.52,84% of Billed Charges,186.96,Pays Based On Per Visit,202.92,89% of Billed Charges,202.92,89% of Billed Charges,202.92,89% of Billed Charges,16.45,120% of HEALTHY BLUE Fees Schedule,16.45,120% of HOMESTATE Fees Schedule,16.45,120% of MO Fee Schedule,57,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,175.56,77% of Billed Charges,193.8,85% of Billed Charges,65.55,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,16.45,120% of UHC COMMUNITY PLAN fee Schedule,57,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,57,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,16.45,202.92,114
Outpatient Medical Services,LABORATORY,80320,Drug Test,301,134.5,103.57,77% of Billed Charges,34.3,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,34.3,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,42.03,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,99.53,74% OF Billed Charges,92.81,69% of Billed Charges,92.81,69% of Billed charges,33.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,92.81,69% of Billed Charges,92.81,69% of Billed Charges,112.98,84% of Billed Charges,110.29,Pays Based On Per Visit,119.71,89% of Billed Charges,119.71,89% of Billed Charges,119.71,89% of Billed Charges,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,33.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,103.57,77% of Billed Charges,114.33,85% of Billed Charges,38.67,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,N/A,NOT REIMBURSABLE,33.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,33.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,33.63,119.71,67.25
Outpatient Medical Services,LABORATORY,81000,Manual urinalysis test with examination using microscope,521,24,18.48,77% of Billed Charges,6.12,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,6.12,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,7.5,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,6,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,23.15,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,23.15,500% of HEALTHLINK HMO Fees Schedule,23.15,500% of HEALTHLINK PPO Fees Schedule,3.85,120% of HEALTHY BLUE Fees Schedule,3.85,120% of HOMESTATE Fees Schedule,3.85,120% of MO Fee Schedule,6,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,18.48,77% of Billed Charges,20.4,85% of Billed Charges,6.9,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,3.85,120% of UHC COMMUNITY PLAN fee Schedule,6,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,6,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,3.85,23.15,12
Outpatient Medical Services,LABORATORY,81001,Manual urinalysis test with examination using microscope,307,51.5,39.66,77% of Billed Charges,13.13,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,13.13,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,16.09,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,38.11,74% OF Billed Charges,35.54,69% of Billed Charges,35.54,69% of Billed charges,12.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,35.54,69% of Billed Charges,35.54,69% of Billed Charges,43.26,84% of Billed Charges,42.23,Pays Based On Per Visit,23.15,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,23.15,500% of HEALTHLINK HMO Fees Schedule,23.15,500% of HEALTHLINK PPO Fees Schedule,3.04,120% of HEALTHY BLUE Fees Schedule,3.04,120% of HOMESTATE Fees Schedule,3.04,120% of MO Fee Schedule,12.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,39.66,77% of Billed Charges,43.78,85% of Billed Charges,14.81,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,3.04,120% of UHC COMMUNITY PLAN fee Schedule,12.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,12.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,3.04,64,25.75
Outpatient Medical Services,LABORATORY,81002,Automated urinalysis test,300,49,37.73,77% of Billed Charges,12.5,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,12.5,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,15.31,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,36.26,74% OF Billed Charges,33.81,69% of Billed Charges,33.81,69% of Billed charges,12.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,33.81,69% of Billed Charges,33.81,69% of Billed Charges,41.16,84% of Billed Charges,40.18,Pays Based On Per Visit,15.25,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,15.25,500% of HEALTHLINK HMO Fees Schedule,15.25,500% of HEALTHLINK PPO Fees Schedule,3.34,120% of HEALTHY BLUE Fees Schedule,3.34,120% of HOMESTATE Fees Schedule,3.34,120% of MO Fee Schedule,12.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,37.73,77% of Billed Charges,41.65,85% of Billed Charges,14.09,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,3.34,120% of UHC COMMUNITY PLAN fee Schedule,12.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,12.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,3.34,64,24.5
Outpatient Medical Services,LABORATORY,81003,"Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH,",307,50,38.5,77% of Billed Charges,12.75,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,12.75,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,15.63,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,37,74% OF Billed Charges,34.5,69% of Billed Charges,34.5,69% of Billed charges,12.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,34.5,69% of Billed Charges,34.5,69% of Billed Charges,42,84% of Billed Charges,41,Pays Based On Per Visit,15.25,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,15.25,500% of HEALTHLINK HMO Fees Schedule,15.25,500% of HEALTHLINK PPO Fees Schedule,2.16,120% of HEALTHY BLUE Fees Schedule,2.16,120% of HOMESTATE Fees Schedule,2.16,120% of MO Fee Schedule,12.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,38.5,77% of Billed Charges,42.5,85% of Billed Charges,14.38,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,2.16,120% of UHC COMMUNITY PLAN fee Schedule,12.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,12.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,2.16,64,25
Outpatient Medical Services,LABORATORY,81015,"Urinalysis, microscopic only",307,47.5,36.58,77% of Billed Charges,12.11,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,12.11,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,14.84,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,35.15,74% OF Billed Charges,32.78,69% of Billed Charges,32.78,69% of Billed charges,11.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,32.78,69% of Billed Charges,32.78,69% of Billed Charges,39.9,84% of Billed Charges,38.95,Pays Based On Per Visit,21,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,21,500% of HEALTHLINK HMO Fees Schedule,21,500% of HEALTHLINK PPO Fees Schedule,2.93,120% of HEALTHY BLUE Fees Schedule,2.93,120% of HOMESTATE Fees Schedule,2.93,120% of MO Fee Schedule,11.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,36.58,77% of Billed Charges,40.38,85% of Billed Charges,13.66,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,2.93,120% of UHC COMMUNITY PLAN fee Schedule,11.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,11.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,2.93,64,23.75
Outpatient Medical Services,LABORATORY,81025,"urine pregnancy test, by visual color comparison methods",521,43,33.11,77% of Billed Charges,10.97,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,10.97,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,13.44,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,10.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,46.2,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,46.2,500% of HEALTHLINK HMO Fees Schedule,46.2,500% of HEALTHLINK PPO Fees Schedule,8.26,120% of HEALTHY BLUE Fees Schedule,8.26,120% of HOMESTATE Fees Schedule,8.26,120% of MO Fee Schedule,10.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,33.11,77% of Billed Charges,36.55,85% of Billed Charges,12.36,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,8.26,120% of UHC COMMUNITY PLAN fee Schedule,10.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,10.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,8.26,46.2,21.5
Outpatient Medical Services,LABORATORY,82043,Microalbumin Creatinine Microalbumin/creatinine ratio,301,110,84.7,77% of Billed Charges,28.05,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,28.05,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,34.38,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,81.4,74% OF Billed Charges,75.9,69% of Billed Charges,75.9,69% of Billed charges,27.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,75.9,69% of Billed Charges,75.9,69% of Billed Charges,92.4,84% of Billed Charges,90.2,Pays Based On Per Visit,42.25,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,42.25,500% of HEALTHLINK HMO Fees Schedule,42.25,500% of HEALTHLINK PPO Fees Schedule,5.54,120% of HEALTHY BLUE Fees Schedule,5.54,120% of HOMESTATE Fees Schedule,5.54,120% of MO Fee Schedule,27.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,84.7,77% of Billed Charges,93.5,85% of Billed Charges,31.63,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,5.54,120% of UHC COMMUNITY PLAN fee Schedule,27.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,27.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,5.54,93.5,55
Outpatient Medical Services,LABORATORY,82150,Amylase,301,133,102.41,77% of Billed Charges,33.92,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,33.92,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,41.56,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,98.42,74% OF Billed Charges,91.77,69% of Billed Charges,91.77,69% of Billed charges,33.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,91.77,69% of Billed Charges,91.77,69% of Billed Charges,111.72,84% of Billed Charges,109.06,Pays Based On Per Visit,47.3,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,47.3,500% of HEALTHLINK HMO Fees Schedule,47.3,500% of HEALTHLINK PPO Fees Schedule,6.22,120% of HEALTHY BLUE Fees Schedule,6.22,120% of HOMESTATE Fees Schedule,6.22,120% of MO Fee Schedule,33.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,102.41,77% of Billed Charges,113.05,85% of Billed Charges,38.24,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,6.22,120% of UHC COMMUNITY PLAN fee Schedule,33.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,33.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,6.22,113.05,66.5
Outpatient Medical Services,LABORATORY,82248,Total Bilirubin Direct Bilirubin Indirect Bilirubin,301,112,86.24,77% of Billed Charges,28.56,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,28.56,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,35,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,82.88,74% OF Billed Charges,77.28,69% of Billed Charges,77.28,69% of Billed charges,28,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,77.28,69% of Billed Charges,77.28,69% of Billed Charges,94.08,84% of Billed Charges,91.84,Pays Based On Per Visit,36.65,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,36.65,500% of HEALTHLINK HMO Fees Schedule,36.65,500% of HEALTHLINK PPO Fees Schedule,4.81,120% of HEALTHY BLUE Fees Schedule,4.81,120% of HOMESTATE Fees Schedule,4.81,120% of MO Fee Schedule,28,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,86.24,77% of Billed Charges,95.2,85% of Billed Charges,32.2,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,4.81,120% of UHC COMMUNITY PLAN fee Schedule,28,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,28,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,4.81,95.2,56
Outpatient Medical Services,LABORATORY,82306,Vitamin D testing,301,273,210.21,77% of Billed Charges,69.62,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,69.62,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,85.31,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,202.02,74% OF Billed Charges,188.37,69% of Billed Charges,188.37,69% of Billed charges,68.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,188.37,69% of Billed Charges,188.37,69% of Billed Charges,229.32,84% of Billed Charges,223.86,Pays Based On Per Visit,216.1,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,216.1,500% of HEALTHLINK HMO Fees Schedule,216.1,500% of HEALTHLINK PPO Fees Schedule,28.42,120% of HEALTHY BLUE Fees Schedule,28.42,120% of HOMESTATE Fees Schedule,28.42,120% of MO Fee Schedule,68.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,210.21,77% of Billed Charges,232.05,85% of Billed Charges,78.49,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,28.42,120% of UHC COMMUNITY PLAN fee Schedule,68.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,68.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,28.42,232.05,136.5
Outpatient Medical Services,LABORATORY,82550,Creatine Kinase,301,92.5,71.23,77% of Billed Charges,23.59,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,23.59,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,28.91,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,68.45,74% OF Billed Charges,63.83,69% of Billed Charges,63.83,69% of Billed charges,23.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,63.83,69% of Billed Charges,63.83,69% of Billed Charges,77.7,84% of Billed Charges,75.85,Pays Based On Per Visit,47.55,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,47.55,500% of HEALTHLINK HMO Fees Schedule,47.55,500% of HEALTHLINK PPO Fees Schedule,6.24,120% of HEALTHY BLUE Fees Schedule,6.24,120% of HOMESTATE Fees Schedule,6.24,120% of MO Fee Schedule,23.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,71.23,77% of Billed Charges,78.63,85% of Billed Charges,26.59,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,6.24,120% of UHC COMMUNITY PLAN fee Schedule,23.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,23.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,6.24,78.63,46.25
Outpatient Medical Services,LABORATORY,82565,Copper Level Test,301,68.5,52.75,77% of Billed Charges,17.47,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,17.47,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,21.41,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,50.69,74% OF Billed Charges,47.27,69% of Billed Charges,47.27,69% of Billed charges,17.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,47.27,69% of Billed Charges,47.27,69% of Billed Charges,57.54,84% of Billed Charges,56.17,Pays Based On Per Visit,37.4,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,37.4,500% of HEALTHLINK HMO Fees Schedule,37.4,500% of HEALTHLINK PPO Fees Schedule,4.91,120% of HEALTHY BLUE Fees Schedule,4.91,120% of HOMESTATE Fees Schedule,4.91,120% of MO Fee Schedule,17.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,52.75,77% of Billed Charges,58.23,85% of Billed Charges,19.69,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,4.91,120% of UHC COMMUNITY PLAN fee Schedule,17.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,17.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,4.91,64,34.25
Outpatient Medical Services,LABORATORY,82570,"Albumin:Creatinine ratio, random urine",301,62,47.74,77% of Billed Charges,15.81,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,15.81,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,19.38,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,45.88,74% OF Billed Charges,42.78,69% of Billed Charges,42.78,69% of Billed charges,15.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,42.78,69% of Billed Charges,42.78,69% of Billed Charges,52.08,84% of Billed Charges,50.84,Pays Based On Per Visit,37.8,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,37.8,500% of HEALTHLINK HMO Fees Schedule,37.8,500% of HEALTHLINK PPO Fees Schedule,4.97,120% of HEALTHY BLUE Fees Schedule,4.97,120% of HOMESTATE Fees Schedule,4.97,120% of MO Fee Schedule,15.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,47.74,77% of Billed Charges,52.7,85% of Billed Charges,17.83,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,4.97,120% of UHC COMMUNITY PLAN fee Schedule,15.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,15.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,4.97,64,31
Outpatient Medical Services,LABORATORY,82607,Vitamin B-12 Testing,301,176,135.52,77% of Billed Charges,44.88,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,44.88,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,55,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,130.24,74% OF Billed Charges,121.44,69% of Billed Charges,121.44,69% of Billed charges,44,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,121.44,69% of Billed Charges,121.44,69% of Billed Charges,147.84,84% of Billed Charges,144.32,Pays Based On Per Visit,110.05,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,110.05,500% of HEALTHLINK HMO Fees Schedule,110.05,500% of HEALTHLINK PPO Fees Schedule,14.47,120% of HEALTHY BLUE Fees Schedule,14.47,120% of HOMESTATE Fees Schedule,14.47,120% of MO Fee Schedule,44,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,135.52,77% of Billed Charges,149.6,85% of Billed Charges,50.6,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,14.47,120% of UHC COMMUNITY PLAN fee Schedule,44,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,44,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,14.47,149.6,88
Outpatient Medical Services,LABORATORY,82672,estrogen analysis,301,235,180.95,77% of Billed Charges,59.93,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,59.93,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,73.44,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,173.9,74% OF Billed Charges,162.15,69% of Billed Charges,162.15,69% of Billed charges,58.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,162.15,69% of Billed Charges,162.15,69% of Billed Charges,197.4,84% of Billed Charges,192.7,Pays Based On Per Visit,158.3,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,158.3,500% of HEALTHLINK HMO Fees Schedule,158.3,500% of HEALTHLINK PPO Fees Schedule,20.83,120% of HEALTHY BLUE Fees Schedule,20.83,120% of HOMESTATE Fees Schedule,20.83,120% of MO Fee Schedule,58.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,180.95,77% of Billed Charges,199.75,85% of Billed Charges,67.56,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,20.83,120% of UHC COMMUNITY PLAN fee Schedule,58.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,58.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,20.83,199.75,117.5
Outpatient Medical Services,LABORATORY,82728,Ferritin Iron Transferrin Calculated total iron binding capacity (TIBC) % Saturation,301,185.5,142.84,77% of Billed Charges,47.3,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,47.3,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,57.97,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,137.27,74% OF Billed Charges,128,69% of Billed Charges,128,69% of Billed charges,46.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,128,69% of Billed Charges,128,69% of Billed Charges,155.82,84% of Billed Charges,152.11,Pays Based On Per Visit,99.45,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,99.45,500% of HEALTHLINK HMO Fees Schedule,99.45,500% of HEALTHLINK PPO Fees Schedule,13.08,120% of HEALTHY BLUE Fees Schedule,13.08,120% of HOMESTATE Fees Schedule,13.08,120% of MO Fee Schedule,46.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,142.84,77% of Billed Charges,157.68,85% of Billed Charges,53.33,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,13.08,120% of UHC COMMUNITY PLAN fee Schedule,46.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,46.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,13.08,157.68,92.75
Outpatient Medical Services,LABORATORY,82746,"Vitamin B12 Folate, Serum",301,157,120.89,77% of Billed Charges,40.04,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,40.04,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,49.06,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,116.18,74% OF Billed Charges,108.33,69% of Billed Charges,108.33,69% of Billed charges,39.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,108.33,69% of Billed Charges,108.33,69% of Billed Charges,131.88,84% of Billed Charges,128.74,Pays Based On Per Visit,107.35,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,107.35,500% of HEALTHLINK HMO Fees Schedule,107.35,500% of HEALTHLINK PPO Fees Schedule,14.11,120% of HEALTHY BLUE Fees Schedule,14.11,120% of HOMESTATE Fees Schedule,14.11,120% of MO Fee Schedule,39.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,120.89,77% of Billed Charges,133.45,85% of Billed Charges,45.14,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,14.11,120% of UHC COMMUNITY PLAN fee Schedule,39.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,39.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,14.11,133.45,78.5
Outpatient Medical Services,LABORATORY,82784,Gammaglobulin (immunoglobulin),301,122,93.94,77% of Billed Charges,31.11,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,31.11,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,38.13,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,90.28,74% OF Billed Charges,84.18,69% of Billed Charges,84.18,69% of Billed charges,30.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,84.18,69% of Billed Charges,84.18,69% of Billed Charges,102.48,84% of Billed Charges,100.04,Pays Based On Per Visit,40.65,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,40.65,500% of HEALTHLINK HMO Fees Schedule,40.65,500% of HEALTHLINK PPO Fees Schedule,8.93,120% of HEALTHY BLUE Fees Schedule,8.93,120% of HOMESTATE Fees Schedule,8.93,120% of MO Fee Schedule,30.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,93.94,77% of Billed Charges,103.7,85% of Billed Charges,35.08,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,8.93,120% of UHC COMMUNITY PLAN fee Schedule,30.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,30.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,8.93,103.7,61
Outpatient Medical Services,LABORATORY,82805,"Gases, blood, any combination of pH, pCO2, pO2, CO2, HCO3",301,280,215.6,77% of Billed Charges,71.4,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,71.4,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,87.5,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,207.2,74% OF Billed Charges,193.2,69% of Billed Charges,193.2,69% of Billed charges,70,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,193.2,69% of Billed Charges,193.2,69% of Billed Charges,235.2,84% of Billed Charges,229.6,Pays Based On Per Visit,207.15,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,207.15,500% of HEALTHLINK HMO Fees Schedule,207.15,500% of HEALTHLINK PPO Fees Schedule,75.61,120% of HEALTHY BLUE Fees Schedule,75.61,120% of HOMESTATE Fees Schedule,75.61,120% of MO Fee Schedule,70,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,215.6,77% of Billed Charges,238,85% of Billed Charges,80.5,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,75.61,120% of UHC COMMUNITY PLAN fee Schedule,70,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,70,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,238,140
Outpatient Medical Services,LABORATORY,82947,"Glucose; quantitative, blood (except reagent strip)",300,81.5,62.76,77% of Billed Charges,20.78,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,20.78,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,25.47,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,60.31,74% OF Billed Charges,56.24,69% of Billed Charges,56.24,69% of Billed charges,20.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,56.24,69% of Billed Charges,56.24,69% of Billed Charges,68.46,84% of Billed Charges,66.83,Pays Based On Per Visit,28.65,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,28.65,500% of HEALTHLINK HMO Fees Schedule,28.65,500% of HEALTHLINK PPO Fees Schedule,3.77,120% of HEALTHY BLUE Fees Schedule,3.77,120% of HOMESTATE Fees Schedule,3.77,120% of MO Fee Schedule,20.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,62.76,77% of Billed Charges,69.28,85% of Billed Charges,23.43,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,3.77,120% of UHC COMMUNITY PLAN fee Schedule,20.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,20.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,3.77,69.28,40.75
Outpatient Medical Services,LABORATORY,82950,Glucose; post glucose dose (includes glucose),310,68.5,52.75,77% of Billed Charges,17.47,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,17.47,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,21.41,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,50.69,74% OF Billed Charges,47.27,69% of Billed Charges,47.27,69% of Billed charges,17.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,47.27,69% of Billed Charges,47.27,69% of Billed Charges,57.54,84% of Billed Charges,56.17,Pays Based On Per Visit,34.65,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,34.65,500% of HEALTHLINK HMO Fees Schedule,34.65,500% of HEALTHLINK PPO Fees Schedule,4.56,120% of HEALTHY BLUE Fees Schedule,4.56,120% of HOMESTATE Fees Schedule,4.56,120% of MO Fee Schedule,17.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,52.75,77% of Billed Charges,58.23,85% of Billed Charges,19.69,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,81,Pays Based On Per Visit,4.56,120% of UHC COMMUNITY PLAN fee Schedule,17.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,17.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,4.56,81,34.25
Outpatient Medical Services,LABORATORY,83001,Gonadotropin; follicle stimulating hormone. Test,301,182,140.14,77% of Billed Charges,46.41,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,46.41,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,56.88,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,134.68,74% OF Billed Charges,125.58,69% of Billed Charges,125.58,69% of Billed charges,45.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,125.58,69% of Billed Charges,125.58,69% of Billed Charges,152.88,84% of Billed Charges,149.24,Pays Based On Per Visit,135.7,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,135.7,500% of HEALTHLINK HMO Fees Schedule,135.7,500% of HEALTHLINK PPO Fees Schedule,17.83,120% of HEALTHY BLUE Fees Schedule,17.83,120% of HOMESTATE Fees Schedule,17.83,120% of MO Fee Schedule,45.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,140.14,77% of Billed Charges,154.7,85% of Billed Charges,52.33,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,17.83,120% of UHC COMMUNITY PLAN fee Schedule,45.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,45.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,17.83,154.7,91
Outpatient Medical Services,LABORATORY,83036,Hemoglobin; glycosylated,301,131,100.87,77% of Billed Charges,33.41,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,33.41,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,40.94,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,96.94,74% OF Billed Charges,90.39,69% of Billed Charges,90.39,69% of Billed charges,32.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,90.39,69% of Billed Charges,90.39,69% of Billed Charges,110.04,84% of Billed Charges,107.42,Pays Based On Per Visit,70.85,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,70.85,500% of HEALTHLINK HMO Fees Schedule,70.85,500% of HEALTHLINK PPO Fees Schedule,9.31,120% of HEALTHY BLUE Fees Schedule,9.31,120% of HOMESTATE Fees Schedule,9.31,120% of MO Fee Schedule,32.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,100.87,77% of Billed Charges,111.35,85% of Billed Charges,37.66,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,9.31,120% of UHC COMMUNITY PLAN fee Schedule,32.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,32.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,9.31,111.35,65.5
Outpatient Medical Services,LABORATORY,83516,Immunoassay for analyte other than infectious agent antibody or infectious agent antigen.,301,184.5,142.07,77% of Billed Charges,47.05,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,47.05,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,57.66,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,136.53,74% OF Billed Charges,127.31,69% of Billed Charges,127.31,69% of Billed charges,46.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,127.31,69% of Billed Charges,127.31,69% of Billed Charges,154.98,84% of Billed Charges,151.29,Pays Based On Per Visit,84.25,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,84.25,500% of HEALTHLINK HMO Fees Schedule,84.25,500% of HEALTHLINK PPO Fees Schedule,11.06,120% of HEALTHY BLUE Fees Schedule,11.06,120% of HOMESTATE Fees Schedule,11.06,120% of MO Fee Schedule,46.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,142.07,77% of Billed Charges,156.83,85% of Billed Charges,53.04,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,11.06,120% of UHC COMMUNITY PLAN fee Schedule,46.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,46.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,11.06,156.83,92.25
Outpatient Medical Services,LABORATORY,83525,Insulin,301,123.5,95.1,77% of Billed Charges,31.49,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,31.49,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,38.59,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,91.39,74% OF Billed Charges,85.22,69% of Billed Charges,85.22,69% of Billed charges,30.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,85.22,69% of Billed Charges,85.22,69% of Billed Charges,103.74,84% of Billed Charges,101.27,Pays Based On Per Visit,83.45,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,83.45,500% of HEALTHLINK HMO Fees Schedule,83.45,500% of HEALTHLINK PPO Fees Schedule,10.97,120% of HEALTHY BLUE Fees Schedule,10.97,120% of HOMESTATE Fees Schedule,10.97,120% of MO Fee Schedule,30.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,95.1,77% of Billed Charges,104.98,85% of Billed Charges,35.51,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,10.97,120% of UHC COMMUNITY PLAN fee Schedule,30.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,30.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,10.97,104.98,61.75
Outpatient Medical Services,LABORATORY,83540,Iron Transferrin Calculated TIBC % Saturation,301,91,70.07,77% of Billed Charges,23.21,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,23.21,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,28.44,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,67.34,74% OF Billed Charges,62.79,69% of Billed Charges,62.79,69% of Billed charges,22.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,62.79,69% of Billed Charges,62.79,69% of Billed Charges,76.44,84% of Billed Charges,74.62,Pays Based On Per Visit,47.3,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,47.3,500% of HEALTHLINK HMO Fees Schedule,47.3,500% of HEALTHLINK PPO Fees Schedule,6.2,120% of HEALTHY BLUE Fees Schedule,6.2,120% of HOMESTATE Fees Schedule,6.2,120% of MO Fee Schedule,22.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,70.07,77% of Billed Charges,77.35,85% of Billed Charges,26.16,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,6.2,120% of UHC COMMUNITY PLAN fee Schedule,22.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,22.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,6.2,77.35,45.5
Outpatient Medical Services,LABORATORY,83550,Iron Binding Capacity,301,101,77.77,77% of Billed Charges,25.76,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,25.76,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,31.56,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,74.74,74% OF Billed Charges,69.69,69% of Billed Charges,69.69,69% of Billed charges,25.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,69.69,69% of Billed Charges,69.69,69% of Billed Charges,84.84,84% of Billed Charges,82.82,Pays Based On Per Visit,63.85,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,63.85,500% of HEALTHLINK HMO Fees Schedule,63.85,500% of HEALTHLINK PPO Fees Schedule,8.39,120% of HEALTHY BLUE Fees Schedule,8.39,120% of HOMESTATE Fees Schedule,8.39,120% of MO Fee Schedule,25.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,77.77,77% of Billed Charges,85.85,85% of Billed Charges,29.04,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,8.39,120% of UHC COMMUNITY PLAN fee Schedule,25.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,25.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,8.39,85.85,50.5
Outpatient Medical Services,LABORATORY,83605,lactic acid test,301,142.5,109.73,77% of Billed Charges,36.34,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,36.34,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,44.53,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,105.45,74% OF Billed Charges,98.33,69% of Billed Charges,98.33,69% of Billed charges,35.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,98.33,69% of Billed Charges,98.33,69% of Billed Charges,119.7,84% of Billed Charges,116.85,Pays Based On Per Visit,77.95,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,77.95,500% of HEALTHLINK HMO Fees Schedule,77.95,500% of HEALTHLINK PPO Fees Schedule,11.1,120% of HEALTHY BLUE Fees Schedule,11.1,120% of HOMESTATE Fees Schedule,11.1,120% of MO Fee Schedule,35.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,109.73,77% of Billed Charges,121.13,85% of Billed Charges,40.97,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,11.1,120% of UHC COMMUNITY PLAN fee Schedule,35.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,35.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,11.1,121.13,71.25
Outpatient Medical Services,LABORATORY,83615,complete examination of all four quadrants of the breast and the retroareolar region;,301,97,74.69,77% of Billed Charges,24.74,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,24.74,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,30.31,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,71.78,74% OF Billed Charges,66.93,69% of Billed Charges,66.93,69% of Billed charges,24.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,66.93,69% of Billed Charges,66.93,69% of Billed Charges,81.48,84% of Billed Charges,79.54,Pays Based On Per Visit,44.05,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,44.05,500% of HEALTHLINK HMO Fees Schedule,44.05,500% of HEALTHLINK PPO Fees Schedule,5.8,120% of HEALTHY BLUE Fees Schedule,5.8,120% of HOMESTATE Fees Schedule,5.8,120% of MO Fee Schedule,24.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,74.69,77% of Billed Charges,82.45,85% of Billed Charges,27.89,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,5.8,120% of UHC COMMUNITY PLAN fee Schedule,24.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,24.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,5.8,82.45,48.5
Outpatient Medical Services,LABORATORY,83690,Lipase (fat enzyme) level,301,164.5,126.67,77% of Billed Charges,41.95,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,41.95,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,51.41,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,121.73,74% OF Billed Charges,113.51,69% of Billed Charges,113.51,69% of Billed charges,41.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,113.51,69% of Billed Charges,113.51,69% of Billed Charges,138.18,84% of Billed Charges,134.89,Pays Based On Per Visit,50.3,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,50.3,500% of HEALTHLINK HMO Fees Schedule,50.3,500% of HEALTHLINK PPO Fees Schedule,6.61,120% of HEALTHY BLUE Fees Schedule,6.61,120% of HOMESTATE Fees Schedule,6.61,120% of MO Fee Schedule,41.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,126.67,77% of Billed Charges,139.83,85% of Billed Charges,47.29,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,6.61,120% of UHC COMMUNITY PLAN fee Schedule,41.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,41.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,6.61,139.83,82.25
Outpatient Medical Services,LABORATORY,83735,Serum Magnesium,301,87.5,67.38,77% of Billed Charges,22.31,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,22.31,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,27.34,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,64.75,74% OF Billed Charges,60.38,69% of Billed Charges,60.38,69% of Billed charges,21.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,60.38,69% of Billed Charges,60.38,69% of Billed Charges,73.5,84% of Billed Charges,71.75,Pays Based On Per Visit,48.9,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,48.9,500% of HEALTHLINK HMO Fees Schedule,48.9,500% of HEALTHLINK PPO Fees Schedule,6.43,120% of HEALTHY BLUE Fees Schedule,6.43,120% of HOMESTATE Fees Schedule,6.43,120% of MO Fee Schedule,21.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,67.38,77% of Billed Charges,74.38,85% of Billed Charges,25.16,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,6.43,120% of UHC COMMUNITY PLAN fee Schedule,21.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,21.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,6.43,74.38,43.75
Outpatient Medical Services,LABORATORY,83880,Assay of natriuretic peptide,301,298.5,229.85,77% of Billed Charges,76.12,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,76.12,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,93.28,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,220.89,74% OF Billed Charges,205.97,69% of Billed Charges,205.97,69% of Billed charges,74.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,205.97,69% of Billed Charges,205.97,69% of Billed Charges,250.74,84% of Billed Charges,244.77,Pays Based On Per Visit,203.7,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,203.7,500% of HEALTHLINK HMO Fees Schedule,203.7,500% of HEALTHLINK PPO Fees Schedule,37.68,120% of HEALTHY BLUE Fees Schedule,37.68,120% of HOMESTATE Fees Schedule,37.68,120% of MO Fee Schedule,74.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,229.85,77% of Billed Charges,253.73,85% of Billed Charges,85.82,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,37.68,120% of UHC COMMUNITY PLAN fee Schedule,74.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,74.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,37.68,253.73,149.25
Outpatient Medical Services,LABORATORY,84144,Progerstone,301,132,101.64,77% of Billed Charges,33.66,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,33.66,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,41.25,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,97.68,74% OF Billed Charges,91.08,69% of Billed Charges,91.08,69% of Billed charges,33,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,91.08,69% of Billed Charges,91.08,69% of Billed Charges,110.88,84% of Billed Charges,108.24,Pays Based On Per Visit,152.3,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,152.3,500% of HEALTHLINK HMO Fees Schedule,152.3,500% of HEALTHLINK PPO Fees Schedule,20.02,120% of HEALTHY BLUE Fees Schedule,20.02,120% of HOMESTATE Fees Schedule,20.02,120% of MO Fee Schedule,33,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,101.64,77% of Billed Charges,112.2,85% of Billed Charges,37.95,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,20.02,120% of UHC COMMUNITY PLAN fee Schedule,33,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,33,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,20.02,152.3,66
Outpatient Medical Services,LABORATORY,84145,procalcitonin (hormone) level,301,235.5,181.34,77% of Billed Charges,60.05,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,60.05,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,73.59,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,174.27,74% OF Billed Charges,162.5,69% of Billed Charges,162.5,69% of Billed charges,58.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,162.5,69% of Billed Charges,162.5,69% of Billed Charges,197.82,84% of Billed Charges,193.11,Pays Based On Per Visit,209.6,89% of Billed Charges,209.6,89% of Billed Charges,209.6,89% of Billed Charges,26.12,120% of HEALTHY BLUE Fees Schedule,26.12,120% of HOMESTATE Fees Schedule,26.12,120% of MO Fee Schedule,58.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,181.34,77% of Billed Charges,200.18,85% of Billed Charges,67.71,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,26.12,120% of UHC COMMUNITY PLAN fee Schedule,58.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,58.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,26.12,209.6,117.75
Outpatient Medical Services,LABORATORY,84146,Prolactin lab,301,152,117.04,77% of Billed Charges,38.76,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,38.76,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,47.5,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,112.48,74% OF Billed Charges,104.88,69% of Billed Charges,104.88,69% of Billed charges,38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,104.88,69% of Billed Charges,104.88,69% of Billed Charges,127.68,84% of Billed Charges,124.64,Pays Based On Per Visit,141.5,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,141.5,500% of HEALTHLINK HMO Fees Schedule,141.5,500% of HEALTHLINK PPO Fees Schedule,18.6,120% of HEALTHY BLUE Fees Schedule,18.6,120% of HOMESTATE Fees Schedule,18.6,120% of MO Fee Schedule,38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,117.04,77% of Billed Charges,129.2,85% of Billed Charges,43.7,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,18.6,120% of UHC COMMUNITY PLAN fee Schedule,38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,18.6,141.5,76
Outpatient Medical Services,LABORATORY,84153,PSA (prostate specific antigen),301,167,128.59,77% of Billed Charges,42.59,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,42.59,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,52.19,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,123.58,74% OF Billed Charges,115.23,69% of Billed Charges,115.23,69% of Billed charges,41.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,115.23,69% of Billed Charges,115.23,69% of Billed Charges,140.28,84% of Billed Charges,136.94,Pays Based On Per Visit,134.25,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,134.25,500% of HEALTHLINK HMO Fees Schedule,134.25,500% of HEALTHLINK PPO Fees Schedule,17.65,120% of HEALTHY BLUE Fees Schedule,17.65,120% of HOMESTATE Fees Schedule,17.65,120% of MO Fee Schedule,41.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,128.59,77% of Billed Charges,141.95,85% of Billed Charges,48.01,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,17.65,120% of UHC COMMUNITY PLAN fee Schedule,41.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,41.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,17.65,141.95,83.5
Outpatient Medical Services,LABORATORY,84154,PSA (prostate specific antigen) measurement,301,245,188.65,77% of Billed Charges,62.48,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,62.48,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,76.56,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,181.3,74% OF Billed Charges,169.05,69% of Billed Charges,169.05,69% of Billed charges,61.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,169.05,69% of Billed Charges,169.05,69% of Billed Charges,205.8,84% of Billed Charges,200.9,Pays Based On Per Visit,134.25,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,134.25,500% of HEALTHLINK HMO Fees Schedule,134.25,500% of HEALTHLINK PPO Fees Schedule,17.65,120% of HEALTHY BLUE Fees Schedule,17.65,120% of HOMESTATE Fees Schedule,17.65,120% of MO Fee Schedule,61.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,188.65,77% of Billed Charges,208.25,85% of Billed Charges,70.44,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,17.65,120% of UHC COMMUNITY PLAN fee Schedule,61.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,61.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,17.65,208.25,122.5
Outpatient Medical Services,LABORATORY,84156,"Protein, total, except by refractometry",301,118.5,91.25,77% of Billed Charges,30.22,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,30.22,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,37.03,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,87.69,74% OF Billed Charges,81.77,69% of Billed Charges,81.77,69% of Billed charges,29.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,81.77,69% of Billed Charges,81.77,69% of Billed Charges,99.54,84% of Billed Charges,97.17,Pays Based On Per Visit,26.75,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,26.75,500% of HEALTHLINK HMO Fees Schedule,26.75,500% of HEALTHLINK PPO Fees Schedule,3.52,120% of HEALTHY BLUE Fees Schedule,3.52,120% of HOMESTATE Fees Schedule,3.52,120% of MO Fee Schedule,29.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,91.25,77% of Billed Charges,100.73,85% of Billed Charges,34.07,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,3.52,120% of UHC COMMUNITY PLAN fee Schedule,29.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,29.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,3.52,100.73,59.25
Outpatient Medical Services,LABORATORY,84402,"Testosterone, Free and Total",301,235,180.95,77% of Billed Charges,59.93,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,59.93,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,73.44,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,173.9,74% OF Billed Charges,162.15,69% of Billed Charges,162.15,69% of Billed charges,58.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,162.15,69% of Billed Charges,162.15,69% of Billed Charges,197.4,84% of Billed Charges,192.7,Pays Based On Per Visit,185.9,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,185.9,500% of HEALTHLINK HMO Fees Schedule,185.9,500% of HEALTHLINK PPO Fees Schedule,24.44,120% of HEALTHY BLUE Fees Schedule,24.44,120% of HOMESTATE Fees Schedule,24.44,120% of MO Fee Schedule,58.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,180.95,77% of Billed Charges,199.75,85% of Billed Charges,67.56,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,24.44,120% of UHC COMMUNITY PLAN fee Schedule,58.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,58.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,24.44,199.75,117.5
Outpatient Medical Services,LABORATORY,84403,Testosterone Total,301,291,224.07,77% of Billed Charges,74.21,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,74.21,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,90.94,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,215.34,74% OF Billed Charges,200.79,69% of Billed Charges,200.79,69% of Billed charges,72.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,200.79,69% of Billed Charges,200.79,69% of Billed Charges,244.44,84% of Billed Charges,238.62,Pays Based On Per Visit,188.5,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,188.5,500% of HEALTHLINK HMO Fees Schedule,188.5,500% of HEALTHLINK PPO Fees Schedule,24.77,120% of HEALTHY BLUE Fees Schedule,24.77,120% of HOMESTATE Fees Schedule,24.77,120% of MO Fee Schedule,72.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,224.07,77% of Billed Charges,247.35,85% of Billed Charges,83.66,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,24.77,120% of UHC COMMUNITY PLAN fee Schedule,72.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,72.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,24.77,247.35,145.5
Outpatient Medical Services,LABORATORY,84439,Thyroid Funtion Test,301,153,117.81,77% of Billed Charges,39.02,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,39.02,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,47.81,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,113.22,74% OF Billed Charges,105.57,69% of Billed Charges,105.57,69% of Billed charges,38.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,105.57,69% of Billed Charges,105.57,69% of Billed Charges,128.52,84% of Billed Charges,125.46,Pays Based On Per Visit,65.85,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,65.85,500% of HEALTHLINK HMO Fees Schedule,65.85,500% of HEALTHLINK PPO Fees Schedule,8.65,120% of HEALTHY BLUE Fees Schedule,8.65,120% of HOMESTATE Fees Schedule,8.65,120% of MO Fee Schedule,38.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,117.81,77% of Billed Charges,130.05,85% of Billed Charges,43.99,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,8.65,120% of UHC COMMUNITY PLAN fee Schedule,38.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,38.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,8.65,130.05,76.5
Outpatient Medical Services,LABORATORY,84443,"Blood test, thyroid stimulating hormone (TSH)",301,152,117.04,77% of Billed Charges,38.76,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,38.76,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,47.5,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,112.48,74% OF Billed Charges,104.88,69% of Billed Charges,104.88,69% of Billed charges,38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,104.88,69% of Billed Charges,104.88,69% of Billed Charges,127.68,84% of Billed Charges,124.64,Pays Based On Per Visit,122.65,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,122.65,500% of HEALTHLINK HMO Fees Schedule,122.65,500% of HEALTHLINK PPO Fees Schedule,16.13,120% of HEALTHY BLUE Fees Schedule,16.13,120% of HOMESTATE Fees Schedule,16.13,120% of MO Fee Schedule,38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,117.04,77% of Billed Charges,129.2,85% of Billed Charges,43.7,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,16.13,120% of UHC COMMUNITY PLAN fee Schedule,38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,16.13,129.2,76
Outpatient Medical Services,LABORATORY,84480,T3 test,301,124,95.48,77% of Billed Charges,31.62,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,31.62,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,38.75,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,91.76,74% OF Billed Charges,85.56,69% of Billed Charges,85.56,69% of Billed charges,31,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,85.56,69% of Billed Charges,85.56,69% of Billed Charges,104.16,84% of Billed Charges,101.68,Pays Based On Per Visit,103.5,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,103.5,500% of HEALTHLINK HMO Fees Schedule,103.5,500% of HEALTHLINK PPO Fees Schedule,13.61,120% of HEALTHY BLUE Fees Schedule,13.61,120% of HOMESTATE Fees Schedule,13.61,120% of MO Fee Schedule,31,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,95.48,77% of Billed Charges,105.4,85% of Billed Charges,35.65,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,13.61,120% of UHC COMMUNITY PLAN fee Schedule,31,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,31,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,13.61,105.4,62
Outpatient Medical Services,LABORATORY,84481,Triiodothyronine Unbound T3,301,124,95.48,77% of Billed Charges,31.62,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,31.62,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,38.75,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,91.76,74% OF Billed Charges,85.56,69% of Billed Charges,85.56,69% of Billed charges,31,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,85.56,69% of Billed Charges,85.56,69% of Billed Charges,104.16,84% of Billed Charges,101.68,Pays Based On Per Visit,123.7,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,123.7,500% of HEALTHLINK HMO Fees Schedule,123.7,500% of HEALTHLINK PPO Fees Schedule,16.26,120% of HEALTHY BLUE Fees Schedule,16.26,120% of HOMESTATE Fees Schedule,16.26,120% of MO Fee Schedule,31,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,95.48,77% of Billed Charges,105.4,85% of Billed Charges,35.65,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,16.26,120% of UHC COMMUNITY PLAN fee Schedule,31,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,31,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,16.26,123.7,62
Outpatient Medical Services,LABORATORY,84484,"Troponin, quantitative",301,179.5,138.22,77% of Billed Charges,45.77,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,45.77,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,56.09,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,132.83,74% OF Billed Charges,123.86,69% of Billed Charges,123.86,69% of Billed charges,44.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,123.86,69% of Billed Charges,123.86,69% of Billed Charges,150.78,84% of Billed Charges,147.19,Pays Based On Per Visit,71.85,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,71.85,500% of HEALTHLINK HMO Fees Schedule,71.85,500% of HEALTHLINK PPO Fees Schedule,11.96,120% of HEALTHY BLUE Fees Schedule,11.96,120% of HOMESTATE Fees Schedule,11.96,120% of MO Fee Schedule,44.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,138.22,77% of Billed Charges,152.58,85% of Billed Charges,51.61,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,11.96,120% of UHC COMMUNITY PLAN fee Schedule,44.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,44.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,11.96,152.58,89.75
Outpatient Medical Services,LABORATORY,84520,Urea nitrogen,301,68.5,52.75,77% of Billed Charges,17.47,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,17.47,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,21.41,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,50.69,74% OF Billed Charges,47.27,69% of Billed Charges,47.27,69% of Billed charges,17.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,47.27,69% of Billed Charges,47.27,69% of Billed Charges,57.54,84% of Billed Charges,56.17,Pays Based On Per Visit,28.8,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,28.8,500% of HEALTHLINK HMO Fees Schedule,28.8,500% of HEALTHLINK PPO Fees Schedule,3.79,120% of HEALTHY BLUE Fees Schedule,3.79,120% of HOMESTATE Fees Schedule,3.79,120% of MO Fee Schedule,17.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,52.75,77% of Billed Charges,58.23,85% of Billed Charges,19.69,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,3.79,120% of UHC COMMUNITY PLAN fee Schedule,17.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,17.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,3.79,64,34.25
Outpatient Medical Services,LABORATORY,84550,Uric Acid,301,84,64.68,77% of Billed Charges,21.42,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,21.42,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,26.25,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,62.16,74% OF Billed Charges,57.96,69% of Billed Charges,57.96,69% of Billed charges,21,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,57.96,69% of Billed Charges,57.96,69% of Billed Charges,70.56,84% of Billed Charges,68.88,Pays Based On Per Visit,32.95,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,32.95,500% of HEALTHLINK HMO Fees Schedule,32.95,500% of HEALTHLINK PPO Fees Schedule,4.33,120% of HEALTHY BLUE Fees Schedule,4.33,120% of HOMESTATE Fees Schedule,4.33,120% of MO Fee Schedule,21,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,64.68,77% of Billed Charges,71.4,85% of Billed Charges,24.15,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,4.33,120% of UHC COMMUNITY PLAN fee Schedule,21,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,21,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,4.33,71.4,42
Outpatient Medical Services,LABORATORY,84702,"Gonadotropin, chorionic (hCG)",301,210,161.7,77% of Billed Charges,53.55,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,53.55,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,65.63,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,155.4,74% OF Billed Charges,144.9,69% of Billed Charges,144.9,69% of Billed charges,52.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,144.9,69% of Billed Charges,144.9,69% of Billed Charges,176.4,84% of Billed Charges,172.2,Pays Based On Per Visit,51,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,51,500% of HEALTHLINK HMO Fees Schedule,51,500% of HEALTHLINK PPO Fees Schedule,14.45,120% of HEALTHY BLUE Fees Schedule,14.45,120% of HOMESTATE Fees Schedule,14.45,120% of MO Fee Schedule,52.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,161.7,77% of Billed Charges,178.5,85% of Billed Charges,60.38,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,14.45,120% of UHC COMMUNITY PLAN fee Schedule,52.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,52.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,14.45,178.5,105
Outpatient Medical Services,LABORATORY,84703,"Gonadotropin, chorionic (hCG)",301,101.4,78.08,77% of Billed Charges,25.86,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,25.86,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,31.69,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,75.04,74% OF Billed Charges,69.97,69% of Billed Charges,69.97,69% of Billed charges,25.35,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,69.97,69% of Billed Charges,69.97,69% of Billed Charges,85.18,84% of Billed Charges,83.15,Pays Based On Per Visit,54.85,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,54.85,500% of HEALTHLINK HMO Fees Schedule,54.85,500% of HEALTHLINK PPO Fees Schedule,7.21,120% of HEALTHY BLUE Fees Schedule,7.21,120% of HOMESTATE Fees Schedule,7.21,120% of MO Fee Schedule,25.35,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,78.08,77% of Billed Charges,86.19,85% of Billed Charges,29.15,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,7.21,120% of UHC COMMUNITY PLAN fee Schedule,25.35,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,25.35,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,7.21,86.19,50.7
Outpatient Medical Services,LABORATORY,85007,"blood smear, with differential WBC count",305,52,40.04,77% of Billed Charges,13.26,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,13.26,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,16.25,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,38.48,74% OF Billed Charges,35.88,69% of Billed Charges,35.88,69% of Billed charges,13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,35.88,69% of Billed Charges,35.88,69% of Billed Charges,43.68,84% of Billed Charges,42.64,Pays Based On Per Visit,21,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,21,500% of HEALTHLINK HMO Fees Schedule,21,500% of HEALTHLINK PPO Fees Schedule,3.65,120% of HEALTHY BLUE Fees Schedule,3.65,120% of HOMESTATE Fees Schedule,3.65,120% of MO Fee Schedule,13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,40.04,77% of Billed Charges,44.2,85% of Billed Charges,14.95,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,3.65,120% of UHC COMMUNITY PLAN fee Schedule,13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,3.65,64,26
Outpatient Medical Services,LABORATORY,85018,hemoglobin and hematocrit,305,50,38.5,77% of Billed Charges,12.75,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,12.75,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,15.63,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,37,74% OF Billed Charges,34.5,69% of Billed Charges,34.5,69% of Billed charges,12.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,34.5,69% of Billed Charges,34.5,69% of Billed Charges,42,84% of Billed Charges,41,Pays Based On Per Visit,17.3,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,17.3,500% of HEALTHLINK HMO Fees Schedule,17.3,500% of HEALTHLINK PPO Fees Schedule,2.27,120% of HEALTHY BLUE Fees Schedule,2.27,120% of HOMESTATE Fees Schedule,2.27,120% of MO Fee Schedule,12.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,38.5,77% of Billed Charges,42.5,85% of Billed Charges,14.38,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,2.27,120% of UHC COMMUNITY PLAN fee Schedule,12.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,12.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,2.27,64,25
Outpatient Medical Services,LABORATORY,85025,"Complete blood cell count, with differential white blood cells, automated",300,113,87.01,77% of Billed Charges,28.82,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,28.82,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,35.31,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,83.62,74% OF Billed Charges,77.97,69% of Billed Charges,77.97,69% of Billed charges,28.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,77.97,69% of Billed Charges,77.97,69% of Billed Charges,94.92,84% of Billed Charges,92.66,Pays Based On Per Visit,56.75,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,56.75,500% of HEALTHLINK HMO Fees Schedule,56.75,500% of HEALTHLINK PPO Fees Schedule,7.45,120% of HEALTHY BLUE Fees Schedule,7.45,120% of HOMESTATE Fees Schedule,7.45,120% of MO Fee Schedule,28.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,87.01,77% of Billed Charges,96.05,85% of Billed Charges,32.49,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,7.45,120% of UHC COMMUNITY PLAN fee Schedule,28.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,28.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,7.45,96.05,56.5
Outpatient Medical Services,LABORATORY,85027,"Complete blood count, automated",305,95.5,73.54,77% of Billed Charges,24.35,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,24.35,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,29.84,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,70.67,74% OF Billed Charges,65.9,69% of Billed Charges,65.9,69% of Billed charges,23.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,65.9,69% of Billed Charges,65.9,69% of Billed Charges,80.22,84% of Billed Charges,78.31,Pays Based On Per Visit,47.25,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,47.25,500% of HEALTHLINK HMO Fees Schedule,47.25,500% of HEALTHLINK PPO Fees Schedule,6.2,120% of HEALTHY BLUE Fees Schedule,6.2,120% of HOMESTATE Fees Schedule,6.2,120% of MO Fee Schedule,23.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,73.54,77% of Billed Charges,81.18,85% of Billed Charges,27.46,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,6.2,120% of UHC COMMUNITY PLAN fee Schedule,23.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,23.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,6.2,81.18,47.75
Outpatient Medical Services,LABORATORY,85379,D-dimer; quantitative (fibrin degradation products),305,258.5,199.05,77% of Billed Charges,65.92,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,65.92,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,80.78,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,191.29,74% OF Billed Charges,178.37,69% of Billed Charges,178.37,69% of Billed charges,64.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,178.37,69% of Billed Charges,178.37,69% of Billed Charges,217.14,84% of Billed Charges,211.97,Pays Based On Per Visit,74.25,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,74.25,500% of HEALTHLINK HMO Fees Schedule,74.25,500% of HEALTHLINK PPO Fees Schedule,9.77,120% of HEALTHY BLUE Fees Schedule,9.77,120% of HOMESTATE Fees Schedule,9.77,120% of MO Fee Schedule,64.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,199.05,77% of Billed Charges,219.73,85% of Billed Charges,74.32,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,9.77,120% of UHC COMMUNITY PLAN fee Schedule,64.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,64.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,9.77,219.73,129.25
Outpatient Medical Services,LABORATORY,85610,"Blood test, clotting time",305,65,50.05,77% of Billed Charges,16.58,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,16.58,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,20.31,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,48.1,74% OF Billed Charges,44.85,69% of Billed Charges,44.85,69% of Billed charges,16.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,44.85,69% of Billed Charges,44.85,69% of Billed Charges,54.6,84% of Billed Charges,53.3,Pays Based On Per Visit,28.7,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,28.7,500% of HEALTHLINK HMO Fees Schedule,28.7,500% of HEALTHLINK PPO Fees Schedule,4.12,120% of HEALTHY BLUE Fees Schedule,4.12,120% of HOMESTATE Fees Schedule,4.12,120% of MO Fee Schedule,16.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,50.05,77% of Billed Charges,55.25,85% of Billed Charges,18.69,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,4.12,120% of UHC COMMUNITY PLAN fee Schedule,16.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,16.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,4.12,64,32.5
Outpatient Medical Services,LABORATORY,85651,"Sedimentation Rate, Erythrocyte",305,81.5,62.76,77% of Billed Charges,20.78,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,20.78,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,25.47,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,60.31,74% OF Billed Charges,56.24,69% of Billed Charges,56.24,69% of Billed charges,20.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,56.24,69% of Billed Charges,56.24,69% of Billed Charges,68.46,84% of Billed Charges,66.83,Pays Based On Per Visit,25.9,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,25.9,500% of HEALTHLINK HMO Fees Schedule,25.9,500% of HEALTHLINK PPO Fees Schedule,4.09,120% of HEALTHY BLUE Fees Schedule,4.09,120% of HOMESTATE Fees Schedule,4.09,120% of MO Fee Schedule,20.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,62.76,77% of Billed Charges,69.28,85% of Billed Charges,23.43,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,4.09,120% of UHC COMMUNITY PLAN fee Schedule,20.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,20.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,4.09,69.28,40.75
Outpatient Medical Services,LABORATORY,85730,Coagulation assessment blood test,305,98,75.46,77% of Billed Charges,24.99,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,24.99,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,30.63,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,72.52,74% OF Billed Charges,67.62,69% of Billed Charges,67.62,69% of Billed charges,24.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,67.62,69% of Billed Charges,67.62,69% of Billed Charges,82.32,84% of Billed Charges,80.36,Pays Based On Per Visit,43.8,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,43.8,500% of HEALTHLINK HMO Fees Schedule,43.8,500% of HEALTHLINK PPO Fees Schedule,5.76,120% of HEALTHY BLUE Fees Schedule,5.76,120% of HOMESTATE Fees Schedule,5.76,120% of MO Fee Schedule,24.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,75.46,77% of Billed Charges,83.3,85% of Billed Charges,28.18,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,5.76,120% of UHC COMMUNITY PLAN fee Schedule,24.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,24.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,5.76,83.3,49
Outpatient Medical Services,LABORATORY,86003,"Herpes Simplex Virus 1/2 Antibody (IgM), IFA with Reflex to Titer, CSF",302,1073.5,826.6,77% of Billed Charges,273.74,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,273.74,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,335.47,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,794.39,74% OF Billed Charges,740.72,69% of Billed Charges,740.72,69% of Billed charges,268.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,740.72,69% of Billed Charges,740.72,69% of Billed Charges,901.74,84% of Billed Charges,880.27,Pays Based On Per Visit,38.1,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,38.1,500% of HEALTHLINK HMO Fees Schedule,38.1,500% of HEALTHLINK PPO Fees Schedule,5,120% of HEALTHY BLUE Fees Schedule,5,120% of HOMESTATE Fees Schedule,5,120% of MO Fee Schedule,268.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,826.6,77% of Billed Charges,912.48,85% of Billed Charges,308.63,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,5,120% of UHC COMMUNITY PLAN fee Schedule,268.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,268.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,5,912.48,536.75
Outpatient Medical Services,LABORATORY,86038,Antinuclear antibodies (ANA),302,157,120.89,77% of Billed Charges,40.04,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,40.04,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,49.06,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,116.18,74% OF Billed Charges,108.33,69% of Billed Charges,108.33,69% of Billed charges,39.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,108.33,69% of Billed Charges,108.33,69% of Billed Charges,131.88,84% of Billed Charges,128.74,Pays Based On Per Visit,88.25,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,88.25,500% of HEALTHLINK HMO Fees Schedule,88.25,500% of HEALTHLINK PPO Fees Schedule,11.6,120% of HEALTHY BLUE Fees Schedule,11.6,120% of HOMESTATE Fees Schedule,11.6,120% of MO Fee Schedule,39.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,120.89,77% of Billed Charges,133.45,85% of Billed Charges,45.14,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,11.6,120% of UHC COMMUNITY PLAN fee Schedule,39.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,39.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,11.6,133.45,78.5
Outpatient Medical Services,LABORATORY,86039,Antinuclear antibodies (ANA),302,153,117.81,77% of Billed Charges,39.02,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,39.02,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,47.81,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,113.22,74% OF Billed Charges,105.57,69% of Billed Charges,105.57,69% of Billed charges,38.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,105.57,69% of Billed Charges,105.57,69% of Billed Charges,128.52,84% of Billed Charges,125.46,Pays Based On Per Visit,81.5,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,81.5,500% of HEALTHLINK HMO Fees Schedule,81.5,500% of HEALTHLINK PPO Fees Schedule,10.7,120% of HEALTHY BLUE Fees Schedule,10.7,120% of HOMESTATE Fees Schedule,10.7,120% of MO Fee Schedule,38.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,117.81,77% of Billed Charges,130.05,85% of Billed Charges,43.99,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,10.7,120% of UHC COMMUNITY PLAN fee Schedule,38.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,38.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,10.7,130.05,76.5
Outpatient Medical Services,LABORATORY,86140,Qualitative or Semiquantitative Immunoassays.,302,139.5,107.42,77% of Billed Charges,35.57,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,35.57,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,43.59,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,103.23,74% OF Billed Charges,96.26,69% of Billed Charges,96.26,69% of Billed charges,34.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,96.26,69% of Billed Charges,96.26,69% of Billed Charges,117.18,84% of Billed Charges,114.39,Pays Based On Per Visit,37.8,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,37.8,500% of HEALTHLINK HMO Fees Schedule,37.8,500% of HEALTHLINK PPO Fees Schedule,4.97,120% of HEALTHY BLUE Fees Schedule,4.97,120% of HOMESTATE Fees Schedule,4.97,120% of MO Fee Schedule,34.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,107.42,77% of Billed Charges,118.58,85% of Billed Charges,40.11,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,4.97,120% of UHC COMMUNITY PLAN fee Schedule,34.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,34.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,4.97,118.58,69.75
Outpatient Medical Services,LABORATORY,86200,Cyclic Citrullinated Peptide (CCP) Antibody (IgG),302,287,220.99,77% of Billed Charges,73.19,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,73.19,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,89.69,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,212.38,74% OF Billed Charges,198.03,69% of Billed Charges,198.03,69% of Billed charges,71.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,198.03,69% of Billed Charges,198.03,69% of Billed Charges,241.08,84% of Billed Charges,235.34,Pays Based On Per Visit,94.55,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,94.55,500% of HEALTHLINK HMO Fees Schedule,94.55,500% of HEALTHLINK PPO Fees Schedule,12.43,120% of HEALTHY BLUE Fees Schedule,12.43,120% of HOMESTATE Fees Schedule,12.43,120% of MO Fee Schedule,71.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,220.99,77% of Billed Charges,243.95,85% of Billed Charges,82.51,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,12.43,120% of UHC COMMUNITY PLAN fee Schedule,71.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55,Pays Based On Per Visit,71.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,12.43,243.95,143.5
Outpatient Medical Services,LABORATORY,86225,Deoxyribonucleic acid (DNA) antibody; native or double stranded,302,182,140.14,77% of Billed Charges,46.41,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,46.41,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,56.88,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,134.68,74% OF Billed Charges,125.58,69% of Billed Charges,125.58,69% of Billed charges,45.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,125.58,69% of Billed Charges,125.58,69% of Billed Charges,152.88,84% of Billed Charges,149.24,Pays Based On Per Visit,100.3,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,100.3,500% of HEALTHLINK HMO Fees Schedule,100.3,500% of HEALTHLINK PPO Fees Schedule,13.19,120% of HEALTHY BLUE Fees Schedule,13.19,120% of HOMESTATE Fees Schedule,13.19,120% of MO Fee Schedule,45.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,140.14,77% of Billed Charges,154.7,85% of Billed Charges,52.33,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,13.19,120% of UHC COMMUNITY PLAN fee Schedule,45.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,153,Pays Based On Per Visit,45.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,13.19,154.7,91
Outpatient Medical Services,LABORATORY,86235,Nuclear antigen antibody,301,747.5,575.58,77% of Billed Charges,190.61,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,190.61,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,233.59,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,553.15,74% OF Billed Charges,515.78,69% of Billed Charges,515.78,69% of Billed charges,186.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,515.78,69% of Billed Charges,515.78,69% of Billed Charges,627.9,84% of Billed Charges,612.95,Pays Based On Per Visit,130.9,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,130.9,500% of HEALTHLINK HMO Fees Schedule,130.9,500% of HEALTHLINK PPO Fees Schedule,17.21,120% of HEALTHY BLUE Fees Schedule,17.21,120% of HOMESTATE Fees Schedule,17.21,120% of MO Fee Schedule,186.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,575.58,77% of Billed Charges,635.38,85% of Billed Charges,214.91,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,17.21,120% of UHC COMMUNITY PLAN fee Schedule,186.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,153,Pays Based On Per Visit,186.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,17.21,635.38,373.75
Outpatient Medical Services,LABORATORY,86376,Thyroid Antibody Panel,302,158.5,122.05,77% of Billed Charges,40.42,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,40.42,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,49.53,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,117.29,74% OF Billed Charges,109.37,69% of Billed Charges,109.37,69% of Billed charges,39.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,109.37,69% of Billed Charges,109.37,69% of Billed Charges,133.14,84% of Billed Charges,129.97,Pays Based On Per Visit,106.25,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,106.25,500% of HEALTHLINK HMO Fees Schedule,106.25,500% of HEALTHLINK PPO Fees Schedule,13.97,120% of HEALTHY BLUE Fees Schedule,13.97,120% of HOMESTATE Fees Schedule,13.97,120% of MO Fee Schedule,39.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,122.05,77% of Billed Charges,134.73,85% of Billed Charges,45.57,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,13.97,120% of UHC COMMUNITY PLAN fee Schedule,39.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,153,Pays Based On Per Visit,39.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,13.97,153,79.25
Outpatient Medical Services,LABORATORY,86430,RA RF with reflex titer Rheumatoid Arthritis Factor with reflex titer,302,90,69.3,77% of Billed Charges,22.95,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,22.95,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,28.13,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,66.6,74% OF Billed Charges,62.1,69% of Billed Charges,62.1,69% of Billed charges,22.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,62.1,69% of Billed Charges,62.1,69% of Billed Charges,75.6,84% of Billed Charges,73.8,Pays Based On Per Visit,41.45,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,41.45,500% of HEALTHLINK HMO Fees Schedule,41.45,500% of HEALTHLINK PPO Fees Schedule,5.89,120% of HEALTHY BLUE Fees Schedule,5.89,120% of HOMESTATE Fees Schedule,5.89,120% of MO Fee Schedule,22.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,69.3,77% of Billed Charges,76.5,85% of Billed Charges,25.88,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,5.89,120% of UHC COMMUNITY PLAN fee Schedule,22.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,153,Pays Based On Per Visit,22.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,5.89,153,45
Outpatient Medical Services,LABORATORY,86592,"Syphilis test, non-treponemal antibody",302,71.5,55.06,77% of Billed Charges,18.23,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,18.23,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,22.34,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,52.91,74% OF Billed Charges,49.34,69% of Billed Charges,49.34,69% of Billed charges,17.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,49.34,69% of Billed Charges,49.34,69% of Billed Charges,60.06,84% of Billed Charges,58.63,Pays Based On Per Visit,31.15,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,31.15,500% of HEALTHLINK HMO Fees Schedule,31.15,500% of HEALTHLINK PPO Fees Schedule,4.09,120% of HEALTHY BLUE Fees Schedule,4.09,120% of HOMESTATE Fees Schedule,4.09,120% of MO Fee Schedule,17.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,55.06,77% of Billed Charges,60.78,85% of Billed Charges,20.56,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,4.09,120% of UHC COMMUNITY PLAN fee Schedule,17.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,1280,Pays Based On Per Visit,17.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,4.09,1280,35.75
Outpatient Medical Services,LABORATORY,86696,Test panel that detects the flu and respiratory syncytial virus (RSV) infections,302,200,154,77% of Billed Charges,51,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,51,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,62.5,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,148,74% OF Billed Charges,138,69% of Billed Charges,138,69% of Billed charges,50,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,138,69% of Billed Charges,138,69% of Billed Charges,168,84% of Billed Charges,164,Pays Based On Per Visit,141.3,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,141.3,500% of HEALTHLINK HMO Fees Schedule,141.3,500% of HEALTHLINK PPO Fees Schedule,18.58,120% of HEALTHY BLUE Fees Schedule,18.58,120% of HOMESTATE Fees Schedule,18.58,120% of MO Fee Schedule,50,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,154,77% of Billed Charges,170,85% of Billed Charges,57.5,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,18.58,120% of UHC COMMUNITY PLAN fee Schedule,50,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,1280,Pays Based On Per Visit,50,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,18.58,1280,100
Outpatient Medical Services,LABORATORY,86710,antibody serum test for influenza,302,112,86.24,77% of Billed Charges,28.56,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,28.56,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,35,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,82.88,74% OF Billed Charges,77.28,69% of Billed Charges,77.28,69% of Billed charges,28,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,77.28,69% of Billed Charges,77.28,69% of Billed Charges,94.08,84% of Billed Charges,91.84,Pays Based On Per Visit,55.8,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,55.8,500% of HEALTHLINK HMO Fees Schedule,55.8,500% of HEALTHLINK PPO Fees Schedule,13.01,120% of HEALTHY BLUE Fees Schedule,13.01,120% of HOMESTATE Fees Schedule,13.01,120% of MO Fee Schedule,28,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,86.24,77% of Billed Charges,95.2,85% of Billed Charges,32.2,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,13.01,120% of UHC COMMUNITY PLAN fee Schedule,28,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,1280,Pays Based On Per Visit,28,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,13.01,1280,56
Outpatient Medical Services,LABORATORY,86769,Antibody; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]),300,225.5,173.64,77% of Billed Charges,57.5,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,57.5,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,70.47,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,166.87,74% OF Billed Charges,155.6,69% of Billed Charges,155.6,69% of Billed charges,56.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,155.6,69% of Billed Charges,155.6,69% of Billed Charges,189.42,84% of Billed Charges,184.91,Pays Based On Per Visit,200.7,89% of Billed Charges,200.7,89% of Billed Charges,200.7,89% of Billed Charges,36.4,120% of HEALTHY BLUE Fees Schedule,36.4,120% of HOMESTATE Fees Schedule,36.4,120% of MO Fee Schedule,56.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,173.64,77% of Billed Charges,191.68,85% of Billed Charges,64.83,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,36.4,120% of UHC COMMUNITY PLAN fee Schedule,56.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,1280,Pays Based On Per Visit,56.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,36.4,1280,112.75
Outpatient Medical Services,LABORATORY,86787,Varicella-Zoster Virus Antibody,302,232,178.64,77% of Billed Charges,59.16,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,59.16,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,72.5,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,171.68,74% OF Billed Charges,160.08,69% of Billed Charges,160.08,69% of Billed charges,58,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,160.08,69% of Billed Charges,160.08,69% of Billed Charges,194.88,84% of Billed Charges,190.24,Pays Based On Per Visit,94.05,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,94.05,500% of HEALTHLINK HMO Fees Schedule,94.05,500% of HEALTHLINK PPO Fees Schedule,12.36,120% of HEALTHY BLUE Fees Schedule,12.36,120% of HOMESTATE Fees Schedule,12.36,120% of MO Fee Schedule,58,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,178.64,77% of Billed Charges,197.2,85% of Billed Charges,66.7,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,12.36,120% of UHC COMMUNITY PLAN fee Schedule,58,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,1280,Pays Based On Per Visit,58,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,12.36,1280,116
Outpatient Medical Services,LABORATORY,86800,TPO Antibody Thyroglobulin Antibody (Anti-Tg),301,279,214.83,77% of Billed Charges,71.15,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,71.15,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,87.19,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,206.46,74% OF Billed Charges,192.51,69% of Billed Charges,192.51,69% of Billed charges,69.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,192.51,69% of Billed Charges,192.51,69% of Billed Charges,234.36,84% of Billed Charges,228.78,Pays Based On Per Visit,116.1,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,116.1,500% of HEALTHLINK HMO Fees Schedule,116.1,500% of HEALTHLINK PPO Fees Schedule,15.26,120% of HEALTHY BLUE Fees Schedule,15.26,120% of HOMESTATE Fees Schedule,15.26,120% of MO Fee Schedule,69.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,214.83,77% of Billed Charges,237.15,85% of Billed Charges,80.21,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,15.26,120% of UHC COMMUNITY PLAN fee Schedule,69.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,1280,Pays Based On Per Visit,69.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,15.26,1280,139.5
Outpatient Medical Services,LABORATORY,86803,Hepatitis C antibody.,302,54,41.58,77% of Billed Charges,13.77,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,13.77,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,16.88,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,39.96,74% OF Billed Charges,37.26,69% of Billed Charges,37.26,69% of Billed charges,13.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,37.26,69% of Billed Charges,37.26,69% of Billed Charges,45.36,84% of Billed Charges,44.28,Pays Based On Per Visit,104.2,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,104.2,500% of HEALTHLINK HMO Fees Schedule,104.2,500% of HEALTHLINK PPO Fees Schedule,13.69,120% of HEALTHY BLUE Fees Schedule,13.69,120% of HOMESTATE Fees Schedule,13.69,120% of MO Fee Schedule,13.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,41.58,77% of Billed Charges,45.9,85% of Billed Charges,15.53,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,13.69,120% of UHC COMMUNITY PLAN fee Schedule,13.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,1280,Pays Based On Per Visit,13.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,13.5,1280,27
Outpatient Medical Services,LABORATORY,86812,HLA-B27 Antigen,302,562.5,433.13,77% of Billed Charges,143.44,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,143.44,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,175.78,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,416.25,74% OF Billed Charges,388.13,69% of Billed Charges,388.13,69% of Billed charges,140.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,388.13,69% of Billed Charges,388.13,69% of Billed Charges,472.5,84% of Billed Charges,461.25,Pays Based On Per Visit,188.4,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,188.4,500% of HEALTHLINK HMO Fees Schedule,188.4,500% of HEALTHLINK PPO Fees Schedule,24.77,120% of HEALTHY BLUE Fees Schedule,24.77,120% of HOMESTATE Fees Schedule,24.77,120% of MO Fee Schedule,140.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,433.13,77% of Billed Charges,478.13,85% of Billed Charges,161.72,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,24.77,120% of UHC COMMUNITY PLAN fee Schedule,140.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,733,Pays Based On Per Visit,140.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,24.77,733,281.25
Outpatient Medical Services,LABORATORY,86886,Antihuman globulin test,300,241,185.57,77% of Billed Charges,61.46,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,61.46,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,75.31,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,178.34,74% OF Billed Charges,166.29,69% of Billed Charges,166.29,69% of Billed charges,60.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,166.29,69% of Billed Charges,166.29,69% of Billed Charges,202.44,84% of Billed Charges,197.62,Pays Based On Per Visit,37.8,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,37.8,500% of HEALTHLINK HMO Fees Schedule,37.8,500% of HEALTHLINK PPO Fees Schedule,4.97,120% of HEALTHY BLUE Fees Schedule,4.97,120% of HOMESTATE Fees Schedule,4.97,120% of MO Fee Schedule,60.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,185.57,77% of Billed Charges,204.85,85% of Billed Charges,69.29,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,4.97,120% of UHC COMMUNITY PLAN fee Schedule,60.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,1978,Pays Based On Per Visit,60.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,4.97,1978,120.5
Outpatient Medical Services,LABORATORY,86900,Blood Typing Test,300,108.5,83.55,77% of Billed Charges,27.67,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,27.67,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,33.91,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,80.29,74% OF Billed Charges,74.87,69% of Billed Charges,74.87,69% of Billed charges,27.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,74.87,69% of Billed Charges,74.87,69% of Billed Charges,91.14,84% of Billed Charges,88.97,Pays Based On Per Visit,21.75,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,21.75,500% of HEALTHLINK HMO Fees Schedule,21.75,500% of HEALTHLINK PPO Fees Schedule,2.87,120% of HEALTHY BLUE Fees Schedule,2.87,120% of HOMESTATE Fees Schedule,2.87,120% of MO Fee Schedule,27.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,83.55,77% of Billed Charges,92.23,85% of Billed Charges,31.19,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,2.87,120% of UHC COMMUNITY PLAN fee Schedule,27.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,235,Pays Based On Per Visit,27.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,2.87,235,54.25
Outpatient Medical Services,LABORATORY,86901,RH Blood Typing Test,309,108.5,83.55,77% of Billed Charges,27.67,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,27.67,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,33.91,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,80.29,74% OF Billed Charges,74.87,69% of Billed Charges,74.87,69% of Billed charges,27.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,74.87,69% of Billed Charges,74.87,69% of Billed Charges,91.14,84% of Billed Charges,88.97,Pays Based On Per Visit,21.75,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,21.75,500% of HEALTHLINK HMO Fees Schedule,21.75,500% of HEALTHLINK PPO Fees Schedule,2.87,120% of HEALTHY BLUE Fees Schedule,2.87,120% of HOMESTATE Fees Schedule,2.87,120% of MO Fee Schedule,27.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,83.55,77% of Billed Charges,92.23,85% of Billed Charges,31.19,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,2.87,120% of UHC COMMUNITY PLAN fee Schedule,27.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,235,Pays Based On Per Visit,27.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,2.87,235,54.25
Outpatient Medical Services,LABORATORY,86920,Compatibility test each unit,300,189,145.53,77% of Billed Charges,48.2,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,48.2,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,59.06,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,139.86,74% OF Billed Charges,130.41,69% of Billed Charges,130.41,69% of Billed charges,47.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,130.41,69% of Billed Charges,130.41,69% of Billed Charges,158.76,84% of Billed Charges,154.98,Pays Based On Per Visit,168.21,89% of Billed Charges,168.21,89% of Billed Charges,168.21,89% of Billed Charges,143.18,120% of HEALTHY BLUE Fees Schedule,143.18,120% of HOMESTATE Fees Schedule,143.18,120% of MO Fee Schedule,47.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,145.53,77% of Billed Charges,160.65,85% of Billed Charges,54.34,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,143.18,120% of UHC COMMUNITY PLAN fee Schedule,47.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,235,Pays Based On Per Visit,47.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,47.25,235,94.5
Outpatient Medical Services,LABORATORY,86922,Compatibility test each unit,300,470.5,362.29,77% of Billed Charges,119.98,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,119.98,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,147.03,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,348.17,74% OF Billed Charges,324.65,69% of Billed Charges,324.65,69% of Billed charges,117.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,324.65,69% of Billed Charges,324.65,69% of Billed Charges,395.22,84% of Billed Charges,385.81,Pays Based On Per Visit,418.75,89% of Billed Charges,418.75,89% of Billed Charges,418.75,89% of Billed Charges,143.18,120% of HEALTHY BLUE Fees Schedule,143.18,120% of HOMESTATE Fees Schedule,143.18,120% of MO Fee Schedule,117.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,362.29,77% of Billed Charges,399.93,85% of Billed Charges,135.27,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,143.18,120% of UHC COMMUNITY PLAN fee Schedule,117.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,235,Pays Based On Per Visit,117.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,64,418.75,235.25
Outpatient Medical Services,LABORATORY,87040,"Culture, bacterial; blood aerobic with isolation and presumptive identification of isolates.",306,183.5,141.3,77% of Billed Charges,46.79,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,46.79,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,57.34,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,135.79,74% OF Billed Charges,126.62,69% of Billed Charges,126.62,69% of Billed charges,45.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,126.62,69% of Billed Charges,126.62,69% of Billed Charges,154.14,84% of Billed Charges,150.47,Pays Based On Per Visit,75.35,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,75.35,500% of HEALTHLINK HMO Fees Schedule,75.35,500% of HEALTHLINK PPO Fees Schedule,9.9,120% of HEALTHY BLUE Fees Schedule,9.9,120% of HOMESTATE Fees Schedule,9.9,120% of MO Fee Schedule,45.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,141.3,77% of Billed Charges,155.98,85% of Billed Charges,52.76,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,9.9,120% of UHC COMMUNITY PLAN fee Schedule,45.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,235,Pays Based On Per Visit,45.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,9.9,235,91.75
Outpatient Medical Services,LABORATORY,87070,"Culture, bacterial; any other source but urine, blood or stool, with isolation and presumptive identification of isolates",306,171.5,132.06,77% of Billed Charges,43.73,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,43.73,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,53.59,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,126.91,74% OF Billed Charges,118.34,69% of Billed Charges,118.34,69% of Billed charges,42.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,118.34,69% of Billed Charges,118.34,69% of Billed Charges,144.06,84% of Billed Charges,140.63,Pays Based On Per Visit,62.85,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,62.85,500% of HEALTHLINK HMO Fees Schedule,62.85,500% of HEALTHLINK PPO Fees Schedule,8.27,120% of HEALTHY BLUE Fees Schedule,8.27,120% of HOMESTATE Fees Schedule,8.27,120% of MO Fee Schedule,42.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,132.06,77% of Billed Charges,145.78,85% of Billed Charges,49.31,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,8.27,120% of UHC COMMUNITY PLAN fee Schedule,42.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,235,Pays Based On Per Visit,42.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,8.27,235,85.75
Outpatient Medical Services,LABORATORY,87075,Bacterial Culture,306,148.5,114.35,77% of Billed Charges,37.87,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,37.87,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,46.41,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,109.89,74% OF Billed Charges,102.47,69% of Billed Charges,102.47,69% of Billed charges,37.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,102.47,69% of Billed Charges,102.47,69% of Billed Charges,124.74,84% of Billed Charges,121.77,Pays Based On Per Visit,51.05,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,51.05,500% of HEALTHLINK HMO Fees Schedule,51.05,500% of HEALTHLINK PPO Fees Schedule,9.08,120% of HEALTHY BLUE Fees Schedule,9.08,120% of HOMESTATE Fees Schedule,9.08,120% of MO Fee Schedule,37.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,114.35,77% of Billed Charges,126.23,85% of Billed Charges,42.69,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,9.08,120% of UHC COMMUNITY PLAN fee Schedule,37.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,235,Pays Based On Per Visit,37.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,9.08,235,74.25
Outpatient Medical Services,LABORATORY,87077,"Culture, bacterial; aerobic isolate, additional. methods required for definitive identification, each isolate.",306,157,120.89,77% of Billed Charges,40.04,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,40.04,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,49.06,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,116.18,74% OF Billed Charges,108.33,69% of Billed Charges,108.33,69% of Billed charges,39.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,108.33,69% of Billed Charges,108.33,69% of Billed Charges,131.88,84% of Billed Charges,128.74,Pays Based On Per Visit,59,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,59,500% of HEALTHLINK HMO Fees Schedule,59,500% of HEALTHLINK PPO Fees Schedule,7.75,120% of HEALTHY BLUE Fees Schedule,7.75,120% of HOMESTATE Fees Schedule,7.75,120% of MO Fee Schedule,39.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,120.89,77% of Billed Charges,133.45,85% of Billed Charges,45.14,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,7.75,120% of UHC COMMUNITY PLAN fee Schedule,39.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,235,Pays Based On Per Visit,39.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,7.75,235,78.5
Outpatient Medical Services,LABORATORY,87086,"Urine Culture, Bacteria",306,148.5,114.35,77% of Billed Charges,37.87,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,37.87,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,46.41,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,109.89,74% OF Billed Charges,102.47,69% of Billed Charges,102.47,69% of Billed charges,37.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,102.47,69% of Billed Charges,102.47,69% of Billed Charges,124.74,84% of Billed Charges,121.77,Pays Based On Per Visit,51.05,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,51.05,500% of HEALTHLINK HMO Fees Schedule,51.05,500% of HEALTHLINK PPO Fees Schedule,7.74,120% of HEALTHY BLUE Fees Schedule,7.74,120% of HOMESTATE Fees Schedule,7.74,120% of MO Fee Schedule,37.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,114.35,77% of Billed Charges,126.23,85% of Billed Charges,42.69,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,7.74,120% of UHC COMMUNITY PLAN fee Schedule,37.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,235,Pays Based On Per Visit,37.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,7.74,235,74.25
Outpatient Medical Services,LABORATORY,87088,bacterial urine culture with isolation,306,98,75.46,77% of Billed Charges,24.99,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,24.99,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,30.63,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,72.52,74% OF Billed Charges,67.62,69% of Billed Charges,67.62,69% of Billed charges,24.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,67.62,69% of Billed Charges,67.62,69% of Billed Charges,82.32,84% of Billed Charges,80.36,Pays Based On Per Visit,40.65,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,40.65,500% of HEALTHLINK HMO Fees Schedule,40.65,500% of HEALTHLINK PPO Fees Schedule,7.76,120% of HEALTHY BLUE Fees Schedule,7.76,120% of HOMESTATE Fees Schedule,7.76,120% of MO Fee Schedule,24.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,75.46,77% of Billed Charges,83.3,85% of Billed Charges,28.18,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,7.76,120% of UHC COMMUNITY PLAN fee Schedule,24.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,235,Pays Based On Per Visit,24.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,7.76,235,49
Outpatient Medical Services,LABORATORY,87147,Bordetella LAB9442 Pertussis Whooping Cough,306,79,60.83,77% of Billed Charges,20.15,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,20.15,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,24.69,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,58.46,74% OF Billed Charges,54.51,69% of Billed Charges,54.51,69% of Billed charges,19.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,54.51,69% of Billed Charges,54.51,69% of Billed Charges,66.36,84% of Billed Charges,64.78,Pays Based On Per Visit,30.5,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,30.5,500% of HEALTHLINK HMO Fees Schedule,30.5,500% of HEALTHLINK PPO Fees Schedule,4.97,120% of HEALTHY BLUE Fees Schedule,4.97,120% of HOMESTATE Fees Schedule,4.97,120% of MO Fee Schedule,19.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,60.83,77% of Billed Charges,67.15,85% of Billed Charges,22.71,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,4.97,120% of UHC COMMUNITY PLAN fee Schedule,19.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,235,Pays Based On Per Visit,19.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,4.97,235,39.5
Outpatient Medical Services,LABORATORY,87186,"Susceptibility studies, antimicrobial agent.",306,193.5,149,77% of Billed Charges,49.34,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,49.34,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,60.47,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,143.19,74% OF Billed Charges,133.52,69% of Billed Charges,133.52,69% of Billed charges,48.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,133.52,69% of Billed Charges,133.52,69% of Billed Charges,162.54,84% of Billed Charges,158.67,Pays Based On Per Visit,63.1,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,63.1,500% of HEALTHLINK HMO Fees Schedule,63.1,500% of HEALTHLINK PPO Fees Schedule,8.3,120% of HEALTHY BLUE Fees Schedule,8.3,120% of HOMESTATE Fees Schedule,8.3,120% of MO Fee Schedule,48.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,149,77% of Billed Charges,164.48,85% of Billed Charges,55.63,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,8.3,120% of UHC COMMUNITY PLAN fee Schedule,48.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,235,Pays Based On Per Visit,48.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,8.3,235,96.75
Outpatient Medical Services,LABORATORY,87205,"Smear, primary source with interpretation",306,63,48.51,77% of Billed Charges,16.07,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,16.07,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,19.69,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,46.62,74% OF Billed Charges,43.47,69% of Billed Charges,43.47,69% of Billed charges,15.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,43.47,69% of Billed Charges,43.47,69% of Billed Charges,52.92,84% of Billed Charges,51.66,Pays Based On Per Visit,30.5,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,30.5,500% of HEALTHLINK HMO Fees Schedule,30.5,500% of HEALTHLINK PPO Fees Schedule,4.09,120% of HEALTHY BLUE Fees Schedule,4.09,120% of HOMESTATE Fees Schedule,4.09,120% of MO Fee Schedule,15.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,48.51,77% of Billed Charges,53.55,85% of Billed Charges,18.11,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,4.09,120% of UHC COMMUNITY PLAN fee Schedule,15.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,235,Pays Based On Per Visit,15.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,4.09,235,31.5
Outpatient Medical Services,LABORATORY,87340,"Infectious agent antigen detection by immunoassay technique, [e.g., enzyme immunoassay (EIA), enzyme-linked immunosorbent assay",306,118.5,91.25,77% of Billed Charges,30.22,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,30.22,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,37.03,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,87.69,74% OF Billed Charges,81.77,69% of Billed Charges,81.77,69% of Billed charges,29.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,81.77,69% of Billed Charges,81.77,69% of Billed Charges,99.54,84% of Billed Charges,97.17,Pays Based On Per Visit,74.05,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,74.05,500% of HEALTHLINK HMO Fees Schedule,74.05,500% of HEALTHLINK PPO Fees Schedule,9.91,120% of HEALTHY BLUE Fees Schedule,9.91,120% of HOMESTATE Fees Schedule,9.91,120% of MO Fee Schedule,29.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,91.25,77% of Billed Charges,100.73,85% of Billed Charges,34.07,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,9.91,120% of UHC COMMUNITY PLAN fee Schedule,29.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,235,Pays Based On Per Visit,29.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,9.91,235,59.25
Outpatient Medical Services,LABORATORY,87389,HIV antigen test,306,160.5,123.59,77% of Billed Charges,40.93,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,40.93,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,50.16,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,118.77,74% OF Billed Charges,110.75,69% of Billed Charges,110.75,69% of Billed charges,40.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,110.75,69% of Billed Charges,110.75,69% of Billed Charges,134.82,84% of Billed Charges,131.61,Pays Based On Per Visit,142.85,89% of Billed Charges,142.85,89% of Billed Charges,142.85,89% of Billed Charges,23.11,120% of HEALTHY BLUE Fees Schedule,23.11,120% of HOMESTATE Fees Schedule,23.11,120% of MO Fee Schedule,40.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,123.59,77% of Billed Charges,136.43,85% of Billed Charges,46.14,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,23.11,120% of UHC COMMUNITY PLAN fee Schedule,40.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,235,Pays Based On Per Visit,40.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,23.11,235,80.25
Outpatient Medical Services,LABORATORY,87486,Infectious Agent Antigen Detection.,306,438,337.26,77% of Billed Charges,111.69,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,111.69,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,136.88,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,324.12,74% OF Billed Charges,302.22,69% of Billed Charges,302.22,69% of Billed charges,109.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,302.22,69% of Billed Charges,302.22,69% of Billed Charges,367.92,84% of Billed Charges,359.16,Pays Based On Per Visit,256.25,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,256.25,500% of HEALTHLINK HMO Fees Schedule,256.25,500% of HEALTHLINK PPO Fees Schedule,33.68,120% of HEALTHY BLUE Fees Schedule,33.68,120% of HOMESTATE Fees Schedule,33.68,120% of MO Fee Schedule,109.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,337.26,77% of Billed Charges,372.3,85% of Billed Charges,125.93,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,33.68,120% of UHC COMMUNITY PLAN fee Schedule,109.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,235,Pays Based On Per Visit,109.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,33.68,372.3,219
Outpatient Medical Services,LABORATORY,87491,Routine screening for chlamydia infection,306,62,47.74,77% of Billed Charges,15.81,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,15.81,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,19.38,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,45.88,74% OF Billed Charges,42.78,69% of Billed Charges,42.78,69% of Billed charges,15.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,42.78,69% of Billed Charges,42.78,69% of Billed Charges,52.08,84% of Billed Charges,50.84,Pays Based On Per Visit,256.25,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,256.25,500% of HEALTHLINK HMO Fees Schedule,256.25,500% of HEALTHLINK PPO Fees Schedule,33.68,120% of HEALTHY BLUE Fees Schedule,33.68,120% of HOMESTATE Fees Schedule,33.68,120% of MO Fee Schedule,15.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,47.74,77% of Billed Charges,52.7,85% of Billed Charges,17.83,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,33.68,120% of UHC COMMUNITY PLAN fee Schedule,15.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,235,Pays Based On Per Visit,15.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,15.5,256.25,31
Outpatient Medical Services,LABORATORY,87493,Infectious agent detection by nucleic acid (DNA or RNA),306,302.5,232.93,77% of Billed Charges,77.14,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,77.14,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,94.53,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,223.85,74% OF Billed Charges,208.73,69% of Billed Charges,208.73,69% of Billed charges,75.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,208.73,69% of Billed Charges,208.73,69% of Billed Charges,254.1,84% of Billed Charges,248.05,Pays Based On Per Visit,269.23,89% of Billed Charges,269.23,89% of Billed Charges,269.23,89% of Billed Charges,35.77,120% of HEALTHY BLUE Fees Schedule,35.77,120% of HOMESTATE Fees Schedule,35.77,120% of MO Fee Schedule,75.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,232.93,77% of Billed Charges,257.13,85% of Billed Charges,86.97,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,35.77,120% of UHC COMMUNITY PLAN fee Schedule,75.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,235,Pays Based On Per Visit,75.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,35.77,269.23,151.25
Outpatient Medical Services,LABORATORY,87581,Infectious agent detection by nucleic acid (DNA or RNA,306,438,337.26,77% of Billed Charges,111.69,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,111.69,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,136.88,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,324.12,74% OF Billed Charges,302.22,69% of Billed Charges,302.22,69% of Billed charges,109.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,302.22,69% of Billed Charges,302.22,69% of Billed Charges,367.92,84% of Billed Charges,359.16,Pays Based On Per Visit,256.25,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,256.25,500% of HEALTHLINK HMO Fees Schedule,256.25,500% of HEALTHLINK PPO Fees Schedule,33.68,120% of HEALTHY BLUE Fees Schedule,33.68,120% of HOMESTATE Fees Schedule,33.68,120% of MO Fee Schedule,109.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,337.26,77% of Billed Charges,372.3,85% of Billed Charges,125.93,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,33.68,120% of UHC COMMUNITY PLAN fee Schedule,109.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,235,Pays Based On Per Visit,109.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,33.68,372.3,219
Outpatient Medical Services,LABORATORY,87591,Infectious agent detection by nucleic acid,306,62,47.74,77% of Billed Charges,15.81,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,15.81,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,19.38,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,45.88,74% OF Billed Charges,42.78,69% of Billed Charges,42.78,69% of Billed charges,15.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,42.78,69% of Billed Charges,42.78,69% of Billed Charges,52.08,84% of Billed Charges,50.84,Pays Based On Per Visit,256.25,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,256.25,500% of HEALTHLINK HMO Fees Schedule,256.25,500% of HEALTHLINK PPO Fees Schedule,33.68,120% of HEALTHY BLUE Fees Schedule,33.68,120% of HOMESTATE Fees Schedule,33.68,120% of MO Fee Schedule,15.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,47.74,77% of Billed Charges,52.7,85% of Billed Charges,17.83,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,33.68,120% of UHC COMMUNITY PLAN fee Schedule,15.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,235,Pays Based On Per Visit,15.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,15.5,256.25,31
Outpatient Medical Services,LABORATORY,87624,Infectious Agent Antigen Detection,306,92,70.84,77% of Billed Charges,23.46,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,23.46,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,28.75,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,68.08,74% OF Billed Charges,63.48,69% of Billed Charges,63.48,69% of Billed charges,23,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,63.48,69% of Billed Charges,63.48,69% of Billed Charges,77.28,84% of Billed Charges,75.44,Pays Based On Per Visit,81.88,89% of Billed Charges,81.88,89% of Billed Charges,81.88,89% of Billed Charges,33.68,120% of HEALTHY BLUE Fees Schedule,33.68,120% of HOMESTATE Fees Schedule,33.68,120% of MO Fee Schedule,23,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,70.84,77% of Billed Charges,78.2,85% of Billed Charges,26.45,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,33.68,120% of UHC COMMUNITY PLAN fee Schedule,23,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,235,Pays Based On Per Visit,23,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,23,235,46
Outpatient Medical Services,LABORATORY,87631,test panel that detects the flu and respiratory syncytial virus (RSV) infections,300,563,433.51,77% of Billed Charges,143.57,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,143.57,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,175.94,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,416.62,74% OF Billed Charges,388.47,69% of Billed Charges,388.47,69% of Billed charges,140.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,388.47,69% of Billed Charges,388.47,69% of Billed Charges,472.92,84% of Billed Charges,461.66,Pays Based On Per Visit,501.07,89% of Billed Charges,501.07,89% of Billed Charges,501.07,89% of Billed Charges,136.92,120% of HEALTHY BLUE Fees Schedule,136.92,120% of HOMESTATE Fees Schedule,136.92,120% of MO Fee Schedule,140.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,433.51,77% of Billed Charges,478.55,85% of Billed Charges,161.86,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,136.92,120% of UHC COMMUNITY PLAN fee Schedule,140.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,235,Pays Based On Per Visit,140.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,64,501.07,281.5
Outpatient Medical Services,LABORATORY,87633,Infectious agent detection by nucleic acid (DNA or RNA),300,670,515.9,77% of Billed Charges,170.85,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,170.85,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,209.38,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,495.8,74% OF Billed Charges,462.3,69% of Billed Charges,462.3,69% of Billed charges,167.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,462.3,69% of Billed Charges,462.3,69% of Billed Charges,562.8,84% of Billed Charges,549.4,Pays Based On Per Visit,596.3,89% of Billed Charges,596.3,89% of Billed Charges,596.3,89% of Billed Charges,400.1,120% of HEALTHY BLUE Fees Schedule,400.1,120% of HOMESTATE Fees Schedule,400.1,120% of MO Fee Schedule,167.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,515.9,77% of Billed Charges,569.5,85% of Billed Charges,192.63,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,400.1,120% of UHC COMMUNITY PLAN fee Schedule,167.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,103,Pays Based On Per Visit,167.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,64,596.3,335
Outpatient Medical Services,LABORATORY,87651,Infectious agent detection by nucleic acid (DNA or RNA),306,139,107.03,77% of Billed Charges,35.45,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,35.45,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,43.44,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,102.86,74% OF Billed Charges,95.91,69% of Billed Charges,95.91,69% of Billed charges,34.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,95.91,69% of Billed Charges,95.91,69% of Billed Charges,116.76,84% of Billed Charges,113.98,Pays Based On Per Visit,256.25,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,256.25,500% of HEALTHLINK HMO Fees Schedule,256.25,500% of HEALTHLINK PPO Fees Schedule,33.68,120% of HEALTHY BLUE Fees Schedule,33.68,120% of HOMESTATE Fees Schedule,33.68,120% of MO Fee Schedule,34.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,107.03,77% of Billed Charges,118.15,85% of Billed Charges,39.96,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,33.68,120% of UHC COMMUNITY PLAN fee Schedule,34.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,103,Pays Based On Per Visit,34.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,33.68,256.25,69.5
Outpatient Medical Services,LABORATORY,87798,"Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified",306,1517,1168.09,77% of Billed Charges,386.84,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,386.84,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,474.06,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,1122.58,74% OF Billed Charges,1046.73,69% of Billed Charges,1046.73,69% of Billed charges,379.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,1046.73,69% of Billed Charges,1046.73,69% of Billed Charges,1274.28,84% of Billed Charges,1243.94,Pays Based On Per Visit,256.25,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,256.25,500% of HEALTHLINK HMO Fees Schedule,256.25,500% of HEALTHLINK PPO Fees Schedule,33.68,120% of HEALTHY BLUE Fees Schedule,33.68,120% of HOMESTATE Fees Schedule,33.68,120% of MO Fee Schedule,379.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,1168.09,77% of Billed Charges,1289.45,85% of Billed Charges,436.14,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,33.68,120% of UHC COMMUNITY PLAN fee Schedule,379.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,103,Pays Based On Per Visit,379.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,33.68,1289.45,758.5
Outpatient Medical Services,LABORATORY,87807,"Infectious agent antigen detection by immunoassay with direct optical observation; respiratory syncytial
virus",306,138,106.26,77% of Billed Charges,35.19,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,35.19,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,43.13,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,102.12,74% OF Billed Charges,95.22,69% of Billed Charges,95.22,69% of Billed charges,34.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,95.22,69% of Billed Charges,95.22,69% of Billed Charges,115.92,84% of Billed Charges,113.16,Pays Based On Per Visit,87.6,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,87.6,500% of HEALTHLINK HMO Fees Schedule,87.6,500% of HEALTHLINK PPO Fees Schedule,12.58,120% of HEALTHY BLUE Fees Schedule,12.58,120% of HOMESTATE Fees Schedule,12.58,120% of MO Fee Schedule,34.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,106.26,77% of Billed Charges,117.3,85% of Billed Charges,39.68,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,12.58,120% of UHC COMMUNITY PLAN fee Schedule,34.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,117,Pays Based On Per Visit,34.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,12.58,117.3,69
Outpatient Medical Services,LABORATORY,87880,"Infectious agent detection by immunoassay with direct optical observation; Streptococcus, group A",521,68,52.36,77% of Billed Charges,17.34,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,17.34,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,21.25,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,17,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,87.6,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,87.6,500% of HEALTHLINK HMO Fees Schedule,87.6,500% of HEALTHLINK PPO Fees Schedule,15.86,120% of HEALTHY BLUE Fees Schedule,15.86,120% of HOMESTATE Fees Schedule,15.86,120% of MO Fee Schedule,17,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,52.36,77% of Billed Charges,57.8,85% of Billed Charges,19.55,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,15.86,120% of UHC COMMUNITY PLAN fee Schedule,17,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,17,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,15.86,87.6,34
Outpatient Medical Services,LABORATORY,88142,"Cytopathology, cervical or vaginal",311,145.5,112.04,77% of Billed Charges,37.1,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,37.1,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,45.47,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,107.67,74% OF Billed Charges,100.4,69% of Billed Charges,100.4,69% of Billed charges,36.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,100.4,69% of Billed Charges,100.4,69% of Billed Charges,122.22,84% of Billed Charges,119.31,Pays Based On Per Visit,110.25,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,110.25,500% of HEALTHLINK HMO Fees Schedule,110.25,500% of HEALTHLINK PPO Fees Schedule,19.44,120% of HEALTHY BLUE Fees Schedule,19.44,120% of HOMESTATE Fees Schedule,19.44,120% of MO Fee Schedule,36.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,112.04,77% of Billed Charges,123.68,85% of Billed Charges,41.83,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,81,Pays Based On Per Visit,19.44,120% of UHC COMMUNITY PLAN fee Schedule,36.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,117,Pays Based On Per Visit,36.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,19.44,123.68,72.75
Outpatient Medical Services,LABORATORY,88175,"Cytopathology, cervical or vaginal",311,182,140.14,77% of Billed Charges,46.41,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,46.41,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,56.88,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,134.68,74% OF Billed Charges,125.58,69% of Billed Charges,125.58,69% of Billed charges,45.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,125.58,69% of Billed Charges,125.58,69% of Billed Charges,152.88,84% of Billed Charges,149.24,Pays Based On Per Visit,134.3,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,134.3,500% of HEALTHLINK HMO Fees Schedule,134.3,500% of HEALTHLINK PPO Fees Schedule,25.54,120% of HEALTHY BLUE Fees Schedule,25.54,120% of HOMESTATE Fees Schedule,25.54,120% of MO Fee Schedule,45.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,140.14,77% of Billed Charges,154.7,85% of Billed Charges,52.33,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,81,Pays Based On Per Visit,25.54,120% of UHC COMMUNITY PLAN fee Schedule,45.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,117,Pays Based On Per Visit,45.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,25.54,154.7,91
Outpatient Medical Services,LABORATORY,88305,"surgical pathology, gross and microscopic examination",310,189.5,145.92,77% of Billed Charges,48.32,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,48.32,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,59.22,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,140.23,74% OF Billed Charges,130.76,69% of Billed Charges,130.76,69% of Billed charges,47.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,130.76,69% of Billed Charges,130.76,69% of Billed Charges,159.18,84% of Billed Charges,155.39,Pays Based On Per Visit,168.66,89% of Billed Charges,168.66,89% of Billed Charges,168.66,89% of Billed Charges,32.62,120% of HEALTHY BLUE Fees Schedule,32.62,120% of HOMESTATE Fees Schedule,32.62,120% of MO Fee Schedule,47.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,145.92,77% of Billed Charges,161.08,85% of Billed Charges,54.48,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,81,Pays Based On Per Visit,32.62,120% of UHC COMMUNITY PLAN fee Schedule,47.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,117,Pays Based On Per Visit,47.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,32.62,168.66,94.75
Outpatient Medical Services,LABORATORY,0240U,"Oncology (thyroid), mRNA, gene expression analysis of 593 genes.",300,541,416.57,77% of Billed Charges,137.96,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,137.96,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,169.06,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,400.34,74% OF Billed Charges,373.29,69% of Billed Charges,373.29,69% of Billed charges,135.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,373.29,69% of Billed Charges,373.29,69% of Billed Charges,454.44,84% of Billed Charges,443.62,Pays Based On Per Visit,481.49,89% of Billed Charges,481.49,89% of Billed Charges,481.49,89% of Billed Charges,123.23,120% of HEALTHY BLUE Fees Schedule,123.23,120% of HOMESTATE Fees Schedule,123.23,120% of MO Fee Schedule,135.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,416.57,77% of Billed Charges,459.85,85% of Billed Charges,155.54,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,123.23,120% of UHC COMMUNITY PLAN fee Schedule,135.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,117,Pays Based On Per Visit,135.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,64,481.49,270.5
Outpatient Medical Services,LABORATORY,0241U,"Infectious disease (viral respiratory tract infection), pathogen-specific RNA, 4 targets.",300,585.5,450.84,77% of Billed Charges,149.3,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,149.3,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,182.97,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,433.27,74% OF Billed Charges,404,69% of Billed Charges,404,69% of Billed charges,146.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,404,69% of Billed Charges,404,69% of Billed Charges,491.82,84% of Billed Charges,480.11,Pays Based On Per Visit,521.1,89% of Billed Charges,521.1,89% of Billed Charges,521.1,89% of Billed Charges,123.23,120% of HEALTHY BLUE Fees Schedule,123.23,120% of HOMESTATE Fees Schedule,123.23,120% of MO Fee Schedule,146.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,450.84,77% of Billed Charges,497.68,85% of Billed Charges,168.33,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,123.23,120% of UHC COMMUNITY PLAN fee Schedule,146.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,117,Pays Based On Per Visit,146.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,64,521.1,292.75
Outpatient Medical Services,LABORATORY,C9803,symptom assessment and specimen collection performed by hospital outpatient departments,300,78,60.06,77% of Billed Charges,19.89,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,19.89,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,24.38,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,57.72,74% OF Billed Charges,53.82,69% of Billed Charges,53.82,69% of Billed charges,19.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,53.82,69% of Billed Charges,53.82,69% of Billed Charges,65.52,84% of Billed Charges,63.96,Pays Based On Per Visit,69.42,89% of Billed Charges,69.42,89% of Billed Charges,69.42,89% of Billed Charges,31.82,40.8% of Billed Charges,31.82,40.8% of Billed Charges,31.82,40.8% of Billed Charges,19.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,60.06,77% of Billed Charges,66.3,85% of Billed Charges,22.43,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,31.82,40.8% of Billed Charges,19.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,117,Pays Based On Per Visit,19.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,19.5,117,39
Outpatient Medical Services,LABORATORY,U0002,: CDC 2019 Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic Panel,300,278.5,214.45,77% of Billed Charges,71.02,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,71.02,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,87.03,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,206.09,74% OF Billed Charges,192.17,69% of Billed Charges,192.17,69% of Billed charges,69.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,192.17,69% of Billed Charges,192.17,69% of Billed Charges,233.94,84% of Billed Charges,228.37,Pays Based On Per Visit,247.87,89% of Billed Charges,247.87,89% of Billed Charges,247.87,89% of Billed Charges,43.85,120% of HEALTHY BLUE Fees Schedule,43.85,120% of HOMESTATE Fees Schedule,43.85,120% of MO Fee Schedule,69.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,214.45,77% of Billed Charges,236.73,85% of Billed Charges,80.07,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,64,Pays Based On Per Visit,43.85,120% of UHC COMMUNITY PLAN fee Schedule,69.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,117,Pays Based On Per Visit,69.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,43.85,247.87,139.25
Outpatient Medical Services,RESPIRATORY THERAPY SLEEP,94010,Pulmonary Function Testing—no bronchodilator,460,534.5,411.57,77% of Billed Charges,136.3,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,136.3,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,167.03,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,395.53,74% OF Billed Charges,368.81,69% of Billed Charges,368.81,69% of Billed charges,133.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,368.81,69% of Billed Charges,368.81,69% of Billed Charges,448.98,84% of Billed Charges,438.29,82% of Billed Charges,475.71,89% of Billed Charges,475.71,89% of Billed Charges,475.71,89% of Billed Charges,18.9,120% of HEALTHY BLUE Fees Schedule,18.9,120% of HOMESTATE Fees Schedule,18.9,120% of MO Fee Schedule,133.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,411.57,77% of Billed Charges,454.33,85% of Billed Charges,153.67,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,650,Pays Based On Per Visit,18.9,120% of UHC COMMUNITY PLAN fee Schedule,133.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,117,Pays Based On Per Visit,133.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,18.9,650,267.25
Outpatient Medical Services,RESPIRATORY THERAPY SLEEP,94375,Respiratory Flow Volume Loop,460,146,112.42,77% of Billed Charges,37.23,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,37.23,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,45.63,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,108.04,74% OF Billed Charges,100.74,69% of Billed Charges,100.74,69% of Billed charges,36.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,100.74,69% of Billed Charges,100.74,69% of Billed Charges,122.64,84% of Billed Charges,119.72,82% of Billed Charges,129.94,89% of Billed Charges,129.94,89% of Billed Charges,129.94,89% of Billed Charges,21.55,120% of HEALTHY BLUE Fees Schedule,21.55,120% of HOMESTATE Fees Schedule,21.55,120% of MO Fee Schedule,36.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,112.42,77% of Billed Charges,124.1,85% of Billed Charges,41.98,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,650,Pays Based On Per Visit,21.55,120% of UHC COMMUNITY PLAN fee Schedule,36.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,117,Pays Based On Per Visit,36.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,21.55,650,73
Outpatient Medical Services,RESPIRATORY THERAPY SLEEP,94640,Treatment of acute airway obstruction with inhaled medication,410,246,189.42,77% of Billed Charges,62.73,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,62.73,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,76.88,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,182.04,74% OF Billed Charges,169.74,69% of Billed Charges,169.74,69% of Billed charges,61.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,169.74,69% of Billed Charges,169.74,69% of Billed Charges,206.64,84% of Billed Charges,201.72,82% of Billed Charges,218.94,89% of Billed Charges,218.94,89% of Billed Charges,218.94,89% of Billed Charges,10.02,120% of HEALTHY BLUE Fees Schedule,10.02,120% of HOMESTATE Fees Schedule,10.02,120% of MO Fee Schedule,61.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,189.42,77% of Billed Charges,209.1,85% of Billed Charges,70.73,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,163,Pays Based On Per Visit,10.02,120% of UHC COMMUNITY PLAN fee Schedule,61.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,117,Pays Based On Per Visit,61.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,10.02,218.94,123
Outpatient Medical Services,RESPIRATORY THERAPY SLEEP,94726,"Determination of lung volumes, residual volume, functional residual capacity (FRC), and airway resistance",460,238,183.26,77% of Billed Charges,60.69,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,60.69,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,74.38,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,176.12,74% OF Billed Charges,164.22,69% of Billed Charges,164.22,69% of Billed charges,59.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,164.22,69% of Billed Charges,164.22,69% of Billed Charges,199.92,84% of Billed Charges,195.16,82% of Billed Charges,211.82,89% of Billed Charges,211.82,89% of Billed Charges,211.82,89% of Billed Charges,38.26,120% of HEALTHY BLUE Fees Schedule,38.26,120% of HOMESTATE Fees Schedule,38.26,120% of MO Fee Schedule,59.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,183.26,77% of Billed Charges,202.3,85% of Billed Charges,68.43,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,650,Pays Based On Per Visit,38.26,120% of UHC COMMUNITY PLAN fee Schedule,59.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,70,Pays Based On Per Visit,59.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,38.26,650,119
Outpatient Medical Services,RESPIRATORY THERAPY SLEEP,94727,Gas dilution or washout for determination of lung volumes,460,394,303.38,77% of Billed Charges,100.47,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,100.47,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,123.13,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,291.56,74% OF Billed Charges,271.86,69% of Billed Charges,271.86,69% of Billed charges,98.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,271.86,69% of Billed Charges,271.86,69% of Billed Charges,330.96,84% of Billed Charges,323.08,82% of Billed Charges,350.66,89% of Billed Charges,350.66,89% of Billed Charges,350.66,89% of Billed Charges,28.55,120% of HEALTHY BLUE Fees Schedule,28.55,120% of HOMESTATE Fees Schedule,28.55,120% of MO Fee Schedule,98.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,303.38,77% of Billed Charges,334.9,85% of Billed Charges,113.28,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,650,Pays Based On Per Visit,28.55,120% of UHC COMMUNITY PLAN fee Schedule,98.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,70,Pays Based On Per Visit,98.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,28.55,650,197
Outpatient Medical Services,RESPIRATORY THERAPY SLEEP,94729,Pulmonary stress testing,460,394,303.38,77% of Billed Charges,100.47,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,100.47,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,123.13,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,291.56,74% OF Billed Charges,271.86,69% of Billed Charges,271.86,69% of Billed charges,98.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,271.86,69% of Billed Charges,271.86,69% of Billed Charges,330.96,84% of Billed Charges,323.08,82% of Billed Charges,350.66,89% of Billed Charges,350.66,89% of Billed Charges,350.66,89% of Billed Charges,44.66,120% of HEALTHY BLUE Fees Schedule,44.66,120% of HOMESTATE Fees Schedule,44.66,120% of MO Fee Schedule,98.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,303.38,77% of Billed Charges,334.9,85% of Billed Charges,113.28,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,650,Pays Based On Per Visit,44.66,120% of UHC COMMUNITY PLAN fee Schedule,98.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,70,Pays Based On Per Visit,98.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,44.66,650,197
Outpatient Medical Services,RESPIRATORY THERAPY SLEEP,95806,Sleep Study,920,2352,1811.04,77% of Billed Charges,599.76,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,599.76,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,735,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,1433,Pays Based On Per Visit,1389,Pays Based On Per Visit,1389,Pays Based On Per Visit,588,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,1389,PER DIEM,1389,PER DIEM,1475,Pays Based On Per Visit,1928.64,82% of Billed Charges,2093.28,89% of Billed Charges,2093.28,89% of Billed Charges,2093.28,89% of Billed Charges,52.93,120% of HEALTHY BLUE Fees Schedule,52.93,120% of HOMESTATE Fees Schedule,52.93,120% of MO Fee Schedule,588,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,1811.04,77% of Billed Charges,1999.2,85% of Billed Charges,676.2,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,2110,Pays Based On Per Visit,52.93,120% of UHC COMMUNITY PLAN fee Schedule,588,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,70,Pays Based On Per Visit,588,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,52.93,2110,1176
Outpatient Medical Services,RESPIRATORY THERAPY SLEEP,95810,Sleep study,920,3972,3058.44,77% of Billed Charges,1012.86,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,1012.86,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,1241.25,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,1433,Pays Based On Per Visit,1389,Pays Based On Per Visit,1389,Pays Based On Per Visit,993,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,1389,PER DIEM,96,PER DIEM,1475,Pays Based On Per Visit,3257.04,82% of Billed Charges,3535.08,89% of Billed Charges,3535.08,89% of Billed Charges,3535.08,89% of Billed Charges,464.96,120% of HEALTHY BLUE Fees Schedule,464.96,120% of HOMESTATE Fees Schedule,464.96,120% of MO Fee Schedule,993,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,3058.44,77% of Billed Charges,3376.2,85% of Billed Charges,1141.95,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,2369,Pays Based On Per Visit,464.96,120% of UHC COMMUNITY PLAN fee Schedule,993,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,630,Pays Based On Per Visit,993,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,96,3535.08,1986
Outpatient Medical Services,PROVIDER SERVICES,59400,"Routine obstetric care for vaginal delivery, including pre-and post-delivery care",521,4532,3489.64,77% of Billed Charges,1155.66,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,1155.66,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,1416.25,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,1133,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,4033.48,89% of Billed Charges,4033.48,89% of Billed Charges,4033.48,89% of Billed Charges,1849.06,40.8% of Billed Charges,1849.06,40.8% of Billed Charges,1849.06,40.8% of Billed Charges,1133,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,3489.64,77% of Billed Charges,3852.2,85% of Billed Charges,1302.95,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,1849.06,40.8% of Billed Charges,1133,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,1133,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,1133,4033.48,2266
Outpatient Medical Services,PROVIDER SERVICES,59510,"Routine obstetric care for cesarean delivery, including pre-and post-delivery care",521,5030,3873.1,77% of Billed Charges,1282.65,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,1282.65,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,1571.88,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,1257.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,4476.7,89% of Billed Charges,4476.7,89% of Billed Charges,4476.7,89% of Billed Charges,2052.24,40.8% of Billed Charges,2052.24,40.8% of Billed Charges,2052.24,40.8% of Billed Charges,1257.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,3873.1,77% of Billed Charges,4275.5,85% of Billed Charges,1446.13,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,2052.24,40.8% of Billed Charges,1257.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,1257.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,1257.5,4476.7,2515
Outpatient Medical Services,PROVIDER SERVICES,59610,Routine obstetric care for vaginal delivery after prior cesarean delivery including pre-and post-delivery care,521,3958,3047.66,77% of Billed Charges,1009.29,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,1009.29,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,1236.88,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,989.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,3522.62,89% of Billed Charges,3522.62,89% of Billed Charges,3522.62,89% of Billed Charges,1614.86,40.8% of Billed Charges,1614.86,40.8% of Billed Charges,1614.86,40.8% of Billed Charges,989.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,3047.66,77% of Billed Charges,3364.3,85% of Billed Charges,1137.93,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,1614.86,40.8% of Billed Charges,989.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,989.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,989.5,3522.62,1979
Outpatient Medical Services,PROVIDER SERVICES,90832,"Psychotherapy, 30 min",521,135,103.95,77% of Billed Charges,34.43,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,34.43,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,42.19,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,33.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,120.15,89% of Billed Charges,120.15,89% of Billed Charges,120.15,89% of Billed Charges,55.08,40.8% of Billed Charges,55.08,40.8% of Billed Charges,55.08,40.8% of Billed Charges,33.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,103.95,77% of Billed Charges,114.75,85% of Billed Charges,38.81,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,55.08,40.8% of Billed Charges,33.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,33.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,33.75,120.15,67.5
Outpatient Medical Services,PROVIDER SERVICES,90834,"Psychotherapy, 45 min",521,178,137.06,77% of Billed Charges,45.39,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,45.39,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,55.63,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,44.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,158.42,89% of Billed Charges,158.42,89% of Billed Charges,158.42,89% of Billed Charges,72.62,40.8% of Billed Charges,72.62,40.8% of Billed Charges,72.62,40.8% of Billed Charges,44.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,137.06,77% of Billed Charges,151.3,85% of Billed Charges,51.18,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,72.62,40.8% of Billed Charges,44.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,44.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,44.5,158.42,89
Outpatient Medical Services,PROVIDER SERVICES,90837,"Psychotherapy, 60 min",521,215,165.55,77% of Billed Charges,54.83,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,54.83,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,67.19,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,53.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,191.35,89% of Billed Charges,191.35,89% of Billed Charges,191.35,89% of Billed Charges,87.72,40.8% of Billed Charges,87.72,40.8% of Billed Charges,87.72,40.8% of Billed Charges,53.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,165.55,77% of Billed Charges,182.75,85% of Billed Charges,61.81,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,87.72,40.8% of Billed Charges,53.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,53.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,53.75,191.35,107.5
Outpatient Medical Services,PROVIDER SERVICES,90846,"Family psychotherapy, not including patient, 50 min",521,132,101.64,77% of Billed Charges,33.66,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,33.66,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,41.25,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,33,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,117.48,89% of Billed Charges,117.48,89% of Billed Charges,117.48,89% of Billed Charges,53.86,40.8% of Billed Charges,53.86,40.8% of Billed Charges,53.86,40.8% of Billed Charges,33,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,101.64,77% of Billed Charges,112.2,85% of Billed Charges,37.95,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,53.86,40.8% of Billed Charges,33,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,33,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,33,117.48,66
Outpatient Medical Services,PROVIDER SERVICES,90847,"Family psychotherapy, including patient, 50 min",521,165,127.05,77% of Billed Charges,42.08,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,42.08,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,51.56,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,41.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,146.85,89% of Billed Charges,146.85,89% of Billed Charges,146.85,89% of Billed Charges,67.32,40.8% of Billed Charges,67.32,40.8% of Billed Charges,67.32,40.8% of Billed Charges,41.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,127.05,77% of Billed Charges,140.25,85% of Billed Charges,47.44,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,67.32,40.8% of Billed Charges,41.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,41.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,41.25,146.85,82.5
Outpatient Medical Services,PROVIDER SERVICES,90853,Group psychotherapy,521,206,158.62,77% of Billed Charges,52.53,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,52.53,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,64.38,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,51.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,183.34,89% of Billed Charges,183.34,89% of Billed Charges,183.34,89% of Billed Charges,84.05,40.8% of Billed Charges,84.05,40.8% of Billed Charges,84.05,40.8% of Billed Charges,51.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,158.62,77% of Billed Charges,175.1,85% of Billed Charges,59.23,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,84.05,40.8% of Billed Charges,51.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,51.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,51.5,183.34,103
Outpatient Medical Services,PROVIDER SERVICES,99203,"New patient office or other outpatient visit, typically 30 min",510,640,492.8,77% of Billed Charges,163.2,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,163.2,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,200,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,160,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,261.12,40.8% of Billed Charges,261.12,40.8% of Billed Charges,261.12,40.8% of Billed Charges,160,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,492.8,77% of Billed Charges,544,85% of Billed Charges,184,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,320,50% of Billed Charges,261.12,40.8% of Billed Charges,160,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,569.6,89% of Billed Charges,160,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,160,569.6,320
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,510,867.5,667.98,77% of Billed Charges,221.21,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,221.21,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,271.09,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,216.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,353.94,40.8% of Billed Charges,353.94,40.8% of Billed Charges,353.94,40.8% of Billed Charges,216.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,667.98,77% of Billed Charges,737.38,85% of Billed Charges,249.41,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,433.75,50% of Billed Charges,353.94,40.8% of Billed Charges,216.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,772.08,89% of Billed Charges,216.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,216.88,772.08,433.75
Outpatient Medical Services,PROVIDER SERVICES,99205,"New patient office of other outpatient visit, typically 60 min",510,867.5,667.98,77% of Billed Charges,221.21,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,221.21,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,271.09,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,216.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,353.94,40.8% of Billed Charges,353.94,40.8% of Billed Charges,353.94,40.8% of Billed Charges,216.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,667.98,77% of Billed Charges,737.38,85% of Billed Charges,249.41,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,433.75,50% of Billed Charges,353.94,40.8% of Billed Charges,216.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,772.08,89% of Billed Charges,216.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,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,510,510.5,393.09,77% of Billed Charges,130.18,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,130.18,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,159.53,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,127.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,208.28,40.8% of Billed Charges,208.28,40.8% of Billed Charges,208.28,40.8% of Billed Charges,127.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,393.09,77% of Billed Charges,433.93,85% of Billed Charges,146.77,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,255.25,50% of Billed Charges,208.28,40.8% of Billed Charges,127.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,454.35,89% of Billed Charges,127.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,127.63,454.35,255.25
Outpatient Medical Services,PROVIDER SERVICES,99212,An evaluation and management appointment for an established patient,510,510.5,393.09,77% of Billed Charges,130.18,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,130.18,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,159.53,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,127.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,208.28,40.8% of Billed Charges,208.28,40.8% of Billed Charges,208.28,40.8% of Billed Charges,127.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,393.09,77% of Billed Charges,433.93,85% of Billed Charges,146.77,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,255.25,50% of Billed Charges,208.28,40.8% of Billed Charges,127.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,454.35,89% of Billed Charges,127.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,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,510,586,451.22,77% of Billed Charges,149.43,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,149.43,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,183.13,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,146.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,239.09,40.8% of Billed Charges,239.09,40.8% of Billed Charges,239.09,40.8% of Billed Charges,146.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,451.22,77% of Billed Charges,498.1,85% of Billed Charges,168.48,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,293,50% of Billed Charges,239.09,40.8% of Billed Charges,146.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,521.54,89% of Billed Charges,146.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,146.5,521.54,293
Outpatient Medical Services,PROVIDER SERVICES,99214,Office or other outpatient visit for the evaluation and management of an established patient,510,851,655.27,77% of Billed Charges,217.01,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,217.01,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,265.94,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,212.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,347.21,40.8% of Billed Charges,347.21,40.8% of Billed Charges,347.21,40.8% of Billed Charges,212.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,655.27,77% of Billed Charges,723.35,85% of Billed Charges,244.66,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,425.5,50% of Billed Charges,347.21,40.8% of Billed Charges,212.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,757.39,89% of Billed Charges,212.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,212.75,757.39,425.5
Outpatient Medical Services,PROVIDER SERVICES,99215,Office or other outpatient visit for the evaluation and management of an established patient,510,851,655.27,77% of Billed Charges,217.01,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,217.01,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,265.94,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,212.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,347.21,40.8% of Billed Charges,347.21,40.8% of Billed Charges,347.21,40.8% of Billed Charges,212.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,655.27,77% of Billed Charges,723.35,85% of Billed Charges,244.66,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,425.5,50% of Billed Charges,347.21,40.8% of Billed Charges,212.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,757.39,89% of Billed Charges,212.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,212.75,757.39,425.5
Outpatient Medical Services,PROVIDER SERVICES,99217,Observation care discharge day management,762,256.5,197.51,77% of Billed Charges,65.41,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,65.41,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,80.16,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,176.99,Pays Based On Per Visit,176.99,Pays Based On Per Visit,176.99,Pays Based On Per Visit,64.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,176.99,PER DIEM,96,PER DIEM,215.46,Pays Based On Per Visit,210.33,Pays Based On Per Visit,228.29,Pays Based On Per Visit,215.46,Pays Based On Per Visit,228.29,Pays Based On Per Visit,104.65,40.8% of Billed Charges,104.65,40.8% of Billed Charges,104.65,40.8% of Billed Charges,64.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,197.51,77% of Billed Charges,218.03,85% of Billed Charges,73.74,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,2285,Pays Based On Per Visit,104.65,40.8% of Billed Charges,64.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,630,Pays Based On Per Visit,64.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,64.13,2285,128.25
Outpatient Medical Services,PROVIDER SERVICES,99243,"Patient office consultation, typically 40 min",982,318,126.23,135% of AETNA Fees schedule,95.93,115% OF CMS Fees Schedule,97.85,117.3% OF ALLWELL Fees Schedule,119.92,143.75 OF AMBETTER Fees Schedule,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,95.93,115% of CMS Fees Schedule,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,110.84,100% of CIGNA Fees Schedule,106.1,500% of HEALTHLINK COMPMANAGEMENT Fees Schedule,96.62,100% of HEALTHLINK HMO  Fees Schedule,106.1,100% of HEALTHLINK PPO Fees Schedule,286.2,40.8% of Billed Charges,286.2,40.8% of Billed Charges,286.2,40.8% of Billed Charges,95.93,115% of CMS Fees Schedule,126.23,135% of MERITAIN Fee Schedule,148.7,178.25%  of MULTIPLAN/PHCS  Fee Schedule,110.32,132.25% of PPHP Fee schedule,93.58,100% of UHC Fee Schedule,286.2,40.8% of Billed Charges,95.93,115% of CMS Fee Schedule,192,Pays Based On Per Visit,95.93,115% of VA Fee Schedule,93.58,286.2,159
Outpatient Medical Services,PROVIDER SERVICES,99244,"Patient office consultation, typically 60 min",510,459,353.43,77% of Billed Charges,117.05,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,117.05,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,143.44,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,114.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,187.27,40.8% of Billed Charges,187.27,40.8% of Billed Charges,187.27,40.8% of Billed Charges,114.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,353.43,77% of Billed Charges,390.15,85% of Billed Charges,131.96,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,229.5,50% of Billed Charges,187.27,40.8% of Billed Charges,114.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,408.51,89% of Billed Charges,114.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,114.75,408.51,229.5
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",450,367.5,282.98,77% of Billed Charges,93.71,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,93.71,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,114.84,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,216.83,Pays Based On Per Visit,216.83,Pays Based On Per Visit,216.83,Pays Based On Per Visit,91.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,216.83,PER DIEM,284,PER DIEM,308.7,Pays Based On Per Visit,301.35,Pays Based On Per Visit,327.08,Pays Based On Per Visit,308.7,Pays Based On Per Visit,327.08,Pays Based On Per Visit,149.94,40.8% of Billed Charges,149.94,40.8% of Billed Charges,149.94,40.8% of Billed Charges,91.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,282.98,77% of Billed Charges,312.38,85% of Billed Charges,105.66,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,550,Pays Based On Per Visit,149.94,40.8% of Billed Charges,91.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,192,Pays Based On Per Visit,91.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,91.88,550,183.75
Outpatient Medical Services,PROVIDER SERVICES,99282,Emergency department visit for the evaluation and management of a patient,450,539,415.03,77% of Billed Charges,137.45,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,137.45,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,168.44,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,318.01,Pays Based On Per Visit,318.01,Pays Based On Per Visit,318.01,Pays Based On Per Visit,134.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,318.01,PER DIEM,2102,PER DIEM,452.76,Pays Based On Per Visit,441.98,Pays Based On Per Visit,479.71,Pays Based On Per Visit,452.76,Pays Based On Per Visit,479.71,Pays Based On Per Visit,219.91,40.8% of Billed Charges,219.91,40.8% of Billed Charges,219.91,40.8% of Billed Charges,134.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,415.03,77% of Billed Charges,458.15,85% of Billed Charges,154.96,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,736,Pays Based On Per Visit,219.91,40.8% of Billed Charges,134.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,192,Pays Based On Per Visit,134.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,134.75,2102,269.5
Outpatient Medical Services,PROVIDER SERVICES,99283,"Emergency department visit for the evaluation and management of a patient,",450,775,596.75,77% of Billed Charges,197.63,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,197.63,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,242.19,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,457.25,Pays Based On Per Visit,457.25,Pays Based On Per Visit,457.25,Pays Based On Per Visit,193.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,457.25,PER DIEM,2102,PER DIEM,651,Pays Based On Per Visit,635.5,Pays Based On Per Visit,689.75,Pays Based On Per Visit,651,Pays Based On Per Visit,689.75,Pays Based On Per Visit,316.2,40.8% of Billed Charges,316.2,40.8% of Billed Charges,316.2,40.8% of Billed Charges,193.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,596.75,77% of Billed Charges,658.75,85% of Billed Charges,222.81,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,999,Pays Based On Per Visit,316.2,40.8% of Billed Charges,193.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,192,Pays Based On Per Visit,193.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,192,2102,387.5
Outpatient Medical Services,PROVIDER SERVICES,99284,ER Dept visit detailed problem/decision,450,1226.5,944.41,77% of Billed Charges,312.76,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,312.76,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,383.28,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,723.64,Pays Based On Per Visit,723.64,Pays Based On Per Visit,723.64,Pays Based On Per Visit,306.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,723.64,PER DIEM,2102,PER DIEM,1030.26,Pays Based On Per Visit,1005.73,Pays Based On Per Visit,1091.59,Pays Based On Per Visit,1030.26,Pays Based On Per Visit,1091.59,Pays Based On Per Visit,500.41,40.8% of Billed Charges,500.41,40.8% of Billed Charges,500.41,40.8% of Billed Charges,306.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,944.41,77% of Billed Charges,1042.53,85% of Billed Charges,352.62,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,1580,Pays Based On Per Visit,500.41,40.8% of Billed Charges,306.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,192,Pays Based On Per Visit,306.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,192,2102,613.25
Outpatient Medical Services,PROVIDER SERVICES,99285,Emergency department visit for the evaluation and management of a patient,450,1668.5,1284.75,77% of Billed Charges,425.47,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,425.47,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,521.41,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,984.42,Pays Based On Per Visit,984.42,Pays Based On Per Visit,984.42,Pays Based On Per Visit,417.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,984.42,PER DIEM,2102,PER DIEM,1401.54,Pays Based On Per Visit,1368.17,Pays Based On Per Visit,1484.97,Pays Based On Per Visit,1401.54,Pays Based On Per Visit,1484.97,Pays Based On Per Visit,680.75,40.8% of Billed Charges,680.75,40.8% of Billed Charges,680.75,40.8% of Billed Charges,417.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,1284.75,77% of Billed Charges,1418.23,85% of Billed Charges,479.69,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,4232,Pays Based On Per Visit,680.75,40.8% of Billed Charges,417.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,192,Pays Based On Per Visit,417.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,192,4232,834.25
Outpatient Medical Services,PROVIDER SERVICES,99308,"Subsequent nursing facility care, per day",521,158,121.66,77% of Billed Charges,40.29,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,40.29,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,49.38,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,39.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,140.62,89% of Billed Charges,140.62,89% of Billed Charges,140.62,89% of Billed Charges,64.46,40.8% of Billed Charges,64.46,40.8% of Billed Charges,64.46,40.8% of Billed Charges,39.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,121.66,77% of Billed Charges,134.3,85% of Billed Charges,45.43,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,64.46,40.8% of Billed Charges,39.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,39.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,39.5,140.62,79
Outpatient Medical Services,PROVIDER SERVICES,99309,"Subsequent nursing facility care, per day,",521,193,148.61,77% of Billed Charges,49.22,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,49.22,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,60.31,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,48.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,171.77,89% of Billed Charges,171.77,89% of Billed Charges,171.77,89% of Billed Charges,78.74,40.8% of Billed Charges,78.74,40.8% of Billed Charges,78.74,40.8% of Billed Charges,48.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,148.61,77% of Billed Charges,164.05,85% of Billed Charges,55.49,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,78.74,40.8% of Billed Charges,48.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,48.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,48.25,171.77,96.5
Outpatient Medical Services,PROVIDER SERVICES,99310,Subsequent Nursing Facility Care,521,286,220.22,77% of Billed Charges,72.93,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,72.93,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,89.38,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,71.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,254.54,89% of Billed Charges,254.54,89% of Billed Charges,254.54,89% of Billed Charges,116.69,40.8% of Billed Charges,116.69,40.8% of Billed Charges,116.69,40.8% of Billed Charges,71.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,220.22,77% of Billed Charges,243.1,85% of Billed Charges,82.23,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,116.69,40.8% of Billed Charges,71.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,71.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,71.5,254.54,143
Outpatient Medical Services,PROVIDER SERVICES,99336,"Evaluation and Management / Domiciliary, rest home (boarding home) or custodial care services.",521,287,220.99,77% of Billed Charges,73.19,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,73.19,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,89.69,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,71.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,255.43,89% of Billed Charges,255.43,89% of Billed Charges,255.43,89% of Billed Charges,117.1,40.8% of Billed Charges,117.1,40.8% of Billed Charges,117.1,40.8% of Billed Charges,71.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,220.99,77% of Billed Charges,243.95,85% of Billed Charges,82.51,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,117.1,40.8% of Billed Charges,71.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,71.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,71.75,255.43,143.5
Outpatient Medical Services,PROVIDER SERVICES,99350,Level 4 established patient home visit,521,338,260.26,77% of Billed Charges,86.19,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,86.19,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,105.63,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,84.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,300.82,89% of Billed Charges,300.82,89% of Billed Charges,300.82,89% of Billed Charges,137.9,40.8% of Billed Charges,137.9,40.8% of Billed Charges,137.9,40.8% of Billed Charges,84.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,260.26,77% of Billed Charges,287.3,85% of Billed Charges,97.18,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,137.9,40.8% of Billed Charges,84.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,84.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,84.5,300.82,169
Outpatient Medical Services,PROVIDER SERVICES,99385,Initial new patient preventive medicine evaluation (18-39 years),521,303,233.31,77% of Billed Charges,77.27,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,77.27,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,94.69,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,75.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,269.67,89% of Billed Charges,269.67,89% of Billed Charges,269.67,89% of Billed Charges,123.62,40.8% of Billed Charges,123.62,40.8% of Billed Charges,123.62,40.8% of Billed Charges,75.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,233.31,77% of Billed Charges,257.55,85% of Billed Charges,87.11,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,123.62,40.8% of Billed Charges,75.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,75.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,75.75,269.67,151.5
Outpatient Medical Services,PROVIDER SERVICES,99386,Initial new patient preventive medicine evaluation (40-64 years),521,330,254.1,77% of Billed Charges,84.15,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,84.15,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,103.13,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,82.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,293.7,89% of Billed Charges,293.7,89% of Billed Charges,293.7,89% of Billed Charges,134.64,40.8% of Billed Charges,134.64,40.8% of Billed Charges,134.64,40.8% of Billed Charges,82.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,254.1,77% of Billed Charges,280.5,85% of Billed Charges,94.88,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,134.64,40.8% of Billed Charges,82.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,82.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,82.5,293.7,165
Outpatient Medical Services,PROVIDER SERVICES,99391,Wellcare visit for infant under 1 year,521,151,116.27,77% of Billed Charges,38.51,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,38.51,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,47.19,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,37.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,134.39,89% of Billed Charges,134.39,89% of Billed Charges,134.39,89% of Billed Charges,61.61,40.8% of Billed Charges,61.61,40.8% of Billed Charges,61.61,40.8% of Billed Charges,37.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,116.27,77% of Billed Charges,128.35,85% of Billed Charges,43.41,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,61.61,40.8% of Billed Charges,37.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,37.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,37.75,134.39,75.5
Outpatient Medical Services,PROVIDER SERVICES,99392,Established patient well age 1-4 years,521,158,121.66,77% of Billed Charges,40.29,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,40.29,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,49.38,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,39.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,140.62,89% of Billed Charges,140.62,89% of Billed Charges,140.62,89% of Billed Charges,64.46,40.8% of Billed Charges,64.46,40.8% of Billed Charges,64.46,40.8% of Billed Charges,39.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,121.66,77% of Billed Charges,134.3,85% of Billed Charges,45.43,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,64.46,40.8% of Billed Charges,39.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,39.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,39.5,140.62,79
Outpatient Medical Services,PROVIDER SERVICES,99393,Established patient well age 5-11 yeas,521,173,133.21,77% of Billed Charges,44.12,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,44.12,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,54.06,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,43.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,153.97,89% of Billed Charges,153.97,89% of Billed Charges,153.97,89% of Billed Charges,70.58,40.8% of Billed Charges,70.58,40.8% of Billed Charges,70.58,40.8% of Billed Charges,43.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,133.21,77% of Billed Charges,147.05,85% of Billed Charges,49.74,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,70.58,40.8% of Billed Charges,43.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,43.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,43.25,153.97,86.5
Outpatient Medical Services,PROVIDER SERVICES,99394,Established patient well age 12-17 years,521,186,143.22,77% of Billed Charges,47.43,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,47.43,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,58.13,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,46.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,165.54,89% of Billed Charges,165.54,89% of Billed Charges,165.54,89% of Billed Charges,75.89,40.8% of Billed Charges,75.89,40.8% of Billed Charges,75.89,40.8% of Billed Charges,46.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,143.22,77% of Billed Charges,158.1,85% of Billed Charges,53.48,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,75.89,40.8% of Billed Charges,46.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,46.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,46.5,165.54,93
Outpatient Medical Services,PROVIDER SERVICES,G0009,Pneumonia vaccine administration,771,65,50.05,77% of Billed Charges,16.58,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,16.58,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,20.31,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,48.1,74% OF Billed Charges,44.85,69% of Billed Charges,44.85,69% of Billed charges,16.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,44.85,69% of Billed Charges,44.85,69% of Billed Charges,54.6,84% of Billed Charges,53.3,82% of Billed Charges,57.85,89% of Billed Charges,57.85,89% of Billed Charges,57.85,89% of Billed Charges,26.52,40.8% of Billed Charges,26.52,40.8% of Billed Charges,26.52,40.8% of Billed Charges,16.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,50.05,77% of Billed Charges,55.25,85% of Billed Charges,18.69,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,69,Pays Based On Per Visit,26.52,40.8% of Billed Charges,16.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,16.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,16.25,69,32.5
Outpatient Medical Services,PROVIDER SERVICES,G0101,Cervical or vaginal cancer screening; pelvic and clinical breast examination.,521,129,99.33,77% of Billed Charges,32.9,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,32.9,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,40.31,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,32.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,114.81,89% of Billed Charges,114.81,89% of Billed Charges,114.81,89% of Billed Charges,52.63,40.8% of Billed Charges,52.63,40.8% of Billed Charges,52.63,40.8% of Billed Charges,32.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,99.33,77% of Billed Charges,109.65,85% of Billed Charges,37.09,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,52.63,40.8% of Billed Charges,32.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,32.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,32.25,114.81,64.5
Outpatient Medical Services,OUTPATIENT THERAPY,92507,"Therapy services that pertain to auditory rehabilitation, voice prosthetics, and communication and/or cognitive impairments",440,470.5,362.29,77% of Billed Charges,119.98,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,119.98,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,147.03,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,102,Pays Based On Per Visit,96,Pays Based On Per Visit,96,Pays Based On Per Visit,117.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,96,PER DIEM,3159.62,285% of BCBS PATHWAY X Fees Schedule,114,Pays Based On Per Visit,385.81,Pays Based On Per Visit,418.75,89% of Billed Charges,418.75,89% of Billed Charges,418.75,89% of Billed Charges,191.96,40.8% of Billed Charges,191.96,40.8% of Billed Charges,191.96,40.8% of Billed Charges,117.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,362.29,77% of Billed Charges,399.93,85% of Billed Charges,135.27,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,222,Pays Based On Per Visit,191.96,40.8% of Billed Charges,117.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,192,Pays Based On Per Visit,117.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,96,3159.62,235.25
Outpatient Medical Services,OUTPATIENT THERAPY,97010,Any physical agent applied to produce therapeutic changes to biologic tissue,440,47.5,36.58,77% of Billed Charges,12.11,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,12.11,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,14.84,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,102,Pays Based On Per Visit,96,Pays Based On Per Visit,96,Pays Based On Per Visit,11.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,96,PER DIEM,4914.4,285% of BCBS PATHWAY X Fees Schedule,114,Pays Based On Per Visit,38.95,Pays Based On Per Visit,42.28,89% of Billed Charges,42.28,89% of Billed Charges,42.28,89% of Billed Charges,19.38,40.8% of Billed Charges,19.38,40.8% of Billed Charges,19.38,40.8% of Billed Charges,11.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,36.58,77% of Billed Charges,40.38,85% of Billed Charges,13.66,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,222,Pays Based On Per Visit,19.38,40.8% of Billed Charges,11.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,192,Pays Based On Per Visit,11.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,11.88,4914.4,23.75
Outpatient Medical Services,OUTPATIENT THERAPY,97012,Mechanical Traction,420,94,72.38,77% of Billed Charges,23.97,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,23.97,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,29.38,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,155,Pays Based On Per Visit,146,Pays Based On Per Visit,146,Pays Based On Per Visit,23.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,146,PER DIEM,3156.52,285% of BCBS PATHWAY X Fees Schedule,160,Pays Based On Per Visit,77.08,Pays Based On Per Visit,83.66,89% of Billed Charges,83.66,89% of Billed Charges,83.66,89% of Billed Charges,38.35,40.8% of Billed Charges,38.35,40.8% of Billed Charges,38.35,40.8% of Billed Charges,23.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,72.38,77% of Billed Charges,79.9,85% of Billed Charges,27.03,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,222,Pays Based On Per Visit,38.35,40.8% of Billed Charges,23.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,192,Pays Based On Per Visit,23.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,23.5,3156.52,47
Outpatient Medical Services,OUTPATIENT THERAPY,97014,electrical muscle stimulation,420,124.5,95.87,77% of Billed Charges,31.75,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,31.75,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,38.91,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,155,Pays Based On Per Visit,146,Pays Based On Per Visit,146,Pays Based On Per Visit,31.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,146,PER DIEM,3156.52,285% of BCBS PATHWAY X Fees Schedule,160,Pays Based On Per Visit,102.09,Pays Based On Per Visit,110.81,89% of Billed Charges,110.81,89% of Billed Charges,110.81,89% of Billed Charges,50.8,40.8% of Billed Charges,50.8,40.8% of Billed Charges,50.8,40.8% of Billed Charges,31.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,95.87,77% of Billed Charges,105.83,85% of Billed Charges,35.79,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,222,Pays Based On Per Visit,50.8,40.8% of Billed Charges,31.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,192,Pays Based On Per Visit,31.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,31.13,3156.52,62.25
Outpatient Medical Services,OUTPATIENT THERAPY,97035,Therapeutic Ultrasound,420,70.5,54.29,77% of Billed Charges,17.98,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,17.98,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,22.03,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,155,Pays Based On Per Visit,146,Pays Based On Per Visit,146,Pays Based On Per Visit,17.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,146,PER DIEM,3159.62,285% of BCBS PATHWAY X Fees Schedule,160,Pays Based On Per Visit,57.81,Pays Based On Per Visit,62.75,89% of Billed Charges,62.75,89% of Billed Charges,62.75,89% of Billed Charges,28.76,40.8% of Billed Charges,28.76,40.8% of Billed Charges,28.76,40.8% of Billed Charges,17.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,54.29,77% of Billed Charges,59.93,85% of Billed Charges,20.27,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,222,Pays Based On Per Visit,28.76,40.8% of Billed Charges,17.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,562,Pays Based On Per Visit,17.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,17.63,3159.62,35.25
Outpatient Medical Services,OUTPATIENT THERAPY,97110,"Physical therapy, therapeutic exercise",420,96,73.92,77% of Billed Charges,24.48,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,24.48,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,30,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,155,Pays Based On Per Visit,146,Pays Based On Per Visit,146,Pays Based On Per Visit,24,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,146,PER DIEM,3159.62,285% of BCBS PATHWAY X Fees Schedule,160,Pays Based On Per Visit,78.72,Pays Based On Per Visit,85.44,89% of Billed Charges,85.44,89% of Billed Charges,85.44,89% of Billed Charges,39.17,40.8% of Billed Charges,39.17,40.8% of Billed Charges,39.17,40.8% of Billed Charges,24,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,73.92,77% of Billed Charges,81.6,85% of Billed Charges,27.6,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,222,Pays Based On Per Visit,39.17,40.8% of Billed Charges,24,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,562,Pays Based On Per Visit,24,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,24,3159.62,48
Outpatient Medical Services,OUTPATIENT THERAPY,97112,"neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities",420,105.5,81.24,77% of Billed Charges,26.9,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,26.9,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,32.97,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,155,Pays Based On Per Visit,146,Pays Based On Per Visit,146,Pays Based On Per Visit,26.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,146,PER DIEM,2202.79,285% of BCBS PATHWAY X Fees Schedule,160,Pays Based On Per Visit,86.51,Pays Based On Per Visit,93.9,89% of Billed Charges,93.9,89% of Billed Charges,93.9,89% of Billed Charges,43.04,40.8% of Billed Charges,43.04,40.8% of Billed Charges,43.04,40.8% of Billed Charges,26.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,81.24,77% of Billed Charges,89.68,85% of Billed Charges,30.33,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,222,Pays Based On Per Visit,43.04,40.8% of Billed Charges,26.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,562,Pays Based On Per Visit,26.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,26.38,2202.79,52.75
Outpatient Medical Services,OUTPATIENT THERAPY,97113,aquatic physical therapy,420,151,116.27,77% of Billed Charges,38.51,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,38.51,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,47.19,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,155,Pays Based On Per Visit,146,Pays Based On Per Visit,146,Pays Based On Per Visit,37.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,146,PER DIEM,1562,PER DIEM,160,Pays Based On Per Visit,123.82,Pays Based On Per Visit,134.39,89% of Billed Charges,134.39,89% of Billed Charges,134.39,89% of Billed Charges,61.61,40.8% of Billed Charges,61.61,40.8% of Billed Charges,61.61,40.8% of Billed Charges,37.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,116.27,77% of Billed Charges,128.35,85% of Billed Charges,43.41,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,222,Pays Based On Per Visit,61.61,40.8% of Billed Charges,37.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,562,Pays Based On Per Visit,37.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,37.75,1562,75.5
Outpatient Medical Services,OUTPATIENT THERAPY,97140,Manual therapy,420,117.5,90.48,77% of Billed Charges,29.96,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,29.96,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,36.72,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,155,Pays Based On Per Visit,146,Pays Based On Per Visit,146,Pays Based On Per Visit,29.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,146,PER DIEM,1562,PER DIEM,160,Pays Based On Per Visit,96.35,Pays Based On Per Visit,104.58,89% of Billed Charges,104.58,89% of Billed Charges,104.58,89% of Billed Charges,47.94,40.8% of Billed Charges,47.94,40.8% of Billed Charges,47.94,40.8% of Billed Charges,29.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,90.48,77% of Billed Charges,99.88,85% of Billed Charges,33.78,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,222,Pays Based On Per Visit,47.94,40.8% of Billed Charges,29.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,562,Pays Based On Per Visit,29.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,29.38,1562,58.75
Outpatient Medical Services,OUTPATIENT THERAPY,97161,Physical therapy evaluation,424,112,86.24,77% of Billed Charges,28.56,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,28.56,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,35,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,155,Pays Based On Per Visit,146,Pays Based On Per Visit,146,Pays Based On Per Visit,28,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,146,PER DIEM,1562,PER DIEM,160,Pays Based On Per Visit,91.84,Pays Based On Per Visit,99.68,89% of Billed Charges,99.68,89% of Billed Charges,99.68,89% of Billed Charges,45.7,40.8% of Billed Charges,45.7,40.8% of Billed Charges,45.7,40.8% of Billed Charges,28,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,86.24,77% of Billed Charges,95.2,85% of Billed Charges,32.2,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,222,Pays Based On Per Visit,45.7,40.8% of Billed Charges,28,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,141,Pays Based On Per Visit,28,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,28,1562,56
Outpatient Medical Services,OUTPATIENT THERAPY,97530,Theraputic Activities,420,114,87.78,77% of Billed Charges,29.07,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,29.07,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,35.63,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,155,Pays Based On Per Visit,146,Pays Based On Per Visit,146,Pays Based On Per Visit,28.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,146,PER DIEM,1562,PER DIEM,160,Pays Based On Per Visit,93.48,Pays Based On Per Visit,101.46,89% of Billed Charges,101.46,89% of Billed Charges,101.46,89% of Billed Charges,46.51,40.8% of Billed Charges,46.51,40.8% of Billed Charges,46.51,40.8% of Billed Charges,28.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,87.78,77% of Billed Charges,96.9,85% of Billed Charges,32.78,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,222,Pays Based On Per Visit,46.51,40.8% of Billed Charges,28.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,2050,Pays Based On Per Visit,28.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,28.5,2050,57
Outpatient Medical Services,OUTPATIENT THERAPY,97535,self-care/home management training,420,120.5,92.79,77% of Billed Charges,30.73,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,30.73,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,37.66,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,155,Pays Based On Per Visit,146,Pays Based On Per Visit,146,Pays Based On Per Visit,30.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,146,PER DIEM,1562,PER DIEM,160,Pays Based On Per Visit,98.81,Pays Based On Per Visit,107.25,89% of Billed Charges,107.25,89% of Billed Charges,107.25,89% of Billed Charges,49.16,40.8% of Billed Charges,49.16,40.8% of Billed Charges,49.16,40.8% of Billed Charges,30.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,92.79,77% of Billed Charges,102.43,85% of Billed Charges,34.64,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,222,Pays Based On Per Visit,49.16,40.8% of Billed Charges,30.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,1827,Pays Based On Per Visit,30.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,30.13,1827,60.25
Outpatient Medical Services,CARDIAC TESTING,93000,"Electrocardiogram, routine, with interpretation and report",521,28,21.56,77% of Billed Charges,7.14,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,7.14,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,8.75,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,7,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,24.92,89% of Billed Charges,24.92,89% of Billed Charges,24.92,89% of Billed Charges,11.42,40.8% of Billed Charges,11.42,40.8% of Billed Charges,11.42,40.8% of Billed Charges,7,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,21.56,77% of Billed Charges,23.8,85% of Billed Charges,8.05,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,11.42,40.8% of Billed Charges,7,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,7,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,7,24.92,14
Outpatient Medical Services,CARDIAC TESTING,93005,"Electrocardiogram, routine ECG with at least 12 leads; tracing only",730,296,227.92,77% of Billed Charges,75.48,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,75.48,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,92.5,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,160,Pays Based On Per Visit,155,Pays Based On Per Visit,155,Pays Based On Per Visit,74,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,155,PER DIEM,1562,PER DIEM,164,Pays Based On Per Visit,242.72,82% of Billed Charges,263.44,89% of Billed Charges,263.44,89% of Billed Charges,263.44,89% of Billed Charges,12.43,120% of HEALTHY BLUE Fees Schedule,12.43,120% of HOMESTATE Fees Schedule,12.43,120% of MO Fee Schedule,74,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,227.92,77% of Billed Charges,251.6,85% of Billed Charges,85.1,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,296,Pays Based On Per Visit,12.43,120% of UHC COMMUNITY PLAN fee Schedule,74,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,192,Pays Based On Per Visit,74,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,12.43,1562,148
Outpatient Medical Services,CARDIAC TESTING,93010,"ECG, INTERPRETATION AND REPORT",521,16,12.32,77% of Billed Charges,4.08,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,4.08,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,5,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,4,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,14.24,89% of Billed Charges,14.24,89% of Billed Charges,14.24,89% of Billed Charges,6.53,40.8% of Billed Charges,6.53,40.8% of Billed Charges,6.53,40.8% of Billed Charges,4,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,12.32,77% of Billed Charges,13.6,85% of Billed Charges,4.6,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,6.53,40.8% of Billed Charges,4,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,4,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,4,14.24,8
Outpatient Medical Services,CARDIAC TESTING,93017,Cardiovascular stress test,482,745,573.65,77% of Billed Charges,189.98,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,189.98,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,232.81,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,291,Pays Based On Per Visit,284,Pays Based On Per Visit,284,Pays Based On Per Visit,186.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,284,PER DIEM,1562,PER DIEM,312,Pays Based On Per Visit,610.9,82% of Billed Charges,663.05,89% of Billed Charges,663.05,89% of Billed Charges,663.05,89% of Billed Charges,62.29,120% of HEALTHY BLUE Fees Schedule,62.29,120% of HOMESTATE Fees Schedule,62.29,120% of MO Fee Schedule,186.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,573.65,77% of Billed Charges,633.25,85% of Billed Charges,214.19,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,446,Pays Based On Per Visit,62.29,120% of UHC COMMUNITY PLAN fee Schedule,186.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,192,Pays Based On Per Visit,186.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,62.29,1562,372.5
Outpatient Medical Services,CARDIAC TESTING,93270,Cardiovascular Monitoring Services,731,773,595.21,77% of Billed Charges,197.12,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,197.12,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,241.56,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,572.02,74% OF Billed Charges,533.37,69% of Billed Charges,533.37,69% of Billed charges,193.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,533.37,69% of Billed Charges,533.37,69% of Billed Charges,649.32,84% of Billed Charges,633.86,82% of Billed Charges,687.97,89% of Billed Charges,687.97,89% of Billed Charges,687.97,89% of Billed Charges,22.87,120% of HEALTHY BLUE Fees Schedule,22.87,120% of HOMESTATE Fees Schedule,22.87,120% of MO Fee Schedule,193.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,595.21,77% of Billed Charges,657.05,85% of Billed Charges,222.24,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,508,Pays Based On Per Visit,22.87,120% of UHC COMMUNITY PLAN fee Schedule,193.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,386,Pays Based On Per Visit,193.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,22.87,687.97,386.5
Outpatient Medical Services,CARDIAC TESTING,93306,"Echocardiography, transthoracic, real-time with image documentation",480,3053,2350.81,77% of Billed Charges,778.52,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,778.52,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,954.06,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,2259.22,74% OF Billed Charges,2106.57,69% of Billed Charges,2106.57,69% of Billed charges,763.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,2106.57,69% of Billed Charges,2106.57,69% of Billed Charges,2564.52,84% of Billed Charges,2503.46,82% of Billed Charges,2717.17,89% of Billed Charges,2717.17,89% of Billed Charges,2717.17,89% of Billed Charges,142.21,120% of HEALTHY BLUE Fees Schedule,142.21,120% of HOMESTATE Fees Schedule,142.21,120% of MO Fee Schedule,763.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,2350.81,77% of Billed Charges,2595.05,85% of Billed Charges,877.74,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,898,Pays Based On Per Visit,142.21,120% of UHC COMMUNITY PLAN fee Schedule,763.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,386,Pays Based On Per Visit,763.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,142.21,2717.17,1526.5
Outpatient Medical Services,CARDIAC TESTING,93798,CARDIAC REHAB MONITORED,943,354.5,272.97,77% of Billed Charges,90.4,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,90.4,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,110.78,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,262.33,74% OF Billed Charges,244.61,69% of Billed Charges,244.61,69% of Billed charges,88.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,244.61,69% of Billed Charges,244.61,69% of Billed Charges,297.78,84% of Billed Charges,290.69,82% of Billed Charges,315.51,89% of Billed Charges,315.51,89% of Billed Charges,315.51,89% of Billed Charges,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,88.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,272.97,77% of Billed Charges,301.33,85% of Billed Charges,101.92,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,162,Pays Based On Per Visit,N/A,NOT REIMBURSABLE,88.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,386,Pays Based On Per Visit,88.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,88.63,386,177.25
Outpatient Medical Services,CARDIAC TESTING,93880,Duplex scan of extracranial arteries; complete bilateral study,921,1589,1223.53,77% of Billed Charges,405.2,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,405.2,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,496.56,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,1175.86,74% OF Billed Charges,1096.41,69% of Billed Charges,1096.41,69% of Billed charges,397.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,1096.41,69% of Billed Charges,1096.41,69% of Billed Charges,1334.76,84% of Billed Charges,1302.98,82% of Billed Charges,1414.21,89% of Billed Charges,1414.21,89% of Billed Charges,1414.21,89% of Billed Charges,181.34,120% of HEALTHY BLUE Fees Schedule,181.34,120% of HOMESTATE Fees Schedule,181.34,120% of MO Fee Schedule,397.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,1223.53,77% of Billed Charges,1350.65,85% of Billed Charges,456.84,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,728,Pays Based On Per Visit,181.34,120% of UHC COMMUNITY PLAN fee Schedule,397.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,386,Pays Based On Per Visit,397.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,181.34,1414.21,794.5
Outpatient Medical Services,CARDIAC TESTING,93971,Duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited study,921,1297.5,999.08,77% of Billed Charges,330.86,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,330.86,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,405.47,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,960.15,74% OF Billed Charges,895.28,69% of Billed Charges,895.28,69% of Billed charges,324.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,895.28,69% of Billed Charges,895.28,69% of Billed Charges,1089.9,84% of Billed Charges,1063.95,82% of Billed Charges,1154.78,89% of Billed Charges,1154.78,89% of Billed Charges,1154.78,89% of Billed Charges,93.16,120% of HEALTHY BLUE Fees Schedule,93.16,120% of HOMESTATE Fees Schedule,93.16,120% of MO Fee Schedule,324.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,999.08,77% of Billed Charges,1102.88,85% of Billed Charges,373.03,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,728,Pays Based On Per Visit,93.16,120% of UHC COMMUNITY PLAN fee Schedule,324.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,386,Pays Based On Per Visit,324.38,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,93.16,1154.78,648.75
Outpatient Medical Services,OTHER SERVICES,36430,"Transfusion, blood or blood components",391,,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,260,Pays Based On Per Visit,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,260,260,0
Outpatient Medical Services,OTHER SERVICES,36591,collection of blood specimen from a completely implantable venous access device,300,,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,64,Pays Based On Per Visit,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,386,Pays Based On Per Visit,N/A,NOT REIMBURSABLE,64,386,0
Outpatient Medical Services,OTHER SERVICES,36600,"catheter ""placement.",920,,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,119,Pays Based On Per Visit,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,386,Pays Based On Per Visit,N/A,NOT REIMBURSABLE,119,386,0
Outpatient Medical Services,OTHER SERVICES,59025,Fetal non-stress test,920,90,69.3,77% of Billed Charges,22.95,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,22.95,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,28.13,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,66.6,74% OF Billed Charges,62.1,69% of Billed Charges,62.1,69% of Billed charges,22.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,62.1,69% of Billed Charges,62.1,69% of Billed Charges,75.6,84% of Billed Charges,73.8,82% of Billed Charges,80.1,89% of Billed Charges,80.1,89% of Billed Charges,80.1,89% of Billed Charges,17.6,120% of HEALTHY BLUE Fees Schedule,17.6,120% of HOMESTATE Fees Schedule,17.6,120% of MO Fee Schedule,22.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,69.3,77% of Billed Charges,76.5,85% of Billed Charges,25.88,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,119,Pays Based On Per Visit,17.6,120% of UHC COMMUNITY PLAN fee Schedule,22.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,386,Pays Based On Per Visit,22.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,17.6,386,45
Outpatient Medical Services,OTHER SERVICES,59050,"fetal monitoring during labor by consulting physician (i.e., non-attending physician",920,,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,119,Pays Based On Per Visit,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,386,Pays Based On Per Visit,N/A,NOT REIMBURSABLE,119,386,0
Outpatient Medical Services,OTHER SERVICES,90471,"Immunization administration for percutaneous, intra-dermal, subcutaneous or intramuscular injections, initial",771,28,21.56,77% of Billed Charges,7.14,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,7.14,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,8.75,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,20.72,74% OF Billed Charges,19.32,69% of Billed Charges,19.32,69% of Billed charges,7,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,19.32,69% of Billed Charges,19.32,69% of Billed Charges,23.52,84% of Billed Charges,22.96,82% of Billed Charges,24.92,89% of Billed Charges,24.92,89% of Billed Charges,24.92,89% of Billed Charges,11.42,40.8% of Billed Charges,11.42,40.8% of Billed Charges,11.42,40.8% of Billed Charges,7,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,21.56,77% of Billed Charges,23.8,85% of Billed Charges,8.05,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,69,Pays Based On Per Visit,11.42,40.8% of Billed Charges,7,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,7,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,7,69,14
Outpatient Medical Services,OTHER SERVICES,90620,"Meningococcal recombinant protein and outer membrane vesicle vaccine, serogroup B, 2 dose schedule, for intramuscular use",521,284,218.68,77% of Billed Charges,72.42,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,72.42,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,88.75,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,71,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,252.76,89% of Billed Charges,252.76,89% of Billed Charges,252.76,89% of Billed Charges,115.87,40.8% of Billed Charges,115.87,40.8% of Billed Charges,115.87,40.8% of Billed Charges,71,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,218.68,77% of Billed Charges,241.4,85% of Billed Charges,81.65,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,115.87,40.8% of Billed Charges,71,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,71,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,71,252.76,142
Outpatient Medical Services,OTHER SERVICES,90633,Hepatitis A vaccine,521,50,38.5,77% of Billed Charges,12.75,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,12.75,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,15.63,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,12.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,44.5,89% of Billed Charges,44.5,89% of Billed Charges,44.5,89% of Billed Charges,20.4,40.8% of Billed Charges,20.4,40.8% of Billed Charges,20.4,40.8% of Billed Charges,12.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,38.5,77% of Billed Charges,42.5,85% of Billed Charges,14.38,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,20.4,40.8% of Billed Charges,12.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,12.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,12.5,44.5,25
Outpatient Medical Services,OTHER SERVICES,90649,"HPV vaccine,",521,315,242.55,77% of Billed Charges,80.33,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,80.33,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,98.44,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,78.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,280.35,89% of Billed Charges,280.35,89% of Billed Charges,280.35,89% of Billed Charges,128.52,40.8% of Billed Charges,128.52,40.8% of Billed Charges,128.52,40.8% of Billed Charges,78.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,242.55,77% of Billed Charges,267.75,85% of Billed Charges,90.56,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,128.52,40.8% of Billed Charges,78.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,78.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,78.75,280.35,157.5
Outpatient Medical Services,OTHER SERVICES,90670,"Pneumococcal conjugate vaccine, 13 valent, for intramuscular use",636,307,236.39,77% of Billed Charges,78.29,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,78.29,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,95.94,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,211.83,69% of Billed Charges,211.83,69% of Billed Charges,211.83,69% of Billed charges,76.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,211.83,69% of Billed Charges,211.83,69% of Billed Charges,211.83,69% of Billed charges,138.15,45% of Billed Charges,273.23,89% of Billed Charges,273.23,89% of Billed Charges,273.23,89% of Billed Charges,125.26,40.8% of Billed Charges,125.26,40.8% of Billed Charges,125.26,40.8% of Billed Charges,76.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,236.39,77% of Billed Charges,260.95,85% of Billed Charges,88.26,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,125.26,40.8% of Billed Charges,76.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,76.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,76.75,273.23,153.5
Outpatient Medical Services,OTHER SERVICES,90734,"Meningicoccal conjugate vaccine, serogoups A, C, Y and W-135",521,200,154,77% of Billed Charges,51,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,51,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,62.5,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,50,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,178,89% of Billed Charges,178,89% of Billed Charges,178,89% of Billed Charges,81.6,40.8% of Billed Charges,81.6,40.8% of Billed Charges,81.6,40.8% of Billed Charges,50,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,154,77% of Billed Charges,170,85% of Billed Charges,57.5,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,81.6,40.8% of Billed Charges,50,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,50,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,50,178,100
Outpatient Medical Services,OTHER SERVICES,96360,"Intravenous Infusion, hydration; initial, 31 minutes to 1 hour",940,95,73.15,77% of Billed Charges,24.23,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,24.23,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,29.69,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,70.3,74% OF Billed Charges,65.55,69% of Billed Charges,65.55,69% of Billed charges,23.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,65.55,69% of Billed Charges,65.55,69% of Billed Charges,79.8,84% of Billed Charges,77.9,82% of Billed Charges,84.55,89% of Billed Charges,84.55,89% of Billed Charges,84.55,89% of Billed Charges,38.76,40.8% of Billed Charges,38.76,40.8% of Billed Charges,38.76,40.8% of Billed Charges,23.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,73.15,77% of Billed Charges,80.75,85% of Billed Charges,27.31,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,136,Pays Based On Per Visit,38.76,40.8% of Billed Charges,23.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,386,Pays Based On Per Visit,23.75,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,23.75,386,47.5
Outpatient Medical Services,OTHER SERVICES,96361,"Intravenous Infusion, hydration; each additional hour",940,,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,136,Pays Based On Per Visit,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,386,Pays Based On Per Visit,N/A,NOT REIMBURSABLE,136,386,0
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.",940,122.3,94.17,77% of Billed Charges,31.19,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,31.19,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,38.22,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,90.5,74% OF Billed Charges,84.39,69% of Billed Charges,84.39,69% of Billed charges,30.58,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,84.39,69% of Billed Charges,84.39,69% of Billed Charges,102.73,84% of Billed Charges,100.29,82% of Billed Charges,108.85,89% of Billed Charges,108.85,89% of Billed Charges,108.85,89% of Billed Charges,49.9,40.8% of Billed Charges,49.9,40.8% of Billed Charges,49.9,40.8% of Billed Charges,30.58,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,94.17,77% of Billed Charges,103.96,85% of Billed Charges,35.16,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,136,Pays Based On Per Visit,49.9,40.8% of Billed Charges,30.58,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,386,Pays Based On Per Visit,30.58,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,30.58,386,61.15
Outpatient Medical Services,OTHER SERVICES,96366,additional hours code associated with the sequential therapeutic infusion,940,,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,136,Pays Based On Per Visit,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,47.29,100% of UMR Fee schedule,N/A,NOT REIMBURSABLE,47.29,136,0
Outpatient Medical Services,OTHER SERVICES,96367,"Therapeutic, Prophylactic, and Diagnostic Injections and Infusions",940,,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,136,Pays Based On Per Visit,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,82.39,100% of UMR Fee schedule,N/A,NOT REIMBURSABLE,82.39,136,0
Outpatient Medical Services,OTHER SERVICES,96372,"Therapeutic, Prophylactic, and Diagnostic Injections and Infusions",940,26,20.02,77% of Billed Charges,6.63,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,6.63,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,8.13,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,19.24,74% OF Billed Charges,17.94,69% of Billed Charges,17.94,69% of Billed charges,6.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,17.94,69% of Billed Charges,17.94,69% of Billed Charges,21.84,84% of Billed Charges,21.32,82% of Billed Charges,23.14,89% of Billed Charges,23.14,89% of Billed Charges,23.14,89% of Billed Charges,10.61,40.8% of Billed Charges,10.61,40.8% of Billed Charges,10.61,40.8% of Billed Charges,6.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,20.02,77% of Billed Charges,22.1,85% of Billed Charges,7.48,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,136,Pays Based On Per Visit,10.61,40.8% of Billed Charges,6.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,2563,PER DIEM,6.5,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,6.5,2563,13
Outpatient Medical Services,OTHER SERVICES,96374,"Hydration, Therapeutic, Prophylactic, Diagnostic Injections and Infusions, and Chemotherapy and Other Highly Complex Drug",940,,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,136,Pays Based On Per Visit,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,2563,PER DIEM,N/A,NOT REIMBURSABLE,136,2563,0
Outpatient Medical Services,OTHER SERVICES,96375,"Therapeutic, Prophylactic, and Diagnostic Injections and Infusions",940,,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,136,Pays Based On Per Visit,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,2563,PER DIEM,N/A,NOT REIMBURSABLE,136,2563,0
Outpatient Medical Services,OTHER SERVICES,96376,"Therapeutic, prophylactic, or diagnostic injection",940,,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,136,Pays Based On Per Visit,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,2563,PER DIEM,N/A,NOT REIMBURSABLE,136,2563,0
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,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,210,Pays Based On Per Visit,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,2563,PER DIEM,N/A,NOT REIMBURSABLE,210,2563,0
Outpatient Medical Services,OTHER SERVICES,96413,"chemotherapy administration, intravenous infusion technique; up to one hour",940,1237,952.49,77% of Billed Charges,315.44,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,315.44,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,386.56,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,915.38,74% OF Billed Charges,853.53,69% of Billed Charges,853.53,69% of Billed charges,309.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,853.53,69% of Billed Charges,853.53,69% of Billed Charges,1039.08,84% of Billed Charges,1014.34,82% of Billed Charges,1100.93,89% of Billed Charges,1100.93,89% of Billed Charges,1100.93,89% of Billed Charges,504.7,40.8% of Billed Charges,504.7,40.8% of Billed Charges,504.7,40.8% of Billed Charges,309.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,952.49,77% of Billed Charges,1051.45,85% of Billed Charges,355.64,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,136,Pays Based On Per Visit,504.7,40.8% of Billed Charges,309.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,2563,PER DIEM,309.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,136,2563,618.5
Outpatient Medical Services,OTHER SERVICES,96415,Injection and Intravenous Infusion Chemotherapy and Other Highly Complex Drug or Highly Complex Biologic Agent Administration,335,155.5,119.74,77% of Billed Charges,39.65,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,39.65,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,48.59,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,115.07,Pays Based On Per Visit,107.3,Pays Based On Per Visit,107.3,Pays Based On Per Visit,38.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,107.3,PER DIEM,2350,PER DIEM,130.62,Pays Based On Per Visit,127.51,82% of Billed Charges,138.4,89% of Billed Charges,138.4,89% of Billed Charges,138.4,89% of Billed Charges,63.44,40.8% of Billed Charges,63.44,40.8% of Billed Charges,63.44,40.8% of Billed Charges,38.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,119.74,77% of Billed Charges,132.18,85% of Billed Charges,44.71,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,210,Pays Based On Per Visit,63.44,40.8% of Billed Charges,38.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,2563,PER DIEM,38.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,38.88,2563,77.75
Outpatient Medical Services,OTHER SERVICES,96417,Injection and Intravenous Infusion Chemotherapy and Other Highly Complex Drug or Highly Complex Biologic Agent Administration,335,316.5,243.71,77% of Billed Charges,80.71,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,80.71,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,98.91,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,234.21,Pays Based On Per Visit,218.39,Pays Based On Per Visit,218.39,Pays Based On Per Visit,79.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,218.39,PER DIEM,2350,PER DIEM,265.86,Pays Based On Per Visit,259.53,82% of Billed Charges,281.69,89% of Billed Charges,281.69,89% of Billed Charges,281.69,89% of Billed Charges,129.13,40.8% of Billed Charges,129.13,40.8% of Billed Charges,129.13,40.8% of Billed Charges,79.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,243.71,77% of Billed Charges,269.03,85% of Billed Charges,90.99,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,210,Pays Based On Per Visit,129.13,40.8% of Billed Charges,79.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,1024,PER DIEM,79.13,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,79.13,2350,158.25
Outpatient Medical Services,OTHER SERVICES,96523,Irrigation of implanted venous access device for drug delivery system,940,466.5,359.21,77% of Billed Charges,118.96,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,118.96,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,145.78,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,345.21,74% OF Billed Charges,321.89,69% of Billed Charges,321.89,69% of Billed charges,116.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,321.89,69% of Billed Charges,321.89,69% of Billed Charges,391.86,84% of Billed Charges,382.53,82% of Billed Charges,415.19,89% of Billed Charges,415.19,89% of Billed Charges,415.19,89% of Billed Charges,190.33,40.8% of Billed Charges,190.33,40.8% of Billed Charges,190.33,40.8% of Billed Charges,116.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,359.21,77% of Billed Charges,396.53,85% of Billed Charges,134.12,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,136,Pays Based On Per Visit,190.33,40.8% of Billed Charges,116.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,1024,PER DIEM,116.63,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,116.63,1024,233.25
Outpatient Medical Services,OTHER SERVICES,A9502,"Technetium tc-99m tetrofosmin, diagnostic, per study dose",343,265,204.05,77% of Billed Charges,67.58,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,67.58,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,82.81,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,196.1,74% OF Billed Charges,182.85,69% of Billed Charges,182.85,69% of Billed charges,66.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,182.85,69% of Billed Charges,182.85,69% of Billed Charges,222.6,84% of Billed Charges,217.3,82% of Billed Charges,235.85,89% of Billed Charges,235.85,89% of Billed Charges,235.85,89% of Billed Charges,108.12,40.8% of Billed Charges,108.12,40.8% of Billed Charges,108.12,40.8% of Billed Charges,66.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,204.05,77% of Billed Charges,225.25,85% of Billed Charges,76.19,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,132.5,50% of Billed Charges,108.12,40.8% of Billed Charges,66.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,235.85,89% of Billed Charges,66.25,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,66.25,235.85,132.5
Outpatient Medical Services,OTHER SERVICES,M0243,Monoclonal Antibody COVID-19 Infusion,771,1924,1481.48,77% of Billed Charges,490.62,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,490.62,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,601.25,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,1423.76,74% OF Billed Charges,1327.56,69% of Billed Charges,1327.56,69% of Billed charges,481,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,1327.56,69% of Billed Charges,1327.56,69% of Billed Charges,1616.16,84% of Billed Charges,1577.68,82% of Billed Charges,1712.36,89% of Billed Charges,1712.36,89% of Billed Charges,1712.36,89% of Billed Charges,784.99,40.8% of Billed Charges,784.99,40.8% of Billed Charges,784.99,40.8% of Billed Charges,481,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,1481.48,77% of Billed Charges,1635.4,85% of Billed Charges,553.15,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,69,Pays Based On Per Visit,784.99,40.8% of Billed Charges,481,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,481,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,69,1712.36,962
Outpatient Medical Services,OTHER SERVICES,P9016,"Red blood cells, leukocytes reduced, each unit Short description: Rbc leukocytes reduced",390,611.5,470.86,77% of Billed Charges,155.93,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,155.93,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,191.09,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,452.51,74% OF Billed Charges,421.94,69% of Billed Charges,421.94,69% of Billed charges,152.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,421.94,69% of Billed Charges,421.94,69% of Billed Charges,513.66,84% of Billed Charges,501.43,82% of Billed Charges,544.24,89% of Billed Charges,544.24,89% of Billed Charges,544.24,89% of Billed Charges,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,N/A,NOT REIMBURSABLE,152.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,470.86,77% of Billed Charges,519.78,85% of Billed Charges,175.81,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,260,Pays Based On Per Visit,N/A,NOT REIMBURSABLE,152.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,N/A,NOT REIMBURSABLE,152.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,152.88,544.24,305.75
Outpatient Medical Services,OTHER SERVICES,Q3014,Telehealth originating site facility fee,780,111.5,85.86,77% of Billed Charges,28.43,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,28.43,25.5% OF BILLED CHARGES WHICH IS 102% OF MEDICARE RATE,34.84,31.25% OF BILLED CHARGES WHICH IS 125% OF MEDICARE RATE,82.51,74% OF Billed Charges,76.94,69% of Billed Charges,76.94,69% of Billed charges,27.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,76.94,69% of Billed Charges,76.94,69% of Billed Charges,93.66,84% of Billed Charges,91.43,82% of Billed Charges,99.24,89% of Billed Charges,99.24,89% of Billed Charges,99.24,89% of Billed Charges,45.49,40.8% of Billed Charges,45.49,40.8% of Billed Charges,45.49,40.8% of Billed Charges,27.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,85.86,77% of Billed Charges,94.78,85% of Billed Charges,32.06,28.75% OF BILLED CHARGES WHICH IS 115% OF MEDICARE RATE,55.75,50% of Billed Charges,45.49,40.8% of Billed Charges,27.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,99.24,89% of Billed Charges,27.88,25% OF BILLED CHARGES WHICH IS 100% OF MEDICARE RATE,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,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED
Outpatient Medical Services,OUTPATIENT SERVICES,55866,Surgical removal of prostate and surrounding lymph nodes using an endoscope,360,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED
Outpatient Medical Services,CARDIOLOGY,93452,Insertion of catheter into left heart for diagnosis,480,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED
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,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED
Inpatient Medical Services,INPATIENT PROCEDURES,460,Spinal fusion except cervical without major comorbid conditions or complications,100,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED
Inpatient Medical Services,INPATIENT PROCEDURES,473,Cervical spinal fusion without comorbid conditions or major comorbid conditions or complications,100,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED