hospital_name,last_updated_on,version,hospital_location,hospital_address,license_number|FL,"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.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,, Northwest Florida Community Hospital,7/1/2024,2.0.0,Northwest Florida Community Hospital,"1360 Brickyard Road Chipley, FL 32428",596002711,TRUE,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, SERVICE DESCRIPTION,CATEGORY,BILLING MSDRG | CPT | HCPCS,ITEM/SERVICE DESCRIPTION,BILLING REVENUE CODE,GROSS CHARGES,AETNA PLAN,AETNA REIMBURSEMENT METHOD,BLUE CROSS NWB PLAN,BLUE CROSS NWB REIMBURSEMENT METHOD,BLUE CROSS PHS PPO PLAN,BLUE CROSS PHS PPO REIMBURSEMENT METHOD,CIGNA PLAN,CIGNA REIMBURSEMENT METHOD,FLORIDA COMMUNITY CARE PLAN,FLORIDA COMMUNITY CARE REIMBURSEMENT METHOD,HUMANA PLAN,HUMANA REIMBURSEMENT METHOD,HUMANA MEDICAID PLAN,HUMANA MEDICAID REIMBURSEMENT METHOD,HUMANA MEDICARE PLAN,HUMANA MEDICARE REIMBURSEMENT METHOD,LIGHTHOUSE PLAN,LIGHTHOUSE REIMBURSEMENT METHOD,MEDICAID PLAN,MEDICAID REIMBURSEMENT METHOD,MEDICARE PLAN,MEDICARE REIMBURSEMENT METHOD,SUNSHINE PLAN,SUNSHINE REIMBURSEMENT METHOD,UNITED HEALTHCARE PLAN,UNITED HEALTHCARE REIMBURSEMENT METHOD,WELLCARE PLAN,WELLCARE REIMBURSEMENT METHOD,De-Identified Minimum Negotiated Rate,De-Identified Maximum Negotiated Rate,DISCOUNTED CASH PRICE Inpatient Medical Services,Inpatient,92,OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,111,N/A,N/A,Not Applicable. Service not offered,"$5,563.77 ",Pays at 100% of CMS Rate for Inpatient Setting,"$5,856.60 ",Pays at 100% of CMS Rate for Inpatient Setting,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,036.44 ",Pays based on per day rate,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,036.44 ",Pays based on per day rate,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,1036.44,5856.6,N/A Inpatient Medical Services,Inpatient,93,OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,111,N/A,N/A,Not Applicable. Service not offered,"$4,208.31 ",Pays at 100% of CMS Rate for Inpatient Setting,"$4,429.80 ",Pays at 100% of CMS Rate for Inpatient Setting,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,036.44 ",Pays based on per day rate,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,036.44 ",Pays based on per day rate,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,1036.44,4429.8,N/A Inpatient Medical Services,Inpatient,177,RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,111,N/A,N/A,Not Applicable. Service not offered,"$11,026.08 ",Pays at 100% of CMS Rate for Inpatient Setting,"$11,606.40 ",Pays at 100% of CMS Rate for Inpatient Setting,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,036.44 ",Pays based on per day rate,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,036.44 ",Pays based on per day rate,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,1036.44,11606.4,N/A Inpatient Medical Services,Inpatient,178,RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,111,N/A,N/A,Not Applicable. Service not offered,"$11,026.08 ",Pays at 100% of CMS Rate for Inpatient Setting,"$11,606.40 ",Pays at 100% of CMS Rate for Inpatient Setting,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,036.44 ",Pays based on per day rate,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,036.44 ",Pays based on per day rate,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,1036.44,11606.4,N/A Inpatient Medical Services,Inpatient,179,RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,111,N/A,N/A,Not Applicable. Service not offered,"$8,200.59 ",Pays at 100% of CMS Rate for Inpatient Setting,"$8,632.20 ",Pays at 100% of CMS Rate for Inpatient Setting,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,036.44 ",Pays based on per day rate,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,036.44 ",Pays based on per day rate,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,1036.44,8632.2,N/A Inpatient Medical Services,Inpatient,190,CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,111,N/A,N/A,Not Applicable. Service not offered,"$6,137.76 ",Pays at 100% of CMS Rate for Inpatient Setting,"$6,460.80 ",Pays at 100% of CMS Rate for Inpatient Setting,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,036.44 ",Pays based on per day rate,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,036.44 ",Pays based on per day rate,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,1036.44,6460.8,N/A Inpatient Medical Services,Inpatient,192,CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,111,N/A,N/A,Not Applicable. Service not offered,"$6,137.76 ",Pays at 100% of CMS Rate for Inpatient Setting,"$6,460.80 ",Pays at 100% of CMS Rate for Inpatient Setting,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,036.44 ",Pays based on per day rate,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,036.44 ",Pays based on per day rate,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,1036.44,6460.8,N/A Inpatient Medical Services,Inpatient,194,SIMPLE PNEUMONIA AND PLEURISY WITH CC,111,N/A,N/A,Not Applicable. Service not offered,"$6,644.49 ",Pays at 100% of CMS Rate for Inpatient Setting,"$6,994.20 ",Pays at 100% of CMS Rate for Inpatient Setting,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,036.44 ",Pays based on per day rate,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,036.44 ",Pays based on per day rate,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,1036.44,6994.2,N/A Inpatient Medical Services,Inpatient,195,SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,111,N/A,N/A,Not Applicable. Service not offered,"$5,039.94 ",Pays at 100% of CMS Rate for Inpatient Setting,"$5,305.20 ",Pays at 100% of CMS Rate for Inpatient Setting,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,036.44 ",Pays based on per day rate,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,036.44 ",Pays based on per day rate,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,1036.44,5305.2,N/A Inpatient Medical Services,Inpatient,208,RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HO,111,N/A,N/A,Not Applicable. Service not offered,"$18,101.49 ",Pays at 100% of CMS Rate for Inpatient Setting,"$19,054.20 ",Pays at 100% of CMS Rate for Inpatient Setting,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,036.44 ",Pays based on per day rate,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,036.44 ",Pays based on per day rate,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,1036.44,19054.2,N/A Inpatient Medical Services,Inpatient,291,HEART FAILURE AND SHOCK WITH MCC,111,N/A,N/A,Not Applicable. Service not offered,"$5,755.86 ",Pays at 100% of CMS Rate for Inpatient Setting,"$6,058.80 ",Pays at 100% of CMS Rate for Inpatient Setting,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,036.44 ",Pays based on per day rate,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,036.44 ",Pays based on per day rate,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,1036.44,6058.8,N/A Inpatient Medical Services,Inpatient,292,HEART FAILURE AND SHOCK WITH CC,111,N/A,N/A,Not Applicable. Service not offered,"$5,755.86 ",Pays at 100% of CMS Rate for Inpatient Setting,"$6,058.80 ",Pays at 100% of CMS Rate for Inpatient Setting,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,036.44 ",Pays based on per day rate,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,036.44 ",Pays based on per day rate,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,1036.44,6058.8,N/A Inpatient Medical Services,Inpatient,293,HEART FAILURE AND SHOCK WITHOUT CC/MCC,111,N/A,N/A,Not Applicable. Service not offered,"$5,755.86 ",Pays at 100% of CMS Rate for Inpatient Setting,"$6,058.80 ",Pays at 100% of CMS Rate for Inpatient Setting,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,036.44 ",Pays based on per day rate,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,036.44 ",Pays based on per day rate,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,1036.44,6058.8,N/A Inpatient Medical Services,Inpatient,389,GASTROINTESTINAL OBSTRUCTION WITH CC,111,N/A,N/A,Not Applicable. Service not offered,"$4,322.31 ",Pays at 100% of CMS Rate for Inpatient Setting,"$4,549.80 ",Pays at 100% of CMS Rate for Inpatient Setting,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,036.44 ",Pays based on per day rate,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,036.44 ",Pays based on per day rate,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,1036.44,4549.8,N/A Inpatient Medical Services,Inpatient,392,"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DIS",111,N/A,N/A,Not Applicable. Service not offered,"$2,909.28 ",Pays at 100% of CMS Rate for Inpatient Setting,"$3,062.40 ",Pays at 100% of CMS Rate for Inpatient Setting,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,036.44 ",Pays based on per day rate,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,036.44 ",Pays based on per day rate,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,1036.44,3062.4,N/A Inpatient Medical Services,Inpatient,439,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,111,N/A,N/A,Not Applicable. Service not offered,"$5,527.86 ",Pays at 100% of CMS Rate for Inpatient Setting,"$5,818.80 ",Pays at 100% of CMS Rate for Inpatient Setting,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,036.44 ",Pays based on per day rate,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,036.44 ",Pays based on per day rate,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,1036.44,5818.8,N/A Inpatient Medical Services,Inpatient,440,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,111,N/A,N/A,Not Applicable. Service not offered,"$5,527.86 ",Pays at 100% of CMS Rate for Inpatient Setting,"$5,818.80 ",Pays at 100% of CMS Rate for Inpatient Setting,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,036.44 ",Pays based on per day rate,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,036.44 ",Pays based on per day rate,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,1036.44,5818.8,N/A Inpatient Medical Services,Inpatient,560,"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH",111,N/A,N/A,Not Applicable. Service not offered,"$4,488.75 ",Pays at 100% of CMS Rate for Inpatient Setting,"$4,725.00 ",Pays at 100% of CMS Rate for Inpatient Setting,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,036.44 ",Pays based on per day rate,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,036.44 ",Pays based on per day rate,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,1036.44,4725,N/A Inpatient Medical Services,Inpatient,561,"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH",111,N/A,N/A,Not Applicable. Service not offered,"$4,488.75 ",Pays at 100% of CMS Rate for Inpatient Setting,"$4,725.00 ",Pays at 100% of CMS Rate for Inpatient Setting,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,036.44 ",Pays based on per day rate,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,036.44 ",Pays based on per day rate,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,1036.44,4725,N/A Inpatient Medical Services,Inpatient,603,CELLULITIS WITHOUT MCC,111,N/A,N/A,Not Applicable. Service not offered,"$4,321.74 ",Pays at 100% of CMS Rate for Inpatient Setting,"$4,549.20 ",Pays at 100% of CMS Rate for Inpatient Setting,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,036.44 ",Pays based on per day rate,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,036.44 ",Pays based on per day rate,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,1036.44,4549.2,N/A Inpatient Medical Services,Inpatient,638,DIABETES WITH CC,111,N/A,N/A,Not Applicable. Service not offered,"$4,495.02 ",Pays at 100% of CMS Rate for Inpatient Setting,"$4,731.60 ",Pays at 100% of CMS Rate for Inpatient Setting,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,036.44 ",Pays based on per day rate,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,036.44 ",Pays based on per day rate,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,1036.44,4731.6,N/A Inpatient Medical Services,Inpatient,641,"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND",111,N/A,N/A,Not Applicable. Service not offered,"$4,105.71 ",Pays at 100% of CMS Rate for Inpatient Setting,"$4,321.80 ",Pays at 100% of CMS Rate for Inpatient Setting,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,036.44 ",Pays based on per day rate,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,036.44 ",Pays based on per day rate,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,1036.44,4321.8,N/A Inpatient Medical Services,Inpatient,689,KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,111,N/A,N/A,Not Applicable. Service not offered,"$4,916.82 ",Pays at 100% of CMS Rate for Inpatient Setting,"$5,175.60 ",Pays at 100% of CMS Rate for Inpatient Setting,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,036.44 ",Pays based on per day rate,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,036.44 ",Pays based on per day rate,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,1036.44,5175.6,N/A Inpatient Medical Services,Inpatient,690,KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,111,N/A,N/A,Not Applicable. Service not offered,"$3,987.72 ",Pays at 100% of CMS Rate for Inpatient Setting,"$4,197.60 ",Pays at 100% of CMS Rate for Inpatient Setting,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,036.44 ",Pays based on per day rate,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,036.44 ",Pays based on per day rate,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,1036.44,4197.6,N/A Inpatient Medical Services,Inpatient,948,SIGNS AND SYMPTOMS WITHOUT MCC,111,N/A,N/A,Not Applicable. Service not offered,"$3,962.64 ",Pays at 100% of CMS Rate for Inpatient Setting,"$4,171.20 ",Pays at 100% of CMS Rate for Inpatient Setting,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,036.44 ",Pays based on per day rate,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,036.44 ",Pays based on per day rate,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,1036.44,4171.2,N/A Outpatient Medical Services,Radiology,71045,Single view,324,$335.00 ,N/A,Not Applicable. Service not offered,$49.83 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$50.31 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$244.55 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$234.50 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$64.29 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$167.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,49.83,244.55,$335.00 Outpatient Medical Services,Radiology,71046,"2 views, front and back",324,$438.00 ,N/A,Not Applicable. Service not offered,$64.17 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$64.78 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$319.74 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$306.60 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$84.05 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$219.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,64.17,319.74,$438.00 Outpatient Medical Services,Radiology,71111,RIBS WITH CHEST 4+ VIEWS,320,$773.00 ,N/A,Not Applicable. Service not offered,$94.63 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$95.53 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$564.29 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$541.10 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$148.34 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$386.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,94.63,564.29,$773.00 Outpatient Medical Services,Radiology,72040,"Radiologic examination of the neck/spine, 2-3 views",320,$474.00 ,N/A,Not Applicable. Service not offered,$63.41 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$64.01 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$346.02 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$331.80 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$90.96 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$237.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,63.41,346.02,$474.00 Outpatient Medical Services,Radiology,72050,"Radiologic examination of the neck/spine, 4-5 views",320,$643.00 ,N/A,Not Applicable. Service not offered,$94.63 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$95.53 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$469.39 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$450.10 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$123.39 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$321.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,94.63,469.39,$643.00 Outpatient Medical Services,Radiology,72052,SPINE CERVICAL COMPLETE,320,$773.00 ,N/A,Not Applicable. Service not offered,$119.26 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$120.39 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$564.29 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$541.10 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$148.34 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$386.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,119.26,564.29,$773.00 Outpatient Medical Services,Radiology,72072,"Radiologic examination of the middle spine, 3 views",320,$469.00 ,N/A,Not Applicable. Service not offered,$77.99 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$78.74 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$342.37 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$328.30 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$90.00 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$234.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,77.99,342.37,$469.00 Outpatient Medical Services,Radiology,72100,X-ray of the lower spine 2-3 views,320,$504.00 ,N/A,Not Applicable. Service not offered,$70.47 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$71.14 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$367.92 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$352.80 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$96.72 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$252.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,70.47,367.92,$504.00 Outpatient Medical Services,Radiology,72110,"X-ray of lower and sacral spine, minimum of 4 views",320,$742.00 ,N/A,Not Applicable. Service not offered,$96.61 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$97.53 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$541.66 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$519.40 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$142.39 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$371.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,96.61,541.66,$742.00 Outpatient Medical Services,Radiology,72170,Radiologic examination of the pelvis,320,$567.00 ,N/A,Not Applicable. Service not offered,$54.84 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$55.36 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$413.91 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$396.90 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$108.81 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$283.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,54.84,413.91,$567.00 Outpatient Medical Services,Radiology,73521,HIP BIL 2+VIEWS EACH SIDE,320,$608.00 ,N/A,Not Applicable. Service not offered,$70.47 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$71.14 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$443.84 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$425.60 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$116.68 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$304.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,70.47,443.84,$608.00 Outpatient Medical Services,Radiology,74018,ABDOMEN 1 VIEW,320,$386.00 ,N/A,Not Applicable. Service not offered,$54.84 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$55.36 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$281.78 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$270.20 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$74.07 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$193.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,54.84,281.78,$386.00 Outpatient Medical Services,Radiology,74019,ABDOMEN 2 VIEWS,320,$469.00 ,N/A,Not Applicable. Service not offered,$65.14 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$65.76 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$342.37 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$328.30 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$90.00 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$234.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,65.14,342.37,$469.00 Outpatient Medical Services,Radiology,74022,Serial radiologic examination of the abdomen,320,$773.00 ,N/A,Not Applicable. Service not offered,$77.99 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$78.74 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$564.29 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$541.10 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$148.34 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$386.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,77.99,564.29,$773.00 Outpatient Medical Services,Radiology,71101,Radiologic examination of one side of the chest/ribs,320,$700.00 ,N/A,Not Applicable. Service not offered,$70.47 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$71.14 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$511.00 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$490.00 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$134.33 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$350.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,70.47,511,$700.00 Outpatient Medical Services,Radiology,71101,Radiologic examination of one side of the chest/ribs,320,$700.00 ,N/A,Not Applicable. Service not offered,$70.47 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$71.14 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$511.00 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$490.00 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$134.33 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$350.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,70.47,511,$700.00 Outpatient Medical Services,Radiology,73030,Radiologic examination of the shoulder,320,$515.00 ,N/A,Not Applicable. Service not offered,$60.39 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$60.96 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$375.95 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$360.50 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$98.83 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$257.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,60.39,375.95,$515.00 Outpatient Medical Services,Radiology,73030,Radiologic examination of the shoulder,320,$515.00 ,N/A,Not Applicable. Service not offered,$60.39 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$60.96 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$375.95 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$360.50 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$98.83 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$257.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,60.39,375.95,$515.00 Outpatient Medical Services,Radiology,73060,HUMERUS LT 2 VIEWS,320,$433.00 ,N/A,Not Applicable. Service not offered,$60.39 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$60.96 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$316.09 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$303.10 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$83.09 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$216.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,60.39,316.09,$433.00 Outpatient Medical Services,Radiology,73060,HUMERUS RT 2+VIEWS,320,$433.00 ,N/A,Not Applicable. Service not offered,$60.39 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$60.96 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$316.09 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$303.10 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$83.09 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$216.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,60.39,316.09,$433.00 Outpatient Medical Services,Radiology,73080,"Radiologic examination, elbow; 3 or more views",320,$505.00 ,N/A,Not Applicable. Service not offered,$60.39 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$60.96 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$368.65 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$353.50 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$96.91 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$252.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,60.39,368.65,$505.00 Outpatient Medical Services,Radiology,73080,"Radiologic examination, elbow; 3 or more views",320,$505.00 ,N/A,Not Applicable. Service not offered,$60.39 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$60.96 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$368.65 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$353.50 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$96.91 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$252.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,60.39,368.65,$505.00 Outpatient Medical Services,Radiology,73090,Radiologic examination of the forearm,320,$464.00 ,N/A,Not Applicable. Service not offered,$54.84 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$55.36 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$338.72 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$324.80 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$89.04 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$232.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,54.84,338.72,$464.00 Outpatient Medical Services,Radiology,73090,Radiologic examination of the forearm,320,$464.00 ,N/A,Not Applicable. Service not offered,$54.84 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$55.36 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$338.72 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$324.80 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$89.04 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$232.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,54.84,338.72,$464.00 Outpatient Medical Services,Radiology,73100,3 or more views,320,$381.00 ,N/A,Not Applicable. Service not offered,$51.85 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$52.34 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$278.13 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$266.70 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$73.11 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$190.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,51.85,278.13,$381.00 Outpatient Medical Services,Radiology,73110,Up to 3 views,320,$480.00 ,N/A,Not Applicable. Service not offered,$55.85 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$56.38 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$350.40 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$336.00 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$92.11 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$240.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,55.85,350.4,$480.00 Outpatient Medical Services,Radiology,73110,Up to 3 views,320,$480.00 ,N/A,Not Applicable. Service not offered,$55.85 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$56.38 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$350.40 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$336.00 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$92.11 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$240.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,55.85,350.4,$480.00 Outpatient Medical Services,Radiology,73120,X-ray of the hand with 2 views,320,$341.00 ,N/A,Not Applicable. Service not offered,$51.85 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$52.34 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$248.93 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$238.70 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$65.44 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$170.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,51.85,248.93,$341.00 Outpatient Medical Services,Radiology,73130,X-ray of the hand with 3 or more views,320,$530.00 ,N/A,Not Applicable. Service not offered,$55.85 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$56.38 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$386.90 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$371.00 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$101.71 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$265.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,55.85,386.9,$530.00 Outpatient Medical Services,Radiology,73130,X-ray of the hand with 3 or more views,320,$530.00 ,N/A,Not Applicable. Service not offered,$55.85 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$56.38 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$386.90 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$371.00 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$101.71 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$265.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,55.85,386.9,$530.00 Outpatient Medical Services,Radiology,73140,Radiologic examination of the finger(s),320,$427.00 ,N/A,Not Applicable. Service not offered,$44.79 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$45.22 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$311.71 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$298.90 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$81.94 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$213.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,44.79,311.71,$427.00 Outpatient Medical Services,Radiology,73140,Radiologic examination of the finger(s),320,$427.00 ,N/A,Not Applicable. Service not offered,$44.79 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$45.22 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$311.71 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$298.90 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$81.94 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$213.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,44.79,311.71,$427.00 Outpatient Medical Services,Radiology,73502,LT HIP 2+ VIEWS,320,$521.00 ,N/A,Not Applicable. Service not offered,$60.39 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$60.96 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$380.33 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$364.70 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$99.98 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$260.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,60.39,380.33,$521.00 Outpatient Medical Services,Radiology,73502,RT HIP 2+ VIEWS,320,$521.00 ,N/A,Not Applicable. Service not offered,$60.39 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$60.96 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$380.33 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$364.70 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$99.98 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$260.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,60.39,380.33,$521.00 Outpatient Medical Services,Radiology,73552,FEMUR LT 2VIEWS,320,$455.00 ,N/A,Not Applicable. Service not offered,$60.39 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$60.96 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$332.15 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$318.50 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$87.31 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$227.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,60.39,332.15,$455.00 Outpatient Medical Services,Radiology,73552,FEMUR RT 2VIEWS,320,$455.00 ,N/A,Not Applicable. Service not offered,$60.39 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$60.96 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$332.15 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$318.50 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$87.31 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$227.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,60.39,332.15,$455.00 Outpatient Medical Services,Radiology,73560,Radiologic examination of the knee with 1 or 2 views,320,$370.00 ,N/A,Not Applicable. Service not offered,$54.84 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$55.36 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$270.10 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$259.00 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$71.00 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$185.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,54.84,270.1,$370.00 Outpatient Medical Services,Radiology,73560,Radiologic examination of the knee with 1 or 2 views,320,$370.00 ,N/A,Not Applicable. Service not offered,$54.84 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$55.36 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$270.10 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$259.00 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$71.00 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$185.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,54.84,270.1,$370.00 Outpatient Medical Services,Radiology,73564,Radiologic examination of the knee with 4 or more views,320,$570.00 ,N/A,Not Applicable. Service not offered,$65.43 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$66.05 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$416.10 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$399.00 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$109.38 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$285.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,65.43,416.1,$570.00 Outpatient Medical Services,Radiology,73564,Radiologic examination of the knee with 4 or more views,320,$570.00 ,N/A,Not Applicable. Service not offered,$65.43 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$66.05 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$416.10 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$399.00 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$109.38 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$285.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,65.43,416.1,$570.00 Outpatient Medical Services,Radiology,73564,Radiologic examination of the knee with 4 or more views,320,$570.00 ,N/A,Not Applicable. Service not offered,$65.43 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$66.05 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$416.10 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$399.00 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$109.38 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$285.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,65.43,416.1,$570.00 Outpatient Medical Services,Radiology,73590,Radiologic examination of the lower leg,320,$489.00 ,N/A,Not Applicable. Service not offered,$54.84 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$55.36 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$356.97 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$342.30 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$93.84 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$244.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,54.84,356.97,$489.00 Outpatient Medical Services,Radiology,73590,Radiologic examination of the lower leg,320,$489.00 ,N/A,Not Applicable. Service not offered,$54.84 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$55.36 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$356.97 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$342.30 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$93.84 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$244.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,54.84,356.97,$489.00 Outpatient Medical Services,Radiology,73610,Radiologic examination of the ankle with 3 views,320,$525.00 ,N/A,Not Applicable. Service not offered,$55.85 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$56.38 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$383.25 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$367.50 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$100.75 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$262.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,55.85,383.25,$525.00 Outpatient Medical Services,Radiology,73610,Radiologic examination of the ankle with 3 views,320,$525.00 ,N/A,Not Applicable. Service not offered,$55.85 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$56.38 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$383.25 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$367.50 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$100.75 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$262.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,55.85,383.25,$525.00 Outpatient Medical Services,Radiology,73620,"Radiologic examination, foot; 2 views",320,$439.00 ,N/A,Not Applicable. Service not offered,$51.85 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$52.34 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$320.47 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$307.30 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$84.24 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$219.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,51.85,320.47,$439.00 Outpatient Medical Services,Radiology,73620,"Radiologic examination, foot; 2 views",320,$439.00 ,N/A,Not Applicable. Service not offered,$51.85 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$52.34 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$320.47 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$307.30 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$84.24 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$219.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,51.85,320.47,$439.00 Outpatient Medical Services,Radiology,73630,Radiologic examination of the foot with 3 or more views,320,$505.00 ,N/A,Not Applicable. Service not offered,$55.85 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$56.38 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$368.65 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$353.50 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$96.91 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$252.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,55.85,368.65,$505.00 Outpatient Medical Services,Radiology,73630,Radiologic examination of the foot with 3 or more views,320,$505.00 ,N/A,Not Applicable. Service not offered,$55.85 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$56.38 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$368.65 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$353.50 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$96.91 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$252.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,55.85,368.65,$505.00 Outpatient Medical Services,Radiology,73660,Radiologic examination of the toe(s),320,$319.00 ,N/A,Not Applicable. Service not offered,$44.79 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$45.22 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$232.87 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$223.30 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$61.22 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$159.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,44.79,232.87,$319.00 Outpatient Medical Services,CT Scan,70450,CT scan head or brain without dye,351,"$3,069.00 ",N/A,Not Applicable. Service not offered,$496.69 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$501.42 ,Pays at 315% of Custom fee Schedule for Outpatient setting,"$2,240.37 ",Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,"$2,148.30 ",Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$588.94 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,534.50 ",Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,496.69,2240.37,"$3,069.00 " Outpatient Medical Services,CT Scan,Q9967,CT LOCM 300-399 MG/ML IODINE; 100ML,255,$200.00 ,N/A,Not Applicable. Service not offered,$165.00 ,Pays at 82.5% of total billed charges for outpatient setting,$165.00 ,Pays at 82.5% of total billed charges for outpatient setting,$146.00 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$140.00 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$38.38 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$100.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,38.38,165,$200.00 Outpatient Medical Services,CT Scan,74177,CT scan of abdomen and pelvis with contrast,352,"$3,358.00 ",N/A,Not Applicable. Service not offered,"$1,436.27 ",Pays at 315% of Custom fee Schedule for Outpatient setting,"$1,449.95 ",Pays at 315% of Custom fee Schedule for Outpatient setting,"$2,451.34 ",Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,"$2,350.60 ",Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$644.40 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,679.00 ",Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,644.4,2451.34,"$3,358.00 " Outpatient Medical Services,CT Scan,74176,CT of abdomen and pelvis without dye,352,"$2,709.00 ",N/A,Not Applicable. Service not offered,"$1,216.34 ",Pays at 315% of Custom fee Schedule for Outpatient setting,"$1,227.93 ",Pays at 315% of Custom fee Schedule for Outpatient setting,"$1,977.57 ",Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,"$1,896.30 ",Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$519.86 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,354.50 ",Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,519.86,1977.57,"$2,709.00 " Outpatient Medical Services,CT Scan,72125,CT CERV.SPINE W/O CONTRAST,352,"$3,064.00 ",N/A,Not Applicable. Service not offered,$620.99 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$626.91 ,Pays at 315% of Custom fee Schedule for Outpatient setting,"$2,236.72 ",Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,"$2,144.80 ",Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$587.98 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,532.00 ",Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,587.98,2236.72,"$3,064.00 " Outpatient Medical Services,CT Scan,71250,CT scan of the thorax without dye,352,"$2,858.00 ",N/A,Not Applicable. Service not offered,$620.99 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$626.91 ,Pays at 315% of Custom fee Schedule for Outpatient setting,"$2,086.34 ",Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,"$2,000.60 ",Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$548.45 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,429.00 ",Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,548.45,2086.34,"$2,858.00 " Outpatient Medical Services,CT Scan,71260,CT scan of the thorax with dye,352,"$3,760.00 ",N/A,Not Applicable. Service not offered,$743.31 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$750.38 ,Pays at 315% of Custom fee Schedule for Outpatient setting,"$2,744.80 ",Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,"$2,632.00 ",Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$721.54 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,880.00 ",Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,721.54,2744.8,"$3,760.00 " Outpatient Medical Services,CT Scan,72131,CT scan of lower spine without dye,352,"$3,039.00 ",N/A,Not Applicable. Service not offered,$620.99 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$626.91 ,Pays at 315% of Custom fee Schedule for Outpatient setting,"$2,218.47 ",Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,"$2,127.30 ",Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$583.18 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,519.50 ",Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,583.18,2218.47,"$3,039.00 " Outpatient Medical Services,CT Scan,70486,CT Scan of the face and jaw without dye,351,"$2,184.00 ",N/A,Not Applicable. Service not offered,$496.69 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$501.42 ,Pays at 315% of Custom fee Schedule for Outpatient setting,"$1,594.32 ",Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,"$1,528.80 ",Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$419.11 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,092.00 ",Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,419.11,1594.32,"$2,184.00 " Outpatient Medical Services,CT Scan,G0297,CT LOW DOSE LUNG SCREENING,352,"$1,450.00 ",N/A,Not Applicable. Service not offered,"$1,196.25 ",Pays at 82.5% of total billed charges for outpatient setting,"$1,196.25 ",Pays at 82.5% of total billed charges for outpatient setting,"$1,058.50 ",Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,"$1,015.00 ",Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$278.26 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$725.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,278.26,1196.25,"$1,450.00 " Outpatient Medical Services,MRI,73721,MRI of lower extremity joint (knee/ankle) without dye,612,"$3,451.00 ",N/A,Not Applicable. Service not offered,"$1,176.08 ",Pays at 315% of Custom fee Schedule for Outpatient setting,"$1,187.28 ",Pays at 315% of Custom fee Schedule for Outpatient setting,"$2,519.23 ",Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,"$2,415.70 ",Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$662.25 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,725.50 ",Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,662.25,2519.23,"$3,451.00 " Outpatient Medical Services,MRI,73721,MRI of lower extremity joint (knee/ankle) without dye,612,"$3,451.00 ",N/A,Not Applicable. Service not offered,"$1,176.08 ",Pays at 315% of Custom fee Schedule for Outpatient setting,"$1,187.28 ",Pays at 315% of Custom fee Schedule for Outpatient setting,"$2,519.23 ",Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,"$2,415.70 ",Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$662.25 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,725.50 ",Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,662.25,2519.23,"$3,451.00 " Outpatient Medical Services,MRI,73718,MRI of leg without dye,611,"$3,106.00 ",N/A,Not Applicable. Service not offered,"$1,176.08 ",Pays at 315% of Custom fee Schedule for Outpatient setting,"$1,187.28 ",Pays at 315% of Custom fee Schedule for Outpatient setting,"$2,267.38 ",Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,"$2,174.20 ",Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$596.04 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,553.00 ",Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,596.04,2267.38,"$3,106.00 " Outpatient Medical Services,MRI,73221,MRI of upper extremity without dye,610,"$3,106.00 ",N/A,Not Applicable. Service not offered,"$1,176.08 ",Pays at 315% of Custom fee Schedule for Outpatient setting,"$1,187.28 ",Pays at 315% of Custom fee Schedule for Outpatient setting,"$2,267.38 ",Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,"$2,174.20 ",Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$596.04 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,553.00 ",Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,596.04,2267.38,"$3,106.00 " Outpatient Medical Services,MRI,73221,MRI of upper extremity without dye,611,"$3,106.00 ",N/A,Not Applicable. Service not offered,"$1,176.08 ",Pays at 315% of Custom fee Schedule for Outpatient setting,"$1,187.28 ",Pays at 315% of Custom fee Schedule for Outpatient setting,"$2,267.38 ",Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,"$2,174.20 ",Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$596.04 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,553.00 ",Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,596.04,2267.38,"$3,106.00 " Outpatient Medical Services,MRI,72148,MRI scan of lower spinal canal,610,"$3,103.00 ",N/A,Not Applicable. Service not offered,"$1,305.42 ",Pays at 315% of Custom fee Schedule for Outpatient setting,"$1,317.86 ",Pays at 315% of Custom fee Schedule for Outpatient setting,"$2,265.19 ",Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,"$2,172.10 ",Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$595.47 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,551.50 ",Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,595.47,2265.19,"$3,103.00 " Outpatient Medical Services,MRI,72146,MRI of chest and spine without dye,610,"$3,103.00 ",N/A,Not Applicable. Service not offered,"$1,305.42 ",Pays at 315% of Custom fee Schedule for Outpatient setting,"$1,317.86 ",Pays at 315% of Custom fee Schedule for Outpatient setting,"$2,265.19 ",Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,"$2,172.10 ",Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$595.47 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,551.50 ",Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,595.47,2265.19,"$3,103.00 " Outpatient Medical Services,MRI,72141,MRI of the neck or spine without dye,610,"$3,103.00 ",N/A,Not Applicable. Service not offered,"$1,176.08 ",Pays at 315% of Custom fee Schedule for Outpatient setting,"$1,187.28 ",Pays at 315% of Custom fee Schedule for Outpatient setting,"$2,265.19 ",Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,"$2,172.10 ",Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$595.47 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,551.50 ",Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,595.47,2265.19,"$3,103.00 " Outpatient Medical Services,MRI,70553,MRI scan of brain before and after contrast,612,"$4,026.00 ",N/A,Not Applicable. Service not offered,"$2,612.33 ",Pays at 315% of Custom fee Schedule for Outpatient setting,"$2,637.21 ",Pays at 315% of Custom fee Schedule for Outpatient setting,"$2,938.98 ",Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,"$2,818.20 ",Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$772.59 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$2,013.00 ",Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,772.59,2938.98,"$4,026.00 " Outpatient Medical Services,MRI,70551,MRI of brain stem without dye,610,"$3,106.00 ",N/A,Not Applicable. Service not offered,"$1,176.08 ",Pays at 315% of Custom fee Schedule for Outpatient setting,"$1,187.28 ",Pays at 315% of Custom fee Schedule for Outpatient setting,"$2,267.38 ",Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,"$2,174.20 ",Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$596.04 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,553.00 ",Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,596.04,2267.38,"$3,106.00 " Outpatient Medical Services,Mammography,77067,Mammography of both breasts-2 or more views,403,$343.00 ,N/A,Not Applicable. Service not offered,$282.98 ,Pays at 82.5% of total billed charges for outpatient setting,$282.98 ,Pays at 82.5% of total billed charges for outpatient setting,$250.39 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$240.10 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$65.82 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$171.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,65.82,282.98,$343.00 Outpatient Medical Services,Mammography,77066,"Diagnostic mammography, including computer-aided detection (cad) when performed; bilateral",401,$375.00 ,N/A,Not Applicable. Service not offered,$309.38 ,Pays at 82.5% of total billed charges for outpatient setting,$309.38 ,Pays at 82.5% of total billed charges for outpatient setting,$273.75 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$262.50 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$71.96 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$187.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,71.96,309.38,$375.00 Outpatient Medical Services,Nuclear Medicine,78306,"A procedure most commonly ordered to detect areas of abnormal bone growth due to fractures, tumors, infection, or other bone issues",341,"$2,343.00 ",N/A,Not Applicable. Service not offered,$448.91 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$453.18 ,Pays at 315% of Custom fee Schedule for Outpatient setting,"$1,710.39 ",Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,"$1,640.10 ",Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$449.62 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,171.50 ",Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,448.91,1710.39,"$2,343.00 " Outpatient Medical Services,Nuclear Medicine,78264,NM GASTRIC EMPTYING STUDY,341,"$1,597.00 ",N/A,Not Applicable. Service not offered,$433.28 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$437.41 ,Pays at 315% of Custom fee Schedule for Outpatient setting,"$1,165.81 ",Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,"$1,117.90 ",Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$306.46 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$798.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,306.46,1165.81,"$1,597.00 " Outpatient Medical Services,Nuclear Medicine,78226,NM HEPATOBILIARY IMAGING,341,$954.00 ,N/A,Not Applicable. Service not offered,$384.49 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$388.15 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$696.42 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$667.80 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$183.07 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$477.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,183.07,696.42,$954.00 Outpatient Medical Services,Nuclear Medicine,A9537,NM TC99M MEBROFENIN,343,$354.00 ,N/A,Not Applicable. Service not offered,$292.05 ,Pays at 82.5% of total billed charges for outpatient setting,$292.05 ,Pays at 82.5% of total billed charges for outpatient setting,$258.42 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$247.80 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$67.93 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$177.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,67.93,292.05,$354.00 Outpatient Medical Services,Nuclear Medicine,A9541,NM TC99M SULFUR COLLOID,343,$263.00 ,N/A,Not Applicable. Service not offered,$216.98 ,Pays at 82.5% of total billed charges for outpatient setting,$216.98 ,Pays at 82.5% of total billed charges for outpatient setting,$191.99 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$184.10 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$50.47 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$131.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,50.47,216.98,$263.00 Outpatient Medical Services,Ultrasound,76705,A diagnostic procedure that allows a provider to see the organs and other structures in the abdomen,402,$854.00 ,N/A,Not Applicable. Service not offered,$149.47 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$150.89 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$623.42 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$597.80 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$163.88 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$427.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,149.47,623.42,$854.00 Outpatient Medical Services,Ultrasound,76700,Ultrasound of abdomen with all areas scanned,402,"$1,056.00 ",N/A,Not Applicable. Service not offered,$207.33 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$209.31 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$770.88 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$739.20 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$202.65 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$528.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,202.65,770.88,"$1,056.00 " Outpatient Medical Services,Ultrasound,93971,One sided or limited bilateral study,921,$668.00 ,N/A,Not Applicable. Service not offered,$310.53 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$313.48 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$487.64 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$467.60 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$128.19 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$334.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,128.19,487.64,$668.00 Outpatient Medical Services,Ultrasound,93306,"Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function",480,$923.00 ,N/A,Not Applicable. Service not offered,$761.48 ,Pays at 82.5% of total billed charges for outpatient setting,$761.48 ,Pays at 82.5% of total billed charges for outpatient setting,$673.79 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$646.10 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$177.12 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$461.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,177.12,761.48,$923.00 Outpatient Medical Services,Ultrasound,76642,Limited ultrasound of the breast,402,$697.00 ,N/A,Not Applicable. Service not offered,$111.23 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$112.29 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$508.81 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$487.90 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$133.75 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$348.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,111.23,508.81,$697.00 Outpatient Medical Services,Ultrasound,76770,Ultrasound of back wall of the abdomen with all areas viewed,402,"$1,114.00 ",N/A,Not Applicable. Service not offered,$207.33 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$209.31 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$813.22 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$779.80 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$213.78 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$557.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,207.33,813.22,"$1,114.00 " Outpatient Medical Services,Ultrasound,76856,Complete ultrasound of the pelvis,402,$850.00 ,N/A,Not Applicable. Service not offered,$161.03 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$162.56 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$620.50 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$595.00 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$163.12 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$425.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,161.03,620.5,$850.00 Outpatient Medical Services,Ultrasound,76536,Ultrasound of head and neck,402,$711.00 ,N/A,Not Applicable. Service not offered,$149.47 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$150.89 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$519.03 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$497.70 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$136.44 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$355.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,136.44,519.03,$711.00 Outpatient Medical Services,Ultrasound,93880,Study of vessels on both sides of the head and neck,921,"$1,033.00 ",N/A,Not Applicable. Service not offered,$417.72 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$421.70 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$754.09 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$723.10 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$198.23 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$516.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,198.23,754.09,"$1,033.00 " Outpatient Medical Services,Ultrasound,93970,Complete bilateral study of the extremities,921,"$1,826.00 ",N/A,Not Applicable. Service not offered,$465.00 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$469.43 ,Pays at 315% of Custom fee Schedule for Outpatient setting,"$1,332.98 ",Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,"$1,278.20 ",Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$350.41 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$913.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,350.41,1332.98,"$1,826.00 " Outpatient Medical Services,Infusion Therapy,96365,"Intravenous infusion, for therapy, prophylaxis, or diagnosis-initial infusion",761,$936.00 ,N/A,Not Applicable. Service not offered,$772.20 ,Pays at 82.5% of total billed charges for outpatient setting,$772.20 ,Pays at 82.5% of total billed charges for outpatient setting,$683.28 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$655.20 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$179.62 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$468.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,179.62,772.2,$936.00 Outpatient Medical Services,Infusion Therapy,96366,"Intravenous infusion, for therapy, prophylaxis, or diagnosis-additional infusions",761,$189.00 ,N/A,Not Applicable. Service not offered,$155.93 ,Pays at 82.5% of total billed charges for outpatient setting,$155.93 ,Pays at 82.5% of total billed charges for outpatient setting,$137.97 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$132.30 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$36.27 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$94.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,36.27,155.93,$189.00 Outpatient Medical Services,Infusion Therapy,96374,"Intravenous infusion, for therapy, prophylaxis, or diagnosis-IV push",761,$936.00 ,N/A,Not Applicable. Service not offered,$772.20 ,Pays at 82.5% of total billed charges for outpatient setting,$772.20 ,Pays at 82.5% of total billed charges for outpatient setting,$683.28 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$655.20 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$179.62 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$468.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,179.62,772.2,$936.00 Outpatient Medical Services,Infusion Therapy,96372,"INJECTION, SC/IM",761,$299.00 ,N/A,Not Applicable. Service not offered,$246.68 ,Pays at 82.5% of total billed charges for outpatient setting,$246.68 ,Pays at 82.5% of total billed charges for outpatient setting,$218.27 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$209.30 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$57.38 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$149.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,57.38,246.68,$299.00 Outpatient Medical Services,Infusion Therapy,99195,PHLEBOTOMY THER SPX,761,$532.00 ,N/A,Not Applicable. Service not offered,$438.90 ,Pays at 82.5% of total billed charges for outpatient setting,$438.90 ,Pays at 82.5% of total billed charges for outpatient setting,$388.36 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$372.40 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$102.09 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$266.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,102.09,438.9,$532.00 Outpatient Medical Services,Cardiac Rehab,93798,Use of EKG to monitor cardiac rehabilitation,943,$233.00 ,N/A,Not Applicable. Service not offered,$192.23 ,Pays at 82.5% of total billed charges for outpatient setting,$192.23 ,Pays at 82.5% of total billed charges for outpatient setting,$170.09 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$163.10 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$44.71 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$116.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,44.71,192.23,$233.00 Outpatient Medical Services,Cardiac Rehab,93041,CR RHYTHM STRIP EKG,730,$112.00 ,N/A,Not Applicable. Service not offered,$37.14 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$37.49 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$81.76 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$78.40 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$21.49 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$56.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,21.49,81.76,$112.00 Outpatient Medical Services,Cardiac Rehab,93797,CR W/O ECG MONITORING,943,$233.00 ,N/A,Not Applicable. Service not offered,$192.23 ,Pays at 82.5% of total billed charges for outpatient setting,$192.23 ,Pays at 82.5% of total billed charges for outpatient setting,$170.09 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$163.10 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$44.71 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$116.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,44.71,192.23,$233.00 Outpatient Medical Services,Wound Healing,G0277,HYPERBARIC OXYGEN THERAPY (:30 INCREMNT),940,"$1,020.00 ",N/A,Not Applicable. Service not offered,$841.50 ,Pays at 82.5% of total billed charges for outpatient setting,$841.50 ,Pays at 82.5% of total billed charges for outpatient setting,$744.60 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$714.00 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$195.74 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$510.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,195.74,841.5,"$1,020.00 " Outpatient Medical Services,Wound Healing,Q4101,APLIGRAF PER SQ CM,636,$140.00 ,N/A,Not Applicable. Service not offered,$115.50 ,Pays at 82.5% of total billed charges for outpatient setting,$115.50 ,Pays at 82.5% of total billed charges for outpatient setting,$102.20 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$98.00 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$26.87 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$70.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,26.87,115.5,$140.00 Outpatient Medical Services,Wound Healing,Q4186,"EPIFIX, PER SQUARE CM",636,$716.00 ,N/A,Not Applicable. Service not offered,$590.70 ,Pays at 82.5% of total billed charges for outpatient setting,$590.70 ,Pays at 82.5% of total billed charges for outpatient setting,$522.68 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$501.20 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$137.40 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$358.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,137.4,590.7,$716.00 Outpatient Medical Services,Wound Healing,29581,APPLY MULTI-LAYER COMPRESSION LOWER LEG,761,$306.00 ,N/A,Not Applicable. Service not offered,$252.45 ,Pays at 82.5% of total billed charges for outpatient setting,$252.45 ,Pays at 82.5% of total billed charges for outpatient setting,$223.38 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$214.20 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$58.72 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$153.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,58.72,252.45,$306.00 Outpatient Medical Services,Wound Healing,99213,"Established patient office or other outpatient visit, typically 15 minutes",761,$257.00 ,N/A,Not Applicable. Service not offered,$212.03 ,Pays at 82.5% of total billed charges for outpatient setting,$212.03 ,Pays at 82.5% of total billed charges for outpatient setting,$187.61 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$179.90 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$49.32 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$128.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,49.32,212.03,$257.00 Outpatient Medical Services,Wound Healing,11042,WOUND DEBRIDEMENT (SUBQ & TISSUE),761,$510.00 ,N/A,Not Applicable. Service not offered,"$1,319.85 ",Pays at 315% of Asc fee Schedule for Outpatient setting,"$1,332.42 ",Pays at 315% of Asc fee Schedule for Outpatient setting,$372.30 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$357.00 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$97.87 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$255.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,97.87,1332.42,$510.00 Outpatient Medical Services,Wound Healing,99214,"Established patient office or other outpatient visit, typically 25 minutes",761,$290.00 ,N/A,Not Applicable. Service not offered,$239.25 ,Pays at 82.5% of total billed charges for outpatient setting,$239.25 ,Pays at 82.5% of total billed charges for outpatient setting,$211.70 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$203.00 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$55.65 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$145.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,55.65,239.25,$290.00 Outpatient Medical Services,Wound Healing,29580,APPLICATION OF PASTE/UNNA BOOT,761,$214.00 ,N/A,Not Applicable. Service not offered,$176.55 ,Pays at 82.5% of total billed charges for outpatient setting,$176.55 ,Pays at 82.5% of total billed charges for outpatient setting,$156.22 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$149.80 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$41.07 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$107.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,41.07,176.55,$214.00 Outpatient Medical Services,Wound Healing,97605,NEG PRESSURE WOUND TX <50CM,761,$140.00 ,N/A,Not Applicable. Service not offered,$115.50 ,Pays at 82.5% of total billed charges for outpatient setting,$115.50 ,Pays at 82.5% of total billed charges for outpatient setting,$102.20 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$98.00 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$26.87 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$70.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,26.87,115.5,$140.00 Outpatient Medical Services,Wound Healing,17250,Chemical destruction of pre-cancerous lesions of the skin,761,$194.00 ,N/A,Not Applicable. Service not offered,$160.05 ,Pays at 82.5% of total billed charges for outpatient setting,$160.05 ,Pays at 82.5% of total billed charges for outpatient setting,$141.62 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$135.80 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$37.23 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$97.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,37.23,160.05,$194.00 Outpatient Medical Services,Wound Healing,99215,"Established patient office or other outpatient, visit typically 40 minutes",761,$370.00 ,N/A,Not Applicable. Service not offered,$305.25 ,Pays at 82.5% of total billed charges for outpatient setting,$305.25 ,Pays at 82.5% of total billed charges for outpatient setting,$270.10 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$259.00 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$71.00 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$185.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,71,305.25,$370.00 Outpatient Medical Services,Wound Healing,15271,SK SUBGRAFT TRNK/ARM/LEG FIRST 25 SQCM<,761,$255.00 ,N/A,Not Applicable. Service not offered,"$1,319.85 ",Pays at 315% of Asc fee Schedule for Outpatient setting,"$1,332.42 ",Pays at 315% of Asc fee Schedule for Outpatient setting,$186.15 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$178.50 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$48.93 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$127.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,48.93,1332.42,$255.00 Outpatient Medical Services,Wound Healing,99205,"New patient office of other outpatient visit, typically 60 min",761,$546.00 ,N/A,Not Applicable. Service not offered,$450.45 ,Pays at 82.5% of total billed charges for outpatient setting,$450.45 ,Pays at 82.5% of total billed charges for outpatient setting,$398.58 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$382.20 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$104.78 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$273.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,104.78,450.45,$546.00 Outpatient Medical Services,Wound Healing,99204,"New patient office of other outpatient visit, typically 45 min",761,$370.00 ,N/A,Not Applicable. Service not offered,$305.25 ,Pays at 82.5% of total billed charges for outpatient setting,$305.25 ,Pays at 82.5% of total billed charges for outpatient setting,$270.10 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$259.00 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$71.00 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$185.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,71,305.25,$370.00 Outpatient Medical Services,Wound Healing,97607,NEG PRESS WND THER SNAP;TOTAL WND <50CM2,761,$825.00 ,N/A,Not Applicable. Service not offered,$680.63 ,Pays at 82.5% of total billed charges for outpatient setting,$680.63 ,Pays at 82.5% of total billed charges for outpatient setting,$602.25 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$577.50 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$158.32 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$412.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,158.32,680.63,$825.00 Outpatient Medical Services,Wound Healing,97602,ACTIVE WOUND CARE NON-SELECTIVE,761,$890.00 ,N/A,Not Applicable. Service not offered,$734.25 ,Pays at 82.5% of total billed charges for outpatient setting,$734.25 ,Pays at 82.5% of total billed charges for outpatient setting,$649.70 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$623.00 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$170.79 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$445.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,170.79,734.25,$890.00 Outpatient Medical Services,Wound Healing,97606,NEG PRESSURE WOUND TX >50CM,761,$216.00 ,N/A,Not Applicable. Service not offered,$178.20 ,Pays at 82.5% of total billed charges for outpatient setting,$178.20 ,Pays at 82.5% of total billed charges for outpatient setting,$157.68 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$151.20 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$41.45 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$108.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,41.45,178.2,$216.00 Outpatient Medical Services,Wound Healing,15275,SK SUBGRAFT FACE/NK/HF/G FIRST 25 SQCM <,761,$296.00 ,N/A,Not Applicable. Service not offered,"$1,319.85 ",Pays at 315% of Asc fee Schedule for Outpatient setting,"$1,332.42 ",Pays at 315% of Asc fee Schedule for Outpatient setting,$216.08 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$207.20 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$56.80 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$148.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,56.8,1332.42,$296.00 Outpatient Medical Services,Wound Healing,29445,APPLY RIGID TOTAL CONTACT LEG CAST,761,$654.00 ,N/A,Not Applicable. Service not offered,$539.55 ,Pays at 82.5% of total billed charges for outpatient setting,$539.55 ,Pays at 82.5% of total billed charges for outpatient setting,$477.42 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$457.80 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$125.50 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$327.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,125.5,539.55,$654.00 Outpatient Medical Services,Wound Healing,99212,Outpatient visit of established patient requiring a physician,761,$227.00 ,N/A,Not Applicable. Service not offered,$187.28 ,Pays at 82.5% of total billed charges for outpatient setting,$187.28 ,Pays at 82.5% of total billed charges for outpatient setting,$165.71 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$158.90 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$43.56 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$113.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,43.56,187.28,$227.00 Outpatient Medical Services,Wound Healing,10060,Incision and drainage of abscess; simple or single and complex or multiple,761,$480.00 ,N/A,Not Applicable. Service not offered,$396.00 ,Pays at 82.5% of total billed charges for outpatient setting,$396.00 ,Pays at 82.5% of total billed charges for outpatient setting,$350.40 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$336.00 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$92.11 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$240.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,92.11,396,$480.00 Outpatient Medical Services,Wound Healing,Q4195,PURAPLY ANTIMICROBIAL ANY TYPE PER SQ,636,$558.00 ,N/A,Not Applicable. Service not offered,$460.35 ,Pays at 82.5% of total billed charges for outpatient setting,$460.35 ,Pays at 82.5% of total billed charges for outpatient setting,$407.34 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$390.60 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$107.08 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$279.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,107.08,460.35,$558.00 Outpatient Medical Services,Wound Healing,11045,"EXC/DEB SUBQ TISSUE ADD 20 SQCM, OR PART",761,$614.00 ,N/A,Not Applicable. Service not offered,$506.55 ,Pays at 82.5% of total billed charges for outpatient setting,$506.55 ,Pays at 82.5% of total billed charges for outpatient setting,$448.22 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$429.80 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$117.83 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$307.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,117.83,506.55,$614.00 Outpatient Medical Services,Wound Healing,11043,WOUND DEBRIDEMENT (TISSUE & MUSCLE),761,$746.00 ,N/A,Not Applicable. Service not offered,"$1,319.85 ",Pays at 315% of Asc fee Schedule for Outpatient setting,"$1,332.42 ",Pays at 315% of Asc fee Schedule for Outpatient setting,$544.58 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$522.20 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$143.16 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$373.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,143.16,1332.42,$746.00 Outpatient Medical Services,Wound Healing,16020,"TX OF BURNS W/O ANESTHESIA, SMALL",761,$242.00 ,N/A,Not Applicable. Service not offered,$199.65 ,Pays at 82.5% of total billed charges for outpatient setting,$199.65 ,Pays at 82.5% of total billed charges for outpatient setting,$176.66 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$169.40 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$46.44 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$121.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,46.44,199.65,$242.00 Outpatient Medical Services,Lab,36415,Collection of venous blood by venipuncture,300,$25.00 ,N/A,Not Applicable. Service not offered,$9.45 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$9.54 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$18.25 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$17.50 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$4.80 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$12.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,4.8,18.25,$25.00 Outpatient Medical Services,Lab,36430,BLOOD TRANSFUSION,305,$643.00 ,N/A,Not Applicable. Service not offered,$530.48 ,Pays at 82.5% of total billed charges for outpatient setting,$530.48 ,Pays at 82.5% of total billed charges for outpatient setting,$469.39 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$450.10 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$123.39 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$321.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,123.39,530.48,$643.00 Outpatient Medical Services,Lab,80048,Basic metabolic panel,301,$148.00 ,N/A,Not Applicable. Service not offered,$36.86 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$37.21 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$108.04 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$103.60 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$28.40 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$74.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,28.4,108.04,$148.00 Outpatient Medical Services,Lab,80053,"Blood test, comprehensive group of blood chemicals",301,$225.00 ,N/A,Not Applicable. Service not offered,$46.02 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$46.46 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$164.25 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$157.50 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$43.18 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$112.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,43.18,164.25,$225.00 Outpatient Medical Services,Lab,80053,"Blood test, comprehensive group of blood chemicals",301,$215.00 ,N/A,Not Applicable. Service not offered,$46.02 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$46.46 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$156.95 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$150.50 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$41.26 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$107.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,41.26,156.95,$215.00 Outpatient Medical Services,Lab,80061,"Blood test, lipids (cholesterol and triglycerides)",301,$195.00 ,N/A,Not Applicable. Service not offered,$59.88 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$60.45 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$142.35 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$136.50 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$37.42 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$97.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,37.42,142.35,$195.00 Outpatient Medical Services,Lab,80069,Kidney function panel test,301,$132.00 ,N/A,Not Applicable. Service not offered,$108.90 ,Pays at 82.5% of total billed charges for outpatient setting,$108.90 ,Pays at 82.5% of total billed charges for outpatient setting,$96.36 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$92.40 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$25.33 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$66.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,25.33,108.9,$132.00 Outpatient Medical Services,Lab,80076,Liver function blood test panel,301,$125.00 ,N/A,Not Applicable. Service not offered,$35.56 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$35.90 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$91.25 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$87.50 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$23.99 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$62.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,23.99,91.25,$125.00 Outpatient Medical Services,Lab,80162,DIGOXIN LEVEL,301,$119.00 ,N/A,Not Applicable. Service not offered,$59.38 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$59.94 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$86.87 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$83.30 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$22.84 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$59.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,22.84,86.87,$119.00 Outpatient Medical Services,Lab,80164,DEPAKENE- (VALPROIC ACID),307,$141.00 ,N/A,Not Applicable. Service not offered,$60.57 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$61.15 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$102.93 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$98.70 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$27.06 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$70.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,27.06,102.93,$141.00 Outpatient Medical Services,Lab,80185,DILANTIN LEVEL,301,$215.00 ,N/A,Not Applicable. Service not offered,$59.28 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$59.85 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$156.95 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$150.50 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$41.26 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$107.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,41.26,156.95,$215.00 Outpatient Medical Services,Lab,80202,VANCOMYCIN TROUGH,301,$212.00 ,N/A,Not Applicable. Service not offered,$60.57 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$61.15 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$154.76 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$148.40 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$40.68 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$106.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,40.68,154.76,$212.00 Outpatient Medical Services,Lab,80306,DRUG SCREEN-UR QUALITATIVE,306,$87.00 ,N/A,Not Applicable. Service not offered,$61.68 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$62.26 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$63.51 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$60.90 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$16.70 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$43.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,16.7,63.51,$87.00 Outpatient Medical Services,Lab,80329,ACETOMINOPHEN LEVEL (TYLENOL),301,$306.00 ,N/A,Not Applicable. Service not offered,$124.61 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$125.80 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$223.38 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$214.20 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$58.72 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$153.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,58.72,223.38,$306.00 Outpatient Medical Services,Lab,80329,SALICYLATES LEVEL (ASPIRIN),307,$225.00 ,N/A,Not Applicable. Service not offered,$124.61 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$125.80 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$164.25 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$157.50 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$43.18 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$112.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,43.18,164.25,$225.00 Outpatient Medical Services,Lab,81001,Manual urinalysis test with examination with or without using microscope,306,$96.00 ,N/A,Not Applicable. Service not offered,$14.14 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$14.28 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$70.08 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$67.20 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$18.42 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$48.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,14.14,70.08,$96.00 Outpatient Medical Services,Lab,81003,Automated urinalysis test,305,$69.00 ,N/A,Not Applicable. Service not offered,$10.02 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$10.11 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$50.37 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$48.30 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$13.24 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$34.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,10.02,50.37,$69.00 Outpatient Medical Services,Lab,82009,ACETONE/KETONES SERUM,306,$122.00 ,N/A,Not Applicable. Service not offered,$20.19 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$20.38 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$89.06 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$85.40 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$23.41 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$61.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,20.19,89.06,$122.00 Outpatient Medical Services,Lab,82150,AMYLASE,305,$120.00 ,N/A,Not Applicable. Service not offered,$28.98 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$29.26 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$87.60 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$84.00 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$23.03 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$60.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,23.03,87.6,$120.00 Outpatient Medical Services,Lab,82248,Measurement of direct bilirubin,301,$69.00 ,N/A,Not Applicable. Service not offered,$21.86 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$22.07 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$50.37 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$48.30 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$13.24 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$34.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,13.24,50.37,$69.00 Outpatient Medical Services,Lab,82272,OCCULT BLOOD STOOL (GUIAC),301,$48.00 ,N/A,Not Applicable. Service not offered,$39.60 ,Pays at 82.5% of total billed charges for outpatient setting,$39.60 ,Pays at 82.5% of total billed charges for outpatient setting,$35.04 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$33.60 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$9.21 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$24.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,9.21,39.6,$48.00 Outpatient Medical Services,Lab,82306,Blood test to monitor vitamin D levels,301,$105.00 ,N/A,Not Applicable. Service not offered,$132.33 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$133.59 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$76.65 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$73.50 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$20.15 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$52.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,20.15,133.59,$105.00 Outpatient Medical Services,Lab,82550,CPK,301,$92.00 ,N/A,Not Applicable. Service not offered,$29.14 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$29.42 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$67.16 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$64.40 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$17.65 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$46.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,17.65,67.16,$92.00 Outpatient Medical Services,Lab,82553,Blood test to detect heart enzymes,306,$148.00 ,N/A,Not Applicable. Service not offered,$40.51 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$40.89 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$108.04 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$103.60 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$28.40 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$74.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,28.4,108.04,$148.00 Outpatient Medical Services,Lab,82565,CREATININE,301,$70.00 ,N/A,Not Applicable. Service not offered,$22.90 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$23.12 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$51.10 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$49.00 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$13.43 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$35.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,13.43,51.1,$70.00 Outpatient Medical Services,Lab,82607,Blood test to measure B-12,302,$133.00 ,N/A,Not Applicable. Service not offered,$67.38 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$68.02 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$97.09 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$93.10 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$25.52 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$66.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,25.52,97.09,$133.00 Outpatient Medical Services,Lab,82728,Test to determine level of iron in the blood,302,$154.00 ,N/A,Not Applicable. Service not offered,$60.89 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$61.47 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$112.42 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$107.80 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$29.55 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$77.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,29.55,112.42,$154.00 Outpatient Medical Services,Lab,82746,FOLATE,301,$120.00 ,N/A,Not Applicable. Service not offered,$65.74 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$66.37 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$87.60 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$84.00 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$23.03 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$60.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,23.03,87.6,$120.00 Outpatient Medical Services,Lab,82947,Quantitative measure of glucose build up in the blood over time,305,$36.00 ,N/A,Not Applicable. Service not offered,$17.55 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$17.71 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$26.28 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$25.20 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$6.91 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$18.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,6.91,26.28,$36.00 Outpatient Medical Services,Lab,83036,Blood test to measure average blood glucose levels for past 2-3 months,301,$112.00 ,N/A,Not Applicable. Service not offered,$43.41 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$43.82 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$81.76 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$78.40 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$21.49 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$56.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,21.49,81.76,$112.00 Outpatient Medical Services,Lab,83519,BNP [NT PRO],301,$207.00 ,N/A,Not Applicable. Service not offered,$60.39 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$60.96 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$151.11 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$144.90 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$39.72 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$103.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,39.72,151.11,$207.00 Outpatient Medical Services,Lab,83519,BN PEP [B-TYPE NATRIURETIC PEPTIDE],306,$207.00 ,N/A,Not Applicable. Service not offered,$60.39 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$60.96 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$151.11 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$144.90 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$39.72 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$103.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,39.72,151.11,$207.00 Outpatient Medical Services,Lab,83540,Blood test to measure the amount of iron that is in transit in the body,306,$96.00 ,N/A,Not Applicable. Service not offered,$28.98 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$29.26 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$70.08 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$67.20 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$18.42 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$48.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,18.42,70.08,$96.00 Outpatient Medical Services,Lab,83550,Blood test that measures the amount of iron carried in the blood,301,$85.00 ,N/A,Not Applicable. Service not offered,$39.06 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$39.43 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$62.05 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$59.50 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$16.31 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$42.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,16.31,62.05,$85.00 Outpatient Medical Services,Lab,83690,LIPASE,301,$162.00 ,N/A,Not Applicable. Service not offered,$30.78 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$31.07 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$118.26 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$113.40 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$31.09 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$81.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,30.78,118.26,$162.00 Outpatient Medical Services,Lab,83735,MAGNESIUM SERUM,301,$100.00 ,N/A,Not Applicable. Service not offered,$29.96 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$30.24 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$73.00 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$70.00 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$19.19 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$50.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,19.19,73,$100.00 Outpatient Medical Services,Lab,84100,PHOSPHORUS,301,$87.00 ,N/A,Not Applicable. Service not offered,$21.20 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$21.40 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$63.51 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$60.90 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$16.70 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$43.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,16.7,63.51,$87.00 Outpatient Medical Services,Lab,84153,PSA (prostate specific antigen),301,$201.00 ,N/A,Not Applicable. Service not offered,$82.25 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$83.03 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$146.73 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$140.70 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$38.57 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$100.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,38.57,146.73,$201.00 Outpatient Medical Services,Lab,84436,Blood test to measure a type of thyroid hormone,301,$114.00 ,N/A,Not Applicable. Service not offered,$30.74 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$31.04 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$83.22 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$79.80 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$21.88 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$57.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,21.88,83.22,$114.00 Outpatient Medical Services,Lab,84439,Blood test to evaluate thyroid function,301,$127.00 ,N/A,Not Applicable. Service not offered,$40.32 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$40.70 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$92.71 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$88.90 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$24.37 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$63.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,24.37,92.71,$127.00 Outpatient Medical Services,Lab,84443,"Blood test, thyroid stimulating hormone (TSH)",301,$175.00 ,N/A,Not Applicable. Service not offered,$75.10 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$75.81 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$127.75 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$122.50 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$33.58 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$87.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,33.58,127.75,$175.00 Outpatient Medical Services,Lab,84443,"Blood test, thyroid stimulating hormone (TSH)",302,$168.00 ,N/A,Not Applicable. Service not offered,$75.10 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$75.81 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$122.64 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$117.60 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$32.24 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$84.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,32.24,122.64,$168.00 Outpatient Medical Services,Lab,84479,T-3 UPTAKE,306,$86.00 ,N/A,Not Applicable. Service not offered,$28.95 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$29.22 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$62.78 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$60.20 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$16.50 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$43.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,16.5,62.78,$86.00 Outpatient Medical Services,Lab,84484,Blood test to measure a certain protein in the blood to determine heart muscle damage,301,$142.00 ,N/A,Not Applicable. Service not offered,$117.15 ,Pays at 82.5% of total billed charges for outpatient setting,$117.15 ,Pays at 82.5% of total billed charges for outpatient setting,$103.66 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$99.40 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$27.25 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$71.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,27.25,117.15,$142.00 Outpatient Medical Services,Lab,84520,BUN,305,$71.00 ,N/A,Not Applicable. Service not offered,$17.64 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$17.81 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$51.83 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$49.70 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$13.62 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$35.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,13.62,51.83,$71.00 Outpatient Medical Services,Lab,84550,URIC ACID,305,$71.00 ,N/A,Not Applicable. Service not offered,$20.19 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$20.38 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$51.83 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$49.70 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$13.62 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$35.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,13.62,51.83,$71.00 Outpatient Medical Services,Lab,84703,Blood test to assess for pregnancy,301,$128.00 ,N/A,Not Applicable. Service not offered,$33.58 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$33.90 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$93.44 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$89.60 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$24.56 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$64.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,24.56,93.44,$128.00 Outpatient Medical Services,Lab,85025,"Complete blood cell count, with differential white blood cells, automated",301,$135.00 ,N/A,Not Applicable. Service not offered,$34.78 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$35.11 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$98.55 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$94.50 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$25.91 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$67.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,25.91,98.55,$135.00 Outpatient Medical Services,Lab,85378,D-DIMER FIBRIN DEGRADATION,301,$113.00 ,N/A,Not Applicable. Service not offered,$31.88 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$32.18 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$82.49 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$79.10 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$21.68 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$56.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,21.68,82.49,$113.00 Outpatient Medical Services,Lab,85610,"Blood test, clotting time",301,$74.00 ,N/A,Not Applicable. Service not offered,$17.58 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$17.74 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$54.02 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$51.80 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$14.20 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$37.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,14.2,54.02,$74.00 Outpatient Medical Services,Lab,85610,"Blood test, clotting time",301,$74.00 ,N/A,Not Applicable. Service not offered,$17.58 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$17.74 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$54.02 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$51.80 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$14.20 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$37.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,14.2,54.02,$74.00 Outpatient Medical Services,Lab,85651,SED RATE,301,$111.00 ,N/A,Not Applicable. Service not offered,$15.88 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$16.03 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$81.03 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$77.70 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$21.30 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$55.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,15.88,81.03,$111.00 Outpatient Medical Services,Lab,85730,Coagulation assessment blood test,301,$138.00 ,N/A,Not Applicable. Service not offered,$26.84 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$27.09 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$100.74 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$96.60 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$26.48 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$69.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,26.48,100.74,$138.00 Outpatient Medical Services,Lab,86592,Blood test to screen for syphilis,301,$7.26 ,N/A,Not Applicable. Service not offered,$19.09 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$19.27 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$5.30 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$5.08 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$1.39 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$3.63 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,1.39,19.27,$7.26 Outpatient Medical Services,Lab,86677,Blood test to if peptic ulcers are caused by a certain bacterium,301,$78.00 ,N/A,Not Applicable. Service not offered,$64.89 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$65.51 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$56.94 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$54.60 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$14.97 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$39.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,14.97,65.51,$78.00 Outpatient Medical Services,Lab,86703,Blood test to diagnose HIV,390,$58.00 ,N/A,Not Applicable. Service not offered,$59.91 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$60.48 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$42.34 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$40.60 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$11.13 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$29.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,11.13,60.48,$58.00 Outpatient Medical Services,Lab,86769,COVID19 ANTIBODY [SARS-CoV-2],301,$142.00 ,N/A,Not Applicable. Service not offered,$117.15 ,Pays at 82.5% of total billed charges for outpatient setting,$117.15 ,Pays at 82.5% of total billed charges for outpatient setting,$103.66 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$99.40 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$27.25 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$71.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,27.25,117.15,$142.00 Outpatient Medical Services,Lab,86769,COVID19 TOTAL ANTIBODY [SARS-COV-2],301,$142.00 ,N/A,Not Applicable. Service not offered,$117.15 ,Pays at 82.5% of total billed charges for outpatient setting,$117.15 ,Pays at 82.5% of total billed charges for outpatient setting,$103.66 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$99.40 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$27.25 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$71.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,27.25,117.15,$142.00 Outpatient Medical Services,Lab,86850,Blood test to screen for antibodies that could harm red blood cells,301,$109.00 ,N/A,Not Applicable. Service not offered,$89.93 ,Pays at 82.5% of total billed charges for outpatient setting,$89.93 ,Pays at 82.5% of total billed charges for outpatient setting,$79.57 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$76.30 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$20.92 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$54.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,20.92,89.93,$109.00 Outpatient Medical Services,Lab,86900,ABO GROUP,381,$35.00 ,N/A,Not Applicable. Service not offered,$13.32 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$13.45 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$25.55 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$24.50 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$6.72 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$17.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,6.72,25.55,$35.00 Outpatient Medical Services,Lab,86901,RH (D) TYPING,302,$35.00 ,N/A,Not Applicable. Service not offered,$28.88 ,Pays at 82.5% of total billed charges for outpatient setting,$28.88 ,Pays at 82.5% of total billed charges for outpatient setting,$25.55 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$24.50 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$6.72 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$17.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,6.72,28.88,$35.00 Outpatient Medical Services,Lab,86922,IGG CROSSMATCH,301,$116.00 ,N/A,Not Applicable. Service not offered,$95.70 ,Pays at 82.5% of total billed charges for outpatient setting,$95.70 ,Pays at 82.5% of total billed charges for outpatient setting,$84.68 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$81.20 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$22.26 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$58.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,22.26,95.7,$116.00 Outpatient Medical Services,Lab,87070,Test of body fluid other than blood to assess for bacteria,301,$34.60 ,N/A,Not Applicable. Service not offered,$38.49 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$38.86 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$25.26 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$24.22 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$6.64 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$17.30 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,6.64,38.86,$34.60 Outpatient Medical Services,Lab,87400,INFLUENZA B RAPID TEST,301,$71.00 ,N/A,Not Applicable. Service not offered,$58.58 ,Pays at 82.5% of total billed charges for outpatient setting,$58.58 ,Pays at 82.5% of total billed charges for outpatient setting,$51.83 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$49.70 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$13.62 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$35.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,13.62,58.58,$71.00 Outpatient Medical Services,Lab,87400,INFLUENZA A&B RAPID TEST,301,$71.00 ,N/A,Not Applicable. Service not offered,$58.58 ,Pays at 82.5% of total billed charges for outpatient setting,$58.58 ,Pays at 82.5% of total billed charges for outpatient setting,$51.83 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$49.70 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$13.62 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$35.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,13.62,58.58,$71.00 Outpatient Medical Services,Lab,87426,COVID (MERS) RAPID Ag,301,$213.00 ,N/A,Not Applicable. Service not offered,$175.73 ,Pays at 82.5% of total billed charges for outpatient setting,$175.73 ,Pays at 82.5% of total billed charges for outpatient setting,$155.49 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$149.10 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$40.87 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$106.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,40.87,175.73,$213.00 Outpatient Medical Services,Lab,87493,C DIFF QUIK CHECK,301,$142.00 ,N/A,Not Applicable. Service not offered,$117.15 ,Pays at 82.5% of total billed charges for outpatient setting,$117.15 ,Pays at 82.5% of total billed charges for outpatient setting,$103.66 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$99.40 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$27.25 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$71.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,27.25,117.15,$142.00 Outpatient Medical Services,Lab,87802,BETA HEMOLYTIC GROUP A STREP,306,$51.00 ,N/A,Not Applicable. Service not offered,$42.08 ,Pays at 82.5% of total billed charges for outpatient setting,$42.08 ,Pays at 82.5% of total billed charges for outpatient setting,$37.23 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$35.70 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$9.79 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$25.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,9.79,42.08,$51.00 Outpatient Medical Services,Lab,80074,Acute hepatitis panel,306,$62.04 ,N/A,Not Applicable. Service not offered,$207.33 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$209.31 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$45.29 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$43.43 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$11.91 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$31.02 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,11.91,209.31,$62.04 Outpatient Medical Services,Lab,80101,DRUG SC/COLLECTION,302,$16.00 ,N/A,Not Applicable. Service not offered,$13.20 ,Pays at 82.5% of total billed charges for outpatient setting,$13.20 ,Pays at 82.5% of total billed charges for outpatient setting,$11.68 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$11.20 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$3.07 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$8.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,3.07,13.2,$16.00 Outpatient Medical Services,Lab,80177,LEVETRIACETAM (KEPPRA LEVEL),302,$149.00 ,N/A,Not Applicable. Service not offered,$122.93 ,Pays at 82.5% of total billed charges for outpatient setting,$122.93 ,Pays at 82.5% of total billed charges for outpatient setting,$108.77 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$104.30 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$28.59 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$74.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,28.59,122.93,$149.00 Outpatient Medical Services,Lab,80320,BLOOD ALCOHOL,301,$270.00 ,N/A,Not Applicable. Service not offered,$48.32 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$48.78 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$197.10 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$189.00 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$51.81 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$135.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,48.32,197.1,$270.00 Outpatient Medical Services,Lab,82043,Urine test to measure albumin,301,$31.00 ,N/A,Not Applicable. Service not offered,$7.65 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$7.73 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$22.63 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$21.70 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$5.95 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$15.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,5.95,22.63,$31.00 Outpatient Medical Services,Lab,82140,AMMONIA LEVEL,301,$153.00 ,N/A,Not Applicable. Service not offered,$65.14 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$65.76 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$111.69 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$107.10 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$29.36 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$76.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,29.36,111.69,$153.00 Outpatient Medical Services,Lab,83605,LACTIC ACID,302,$112.00 ,N/A,Not Applicable. Service not offered,$47.72 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$48.18 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$81.76 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$78.40 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$21.49 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$56.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,21.49,81.76,$112.00 Outpatient Medical Services,Lab,83970,"PARATHYROID HORMONE, INTACT",301,$63.29 ,N/A,Not Applicable. Service not offered,$184.53 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$186.28 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$46.20 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$44.30 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$12.15 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$31.65 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,12.15,186.28,$63.29 Outpatient Medical Services,Lab,84402,"TEST,FREE/TOTAL NO SBGH",301,$87.00 ,N/A,Not Applicable. Service not offered,$113.84 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$114.93 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$63.51 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$60.90 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$16.70 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$43.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,16.7,114.93,$87.00 Outpatient Medical Services,Lab,84403,TESTOSTERONE-TOTAL,391,$17.80 ,N/A,Not Applicable. Service not offered,$115.42 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$116.52 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$12.99 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$12.46 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$3.42 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$8.90 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,3.42,116.52,$17.80 Outpatient Medical Services,Lab,84481,FREE T-3 (TRI-IODOTHYRONINE),301,$21.49 ,N/A,Not Applicable. Service not offered,$68.45 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$69.10 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$15.69 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$15.04 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$4.12 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$10.75 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,4.12,69.1,$21.49 Outpatient Medical Services,Lab,86038,ANA,301,$18.04 ,N/A,Not Applicable. Service not offered,$54.02 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$54.54 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$13.17 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$12.63 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$3.46 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$9.02 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,3.46,54.54,$18.04 Outpatient Medical Services,Lab,86140,C REACTIVE PROTEIN,302,$29.35 ,N/A,Not Applicable. Service not offered,$23.12 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$23.34 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$21.43 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$20.55 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$5.63 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$14.68 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,5.63,23.34,$29.35 Outpatient Medical Services,Lab,86803,Blood test to determine infection with Hepatitis C,302,$15.71 ,N/A,Not Applicable. Service not offered,$62.15 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$62.74 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$11.47 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$11.00 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$3.01 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$7.86 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,3.01,62.74,$15.71 Outpatient Medical Services,Lab,87040,Blood test to screen for bacteria in the blood,301,$11.00 ,N/A,Not Applicable. Service not offered,$46.15 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$46.59 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$8.03 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$7.70 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$2.11 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$5.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,2.11,46.59,$11.00 Outpatient Medical Services,Lab,87070,Test of body fluid other than blood to assess for bacteria,300,$11.22 ,N/A,Not Applicable. Service not offered,$38.49 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$38.86 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$8.19 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$7.85 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$2.15 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$5.61 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,2.15,38.86,$11.22 Outpatient Medical Services,Lab,87070,Test of body fluid other than blood to assess for bacteria,301,$34.60 ,N/A,Not Applicable. Service not offered,$38.49 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$38.86 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$25.26 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$24.22 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$6.64 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$17.30 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,6.64,38.86,$34.60 Outpatient Medical Services,Lab,87070,Test of body fluid other than blood to assess for bacteria,306,$34.60 ,N/A,Not Applicable. Service not offered,$38.49 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$38.86 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$25.26 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$24.22 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$6.64 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$17.30 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,6.64,38.86,$34.60 Outpatient Medical Services,Lab,87077,Test of a wound for type of bacterial infection,301,$5.72 ,N/A,Not Applicable. Service not offered,$35.15 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$35.49 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$4.18 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$4.00 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$1.10 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$2.86 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,1.1,35.49,$5.72 Outpatient Medical Services,Lab,87086,Culture of the urine to determine number of bacteria,300,$7.75 ,N/A,Not Applicable. Service not offered,$36.10 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$36.44 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$5.66 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$5.43 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$1.49 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$3.88 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,1.49,36.44,$7.75 Outpatient Medical Services,Lab,87186,A test used to determine which medications work on bacteria for fungi,301,$7.50 ,N/A,Not Applicable. Service not offered,$38.65 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$39.02 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$5.48 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$5.25 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$1.44 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$3.75 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,1.44,39.02,$7.50 Outpatient Medical Services,Lab,87340,HEPATITIS B SURF ANTIGEN,306,$63.00 ,N/A,Not Applicable. Service not offered,$44.95 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$45.38 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$45.99 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$44.10 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$12.09 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$31.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,12.09,45.99,$63.00 Outpatient Medical Services,Lab,87490,CHLAMYDIA ONLY DIRECT PROBE,301,$25.41 ,N/A,Not Applicable. Service not offered,$20.96 ,Pays at 82.5% of total billed charges for outpatient setting,$20.96 ,Pays at 82.5% of total billed charges for outpatient setting,$18.55 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$17.79 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$4.88 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$12.71 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,4.88,20.96,$25.41 Outpatient Medical Services,Lab,87590,NEISERRIA ONLY DIRECT PROBE,302,$25.41 ,N/A,Not Applicable. Service not offered,$20.96 ,Pays at 82.5% of total billed charges for outpatient setting,$20.96 ,Pays at 82.5% of total billed charges for outpatient setting,$18.55 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$17.79 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$4.88 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$12.71 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,4.88,20.96,$25.41 Outpatient Medical Services,Lab,G0103,Prostate cancer screening; prostate specific antigen test (psa),302,$201.00 ,N/A,Not Applicable. Service not offered,$165.83 ,Pays at 82.5% of total billed charges for outpatient setting,$165.83 ,Pays at 82.5% of total billed charges for outpatient setting,$146.73 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$140.70 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$38.57 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$100.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,38.57,165.83,$201.00 Outpatient Medical Services,Lab,P9021,RED BLOOD CELLS UNIT,306,$299.00 ,N/A,Not Applicable. Service not offered,$246.68 ,Pays at 82.5% of total billed charges for outpatient setting,$246.68 ,Pays at 82.5% of total billed charges for outpatient setting,$218.27 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$209.30 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$57.38 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$149.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,57.38,246.68,$299.00 Outpatient Medical Services,Lab,U0003,COVID19 [MERS-COV] SEND OUT,301,$205.00 ,N/A,Not Applicable. Service not offered,$169.13 ,Pays at 82.5% of total billed charges for outpatient setting,$169.13 ,Pays at 82.5% of total billed charges for outpatient setting,$149.65 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$143.50 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$39.34 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$102.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,39.34,169.13,$205.00 Outpatient Medical Services,Respiratory,94640,AEROSOL SUBSEQUENT TREATMENTS,410,$118.00 ,N/A,Not Applicable. Service not offered,$97.35 ,Pays at 82.5% of total billed charges for outpatient setting,$97.35 ,Pays at 82.5% of total billed charges for outpatient setting,$86.14 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$82.60 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$22.64 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$59.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,22.64,97.35,$118.00 Outpatient Medical Services,Respiratory,94640,MDI SUBSEQUENT TREATMENTS,410,$118.00 ,N/A,Not Applicable. Service not offered,$97.35 ,Pays at 82.5% of total billed charges for outpatient setting,$97.35 ,Pays at 82.5% of total billed charges for outpatient setting,$86.14 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$82.60 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$22.64 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$59.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,22.64,97.35,$118.00 Outpatient Medical Services,Respiratory,94668,CPT SUBSEQUENT,410,$126.00 ,N/A,Not Applicable. Service not offered,$103.95 ,Pays at 82.5% of total billed charges for outpatient setting,$103.95 ,Pays at 82.5% of total billed charges for outpatient setting,$91.98 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$88.20 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$24.18 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$63.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,24.18,103.95,$126.00 Outpatient Medical Services,Respiratory,94760,PULSE OX SPOT CHECK,460,$100.00 ,N/A,Not Applicable. Service not offered,$67.13 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$67.77 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$73.00 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$70.00 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$19.19 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$50.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,19.19,73,$100.00 Outpatient Medical Services,Respiratory,94640,AEROSOL W/MEDS ALTERNATE SUBSEQUENT TX,410,$125.00 ,N/A,Not Applicable. Service not offered,$103.13 ,Pays at 82.5% of total billed charges for outpatient setting,$103.13 ,Pays at 82.5% of total billed charges for outpatient setting,$91.25 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$87.50 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$23.99 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$62.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,23.99,103.13,$125.00 Outpatient Medical Services,Respiratory,82803,Test to measure arterial blood gases,301,$330.00 ,N/A,Not Applicable. Service not offered,$86.53 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$87.35 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$240.90 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$231.00 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$63.33 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$165.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,63.33,240.9,$330.00 Outpatient Medical Services,Respiratory,36600,ARTERIAL PUNCTURE WITHDRAWAL OF BLOOD,301,$50.00 ,N/A,Not Applicable. Service not offered,$41.25 ,Pays at 82.5% of total billed charges for outpatient setting,$41.25 ,Pays at 82.5% of total billed charges for outpatient setting,$36.50 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$35.00 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$9.60 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$25.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,9.6,41.25,$50.00 Outpatient Medical Services,Respiratory,94664,AEROSOL SETUP AND INITIAL TREATMENT,410,$101.00 ,N/A,Not Applicable. Service not offered,$83.33 ,Pays at 82.5% of total billed charges for outpatient setting,$83.33 ,Pays at 82.5% of total billed charges for outpatient setting,$73.73 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$70.70 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$19.38 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$50.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,19.38,83.33,$101.00 Outpatient Medical Services,Respiratory,94664,FACE TENT/AEROSOL NEBULIZER,410,$101.00 ,N/A,Not Applicable. Service not offered,$83.33 ,Pays at 82.5% of total billed charges for outpatient setting,$83.33 ,Pays at 82.5% of total billed charges for outpatient setting,$73.73 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$70.70 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$19.38 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$50.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,19.38,83.33,$101.00 Outpatient Medical Services,Respiratory,94660,CPAP / BIPAP,410,$527.00 ,N/A,Not Applicable. Service not offered,$434.78 ,Pays at 82.5% of total billed charges for outpatient setting,$434.78 ,Pays at 82.5% of total billed charges for outpatient setting,$384.71 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$368.90 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$101.13 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$263.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,101.13,434.78,$527.00 Outpatient Medical Services,EKG,93005,ELECTROCARDIOGRAM,730,$293.00 ,N/A,Not Applicable. Service not offered,$113.84 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$114.93 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$213.89 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$205.10 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$56.23 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$146.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,56.23,213.89,$293.00 Outpatient Medical Services,Physical Therapy,97010,Use of external hot or cold packs,420,$82.00 ,N/A,Not Applicable. Service not offered,$67.65 ,Pays at 82.5% of total billed charges for outpatient setting,$67.65 ,Pays at 82.5% of total billed charges for outpatient setting,$59.86 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$57.40 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$15.74 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$41.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,15.74,67.65,$82.00 Outpatient Medical Services,Physical Therapy,97012,Form of decompression therapy of the spine,420,$59.00 ,N/A,Not Applicable. Service not offered,$48.68 ,Pays at 82.5% of total billed charges for outpatient setting,$48.68 ,Pays at 82.5% of total billed charges for outpatient setting,$43.07 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$41.30 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$11.32 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$29.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,11.32,48.68,$59.00 Outpatient Medical Services,Physical Therapy,97014,One time use unattended,420,$59.00 ,N/A,Not Applicable. Service not offered,$48.68 ,Pays at 82.5% of total billed charges for outpatient setting,$48.68 ,Pays at 82.5% of total billed charges for outpatient setting,$43.07 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$41.30 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$11.32 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$29.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,11.32,48.68,$59.00 Outpatient Medical Services,Physical Therapy,97016,"Machines designed to pump cold water into an inflatable wrap or brace, compressing the enveloped area of the body",420,$59.00 ,N/A,Not Applicable. Service not offered,$48.68 ,Pays at 82.5% of total billed charges for outpatient setting,$48.68 ,Pays at 82.5% of total billed charges for outpatient setting,$43.07 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$41.30 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$11.32 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$29.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,11.32,48.68,$59.00 Outpatient Medical Services,Physical Therapy,97018,PARAFFIN BATH THERAPY,420,$64.00 ,N/A,Not Applicable. Service not offered,$52.80 ,Pays at 82.5% of total billed charges for outpatient setting,$52.80 ,Pays at 82.5% of total billed charges for outpatient setting,$46.72 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$44.80 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$12.28 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$32.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,12.28,52.8,$64.00 Outpatient Medical Services,Physical Therapy,97032,Repeated application to one or more parts of the body,420,$59.00 ,N/A,Not Applicable. Service not offered,$48.68 ,Pays at 82.5% of total billed charges for outpatient setting,$48.68 ,Pays at 82.5% of total billed charges for outpatient setting,$43.07 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$41.30 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$11.32 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$29.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,11.32,48.68,$59.00 Outpatient Medical Services,Physical Therapy,97033,Psychiatric treatment in which seizures are electrically induced in patients to provide relief from mental disorders,420,$59.00 ,N/A,Not Applicable. Service not offered,$48.68 ,Pays at 82.5% of total billed charges for outpatient setting,$48.68 ,Pays at 82.5% of total billed charges for outpatient setting,$43.07 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$41.30 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$11.32 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$29.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,11.32,48.68,$59.00 Outpatient Medical Services,Physical Therapy,97035,"Use of sound waves to treat medical problems, especially musculoskeletal problems like inflammation from injuries",420,$59.00 ,N/A,Not Applicable. Service not offered,$48.68 ,Pays at 82.5% of total billed charges for outpatient setting,$48.68 ,Pays at 82.5% of total billed charges for outpatient setting,$43.07 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$41.30 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$11.32 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$29.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,11.32,48.68,$59.00 Outpatient Medical Services,Physical Therapy,97110,"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",420,$59.00 ,N/A,Not Applicable. Service not offered,$48.68 ,Pays at 82.5% of total billed charges for outpatient setting,$48.68 ,Pays at 82.5% of total billed charges for outpatient setting,$43.07 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$41.30 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$11.32 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$29.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,11.32,48.68,$59.00 Outpatient Medical Services,Physical Therapy,97112,A technique used by physical therapists to restore normal body movement patterns,420,$59.00 ,N/A,Not Applicable. Service not offered,$48.68 ,Pays at 82.5% of total billed charges for outpatient setting,$48.68 ,Pays at 82.5% of total billed charges for outpatient setting,$43.07 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$41.30 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$11.32 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$29.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,11.32,48.68,$59.00 Outpatient Medical Services,Physical Therapy,97113,Use of water for therapy/exercises,420,$59.00 ,N/A,Not Applicable. Service not offered,$48.68 ,Pays at 82.5% of total billed charges for outpatient setting,$48.68 ,Pays at 82.5% of total billed charges for outpatient setting,$43.07 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$41.30 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$11.32 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$29.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,11.32,48.68,$59.00 Outpatient Medical Services,Physical Therapy,97116,A type of physical therapy,420,$59.00 ,N/A,Not Applicable. Service not offered,$48.68 ,Pays at 82.5% of total billed charges for outpatient setting,$48.68 ,Pays at 82.5% of total billed charges for outpatient setting,$43.07 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$41.30 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$11.32 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$29.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,11.32,48.68,$59.00 Outpatient Medical Services,Physical Therapy,97124,Use of massage,420,$59.00 ,N/A,Not Applicable. Service not offered,$48.68 ,Pays at 82.5% of total billed charges for outpatient setting,$48.68 ,Pays at 82.5% of total billed charges for outpatient setting,$43.07 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$41.30 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$11.32 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$29.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,11.32,48.68,$59.00 Outpatient Medical Services,Physical Therapy,97140,Manipulation of 1 or more regions of the body,420,$59.00 ,N/A,Not Applicable. Service not offered,$48.68 ,Pays at 82.5% of total billed charges for outpatient setting,$48.68 ,Pays at 82.5% of total billed charges for outpatient setting,$43.07 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$41.30 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$11.32 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$29.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,11.32,48.68,$59.00 Outpatient Medical Services,Physical Therapy,97150,GROUP THERAPEUTIC PROCEDURES,420,$42.00 ,N/A,Not Applicable. Service not offered,$34.65 ,Pays at 82.5% of total billed charges for outpatient setting,$34.65 ,Pays at 82.5% of total billed charges for outpatient setting,$30.66 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$29.40 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$8.06 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$21.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,8.06,34.65,$42.00 Outpatient Medical Services,Physical Therapy,97161,"PT EVALUATION;LOW COMPLEX,20 MIN",420,$266.00 ,N/A,Not Applicable. Service not offered,$219.45 ,Pays at 82.5% of total billed charges for outpatient setting,$219.45 ,Pays at 82.5% of total billed charges for outpatient setting,$194.18 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$186.20 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$51.05 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$133.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,51.05,219.45,$266.00 Outpatient Medical Services,Physical Therapy,97162,"PT EVALUATION;MOD COMPLEX,30 MIN",424,$266.00 ,N/A,Not Applicable. Service not offered,$219.45 ,Pays at 82.5% of total billed charges for outpatient setting,$219.45 ,Pays at 82.5% of total billed charges for outpatient setting,$194.18 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$186.20 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$51.05 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$133.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,51.05,219.45,$266.00 Outpatient Medical Services,Physical Therapy,97162,"PT EVALUATION;MOD COMPLEX,30 MIN (KX)",424,$266.00 ,N/A,Not Applicable. Service not offered,$219.45 ,Pays at 82.5% of total billed charges for outpatient setting,$219.45 ,Pays at 82.5% of total billed charges for outpatient setting,$194.18 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$186.20 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$51.05 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$133.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,51.05,219.45,$266.00 Outpatient Medical Services,Physical Therapy,97163,"PT EVALUATION;HIGH COMPLEX,30 MIN",420,$266.00 ,N/A,Not Applicable. Service not offered,$219.45 ,Pays at 82.5% of total billed charges for outpatient setting,$219.45 ,Pays at 82.5% of total billed charges for outpatient setting,$194.18 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$186.20 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$51.05 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$133.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,51.05,219.45,$266.00 Outpatient Medical Services,Physical Therapy,97164,PT RE-EVALUATION; 20 MIN,420,$133.00 ,N/A,Not Applicable. Service not offered,$109.73 ,Pays at 82.5% of total billed charges for outpatient setting,$109.73 ,Pays at 82.5% of total billed charges for outpatient setting,$97.09 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$93.10 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$25.52 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$66.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,25.52,109.73,$133.00 Outpatient Medical Services,Physical Therapy,97530,"Incorporates the use of multiple parameters, such as balance, strength, and range of motion, for a functional activity",420,$59.00 ,N/A,Not Applicable. Service not offered,$48.68 ,Pays at 82.5% of total billed charges for outpatient setting,$48.68 ,Pays at 82.5% of total billed charges for outpatient setting,$43.07 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$41.30 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$11.32 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$29.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,11.32,48.68,$59.00 Outpatient Medical Services,Physical Therapy,97542,"WHEELCHAIR MANAGEMENT, 15 MIN",420,$59.00 ,N/A,Not Applicable. Service not offered,$48.68 ,Pays at 82.5% of total billed charges for outpatient setting,$48.68 ,Pays at 82.5% of total billed charges for outpatient setting,$43.07 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$41.30 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$11.32 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$29.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,11.32,48.68,$59.00 Outpatient Medical Services,Physical Therapy,97760,"JOBST MEASUREMENT, 15 MIN",420,$59.00 ,N/A,Not Applicable. Service not offered,$48.68 ,Pays at 82.5% of total billed charges for outpatient setting,$48.68 ,Pays at 82.5% of total billed charges for outpatient setting,$43.07 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$41.30 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$11.32 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$29.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,11.32,48.68,$59.00 Outpatient Medical Services,Physical Therapy,97014,One time use unattended,420,$59.00 ,N/A,Not Applicable. Service not offered,$48.68 ,Pays at 82.5% of total billed charges for outpatient setting,$48.68 ,Pays at 82.5% of total billed charges for outpatient setting,$43.07 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$41.30 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$11.32 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$29.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,11.32,48.68,$59.00 Outpatient Medical Services,Physical Therapy,97035,"Use of sound waves to treat medical problems, especially musculoskeletal problems like inflammation from injuries",420,$59.00 ,N/A,Not Applicable. Service not offered,$48.68 ,Pays at 82.5% of total billed charges for outpatient setting,$48.68 ,Pays at 82.5% of total billed charges for outpatient setting,$43.07 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$41.30 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$11.32 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$29.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,11.32,48.68,$59.00 Outpatient Medical Services,Physical Therapy,97110,"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",420,$59.00 ,N/A,Not Applicable. Service not offered,$48.68 ,Pays at 82.5% of total billed charges for outpatient setting,$48.68 ,Pays at 82.5% of total billed charges for outpatient setting,$43.07 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$41.30 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$11.32 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$29.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,11.32,48.68,$59.00 Outpatient Medical Services,Physical Therapy,97112,A technique used by physical therapists to restore normal body movement patterns,420,$59.00 ,N/A,Not Applicable. Service not offered,$48.68 ,Pays at 82.5% of total billed charges for outpatient setting,$48.68 ,Pays at 82.5% of total billed charges for outpatient setting,$43.07 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$41.30 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$11.32 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$29.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,11.32,48.68,$59.00 Outpatient Medical Services,Physical Therapy,97113,Use of water for therapy/exercises,420,$59.00 ,N/A,Not Applicable. Service not offered,$48.68 ,Pays at 82.5% of total billed charges for outpatient setting,$48.68 ,Pays at 82.5% of total billed charges for outpatient setting,$43.07 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$41.30 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$11.32 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$29.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,11.32,48.68,$59.00 Outpatient Medical Services,Physical Therapy,97116,A type of physical therapy,420,$59.00 ,N/A,Not Applicable. Service not offered,$48.68 ,Pays at 82.5% of total billed charges for outpatient setting,$48.68 ,Pays at 82.5% of total billed charges for outpatient setting,$43.07 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$41.30 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$11.32 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$29.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,11.32,48.68,$59.00 Outpatient Medical Services,Physical Therapy,97140,Manipulation of 1 or more regions of the body,420,$59.00 ,N/A,Not Applicable. Service not offered,$48.68 ,Pays at 82.5% of total billed charges for outpatient setting,$48.68 ,Pays at 82.5% of total billed charges for outpatient setting,$43.07 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$41.30 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$11.32 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$29.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,11.32,48.68,$59.00 Outpatient Medical Services,Physical Therapy,97161,"PT EVALUATION;LOW COMPLEX,20 MIN (KX)",420,$266.00 ,N/A,Not Applicable. Service not offered,$219.45 ,Pays at 82.5% of total billed charges for outpatient setting,$219.45 ,Pays at 82.5% of total billed charges for outpatient setting,$194.18 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$186.20 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$51.05 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$133.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,51.05,219.45,$266.00 Outpatient Medical Services,Physical Therapy,97530,"Incorporates the use of multiple parameters, such as balance, strength, and range of motion, for a functional activity",420,$59.00 ,N/A,Not Applicable. Service not offered,$48.68 ,Pays at 82.5% of total billed charges for outpatient setting,$48.68 ,Pays at 82.5% of total billed charges for outpatient setting,$43.07 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$41.30 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$11.32 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$29.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,11.32,48.68,$59.00 Outpatient Medical Services,Physical Therapy,97542,"WHEELCHAIR MANAGEMENT (KX), 15 MIN",420,$59.00 ,N/A,Not Applicable. Service not offered,$48.68 ,Pays at 82.5% of total billed charges for outpatient setting,$48.68 ,Pays at 82.5% of total billed charges for outpatient setting,$43.07 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$41.30 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$11.32 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$29.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,11.32,48.68,$59.00 Outpatient Medical Services,Physical Therapy,G0283,ELECTRIC STIMULATION UNATTENDED (KX),420,$59.00 ,N/A,Not Applicable. Service not offered,$48.68 ,Pays at 82.5% of total billed charges for outpatient setting,$48.68 ,Pays at 82.5% of total billed charges for outpatient setting,$43.07 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$41.30 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$11.32 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$29.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,11.32,48.68,$59.00 Outpatient Medical Services,Speech Therapy,92507,Therapy for speech or hearing,440,$160.00 ,N/A,Not Applicable. Service not offered,$132.00 ,Pays at 82.5% of total billed charges for outpatient setting,$132.00 ,Pays at 82.5% of total billed charges for outpatient setting,$116.80 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$112.00 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$30.70 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$80.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,30.7,132,$160.00 Outpatient Medical Services,Speech Therapy,92526,ST TREATMENT OF SWALL DYSF,440,$354.00 ,N/A,Not Applicable. Service not offered,$292.05 ,Pays at 82.5% of total billed charges for outpatient setting,$292.05 ,Pays at 82.5% of total billed charges for outpatient setting,$258.42 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$247.80 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$67.93 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$177.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,67.93,292.05,$354.00 Outpatient Medical Services,Speech Therapy,97129,"ST DEVELOPMENT OF COGN SKILLS, EA 15 MIN",440,$354.00 ,N/A,Not Applicable. Service not offered,$292.05 ,Pays at 82.5% of total billed charges for outpatient setting,$292.05 ,Pays at 82.5% of total billed charges for outpatient setting,$258.42 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$247.80 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$67.93 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$177.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,67.93,292.05,$354.00 Outpatient Medical Services,Speech Therapy,97130,"ST DEVELOPMENT OF COGN SKILLS, EA 15 MIN",440,$354.00 ,N/A,Not Applicable. Service not offered,$292.05 ,Pays at 82.5% of total billed charges for outpatient setting,$292.05 ,Pays at 82.5% of total billed charges for outpatient setting,$258.42 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$247.80 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$67.93 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$177.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,67.93,292.05,$354.00 Outpatient Medical Services,Speech Therapy,92523,Evaluation of speech sound production with evaluation of language comprehension,444,$505.00 ,N/A,Not Applicable. Service not offered,$416.63 ,Pays at 82.5% of total billed charges for outpatient setting,$416.63 ,Pays at 82.5% of total billed charges for outpatient setting,$368.65 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$353.50 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$96.91 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$252.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,96.91,416.63,$505.00 Outpatient Medical Services,Occup Therapy,97530,"Incorporates the use of multiple parameters, such as balance, strength, and range of motion, for a functional activity",430,$59.00 ,N/A,Not Applicable. Service not offered,$48.68 ,Pays at 82.5% of total billed charges for outpatient setting,$48.68 ,Pays at 82.5% of total billed charges for outpatient setting,$43.07 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$41.30 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$11.32 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$29.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,11.32,48.68,$59.00 Outpatient Medical Services,Occup Therapy,97110,"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",430,$59.00 ,N/A,Not Applicable. Service not offered,$48.68 ,Pays at 82.5% of total billed charges for outpatient setting,$48.68 ,Pays at 82.5% of total billed charges for outpatient setting,$43.07 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$41.30 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$11.32 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$29.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,11.32,48.68,$59.00 Outpatient Medical Services,Occup Therapy,97535,Occupational therapy,430,$59.00 ,N/A,Not Applicable. Service not offered,$48.68 ,Pays at 82.5% of total billed charges for outpatient setting,$48.68 ,Pays at 82.5% of total billed charges for outpatient setting,$43.07 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$41.30 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$11.32 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$29.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,11.32,48.68,$59.00 Outpatient Medical Services,Occup Therapy,97166,"OT EVALUATION; MOD COMPLEXTY, 45 MIN",434,$266.00 ,N/A,Not Applicable. Service not offered,$219.45 ,Pays at 82.5% of total billed charges for outpatient setting,$219.45 ,Pays at 82.5% of total billed charges for outpatient setting,$194.18 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$186.20 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$51.05 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$133.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,51.05,219.45,$266.00 Outpatient Medical Services,Occup Therapy,97110,"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",430,$59.00 ,N/A,Not Applicable. Service not offered,$48.68 ,Pays at 82.5% of total billed charges for outpatient setting,$48.68 ,Pays at 82.5% of total billed charges for outpatient setting,$43.07 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$41.30 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$11.32 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$29.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,11.32,48.68,$59.00 Outpatient Medical Services,Emergency,99281,ER VISIT; LEVEL I,450,$215.00 ,N/A,Not Applicable. Service not offered,$177.38 ,Pays at 82.5% of total billed charges for outpatient setting,$177.38 ,Pays at 82.5% of total billed charges for outpatient setting,$156.95 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$150.50 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$41.26 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$107.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,41.26,177.38,$215.00 Outpatient Medical Services,Emergency,99282,ER VISIT; LEVEL II,450,$405.00 ,N/A,Not Applicable. Service not offered,$334.13 ,Pays at 82.5% of total billed charges for outpatient setting,$334.13 ,Pays at 82.5% of total billed charges for outpatient setting,$295.65 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$283.50 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$77.72 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$202.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,77.72,334.13,$405.00 Outpatient Medical Services,Emergency,99283,"Emergency department visit, moderately severe problem",450,$541.00 ,N/A,Not Applicable. Service not offered,$446.33 ,Pays at 82.5% of total billed charges for outpatient setting,$446.33 ,Pays at 82.5% of total billed charges for outpatient setting,$394.93 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$378.70 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$103.82 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$270.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,103.82,446.33,$541.00 Outpatient Medical Services,Emergency,99284,"Emergency department visit, problem of high severity",450,$876.00 ,N/A,Not Applicable. Service not offered,$722.70 ,Pays at 82.5% of total billed charges for outpatient setting,$722.70 ,Pays at 82.5% of total billed charges for outpatient setting,$639.48 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$613.20 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$168.10 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$438.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,168.1,722.7,$876.00 Outpatient Medical Services,Emergency,99285,"Emergency department visit, problem with significant threat to life or function",450,"$1,262.00 ",N/A,Not Applicable. Service not offered,"$1,041.15 ",Pays at 82.5% of total billed charges for outpatient setting,"$1,041.15 ",Pays at 82.5% of total billed charges for outpatient setting,$921.26 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$883.40 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$242.18 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$631.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,242.18,1041.15,"$1,262.00 " Outpatient Medical Services,Emergency,99291,"ER VISIT; CRITICAL, < 74 MIN",450,"$1,735.00 ",N/A,Not Applicable. Service not offered,"$1,431.38 ",Pays at 82.5% of total billed charges for outpatient setting,"$1,431.38 ",Pays at 82.5% of total billed charges for outpatient setting,"$1,266.55 ",Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,"$1,214.50 ",Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$332.95 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$867.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,332.95,1431.38,"$1,735.00 " Outpatient Medical Services,Emergency,99281,ER VISIT; LEVEL I W/ANCILLARY,450,$215.00 ,N/A,Not Applicable. Service not offered,$177.38 ,Pays at 82.5% of total billed charges for outpatient setting,$177.38 ,Pays at 82.5% of total billed charges for outpatient setting,$156.95 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$150.50 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$41.26 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$107.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,41.26,177.38,$215.00 Outpatient Medical Services,Emergency,99282,ER VISIT; LEVEL II W/ANCILLARY,450,$405.00 ,N/A,Not Applicable. Service not offered,$334.13 ,Pays at 82.5% of total billed charges for outpatient setting,$334.13 ,Pays at 82.5% of total billed charges for outpatient setting,$295.65 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$283.50 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$77.72 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$202.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,77.72,334.13,$405.00 Outpatient Medical Services,Emergency,99283,"Emergency department visit, moderately severe problem",450,$541.00 ,N/A,Not Applicable. Service not offered,$446.33 ,Pays at 82.5% of total billed charges for outpatient setting,$446.33 ,Pays at 82.5% of total billed charges for outpatient setting,$394.93 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$378.70 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$103.82 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$270.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,103.82,446.33,$541.00 Outpatient Medical Services,Emergency,99284,"Emergency department visit, problem of high severity",450,$876.00 ,N/A,Not Applicable. Service not offered,$722.70 ,Pays at 82.5% of total billed charges for outpatient setting,$722.70 ,Pays at 82.5% of total billed charges for outpatient setting,$639.48 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$613.20 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$168.10 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$438.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,168.1,722.7,$876.00 Outpatient Medical Services,Emergency,99285,"Emergency department visit, problem with significant threat to life or function",450,"$1,262.00 ",N/A,Not Applicable. Service not offered,"$1,041.15 ",Pays at 82.5% of total billed charges for outpatient setting,"$1,041.15 ",Pays at 82.5% of total billed charges for outpatient setting,$921.26 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$883.40 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$242.18 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$631.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,242.18,1041.15,"$1,262.00 " Outpatient Medical Services,Emergency,99292,ER VISIT; CRITICAL ADD 30 MIN W/ANCILLAR,450,$534.00 ,N/A,Not Applicable. Service not offered,$440.55 ,Pays at 82.5% of total billed charges for outpatient setting,$440.55 ,Pays at 82.5% of total billed charges for outpatient setting,$389.82 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$373.80 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$102.47 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$267.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,102.47,440.55,$534.00 Outpatient Medical Services,Psychotherapy,90853,Group psychotherapy,915,$225.00 ,N/A,Not Applicable. Service not offered,$185.63 ,Pays at 82.5% of total billed charges for outpatient setting,$185.63 ,Pays at 82.5% of total billed charges for outpatient setting,$164.25 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$157.50 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$43.18 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,43.18,185.63,$225.00 Outpatient Medical Services,Psychotherapy,G0463,PSYCHIATRIC HOSPITAL OP CLINIC VISIT,510,$140.00 ,N/A,Not Applicable. Service not offered,$115.50 ,Pays at 82.5% of total billed charges for outpatient setting,$115.50 ,Pays at 82.5% of total billed charges for outpatient setting,$102.20 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$98.00 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$26.87 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$70.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,26.87,115.5,$140.00 Outpatient Medical Services,Psychotherapy,90832,"Psychotherapy, 30 min",914,$188.00 ,N/A,Not Applicable. Service not offered,$155.10 ,Pays at 82.5% of total billed charges for outpatient setting,$155.10 ,Pays at 82.5% of total billed charges for outpatient setting,$137.24 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$131.60 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$36.08 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,36.08,155.1,$188.00 Outpatient Medical Services,Psychotherapy,90837,"Psychotherapy, 60 min",914,$260.00 ,N/A,Not Applicable. Service not offered,$214.50 ,Pays at 82.5% of total billed charges for outpatient setting,$214.50 ,Pays at 82.5% of total billed charges for outpatient setting,$189.80 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$182.00 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$49.89 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,49.89,214.5,$260.00 Outpatient Medical Services,Psychotherapy,90834,"Psychotherapy, 45 min",914,$225.00 ,N/A,Not Applicable. Service not offered,$185.63 ,Pays at 82.5% of total billed charges for outpatient setting,$185.63 ,Pays at 82.5% of total billed charges for outpatient setting,$164.25 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$157.50 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$43.18 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,43.18,185.63,$225.00 Outpatient Medical Services,Psychotherapy,90791,"A diagnostic tool employed by a psychiatrist to diagnose problems with memory, thought processes, and behaviors",900,$295.00 ,N/A,Not Applicable. Service not offered,$243.38 ,Pays at 82.5% of total billed charges for outpatient setting,$243.38 ,Pays at 82.5% of total billed charges for outpatient setting,$215.35 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$206.50 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$56.61 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$147.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,56.61,243.38,$295.00 Outpatient Medical Services,Psychotherapy,90847,"Family psychotherapy, including patient, 50 min",916,$253.00 ,N/A,Not Applicable. Service not offered,$208.73 ,Pays at 82.5% of total billed charges for outpatient setting,$208.73 ,Pays at 82.5% of total billed charges for outpatient setting,$184.69 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$177.10 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$48.55 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,48.55,208.73,$253.00 Outpatient Medical Services,Physician Office,99202,"New patient office or other outpatient visit, typically 10 minutes",510,$55.00 ,N/A,Not Applicable. Service not offered,$45.38 ,Pays at 82.5% of total billed charges for outpatient setting,$45.38 ,Pays at 82.5% of total billed charges for outpatient setting,$40.15 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$38.50 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$10.55 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$27.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,10.55,45.38,$55.00 Outpatient Medical Services,Physician Office,99202,"New patient office or other outpatient visit, typically 10 minutes",983,$60.00 ,N/A,Not Applicable. Service not offered,$60.30 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$60.30 ,Pays at 315% of Custom fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$33.00 ,Pays at 100% of CMS Physician fee Schedule for Outpatient Setting,$55.78 ,Pays at 115% of physician fee Schedule for Outpatient setting,$33.00 ,Pays at 100% of CMS Physician fee Schedule for Outpatient Setting,$55.78 ,Pays at 115% of Physician fee Schedule for Outpatient setting,$33.00 ,Pays at 100% of CMS Physician fee Schedule for Outpatient Setting,$33.00 ,Pays at 100% of CMS Physician fee Schedule for Outpatient Setting,N/A,Not Applicable. Service not offered,$33.00 ,Pays at 100% of CMS Physician fee Schedule for Outpatient Setting,$55.78 ,Pays ar 115% of Physician fee schedule for Outpatient setting,$33.00 ,Pays at 100% of CMS Physician fee Schedule for Outpatient Setting,33,60.3,$60.00 Outpatient Medical Services,Physician Office,99203,"New patient office or other outpatient visit, typically 30 min",510,$84.00 ,N/A,Not Applicable. Service not offered,$69.30 ,Pays at 82.5% of total billed charges for outpatient setting,$69.30 ,Pays at 82.5% of total billed charges for outpatient setting,$61.32 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$58.80 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$16.12 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$42.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,16.12,69.3,$84.00 Outpatient Medical Services,Physician Office,99203,"New patient office or other outpatient visit, typically 30 min",983,$91.00 ,N/A,Not Applicable. Service not offered,$89.09 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$89.09 ,Pays at 315% of Custom fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$51.23 ,Pays at 100% of CMS Physician fee Schedule for Outpatient Setting,$96.86 ,Pays at 115% of physician fee Schedule for Outpatient setting,$51.23 ,Pays at 100% of CMS Physician fee Schedule for Outpatient Setting,$96.86 ,Pays at 115% of Physician fee Schedule for Outpatient setting,$51.23 ,Pays at 100% of CMS Physician fee Schedule for Outpatient Setting,$51.23 ,Pays at 100% of CMS Physician fee Schedule for Outpatient Setting,N/A,Not Applicable. Service not offered,$51.23 ,Pays at 100% of CMS Physician fee Schedule for Outpatient Setting,$96.86 ,Pays ar 115% of Physician fee schedule for Outpatient setting,$51.23 ,Pays at 100% of CMS Physician fee Schedule for Outpatient Setting,51.23,96.86,$91.00 Outpatient Medical Services,Physician Office,99204,"New patient office of other outpatient visit, typically 45 min",983,$153.00 ,N/A,Not Applicable. Service not offered,$129.20 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$129.20 ,Pays at 315% of Custom fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$87.62 ,Pays at 100% of CMS Physician fee Schedule for Outpatient Setting,$154.99 ,Pays at 115% of physician fee Schedule for Outpatient setting,$87.62 ,Pays at 100% of CMS Physician fee Schedule for Outpatient Setting,$154.99 ,Pays at 115% of Physician fee Schedule for Outpatient setting,$87.62 ,Pays at 100% of CMS Physician fee Schedule for Outpatient Setting,$87.62 ,Pays at 100% of CMS Physician fee Schedule for Outpatient Setting,N/A,Not Applicable. Service not offered,$87.62 ,Pays at 100% of CMS Physician fee Schedule for Outpatient Setting,$154.99 ,Pays ar 115% of Physician fee schedule for Outpatient setting,$87.62 ,Pays at 100% of CMS Physician fee Schedule for Outpatient Setting,87.62,154.99,$153.00 Outpatient Medical Services,Physician Office,99204,"New patient office of other outpatient visit, typically 45 min",510,$111.00 ,N/A,Not Applicable. Service not offered,$91.58 ,Pays at 82.5% of total billed charges for outpatient setting,$91.58 ,Pays at 82.5% of total billed charges for outpatient setting,$81.03 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$77.70 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$21.30 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$55.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,21.3,91.58,$111.00 Outpatient Medical Services,Physician Office,99205,"New patient office of other outpatient visit, typically 60 min",510,$184.00 ,N/A,Not Applicable. Service not offered,$151.80 ,Pays at 82.5% of total billed charges for outpatient setting,$151.80 ,Pays at 82.5% of total billed charges for outpatient setting,$134.32 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$128.80 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$35.31 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$92.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,35.31,151.8,$184.00 Outpatient Medical Services,Physician Office,99205,"New patient office of other outpatient visit, typically 60 min",983,$200.00 ,N/A,Not Applicable. Service not offered,$163.15 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$163.15 ,Pays at 315% of Custom fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$114.42 ,Pays at 100% of CMS Physician fee Schedule for Outpatient Setting,$210.34 ,Pays at 115% of physician fee Schedule for Outpatient setting,$114.42 ,Pays at 100% of CMS Physician fee Schedule for Outpatient Setting,$210.34 ,Pays at 115% of Physician fee Schedule for Outpatient setting,$114.42 ,Pays at 100% of CMS Physician fee Schedule for Outpatient Setting,$114.42 ,Pays at 100% of CMS Physician fee Schedule for Outpatient Setting,N/A,Not Applicable. Service not offered,$114.42 ,Pays at 100% of CMS Physician fee Schedule for Outpatient Setting,$210.34 ,Pays ar 115% of Physician fee schedule for Outpatient setting,$114.42 ,Pays at 100% of CMS Physician fee Schedule for Outpatient Setting,114.42,210.34,$200.00 Outpatient Medical Services,Physician Office,99211,Outpatient visit of established patient not requiring a physician,510,$10.00 ,N/A,Not Applicable. Service not offered,$8.25 ,Pays at 82.5% of total billed charges for outpatient setting,$8.25 ,Pays at 82.5% of total billed charges for outpatient setting,$7.30 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$7.00 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$1.92 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$5.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,1.92,8.25,$10.00 Outpatient Medical Services,Physician Office,99211,Outpatient visit of established patient not requiring a physician,983,$11.00 ,N/A,Not Applicable. Service not offered,$19.16 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$19.16 ,Pays at 315% of Custom fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$5.51 ,Pays at 100% of CMS Physician fee Schedule for Outpatient Setting,$10.14 ,Pays at 115% of physician fee Schedule for Outpatient setting,$5.51 ,Pays at 100% of CMS Physician fee Schedule for Outpatient Setting,$10.14 ,Pays at 115% of Physician fee Schedule for Outpatient setting,$5.51 ,Pays at 100% of CMS Physician fee Schedule for Outpatient Setting,$5.51 ,Pays at 100% of CMS Physician fee Schedule for Outpatient Setting,N/A,Not Applicable. Service not offered,$5.51 ,Pays at 100% of CMS Physician fee Schedule for Outpatient Setting,$10.14 ,Pays ar 115% of Physician fee schedule for Outpatient setting,$5.51 ,Pays at 100% of CMS Physician fee Schedule for Outpatient Setting,5.51,19.16,$11.00 Outpatient Medical Services,Physician Office,99212,Outpatient visit of established patient requiring a physician,983,$30.00 ,N/A,Not Applicable. Service not offered,$34.81 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$34.81 ,Pays at 315% of Custom fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$17.48 ,Pays at 100% of CMS Physician fee Schedule for Outpatient Setting,$34.50 ,Pays at 115% of physician fee Schedule for Outpatient setting,$17.48 ,Pays at 100% of CMS Physician fee Schedule for Outpatient Setting,$34.50 ,Pays at 115% of Physician fee Schedule for Outpatient setting,$17.48 ,Pays at 100% of CMS Physician fee Schedule for Outpatient Setting,$17.48 ,Pays at 100% of CMS Physician fee Schedule for Outpatient Setting,N/A,Not Applicable. Service not offered,$17.48 ,Pays at 100% of CMS Physician fee Schedule for Outpatient Setting,$34.50 ,Pays ar 115% of Physician fee schedule for Outpatient setting,$17.48 ,Pays at 100% of CMS Physician fee Schedule for Outpatient Setting,17.48,34.81,$30.00 Outpatient Medical Services,Physician Office,99212,Outpatient visit of established patient requiring a physician,510,$28.00 ,N/A,Not Applicable. Service not offered,$23.10 ,Pays at 82.5% of total billed charges for outpatient setting,$23.10 ,Pays at 82.5% of total billed charges for outpatient setting,$20.44 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$19.60 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$5.37 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$14.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,5.37,23.1,$28.00 Outpatient Medical Services,Physician Office,99213,"Established patient office or other outpatient visit, typically 15 minutes",510,$56.00 ,N/A,Not Applicable. Service not offered,$46.20 ,Pays at 82.5% of total billed charges for outpatient setting,$46.20 ,Pays at 82.5% of total billed charges for outpatient setting,$40.88 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$39.20 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$10.75 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$28.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,10.75,46.2,$56.00 Outpatient Medical Services,Physician Office,99213,"Established patient office or other outpatient visit, typically 15 minutes",983,$60.00 ,N/A,Not Applicable. Service not offered,$48.94 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$48.94 ,Pays at 315% of Custom fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$29.62 ,Pays at 100% of CMS Physician fee Schedule for Outpatient Setting,$69.00 ,Pays at 115% of physician fee Schedule for Outpatient setting,$29.62 ,Pays at 100% of CMS Physician fee Schedule for Outpatient Setting,$69.00 ,Pays at 115% of Physician fee Schedule for Outpatient setting,$29.62 ,Pays at 100% of CMS Physician fee Schedule for Outpatient Setting,$29.62 ,Pays at 100% of CMS Physician fee Schedule for Outpatient Setting,N/A,Not Applicable. Service not offered,$29.62 ,Pays at 100% of CMS Physician fee Schedule for Outpatient Setting,$69.00 ,Pays ar 115% of Physician fee schedule for Outpatient setting,$29.62 ,Pays at 100% of CMS Physician fee Schedule for Outpatient Setting,29.62,69,$60.00 Outpatient Medical Services,Physician Office,99214,"Established patient office or other outpatient visit, typically 25 minutes",983,$92.00 ,N/A,Not Applicable. Service not offered,$76.35 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$76.35 ,Pays at 315% of Custom fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$46.15 ,Pays at 100% of CMS Physician fee Schedule for Outpatient Setting,$105.80 ,Pays at 115% of physician fee Schedule for Outpatient setting,$46.15 ,Pays at 100% of CMS Physician fee Schedule for Outpatient Setting,$105.80 ,Pays at 115% of Physician fee Schedule for Outpatient setting,$46.15 ,Pays at 100% of CMS Physician fee Schedule for Outpatient Setting,$46.15 ,Pays at 100% of CMS Physician fee Schedule for Outpatient Setting,N/A,Not Applicable. Service not offered,$46.15 ,Pays at 100% of CMS Physician fee Schedule for Outpatient Setting,$105.80 ,Pays ar 115% of Physician fee schedule for Outpatient setting,$46.15 ,Pays at 100% of CMS Physician fee Schedule for Outpatient Setting,46.15,105.8,$92.00 Outpatient Medical Services,Physician Office,99214,"Established patient office or other outpatient visit, typically 25 minutes",510,$85.00 ,N/A,Not Applicable. Service not offered,$70.13 ,Pays at 82.5% of total billed charges for outpatient setting,$70.13 ,Pays at 82.5% of total billed charges for outpatient setting,$62.05 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$59.50 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$16.31 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$42.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,16.31,70.13,$85.00 Outpatient Medical Services,Physician Office,99215,"Established patient office or other outpatient, visit typically 40 minutes",510,$120.00 ,N/A,Not Applicable. Service not offered,$99.00 ,Pays at 82.5% of total billed charges for outpatient setting,$99.00 ,Pays at 82.5% of total billed charges for outpatient setting,$87.60 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$84.00 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$23.03 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$60.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,23.03,99,$120.00 Outpatient Medical Services,Physician Office,99215,"Established patient office or other outpatient, visit typically 40 minutes",983,$131.00 ,N/A,Not Applicable. Service not offered,$113.70 ,Pays at 315% of Custom fee Schedule for Outpatient setting,$113.70 ,Pays at 315% of Custom fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$67.08 ,Pays at 100% of CMS Physician fee Schedule for Outpatient Setting,$150.65 ,Pays at 115% of physician fee Schedule for Outpatient setting,$67.08 ,Pays at 100% of CMS Physician fee Schedule for Outpatient Setting,$150.65 ,Pays at 115% of Physician fee Schedule for Outpatient setting,$67.08 ,Pays at 100% of CMS Physician fee Schedule for Outpatient Setting,$67.08 ,Pays at 100% of CMS Physician fee Schedule for Outpatient Setting,N/A,Not Applicable. Service not offered,$67.08 ,Pays at 100% of CMS Physician fee Schedule for Outpatient Setting,$150.65 ,Pays ar 115% of Physician fee schedule for Outpatient setting,$67.08 ,Pays at 100% of CMS Physician fee Schedule for Outpatient Setting,67.08,150.65,$131.00 Outpatient Medical Services,Physician Office,G0438,"ANNUAL WELLNESS VISIT,PPS INITIAL VISIT",983,$385.00 ,N/A,Not Applicable. Service not offered,N/A,Not Applicable.Service not offered,N/A,Not Applicable.Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$189.52 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$189.52 ,Pays at 115% of Physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$189.52 ,Pays ar 115% of Physician fee schedule for Outpatient setting,N/A,Not Applicable. Service not offered,189.52,189.52,$385.00 Outpatient Medical Services,Physician Office,G0439,"ANNUAL WELLNESS VISIT,PPS SUB VISIT",983,$261.00 ,N/A,Not Applicable. Service not offered,N/A,Not Applicable.Service not offered,N/A,Not Applicable.Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$147.55 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$147.55 ,Pays at 115% of Physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$147.55 ,Pays ar 115% of Physician fee schedule for Outpatient setting,N/A,Not Applicable. Service not offered,147.55,147.55,$261.00 Outpatient Medical Services,Surgery,10060,Incision and drainage of abscess; simple or single and complex or multiple,360,"$1,982.00 ",N/A,Not Applicable. Service not offered,"$1,635.15 ",Pays at 82.5% of total billed charges for outpatient setting,"$1,635.15 ",Pays at 82.5% of total billed charges for outpatient setting,"$1,446.86 ",Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,"$1,387.40 ",Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$380.35 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$991.00 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,380.35,1635.15,"$1,982.00 " Outpatient Medical Services,Surgery,42820,Removal of tonsils and adenoid glands patient younger than age 12,360,"$6,092.00 ",N/A,Not Applicable. Service not offered,"$1,508.85 ",Pays at 315% of Asc fee Schedule for Outpatient setting,"$1,523.22 ",Pays at 315% of Asc fee Schedule for Outpatient setting,"$4,447.16 ",Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,"$4,264.40 ",Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,"$1,169.05 ",Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$3,046.00 ",Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,1169.05,4447.16,"$6,092.00 " Outpatient Medical Services,Surgery,43239,"Biopsy of the esophagus, stomach, and/or upper small bowel using an endoscope",360,"$3,969.00 ",N/A,Not Applicable. Service not offered,"$1,319.85 ",Pays at 315% of Asc fee Schedule for Outpatient setting,"$1,332.42 ",Pays at 315% of Asc fee Schedule for Outpatient setting,"$2,897.37 ",Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,"$2,778.30 ",Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$761.65 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,984.50 ",Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,761.65,2897.37,"$3,969.00 " Outpatient Medical Services,Surgery,45378,Diagnostic examination of large bowel using an endoscope,360,"$2,931.00 ",N/A,Not Applicable. Service not offered,"$1,319.85 ",Pays at 315% of Asc fee Schedule for Outpatient setting,"$1,332.42 ",Pays at 315% of Asc fee Schedule for Outpatient setting,"$2,139.63 ",Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,"$2,051.70 ",Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$562.46 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,465.50 ",Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,562.46,2139.63,"$2,931.00 " Outpatient Medical Services,Surgery,45380,Biopsy of large bowel using an endoscope,360,"$3,557.00 ",N/A,Not Applicable. Service not offered,"$1,319.85 ",Pays at 315% of Asc fee Schedule for Outpatient setting,"$1,332.42 ",Pays at 315% of Asc fee Schedule for Outpatient setting,"$2,596.61 ",Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,"$2,489.90 ",Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$682.59 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,778.50 ",Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,682.59,2596.61,"$3,557.00 " Outpatient Medical Services,Surgery,45385,Removal of polyps or growths of large bowel using an endoscope,360,"$5,778.00 ",N/A,Not Applicable. Service not offered,"$1,319.85 ",Pays at 315% of Asc fee Schedule for Outpatient setting,"$1,332.42 ",Pays at 315% of Asc fee Schedule for Outpatient setting,"$4,217.94 ",Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,"$4,044.60 ",Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,"$1,108.80 ",Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$2,889.00 ",Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,1108.8,4217.94,"$5,778.00 " Outpatient Medical Services,Surgery,47562,Removal of gallbladder using an endoscope,360,"$11,121.00 ",N/A,Not Applicable. Service not offered,"$4,725.00 ",Pays at 315% of Asc fee Schedule for Outpatient setting,"$4,770.00 ",Pays at 315% of Asc fee Schedule for Outpatient setting,"$8,118.33 ",Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,"$7,784.70 ",Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,"$2,134.12 ",Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$5,560.50 ",Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,2134.12,8118.33,"$11,121.00 " Outpatient Medical Services,Surgery,49505,Repair of groin hernia patient age 5 years or older,360,"$17,539.00 ",N/A,Not Applicable. Service not offered,"$1,861.65 ",Pays at 315% of Asc fee Schedule for Outpatient setting,"$1,879.38 ",Pays at 315% of Asc fee Schedule for Outpatient setting,"$12,803.47 ",Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,"$12,277.30 ",Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,"$3,365.73 ",Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$8,769.50 ",Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,1861.65,12803.47,"$17,539.00 " Outpatient Medical Services,Surgery,69200,Clear outer ear canal,360,$943.00 ,N/A,Not Applicable. Service not offered,$777.98 ,Pays at 82.5% of total billed charges for outpatient setting,$777.98 ,Pays at 82.5% of total billed charges for outpatient setting,$688.39 ,Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,$660.10 ,Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$180.96 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,$471.50 ,Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,180.96,777.98,$943.00 Outpatient Medical Services,Surgery,69436,Insertion of tubes into one or both ears,360,"$3,208.00 ",N/A,Not Applicable. Service not offered,"$1,508.85 ",Pays at 315% of Asc fee Schedule for Outpatient setting,"$1,523.22 ",Pays at 315% of Asc fee Schedule for Outpatient setting,"$2,341.84 ",Pays at 73% of total Billed charges,N/A,Not Applicable. Service not offered,"$2,245.60 ",Pays at 115% of physician fee Schedule for Outpatient setting,N/A,Not Applicable. Service not offered,$615.62 ,Pays at 19.19% of total Billed charges,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,"$1,604.00 ",Pays at 50% of total Billed charges for outpatient setting,N/A,Not Applicable. Service not offered,615.62,2341.84,"$3,208.00 " Outpatient Medical Services,BEHAVIORAL,90846,"Family psychotherapy, not including patient, 50 minutes",900,SERVICE NOT OFFERED,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,N/A,N/A Outpatient Medical Services,OFFICE VISIT,99243,"Patient office consultation, typically 40 min",761,SERVICE NOT OFFERED,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,N/A,N/A Outpatient Medical Services,OFFICE VISIT,99244,"Patient office consultation, typically 60 min",761,SERVICE NOT OFFERED,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,N/A,N/A Outpatient Medical Services,OFFICE VISIT,99385,"Initial new patient preventive medicine evaluation, for those ages 18 to 39",761,SERVICE NOT OFFERED,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,N/A,N/A Outpatient Medical Services,OFFICE VISIT,99386,"Initial new patient preventive medicine evaluation, for those ages 40 to 64",761,SERVICE NOT OFFERED,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,N/A,N/A Outpatient Medical Services,LAB,80055,Obstetric blood test panel,300,SERVICE NOT OFFERED,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,N/A,N/A Outpatient Medical Services,LAB,81000,Manual urinalysis test with examination using microscope,300,SERVICE NOT OFFERED,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,N/A,N/A Outpatient Medical Services,LAB,81002,Automated urinalysis test,300,SERVICE NOT OFFERED,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,N/A,N/A Outpatient Medical Services,LAB,85027,"Complete blood count, automated",300,SERVICE NOT OFFERED,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,N/A,N/A Outpatient Medical Services,RADIOLOGY,72193,"CT scan, pelvis, with contrast",350,SERVICE NOT OFFERED,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,N/A,N/A Outpatient Medical Services,RADIOLOGY,76805,"Abdominal ultrasound of pregnant uterus, greater or equal to 14 weeks 0 days, single or first fetus",402,SERVICE NOT OFFERED,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,N/A,N/A Outpatient Medical Services,RADIOLOGY,76830,Ultrasound pelvis through vagina,402,SERVICE NOT OFFERED,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,N/A,N/A Outpatient Medical Services,RADIOLOGY,77065,Mammography of one breast,403,SERVICE NOT OFFERED,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,N/A,N/A Outpatient Medical Services,RADIOLOGY,19120,"Removal of 1 or more breast growth, open procedure",360,SERVICE NOT OFFERED,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,N/A,N/A Outpatient Medical Services,OUTPATIENT SERVICES,29826,Shaving of shoulder bone using an endoscope,360,SERVICE NOT OFFERED,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,N/A,N/A Outpatient Medical Services,OUTPATIENT SERVICES,29881,Removal of one knee cartilage using an endoscope,360,SERVICE NOT OFFERED,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,N/A,N/A Outpatient Medical Services,OUTPATIENT SERVICES,43235,"Diagnostic examination of esophagus, stomach, and/or upper small bowel using an endoscop",360,SERVICE NOT OFFERED,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,N/A,N/A Outpatient Medical Services,OUTPATIENT SERVICES,45391,Ultrasound examination of lower large bowel using an endoscope,360,SERVICE NOT OFFERED,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,N/A,N/A Outpatient Medical Services,OUTPATIENT SERVICES,55700,Biopsy of prostate gland,360,SERVICE NOT OFFERED,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,N/A,N/A Outpatient Medical Services,OUTPATIENT SERVICES,55866,Surgical removal of prostate and surrounding lymph nodes using an endoscope,360,SERVICE NOT OFFERED,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,N/A,N/A Outpatient Medical Services,OUTPATIENT SERVICES,59400,"Routine obstetric care for vaginal delivery, including pre-and post-delivery care",720,SERVICE NOT OFFERED,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,N/A,N/A Outpatient Medical Services,OUTPATIENT SERVICES,59510,"Routine obstetric care for cesarean delivery, including pre-and post-delivery care",720,SERVICE NOT OFFERED,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,N/A,N/A Outpatient Medical Services,OUTPATIENT SERVICES,59610,Routine obstetric care for vaginal delivery after prior cesarean delivery including pre-and post-delivery care,720,SERVICE NOT OFFERED,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,N/A,N/A Outpatient Medical Services,OUTPATIENT SERVICES,62323,Injection of substance into spinal canal of lower back or sacrum using imaging guidanc,360,SERVICE NOT OFFERED,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,N/A,N/A Outpatient Medical Services,OUTPATIENT SERVICES,62322,Injection of substance into spinal canal of lower back or sacrum using imaging guidanc,360,SERVICE NOT OFFERED,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,N/A,N/A Outpatient Medical Services,OUTPATIENT SERVICES,64483,Injections of anesthetic and/or steroid drug into lower or sacral spine nerve root using imaging guidance,360,SERVICE NOT OFFERED,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,N/A,N/A Outpatient Medical Services,OUTPATIENT SERVICES,66821,Removal of recurring cataract in lens capsule using laser,360,SERVICE NOT OFFERED,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,N/A,N/A Outpatient Medical Services,OUTPATIENT SERVICES,66984,Removal of cataract with insertion of lens,360,SERVICE NOT OFFERED,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,N/A,N/A Outpatient Medical Services,ECCG,93000,"Electrocardiogram, routine, with interpretation and report",730,SERVICE NOT OFFERED,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,N/A,N/A Outpatient Medical Services,CARDIOLOGY,93452,Insertion of catheter into left heart for diagnosis,480,SERVICE NOT OFFERED,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,N/A,N/A Outpatient Medical Services,SLEEP STUDY,95810,Sleep study,920,SERVICE NOT OFFERED,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,N/A,N/A Inpatient Medical Services,INPATIENT PROCEDURES,216,Cardiac valve and other major cardiothoracic procedures with cardiac catheterization with major complications or comorbidities,100,SERVICE NOT OFFERED,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,N/A,N/A Inpatient Medical Services,INPATIENT PROCEDURES,460,Spinal fusion except cervical without major comorbid conditions or complications,100,SERVICE NOT OFFERED,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,N/A,N/A Inpatient Medical Services,INPATIENT PROCEDURES,470,Major joint replacement or reattachment of lower extremity without major comorbid conditions or complications,100,SERVICE NOT OFFERED,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,N/A,N/A Inpatient Medical Services,INPATIENT PROCEDURES,473,Cervical spinal fusion without comorbid conditions or major comorbid conditions or complications,100,SERVICE NOT OFFERED,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,N/A,N/A Inpatient Medical Services,INPATIENT PROCEDURES,743,Uterine and adnexa procedures for non-malignancy without comorbid conditions or major comorbid conditions or complications,100,SERVICE NOT OFFERED,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,Not Applicable. Service not offered,N/A,N/A,N/A