hospital_name,last_updated_on,version,hospital_location,hospital_address,license_number|CO,"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.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Pagosa Springs Medical Center,4/1/2024,2.0.0,Pagosa Springs Medical Center,"95 S Pagosa Blvd Pagosa Springs, CO 81147",840866061,TRUE,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SERVICE DESCRIPTION,CATEGORY,BILLING MSDRG | CPT | HCPCS,ITEM/SERVICE DESCRIPTION,BILLING REVENUE CODE,GROSS CHARGES,AETNA COMMERCIAL PLAN,AETNA COMMERCIAL Reimbursement Method,AETNA COVENTRY COFINITY PLAN,AETNA COVENTRY COFINITY Reimbursement Method,AETNA MEDICARE ADVANTAGE PLAN,AETNA MEDICARE ADVANTAGE Reimbursement Method,ANTHEM BCBS HMO PLAN,ANTHEM BCBS HMO Reimbursement Method,ANTHEM INDEMNITY BCBS PLAN,ANTHEM BCBS INDEMNITY Reimbursement Method,ANTHEM BCBS MOUNTAIN HMO PLAN,ANTHEM BCBS MOUNTAIN HMO Reimbursement Method,ANTHEM BCBS PPO PLAN,ANTHEM BCBS PPO Reimbursement Method,CIGNA PLAN,CIGNA Reimbursement Method,COLORADO ACCESS MEDICAID HMO PLAN,COLORADO ACCESS MEDICAID HMO Reimbursement Method,COLORADO ACCESS MEDICARE PLAN,COLORADO ACCESS MEDICARE Reimbursement Method,COLORADO NETWORK PLAN,COLORADO NETWORK Reimbursement Method,COVER COLORADO PLAN,COVER COLORADO Reimbursement Method,FIRST HEALTH PLAN,FIRST HEALTH Reimbursement Method,HUMANA CHOICECARE PLAN,HUMANA CHOICECARE Reimbursement Method,HUMANA MEDICARE PLAN,HUMANA MEDICARE Reimbursement Method,MEDICAID PLAN,MEDICAID Reimbursement Method,MEDICAID NEW MEXICO PLAN,MEDICAID NEW MEXICO Reimbursement Method,MEDICARE PLAN,MEDICARE Reimbursement Method,MULTIPLAN PLAN,MULTIPLAN Reimbursement Method,PINNACOL ASSURANCE  PLAN,PINNACOL ASSURANCE  Reimbursement Method,PRESBYTERIAN HEALTH PLAN,PRESBYTERIAN HEALTH Reimbursement Method,PRESBYTERIAN HEALTH MEDICARE PLAN,PRESBYTERIAN HEALTH MEDICARE Reimbursement Method,ROCKY MOUNTAIN HEALTH PLAN,ROCKY MOUNTAIN HEALTH Reimbursement Method,ROCKY MOUNTAIN HEALTH MEDICAID PLAN,ROCKY MOUNTAIN HEALTH MEDICAID Reimbursement Method,ROCKY MOUNTAIN HEALTH MEDICARE PLAN,ROCKY MOUNTAIN HEALTH MEDICARE Reimbursement Method,THREE RIVERS PLAN,THREE RIVERS Reimbursement Method,TRIWEST PLAN,TRIWEST Reimbursement Method,UHC PLAN,UHC Reimbursement Method,WESTERN SKY COMMUNITY CARE PLAN,WESTERN SKY COMMUNITY CARE Reimbursement Method,De-Identified Minimum Negotiated Rate,De-Identified Maximum Negotiated Rate,DISCOUNTED CASH PRICE
Outpatient Medical Services,CARDIOVASCULAR,93000,Routine EKG using at least 12 leads including interpretation and report,480,$173.00 ,$129.75 ,pays at 75% of total billed charges,$138.40 ,pays at 80% of total billed charges,$17.09 ,pays at MCR OPPS,$137.02 ,pays at 79.2% of total billed charges,$137.02 ,pays at 79.2% of total billed charges,$137.02 ,pays at 79.2% of total billed charges,$137.02 ,pays at 79.2% of total billed charges,$147.05 ,pays at 85% of total billed charges,$34.77 ,pays at MCD O/P rates,$69.20 ,pays at MCR OPPS,$164.35 ,pays at 95% of total billed charges,$138.40 ,pays at 80% total billed charges,$147.05 ,pays at 85% of total billed charges,$155.70 ,pays at 90% of total billed charges,$69.20 ,pays at MCR OPPS,$34.77 ,pays at 100% of MCD OPPS,$173.00 ,pays at 100% of MCD OPPS,$69.20 ,pays at MCR OPPS,$155.70 ,pays at 90% of total billed charges,$131.48 ,pays at 80% of total billed charges,$17.09 ,pays at MCR OPPS,$69.20 ,pays at MCR OPPS,$147.05 ,pays at 85% of total billed charges,$34.77 ,pays at MCD OPPS,$69.20 ,pays at MCR OPPS,$138.40 ,pays at 80% of total billed charges,$16.58 ,pays at 97% of MCR OPPS,$147.05 ,pays at 85% of total billed charges,$34.77 ,pays at MCD OPPS,$16.58 ,$173.00 ,$147.05 
Outpatient Medical Services,CARDIOVASCULAR,93005,"Electrocardiogram, routine ECG with at least 12 leads; tracing only, without interpretation and report",480,$173.00 ,$129.75 ,pays at 75% of total billed charges,$138.40 ,pays at 80% of total billed charges,$7.67 ,pays at MCR OPPS,$137.02 ,pays at 79.2% of total billed charges,$137.02 ,pays at 79.2% of total billed charges,$137.02 ,pays at 79.2% of total billed charges,$137.02 ,pays at 79.2% of total billed charges,$147.05 ,pays at 85% of total billed charges,$34.77 ,pays at MCD O/P rates,$69.20 ,pays at MCR OPPS,$164.35 ,pays at 95% of total billed charges,$138.40 ,pays at 80% total billed charges,$147.05 ,pays at 85% of total billed charges,$155.70 ,pays at 90% of total billed charges,$69.20 ,pays at MCR OPPS,$34.77 ,pays at 100% of MCD OPPS,$57.48 ,pays at 100% of MCD OPPS,$69.20 ,pays at MCR OPPS,$155.70 ,pays at 90% of total billed charges,$131.48 ,pays at 80% of total billed charges,$7.67 ,pays at MCR OPPS,$69.20 ,pays at MCR OPPS,$147.05 ,pays at 85% of total billed charges,$34.77 ,pays at MCD OPPS,$69.20 ,pays at MCR OPPS,$138.40 ,pays at 80% of total billed charges,$7.44 ,pays at 97% of MCR OPPS,$147.05 ,pays at 85% of total billed charges,$34.77 ,pays at MCD OPPS,$7.44 ,$164.35 ,$147.05 
Outpatient Medical Services,CARDIOVASCULAR,93270,"External patient and, when performed, auto activated electrocardiographic rhythm derived event recording with symptom-related memory loop with remote",480,$111.20 ,$83.40 ,pays at 75% of total billed charges,$88.96 ,pays at 80% of total billed charges,$10.12 ,pays at MCR OPPS,$88.07 ,pays at 79.2% of total billed charges,$88.07 ,pays at 79.2% of total billed charges,$88.07 ,pays at 79.2% of total billed charges,$88.07 ,pays at 79.2% of total billed charges,$94.52 ,pays at 85% of total billed charges,$111.20 ,pays at MCD O/P rates,$44.48 ,pays at MCR OPPS,$105.64 ,pays at 95% of total billed charges,$88.96 ,pays at 80% total billed charges,$94.52 ,pays at 85% of total billed charges,$100.08 ,pays at 90% of total billed charges,$44.48 ,pays at MCR OPPS,$111.20 ,pays at 100% of MCD OPPS,$35.00 ,pays at 100% of MCD OPPS,$44.48 ,pays at MCR OPPS,$100.08 ,pays at 90% of total billed charges,$84.51 ,pays at 80% of total billed charges,$10.12 ,pays at MCR OPPS,$44.48 ,pays at MCR OPPS,$94.52 ,pays at 85% of total billed charges,$111.20 ,pays at MCD OPPS,$44.48 ,pays at MCR OPPS,$88.96 ,pays at 80% of total billed charges,$9.82 ,pays at 97% of MCR OPPS,$94.52 ,pays at 85% of total billed charges,$111.20 ,pays at MCD OPPS,$9.82 ,$111.20 ,$94.52 
Outpatient Medical Services,CARDIOVASCULAR,93272,"External Patient And, When Performed, Auto Activated Electrocardiographic Rhythm Derived Event Recording With Symptom-Related Memory Loop With Remote",480,$83.40 ,$62.55 ,pays at 75% of total billed charges,$66.72 ,pays at 80% of total billed charges,$27.93 ,pays at MCR OPPS,$66.05 ,pays at 79.2% of total billed charges,$66.05 ,pays at 79.2% of total billed charges,$66.05 ,pays at 79.2% of total billed charges,$66.05 ,pays at 79.2% of total billed charges,$70.89 ,pays at 85% of total billed charges,$83.40 ,pays at MCD O/P rates,$33.36 ,pays at MCR OPPS,$79.23 ,pays at 95% of total billed charges,$66.72 ,pays at 80% total billed charges,$70.89 ,pays at 85% of total billed charges,$75.06 ,pays at 90% of total billed charges,$33.36 ,pays at MCR OPPS,$83.40 ,pays at 100% of MCD OPPS,$83.40 ,pays at 100% of MCD OPPS,$33.36 ,pays at MCR OPPS,$75.06 ,pays at 90% of total billed charges,$63.38 ,pays at 80% of total billed charges,$27.93 ,pays at MCR OPPS,$33.36 ,pays at MCR OPPS,$70.89 ,pays at 85% of total billed charges,$83.40 ,pays at MCD OPPS,$33.36 ,pays at MCR OPPS,$66.72 ,pays at 80% of total billed charges,$27.10 ,pays at 97% of MCR OPPS,$70.89 ,pays at 85% of total billed charges,$83.40 ,pays at MCD OPPS,$27.10 ,$83.40 ,$70.89 
Outpatient Medical Services,CARDIOVASCULAR,93306,"Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function",480,"$1,460.00 ","$1,095.00 ",pays at 75% of total billed charges,"$1,168.00 ",pays at 80% of total billed charges,$236.43 ,pays at MCR OPPS,"$1,156.32 ",pays at 79.2% of total billed charges,"$1,156.32 ",pays at 79.2% of total billed charges,"$1,156.32 ",pays at 79.2% of total billed charges,"$1,156.32 ",pays at 79.2% of total billed charges,"$1,241.00 ",pays at 85% of total billed charges,$611.53 ,pays at MCD O/P rates,$584.00 ,pays at MCR OPPS,"$1,387.00 ",pays at 95% of total billed charges,"$1,168.00 ",pays at 80% total billed charges,"$1,241.00 ",pays at 85% of total billed charges,"$1,314.00 ",pays at 90% of total billed charges,$584.00 ,pays at MCR OPPS,$611.53 ,pays at 100% of MCD OPPS,$503.13 ,pays at 100% of MCD OPPS,$584.00 ,pays at MCR OPPS,"$1,314.00 ",pays at 90% of total billed charges,"$1,109.60 ",pays at 80% of total billed charges,$236.43 ,pays at MCR OPPS,$584.00 ,pays at MCR OPPS,"$1,241.00 ",pays at 85% of total billed charges,$611.53 ,pays at MCD OPPS,$584.00 ,pays at MCR OPPS,"$1,168.00 ",pays at 80% of total billed charges,$229.34 ,pays at 97% of MCR OPPS,"$1,241.00 ",pays at 85% of total billed charges,$611.53 ,pays at MCD OPPS,$229.34 ,"$1,387.00 ","$1,241.00 "
Outpatient Medical Services,CARDIOVASCULAR,93306,"Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function",480,$204.00 ,$153.00 ,pays at 75% of total billed charges,$163.20 ,pays at 80% of total billed charges,$234.60 ,pays at MCR OPPS,$161.57 ,pays at 79.2% of total billed charges,$161.57 ,pays at 79.2% of total billed charges,$161.57 ,pays at 79.2% of total billed charges,$161.57 ,pays at 79.2% of total billed charges,$173.40 ,pays at 85% of total billed charges,$204.00 ,pays at MCD O/P rates,$81.60 ,pays at MCR OPPS,$193.80 ,pays at 95% of total billed charges,$163.20 ,pays at 80% total billed charges,$173.40 ,pays at 85% of total billed charges,$183.60 ,pays at 90% of total billed charges,$81.60 ,pays at MCR OPPS,$611.53 ,pays at 100% of MCD OPPS,$204.00 ,pays at 100% of MCD OPPS,$81.60 ,pays at MCR OPPS,$183.60 ,pays at 90% of total billed charges,$155.04 ,pays at 80% of total billed charges,$234.60 ,pays at MCR OPPS,$81.60 ,pays at MCR OPPS,$173.40 ,pays at 85% of total billed charges,$611.53 ,pays at MCD OPPS,$81.60 ,pays at MCR OPPS,$163.20 ,pays at 80% of total billed charges,$227.56 ,pays at 97% of MCR OPPS,$173.40 ,pays at 85% of total billed charges,$611.53 ,pays at MCD OPPS,$81.60 ,$611.53 ,$173.40 
Outpatient Medical Services,CARDIOVASCULAR,93350,Stress test with echocardiogram,480,"$1,403.00 ","$1,052.25 ",pays at 75% of total billed charges,"$1,122.40 ",pays at 80% of total billed charges,$223.54 ,pays at MCR OPPS,"$1,111.18 ",pays at 79.2% of total billed charges,"$1,111.18 ",pays at 79.2% of total billed charges,"$1,111.18 ",pays at 79.2% of total billed charges,"$1,111.18 ",pays at 79.2% of total billed charges,"$1,192.55 ",pays at 85% of total billed charges,$611.53 ,pays at MCD O/P rates,$561.20 ,pays at MCR OPPS,"$1,332.85 ",pays at 95% of total billed charges,"$1,122.40 ",pays at 80% total billed charges,"$1,192.55 ",pays at 85% of total billed charges,"$1,262.70 ",pays at 90% of total billed charges,$561.20 ,pays at MCR OPPS,$611.53 ,pays at 100% of MCD OPPS,$503.13 ,pays at 100% of MCD OPPS,$561.20 ,pays at MCR OPPS,"$1,262.70 ",pays at 90% of total billed charges,"$1,066.28 ",pays at 80% of total billed charges,$223.54 ,pays at MCR OPPS,$561.20 ,pays at MCR OPPS,"$1,192.55 ",pays at 85% of total billed charges,$611.53 ,pays at MCD OPPS,$561.20 ,pays at MCR OPPS,"$1,122.40 ",pays at 80% of total billed charges,$216.83 ,pays at 97% of MCR OPPS,"$1,192.55 ",pays at 85% of total billed charges,$611.53 ,pays at MCD OPPS,$216.83 ,"$1,332.85 ","$1,192.55 "
Outpatient Medical Services,CARDIOVASCULAR,93016,"Cardiovascular Stress Test Using Maximal Or Submaximal Treadmill Or Bicycle Exercise, Continuous Electrocardiographic Monitoring, And/Or Pharmacologic",480,$73.10 ,$54.83 ,pays at 75% of total billed charges,$58.48 ,pays at 80% of total billed charges,$24.47 ,pays at MCR OPPS,$57.90 ,pays at 79.2% of total billed charges,$57.90 ,pays at 79.2% of total billed charges,$57.90 ,pays at 79.2% of total billed charges,$57.90 ,pays at 79.2% of total billed charges,$62.14 ,pays at 85% of total billed charges,$73.10 ,pays at MCD O/P rates,$29.24 ,pays at MCR OPPS,$69.45 ,pays at 95% of total billed charges,$58.48 ,pays at 80% total billed charges,$62.14 ,pays at 85% of total billed charges,$65.79 ,pays at 90% of total billed charges,$29.24 ,pays at MCR OPPS,$220.84 ,pays at 100% of MCD OPPS,$73.10 ,pays at 100% of MCD OPPS,$29.24 ,pays at MCR OPPS,$65.79 ,pays at 90% of total billed charges,$55.56 ,pays at 80% of total billed charges,$24.47 ,pays at MCR OPPS,$29.24 ,pays at MCR OPPS,$62.14 ,pays at 85% of total billed charges,$220.84 ,pays at MCD OPPS,$29.24 ,pays at MCR OPPS,$58.48 ,pays at 80% of total billed charges,$23.74 ,pays at 97% of MCR OPPS,$62.14 ,pays at 85% of total billed charges,$220.84 ,pays at MCD OPPS,$23.74 ,$220.84 ,$62.14 
Outpatient Medical Services,CARDIOVASCULAR,93018,"Cardiovascular Stress Test Using Maximal Or Submaximal Treadmill Or Bicycle Exercise, Continuous Electrocardiographic Monitoring, And/Or Pharmacologic",480,$47.00 ,$35.25 ,pays at 75% of total billed charges,$37.60 ,pays at 80% of total billed charges,$16.15 ,pays at MCR OPPS,$37.22 ,pays at 79.2% of total billed charges,$37.22 ,pays at 79.2% of total billed charges,$37.22 ,pays at 79.2% of total billed charges,$37.22 ,pays at 79.2% of total billed charges,$39.95 ,pays at 85% of total billed charges,$47.00 ,pays at MCD O/P rates,$18.80 ,pays at MCR OPPS,$44.65 ,pays at 95% of total billed charges,$37.60 ,pays at 80% total billed charges,$39.95 ,pays at 85% of total billed charges,$42.30 ,pays at 90% of total billed charges,$18.80 ,pays at MCR OPPS,$220.84 ,pays at 100% of MCD OPPS,$47.00 ,pays at 100% of MCD OPPS,$18.80 ,pays at MCR OPPS,$42.30 ,pays at 90% of total billed charges,$35.72 ,pays at 80% of total billed charges,$16.15 ,pays at MCR OPPS,$18.80 ,pays at MCR OPPS,$39.95 ,pays at 85% of total billed charges,$220.84 ,pays at MCD OPPS,$18.80 ,pays at MCR OPPS,$37.60 ,pays at 80% of total billed charges,$15.66 ,pays at 97% of MCR OPPS,$39.95 ,pays at 85% of total billed charges,$220.84 ,pays at MCD OPPS,$15.66 ,$220.84 ,$39.95 
Outpatient Medical Services,EVALUATION & MGMT CLINIC,99212,Outpatient visit of established patient requiring a physician,521,$105.10 ,$78.83 ,pays at 75% of total billed charges,$84.08 ,pays at 80% of total billed charges,$423.34 ,pays at MCR OPPS,$83.24 ,pays at 79.2% of total billed charges,$83.24 ,pays at 79.2% of total billed charges,$83.24 ,pays at 79.2% of total billed charges,$83.24 ,pays at 79.2% of total billed charges,$89.34 ,pays at 85% of total billed charges,$105.10 ,pays at MCD O/P rates,$382.20 ,pays at MCR OPPS,$99.85 ,pays at 95% of total billed charges,$84.08 ,pays at 80% total billed charges,$89.34 ,pays at 85% of total billed charges,$94.59 ,pays at 90% of total billed charges,$382.20 ,pays at MCR OPPS,$105.10 ,pays at 100% of MCD OPPS,$105.10 ,pays at 100% of MCD OPPS,$382.20 ,pays at MCR OPPS,$94.59 ,pays at 90% of total billed charges,$79.88 ,pays at 80% of total billed charges,$423.34 ,pays at MCR OPPS,$382.20 ,pays at MCR OPPS,$89.34 ,pays at 85% of total billed charges,$105.10 ,pays at MCD OPPS,$382.20 ,pays at MCR OPPS,$84.08 ,pays at 80% of total billed charges,$410.63 ,pays at 97% of MCR OPPS,$89.34 ,pays at 85% of total billed charges,$105.10 ,pays at MCD OPPS,$78.83 ,$423.34 ,$89.34 
Outpatient Medical Services,EVALUATION & MGMT CLINIC,99213,"Established patient office or other outpatient visit, typically 15 minutes",521,$139.10 ,$104.33 ,pays at 75% of total billed charges,$111.28 ,pays at 80% of total billed charges,$458.72 ,pays at MCR OPPS,$110.17 ,pays at 79.2% of total billed charges,$110.17 ,pays at 79.2% of total billed charges,$110.17 ,pays at 79.2% of total billed charges,$110.17 ,pays at 79.2% of total billed charges,$118.24 ,pays at 85% of total billed charges,$139.10 ,pays at MCD O/P rates,$382.20 ,pays at MCR OPPS,$132.15 ,pays at 95% of total billed charges,$111.28 ,pays at 80% total billed charges,$118.24 ,pays at 85% of total billed charges,$125.19 ,pays at 90% of total billed charges,$382.20 ,pays at MCR OPPS,$139.10 ,pays at 100% of MCD OPPS,$139.10 ,pays at 100% of MCD OPPS,$382.20 ,pays at MCR OPPS,$125.19 ,pays at 90% of total billed charges,$105.72 ,pays at 80% of total billed charges,$458.72 ,pays at MCR OPPS,$382.20 ,pays at MCR OPPS,$118.24 ,pays at 85% of total billed charges,$139.10 ,pays at MCD OPPS,$382.20 ,pays at MCR OPPS,$111.28 ,pays at 80% of total billed charges,$444.96 ,pays at 97% of MCR OPPS,$118.24 ,pays at 85% of total billed charges,$139.10 ,pays at MCD OPPS,$104.33 ,$458.72 ,$118.24 
Outpatient Medical Services,EVALUATION & MGMT CLINIC,99214,"Established patient office or other outpatient visit, typically 25 minutes",521,$196.70 ,$147.53 ,pays at 75% of total billed charges,$157.36 ,pays at 80% of total billed charges,$495.29 ,pays at MCR OPPS,$155.79 ,pays at 79.2% of total billed charges,$155.79 ,pays at 79.2% of total billed charges,$155.79 ,pays at 79.2% of total billed charges,$155.79 ,pays at 79.2% of total billed charges,$167.20 ,pays at 85% of total billed charges,$196.70 ,pays at MCD O/P rates,$382.20 ,pays at MCR OPPS,$186.87 ,pays at 95% of total billed charges,$157.36 ,pays at 80% total billed charges,$167.20 ,pays at 85% of total billed charges,$177.03 ,pays at 90% of total billed charges,$382.20 ,pays at MCR OPPS,$196.70 ,pays at 100% of MCD OPPS,$196.70 ,pays at 100% of MCD OPPS,$382.20 ,pays at MCR OPPS,$177.03 ,pays at 90% of total billed charges,$149.49 ,pays at 80% of total billed charges,$495.29 ,pays at MCR OPPS,$382.20 ,pays at MCR OPPS,$167.20 ,pays at 85% of total billed charges,$196.70 ,pays at MCD OPPS,$382.20 ,pays at MCR OPPS,$157.36 ,pays at 80% of total billed charges,$480.43 ,pays at 97% of MCR OPPS,$167.20 ,pays at 85% of total billed charges,$196.70 ,pays at MCD OPPS,$147.53 ,$495.29 ,$167.20 
Outpatient Medical Services,EVALUATION & MGMT CLINIC,99215,"Established patient office or other outpatient, visit typically 40 minutes",521,$284.30 ,$213.23 ,pays at 75% of total billed charges,$227.44 ,pays at 80% of total billed charges,$548.40 ,pays at MCR OPPS,$225.17 ,pays at 79.2% of total billed charges,$225.17 ,pays at 79.2% of total billed charges,$225.17 ,pays at 79.2% of total billed charges,$225.17 ,pays at 79.2% of total billed charges,$241.66 ,pays at 85% of total billed charges,$284.30 ,pays at MCD O/P rates,$382.20 ,pays at MCR OPPS,$270.09 ,pays at 95% of total billed charges,$227.44 ,pays at 80% total billed charges,$241.66 ,pays at 85% of total billed charges,$255.87 ,pays at 90% of total billed charges,$382.20 ,pays at MCR OPPS,$284.30 ,pays at 100% of MCD OPPS,$284.30 ,pays at 100% of MCD OPPS,$382.20 ,pays at MCR OPPS,$255.87 ,pays at 90% of total billed charges,$216.07 ,pays at 80% of total billed charges,$548.40 ,pays at MCR OPPS,$382.20 ,pays at MCR OPPS,$241.66 ,pays at 85% of total billed charges,$284.30 ,pays at MCD OPPS,$382.20 ,pays at MCR OPPS,$227.44 ,pays at 80% of total billed charges,$531.94 ,pays at 97% of MCR OPPS,$241.66 ,pays at 85% of total billed charges,$284.30 ,pays at MCD OPPS,$213.23 ,$548.40 ,$241.66 
Outpatient Medical Services,EVALUATION & MGMT CLINIC,99243,"Patient office consultation, typically 40 min",521,$239.00 ,$179.25 ,pays at 75% of total billed charges,$191.20 ,pays at 80% of total billed charges,$485.16 ,pays at MCR OPPS,$189.29 ,pays at 79.2% of total billed charges,$189.29 ,pays at 79.2% of total billed charges,$189.29 ,pays at 79.2% of total billed charges,$189.29 ,pays at 79.2% of total billed charges,$203.15 ,pays at 85% of total billed charges,$239.00 ,pays at MCD O/P rates,$382.20 ,pays at MCR OPPS,$227.05 ,pays at 95% of total billed charges,$191.20 ,pays at 80% total billed charges,$203.15 ,pays at 85% of total billed charges,$215.10 ,pays at 90% of total billed charges,$382.20 ,pays at MCR OPPS,$239.00 ,pays at 100% of MCD OPPS,$239.00 ,pays at 100% of MCD OPPS,$382.20 ,pays at MCR OPPS,$215.10 ,pays at 90% of total billed charges,$181.64 ,pays at 80% of total billed charges,$485.16 ,pays at MCR OPPS,$382.20 ,pays at MCR OPPS,$203.15 ,pays at 85% of total billed charges,$239.00 ,pays at MCD OPPS,$382.20 ,pays at MCR OPPS,$191.20 ,pays at 80% of total billed charges,$470.60 ,pays at 97% of MCR OPPS,$203.15 ,pays at 85% of total billed charges,$239.00 ,pays at MCD OPPS,$179.25 ,$485.16 ,$203.15 
Outpatient Medical Services,EVALUATION & MGMT CLINIC,99244,"Patient office consultation, typically 60 min",521,$339.90 ,$254.93 ,pays at 75% of total billed charges,$271.92 ,pays at 80% of total billed charges,$539.47 ,pays at MCR OPPS,$269.20 ,pays at 79.2% of total billed charges,$269.20 ,pays at 79.2% of total billed charges,$269.20 ,pays at 79.2% of total billed charges,$269.20 ,pays at 79.2% of total billed charges,$288.92 ,pays at 85% of total billed charges,$339.90 ,pays at MCD O/P rates,$382.20 ,pays at MCR OPPS,$322.91 ,pays at 95% of total billed charges,$271.92 ,pays at 80% total billed charges,$288.92 ,pays at 85% of total billed charges,$305.91 ,pays at 90% of total billed charges,$382.20 ,pays at MCR OPPS,$339.90 ,pays at 100% of MCD OPPS,$339.90 ,pays at 100% of MCD OPPS,$382.20 ,pays at MCR OPPS,$305.91 ,pays at 90% of total billed charges,$258.32 ,pays at 80% of total billed charges,$539.47 ,pays at MCR OPPS,$382.20 ,pays at MCR OPPS,$288.92 ,pays at 85% of total billed charges,$339.90 ,pays at MCD OPPS,$382.20 ,pays at MCR OPPS,$271.92 ,pays at 80% of total billed charges,$523.29 ,pays at 97% of MCR OPPS,$288.92 ,pays at 85% of total billed charges,$339.90 ,pays at MCD OPPS,$254.93 ,$539.47 ,$288.92 
Outpatient Medical Services,EVALUATION & MGMT CLINIC,99381,Initial visit for an infant,521,$270.90 ,$203.18 ,pays at 75% of total billed charges,$216.72 ,pays at 80% of total billed charges,$467.78 ,pays at MCR OPPS,$214.55 ,pays at 79.2% of total billed charges,$214.55 ,pays at 79.2% of total billed charges,$214.55 ,pays at 79.2% of total billed charges,$214.55 ,pays at 79.2% of total billed charges,$230.27 ,pays at 85% of total billed charges,$270.90 ,pays at MCD O/P rates,$382.20 ,pays at MCR OPPS,$257.36 ,pays at 95% of total billed charges,$216.72 ,pays at 80% total billed charges,$230.27 ,pays at 85% of total billed charges,$243.81 ,pays at 90% of total billed charges,$382.20 ,pays at MCR OPPS,$270.90 ,pays at 100% of MCD OPPS,$113.44 ,pays at 100% of MCD OPPS,$382.20 ,pays at MCR OPPS,$243.81 ,pays at 90% of total billed charges,$205.88 ,pays at 80% of total billed charges,$467.78 ,pays at MCR OPPS,$382.20 ,pays at MCR OPPS,$230.27 ,pays at 85% of total billed charges,$270.90 ,pays at MCD OPPS,$382.20 ,pays at MCR OPPS,$216.72 ,pays at 80% of total billed charges,$453.75 ,pays at 97% of MCR OPPS,$230.27 ,pays at 85% of total billed charges,$270.90 ,pays at MCD OPPS,$113.44 ,$467.78 ,$230.27 
Outpatient Medical Services,EVALUATION & MGMT CLINIC,99385,Initial new patient preventive medicine evaluation (18?39 years),521,$270.90 ,$203.18 ,pays at 75% of total billed charges,$216.72 ,pays at 80% of total billed charges,$491.40 ,pays at MCR OPPS,$214.55 ,pays at 79.2% of total billed charges,$214.55 ,pays at 79.2% of total billed charges,$214.55 ,pays at 79.2% of total billed charges,$214.55 ,pays at 79.2% of total billed charges,$230.27 ,pays at 85% of total billed charges,$270.90 ,pays at MCD O/P rates,$382.20 ,pays at MCR OPPS,$257.36 ,pays at 95% of total billed charges,$216.72 ,pays at 80% total billed charges,$230.27 ,pays at 85% of total billed charges,$243.81 ,pays at 90% of total billed charges,$382.20 ,pays at MCR OPPS,$270.90 ,pays at 100% of MCD OPPS,$113.44 ,pays at 100% of MCD OPPS,$382.20 ,pays at MCR OPPS,$243.81 ,pays at 90% of total billed charges,$205.88 ,pays at 80% of total billed charges,$491.40 ,pays at MCR OPPS,$382.20 ,pays at MCR OPPS,$230.27 ,pays at 85% of total billed charges,$270.90 ,pays at MCD OPPS,$382.20 ,pays at MCR OPPS,$216.72 ,pays at 80% of total billed charges,$476.66 ,pays at 97% of MCR OPPS,$230.27 ,pays at 85% of total billed charges,$270.90 ,pays at MCD OPPS,$113.44 ,$491.40 ,$230.27 
Outpatient Medical Services,EVALUATION & MGMT CLINIC,99386,Initial new patient preventive medicine evaluation (40?64 years),521,$270.90 ,$203.18 ,pays at 75% of total billed charges,$216.72 ,pays at 80% of total billed charges,$514.62 ,pays at MCR OPPS,$214.55 ,pays at 79.2% of total billed charges,$214.55 ,pays at 79.2% of total billed charges,$214.55 ,pays at 79.2% of total billed charges,$214.55 ,pays at 79.2% of total billed charges,$230.27 ,pays at 85% of total billed charges,$270.90 ,pays at MCD O/P rates,$382.20 ,pays at MCR OPPS,$257.36 ,pays at 95% of total billed charges,$216.72 ,pays at 80% total billed charges,$230.27 ,pays at 85% of total billed charges,$243.81 ,pays at 90% of total billed charges,$382.20 ,pays at MCR OPPS,$270.90 ,pays at 100% of MCD OPPS,$270.90 ,pays at 100% of MCD OPPS,$382.20 ,pays at MCR OPPS,$243.81 ,pays at 90% of total billed charges,$205.88 ,pays at 80% of total billed charges,$514.62 ,pays at MCR OPPS,$382.20 ,pays at MCR OPPS,$230.27 ,pays at 85% of total billed charges,$270.90 ,pays at MCD OPPS,$382.20 ,pays at MCR OPPS,$216.72 ,pays at 80% of total billed charges,$499.18 ,pays at 97% of MCR OPPS,$230.27 ,pays at 85% of total billed charges,$270.90 ,pays at MCD OPPS,$203.18 ,$514.62 ,$230.27 
Outpatient Medical Services,EVALUATION & MGMT CLINIC,99391,Periodic primary re-evaluation for an established infant patient,521,$202.90 ,$152.18 ,pays at 75% of total billed charges,$162.32 ,pays at 80% of total billed charges,$460.02 ,pays at MCR OPPS,$160.70 ,pays at 79.2% of total billed charges,$160.70 ,pays at 79.2% of total billed charges,$160.70 ,pays at 79.2% of total billed charges,$160.70 ,pays at 79.2% of total billed charges,$172.47 ,pays at 85% of total billed charges,$202.90 ,pays at MCD O/P rates,$382.20 ,pays at MCR OPPS,$192.76 ,pays at 95% of total billed charges,$162.32 ,pays at 80% total billed charges,$172.47 ,pays at 85% of total billed charges,$182.61 ,pays at 90% of total billed charges,$382.20 ,pays at MCR OPPS,$202.90 ,pays at 100% of MCD OPPS,$113.44 ,pays at 100% of MCD OPPS,$382.20 ,pays at MCR OPPS,$182.61 ,pays at 90% of total billed charges,$154.20 ,pays at 80% of total billed charges,$460.02 ,pays at MCR OPPS,$382.20 ,pays at MCR OPPS,$172.47 ,pays at 85% of total billed charges,$202.90 ,pays at MCD OPPS,$382.20 ,pays at MCR OPPS,$162.32 ,pays at 80% of total billed charges,$446.22 ,pays at 97% of MCR OPPS,$172.47 ,pays at 85% of total billed charges,$202.90 ,pays at MCD OPPS,$113.44 ,$460.02 ,$172.47 
Outpatient Medical Services,EVALUATION & MGMT CLINIC,99392,Initial visit for new patients 1-4 years old,521,$202.90 ,$152.18 ,pays at 75% of total billed charges,$162.32 ,pays at 80% of total billed charges,$467.78 ,pays at MCR OPPS,$160.70 ,pays at 79.2% of total billed charges,$160.70 ,pays at 79.2% of total billed charges,$160.70 ,pays at 79.2% of total billed charges,$160.70 ,pays at 79.2% of total billed charges,$172.47 ,pays at 85% of total billed charges,$202.90 ,pays at MCD O/P rates,$382.20 ,pays at MCR OPPS,$192.76 ,pays at 95% of total billed charges,$162.32 ,pays at 80% total billed charges,$172.47 ,pays at 85% of total billed charges,$182.61 ,pays at 90% of total billed charges,$382.20 ,pays at MCR OPPS,$202.90 ,pays at 100% of MCD OPPS,$113.44 ,pays at 100% of MCD OPPS,$382.20 ,pays at MCR OPPS,$182.61 ,pays at 90% of total billed charges,$154.20 ,pays at 80% of total billed charges,$467.78 ,pays at MCR OPPS,$382.20 ,pays at MCR OPPS,$172.47 ,pays at 85% of total billed charges,$202.90 ,pays at MCD OPPS,$382.20 ,pays at MCR OPPS,$162.32 ,pays at 80% of total billed charges,$453.75 ,pays at 97% of MCR OPPS,$172.47 ,pays at 85% of total billed charges,$202.90 ,pays at MCD OPPS,$113.44 ,$467.78 ,$172.47 
Outpatient Medical Services,EVALUATION & MGMT CLINIC,99393,New preventative visit in new patients 5-11 years old,521,$202.90 ,$152.18 ,pays at 75% of total billed charges,$162.32 ,pays at 80% of total billed charges,$467.78 ,pays at MCR OPPS,$160.70 ,pays at 79.2% of total billed charges,$160.70 ,pays at 79.2% of total billed charges,$160.70 ,pays at 79.2% of total billed charges,$160.70 ,pays at 79.2% of total billed charges,$172.47 ,pays at 85% of total billed charges,$202.90 ,pays at MCD O/P rates,$382.20 ,pays at MCR OPPS,$192.76 ,pays at 95% of total billed charges,$162.32 ,pays at 80% total billed charges,$172.47 ,pays at 85% of total billed charges,$182.61 ,pays at 90% of total billed charges,$382.20 ,pays at MCR OPPS,$202.90 ,pays at 100% of MCD OPPS,$113.44 ,pays at 100% of MCD OPPS,$382.20 ,pays at MCR OPPS,$182.61 ,pays at 90% of total billed charges,$154.20 ,pays at 80% of total billed charges,$467.78 ,pays at MCR OPPS,$382.20 ,pays at MCR OPPS,$172.47 ,pays at 85% of total billed charges,$202.90 ,pays at MCD OPPS,$382.20 ,pays at MCR OPPS,$162.32 ,pays at 80% of total billed charges,$453.75 ,pays at 97% of MCR OPPS,$172.47 ,pays at 85% of total billed charges,$202.90 ,pays at MCD OPPS,$113.44 ,$467.78 ,$172.47 
Outpatient Medical Services,EVALUATION & MGMT CLINIC,99394,New preventative visit in new patients 12-17 years old,521,$202.90 ,$152.18 ,pays at 75% of total billed charges,$162.32 ,pays at 80% of total billed charges,$478.89 ,pays at MCR OPPS,$160.70 ,pays at 79.2% of total billed charges,$160.70 ,pays at 79.2% of total billed charges,$160.70 ,pays at 79.2% of total billed charges,$160.70 ,pays at 79.2% of total billed charges,$172.47 ,pays at 85% of total billed charges,$202.90 ,pays at MCD O/P rates,$382.20 ,pays at MCR OPPS,$192.76 ,pays at 95% of total billed charges,$162.32 ,pays at 80% total billed charges,$172.47 ,pays at 85% of total billed charges,$182.61 ,pays at 90% of total billed charges,$382.20 ,pays at MCR OPPS,$202.90 ,pays at 100% of MCD OPPS,$113.44 ,pays at 100% of MCD OPPS,$382.20 ,pays at MCR OPPS,$182.61 ,pays at 90% of total billed charges,$154.20 ,pays at 80% of total billed charges,$478.89 ,pays at MCR OPPS,$382.20 ,pays at MCR OPPS,$172.47 ,pays at 85% of total billed charges,$202.90 ,pays at MCD OPPS,$382.20 ,pays at MCR OPPS,$162.32 ,pays at 80% of total billed charges,$464.52 ,pays at 97% of MCR OPPS,$172.47 ,pays at 85% of total billed charges,$202.90 ,pays at MCD OPPS,$113.44 ,$478.89 ,$172.47 
Outpatient Medical Services,EVALUATION & MGMT CLINIC,99395,Established patient periodic preventive medicine examination age 18-39 years,521,$202.90 ,$152.18 ,pays at 75% of total billed charges,$162.32 ,pays at 80% of total billed charges,$481.97 ,pays at MCR OPPS,$160.70 ,pays at 79.2% of total billed charges,$160.70 ,pays at 79.2% of total billed charges,$160.70 ,pays at 79.2% of total billed charges,$160.70 ,pays at 79.2% of total billed charges,$172.47 ,pays at 85% of total billed charges,$202.90 ,pays at MCD O/P rates,$382.20 ,pays at MCR OPPS,$192.76 ,pays at 95% of total billed charges,$162.32 ,pays at 80% total billed charges,$172.47 ,pays at 85% of total billed charges,$182.61 ,pays at 90% of total billed charges,$382.20 ,pays at MCR OPPS,$202.90 ,pays at 100% of MCD OPPS,$113.44 ,pays at 100% of MCD OPPS,$382.20 ,pays at MCR OPPS,$182.61 ,pays at 90% of total billed charges,$154.20 ,pays at 80% of total billed charges,$481.97 ,pays at MCR OPPS,$382.20 ,pays at MCR OPPS,$172.47 ,pays at 85% of total billed charges,$202.90 ,pays at MCD OPPS,$382.20 ,pays at MCR OPPS,$162.32 ,pays at 80% of total billed charges,$467.51 ,pays at 97% of MCR OPPS,$172.47 ,pays at 85% of total billed charges,$202.90 ,pays at MCD OPPS,$113.44 ,$481.97 ,$172.47 
Outpatient Medical Services,EVALUATION & MGMT CLINIC,99396,Established patient periodic preventive medicine examination age 40-64 years,521,$202.90 ,$152.18 ,pays at 75% of total billed charges,$162.32 ,pays at 80% of total billed charges,$490.30 ,pays at MCR OPPS,$160.70 ,pays at 79.2% of total billed charges,$160.70 ,pays at 79.2% of total billed charges,$160.70 ,pays at 79.2% of total billed charges,$160.70 ,pays at 79.2% of total billed charges,$172.47 ,pays at 85% of total billed charges,$202.90 ,pays at MCD O/P rates,$382.20 ,pays at MCR OPPS,$192.76 ,pays at 95% of total billed charges,$162.32 ,pays at 80% total billed charges,$172.47 ,pays at 85% of total billed charges,$182.61 ,pays at 90% of total billed charges,$382.20 ,pays at MCR OPPS,$202.90 ,pays at 100% of MCD OPPS,$202.90 ,pays at 100% of MCD OPPS,$382.20 ,pays at MCR OPPS,$182.61 ,pays at 90% of total billed charges,$154.20 ,pays at 80% of total billed charges,$490.30 ,pays at MCR OPPS,$382.20 ,pays at MCR OPPS,$172.47 ,pays at 85% of total billed charges,$202.90 ,pays at MCD OPPS,$382.20 ,pays at MCR OPPS,$162.32 ,pays at 80% of total billed charges,$475.59 ,pays at 97% of MCR OPPS,$172.47 ,pays at 85% of total billed charges,$202.90 ,pays at MCD OPPS,$152.18 ,$490.30 ,$172.47 
Outpatient Medical Services,EVALUATION & MGMT CLINIC,99441,"Physician telephone patient service, 5-10 minutes of medical discussion",521,$105.10 ,$78.83 ,pays at 75% of total billed charges,$84.08 ,pays at 80% of total billed charges,$422.71 ,pays at MCR OPPS,$83.24 ,pays at 79.2% of total billed charges,$83.24 ,pays at 79.2% of total billed charges,$83.24 ,pays at 79.2% of total billed charges,$83.24 ,pays at 79.2% of total billed charges,$89.34 ,pays at 85% of total billed charges,$105.10 ,pays at MCD O/P rates,$382.20 ,pays at MCR OPPS,$99.85 ,pays at 95% of total billed charges,$84.08 ,pays at 80% total billed charges,$89.34 ,pays at 85% of total billed charges,$94.59 ,pays at 90% of total billed charges,$382.20 ,pays at MCR OPPS,$105.10 ,pays at 100% of MCD OPPS,$105.10 ,pays at 100% of MCD OPPS,$382.20 ,pays at MCR OPPS,$94.59 ,pays at 90% of total billed charges,$79.88 ,pays at 80% of total billed charges,$422.71 ,pays at MCR OPPS,$382.20 ,pays at MCR OPPS,$89.34 ,pays at 85% of total billed charges,$105.10 ,pays at MCD OPPS,$382.20 ,pays at MCR OPPS,$84.08 ,pays at 80% of total billed charges,$410.03 ,pays at 97% of MCR OPPS,$89.34 ,pays at 85% of total billed charges,$105.10 ,pays at MCD OPPS,$78.83 ,$422.71 ,$89.34 
Outpatient Medical Services,EVALUATION & MGMT CLINIC,99442,"Physician telephone patient service, 11-20 minutes of medical discussion",521,$139.10 ,$104.33 ,pays at 75% of total billed charges,$111.28 ,pays at 80% of total billed charges,$458.72 ,pays at MCR OPPS,$110.17 ,pays at 79.2% of total billed charges,$110.17 ,pays at 79.2% of total billed charges,$110.17 ,pays at 79.2% of total billed charges,$110.17 ,pays at 79.2% of total billed charges,$118.24 ,pays at 85% of total billed charges,$139.10 ,pays at MCD O/P rates,$382.20 ,pays at MCR OPPS,$132.15 ,pays at 95% of total billed charges,$111.28 ,pays at 80% total billed charges,$118.24 ,pays at 85% of total billed charges,$125.19 ,pays at 90% of total billed charges,$382.20 ,pays at MCR OPPS,$139.10 ,pays at 100% of MCD OPPS,$139.10 ,pays at 100% of MCD OPPS,$382.20 ,pays at MCR OPPS,$125.19 ,pays at 90% of total billed charges,$105.72 ,pays at 80% of total billed charges,$458.72 ,pays at MCR OPPS,$382.20 ,pays at MCR OPPS,$118.24 ,pays at 85% of total billed charges,$139.10 ,pays at MCD OPPS,$382.20 ,pays at MCR OPPS,$111.28 ,pays at 80% of total billed charges,$444.96 ,pays at 97% of MCR OPPS,$118.24 ,pays at 85% of total billed charges,$139.10 ,pays at MCD OPPS,$104.33 ,$458.72 ,$118.24 
Outpatient Medical Services,EVALUATION & MGMT CLINIC,99443,"Physician telephone patient service, 21-30 minutes of medical discussion",521,$196.70 ,$147.53 ,pays at 75% of total billed charges,$157.36 ,pays at 80% of total billed charges,$494.67 ,pays at MCR OPPS,$155.79 ,pays at 79.2% of total billed charges,$155.79 ,pays at 79.2% of total billed charges,$155.79 ,pays at 79.2% of total billed charges,$155.79 ,pays at 79.2% of total billed charges,$167.20 ,pays at 85% of total billed charges,$196.70 ,pays at MCD O/P rates,$382.20 ,pays at MCR OPPS,$186.87 ,pays at 95% of total billed charges,$157.36 ,pays at 80% total billed charges,$167.20 ,pays at 85% of total billed charges,$177.03 ,pays at 90% of total billed charges,$382.20 ,pays at MCR OPPS,$196.70 ,pays at 100% of MCD OPPS,$196.70 ,pays at 100% of MCD OPPS,$382.20 ,pays at MCR OPPS,$177.03 ,pays at 90% of total billed charges,$149.49 ,pays at 80% of total billed charges,$494.67 ,pays at MCR OPPS,$382.20 ,pays at MCR OPPS,$167.20 ,pays at 85% of total billed charges,$196.70 ,pays at MCD OPPS,$382.20 ,pays at MCR OPPS,$157.36 ,pays at 80% of total billed charges,$479.83 ,pays at 97% of MCR OPPS,$167.20 ,pays at 85% of total billed charges,$196.70 ,pays at MCD OPPS,$147.53 ,$494.67 ,$167.20 
Outpatient Medical Services,EVALUATION & MGMT CLINIC,90834,"Psychotherapy, 45 min",521,$197.80 ,$148.35 ,pays at 75% of total billed charges,$158.24 ,pays at 80% of total billed charges,$484.07 ,pays at MCR OPPS,$156.66 ,pays at 79.2% of total billed charges,$156.66 ,pays at 79.2% of total billed charges,$156.66 ,pays at 79.2% of total billed charges,$156.66 ,pays at 79.2% of total billed charges,$168.13 ,pays at 85% of total billed charges,$192.61 ,pays at MCD O/P rates,$382.20 ,pays at MCR OPPS,$187.91 ,pays at 95% of total billed charges,$158.24 ,pays at 80% total billed charges,$168.13 ,pays at 85% of total billed charges,$178.02 ,pays at 90% of total billed charges,$382.20 ,pays at MCR OPPS,$192.61 ,pays at 100% of MCD OPPS,$145.69 ,pays at 100% of MCD OPPS,$382.20 ,pays at MCR OPPS,$178.02 ,pays at 90% of total billed charges,$150.33 ,pays at 80% of total billed charges,$484.07 ,pays at MCR OPPS,$382.20 ,pays at MCR OPPS,$168.13 ,pays at 85% of total billed charges,$192.61 ,pays at MCD OPPS,$382.20 ,pays at MCR OPPS,$158.24 ,pays at 80% of total billed charges,$469.54 ,pays at 97% of MCR OPPS,$168.13 ,pays at 85% of total billed charges,$192.61 ,pays at MCD OPPS,$145.69 ,$484.07 ,$168.13 
Outpatient Medical Services,EVALUATION & MGMT CLINIC,90832,"Psychotherapy, 30 min",521,$128.80 ,$96.60 ,pays at 75% of total billed charges,$103.04 ,pays at 80% of total billed charges,$459.02 ,pays at MCR OPPS,$102.01 ,pays at 79.2% of total billed charges,$102.01 ,pays at 79.2% of total billed charges,$102.01 ,pays at 79.2% of total billed charges,$102.01 ,pays at 79.2% of total billed charges,$109.48 ,pays at 85% of total billed charges,$128.80 ,pays at MCD O/P rates,$382.20 ,pays at MCR OPPS,$122.36 ,pays at 95% of total billed charges,$103.04 ,pays at 80% total billed charges,$109.48 ,pays at 85% of total billed charges,$115.92 ,pays at 90% of total billed charges,$382.20 ,pays at MCR OPPS,$159.70 ,pays at 100% of MCD OPPS,$128.80 ,pays at 100% of MCD OPPS,$382.20 ,pays at MCR OPPS,$115.92 ,pays at 90% of total billed charges,$97.89 ,pays at 80% of total billed charges,$459.02 ,pays at MCR OPPS,$382.20 ,pays at MCR OPPS,$109.48 ,pays at 85% of total billed charges,$159.70 ,pays at MCD OPPS,$382.20 ,pays at MCR OPPS,$103.04 ,pays at 80% of total billed charges,$445.25 ,pays at 97% of MCR OPPS,$109.48 ,pays at 85% of total billed charges,$159.70 ,pays at MCD OPPS,$96.60 ,$459.02 ,$109.48 
Outpatient Medical Services,EVALUATION & MGMT CLINIC,90791,"A diagnostic tool employed by a psychiatrist to diagnose problems with memory, thought processes, and behaviors",521,$360.50 ,$270.38 ,pays at 75% of total billed charges,$288.40 ,pays at 80% of total billed charges,$556.56 ,pays at MCR OPPS,$285.52 ,pays at 79.2% of total billed charges,$285.52 ,pays at 79.2% of total billed charges,$285.52 ,pays at 79.2% of total billed charges,$285.52 ,pays at 79.2% of total billed charges,$306.43 ,pays at 85% of total billed charges,$346.27 ,pays at MCD O/P rates,$382.20 ,pays at MCR OPPS,$342.48 ,pays at 95% of total billed charges,$288.40 ,pays at 80% total billed charges,$306.43 ,pays at 85% of total billed charges,$324.45 ,pays at 90% of total billed charges,$382.20 ,pays at MCR OPPS,$346.27 ,pays at 100% of MCD OPPS,$145.69 ,pays at 100% of MCD OPPS,$382.20 ,pays at MCR OPPS,$324.45 ,pays at 90% of total billed charges,$273.98 ,pays at 80% of total billed charges,$556.56 ,pays at MCR OPPS,$382.20 ,pays at MCR OPPS,$306.43 ,pays at 85% of total billed charges,$346.27 ,pays at MCD OPPS,$382.20 ,pays at MCR OPPS,$288.40 ,pays at 80% of total billed charges,$539.86 ,pays at 97% of MCR OPPS,$306.43 ,pays at 85% of total billed charges,$346.27 ,pays at MCD OPPS,$145.69 ,$556.56 ,$306.43 
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,19101,"19101 - Biopsy Of Breast; Open, Incisional",360,"$5,807.00 ","$4,355.25 ",pays at 75% of total billed charges,"$4,645.60 ",pays at 80% of total billed charges,$261.30 ,pays at MCR OPPS,"$3,050.00 ",pays at 79.2% of total billed charges,"$3,050.00 ",pays at 79.2% of total billed charges,"$3,050.00 ",pays at 79.2% of total billed charges,"$3,050.00 ",pays at 79.2% of total billed charges,"$4,935.95 ",pays at 85% of total billed charges,"$1,843.84 ",pays at MCD O/P rates,"$2,322.80 ",pays at MCR OPPS,"$5,516.65 ",pays at 95% of total billed charges,"$4,645.60 ",pays at 80% total billed charges,"$4,935.95 ",pays at 85% of total billed charges,"$5,226.30 ",pays at 90% of total billed charges,"$2,322.80 ",pays at MCR OPPS,"$1,843.84 ",pays at 100% of MCD OPPS,"$3,437.80 ",pays at 100% of MCD OPPS,"$2,322.80 ",pays at MCR OPPS,"$5,226.30 ",pays at 90% of total billed charges,"$4,413.32 ",pays at 80% of total billed charges,$261.30 ,pays at MCR OPPS,"$2,322.80 ",pays at MCR OPPS,"$4,935.95 ",pays at 85% of total billed charges,"$1,843.84 ",pays at MCD OPPS,"$2,322.80 ",pays at MCR OPPS,"$4,645.60 ",pays at 80% of total billed charges,$253.46 ,pays at 97% of MCR OPPS,"$4,935.95 ",pays at 85% of total billed charges,"$1,843.84 ",pays at MCD OPPS,$253.46 ,"$5,516.65 ","$4,935.95 "
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,19120,REMOVAL OF BREAST LESION,360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,843.84 ",pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,843.84 ",pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,843.84 ",pays at MCD OPPS,"$1,843.84 ","$1,843.84 ",#VALUE!
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,19301,"19301 - Mastectomy, Partial (Eg, Lumpectomy, Tylectomy, Quadrantectomy, Segmentectomy);",360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$4,267.46 ",pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$4,267.46 ",pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$4,267.46 ",pays at MCD OPPS,"$4,267.46 ","$4,267.46 ",#VALUE!
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,20240,"20240 - Biopsy, Bone, Open; Superficial (Eg, Ilium, Sternum, Spinous Process, Ribs, Trochanter Of Femur)",360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$2,299.05 ",pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$2,299.05 ",pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$2,299.05 ",pays at MCD OPPS,"$2,299.05 ","$2,299.05 ",#VALUE!
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,20610,Draining or injecting medication into a major joint/bursa without ultrasound,360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,$317.00 ,pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,$317.00 ,pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,$317.00 ,pays at MCD OPPS,$317.00 ,$317.00 ,#VALUE!
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,20680,"20680 - Removal Of Implant; Deep (Eg, Buried Wire, Pin, Screw, Metal Band, Nail, Rod Or Plate)",360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$3,172.22 ",pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$3,172.22 ",pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$3,172.22 ",pays at MCD OPPS,"$3,172.22 ","$3,172.22 ",#VALUE!
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,21556,"21556 - Excision, Tumor, Soft Tissue Of Neck Or Anterior Thorax, Subfascial (Eg, Intramuscular); Less Than 5 Cm",360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$2,955.66 ",pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$2,955.66 ",pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$2,955.66 ",pays at MCD OPPS,"$2,955.66 ","$2,955.66 ",#VALUE!
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,23700,"23700 - Manipulation Under Anesthesia, Shoulder Joint, Including Application Of Fixation Apparatus (Dislocation Excluded)",360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,300.94 ",pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,300.94 ",pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,300.94 ",pays at MCD OPPS,"$1,300.94 ","$1,300.94 ",#VALUE!
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,24341,"24341 - Repair, Tendon Or Muscle, Upper Arm Or Elbow, Each Tendon Or Muscle, Primary Or Secondary (Excludes Rotator Cuff)",360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$5,880.12 ",pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$5,880.12 ",pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$5,880.12 ",pays at MCD OPPS,"$5,880.12 ","$5,880.12 ",#VALUE!
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,24342,"24342 - Reinsertion Of Ruptured Biceps Or Triceps Tendon, Distal, With Or Without Tendon Graft",360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$5,880.12 ",pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$5,880.12 ",pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$5,880.12 ",pays at MCD OPPS,"$5,880.12 ","$5,880.12 ",#VALUE!
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,24358,"24358 - Tenotomy, Elbow, Lateral Or Medial (Eg, Epicondylitis, Tennis Elbow, Golfer'S Elbow); Debridement, Soft Tissue And/Or Bone, Open",360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$2,279.49 ",pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$2,279.49 ",pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$2,279.49 ",pays at MCD OPPS,"$2,279.49 ","$2,279.49 ",#VALUE!
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,25000,"25000 - Incision, Extensor Tendon Sheath, Wrist (Eg, Dequervains Disease)",360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$2,279.49 ",pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$2,279.49 ",pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$2,279.49 ",pays at MCD OPPS,"$2,279.49 ","$2,279.49 ",#VALUE!
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,26055,"26055 - Tendon Sheath Incision (Eg, For Trigger Finger)",360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,745.37 ",pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,745.37 ",pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,745.37 ",pays at MCD OPPS,"$1,745.37 ","$1,745.37 ",#VALUE!
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,26111,"26111 - Excision, Tumor Or Vascular Malformation, Soft Tissue Of Hand Or Finger, Subcutaneous; 1.5 Cm Or Greater",360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,745.37 ",pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,745.37 ",pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,745.37 ",pays at MCD OPPS,"$1,745.37 ","$1,745.37 ",#VALUE!
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,26160,"26160 - Excision Of Lesion Of Tendon Sheath Or Joint Capsule (Eg, Cyst, Mucous Cyst, Or Ganglion), Hand Or Finger",360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,745.37 ",pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,745.37 ",pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,745.37 ",pays at MCD OPPS,"$1,745.37 ","$1,745.37 ",#VALUE!
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,26410,"26410 - Repair, Extensor Tendon, Hand, Primary Or Secondary; Without Free Graft, Each Tendon",360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,745.37 ",pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,745.37 ",pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,745.37 ",pays at MCD OPPS,"$1,745.37 ","$1,745.37 ",#VALUE!
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,26951,"26951 - Amputation, Finger Or Thumb, Primary Or Secondary, Any Joint Or Phalanx, Single, Including Neurectomies; With Direct Closure",360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,745.37 ",pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,745.37 ",pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,745.37 ",pays at MCD OPPS,"$1,745.37 ","$1,745.37 ",#VALUE!
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,27096,"27096 - Injection Procedure For Sacroiliac Joint, Anesthetic/Steroid, With Image Guidance (Fluoroscopy Or Ct) Including Arthrography When Performed",360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,$649.07 ,pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,$649.07 ,pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,$649.07 ,pays at MCD OPPS,$649.07 ,$649.07 ,#VALUE!
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,27130,"27130 - Arthroplasty, Acetabular And Proximal Femoral Prosthetic Replacement (Total Hip Arthroplasty), With Or Without Autograft Or Allograft",360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$12,285.93 ",pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$12,285.93 ",pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$12,285.93 ",pays at MCD OPPS,"$12,285.93 ","$12,285.93 ",#VALUE!
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,27420,"27420 - Reconstruction Of Dislocating Patella; (Eg, Hauser Type Procedure)",360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$9,201.13 ",pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$9,201.13 ",pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$9,201.13 ",pays at MCD OPPS,"$9,201.13 ","$9,201.13 ",#VALUE!
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,27427,"27427 - Ligamentous Reconstruction (Augmentation), Knee; Extra-Articular",360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$9,201.13 ",pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$9,201.13 ",pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$9,201.13 ",pays at MCD OPPS,"$9,201.13 ","$9,201.13 ",#VALUE!
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,27447,"27447 - Arthroplasty, Knee, Condyle And Plateau; Medial And Lateral Compartments With Or Without Patella Resurfacing (Total Knee Arthroplasty)",360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$12,285.93 ",pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$12,285.93 ",pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$12,285.93 ",pays at MCD OPPS,"$12,285.93 ","$12,285.93 ",#VALUE!
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,27486,"27486 - Revision Of Total Knee Arthroplasty, With Or Without Allograft; 1 Component",360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$12,285.93 ",pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$12,285.93 ",pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$12,285.93 ",pays at MCD OPPS,"$12,285.93 ","$12,285.93 ",#VALUE!
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,27658,"27658 - Repair, Flexor Tendon, Leg; Primary, Without Graft, Each Tendon",360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$4,109.37 ",pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$4,109.37 ",pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$4,109.37 ",pays at MCD OPPS,"$4,109.37 ","$4,109.37 ",#VALUE!
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,27814,"27814 - Open Treatment Of Bimalleolar Ankle Fracture (Eg, Lateral And Medial Malleoli, Or Lateral And Posterior Malleoli, Or Medial And Posterior Mall",360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$7,000.46 ",pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$7,000.46 ",pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$7,000.46 ",pays at MCD OPPS,"$7,000.46 ","$7,000.46 ",#VALUE!
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,28090,"28090 - Excision Of Lesion, Tendon, Tendon Sheath, Or Capsule (Including Synovectomy) (Eg, Cyst Or Ganglion); Foot",360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$2,842.68 ",pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$2,842.68 ",pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$2,842.68 ",pays at MCD OPPS,"$2,842.68 ","$2,842.68 ",#VALUE!
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,28119,"28119 - Ostectomy, Calcaneus; For Spur, With Or Without Plantar Fascial Release",360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$2,842.68 ",pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$2,842.68 ",pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$2,842.68 ",pays at MCD OPPS,"$2,842.68 ","$2,842.68 ",#VALUE!
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,28285,"28285 - Correction, Hammertoe (Eg, Interphalangeal Fusion, Partial Or Total Phalangectomy)",360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$2,842.68 ",pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$2,842.68 ",pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$2,842.68 ",pays at MCD OPPS,"$2,842.68 ","$2,842.68 ",#VALUE!
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,28820,"28820 - Amputation, Toe; Metatarsophalangeal Joint",360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$2,842.68 ",pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$2,842.68 ",pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$2,842.68 ",pays at MCD OPPS,"$2,842.68 ","$2,842.68 ",#VALUE!
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,29806,"29806 - Arthroscopy, Shoulder, Surgical; Capsulorrhaphy",360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$7,369.00 ",pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$7,369.00 ",pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$7,369.00 ",pays at MCD OPPS,"$7,369.00 ","$7,369.00 ",#VALUE!
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,29822,"29822 - Arthroscopy, Shoulder, Surgical; Debridement, Limited",360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$2,945.99 ",pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$2,945.99 ",pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$2,945.99 ",pays at MCD OPPS,"$2,945.99 ","$2,945.99 ",#VALUE!
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,29827,"29827 - Arthroscopy, Shoulder, Surgical; With Rotator Cuff Repair",360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$7,369.00 ",pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$7,369.00 ",pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$7,369.00 ",pays at MCD OPPS,"$7,369.00 ","$7,369.00 ",#VALUE!
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,29877,"29877 - Arthroscopy, Knee, Surgical; Debridement/Shaving Of Articular Cartilage (Chondroplasty)",360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$2,945.99 ",pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$2,945.99 ",pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$2,945.99 ",pays at MCD OPPS,"$2,945.99 ","$2,945.99 ",#VALUE!
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,29879,"29879 - Arthroscopy, Knee, Surgical; Abrasion Arthroplasty (Includes Chondroplasty Where Necessary) Or Multiple Drilling Or Microfracture",360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$2,945.99 ",pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$2,945.99 ",pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$2,945.99 ",pays at MCD OPPS,"$2,945.99 ","$2,945.99 ",#VALUE!
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,29880,Surgery to remove of all or part of a torn meniscus in both medial and lateral compartments,360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$2,945.99 ",pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$2,945.99 ",pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$2,945.99 ",pays at MCD OPPS,"$2,945.99 ","$2,945.99 ",#VALUE!
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,29881,Surgery to remove of all or part of a torn meniscus in one compartment,360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$2,945.99 ",pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$2,945.99 ",pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$2,945.99 ",pays at MCD OPPS,"$2,945.99 ","$2,945.99 ",#VALUE!
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,29882,"29882 - Arthroscopy, Knee, Surgical; With Meniscus Repair (Medial Or Lateral)",360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$2,945.99 ",pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$2,945.99 ",pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$2,945.99 ",pays at MCD OPPS,"$2,945.99 ","$2,945.99 ",#VALUE!
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,29888,ACL reconstruction,360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$7,369.00 ",pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$7,369.00 ",pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$7,369.00 ",pays at MCD OPPS,"$7,369.00 ","$7,369.00 ",#VALUE!
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,30520,Repair procedures of the nose,360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$3,946.26 ",pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$3,946.26 ",pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$3,946.26 ",pays at MCD OPPS,"$3,946.26 ","$3,946.26 ",#VALUE!
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,31254,"31254 - Nasal/Sinus Endoscopy, Surgical; With Ethmoidectomy, Partial (Anterior)",360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$3,833.04 ",pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$3,833.04 ",pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$3,833.04 ",pays at MCD OPPS,"$3,833.04 ","$3,833.04 ",#VALUE!
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,36561,"36561 - Insertion Of Tunneled Centrally Inserted Central Venous Access Device, With Subcutaneous Port; Age 5 Years Or Older",360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$2,894.73 ",pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$2,894.73 ",pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$2,894.73 ",pays at MCD OPPS,"$2,894.73 ","$2,894.73 ",#VALUE!
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,42820,Removal of tonsils and adenoid glands patient younger than age 12,360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$2,632.88 ",pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$2,632.88 ",pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$2,632.88 ",pays at MCD OPPS,"$2,632.88 ","$2,632.88 ",#VALUE!
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,42825,"42825 - Tonsillectomy, Primary Or Secondary; Younger Than Age 12",360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$2,632.88 ",pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$2,632.88 ",pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$2,632.88 ",pays at MCD OPPS,"$2,632.88 ","$2,632.88 ",#VALUE!
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,42826,Primary or secondary removal of tonsils,360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$2,632.88 ",pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$2,632.88 ",pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$2,632.88 ",pays at MCD OPPS,"$2,632.88 ","$2,632.88 ",#VALUE!
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,43235,"Diagnostic examination of esophagus, stomach, and/or upper small bowel using an endoscope",360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,260.54 ",pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,260.54 ",pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,260.54 ",pays at MCD OPPS,"$1,260.54 ","$1,260.54 ",#VALUE!
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,43239,"Biopsy of the esophagus, stomach, and/or upper small bowel using an endoscope",360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,260.54 ",pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,260.54 ",pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,260.54 ",pays at MCD OPPS,"$1,260.54 ","$1,260.54 ",#VALUE!
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,44970,"44970 - Laparoscopy, Surgical, Appendectomy",360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$6,650.08 ",pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$6,650.08 ",pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$6,650.08 ",pays at MCD OPPS,"$6,650.08 ","$6,650.08 ",#VALUE!
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,45330,"45330 - Sigmoidoscopy, Flexible; Diagnostic, With Or Without Collection Of Specimen(S) By Brushing Or Washing (Separate Procedure)",360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,279.37 ",pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,279.37 ",pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,279.37 ",pays at MCD OPPS,"$1,279.37 ","$1,279.37 ",#VALUE!
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,45331,"45331 - Sigmoidoscopy, Flexible; With Biopsy, Single Or Multiple",360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,279.37 ",pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,279.37 ",pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,279.37 ",pays at MCD OPPS,"$1,279.37 ","$1,279.37 ",#VALUE!
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,45378,Diagnostic examination of large bowel using an endoscope,360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,279.37 ",pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,279.37 ",pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,279.37 ",pays at MCD OPPS,"$1,279.37 ","$1,279.37 ",#VALUE!
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,45380,Biopsy of large bowel using an endoscope,360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,279.37 ",pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,279.37 ",pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,279.37 ",pays at MCD OPPS,"$1,279.37 ","$1,279.37 ",#VALUE!
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,45384,Removal of polyps or growths in large bowel using an endoscope,360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,279.37 ",pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,279.37 ",pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,279.37 ",pays at MCD OPPS,"$1,279.37 ","$1,279.37 ",#VALUE!
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,45385,Removal of polyps or growths of large bowel using an endoscope,360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,279.37 ",pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,279.37 ",pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,279.37 ",pays at MCD OPPS,"$1,279.37 ","$1,279.37 ",#VALUE!
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,45388,Destruction of large bowel growths using an endoscope,360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,279.37 ",pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,279.37 ",pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,279.37 ",pays at MCD OPPS,"$1,279.37 ","$1,279.37 ",#VALUE!
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,45990,"45990 - Anorectal Exam, Surgical, Requiring Anesthesia (General, Spinal, Or Epidural), Diagnostic",360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,941.25 ",pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,941.25 ",pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,941.25 ",pays at MCD OPPS,"$1,941.25 ","$1,941.25 ",#VALUE!
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,46221,"46221 - Hemorrhoidectomy, Internal, By Rubber Band Ligation(S)",360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,941.25 ",pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,941.25 ",pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,941.25 ",pays at MCD OPPS,"$1,941.25 ","$1,941.25 ",#VALUE!
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,46922,"46922 - Destruction Of Lesion(S), Anus (Eg, Condyloma, Papilloma, Molluscum Contagiosum, Herpetic Vesicle), Simple; Surgical Excision",360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,941.25 ",pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,941.25 ",pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,941.25 ",pays at MCD OPPS,"$1,941.25 ","$1,941.25 ",#VALUE!
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,46945,"46945 - Hemorrhoidectomy, Internal, By Ligation Other Than Rubber Band; Single Hemorrhoid Column/Group",360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,941.25 ",pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,941.25 ",pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,941.25 ",pays at MCD OPPS,"$1,941.25 ","$1,941.25 ",#VALUE!
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,47562,Removal of gallbladder using an endoscope,360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$4,545.20 ",pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$4,545.20 ",pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$4,545.20 ",pays at MCD OPPS,"$4,545.20 ","$4,545.20 ",#VALUE!
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,49321,"49321 - Laparoscopy, Surgical; With Biopsy (Single Or Multiple)",360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$4,907.81 ",pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$4,907.81 ",pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$4,907.81 ",pays at MCD OPPS,"$4,907.81 ","$4,907.81 ",#VALUE!
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,49505,Repair of groin hernia patient age 5 years or older,360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$4,615.83 ",pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$4,615.83 ",pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$4,615.83 ",pays at MCD OPPS,"$4,615.83 ","$4,615.83 ",#VALUE!
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,49585,Repair of umbilical hernia in patients over 5 years old,360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$4,615.83 ",pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$4,615.83 ",pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$4,615.83 ",pays at MCD OPPS,"$4,615.83 ","$4,615.83 ",#VALUE!
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,58661,"Removal of either benign or malignant tissue from the uterus, ovaries, fallopian tubes, or any of the surrounding tissues using a laparoscope",360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$5,567.34 ",pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$5,567.34 ",pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$5,567.34 ",pays at MCD OPPS,"$5,567.34 ","$5,567.34 ",#VALUE!
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,58662,"Removal of lesions of the ovary, pelvic viscera, or peritoneal surface",360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$5,567.34 ",pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$5,567.34 ",pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$5,567.34 ",pays at MCD OPPS,"$5,567.34 ","$5,567.34 ",#VALUE!
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,58670,"58670 - Laparoscopy, Surgical; With Fulguration Of Oviducts (With Or Without Transection)",360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$5,567.34 ",pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$5,567.34 ",pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$5,567.34 ",pays at MCD OPPS,"$5,567.34 ","$5,567.34 ",#VALUE!
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,60500,60500 - Parathyroidectomy Or Exploration Of Parathyroid(S);,360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$5,568.74 ",pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$5,568.74 ",pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$5,568.74 ",pays at MCD OPPS,"$5,568.74 ","$5,568.74 ",#VALUE!
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,62323,Injection of substance into spinal canal of lower back or sacrum using imaging guidance,360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,127.24 ",pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,127.24 ",pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,127.24 ",pays at MCD OPPS,"$1,127.24 ","$1,127.24 ",#VALUE!
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,64483,Injections of anesthetic and/or steroid drug into lower or sacral spine nerve root using imaging guidance,360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,127.24 ",pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,127.24 ",pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,127.24 ",pays at MCD OPPS,"$1,127.24 ","$1,127.24 ",#VALUE!
Outpatient Medical Services,HOSPITAL SURGERY SERVICES,64721,Release of the transverse carpal ligament,360,N/A,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,812.63 ",pays at 100% of MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,812.63 ",pays at MCD OPPS,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,N/A,not reimburseable per contract,"$1,812.63 ",pays at MCD OPPS,"$1,812.63 ","$1,812.63 ",#VALUE!
Outpatient Medical Services,INFUSION & MEDICINE ADMIN,96360,"Intravenous Infusion, Hydration; Initial, 31 Minutes To 1 Hour",260,$251.30 ,$188.48 ,pays at 75% of total billed charges,$201.04 ,pays at 80% of total billed charges,$39.28 ,pays at MCR OPPS,$199.03 ,pays at 79.2% of total billed charges,$199.03 ,pays at 79.2% of total billed charges,$199.03 ,pays at 79.2% of total billed charges,$199.03 ,pays at 79.2% of total billed charges,$213.61 ,pays at 85% of total billed charges,$251.30 ,pays at MCD O/P rates,$100.52 ,pays at MCR OPPS,$238.74 ,pays at 95% of total billed charges,$201.04 ,pays at 80% total billed charges,$213.61 ,pays at 85% of total billed charges,$226.17 ,pays at 90% of total billed charges,$100.52 ,pays at MCR OPPS,$399.29 ,pays at 100% of MCD OPPS,$206.57 ,pays at 100% of MCD OPPS,$100.52 ,pays at MCR OPPS,$226.17 ,pays at 90% of total billed charges,$190.99 ,pays at 80% of total billed charges,$39.28 ,pays at MCR OPPS,$100.52 ,pays at MCR OPPS,$213.61 ,pays at 85% of total billed charges,$399.29 ,pays at MCD OPPS,$100.52 ,pays at MCR OPPS,$201.04 ,pays at 80% of total billed charges,$38.11 ,pays at 97% of MCR OPPS,$213.61 ,pays at 85% of total billed charges,$399.29 ,pays at MCD OPPS,$38.11 ,$399.29 ,$213.61 
Outpatient Medical Services,INFUSION & MEDICINE ADMIN,96361,"Intravenous Infusion, Hydration; Each Additional Hour (List Separately In Addition To Code For Primary Procedure)",260,$107.10 ,$80.33 ,pays at 75% of total billed charges,$85.68 ,pays at 80% of total billed charges,$15.28 ,pays at MCR OPPS,$84.82 ,pays at 79.2% of total billed charges,$84.82 ,pays at 79.2% of total billed charges,$84.82 ,pays at 79.2% of total billed charges,$84.82 ,pays at 79.2% of total billed charges,$91.04 ,pays at 85% of total billed charges,$107.10 ,pays at MCD O/P rates,$42.84 ,pays at MCR OPPS,$101.75 ,pays at 95% of total billed charges,$85.68 ,pays at 80% total billed charges,$91.04 ,pays at 85% of total billed charges,$96.39 ,pays at 90% of total billed charges,$42.84 ,pays at MCR OPPS,$675.81 ,pays at 100% of MCD OPPS,$42.37 ,pays at 100% of MCD OPPS,$42.84 ,pays at MCR OPPS,$96.39 ,pays at 90% of total billed charges,$81.40 ,pays at 80% of total billed charges,$15.28 ,pays at MCR OPPS,$42.84 ,pays at MCR OPPS,$91.04 ,pays at 85% of total billed charges,$675.81 ,pays at MCD OPPS,$42.84 ,pays at MCR OPPS,$85.68 ,pays at 80% of total billed charges,$14.82 ,pays at 97% of MCR OPPS,$91.04 ,pays at 85% of total billed charges,$675.81 ,pays at MCD OPPS,$14.82 ,$675.81 ,$91.04 
Outpatient Medical Services,INFUSION & MEDICINE ADMIN,96365,"Intravenous infusion, for therapy, prophylaxis, or diagnosis-initial infusion",260,$271.90 ,$203.93 ,pays at 75% of total billed charges,$217.52 ,pays at 80% of total billed charges,$77.38 ,pays at MCR OPPS,$215.34 ,pays at 79.2% of total billed charges,$215.34 ,pays at 79.2% of total billed charges,$215.34 ,pays at 79.2% of total billed charges,$215.34 ,pays at 79.2% of total billed charges,$231.12 ,pays at 85% of total billed charges,$271.90 ,pays at MCD O/P rates,$108.76 ,pays at MCR OPPS,$258.31 ,pays at 95% of total billed charges,$217.52 ,pays at 80% total billed charges,$231.12 ,pays at 85% of total billed charges,$244.71 ,pays at 90% of total billed charges,$108.76 ,pays at MCR OPPS,$399.29 ,pays at 100% of MCD OPPS,$206.57 ,pays at 100% of MCD OPPS,$108.76 ,pays at MCR OPPS,$244.71 ,pays at 90% of total billed charges,$206.64 ,pays at 80% of total billed charges,$77.38 ,pays at MCR OPPS,$108.76 ,pays at MCR OPPS,$231.12 ,pays at 85% of total billed charges,$399.29 ,pays at MCD OPPS,$108.76 ,pays at MCR OPPS,$217.52 ,pays at 80% of total billed charges,$75.06 ,pays at 97% of MCR OPPS,$231.12 ,pays at 85% of total billed charges,$399.29 ,pays at MCD OPPS,$75.06 ,$399.29 ,$231.12 
Outpatient Medical Services,INFUSION & MEDICINE ADMIN,96366,"Intravenous infusion, for therapy, prophylaxis, or diagnosis-additional infusions",260,$74.20 ,$55.65 ,pays at 75% of total billed charges,$59.36 ,pays at 80% of total billed charges,$24.54 ,pays at MCR OPPS,$58.77 ,pays at 79.2% of total billed charges,$58.77 ,pays at 79.2% of total billed charges,$58.77 ,pays at 79.2% of total billed charges,$58.77 ,pays at 79.2% of total billed charges,$63.07 ,pays at 85% of total billed charges,$74.20 ,pays at MCD O/P rates,$29.68 ,pays at MCR OPPS,$70.49 ,pays at 95% of total billed charges,$59.36 ,pays at 80% total billed charges,$63.07 ,pays at 85% of total billed charges,$66.78 ,pays at 90% of total billed charges,$29.68 ,pays at MCR OPPS,$675.81 ,pays at 100% of MCD OPPS,$42.37 ,pays at 100% of MCD OPPS,$29.68 ,pays at MCR OPPS,$66.78 ,pays at 90% of total billed charges,$56.39 ,pays at 80% of total billed charges,$24.54 ,pays at MCR OPPS,$29.68 ,pays at MCR OPPS,$63.07 ,pays at 85% of total billed charges,$675.81 ,pays at MCD OPPS,$29.68 ,pays at MCR OPPS,$59.36 ,pays at 80% of total billed charges,$23.80 ,pays at 97% of MCR OPPS,$63.07 ,pays at 85% of total billed charges,$675.81 ,pays at MCD OPPS,$23.80 ,$675.81 ,$63.07 
Outpatient Medical Services,INFUSION & MEDICINE ADMIN,96367,"Intravenous Infusion, For Therapy, Prophylaxis, Or Diagnosis (Specify Substance Or Drug); Additional Sequential Infusion Of A New Drug/Substance, Up T",260,$198.80 ,$149.10 ,pays at 75% of total billed charges,$159.04 ,pays at 80% of total billed charges,$34.75 ,pays at MCR OPPS,$157.45 ,pays at 79.2% of total billed charges,$157.45 ,pays at 79.2% of total billed charges,$157.45 ,pays at 79.2% of total billed charges,$157.45 ,pays at 79.2% of total billed charges,$168.98 ,pays at 85% of total billed charges,$198.80 ,pays at MCD O/P rates,$79.52 ,pays at MCR OPPS,$188.86 ,pays at 95% of total billed charges,$159.04 ,pays at 80% total billed charges,$168.98 ,pays at 85% of total billed charges,$178.92 ,pays at 90% of total billed charges,$79.52 ,pays at MCR OPPS,$399.29 ,pays at 100% of MCD OPPS,$67.47 ,pays at 100% of MCD OPPS,$79.52 ,pays at MCR OPPS,$178.92 ,pays at 90% of total billed charges,$151.09 ,pays at 80% of total billed charges,$34.75 ,pays at MCR OPPS,$79.52 ,pays at MCR OPPS,$168.98 ,pays at 85% of total billed charges,$399.29 ,pays at MCD OPPS,$79.52 ,pays at MCR OPPS,$159.04 ,pays at 80% of total billed charges,$33.71 ,pays at 97% of MCR OPPS,$168.98 ,pays at 85% of total billed charges,$399.29 ,pays at MCD OPPS,$33.71 ,$399.29 ,$168.98 
Outpatient Medical Services,INFUSION & MEDICINE ADMIN,96368,"Intravenous Infusion, For Therapy, Prophylaxis, Or Diagnosis (Specify Substance Or Drug); Concurrent Infusion (List Separately In Addition To Code For",260,$69.00 ,$51.75 ,pays at 75% of total billed charges,$55.20 ,pays at 80% of total billed charges,$23.74 ,pays at MCR OPPS,$54.65 ,pays at 79.2% of total billed charges,$54.65 ,pays at 79.2% of total billed charges,$54.65 ,pays at 79.2% of total billed charges,$54.65 ,pays at 79.2% of total billed charges,$58.65 ,pays at 85% of total billed charges,$69.00 ,pays at MCD O/P rates,$27.60 ,pays at MCR OPPS,$65.55 ,pays at 95% of total billed charges,$55.20 ,pays at 80% total billed charges,$58.65 ,pays at 85% of total billed charges,$62.10 ,pays at 90% of total billed charges,$27.60 ,pays at MCR OPPS,$399.29 ,pays at 100% of MCD OPPS,$69.00 ,pays at 100% of MCD OPPS,$27.60 ,pays at MCR OPPS,$62.10 ,pays at 90% of total billed charges,$52.44 ,pays at 80% of total billed charges,$23.74 ,pays at MCR OPPS,$27.60 ,pays at MCR OPPS,$58.65 ,pays at 85% of total billed charges,$399.29 ,pays at MCD OPPS,$27.60 ,pays at MCR OPPS,$55.20 ,pays at 80% of total billed charges,$23.02 ,pays at 97% of MCR OPPS,$58.65 ,pays at 85% of total billed charges,$399.29 ,pays at MCD OPPS,$23.02 ,$399.29 ,$58.65 
Outpatient Medical Services,INFUSION & MEDICINE ADMIN,96372,"Therapeutic, Prophylactic, Or Diagnostic Injection (Specify Substance Or Drug); Subcutaneous Or Intramuscular",260,$98.90 ,$74.18 ,pays at 75% of total billed charges,$79.12 ,pays at 80% of total billed charges,$16.78 ,pays at MCR OPPS,$78.33 ,pays at 79.2% of total billed charges,$78.33 ,pays at 79.2% of total billed charges,$78.33 ,pays at 79.2% of total billed charges,$78.33 ,pays at 79.2% of total billed charges,$84.07 ,pays at 85% of total billed charges,$58.22 ,pays at MCD O/P rates,$39.56 ,pays at MCR OPPS,$93.96 ,pays at 95% of total billed charges,$79.12 ,pays at 80% total billed charges,$84.07 ,pays at 85% of total billed charges,$89.01 ,pays at 90% of total billed charges,$39.56 ,pays at MCR OPPS,$58.22 ,pays at 100% of MCD OPPS,$67.47 ,pays at 100% of MCD OPPS,$39.56 ,pays at MCR OPPS,$89.01 ,pays at 90% of total billed charges,$75.16 ,pays at 80% of total billed charges,$16.78 ,pays at MCR OPPS,$39.56 ,pays at MCR OPPS,$84.07 ,pays at 85% of total billed charges,$58.22 ,pays at MCD OPPS,$39.56 ,pays at MCR OPPS,$79.12 ,pays at 80% of total billed charges,$16.28 ,pays at 97% of MCR OPPS,$84.07 ,pays at 85% of total billed charges,$58.22 ,pays at MCD OPPS,$16.28 ,$93.96 ,$84.07 
Outpatient Medical Services,INFUSION & MEDICINE ADMIN,96374,"Intravenous infusion, for therapy, prophylaxis, or diagnosis-IV push",260,$235.90 ,$176.93 ,pays at 75% of total billed charges,$188.72 ,pays at 80% of total billed charges,$44.90 ,pays at MCR OPPS,$186.83 ,pays at 79.2% of total billed charges,$186.83 ,pays at 79.2% of total billed charges,$186.83 ,pays at 79.2% of total billed charges,$186.83 ,pays at 79.2% of total billed charges,$200.52 ,pays at 85% of total billed charges,$58.22 ,pays at MCD O/P rates,$94.36 ,pays at MCR OPPS,$224.11 ,pays at 95% of total billed charges,$188.72 ,pays at 80% total billed charges,$200.52 ,pays at 85% of total billed charges,$212.31 ,pays at 90% of total billed charges,$94.36 ,pays at MCR OPPS,$58.22 ,pays at 100% of MCD OPPS,$206.57 ,pays at 100% of MCD OPPS,$94.36 ,pays at MCR OPPS,$212.31 ,pays at 90% of total billed charges,$179.28 ,pays at 80% of total billed charges,$44.90 ,pays at MCR OPPS,$94.36 ,pays at MCR OPPS,$200.52 ,pays at 85% of total billed charges,$58.22 ,pays at MCD OPPS,$94.36 ,pays at MCR OPPS,$188.72 ,pays at 80% of total billed charges,$43.55 ,pays at 97% of MCR OPPS,$200.52 ,pays at 85% of total billed charges,$58.22 ,pays at MCD OPPS,$43.55 ,$224.11 ,$200.52 
Outpatient Medical Services,INFUSION & MEDICINE ADMIN,96375,"Intravenous infusion, for treatment, prophylaxis, or diagnosis-new drug add on",260,$96.80 ,$72.60 ,pays at 75% of total billed charges,$77.44 ,pays at 80% of total billed charges,$18.54 ,pays at MCR OPPS,$76.67 ,pays at 79.2% of total billed charges,$76.67 ,pays at 79.2% of total billed charges,$76.67 ,pays at 79.2% of total billed charges,$76.67 ,pays at 79.2% of total billed charges,$82.28 ,pays at 85% of total billed charges,$58.22 ,pays at MCD O/P rates,$38.72 ,pays at MCR OPPS,$91.96 ,pays at 95% of total billed charges,$77.44 ,pays at 80% total billed charges,$82.28 ,pays at 85% of total billed charges,$87.12 ,pays at 90% of total billed charges,$38.72 ,pays at MCR OPPS,$58.22 ,pays at 100% of MCD OPPS,$42.37 ,pays at 100% of MCD OPPS,$38.72 ,pays at MCR OPPS,$87.12 ,pays at 90% of total billed charges,$73.57 ,pays at 80% of total billed charges,$18.54 ,pays at MCR OPPS,$38.72 ,pays at MCR OPPS,$82.28 ,pays at 85% of total billed charges,$58.22 ,pays at MCD OPPS,$38.72 ,pays at MCR OPPS,$77.44 ,pays at 80% of total billed charges,$17.98 ,pays at 97% of MCR OPPS,$82.28 ,pays at 85% of total billed charges,$58.22 ,pays at MCD OPPS,$17.98 ,$91.96 ,$82.28 
Outpatient Medical Services,INFUSION & MEDICINE ADMIN,96376,"Intravenous infusion, for treatment, prophylaxis, or diagnosis-same drug add on",260,$96.80 ,$72.60 ,pays at 75% of total billed charges,$77.44 ,pays at 80% of total billed charges,N/A,AUDIT: // Allowable RM =  Physician Fee Schedule (outpatient):(96376) $0.00 * 1 * 115% = $0.00,$76.67 ,pays at 79.2% of total billed charges,$76.67 ,pays at 79.2% of total billed charges,$76.67 ,pays at 79.2% of total billed charges,$76.67 ,pays at 79.2% of total billed charges,$82.28 ,pays at 85% of total billed charges,$58.22 ,pays at MCD O/P rates,$38.72 ,pays at MCR OPPS,$91.96 ,pays at 95% of total billed charges,$77.44 ,pays at 80% total billed charges,$82.28 ,pays at 85% of total billed charges,$87.12 ,pays at 90% of total billed charges,$38.72 ,pays at MCR OPPS,$58.22 ,pays at 100% of MCD OPPS,$96.80 ,pays at 100% of MCD OPPS,$38.72 ,pays at MCR OPPS,$87.12 ,pays at 90% of total billed charges,$73.57 ,pays at 80% of total billed charges,N/A,not reimburseable per contract,$38.72 ,pays at MCR OPPS,$82.28 ,pays at 85% of total billed charges,$58.22 ,pays at MCD OPPS,$38.72 ,pays at MCR OPPS,$77.44 ,pays at 80% of total billed charges,N/A,not reimburseable per contract,$82.28 ,pays at 85% of total billed charges,$58.22 ,pays at MCD OPPS,$38.72 ,$96.80 ,$82.28 
Outpatient Medical Services,INFUSION & MEDICINE ADMIN,96411,"Chemotherapy Administration; Intravenous, Push Technique, Each Additional Substance/Drug (List Separately In Addition To Code For Primary Procedure)",260,$171.00 ,$128.25 ,pays at 75% of total billed charges,$136.80 ,pays at 80% of total billed charges,$66.77 ,pays at MCR OPPS,$135.43 ,pays at 79.2% of total billed charges,$135.43 ,pays at 79.2% of total billed charges,$135.43 ,pays at 79.2% of total billed charges,$135.43 ,pays at 79.2% of total billed charges,$145.35 ,pays at 85% of total billed charges,$58.22 ,pays at MCD O/P rates,$68.40 ,pays at MCR OPPS,$162.45 ,pays at 95% of total billed charges,$136.80 ,pays at 80% total billed charges,$145.35 ,pays at 85% of total billed charges,$153.90 ,pays at 90% of total billed charges,$68.40 ,pays at MCR OPPS,$58.22 ,pays at 100% of MCD OPPS,$67.47 ,pays at 100% of MCD OPPS,$68.40 ,pays at MCR OPPS,$153.90 ,pays at 90% of total billed charges,$129.96 ,pays at 80% of total billed charges,$66.77 ,pays at MCR OPPS,$68.40 ,pays at MCR OPPS,$145.35 ,pays at 85% of total billed charges,$58.22 ,pays at MCD OPPS,$68.40 ,pays at MCR OPPS,$136.80 ,pays at 80% of total billed charges,$64.77 ,pays at 97% of MCR OPPS,$145.35 ,pays at 85% of total billed charges,$58.22 ,pays at MCD OPPS,$58.22 ,$162.45 ,$145.35 
Outpatient Medical Services,INFUSION & MEDICINE ADMIN,96413,"Chemotherapy Administration, Intravenous Infusion Technique; Up To 1 Hour, Single Or Initial Substance/Drug",260,$898.20 ,$673.65 ,pays at 75% of total billed charges,$718.56 ,pays at 80% of total billed charges,$158.40 ,pays at MCR OPPS,$711.37 ,pays at 79.2% of total billed charges,$711.37 ,pays at 79.2% of total billed charges,$711.37 ,pays at 79.2% of total billed charges,$711.37 ,pays at 79.2% of total billed charges,$763.47 ,pays at 85% of total billed charges,$399.29 ,pays at MCD O/P rates,$359.28 ,pays at MCR OPPS,$853.29 ,pays at 95% of total billed charges,$718.56 ,pays at 80% total billed charges,$763.47 ,pays at 85% of total billed charges,$808.38 ,pays at 90% of total billed charges,$359.28 ,pays at MCR OPPS,$399.29 ,pays at 100% of MCD OPPS,$332.62 ,pays at 100% of MCD OPPS,$359.28 ,pays at MCR OPPS,$808.38 ,pays at 90% of total billed charges,$682.63 ,pays at 80% of total billed charges,$158.40 ,pays at MCR OPPS,$359.28 ,pays at MCR OPPS,$763.47 ,pays at 85% of total billed charges,$399.29 ,pays at MCD OPPS,$359.28 ,pays at MCR OPPS,$718.56 ,pays at 80% of total billed charges,$153.65 ,pays at 97% of MCR OPPS,$763.47 ,pays at 85% of total billed charges,$399.29 ,pays at MCD OPPS,$153.65 ,$853.29 ,$763.47 
Outpatient Medical Services,INFUSION & MEDICINE ADMIN,96415,Chemotherapy infusion-each additional hour,260,$171.00 ,$128.25 ,pays at 75% of total billed charges,$136.80 ,pays at 80% of total billed charges,$33.83 ,pays at MCR OPPS,$135.43 ,pays at 79.2% of total billed charges,$135.43 ,pays at 79.2% of total billed charges,$135.43 ,pays at 79.2% of total billed charges,$135.43 ,pays at 79.2% of total billed charges,$145.35 ,pays at 85% of total billed charges,$171.00 ,pays at MCD O/P rates,$68.40 ,pays at MCR OPPS,$162.45 ,pays at 95% of total billed charges,$136.80 ,pays at 80% total billed charges,$145.35 ,pays at 85% of total billed charges,$153.90 ,pays at 90% of total billed charges,$68.40 ,pays at MCR OPPS,$675.81 ,pays at 100% of MCD OPPS,$67.47 ,pays at 100% of MCD OPPS,$68.40 ,pays at MCR OPPS,$153.90 ,pays at 90% of total billed charges,$129.96 ,pays at 80% of total billed charges,$33.83 ,pays at MCR OPPS,$68.40 ,pays at MCR OPPS,$145.35 ,pays at 85% of total billed charges,$675.81 ,pays at MCD OPPS,$68.40 ,pays at MCR OPPS,$136.80 ,pays at 80% of total billed charges,$32.82 ,pays at 97% of MCR OPPS,$145.35 ,pays at 85% of total billed charges,$675.81 ,pays at MCD OPPS,$32.82 ,$675.81 ,$145.35 
Outpatient Medical Services,INFUSION & MEDICINE ADMIN,96417,Chemotherapy infusion-additional IV pushes of the same medication,260,$171.00 ,$128.25 ,pays at 75% of total billed charges,$136.80 ,pays at 80% of total billed charges,$77.80 ,pays at MCR OPPS,$135.43 ,pays at 79.2% of total billed charges,$135.43 ,pays at 79.2% of total billed charges,$135.43 ,pays at 79.2% of total billed charges,$135.43 ,pays at 79.2% of total billed charges,$145.35 ,pays at 85% of total billed charges,$171.00 ,pays at MCD O/P rates,$68.40 ,pays at MCR OPPS,$162.45 ,pays at 95% of total billed charges,$136.80 ,pays at 80% total billed charges,$145.35 ,pays at 85% of total billed charges,$153.90 ,pays at 90% of total billed charges,$68.40 ,pays at MCR OPPS,$399.29 ,pays at 100% of MCD OPPS,$67.47 ,pays at 100% of MCD OPPS,$68.40 ,pays at MCR OPPS,$153.90 ,pays at 90% of total billed charges,$129.96 ,pays at 80% of total billed charges,$77.80 ,pays at MCR OPPS,$68.40 ,pays at MCR OPPS,$145.35 ,pays at 85% of total billed charges,$399.29 ,pays at MCD OPPS,$68.40 ,pays at MCR OPPS,$136.80 ,pays at 80% of total billed charges,$75.46 ,pays at 97% of MCR OPPS,$145.35 ,pays at 85% of total billed charges,$399.29 ,pays at MCD OPPS,$67.47 ,$399.29 ,$145.35 
Outpatient Medical Services,INFUSION & MEDICINE ADMIN,36430,"Transfusion, Blood Or Blood Components",260,"$1,183.20 ",$887.40 ,pays at 75% of total billed charges,$946.56 ,pays at 80% of total billed charges,$47.67 ,pays at MCR OPPS,$937.09 ,pays at 79.2% of total billed charges,$937.09 ,pays at 79.2% of total billed charges,$937.09 ,pays at 79.2% of total billed charges,$937.09 ,pays at 79.2% of total billed charges,"$1,005.72 ",pays at 85% of total billed charges,$606.63 ,pays at MCD O/P rates,$473.28 ,pays at MCR OPPS,"$1,124.04 ",pays at 95% of total billed charges,$946.56 ,pays at 80% total billed charges,"$1,005.72 ",pays at 85% of total billed charges,"$1,064.88 ",pays at 90% of total billed charges,$473.28 ,pays at MCR OPPS,$606.63 ,pays at 100% of MCD OPPS,$407.75 ,pays at 100% of MCD OPPS,$473.28 ,pays at MCR OPPS,"$1,064.88 ",pays at 90% of total billed charges,$899.23 ,pays at 80% of total billed charges,$47.67 ,pays at MCR OPPS,$473.28 ,pays at MCR OPPS,"$1,005.72 ",pays at 85% of total billed charges,$606.63 ,pays at MCD OPPS,$473.28 ,pays at MCR OPPS,$946.56 ,pays at 80% of total billed charges,$46.24 ,pays at 97% of MCR OPPS,"$1,005.72 ",pays at 85% of total billed charges,$606.63 ,pays at MCD OPPS,$46.24 ,"$1,124.04 ","$1,005.72 "
Outpatient Medical Services,INFUSION & MEDICINE ADMIN,96523,Irrigation Of Implanted Venous Access Device For Drug Delivery Systems,260,$176.10 ,$132.08 ,pays at 75% of total billed charges,$140.88 ,pays at 80% of total billed charges,$30.92 ,pays at MCR OPPS,$139.47 ,pays at 79.2% of total billed charges,$139.47 ,pays at 79.2% of total billed charges,$139.47 ,pays at 79.2% of total billed charges,$139.47 ,pays at 79.2% of total billed charges,$149.69 ,pays at 85% of total billed charges,$58.22 ,pays at MCD O/P rates,$70.44 ,pays at MCR OPPS,$167.30 ,pays at 95% of total billed charges,$140.88 ,pays at 80% total billed charges,$149.69 ,pays at 85% of total billed charges,$158.49 ,pays at 90% of total billed charges,$70.44 ,pays at MCR OPPS,$58.22 ,pays at 100% of MCD OPPS,$57.48 ,pays at 100% of MCD OPPS,$70.44 ,pays at MCR OPPS,$158.49 ,pays at 90% of total billed charges,$133.84 ,pays at 80% of total billed charges,$30.92 ,pays at MCR OPPS,$70.44 ,pays at MCR OPPS,$149.69 ,pays at 85% of total billed charges,$58.22 ,pays at MCD OPPS,$70.44 ,pays at MCR OPPS,$140.88 ,pays at 80% of total billed charges,$30.00 ,pays at 97% of MCR OPPS,$149.69 ,pays at 85% of total billed charges,$58.22 ,pays at MCD OPPS,$30.00 ,$167.30 ,$149.69 
Outpatient Medical Services,LABORATORY & PATHOLOGY,36415,Collection of venous blood by venipuncture,300,$12.40 ,$9.30 ,pays at 75% of total billed charges,$9.92 ,pays at 80% of total billed charges,$8.57 ,pays at MCR OPPS,$9.82 ,pays at 79.2% of total billed charges,$9.82 ,pays at 79.2% of total billed charges,$9.82 ,pays at 79.2% of total billed charges,$9.82 ,pays at 79.2% of total billed charges,$10.54 ,pays at 85% of total billed charges,$3.07 ,pays at MCD O/P rates,$4.96 ,pays at MCR OPPS,$11.78 ,pays at 95% of total billed charges,$9.92 ,pays at 80% total billed charges,$10.54 ,pays at 85% of total billed charges,$11.16 ,pays at 90% of total billed charges,$4.96 ,pays at MCR OPPS,$3.07 ,pays at 100% of MCD OPPS,$8.06 ,pays at 100% of MCD OPPS,$4.96 ,pays at MCR OPPS,$11.16 ,pays at 90% of total billed charges,$9.42 ,pays at 80% of total billed charges,$8.57 ,pays at MCR OPPS,$4.96 ,pays at MCR OPPS,$10.54 ,pays at 85% of total billed charges,$3.07 ,pays at MCD OPPS,$4.96 ,pays at MCR OPPS,$9.92 ,pays at 80% of total billed charges,$8.31 ,pays at 97% of MCR OPPS,$10.54 ,pays at 85% of total billed charges,$3.07 ,pays at MCD OPPS,$3.07 ,$11.78 ,$10.54 
Outpatient Medical Services,LABORATORY & PATHOLOGY,36600,"Arterial Puncture, Withdrawal Of Blood For Diagnosis",300,$124.60 ,$93.45 ,pays at 75% of total billed charges,$99.68 ,pays at 80% of total billed charges,$17.24 ,pays at MCR OPPS,$98.68 ,pays at 79.2% of total billed charges,$98.68 ,pays at 79.2% of total billed charges,$98.68 ,pays at 79.2% of total billed charges,$98.68 ,pays at 79.2% of total billed charges,$105.91 ,pays at 85% of total billed charges,$77.32 ,pays at MCD O/P rates,$49.84 ,pays at MCR OPPS,$118.37 ,pays at 95% of total billed charges,$99.68 ,pays at 80% total billed charges,$105.91 ,pays at 85% of total billed charges,$112.14 ,pays at 90% of total billed charges,$49.84 ,pays at MCR OPPS,$77.32 ,pays at 100% of MCD OPPS,$116.11 ,pays at 100% of MCD OPPS,$49.84 ,pays at MCR OPPS,$112.14 ,pays at 90% of total billed charges,$94.70 ,pays at 80% of total billed charges,$17.24 ,pays at MCR OPPS,$49.84 ,pays at MCR OPPS,$105.91 ,pays at 85% of total billed charges,$77.32 ,pays at MCD OPPS,$49.84 ,pays at MCR OPPS,$99.68 ,pays at 80% of total billed charges,$16.72 ,pays at 97% of MCR OPPS,$105.91 ,pays at 85% of total billed charges,$77.32 ,pays at MCD OPPS,$16.72 ,$118.37 ,$105.91 
Outpatient Medical Services,LABORATORY & PATHOLOGY,36592,"Collection Of Blood Specimen Using Established Central Or Peripheral Catheter, Venous, Not Otherwise Specified",300,$324.50 ,$243.38 ,pays at 75% of total billed charges,$259.60 ,pays at 80% of total billed charges,$35.50 ,pays at MCR OPPS,$257.00 ,pays at 79.2% of total billed charges,$257.00 ,pays at 79.2% of total billed charges,$257.00 ,pays at 79.2% of total billed charges,$257.00 ,pays at 79.2% of total billed charges,$275.83 ,pays at 85% of total billed charges,$77.32 ,pays at MCD O/P rates,$129.80 ,pays at MCR OPPS,$308.28 ,pays at 95% of total billed charges,$259.60 ,pays at 80% total billed charges,$275.83 ,pays at 85% of total billed charges,$292.05 ,pays at 90% of total billed charges,$129.80 ,pays at MCR OPPS,$77.32 ,pays at 100% of MCD OPPS,$116.11 ,pays at 100% of MCD OPPS,$129.80 ,pays at MCR OPPS,$292.05 ,pays at 90% of total billed charges,$246.62 ,pays at 80% of total billed charges,$35.50 ,pays at MCR OPPS,$129.80 ,pays at MCR OPPS,$275.83 ,pays at 85% of total billed charges,$77.32 ,pays at MCD OPPS,$129.80 ,pays at MCR OPPS,$259.60 ,pays at 80% of total billed charges,$34.44 ,pays at 97% of MCR OPPS,$275.83 ,pays at 85% of total billed charges,$77.32 ,pays at MCD OPPS,$34.44 ,$308.28 ,$275.83 
Outpatient Medical Services,LABORATORY & PATHOLOGY,36591,Collection Of Blood Specimen From A Completely Implantable Venous Access Device,300,$309.00 ,$231.75 ,pays at 75% of total billed charges,$247.20 ,pays at 80% of total billed charges,$32.63 ,pays at MCR OPPS,$244.73 ,pays at 79.2% of total billed charges,$244.73 ,pays at 79.2% of total billed charges,$244.73 ,pays at 79.2% of total billed charges,$244.73 ,pays at 79.2% of total billed charges,$262.65 ,pays at 85% of total billed charges,$77.32 ,pays at MCD O/P rates,$123.60 ,pays at MCR OPPS,$293.55 ,pays at 95% of total billed charges,$247.20 ,pays at 80% total billed charges,$262.65 ,pays at 85% of total billed charges,$278.10 ,pays at 90% of total billed charges,$123.60 ,pays at MCR OPPS,$77.32 ,pays at 100% of MCD OPPS,$116.11 ,pays at 100% of MCD OPPS,$123.60 ,pays at MCR OPPS,$278.10 ,pays at 90% of total billed charges,$234.84 ,pays at 80% of total billed charges,$32.63 ,pays at MCR OPPS,$123.60 ,pays at MCR OPPS,$262.65 ,pays at 85% of total billed charges,$77.32 ,pays at MCD OPPS,$123.60 ,pays at MCR OPPS,$247.20 ,pays at 80% of total billed charges,$31.65 ,pays at 97% of MCR OPPS,$262.65 ,pays at 85% of total billed charges,$77.32 ,pays at MCD OPPS,$31.65 ,$293.55 ,$262.65 
Outpatient Medical Services,LABORATORY & PATHOLOGY,80048,Basic metabolic panel,300,$94.00 ,$70.50 ,pays at 75% of total billed charges,$75.20 ,pays at 80% of total billed charges,$8.46 ,pays at MCR OPPS,$74.45 ,pays at 79.2% of total billed charges,$74.45 ,pays at 79.2% of total billed charges,$74.45 ,pays at 79.2% of total billed charges,$74.45 ,pays at 79.2% of total billed charges,$79.90 ,pays at 85% of total billed charges,$10.92 ,pays at MCD O/P rates,$37.60 ,pays at MCR OPPS,$89.30 ,pays at 95% of total billed charges,$75.20 ,pays at 80% total billed charges,$79.90 ,pays at 85% of total billed charges,$84.60 ,pays at 90% of total billed charges,$37.60 ,pays at MCR OPPS,$10.92 ,pays at 100% of MCD OPPS,$7.95 ,pays at 100% of MCD OPPS,$37.60 ,pays at MCR OPPS,$84.60 ,pays at 90% of total billed charges,$71.44 ,pays at 80% of total billed charges,$8.46 ,pays at MCR OPPS,$37.60 ,pays at MCR OPPS,$79.90 ,pays at 85% of total billed charges,$10.92 ,pays at MCD OPPS,$37.60 ,pays at MCR OPPS,$75.20 ,pays at 80% of total billed charges,$8.21 ,pays at 97% of MCR OPPS,$79.90 ,pays at 85% of total billed charges,$10.92 ,pays at MCD OPPS,$7.95 ,$89.30 ,$79.90 
Outpatient Medical Services,LABORATORY & PATHOLOGY,80053,"Blood test, comprehensive group of blood chemicals",300,$124.00 ,$93.00 ,pays at 75% of total billed charges,$99.20 ,pays at 80% of total billed charges,$10.56 ,pays at MCR OPPS,$98.21 ,pays at 79.2% of total billed charges,$98.21 ,pays at 79.2% of total billed charges,$98.21 ,pays at 79.2% of total billed charges,$98.21 ,pays at 79.2% of total billed charges,$105.40 ,pays at 85% of total billed charges,$10.92 ,pays at MCD O/P rates,$49.60 ,pays at MCR OPPS,$117.80 ,pays at 95% of total billed charges,$99.20 ,pays at 80% total billed charges,$105.40 ,pays at 85% of total billed charges,$111.60 ,pays at 90% of total billed charges,$49.60 ,pays at MCR OPPS,$10.92 ,pays at 100% of MCD OPPS,$9.93 ,pays at 100% of MCD OPPS,$49.60 ,pays at MCR OPPS,$111.60 ,pays at 90% of total billed charges,$94.24 ,pays at 80% of total billed charges,$10.56 ,pays at MCR OPPS,$49.60 ,pays at MCR OPPS,$105.40 ,pays at 85% of total billed charges,$10.92 ,pays at MCD OPPS,$49.60 ,pays at MCR OPPS,$99.20 ,pays at 80% of total billed charges,$10.24 ,pays at 97% of MCR OPPS,$105.40 ,pays at 85% of total billed charges,$10.92 ,pays at MCD OPPS,$9.93 ,$117.80 ,$105.40 
Outpatient Medical Services,LABORATORY & PATHOLOGY,80055,Obstetric blood test panel,300,$294.00 ,$220.50 ,pays at 75% of total billed charges,$235.20 ,pays at 80% of total billed charges,$47.81 ,pays at MCR OPPS,$232.85 ,pays at 79.2% of total billed charges,$232.85 ,pays at 79.2% of total billed charges,$232.85 ,pays at 79.2% of total billed charges,$232.85 ,pays at 79.2% of total billed charges,$249.90 ,pays at 85% of total billed charges,$10.92 ,pays at MCD O/P rates,$117.60 ,pays at MCR OPPS,$279.30 ,pays at 95% of total billed charges,$235.20 ,pays at 80% total billed charges,$249.90 ,pays at 85% of total billed charges,$264.60 ,pays at 90% of total billed charges,$117.60 ,pays at MCR OPPS,$10.92 ,pays at 100% of MCD OPPS,$44.94 ,pays at 100% of MCD OPPS,$117.60 ,pays at MCR OPPS,$264.60 ,pays at 90% of total billed charges,$223.44 ,pays at 80% of total billed charges,$47.81 ,pays at MCR OPPS,$117.60 ,pays at MCR OPPS,$249.90 ,pays at 85% of total billed charges,$10.92 ,pays at MCD OPPS,$117.60 ,pays at MCR OPPS,$235.20 ,pays at 80% of total billed charges,$46.38 ,pays at 97% of MCR OPPS,$249.90 ,pays at 85% of total billed charges,$10.92 ,pays at MCD OPPS,$10.92 ,$279.30 ,$249.90 
Outpatient Medical Services,LABORATORY & PATHOLOGY,80061,"Blood test, lipids (cholesterol and triglycerides)",300,$134.00 ,$100.50 ,pays at 75% of total billed charges,$107.20 ,pays at 80% of total billed charges,$13.39 ,pays at MCR OPPS,$106.13 ,pays at 79.2% of total billed charges,$106.13 ,pays at 79.2% of total billed charges,$106.13 ,pays at 79.2% of total billed charges,$106.13 ,pays at 79.2% of total billed charges,$113.90 ,pays at 85% of total billed charges,$10.92 ,pays at MCD O/P rates,$53.60 ,pays at MCR OPPS,$127.30 ,pays at 95% of total billed charges,$107.20 ,pays at 80% total billed charges,$113.90 ,pays at 85% of total billed charges,$120.60 ,pays at 90% of total billed charges,$53.60 ,pays at MCR OPPS,$10.92 ,pays at 100% of MCD OPPS,$12.59 ,pays at 100% of MCD OPPS,$53.60 ,pays at MCR OPPS,$120.60 ,pays at 90% of total billed charges,$101.84 ,pays at 80% of total billed charges,$13.39 ,pays at MCR OPPS,$53.60 ,pays at MCR OPPS,$113.90 ,pays at 85% of total billed charges,$10.92 ,pays at MCD OPPS,$53.60 ,pays at MCR OPPS,$107.20 ,pays at 80% of total billed charges,$12.99 ,pays at 97% of MCR OPPS,$113.90 ,pays at 85% of total billed charges,$10.92 ,pays at MCD OPPS,$10.92 ,$127.30 ,$113.90 
Outpatient Medical Services,LABORATORY & PATHOLOGY,80069,Kidney function panel test,300,$60.00 ,$45.00 ,pays at 75% of total billed charges,$48.00 ,pays at 80% of total billed charges,$8.68 ,pays at MCR OPPS,$47.52 ,pays at 79.2% of total billed charges,$47.52 ,pays at 79.2% of total billed charges,$47.52 ,pays at 79.2% of total billed charges,$47.52 ,pays at 79.2% of total billed charges,$51.00 ,pays at 85% of total billed charges,$10.92 ,pays at MCD O/P rates,$24.00 ,pays at MCR OPPS,$57.00 ,pays at 95% of total billed charges,$48.00 ,pays at 80% total billed charges,$51.00 ,pays at 85% of total billed charges,$54.00 ,pays at 90% of total billed charges,$24.00 ,pays at MCR OPPS,$10.92 ,pays at 100% of MCD OPPS,$8.16 ,pays at 100% of MCD OPPS,$24.00 ,pays at MCR OPPS,$54.00 ,pays at 90% of total billed charges,$45.60 ,pays at 80% of total billed charges,$8.68 ,pays at MCR OPPS,$24.00 ,pays at MCR OPPS,$51.00 ,pays at 85% of total billed charges,$10.92 ,pays at MCD OPPS,$24.00 ,pays at MCR OPPS,$48.00 ,pays at 80% of total billed charges,$8.42 ,pays at 97% of MCR OPPS,$51.00 ,pays at 85% of total billed charges,$10.92 ,pays at MCD OPPS,$8.16 ,$57.00 ,$51.00 
Outpatient Medical Services,LABORATORY & PATHOLOGY,80074,Acute hepatitis panel,300,$350.00 ,$262.50 ,pays at 75% of total billed charges,$280.00 ,pays at 80% of total billed charges,$47.63 ,pays at MCR OPPS,$277.20 ,pays at 79.2% of total billed charges,$277.20 ,pays at 79.2% of total billed charges,$277.20 ,pays at 79.2% of total billed charges,$277.20 ,pays at 79.2% of total billed charges,$297.50 ,pays at 85% of total billed charges,$10.92 ,pays at MCD O/P rates,$140.00 ,pays at MCR OPPS,$332.50 ,pays at 95% of total billed charges,$280.00 ,pays at 80% total billed charges,$297.50 ,pays at 85% of total billed charges,$315.00 ,pays at 90% of total billed charges,$140.00 ,pays at MCR OPPS,$10.92 ,pays at 100% of MCD OPPS,$44.77 ,pays at 100% of MCD OPPS,$140.00 ,pays at MCR OPPS,$315.00 ,pays at 90% of total billed charges,$266.00 ,pays at 80% of total billed charges,$47.63 ,pays at MCR OPPS,$140.00 ,pays at MCR OPPS,$297.50 ,pays at 85% of total billed charges,$10.92 ,pays at MCD OPPS,$140.00 ,pays at MCR OPPS,$280.00 ,pays at 80% of total billed charges,$46.20 ,pays at 97% of MCR OPPS,$297.50 ,pays at 85% of total billed charges,$10.92 ,pays at MCD OPPS,$10.92 ,$332.50 ,$297.50 
Outpatient Medical Services,LABORATORY & PATHOLOGY,80076,Liver function blood test panel,300,$158.00 ,$118.50 ,pays at 75% of total billed charges,$126.40 ,pays at 80% of total billed charges,$8.17 ,pays at MCR OPPS,$125.14 ,pays at 79.2% of total billed charges,$125.14 ,pays at 79.2% of total billed charges,$125.14 ,pays at 79.2% of total billed charges,$125.14 ,pays at 79.2% of total billed charges,$134.30 ,pays at 85% of total billed charges,$10.92 ,pays at MCD O/P rates,$63.20 ,pays at MCR OPPS,$150.10 ,pays at 95% of total billed charges,$126.40 ,pays at 80% total billed charges,$134.30 ,pays at 85% of total billed charges,$142.20 ,pays at 90% of total billed charges,$63.20 ,pays at MCR OPPS,$10.92 ,pays at 100% of MCD OPPS,$7.68 ,pays at 100% of MCD OPPS,$63.20 ,pays at MCR OPPS,$142.20 ,pays at 90% of total billed charges,$120.08 ,pays at 80% of total billed charges,$8.17 ,pays at MCR OPPS,$63.20 ,pays at MCR OPPS,$134.30 ,pays at 85% of total billed charges,$10.92 ,pays at MCD OPPS,$63.20 ,pays at MCR OPPS,$126.40 ,pays at 80% of total billed charges,$7.92 ,pays at 97% of MCR OPPS,$134.30 ,pays at 85% of total billed charges,$10.92 ,pays at MCD OPPS,$7.68 ,$150.10 ,$134.30 
Outpatient Medical Services,LABORATORY & PATHOLOGY,80306,"Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; read by instrument assisted direct optical observation (eg",300,$105.00 ,$78.75 ,pays at 75% of total billed charges,$84.00 ,pays at 80% of total billed charges,$17.14 ,pays at MCR OPPS,$83.16 ,pays at 79.2% of total billed charges,$83.16 ,pays at 79.2% of total billed charges,$83.16 ,pays at 79.2% of total billed charges,$83.16 ,pays at 79.2% of total billed charges,$89.25 ,pays at 85% of total billed charges,$105.00 ,pays at MCD O/P rates,$42.00 ,pays at MCR OPPS,$99.75 ,pays at 95% of total billed charges,$84.00 ,pays at 80% total billed charges,$89.25 ,pays at 85% of total billed charges,$94.50 ,pays at 90% of total billed charges,$42.00 ,pays at MCR OPPS,$105.00 ,pays at 100% of MCD OPPS,$16.11 ,pays at 100% of MCD OPPS,$42.00 ,pays at MCR OPPS,$94.50 ,pays at 90% of total billed charges,$79.80 ,pays at 80% of total billed charges,$17.14 ,pays at MCR OPPS,$42.00 ,pays at MCR OPPS,$89.25 ,pays at 85% of total billed charges,$105.00 ,pays at MCD OPPS,$42.00 ,pays at MCR OPPS,$84.00 ,pays at 80% of total billed charges,$16.63 ,pays at 97% of MCR OPPS,$89.25 ,pays at 85% of total billed charges,$105.00 ,pays at MCD OPPS,$16.11 ,$105.00 ,$89.25 
Outpatient Medical Services,LABORATORY & PATHOLOGY,80320,Alcohols,300,$111.00 ,$83.25 ,pays at 75% of total billed charges,$88.80 ,pays at 80% of total billed charges,N/A,AUDIT: // Allowable RM =  Physician Fee Schedule (outpatient):(80320) $0.00 * 1 * 115% = $0.00,$87.91 ,pays at 79.2% of total billed charges,$87.91 ,pays at 79.2% of total billed charges,$87.91 ,pays at 79.2% of total billed charges,$87.91 ,pays at 79.2% of total billed charges,$94.35 ,pays at 85% of total billed charges,$111.00 ,pays at MCD O/P rates,$44.40 ,pays at MCR OPPS,$105.45 ,pays at 95% of total billed charges,$88.80 ,pays at 80% total billed charges,$94.35 ,pays at 85% of total billed charges,$99.90 ,pays at 90% of total billed charges,$44.40 ,pays at MCR OPPS,$111.00 ,pays at 100% of MCD OPPS,$111.00 ,pays at 100% of MCD OPPS,$44.40 ,pays at MCR OPPS,$99.90 ,pays at 90% of total billed charges,$84.36 ,pays at 80% of total billed charges,N/A,not reimburseable per contract,$44.40 ,pays at MCR OPPS,$94.35 ,pays at 85% of total billed charges,$111.00 ,pays at MCD OPPS,$44.40 ,pays at MCR OPPS,$88.80 ,pays at 80% of total billed charges,N/A,not reimburseable per contract,$94.35 ,pays at 85% of total billed charges,$111.00 ,pays at MCD OPPS,$44.40 ,$111.00 ,$94.35 
Outpatient Medical Services,LABORATORY & PATHOLOGY,80329,"Analgesics, Non-Opioid; 1 Or 2",300,$133.00 ,$99.75 ,pays at 75% of total billed charges,$106.40 ,pays at 80% of total billed charges,N/A,AUDIT: // Allowable RM =  Physician Fee Schedule (outpatient):(80329) $0.00 * 1 * 115% = $0.00,$105.34 ,pays at 79.2% of total billed charges,$105.34 ,pays at 79.2% of total billed charges,$105.34 ,pays at 79.2% of total billed charges,$105.34 ,pays at 79.2% of total billed charges,$113.05 ,pays at 85% of total billed charges,$133.00 ,pays at MCD O/P rates,$53.20 ,pays at MCR OPPS,$126.35 ,pays at 95% of total billed charges,$106.40 ,pays at 80% total billed charges,$113.05 ,pays at 85% of total billed charges,$119.70 ,pays at 90% of total billed charges,$53.20 ,pays at MCR OPPS,$133.00 ,pays at 100% of MCD OPPS,$133.00 ,pays at 100% of MCD OPPS,$53.20 ,pays at MCR OPPS,$119.70 ,pays at 90% of total billed charges,$101.08 ,pays at 80% of total billed charges,N/A,not reimburseable per contract,$53.20 ,pays at MCR OPPS,$113.05 ,pays at 85% of total billed charges,$133.00 ,pays at MCD OPPS,$53.20 ,pays at MCR OPPS,$106.40 ,pays at 80% of total billed charges,N/A,not reimburseable per contract,$113.05 ,pays at 85% of total billed charges,$133.00 ,pays at MCD OPPS,$53.20 ,$133.00 ,$113.05 
Outpatient Medical Services,LABORATORY & PATHOLOGY,81001,Manual urinalysis test with examination with or without using microscope,300,$70.00 ,$52.50 ,pays at 75% of total billed charges,$56.00 ,pays at 80% of total billed charges,$3.17 ,pays at MCR OPPS,$55.44 ,pays at 79.2% of total billed charges,$55.44 ,pays at 79.2% of total billed charges,$55.44 ,pays at 79.2% of total billed charges,$55.44 ,pays at 79.2% of total billed charges,$59.50 ,pays at 85% of total billed charges,$3.61 ,pays at MCD O/P rates,$28.00 ,pays at MCR OPPS,$66.50 ,pays at 95% of total billed charges,$56.00 ,pays at 80% total billed charges,$59.50 ,pays at 85% of total billed charges,$63.00 ,pays at 90% of total billed charges,$28.00 ,pays at MCR OPPS,$3.61 ,pays at 100% of MCD OPPS,$2.98 ,pays at 100% of MCD OPPS,$28.00 ,pays at MCR OPPS,$63.00 ,pays at 90% of total billed charges,$53.20 ,pays at 80% of total billed charges,$3.17 ,pays at MCR OPPS,$28.00 ,pays at MCR OPPS,$59.50 ,pays at 85% of total billed charges,$3.61 ,pays at MCD OPPS,$28.00 ,pays at MCR OPPS,$56.00 ,pays at 80% of total billed charges,$3.07 ,pays at 97% of MCR OPPS,$59.50 ,pays at 85% of total billed charges,$3.61 ,pays at MCD OPPS,$2.98 ,$66.50 ,$59.50 
Outpatient Medical Services,LABORATORY & PATHOLOGY,81002,Manual urinalysis test with examination without using microscope,300,$33.00 ,$24.75 ,pays at 75% of total billed charges,$26.40 ,pays at 80% of total billed charges,$3.48 ,pays at MCR OPPS,$26.14 ,pays at 79.2% of total billed charges,$26.14 ,pays at 79.2% of total billed charges,$26.14 ,pays at 79.2% of total billed charges,$26.14 ,pays at 79.2% of total billed charges,$28.05 ,pays at 85% of total billed charges,$3.61 ,pays at MCD O/P rates,$13.20 ,pays at MCR OPPS,$31.35 ,pays at 95% of total billed charges,$26.40 ,pays at 80% total billed charges,$28.05 ,pays at 85% of total billed charges,$29.70 ,pays at 90% of total billed charges,$13.20 ,pays at MCR OPPS,$3.61 ,pays at 100% of MCD OPPS,$3.27 ,pays at 100% of MCD OPPS,$13.20 ,pays at MCR OPPS,$29.70 ,pays at 90% of total billed charges,$25.08 ,pays at 80% of total billed charges,$3.48 ,pays at MCR OPPS,$13.20 ,pays at MCR OPPS,$28.05 ,pays at 85% of total billed charges,$3.61 ,pays at MCD OPPS,$13.20 ,pays at MCR OPPS,$26.40 ,pays at 80% of total billed charges,$3.38 ,pays at 97% of MCR OPPS,$28.05 ,pays at 85% of total billed charges,$3.61 ,pays at MCD OPPS,$3.27 ,$31.35 ,$28.05 
Outpatient Medical Services,LABORATORY & PATHOLOGY,81003,Automated urinalysis test,300,$38.00 ,$28.50 ,pays at 75% of total billed charges,$30.40 ,pays at 80% of total billed charges,$2.25 ,pays at MCR OPPS,$30.10 ,pays at 79.2% of total billed charges,$30.10 ,pays at 79.2% of total billed charges,$30.10 ,pays at 79.2% of total billed charges,$30.10 ,pays at 79.2% of total billed charges,$32.30 ,pays at 85% of total billed charges,$3.61 ,pays at MCD O/P rates,$15.20 ,pays at MCR OPPS,$36.10 ,pays at 95% of total billed charges,$30.40 ,pays at 80% total billed charges,$32.30 ,pays at 85% of total billed charges,$34.20 ,pays at 90% of total billed charges,$15.20 ,pays at MCR OPPS,$3.61 ,pays at 100% of MCD OPPS,$2.12 ,pays at 100% of MCD OPPS,$15.20 ,pays at MCR OPPS,$34.20 ,pays at 90% of total billed charges,$28.88 ,pays at 80% of total billed charges,$2.25 ,pays at MCR OPPS,$15.20 ,pays at MCR OPPS,$32.30 ,pays at 85% of total billed charges,$3.61 ,pays at MCD OPPS,$15.20 ,pays at MCR OPPS,$30.40 ,pays at 80% of total billed charges,$2.18 ,pays at 97% of MCR OPPS,$32.30 ,pays at 85% of total billed charges,$3.61 ,pays at MCD OPPS,$2.12 ,$36.10 ,$32.30 
Outpatient Medical Services,LABORATORY & PATHOLOGY,81015,Urinalysis; Microscopic Only,300,$56.00 ,$42.00 ,pays at 75% of total billed charges,$44.80 ,pays at 80% of total billed charges,$3.05 ,pays at MCR OPPS,$44.35 ,pays at 79.2% of total billed charges,$44.35 ,pays at 79.2% of total billed charges,$44.35 ,pays at 79.2% of total billed charges,$44.35 ,pays at 79.2% of total billed charges,$47.60 ,pays at 85% of total billed charges,$3.61 ,pays at MCD O/P rates,$22.40 ,pays at MCR OPPS,$53.20 ,pays at 95% of total billed charges,$44.80 ,pays at 80% total billed charges,$47.60 ,pays at 85% of total billed charges,$50.40 ,pays at 90% of total billed charges,$22.40 ,pays at MCR OPPS,$3.61 ,pays at 100% of MCD OPPS,$2.87 ,pays at 100% of MCD OPPS,$22.40 ,pays at MCR OPPS,$50.40 ,pays at 90% of total billed charges,$42.56 ,pays at 80% of total billed charges,$3.05 ,pays at MCR OPPS,$22.40 ,pays at MCR OPPS,$47.60 ,pays at 85% of total billed charges,$3.61 ,pays at MCD OPPS,$22.40 ,pays at MCR OPPS,$44.80 ,pays at 80% of total billed charges,$2.96 ,pays at 97% of MCR OPPS,$47.60 ,pays at 85% of total billed charges,$3.61 ,pays at MCD OPPS,$2.87 ,$53.20 ,$47.60 
Outpatient Medical Services,LABORATORY & PATHOLOGY,81025,Urine pregnancy test,300,$114.00 ,$85.50 ,pays at 75% of total billed charges,$91.20 ,pays at 80% of total billed charges,$8.61 ,pays at MCR OPPS,$90.29 ,pays at 79.2% of total billed charges,$90.29 ,pays at 79.2% of total billed charges,$90.29 ,pays at 79.2% of total billed charges,$90.29 ,pays at 79.2% of total billed charges,$96.90 ,pays at 85% of total billed charges,$3.61 ,pays at MCD O/P rates,$45.60 ,pays at MCR OPPS,$108.30 ,pays at 95% of total billed charges,$91.20 ,pays at 80% total billed charges,$96.90 ,pays at 85% of total billed charges,$102.60 ,pays at 90% of total billed charges,$45.60 ,pays at MCR OPPS,$3.61 ,pays at 100% of MCD OPPS,$8.09 ,pays at 100% of MCD OPPS,$45.60 ,pays at MCR OPPS,$102.60 ,pays at 90% of total billed charges,$86.64 ,pays at 80% of total billed charges,$8.61 ,pays at MCR OPPS,$45.60 ,pays at MCR OPPS,$96.90 ,pays at 85% of total billed charges,$3.61 ,pays at MCD OPPS,$45.60 ,pays at MCR OPPS,$91.20 ,pays at 80% of total billed charges,$8.35 ,pays at 97% of MCR OPPS,$96.90 ,pays at 85% of total billed charges,$3.61 ,pays at MCD OPPS,$3.61 ,$108.30 ,$96.90 
Outpatient Medical Services,LABORATORY & PATHOLOGY,81241,"F5 (Coagulation Factor V) (Eg, Hereditary Hypercoagulability) Gene Analysis, Leiden Variant",300,$460.00 ,$345.00 ,pays at 75% of total billed charges,$368.00 ,pays at 80% of total billed charges,$73.37 ,pays at MCR OPPS,$364.32 ,pays at 79.2% of total billed charges,$364.32 ,pays at 79.2% of total billed charges,$364.32 ,pays at 79.2% of total billed charges,$364.32 ,pays at 79.2% of total billed charges,$391.00 ,pays at 85% of total billed charges,$57.09 ,pays at MCD O/P rates,$184.00 ,pays at MCR OPPS,$437.00 ,pays at 95% of total billed charges,$368.00 ,pays at 80% total billed charges,$391.00 ,pays at 85% of total billed charges,$414.00 ,pays at 90% of total billed charges,$184.00 ,pays at MCR OPPS,$57.09 ,pays at 100% of MCD OPPS,$68.97 ,pays at 100% of MCD OPPS,$184.00 ,pays at MCR OPPS,$414.00 ,pays at 90% of total billed charges,$349.60 ,pays at 80% of total billed charges,$73.37 ,pays at MCR OPPS,$184.00 ,pays at MCR OPPS,$391.00 ,pays at 85% of total billed charges,$57.09 ,pays at MCD OPPS,$184.00 ,pays at MCR OPPS,$368.00 ,pays at 80% of total billed charges,$71.17 ,pays at 97% of MCR OPPS,$391.00 ,pays at 85% of total billed charges,$57.09 ,pays at MCD OPPS,$57.09 ,$437.00 ,$391.00 
Outpatient Medical Services,LABORATORY & PATHOLOGY,82009,"Ketone Body(S) (Eg, Acetone, Acetoacetic Acid, Beta-Hydroxybutyrate); Qualitative",300,$35.00 ,$26.25 ,pays at 75% of total billed charges,$28.00 ,pays at 80% of total billed charges,$4.52 ,pays at MCR OPPS,$27.72 ,pays at 79.2% of total billed charges,$27.72 ,pays at 79.2% of total billed charges,$27.72 ,pays at 79.2% of total billed charges,$27.72 ,pays at 79.2% of total billed charges,$29.75 ,pays at 85% of total billed charges,$6.44 ,pays at MCD O/P rates,$14.00 ,pays at MCR OPPS,$33.25 ,pays at 95% of total billed charges,$28.00 ,pays at 80% total billed charges,$29.75 ,pays at 85% of total billed charges,$31.50 ,pays at 90% of total billed charges,$14.00 ,pays at MCR OPPS,$6.44 ,pays at 100% of MCD OPPS,$4.25 ,pays at 100% of MCD OPPS,$14.00 ,pays at MCR OPPS,$31.50 ,pays at 90% of total billed charges,$26.60 ,pays at 80% of total billed charges,$4.52 ,pays at MCR OPPS,$14.00 ,pays at MCR OPPS,$29.75 ,pays at 85% of total billed charges,$6.44 ,pays at MCD OPPS,$14.00 ,pays at MCR OPPS,$28.00 ,pays at 80% of total billed charges,$4.38 ,pays at 97% of MCR OPPS,$29.75 ,pays at 85% of total billed charges,$6.44 ,pays at MCD OPPS,$4.25 ,$33.25 ,$29.75 
Outpatient Medical Services,LABORATORY & PATHOLOGY,82043,Urine test to measure albumin,300,$72.00 ,$54.00 ,pays at 75% of total billed charges,$57.60 ,pays at 80% of total billed charges,$5.78 ,pays at MCR OPPS,$57.02 ,pays at 79.2% of total billed charges,$57.02 ,pays at 79.2% of total billed charges,$57.02 ,pays at 79.2% of total billed charges,$57.02 ,pays at 79.2% of total billed charges,$61.20 ,pays at 85% of total billed charges,$3.61 ,pays at MCD O/P rates,$28.80 ,pays at MCR OPPS,$68.40 ,pays at 95% of total billed charges,$57.60 ,pays at 80% total billed charges,$61.20 ,pays at 85% of total billed charges,$64.80 ,pays at 90% of total billed charges,$28.80 ,pays at MCR OPPS,$3.61 ,pays at 100% of MCD OPPS,$5.43 ,pays at 100% of MCD OPPS,$28.80 ,pays at MCR OPPS,$64.80 ,pays at 90% of total billed charges,$54.72 ,pays at 80% of total billed charges,$5.78 ,pays at MCR OPPS,$28.80 ,pays at MCR OPPS,$61.20 ,pays at 85% of total billed charges,$3.61 ,pays at MCD OPPS,$28.80 ,pays at MCR OPPS,$57.60 ,pays at 80% of total billed charges,$5.61 ,pays at 97% of MCR OPPS,$61.20 ,pays at 85% of total billed charges,$3.61 ,pays at MCD OPPS,$3.61 ,$68.40 ,$61.20 
Outpatient Medical Services,LABORATORY & PATHOLOGY,82105,Alpha-Fetoprotein (Afp); Serum,300,$118.00 ,$88.50 ,pays at 75% of total billed charges,$94.40 ,pays at 80% of total billed charges,$16.77 ,pays at MCR OPPS,$93.46 ,pays at 79.2% of total billed charges,$93.46 ,pays at 79.2% of total billed charges,$93.46 ,pays at 79.2% of total billed charges,$93.46 ,pays at 79.2% of total billed charges,$100.30 ,pays at 85% of total billed charges,$16.03 ,pays at MCD O/P rates,$47.20 ,pays at MCR OPPS,$112.10 ,pays at 95% of total billed charges,$94.40 ,pays at 80% total billed charges,$100.30 ,pays at 85% of total billed charges,$106.20 ,pays at 90% of total billed charges,$47.20 ,pays at MCR OPPS,$16.03 ,pays at 100% of MCD OPPS,$15.76 ,pays at 100% of MCD OPPS,$47.20 ,pays at MCR OPPS,$106.20 ,pays at 90% of total billed charges,$89.68 ,pays at 80% of total billed charges,$16.77 ,pays at MCR OPPS,$47.20 ,pays at MCR OPPS,$100.30 ,pays at 85% of total billed charges,$16.03 ,pays at MCD OPPS,$47.20 ,pays at MCR OPPS,$94.40 ,pays at 80% of total billed charges,$16.27 ,pays at 97% of MCR OPPS,$100.30 ,pays at 85% of total billed charges,$16.03 ,pays at MCD OPPS,$15.76 ,$112.10 ,$100.30 
Outpatient Medical Services,LABORATORY & PATHOLOGY,82140,Ammonia,300,$141.00 ,$105.75 ,pays at 75% of total billed charges,$112.80 ,pays at 80% of total billed charges,$14.57 ,pays at MCR OPPS,$111.67 ,pays at 79.2% of total billed charges,$111.67 ,pays at 79.2% of total billed charges,$111.67 ,pays at 79.2% of total billed charges,$111.67 ,pays at 79.2% of total billed charges,$119.85 ,pays at 85% of total billed charges,$16.03 ,pays at MCD O/P rates,$56.40 ,pays at MCR OPPS,$133.95 ,pays at 95% of total billed charges,$112.80 ,pays at 80% total billed charges,$119.85 ,pays at 85% of total billed charges,$126.90 ,pays at 90% of total billed charges,$56.40 ,pays at MCR OPPS,$16.03 ,pays at 100% of MCD OPPS,$13.70 ,pays at 100% of MCD OPPS,$56.40 ,pays at MCR OPPS,$126.90 ,pays at 90% of total billed charges,$107.16 ,pays at 80% of total billed charges,$14.57 ,pays at MCR OPPS,$56.40 ,pays at MCR OPPS,$119.85 ,pays at 85% of total billed charges,$16.03 ,pays at MCD OPPS,$56.40 ,pays at MCR OPPS,$112.80 ,pays at 80% of total billed charges,$14.13 ,pays at 97% of MCR OPPS,$119.85 ,pays at 85% of total billed charges,$16.03 ,pays at MCD OPPS,$13.70 ,$133.95 ,$119.85 
Outpatient Medical Services,LABORATORY & PATHOLOGY,82150,Amylase,300,$57.00 ,$42.75 ,pays at 75% of total billed charges,$45.60 ,pays at 80% of total billed charges,$6.48 ,pays at MCR OPPS,$45.14 ,pays at 79.2% of total billed charges,$45.14 ,pays at 79.2% of total billed charges,$45.14 ,pays at 79.2% of total billed charges,$45.14 ,pays at 79.2% of total billed charges,$48.45 ,pays at 85% of total billed charges,$6.44 ,pays at MCD O/P rates,$22.80 ,pays at MCR OPPS,$54.15 ,pays at 95% of total billed charges,$45.60 ,pays at 80% total billed charges,$48.45 ,pays at 85% of total billed charges,$51.30 ,pays at 90% of total billed charges,$22.80 ,pays at MCR OPPS,$6.44 ,pays at 100% of MCD OPPS,$6.09 ,pays at 100% of MCD OPPS,$22.80 ,pays at MCR OPPS,$51.30 ,pays at 90% of total billed charges,$43.32 ,pays at 80% of total billed charges,$6.48 ,pays at MCR OPPS,$22.80 ,pays at MCR OPPS,$48.45 ,pays at 85% of total billed charges,$6.44 ,pays at MCD OPPS,$22.80 ,pays at MCR OPPS,$45.60 ,pays at 80% of total billed charges,$6.29 ,pays at 97% of MCR OPPS,$48.45 ,pays at 85% of total billed charges,$6.44 ,pays at MCD OPPS,$6.09 ,$54.15 ,$48.45 
Outpatient Medical Services,LABORATORY & PATHOLOGY,82270,"Blood, Occult, By Peroxidase Activity (Eg, Guaiac), Qualitative; Feces, Consecutive Collected Specimens With Single Determination, For Colorectal Neop",300,$29.00 ,$21.75 ,pays at 75% of total billed charges,$23.20 ,pays at 80% of total billed charges,$4.38 ,pays at MCR OPPS,$22.97 ,pays at 79.2% of total billed charges,$22.97 ,pays at 79.2% of total billed charges,$22.97 ,pays at 79.2% of total billed charges,$22.97 ,pays at 79.2% of total billed charges,$24.65 ,pays at 85% of total billed charges,$6.44 ,pays at MCD O/P rates,$11.60 ,pays at MCR OPPS,$27.55 ,pays at 95% of total billed charges,$23.20 ,pays at 80% total billed charges,$24.65 ,pays at 85% of total billed charges,$26.10 ,pays at 90% of total billed charges,$11.60 ,pays at MCR OPPS,$6.44 ,pays at 100% of MCD OPPS,$4.12 ,pays at 100% of MCD OPPS,$11.60 ,pays at MCR OPPS,$26.10 ,pays at 90% of total billed charges,$22.04 ,pays at 80% of total billed charges,$4.38 ,pays at MCR OPPS,$11.60 ,pays at MCR OPPS,$24.65 ,pays at 85% of total billed charges,$6.44 ,pays at MCD OPPS,$11.60 ,pays at MCR OPPS,$23.20 ,pays at 80% of total billed charges,$4.25 ,pays at 97% of MCR OPPS,$24.65 ,pays at 85% of total billed charges,$6.44 ,pays at MCD OPPS,$4.12 ,$27.55 ,$24.65 
Outpatient Medical Services,LABORATORY & PATHOLOGY,82274,"Blood, Occult, By Fecal Hemoglobin Determination By Immunoassay, Qualitative, Feces, 1-3 Simultaneous Determinations",300,$106.00 ,$79.50 ,pays at 75% of total billed charges,$84.80 ,pays at 80% of total billed charges,$15.92 ,pays at MCR OPPS,$83.95 ,pays at 79.2% of total billed charges,$83.95 ,pays at 79.2% of total billed charges,$83.95 ,pays at 79.2% of total billed charges,$83.95 ,pays at 79.2% of total billed charges,$90.10 ,pays at 85% of total billed charges,$16.03 ,pays at MCD O/P rates,$42.40 ,pays at MCR OPPS,$100.70 ,pays at 95% of total billed charges,$84.80 ,pays at 80% total billed charges,$90.10 ,pays at 85% of total billed charges,$95.40 ,pays at 90% of total billed charges,$42.40 ,pays at MCR OPPS,$16.03 ,pays at 100% of MCD OPPS,$14.96 ,pays at 100% of MCD OPPS,$42.40 ,pays at MCR OPPS,$95.40 ,pays at 90% of total billed charges,$80.56 ,pays at 80% of total billed charges,$15.92 ,pays at MCR OPPS,$42.40 ,pays at MCR OPPS,$90.10 ,pays at 85% of total billed charges,$16.03 ,pays at MCD OPPS,$42.40 ,pays at MCR OPPS,$84.80 ,pays at 80% of total billed charges,$15.44 ,pays at 97% of MCR OPPS,$90.10 ,pays at 85% of total billed charges,$16.03 ,pays at MCD OPPS,$14.96 ,$100.70 ,$90.10 
Outpatient Medical Services,LABORATORY & PATHOLOGY,82306,Blood test to monitor vitamin D levels,300,$405.00 ,$303.75 ,pays at 75% of total billed charges,$324.00 ,pays at 80% of total billed charges,$29.60 ,pays at MCR OPPS,$320.76 ,pays at 79.2% of total billed charges,$320.76 ,pays at 79.2% of total billed charges,$320.76 ,pays at 79.2% of total billed charges,$320.76 ,pays at 79.2% of total billed charges,$344.25 ,pays at 85% of total billed charges,$42.13 ,pays at MCD O/P rates,$162.00 ,pays at MCR OPPS,$384.75 ,pays at 95% of total billed charges,$324.00 ,pays at 80% total billed charges,$344.25 ,pays at 85% of total billed charges,$364.50 ,pays at 90% of total billed charges,$162.00 ,pays at MCR OPPS,$42.13 ,pays at 100% of MCD OPPS,$27.82 ,pays at 100% of MCD OPPS,$162.00 ,pays at MCR OPPS,$364.50 ,pays at 90% of total billed charges,$307.80 ,pays at 80% of total billed charges,$29.60 ,pays at MCR OPPS,$162.00 ,pays at MCR OPPS,$344.25 ,pays at 85% of total billed charges,$42.13 ,pays at MCD OPPS,$162.00 ,pays at MCR OPPS,$324.00 ,pays at 80% of total billed charges,$28.71 ,pays at 97% of MCR OPPS,$344.25 ,pays at 85% of total billed charges,$42.13 ,pays at MCD OPPS,$27.82 ,$384.75 ,$344.25 
Outpatient Medical Services,LABORATORY & PATHOLOGY,82378,Carcinoembryonic Antigen (Cea),300,$138.00 ,$103.50 ,pays at 75% of total billed charges,$110.40 ,pays at 80% of total billed charges,$18.96 ,pays at MCR OPPS,$109.30 ,pays at 79.2% of total billed charges,$109.30 ,pays at 79.2% of total billed charges,$109.30 ,pays at 79.2% of total billed charges,$109.30 ,pays at 79.2% of total billed charges,$117.30 ,pays at 85% of total billed charges,$16.03 ,pays at MCD O/P rates,$55.20 ,pays at MCR OPPS,$131.10 ,pays at 95% of total billed charges,$110.40 ,pays at 80% total billed charges,$117.30 ,pays at 85% of total billed charges,$124.20 ,pays at 90% of total billed charges,$55.20 ,pays at MCR OPPS,$16.03 ,pays at 100% of MCD OPPS,$17.82 ,pays at 100% of MCD OPPS,$55.20 ,pays at MCR OPPS,$124.20 ,pays at 90% of total billed charges,$104.88 ,pays at 80% of total billed charges,$18.96 ,pays at MCR OPPS,$55.20 ,pays at MCR OPPS,$117.30 ,pays at 85% of total billed charges,$16.03 ,pays at MCD OPPS,$55.20 ,pays at MCR OPPS,$110.40 ,pays at 80% of total billed charges,$18.39 ,pays at 97% of MCR OPPS,$117.30 ,pays at 85% of total billed charges,$16.03 ,pays at MCD OPPS,$16.03 ,$131.10 ,$117.30 
Outpatient Medical Services,LABORATORY & PATHOLOGY,82533,Cortisol; Total,300,$143.00 ,$107.25 ,pays at 75% of total billed charges,$114.40 ,pays at 80% of total billed charges,$16.30 ,pays at MCR OPPS,$113.26 ,pays at 79.2% of total billed charges,$113.26 ,pays at 79.2% of total billed charges,$113.26 ,pays at 79.2% of total billed charges,$113.26 ,pays at 79.2% of total billed charges,$121.55 ,pays at 85% of total billed charges,$16.57 ,pays at MCD O/P rates,$57.20 ,pays at MCR OPPS,$135.85 ,pays at 95% of total billed charges,$114.40 ,pays at 80% total billed charges,$121.55 ,pays at 85% of total billed charges,$128.70 ,pays at 90% of total billed charges,$57.20 ,pays at MCR OPPS,$16.57 ,pays at 100% of MCD OPPS,$15.32 ,pays at 100% of MCD OPPS,$57.20 ,pays at MCR OPPS,$128.70 ,pays at 90% of total billed charges,$108.68 ,pays at 80% of total billed charges,$16.30 ,pays at MCR OPPS,$57.20 ,pays at MCR OPPS,$121.55 ,pays at 85% of total billed charges,$16.57 ,pays at MCD OPPS,$57.20 ,pays at MCR OPPS,$114.40 ,pays at 80% of total billed charges,$15.81 ,pays at 97% of MCR OPPS,$121.55 ,pays at 85% of total billed charges,$16.57 ,pays at MCD OPPS,$15.32 ,$135.85 ,$121.55 
Outpatient Medical Services,LABORATORY & PATHOLOGY,82550,"Creatine Kinase (Ck), (Cpk); Total",300,$72.00 ,$54.00 ,pays at 75% of total billed charges,$57.60 ,pays at 80% of total billed charges,$6.51 ,pays at MCR OPPS,$57.02 ,pays at 79.2% of total billed charges,$57.02 ,pays at 79.2% of total billed charges,$57.02 ,pays at 79.2% of total billed charges,$57.02 ,pays at 79.2% of total billed charges,$61.20 ,pays at 85% of total billed charges,$6.44 ,pays at MCD O/P rates,$28.80 ,pays at MCR OPPS,$68.40 ,pays at 95% of total billed charges,$57.60 ,pays at 80% total billed charges,$61.20 ,pays at 85% of total billed charges,$64.80 ,pays at 90% of total billed charges,$28.80 ,pays at MCR OPPS,$6.44 ,pays at 100% of MCD OPPS,$6.12 ,pays at 100% of MCD OPPS,$28.80 ,pays at MCR OPPS,$64.80 ,pays at 90% of total billed charges,$54.72 ,pays at 80% of total billed charges,$6.51 ,pays at MCR OPPS,$28.80 ,pays at MCR OPPS,$61.20 ,pays at 85% of total billed charges,$6.44 ,pays at MCD OPPS,$28.80 ,pays at MCR OPPS,$57.60 ,pays at 80% of total billed charges,$6.31 ,pays at 97% of MCR OPPS,$61.20 ,pays at 85% of total billed charges,$6.44 ,pays at MCD OPPS,$6.12 ,$68.40 ,$61.20 
Outpatient Medical Services,LABORATORY & PATHOLOGY,82565,Creatinine; Blood,300,$38.00 ,$28.50 ,pays at 75% of total billed charges,$30.40 ,pays at 80% of total billed charges,$5.12 ,pays at MCR OPPS,$30.10 ,pays at 79.2% of total billed charges,$30.10 ,pays at 79.2% of total billed charges,$30.10 ,pays at 79.2% of total billed charges,$30.10 ,pays at 79.2% of total billed charges,$32.30 ,pays at 85% of total billed charges,$6.44 ,pays at MCD O/P rates,$15.20 ,pays at MCR OPPS,$36.10 ,pays at 95% of total billed charges,$30.40 ,pays at 80% total billed charges,$32.30 ,pays at 85% of total billed charges,$34.20 ,pays at 90% of total billed charges,$15.20 ,pays at MCR OPPS,$6.44 ,pays at 100% of MCD OPPS,$4.80 ,pays at 100% of MCD OPPS,$15.20 ,pays at MCR OPPS,$34.20 ,pays at 90% of total billed charges,$28.88 ,pays at 80% of total billed charges,$5.12 ,pays at MCR OPPS,$15.20 ,pays at MCR OPPS,$32.30 ,pays at 85% of total billed charges,$6.44 ,pays at MCD OPPS,$15.20 ,pays at MCR OPPS,$30.40 ,pays at 80% of total billed charges,$4.97 ,pays at 97% of MCR OPPS,$32.30 ,pays at 85% of total billed charges,$6.44 ,pays at MCD OPPS,$4.80 ,$36.10 ,$32.30 
Outpatient Medical Services,LABORATORY & PATHOLOGY,82570,Test to measure creatinine in the urine,300,$62.00 ,$46.50 ,pays at 75% of total billed charges,$49.60 ,pays at 80% of total billed charges,$5.18 ,pays at MCR OPPS,$49.10 ,pays at 79.2% of total billed charges,$49.10 ,pays at 79.2% of total billed charges,$49.10 ,pays at 79.2% of total billed charges,$49.10 ,pays at 79.2% of total billed charges,$52.70 ,pays at 85% of total billed charges,$6.44 ,pays at MCD O/P rates,$24.80 ,pays at MCR OPPS,$58.90 ,pays at 95% of total billed charges,$49.60 ,pays at 80% total billed charges,$52.70 ,pays at 85% of total billed charges,$55.80 ,pays at 90% of total billed charges,$24.80 ,pays at MCR OPPS,$6.44 ,pays at 100% of MCD OPPS,$4.87 ,pays at 100% of MCD OPPS,$24.80 ,pays at MCR OPPS,$55.80 ,pays at 90% of total billed charges,$47.12 ,pays at 80% of total billed charges,$5.18 ,pays at MCR OPPS,$24.80 ,pays at MCR OPPS,$52.70 ,pays at 85% of total billed charges,$6.44 ,pays at MCD OPPS,$24.80 ,pays at MCR OPPS,$49.60 ,pays at 80% of total billed charges,$5.02 ,pays at 97% of MCR OPPS,$52.70 ,pays at 85% of total billed charges,$6.44 ,pays at MCD OPPS,$4.87 ,$58.90 ,$52.70 
Outpatient Medical Services,LABORATORY & PATHOLOGY,82607,Blood test to measure B-12,300,$122.00 ,$91.50 ,pays at 75% of total billed charges,$97.60 ,pays at 80% of total billed charges,$15.08 ,pays at MCR OPPS,$96.62 ,pays at 79.2% of total billed charges,$96.62 ,pays at 79.2% of total billed charges,$96.62 ,pays at 79.2% of total billed charges,$96.62 ,pays at 79.2% of total billed charges,$103.70 ,pays at 85% of total billed charges,$16.57 ,pays at MCD O/P rates,$48.80 ,pays at MCR OPPS,$115.90 ,pays at 95% of total billed charges,$97.60 ,pays at 80% total billed charges,$103.70 ,pays at 85% of total billed charges,$109.80 ,pays at 90% of total billed charges,$48.80 ,pays at MCR OPPS,$16.57 ,pays at 100% of MCD OPPS,$14.18 ,pays at 100% of MCD OPPS,$48.80 ,pays at MCR OPPS,$109.80 ,pays at 90% of total billed charges,$92.72 ,pays at 80% of total billed charges,$15.08 ,pays at MCR OPPS,$48.80 ,pays at MCR OPPS,$103.70 ,pays at 85% of total billed charges,$16.57 ,pays at MCD OPPS,$48.80 ,pays at MCR OPPS,$97.60 ,pays at 80% of total billed charges,$14.63 ,pays at 97% of MCR OPPS,$103.70 ,pays at 85% of total billed charges,$16.57 ,pays at MCD OPPS,$14.18 ,$115.90 ,$103.70 
Outpatient Medical Services,LABORATORY & PATHOLOGY,82728,Test to determine level of iron in the blood,300,$100.00 ,$75.00 ,pays at 75% of total billed charges,$80.00 ,pays at 80% of total billed charges,$13.63 ,pays at MCR OPPS,$79.20 ,pays at 79.2% of total billed charges,$79.20 ,pays at 79.2% of total billed charges,$79.20 ,pays at 79.2% of total billed charges,$79.20 ,pays at 79.2% of total billed charges,$85.00 ,pays at 85% of total billed charges,$16.03 ,pays at MCD O/P rates,$40.00 ,pays at MCR OPPS,$95.00 ,pays at 95% of total billed charges,$80.00 ,pays at 80% total billed charges,$85.00 ,pays at 85% of total billed charges,$90.00 ,pays at 90% of total billed charges,$40.00 ,pays at MCR OPPS,$16.03 ,pays at 100% of MCD OPPS,$12.81 ,pays at 100% of MCD OPPS,$40.00 ,pays at MCR OPPS,$90.00 ,pays at 90% of total billed charges,$76.00 ,pays at 80% of total billed charges,$13.63 ,pays at MCR OPPS,$40.00 ,pays at MCR OPPS,$85.00 ,pays at 85% of total billed charges,$16.03 ,pays at MCD OPPS,$40.00 ,pays at MCR OPPS,$80.00 ,pays at 80% of total billed charges,$13.22 ,pays at 97% of MCR OPPS,$85.00 ,pays at 85% of total billed charges,$16.03 ,pays at MCD OPPS,$12.81 ,$95.00 ,$85.00 
Outpatient Medical Services,LABORATORY & PATHOLOGY,82784,Test to determine levels of immunoglobulins in the blood,300,$258.00 ,$193.50 ,pays at 75% of total billed charges,$206.40 ,pays at 80% of total billed charges,$9.30 ,pays at MCR OPPS,$204.34 ,pays at 79.2% of total billed charges,$204.34 ,pays at 79.2% of total billed charges,$204.34 ,pays at 79.2% of total billed charges,$204.34 ,pays at 79.2% of total billed charges,$219.30 ,pays at 85% of total billed charges,$6.44 ,pays at MCD O/P rates,$103.20 ,pays at MCR OPPS,$245.10 ,pays at 95% of total billed charges,$206.40 ,pays at 80% total billed charges,$219.30 ,pays at 85% of total billed charges,$232.20 ,pays at 90% of total billed charges,$103.20 ,pays at MCR OPPS,$6.44 ,pays at 100% of MCD OPPS,$8.74 ,pays at 100% of MCD OPPS,$103.20 ,pays at MCR OPPS,$232.20 ,pays at 90% of total billed charges,$196.08 ,pays at 80% of total billed charges,$9.30 ,pays at MCR OPPS,$103.20 ,pays at MCR OPPS,$219.30 ,pays at 85% of total billed charges,$6.44 ,pays at MCD OPPS,$103.20 ,pays at MCR OPPS,$206.40 ,pays at 80% of total billed charges,$9.02 ,pays at 97% of MCR OPPS,$219.30 ,pays at 85% of total billed charges,$6.44 ,pays at MCD OPPS,$6.44 ,$245.10 ,$219.30 
Outpatient Medical Services,LABORATORY & PATHOLOGY,82803,Test to measure arterial blood gases,300,$137.00 ,$102.75 ,pays at 75% of total billed charges,$109.60 ,pays at 80% of total billed charges,$26.07 ,pays at MCR OPPS,$108.50 ,pays at 79.2% of total billed charges,$108.50 ,pays at 79.2% of total billed charges,$108.50 ,pays at 79.2% of total billed charges,$108.50 ,pays at 79.2% of total billed charges,$116.45 ,pays at 85% of total billed charges,$42.13 ,pays at MCD O/P rates,$54.80 ,pays at MCR OPPS,$130.15 ,pays at 95% of total billed charges,$109.60 ,pays at 80% total billed charges,$116.45 ,pays at 85% of total billed charges,$123.30 ,pays at 90% of total billed charges,$54.80 ,pays at MCR OPPS,$42.13 ,pays at 100% of MCD OPPS,$24.51 ,pays at 100% of MCD OPPS,$54.80 ,pays at MCR OPPS,$123.30 ,pays at 90% of total billed charges,$104.12 ,pays at 80% of total billed charges,$26.07 ,pays at MCR OPPS,$54.80 ,pays at MCR OPPS,$116.45 ,pays at 85% of total billed charges,$42.13 ,pays at MCD OPPS,$54.80 ,pays at MCR OPPS,$109.60 ,pays at 80% of total billed charges,$25.29 ,pays at 97% of MCR OPPS,$116.45 ,pays at 85% of total billed charges,$42.13 ,pays at MCD OPPS,$24.51 ,$130.15 ,$116.45 
Outpatient Medical Services,LABORATORY & PATHOLOGY,82948,"Glucose; Blood, Reagent Strip",300,$24.00 ,$18.00 ,pays at 75% of total billed charges,$19.20 ,pays at 80% of total billed charges,$5.04 ,pays at MCR OPPS,$19.01 ,pays at 79.2% of total billed charges,$19.01 ,pays at 79.2% of total billed charges,$19.01 ,pays at 79.2% of total billed charges,$19.01 ,pays at 79.2% of total billed charges,$20.40 ,pays at 85% of total billed charges,$6.44 ,pays at MCD O/P rates,$9.60 ,pays at MCR OPPS,$22.80 ,pays at 95% of total billed charges,$19.20 ,pays at 80% total billed charges,$20.40 ,pays at 85% of total billed charges,$21.60 ,pays at 90% of total billed charges,$9.60 ,pays at MCR OPPS,$6.44 ,pays at 100% of MCD OPPS,$4.74 ,pays at 100% of MCD OPPS,$9.60 ,pays at MCR OPPS,$21.60 ,pays at 90% of total billed charges,$18.24 ,pays at 80% of total billed charges,$5.04 ,pays at MCR OPPS,$9.60 ,pays at MCR OPPS,$20.40 ,pays at 85% of total billed charges,$6.44 ,pays at MCD OPPS,$9.60 ,pays at MCR OPPS,$19.20 ,pays at 80% of total billed charges,$4.89 ,pays at 97% of MCR OPPS,$20.40 ,pays at 85% of total billed charges,$6.44 ,pays at MCD OPPS,$4.74 ,$22.80 ,$20.40 
Outpatient Medical Services,LABORATORY & PATHOLOGY,82977,"Glutamyltransferase, Gamma (Ggt)",300,$75.00 ,$56.25 ,pays at 75% of total billed charges,$60.00 ,pays at 80% of total billed charges,$7.20 ,pays at MCR OPPS,$59.40 ,pays at 79.2% of total billed charges,$59.40 ,pays at 79.2% of total billed charges,$59.40 ,pays at 79.2% of total billed charges,$59.40 ,pays at 79.2% of total billed charges,$63.75 ,pays at 85% of total billed charges,$6.44 ,pays at MCD O/P rates,$30.00 ,pays at MCR OPPS,$71.25 ,pays at 95% of total billed charges,$60.00 ,pays at 80% total billed charges,$63.75 ,pays at 85% of total billed charges,$67.50 ,pays at 90% of total billed charges,$30.00 ,pays at MCR OPPS,$6.44 ,pays at 100% of MCD OPPS,$6.77 ,pays at 100% of MCD OPPS,$30.00 ,pays at MCR OPPS,$67.50 ,pays at 90% of total billed charges,$57.00 ,pays at 80% of total billed charges,$7.20 ,pays at MCR OPPS,$30.00 ,pays at MCR OPPS,$63.75 ,pays at 85% of total billed charges,$6.44 ,pays at MCD OPPS,$30.00 ,pays at MCR OPPS,$60.00 ,pays at 80% of total billed charges,$6.98 ,pays at 97% of MCR OPPS,$63.75 ,pays at 85% of total billed charges,$6.44 ,pays at MCD OPPS,$6.44 ,$71.25 ,$63.75 
Outpatient Medical Services,LABORATORY & PATHOLOGY,83036,Blood test to measure average blood glucose levels for past 2-3 months,300,$80.00 ,$60.00 ,pays at 75% of total billed charges,$64.00 ,pays at 80% of total billed charges,$9.71 ,pays at MCR OPPS,$63.36 ,pays at 79.2% of total billed charges,$63.36 ,pays at 79.2% of total billed charges,$63.36 ,pays at 79.2% of total billed charges,$63.36 ,pays at 79.2% of total billed charges,$68.00 ,pays at 85% of total billed charges,$6.44 ,pays at MCD O/P rates,$32.00 ,pays at MCR OPPS,$76.00 ,pays at 95% of total billed charges,$64.00 ,pays at 80% total billed charges,$68.00 ,pays at 85% of total billed charges,$72.00 ,pays at 90% of total billed charges,$32.00 ,pays at MCR OPPS,$6.44 ,pays at 100% of MCD OPPS,$9.13 ,pays at 100% of MCD OPPS,$32.00 ,pays at MCR OPPS,$72.00 ,pays at 90% of total billed charges,$60.80 ,pays at 80% of total billed charges,$9.71 ,pays at MCR OPPS,$32.00 ,pays at MCR OPPS,$68.00 ,pays at 85% of total billed charges,$6.44 ,pays at MCD OPPS,$32.00 ,pays at MCR OPPS,$64.00 ,pays at 80% of total billed charges,$9.42 ,pays at 97% of MCR OPPS,$68.00 ,pays at 85% of total billed charges,$6.44 ,pays at MCD OPPS,$6.44 ,$76.00 ,$68.00 
Outpatient Medical Services,LABORATORY & PATHOLOGY,83540,Blood test to measure the amount of iron that is in transit in the body,300,$67.00 ,$50.25 ,pays at 75% of total billed charges,$53.60 ,pays at 80% of total billed charges,$6.47 ,pays at MCR OPPS,$53.06 ,pays at 79.2% of total billed charges,$53.06 ,pays at 79.2% of total billed charges,$53.06 ,pays at 79.2% of total billed charges,$53.06 ,pays at 79.2% of total billed charges,$56.95 ,pays at 85% of total billed charges,$6.44 ,pays at MCD O/P rates,$26.80 ,pays at MCR OPPS,$63.65 ,pays at 95% of total billed charges,$53.60 ,pays at 80% total billed charges,$56.95 ,pays at 85% of total billed charges,$60.30 ,pays at 90% of total billed charges,$26.80 ,pays at MCR OPPS,$6.44 ,pays at 100% of MCD OPPS,$6.08 ,pays at 100% of MCD OPPS,$26.80 ,pays at MCR OPPS,$60.30 ,pays at 90% of total billed charges,$50.92 ,pays at 80% of total billed charges,$6.47 ,pays at MCR OPPS,$26.80 ,pays at MCR OPPS,$56.95 ,pays at 85% of total billed charges,$6.44 ,pays at MCD OPPS,$26.80 ,pays at MCR OPPS,$53.60 ,pays at 80% of total billed charges,$6.28 ,pays at 97% of MCR OPPS,$56.95 ,pays at 85% of total billed charges,$6.44 ,pays at MCD OPPS,$6.08 ,$63.65 ,$56.95 
Outpatient Medical Services,LABORATORY & PATHOLOGY,83550,Blood test that measures the amount of iron carried in the blood,300,$80.00 ,$60.00 ,pays at 75% of total billed charges,$64.00 ,pays at 80% of total billed charges,$8.74 ,pays at MCR OPPS,$63.36 ,pays at 79.2% of total billed charges,$63.36 ,pays at 79.2% of total billed charges,$63.36 ,pays at 79.2% of total billed charges,$63.36 ,pays at 79.2% of total billed charges,$68.00 ,pays at 85% of total billed charges,$6.44 ,pays at MCD O/P rates,$32.00 ,pays at MCR OPPS,$76.00 ,pays at 95% of total billed charges,$64.00 ,pays at 80% total billed charges,$68.00 ,pays at 85% of total billed charges,$72.00 ,pays at 90% of total billed charges,$32.00 ,pays at MCR OPPS,$6.44 ,pays at 100% of MCD OPPS,$8.22 ,pays at 100% of MCD OPPS,$32.00 ,pays at MCR OPPS,$72.00 ,pays at 90% of total billed charges,$60.80 ,pays at 80% of total billed charges,$8.74 ,pays at MCR OPPS,$32.00 ,pays at MCR OPPS,$68.00 ,pays at 85% of total billed charges,$6.44 ,pays at MCD OPPS,$32.00 ,pays at MCR OPPS,$64.00 ,pays at 80% of total billed charges,$8.48 ,pays at 97% of MCR OPPS,$68.00 ,pays at 85% of total billed charges,$6.44 ,pays at MCD OPPS,$6.44 ,$76.00 ,$68.00 
Outpatient Medical Services,LABORATORY & PATHOLOGY,83605,Lactate (Lactic Acid),300,$102.00 ,$76.50 ,pays at 75% of total billed charges,$81.60 ,pays at 80% of total billed charges,$11.57 ,pays at MCR OPPS,$80.78 ,pays at 79.2% of total billed charges,$80.78 ,pays at 79.2% of total billed charges,$80.78 ,pays at 79.2% of total billed charges,$80.78 ,pays at 79.2% of total billed charges,$86.70 ,pays at 85% of total billed charges,$16.03 ,pays at MCD O/P rates,$40.80 ,pays at MCR OPPS,$96.90 ,pays at 95% of total billed charges,$81.60 ,pays at 80% total billed charges,$86.70 ,pays at 85% of total billed charges,$91.80 ,pays at 90% of total billed charges,$40.80 ,pays at MCR OPPS,$16.03 ,pays at 100% of MCD OPPS,$10.88 ,pays at 100% of MCD OPPS,$40.80 ,pays at MCR OPPS,$91.80 ,pays at 90% of total billed charges,$77.52 ,pays at 80% of total billed charges,$11.57 ,pays at MCR OPPS,$40.80 ,pays at MCR OPPS,$86.70 ,pays at 85% of total billed charges,$16.03 ,pays at MCD OPPS,$40.80 ,pays at MCR OPPS,$81.60 ,pays at 80% of total billed charges,$11.22 ,pays at 97% of MCR OPPS,$86.70 ,pays at 85% of total billed charges,$16.03 ,pays at MCD OPPS,$10.88 ,$96.90 ,$86.70 
Outpatient Medical Services,LABORATORY & PATHOLOGY,83615,"Lactate Dehydrogenase (Ld), (Ldh);",300,$57.00 ,$42.75 ,pays at 75% of total billed charges,$45.60 ,pays at 80% of total billed charges,$6.04 ,pays at MCR OPPS,$45.14 ,pays at 79.2% of total billed charges,$45.14 ,pays at 79.2% of total billed charges,$45.14 ,pays at 79.2% of total billed charges,$45.14 ,pays at 79.2% of total billed charges,$48.45 ,pays at 85% of total billed charges,$6.44 ,pays at MCD O/P rates,$22.80 ,pays at MCR OPPS,$54.15 ,pays at 95% of total billed charges,$45.60 ,pays at 80% total billed charges,$48.45 ,pays at 85% of total billed charges,$51.30 ,pays at 90% of total billed charges,$22.80 ,pays at MCR OPPS,$6.44 ,pays at 100% of MCD OPPS,$5.68 ,pays at 100% of MCD OPPS,$22.80 ,pays at MCR OPPS,$51.30 ,pays at 90% of total billed charges,$43.32 ,pays at 80% of total billed charges,$6.04 ,pays at MCR OPPS,$22.80 ,pays at MCR OPPS,$48.45 ,pays at 85% of total billed charges,$6.44 ,pays at MCD OPPS,$22.80 ,pays at MCR OPPS,$45.60 ,pays at 80% of total billed charges,$5.86 ,pays at 97% of MCR OPPS,$48.45 ,pays at 85% of total billed charges,$6.44 ,pays at MCD OPPS,$5.68 ,$54.15 ,$48.45 
Outpatient Medical Services,LABORATORY & PATHOLOGY,83690,Lipase,300,$56.00 ,$42.00 ,pays at 75% of total billed charges,$44.80 ,pays at 80% of total billed charges,$6.89 ,pays at MCR OPPS,$44.35 ,pays at 79.2% of total billed charges,$44.35 ,pays at 79.2% of total billed charges,$44.35 ,pays at 79.2% of total billed charges,$44.35 ,pays at 79.2% of total billed charges,$47.60 ,pays at 85% of total billed charges,$6.44 ,pays at MCD O/P rates,$22.40 ,pays at MCR OPPS,$53.20 ,pays at 95% of total billed charges,$44.80 ,pays at 80% total billed charges,$47.60 ,pays at 85% of total billed charges,$50.40 ,pays at 90% of total billed charges,$22.40 ,pays at MCR OPPS,$6.44 ,pays at 100% of MCD OPPS,$6.48 ,pays at 100% of MCD OPPS,$22.40 ,pays at MCR OPPS,$50.40 ,pays at 90% of total billed charges,$42.56 ,pays at 80% of total billed charges,$6.89 ,pays at MCR OPPS,$22.40 ,pays at MCR OPPS,$47.60 ,pays at 85% of total billed charges,$6.44 ,pays at MCD OPPS,$22.40 ,pays at MCR OPPS,$44.80 ,pays at 80% of total billed charges,$6.68 ,pays at 97% of MCR OPPS,$47.60 ,pays at 85% of total billed charges,$6.44 ,pays at MCD OPPS,$6.44 ,$53.20 ,$47.60 
Outpatient Medical Services,LABORATORY & PATHOLOGY,83735,Magnesium,300,$81.00 ,$60.75 ,pays at 75% of total billed charges,$64.80 ,pays at 80% of total billed charges,$6.70 ,pays at MCR OPPS,$64.15 ,pays at 79.2% of total billed charges,$64.15 ,pays at 79.2% of total billed charges,$64.15 ,pays at 79.2% of total billed charges,$64.15 ,pays at 79.2% of total billed charges,$68.85 ,pays at 85% of total billed charges,$6.44 ,pays at MCD O/P rates,$32.40 ,pays at MCR OPPS,$76.95 ,pays at 95% of total billed charges,$64.80 ,pays at 80% total billed charges,$68.85 ,pays at 85% of total billed charges,$72.90 ,pays at 90% of total billed charges,$32.40 ,pays at MCR OPPS,$6.44 ,pays at 100% of MCD OPPS,$6.30 ,pays at 100% of MCD OPPS,$32.40 ,pays at MCR OPPS,$72.90 ,pays at 90% of total billed charges,$61.56 ,pays at 80% of total billed charges,$6.70 ,pays at MCR OPPS,$32.40 ,pays at MCR OPPS,$68.85 ,pays at 85% of total billed charges,$6.44 ,pays at MCD OPPS,$32.40 ,pays at MCR OPPS,$64.80 ,pays at 80% of total billed charges,$6.50 ,pays at 97% of MCR OPPS,$68.85 ,pays at 85% of total billed charges,$6.44 ,pays at MCD OPPS,$6.30 ,$76.95 ,$68.85 
Outpatient Medical Services,LABORATORY & PATHOLOGY,83880,Blood test used to diagnose heart failure,300,$224.00 ,$168.00 ,pays at 75% of total billed charges,$179.20 ,pays at 80% of total billed charges,$39.26 ,pays at MCR OPPS,$177.41 ,pays at 79.2% of total billed charges,$177.41 ,pays at 79.2% of total billed charges,$177.41 ,pays at 79.2% of total billed charges,$177.41 ,pays at 79.2% of total billed charges,$190.40 ,pays at 85% of total billed charges,$42.13 ,pays at MCD O/P rates,$89.60 ,pays at MCR OPPS,$212.80 ,pays at 95% of total billed charges,$179.20 ,pays at 80% total billed charges,$190.40 ,pays at 85% of total billed charges,$201.60 ,pays at 90% of total billed charges,$89.60 ,pays at MCR OPPS,$42.13 ,pays at 100% of MCD OPPS,$36.90 ,pays at 100% of MCD OPPS,$89.60 ,pays at MCR OPPS,$201.60 ,pays at 90% of total billed charges,$170.24 ,pays at 80% of total billed charges,$39.26 ,pays at MCR OPPS,$89.60 ,pays at MCR OPPS,$190.40 ,pays at 85% of total billed charges,$42.13 ,pays at MCD OPPS,$89.60 ,pays at MCR OPPS,$179.20 ,pays at 80% of total billed charges,$38.08 ,pays at 97% of MCR OPPS,$190.40 ,pays at 85% of total billed charges,$42.13 ,pays at MCD OPPS,$36.90 ,$212.80 ,$190.40 
Outpatient Medical Services,LABORATORY & PATHOLOGY,83883,"Nephelometry, Each Analyte Not Elsewhere Specified",300,$100.00 ,$75.00 ,pays at 75% of total billed charges,$80.00 ,pays at 80% of total billed charges,$13.60 ,pays at MCR OPPS,$79.20 ,pays at 79.2% of total billed charges,$79.20 ,pays at 79.2% of total billed charges,$79.20 ,pays at 79.2% of total billed charges,$79.20 ,pays at 79.2% of total billed charges,$85.00 ,pays at 85% of total billed charges,$13.74 ,pays at MCD O/P rates,$40.00 ,pays at MCR OPPS,$95.00 ,pays at 95% of total billed charges,$80.00 ,pays at 80% total billed charges,$85.00 ,pays at 85% of total billed charges,$90.00 ,pays at 90% of total billed charges,$40.00 ,pays at MCR OPPS,$13.74 ,pays at 100% of MCD OPPS,$12.78 ,pays at 100% of MCD OPPS,$40.00 ,pays at MCR OPPS,$90.00 ,pays at 90% of total billed charges,$76.00 ,pays at 80% of total billed charges,$13.60 ,pays at MCR OPPS,$40.00 ,pays at MCR OPPS,$85.00 ,pays at 85% of total billed charges,$13.74 ,pays at MCD OPPS,$40.00 ,pays at MCR OPPS,$80.00 ,pays at 80% of total billed charges,$13.19 ,pays at 97% of MCR OPPS,$85.00 ,pays at 85% of total billed charges,$13.74 ,pays at MCD OPPS,$12.78 ,$95.00 ,$85.00 
Outpatient Medical Services,LABORATORY & PATHOLOGY,83970,Parathormone (Parathyroid Hormone),300,$284.00 ,$213.00 ,pays at 75% of total billed charges,$227.20 ,pays at 80% of total billed charges,$41.28 ,pays at MCR OPPS,$224.93 ,pays at 79.2% of total billed charges,$224.93 ,pays at 79.2% of total billed charges,$224.93 ,pays at 79.2% of total billed charges,$224.93 ,pays at 79.2% of total billed charges,$241.40 ,pays at 85% of total billed charges,$42.64 ,pays at MCD O/P rates,$113.60 ,pays at MCR OPPS,$269.80 ,pays at 95% of total billed charges,$227.20 ,pays at 80% total billed charges,$241.40 ,pays at 85% of total billed charges,$255.60 ,pays at 90% of total billed charges,$113.60 ,pays at MCR OPPS,$42.64 ,pays at 100% of MCD OPPS,$38.79 ,pays at 100% of MCD OPPS,$113.60 ,pays at MCR OPPS,$255.60 ,pays at 90% of total billed charges,$215.84 ,pays at 80% of total billed charges,$41.28 ,pays at MCR OPPS,$113.60 ,pays at MCR OPPS,$241.40 ,pays at 85% of total billed charges,$42.64 ,pays at MCD OPPS,$113.60 ,pays at MCR OPPS,$227.20 ,pays at 80% of total billed charges,$40.04 ,pays at 97% of MCR OPPS,$241.40 ,pays at 85% of total billed charges,$42.64 ,pays at MCD OPPS,$38.79 ,$269.80 ,$241.40 
Outpatient Medical Services,LABORATORY & PATHOLOGY,84100,Phosphorus Inorganic (Phosphate);,300,$57.00 ,$42.75 ,pays at 75% of total billed charges,$45.60 ,pays at 80% of total billed charges,$4.74 ,pays at MCR OPPS,$45.14 ,pays at 79.2% of total billed charges,$45.14 ,pays at 79.2% of total billed charges,$45.14 ,pays at 79.2% of total billed charges,$45.14 ,pays at 79.2% of total billed charges,$48.45 ,pays at 85% of total billed charges,$6.44 ,pays at MCD O/P rates,$22.80 ,pays at MCR OPPS,$54.15 ,pays at 95% of total billed charges,$45.60 ,pays at 80% total billed charges,$48.45 ,pays at 85% of total billed charges,$51.30 ,pays at 90% of total billed charges,$22.80 ,pays at MCR OPPS,$6.44 ,pays at 100% of MCD OPPS,$4.46 ,pays at 100% of MCD OPPS,$22.80 ,pays at MCR OPPS,$51.30 ,pays at 90% of total billed charges,$43.32 ,pays at 80% of total billed charges,$4.74 ,pays at MCR OPPS,$22.80 ,pays at MCR OPPS,$48.45 ,pays at 85% of total billed charges,$6.44 ,pays at MCD OPPS,$22.80 ,pays at MCR OPPS,$45.60 ,pays at 80% of total billed charges,$4.60 ,pays at 97% of MCR OPPS,$48.45 ,pays at 85% of total billed charges,$6.44 ,pays at MCD OPPS,$4.46 ,$54.15 ,$48.45 
Outpatient Medical Services,LABORATORY & PATHOLOGY,84145,Procalcitonin (Pct),300,$135.00 ,$101.25 ,pays at 75% of total billed charges,$108.00 ,pays at 80% of total billed charges,$27.22 ,pays at MCR OPPS,$106.92 ,pays at 79.2% of total billed charges,$106.92 ,pays at 79.2% of total billed charges,$106.92 ,pays at 79.2% of total billed charges,$106.92 ,pays at 79.2% of total billed charges,$114.75 ,pays at 85% of total billed charges,$16.57 ,pays at MCD O/P rates,$54.00 ,pays at MCR OPPS,$128.25 ,pays at 95% of total billed charges,$108.00 ,pays at 80% total billed charges,$114.75 ,pays at 85% of total billed charges,$121.50 ,pays at 90% of total billed charges,$54.00 ,pays at MCR OPPS,$16.57 ,pays at 100% of MCD OPPS,$25.59 ,pays at 100% of MCD OPPS,$54.00 ,pays at MCR OPPS,$121.50 ,pays at 90% of total billed charges,$102.60 ,pays at 80% of total billed charges,$27.22 ,pays at MCR OPPS,$54.00 ,pays at MCR OPPS,$114.75 ,pays at 85% of total billed charges,$16.57 ,pays at MCD OPPS,$54.00 ,pays at MCR OPPS,$108.00 ,pays at 80% of total billed charges,$26.40 ,pays at 97% of MCR OPPS,$114.75 ,pays at 85% of total billed charges,$16.57 ,pays at MCD OPPS,$16.57 ,$128.25 ,$114.75 
Outpatient Medical Services,LABORATORY & PATHOLOGY,84153,PSA (prostate specific antigen),300,$112.00 ,$84.00 ,pays at 75% of total billed charges,$89.60 ,pays at 80% of total billed charges,$18.39 ,pays at MCR OPPS,$88.70 ,pays at 79.2% of total billed charges,$88.70 ,pays at 79.2% of total billed charges,$88.70 ,pays at 79.2% of total billed charges,$88.70 ,pays at 79.2% of total billed charges,$95.20 ,pays at 85% of total billed charges,$16.03 ,pays at MCD O/P rates,$44.80 ,pays at MCR OPPS,$106.40 ,pays at 95% of total billed charges,$89.60 ,pays at 80% total billed charges,$95.20 ,pays at 85% of total billed charges,$100.80 ,pays at 90% of total billed charges,$44.80 ,pays at MCR OPPS,$16.03 ,pays at 100% of MCD OPPS,$17.29 ,pays at 100% of MCD OPPS,$44.80 ,pays at MCR OPPS,$100.80 ,pays at 90% of total billed charges,$85.12 ,pays at 80% of total billed charges,$18.39 ,pays at MCR OPPS,$44.80 ,pays at MCR OPPS,$95.20 ,pays at 85% of total billed charges,$16.03 ,pays at MCD OPPS,$44.80 ,pays at MCR OPPS,$89.60 ,pays at 80% of total billed charges,$17.84 ,pays at 97% of MCR OPPS,$95.20 ,pays at 85% of total billed charges,$16.03 ,pays at MCD OPPS,$16.03 ,$106.40 ,$95.20 
Outpatient Medical Services,LABORATORY & PATHOLOGY,84155,"Protein, Total, Except By Refractometry; Serum, Plasma Or Whole Blood",300,$57.00 ,$42.75 ,pays at 75% of total billed charges,$45.60 ,pays at 80% of total billed charges,$3.67 ,pays at MCR OPPS,$45.14 ,pays at 79.2% of total billed charges,$45.14 ,pays at 79.2% of total billed charges,$45.14 ,pays at 79.2% of total billed charges,$45.14 ,pays at 79.2% of total billed charges,$48.45 ,pays at 85% of total billed charges,$6.44 ,pays at MCD O/P rates,$22.80 ,pays at MCR OPPS,$54.15 ,pays at 95% of total billed charges,$45.60 ,pays at 80% total billed charges,$48.45 ,pays at 85% of total billed charges,$51.30 ,pays at 90% of total billed charges,$22.80 ,pays at MCR OPPS,$6.44 ,pays at 100% of MCD OPPS,$3.45 ,pays at 100% of MCD OPPS,$22.80 ,pays at MCR OPPS,$51.30 ,pays at 90% of total billed charges,$43.32 ,pays at 80% of total billed charges,$3.67 ,pays at MCR OPPS,$22.80 ,pays at MCR OPPS,$48.45 ,pays at 85% of total billed charges,$6.44 ,pays at MCD OPPS,$22.80 ,pays at MCR OPPS,$45.60 ,pays at 80% of total billed charges,$3.56 ,pays at 97% of MCR OPPS,$48.45 ,pays at 85% of total billed charges,$6.44 ,pays at MCD OPPS,$3.45 ,$54.15 ,$48.45 
Outpatient Medical Services,LABORATORY & PATHOLOGY,84156,"Protein, Total, Except By Refractometry; Urine",300,$60.00 ,$45.00 ,pays at 75% of total billed charges,$48.00 ,pays at 80% of total billed charges,$3.67 ,pays at MCR OPPS,$47.52 ,pays at 79.2% of total billed charges,$47.52 ,pays at 79.2% of total billed charges,$47.52 ,pays at 79.2% of total billed charges,$47.52 ,pays at 79.2% of total billed charges,$51.00 ,pays at 85% of total billed charges,$6.44 ,pays at MCD O/P rates,$24.00 ,pays at MCR OPPS,$57.00 ,pays at 95% of total billed charges,$48.00 ,pays at 80% total billed charges,$51.00 ,pays at 85% of total billed charges,$54.00 ,pays at 90% of total billed charges,$24.00 ,pays at MCR OPPS,$6.44 ,pays at 100% of MCD OPPS,$3.45 ,pays at 100% of MCD OPPS,$24.00 ,pays at MCR OPPS,$54.00 ,pays at 90% of total billed charges,$45.60 ,pays at 80% of total billed charges,$3.67 ,pays at MCR OPPS,$24.00 ,pays at MCR OPPS,$51.00 ,pays at 85% of total billed charges,$6.44 ,pays at MCD OPPS,$24.00 ,pays at MCR OPPS,$48.00 ,pays at 80% of total billed charges,$3.56 ,pays at 97% of MCR OPPS,$51.00 ,pays at 85% of total billed charges,$6.44 ,pays at MCD OPPS,$3.45 ,$57.00 ,$51.00 
Outpatient Medical Services,LABORATORY & PATHOLOGY,84165,"Protein; Electrophoretic Fractionation And Quantitation, Serum",300,$60.00 ,$45.00 ,pays at 75% of total billed charges,$48.00 ,pays at 80% of total billed charges,$10.74 ,pays at MCR OPPS,$47.52 ,pays at 79.2% of total billed charges,$47.52 ,pays at 79.2% of total billed charges,$47.52 ,pays at 79.2% of total billed charges,$47.52 ,pays at 79.2% of total billed charges,$51.00 ,pays at 85% of total billed charges,$6.44 ,pays at MCD O/P rates,$24.00 ,pays at MCR OPPS,$57.00 ,pays at 95% of total billed charges,$48.00 ,pays at 80% total billed charges,$51.00 ,pays at 85% of total billed charges,$54.00 ,pays at 90% of total billed charges,$24.00 ,pays at MCR OPPS,$6.44 ,pays at 100% of MCD OPPS,$10.10 ,pays at 100% of MCD OPPS,$24.00 ,pays at MCR OPPS,$54.00 ,pays at 90% of total billed charges,$45.60 ,pays at 80% of total billed charges,$10.74 ,pays at MCR OPPS,$24.00 ,pays at MCR OPPS,$51.00 ,pays at 85% of total billed charges,$6.44 ,pays at MCD OPPS,$24.00 ,pays at MCR OPPS,$48.00 ,pays at 80% of total billed charges,$10.42 ,pays at 97% of MCR OPPS,$51.00 ,pays at 85% of total billed charges,$6.44 ,pays at MCD OPPS,$6.44 ,$57.00 ,$51.00 
Outpatient Medical Services,LABORATORY & PATHOLOGY,84402,Testosterone; Free,300,$250.00 ,$187.50 ,pays at 75% of total billed charges,$200.00 ,pays at 80% of total billed charges,$25.47 ,pays at MCR OPPS,$198.00 ,pays at 79.2% of total billed charges,$198.00 ,pays at 79.2% of total billed charges,$198.00 ,pays at 79.2% of total billed charges,$198.00 ,pays at 79.2% of total billed charges,$212.50 ,pays at 85% of total billed charges,$16.57 ,pays at MCD O/P rates,$100.00 ,pays at MCR OPPS,$237.50 ,pays at 95% of total billed charges,$200.00 ,pays at 80% total billed charges,$212.50 ,pays at 85% of total billed charges,$225.00 ,pays at 90% of total billed charges,$100.00 ,pays at MCR OPPS,$16.57 ,pays at 100% of MCD OPPS,$23.94 ,pays at 100% of MCD OPPS,$100.00 ,pays at MCR OPPS,$225.00 ,pays at 90% of total billed charges,$190.00 ,pays at 80% of total billed charges,$25.47 ,pays at MCR OPPS,$100.00 ,pays at MCR OPPS,$212.50 ,pays at 85% of total billed charges,$16.57 ,pays at MCD OPPS,$100.00 ,pays at MCR OPPS,$200.00 ,pays at 80% of total billed charges,$24.71 ,pays at 97% of MCR OPPS,$212.50 ,pays at 85% of total billed charges,$16.57 ,pays at MCD OPPS,$16.57 ,$237.50 ,$212.50 
Outpatient Medical Services,LABORATORY & PATHOLOGY,84403,Testosterone; Total,300,$184.00 ,$138.00 ,pays at 75% of total billed charges,$147.20 ,pays at 80% of total billed charges,$25.81 ,pays at MCR OPPS,$145.73 ,pays at 79.2% of total billed charges,$145.73 ,pays at 79.2% of total billed charges,$145.73 ,pays at 79.2% of total billed charges,$145.73 ,pays at 79.2% of total billed charges,$156.40 ,pays at 85% of total billed charges,$16.57 ,pays at MCD O/P rates,$73.60 ,pays at MCR OPPS,$174.80 ,pays at 95% of total billed charges,$147.20 ,pays at 80% total billed charges,$156.40 ,pays at 85% of total billed charges,$165.60 ,pays at 90% of total billed charges,$73.60 ,pays at MCR OPPS,$16.57 ,pays at 100% of MCD OPPS,$24.26 ,pays at 100% of MCD OPPS,$73.60 ,pays at MCR OPPS,$165.60 ,pays at 90% of total billed charges,$139.84 ,pays at 80% of total billed charges,$25.81 ,pays at MCR OPPS,$73.60 ,pays at MCR OPPS,$156.40 ,pays at 85% of total billed charges,$16.57 ,pays at MCD OPPS,$73.60 ,pays at MCR OPPS,$147.20 ,pays at 80% of total billed charges,$25.04 ,pays at 97% of MCR OPPS,$156.40 ,pays at 85% of total billed charges,$16.57 ,pays at MCD OPPS,$16.57 ,$174.80 ,$156.40 
Outpatient Medical Services,LABORATORY & PATHOLOGY,84436,Blood test to measure a type of thyroid hormone,300,$77.00 ,$57.75 ,pays at 75% of total billed charges,$61.60 ,pays at 80% of total billed charges,$6.87 ,pays at MCR OPPS,$60.98 ,pays at 79.2% of total billed charges,$60.98 ,pays at 79.2% of total billed charges,$60.98 ,pays at 79.2% of total billed charges,$60.98 ,pays at 79.2% of total billed charges,$65.45 ,pays at 85% of total billed charges,$16.57 ,pays at MCD O/P rates,$30.80 ,pays at MCR OPPS,$73.15 ,pays at 95% of total billed charges,$61.60 ,pays at 80% total billed charges,$65.45 ,pays at 85% of total billed charges,$69.30 ,pays at 90% of total billed charges,$30.80 ,pays at MCR OPPS,$16.57 ,pays at 100% of MCD OPPS,$6.46 ,pays at 100% of MCD OPPS,$30.80 ,pays at MCR OPPS,$69.30 ,pays at 90% of total billed charges,$58.52 ,pays at 80% of total billed charges,$6.87 ,pays at MCR OPPS,$30.80 ,pays at MCR OPPS,$65.45 ,pays at 85% of total billed charges,$16.57 ,pays at MCD OPPS,$30.80 ,pays at MCR OPPS,$61.60 ,pays at 80% of total billed charges,$6.66 ,pays at 97% of MCR OPPS,$65.45 ,pays at 85% of total billed charges,$16.57 ,pays at MCD OPPS,$6.46 ,$73.15 ,$65.45 
Outpatient Medical Services,LABORATORY & PATHOLOGY,84439,Blood test to evaluate thyroid function,300,$125.00 ,$93.75 ,pays at 75% of total billed charges,$100.00 ,pays at 80% of total billed charges,$9.02 ,pays at MCR OPPS,$99.00 ,pays at 79.2% of total billed charges,$99.00 ,pays at 79.2% of total billed charges,$99.00 ,pays at 79.2% of total billed charges,$99.00 ,pays at 79.2% of total billed charges,$106.25 ,pays at 85% of total billed charges,$16.57 ,pays at MCD O/P rates,$50.00 ,pays at MCR OPPS,$118.75 ,pays at 95% of total billed charges,$100.00 ,pays at 80% total billed charges,$106.25 ,pays at 85% of total billed charges,$112.50 ,pays at 90% of total billed charges,$50.00 ,pays at MCR OPPS,$16.57 ,pays at 100% of MCD OPPS,$8.48 ,pays at 100% of MCD OPPS,$50.00 ,pays at MCR OPPS,$112.50 ,pays at 90% of total billed charges,$95.00 ,pays at 80% of total billed charges,$9.02 ,pays at MCR OPPS,$50.00 ,pays at MCR OPPS,$106.25 ,pays at 85% of total billed charges,$16.57 ,pays at MCD OPPS,$50.00 ,pays at MCR OPPS,$100.00 ,pays at 80% of total billed charges,$8.75 ,pays at 97% of MCR OPPS,$106.25 ,pays at 85% of total billed charges,$16.57 ,pays at MCD OPPS,$8.48 ,$118.75 ,$106.25 
Outpatient Medical Services,LABORATORY & PATHOLOGY,84443,"Blood test, thyroid stimulating hormone (TSH)",300,$118.00 ,$88.50 ,pays at 75% of total billed charges,$94.40 ,pays at 80% of total billed charges,$16.80 ,pays at MCR OPPS,$93.46 ,pays at 79.2% of total billed charges,$93.46 ,pays at 79.2% of total billed charges,$93.46 ,pays at 79.2% of total billed charges,$93.46 ,pays at 79.2% of total billed charges,$100.30 ,pays at 85% of total billed charges,$16.57 ,pays at MCD O/P rates,$47.20 ,pays at MCR OPPS,$112.10 ,pays at 95% of total billed charges,$94.40 ,pays at 80% total billed charges,$100.30 ,pays at 85% of total billed charges,$106.20 ,pays at 90% of total billed charges,$47.20 ,pays at MCR OPPS,$16.57 ,pays at 100% of MCD OPPS,$15.79 ,pays at 100% of MCD OPPS,$47.20 ,pays at MCR OPPS,$106.20 ,pays at 90% of total billed charges,$89.68 ,pays at 80% of total billed charges,$16.80 ,pays at MCR OPPS,$47.20 ,pays at MCR OPPS,$100.30 ,pays at 85% of total billed charges,$16.57 ,pays at MCD OPPS,$47.20 ,pays at MCR OPPS,$94.40 ,pays at 80% of total billed charges,$16.30 ,pays at 97% of MCR OPPS,$100.30 ,pays at 85% of total billed charges,$16.57 ,pays at MCD OPPS,$15.79 ,$112.10 ,$100.30 
Outpatient Medical Services,LABORATORY & PATHOLOGY,84450,Transferase; Aspartate Amino (Ast) (Sgot),300,$57.00 ,$42.75 ,pays at 75% of total billed charges,$45.60 ,pays at 80% of total billed charges,$5.18 ,pays at MCR OPPS,$45.14 ,pays at 79.2% of total billed charges,$45.14 ,pays at 79.2% of total billed charges,$45.14 ,pays at 79.2% of total billed charges,$45.14 ,pays at 79.2% of total billed charges,$48.45 ,pays at 85% of total billed charges,$6.44 ,pays at MCD O/P rates,$22.80 ,pays at MCR OPPS,$54.15 ,pays at 95% of total billed charges,$45.60 ,pays at 80% total billed charges,$48.45 ,pays at 85% of total billed charges,$51.30 ,pays at 90% of total billed charges,$22.80 ,pays at MCR OPPS,$6.44 ,pays at 100% of MCD OPPS,$4.87 ,pays at 100% of MCD OPPS,$22.80 ,pays at MCR OPPS,$51.30 ,pays at 90% of total billed charges,$43.32 ,pays at 80% of total billed charges,$5.18 ,pays at MCR OPPS,$22.80 ,pays at MCR OPPS,$48.45 ,pays at 85% of total billed charges,$6.44 ,pays at MCD OPPS,$22.80 ,pays at MCR OPPS,$45.60 ,pays at 80% of total billed charges,$5.02 ,pays at 97% of MCR OPPS,$48.45 ,pays at 85% of total billed charges,$6.44 ,pays at MCD OPPS,$4.87 ,$54.15 ,$48.45 
Outpatient Medical Services,LABORATORY & PATHOLOGY,84460,Blood test to evaluate liver function,300,$59.00 ,$44.25 ,pays at 75% of total billed charges,$47.20 ,pays at 80% of total billed charges,$5.30 ,pays at MCR OPPS,$46.73 ,pays at 79.2% of total billed charges,$46.73 ,pays at 79.2% of total billed charges,$46.73 ,pays at 79.2% of total billed charges,$46.73 ,pays at 79.2% of total billed charges,$50.15 ,pays at 85% of total billed charges,$6.44 ,pays at MCD O/P rates,$23.60 ,pays at MCR OPPS,$56.05 ,pays at 95% of total billed charges,$47.20 ,pays at 80% total billed charges,$50.15 ,pays at 85% of total billed charges,$53.10 ,pays at 90% of total billed charges,$23.60 ,pays at MCR OPPS,$6.44 ,pays at 100% of MCD OPPS,$4.98 ,pays at 100% of MCD OPPS,$23.60 ,pays at MCR OPPS,$53.10 ,pays at 90% of total billed charges,$44.84 ,pays at 80% of total billed charges,$5.30 ,pays at MCR OPPS,$23.60 ,pays at MCR OPPS,$50.15 ,pays at 85% of total billed charges,$6.44 ,pays at MCD OPPS,$23.60 ,pays at MCR OPPS,$47.20 ,pays at 80% of total billed charges,$5.14 ,pays at 97% of MCR OPPS,$50.15 ,pays at 85% of total billed charges,$6.44 ,pays at MCD OPPS,$4.98 ,$56.05 ,$50.15 
Outpatient Medical Services,LABORATORY & PATHOLOGY,84478,Triglycerides,300,$57.00 ,$42.75 ,pays at 75% of total billed charges,$45.60 ,pays at 80% of total billed charges,$5.74 ,pays at MCR OPPS,$45.14 ,pays at 79.2% of total billed charges,$45.14 ,pays at 79.2% of total billed charges,$45.14 ,pays at 79.2% of total billed charges,$45.14 ,pays at 79.2% of total billed charges,$48.45 ,pays at 85% of total billed charges,$6.44 ,pays at MCD O/P rates,$22.80 ,pays at MCR OPPS,$54.15 ,pays at 95% of total billed charges,$45.60 ,pays at 80% total billed charges,$48.45 ,pays at 85% of total billed charges,$51.30 ,pays at 90% of total billed charges,$22.80 ,pays at MCR OPPS,$6.44 ,pays at 100% of MCD OPPS,$5.40 ,pays at 100% of MCD OPPS,$22.80 ,pays at MCR OPPS,$51.30 ,pays at 90% of total billed charges,$43.32 ,pays at 80% of total billed charges,$5.74 ,pays at MCR OPPS,$22.80 ,pays at MCR OPPS,$48.45 ,pays at 85% of total billed charges,$6.44 ,pays at MCD OPPS,$22.80 ,pays at MCR OPPS,$45.60 ,pays at 80% of total billed charges,$5.57 ,pays at 97% of MCR OPPS,$48.45 ,pays at 85% of total billed charges,$6.44 ,pays at MCD OPPS,$5.40 ,$54.15 ,$48.45 
Outpatient Medical Services,LABORATORY & PATHOLOGY,84480,Blood test to evaluate thyroid function,300,$130.00 ,$97.50 ,pays at 75% of total billed charges,$104.00 ,pays at 80% of total billed charges,$14.18 ,pays at MCR OPPS,$102.96 ,pays at 79.2% of total billed charges,$102.96 ,pays at 79.2% of total billed charges,$102.96 ,pays at 79.2% of total billed charges,$102.96 ,pays at 79.2% of total billed charges,$110.50 ,pays at 85% of total billed charges,$16.57 ,pays at MCD O/P rates,$52.00 ,pays at MCR OPPS,$123.50 ,pays at 95% of total billed charges,$104.00 ,pays at 80% total billed charges,$110.50 ,pays at 85% of total billed charges,$117.00 ,pays at 90% of total billed charges,$52.00 ,pays at MCR OPPS,$16.57 ,pays at 100% of MCD OPPS,$13.33 ,pays at 100% of MCD OPPS,$52.00 ,pays at MCR OPPS,$117.00 ,pays at 90% of total billed charges,$98.80 ,pays at 80% of total billed charges,$14.18 ,pays at MCR OPPS,$52.00 ,pays at MCR OPPS,$110.50 ,pays at 85% of total billed charges,$16.57 ,pays at MCD OPPS,$52.00 ,pays at MCR OPPS,$104.00 ,pays at 80% of total billed charges,$13.75 ,pays at 97% of MCR OPPS,$110.50 ,pays at 85% of total billed charges,$16.57 ,pays at MCD OPPS,$13.33 ,$123.50 ,$110.50 
Outpatient Medical Services,LABORATORY & PATHOLOGY,84481,Triiodothyronine T3; Free,300,$260.00 ,$195.00 ,pays at 75% of total billed charges,$208.00 ,pays at 80% of total billed charges,$16.94 ,pays at MCR OPPS,$205.92 ,pays at 79.2% of total billed charges,$205.92 ,pays at 79.2% of total billed charges,$205.92 ,pays at 79.2% of total billed charges,$205.92 ,pays at 79.2% of total billed charges,$221.00 ,pays at 85% of total billed charges,$16.57 ,pays at MCD O/P rates,$104.00 ,pays at MCR OPPS,$247.00 ,pays at 95% of total billed charges,$208.00 ,pays at 80% total billed charges,$221.00 ,pays at 85% of total billed charges,$234.00 ,pays at 90% of total billed charges,$104.00 ,pays at MCR OPPS,$16.57 ,pays at 100% of MCD OPPS,$15.92 ,pays at 100% of MCD OPPS,$104.00 ,pays at MCR OPPS,$234.00 ,pays at 90% of total billed charges,$197.60 ,pays at 80% of total billed charges,$16.94 ,pays at MCR OPPS,$104.00 ,pays at MCR OPPS,$221.00 ,pays at 85% of total billed charges,$16.57 ,pays at MCD OPPS,$104.00 ,pays at MCR OPPS,$208.00 ,pays at 80% of total billed charges,$16.43 ,pays at 97% of MCR OPPS,$221.00 ,pays at 85% of total billed charges,$16.57 ,pays at MCD OPPS,$15.92 ,$247.00 ,$221.00 
Outpatient Medical Services,LABORATORY & PATHOLOGY,84484,Blood test to measure a certain protein in the blood to determine heart muscle damage,300,$168.00 ,$126.00 ,pays at 75% of total billed charges,$134.40 ,pays at 80% of total billed charges,$12.47 ,pays at MCR OPPS,$133.06 ,pays at 79.2% of total billed charges,$133.06 ,pays at 79.2% of total billed charges,$133.06 ,pays at 79.2% of total billed charges,$133.06 ,pays at 79.2% of total billed charges,$142.80 ,pays at 85% of total billed charges,$16.03 ,pays at MCD O/P rates,$67.20 ,pays at MCR OPPS,$159.60 ,pays at 95% of total billed charges,$134.40 ,pays at 80% total billed charges,$142.80 ,pays at 85% of total billed charges,$151.20 ,pays at 90% of total billed charges,$67.20 ,pays at MCR OPPS,$16.03 ,pays at 100% of MCD OPPS,$11.72 ,pays at 100% of MCD OPPS,$67.20 ,pays at MCR OPPS,$151.20 ,pays at 90% of total billed charges,$127.68 ,pays at 80% of total billed charges,$12.47 ,pays at MCR OPPS,$67.20 ,pays at MCR OPPS,$142.80 ,pays at 85% of total billed charges,$16.03 ,pays at MCD OPPS,$67.20 ,pays at MCR OPPS,$134.40 ,pays at 80% of total billed charges,$12.10 ,pays at 97% of MCR OPPS,$142.80 ,pays at 85% of total billed charges,$16.03 ,pays at MCD OPPS,$11.72 ,$159.60 ,$142.80 
Outpatient Medical Services,LABORATORY & PATHOLOGY,84550,Uric Acid; Blood,300,$57.00 ,$42.75 ,pays at 75% of total billed charges,$45.60 ,pays at 80% of total billed charges,$4.52 ,pays at MCR OPPS,$45.14 ,pays at 79.2% of total billed charges,$45.14 ,pays at 79.2% of total billed charges,$45.14 ,pays at 79.2% of total billed charges,$45.14 ,pays at 79.2% of total billed charges,$48.45 ,pays at 85% of total billed charges,$6.44 ,pays at MCD O/P rates,$22.80 ,pays at MCR OPPS,$54.15 ,pays at 95% of total billed charges,$45.60 ,pays at 80% total billed charges,$48.45 ,pays at 85% of total billed charges,$51.30 ,pays at 90% of total billed charges,$22.80 ,pays at MCR OPPS,$6.44 ,pays at 100% of MCD OPPS,$4.25 ,pays at 100% of MCD OPPS,$22.80 ,pays at MCR OPPS,$51.30 ,pays at 90% of total billed charges,$43.32 ,pays at 80% of total billed charges,$4.52 ,pays at MCR OPPS,$22.80 ,pays at MCR OPPS,$48.45 ,pays at 85% of total billed charges,$6.44 ,pays at MCD OPPS,$22.80 ,pays at MCR OPPS,$45.60 ,pays at 80% of total billed charges,$4.38 ,pays at 97% of MCR OPPS,$48.45 ,pays at 85% of total billed charges,$6.44 ,pays at MCD OPPS,$4.25 ,$54.15 ,$48.45 
Outpatient Medical Services,LABORATORY & PATHOLOGY,84702,"Gonadotropin, Chorionic (Hcg); Quantitative",300,$170.00 ,$127.50 ,pays at 75% of total billed charges,$136.00 ,pays at 80% of total billed charges,$15.05 ,pays at MCR OPPS,$134.64 ,pays at 79.2% of total billed charges,$134.64 ,pays at 79.2% of total billed charges,$134.64 ,pays at 79.2% of total billed charges,$134.64 ,pays at 79.2% of total billed charges,$144.50 ,pays at 85% of total billed charges,$16.57 ,pays at MCD O/P rates,$68.00 ,pays at MCR OPPS,$161.50 ,pays at 95% of total billed charges,$136.00 ,pays at 80% total billed charges,$144.50 ,pays at 85% of total billed charges,$153.00 ,pays at 90% of total billed charges,$68.00 ,pays at MCR OPPS,$16.57 ,pays at 100% of MCD OPPS,$14.15 ,pays at 100% of MCD OPPS,$68.00 ,pays at MCR OPPS,$153.00 ,pays at 90% of total billed charges,$129.20 ,pays at 80% of total billed charges,$15.05 ,pays at MCR OPPS,$68.00 ,pays at MCR OPPS,$144.50 ,pays at 85% of total billed charges,$16.57 ,pays at MCD OPPS,$68.00 ,pays at MCR OPPS,$136.00 ,pays at 80% of total billed charges,$14.60 ,pays at 97% of MCR OPPS,$144.50 ,pays at 85% of total billed charges,$16.57 ,pays at MCD OPPS,$14.15 ,$161.50 ,$144.50 
Outpatient Medical Services,LABORATORY & PATHOLOGY,84703,Blood test to assess for pregnancy,300,$114.00 ,$85.50 ,pays at 75% of total billed charges,$91.20 ,pays at 80% of total billed charges,$7.52 ,pays at MCR OPPS,$90.29 ,pays at 79.2% of total billed charges,$90.29 ,pays at 79.2% of total billed charges,$90.29 ,pays at 79.2% of total billed charges,$90.29 ,pays at 79.2% of total billed charges,$96.90 ,pays at 85% of total billed charges,$6.44 ,pays at MCD O/P rates,$45.60 ,pays at MCR OPPS,$108.30 ,pays at 95% of total billed charges,$91.20 ,pays at 80% total billed charges,$96.90 ,pays at 85% of total billed charges,$102.60 ,pays at 90% of total billed charges,$45.60 ,pays at MCR OPPS,$6.44 ,pays at 100% of MCD OPPS,$7.07 ,pays at 100% of MCD OPPS,$45.60 ,pays at MCR OPPS,$102.60 ,pays at 90% of total billed charges,$86.64 ,pays at 80% of total billed charges,$7.52 ,pays at MCR OPPS,$45.60 ,pays at MCR OPPS,$96.90 ,pays at 85% of total billed charges,$6.44 ,pays at MCD OPPS,$45.60 ,pays at MCR OPPS,$91.20 ,pays at 80% of total billed charges,$7.29 ,pays at 97% of MCR OPPS,$96.90 ,pays at 85% of total billed charges,$6.44 ,pays at MCD OPPS,$6.44 ,$108.30 ,$96.90 
Outpatient Medical Services,LABORATORY & PATHOLOGY,85007,Blood test to assess for infection,300,$33.00 ,$24.75 ,pays at 75% of total billed charges,$26.40 ,pays at 80% of total billed charges,$3.80 ,pays at MCR OPPS,$26.14 ,pays at 79.2% of total billed charges,$26.14 ,pays at 79.2% of total billed charges,$26.14 ,pays at 79.2% of total billed charges,$26.14 ,pays at 79.2% of total billed charges,$28.05 ,pays at 85% of total billed charges,$7.45 ,pays at MCD O/P rates,$13.20 ,pays at MCR OPPS,$31.35 ,pays at 95% of total billed charges,$26.40 ,pays at 80% total billed charges,$28.05 ,pays at 85% of total billed charges,$29.70 ,pays at 90% of total billed charges,$13.20 ,pays at MCR OPPS,$7.45 ,pays at 100% of MCD OPPS,$3.57 ,pays at 100% of MCD OPPS,$13.20 ,pays at MCR OPPS,$29.70 ,pays at 90% of total billed charges,$25.08 ,pays at 80% of total billed charges,$3.80 ,pays at MCR OPPS,$13.20 ,pays at MCR OPPS,$28.05 ,pays at 85% of total billed charges,$7.45 ,pays at MCD OPPS,$13.20 ,pays at MCR OPPS,$26.40 ,pays at 80% of total billed charges,$3.69 ,pays at 97% of MCR OPPS,$28.05 ,pays at 85% of total billed charges,$7.45 ,pays at MCD OPPS,$3.57 ,$31.35 ,$28.05 
Outpatient Medical Services,LABORATORY & PATHOLOGY,85014,Blood Count; Hematocrit (Hct),300,$37.00 ,$27.75 ,pays at 75% of total billed charges,$29.60 ,pays at 80% of total billed charges,$2.37 ,pays at MCR OPPS,$29.30 ,pays at 79.2% of total billed charges,$29.30 ,pays at 79.2% of total billed charges,$29.30 ,pays at 79.2% of total billed charges,$29.30 ,pays at 79.2% of total billed charges,$31.45 ,pays at 85% of total billed charges,$7.45 ,pays at MCD O/P rates,$14.80 ,pays at MCR OPPS,$35.15 ,pays at 95% of total billed charges,$29.60 ,pays at 80% total billed charges,$31.45 ,pays at 85% of total billed charges,$33.30 ,pays at 90% of total billed charges,$14.80 ,pays at MCR OPPS,$7.45 ,pays at 100% of MCD OPPS,$2.23 ,pays at 100% of MCD OPPS,$14.80 ,pays at MCR OPPS,$33.30 ,pays at 90% of total billed charges,$28.12 ,pays at 80% of total billed charges,$2.37 ,pays at MCR OPPS,$14.80 ,pays at MCR OPPS,$31.45 ,pays at 85% of total billed charges,$7.45 ,pays at MCD OPPS,$14.80 ,pays at MCR OPPS,$29.60 ,pays at 80% of total billed charges,$2.30 ,pays at 97% of MCR OPPS,$31.45 ,pays at 85% of total billed charges,$7.45 ,pays at MCD OPPS,$2.23 ,$35.15 ,$31.45 
Outpatient Medical Services,LABORATORY & PATHOLOGY,85018,Blood test to measure levels of hemoglobin,300,$38.00 ,$28.50 ,pays at 75% of total billed charges,$30.40 ,pays at 80% of total billed charges,$2.37 ,pays at MCR OPPS,$30.10 ,pays at 79.2% of total billed charges,$30.10 ,pays at 79.2% of total billed charges,$30.10 ,pays at 79.2% of total billed charges,$30.10 ,pays at 79.2% of total billed charges,$32.30 ,pays at 85% of total billed charges,$7.45 ,pays at MCD O/P rates,$15.20 ,pays at MCR OPPS,$36.10 ,pays at 95% of total billed charges,$30.40 ,pays at 80% total billed charges,$32.30 ,pays at 85% of total billed charges,$34.20 ,pays at 90% of total billed charges,$15.20 ,pays at MCR OPPS,$7.45 ,pays at 100% of MCD OPPS,$2.23 ,pays at 100% of MCD OPPS,$15.20 ,pays at MCR OPPS,$34.20 ,pays at 90% of total billed charges,$28.88 ,pays at 80% of total billed charges,$2.37 ,pays at MCR OPPS,$15.20 ,pays at MCR OPPS,$32.30 ,pays at 85% of total billed charges,$7.45 ,pays at MCD OPPS,$15.20 ,pays at MCR OPPS,$30.40 ,pays at 80% of total billed charges,$2.30 ,pays at 97% of MCR OPPS,$32.30 ,pays at 85% of total billed charges,$7.45 ,pays at MCD OPPS,$2.23 ,$36.10 ,$32.30 
Outpatient Medical Services,LABORATORY & PATHOLOGY,85025,"Complete blood cell count, with differential white blood cells, automated",300,$85.00 ,$63.75 ,pays at 75% of total billed charges,$68.00 ,pays at 80% of total billed charges,$7.77 ,pays at MCR OPPS,$67.32 ,pays at 79.2% of total billed charges,$67.32 ,pays at 79.2% of total billed charges,$67.32 ,pays at 79.2% of total billed charges,$67.32 ,pays at 79.2% of total billed charges,$72.25 ,pays at 85% of total billed charges,$7.45 ,pays at MCD O/P rates,$34.00 ,pays at MCR OPPS,$80.75 ,pays at 95% of total billed charges,$68.00 ,pays at 80% total billed charges,$72.25 ,pays at 85% of total billed charges,$76.50 ,pays at 90% of total billed charges,$34.00 ,pays at MCR OPPS,$7.45 ,pays at 100% of MCD OPPS,$7.30 ,pays at 100% of MCD OPPS,$34.00 ,pays at MCR OPPS,$76.50 ,pays at 90% of total billed charges,$64.60 ,pays at 80% of total billed charges,$7.77 ,pays at MCR OPPS,$34.00 ,pays at MCR OPPS,$72.25 ,pays at 85% of total billed charges,$7.45 ,pays at MCD OPPS,$34.00 ,pays at MCR OPPS,$68.00 ,pays at 80% of total billed charges,$7.54 ,pays at 97% of MCR OPPS,$72.25 ,pays at 85% of total billed charges,$7.45 ,pays at MCD OPPS,$7.30 ,$80.75 ,$72.25 
Outpatient Medical Services,LABORATORY & PATHOLOGY,85027,"Complete blood count, automated",300,$85.00 ,$63.75 ,pays at 75% of total billed charges,$68.00 ,pays at 80% of total billed charges,$6.47 ,pays at MCR OPPS,$67.32 ,pays at 79.2% of total billed charges,$67.32 ,pays at 79.2% of total billed charges,$67.32 ,pays at 79.2% of total billed charges,$67.32 ,pays at 79.2% of total billed charges,$72.25 ,pays at 85% of total billed charges,$7.45 ,pays at MCD O/P rates,$34.00 ,pays at MCR OPPS,$80.75 ,pays at 95% of total billed charges,$68.00 ,pays at 80% total billed charges,$72.25 ,pays at 85% of total billed charges,$76.50 ,pays at 90% of total billed charges,$34.00 ,pays at MCR OPPS,$7.45 ,pays at 100% of MCD OPPS,$6.08 ,pays at 100% of MCD OPPS,$34.00 ,pays at MCR OPPS,$76.50 ,pays at 90% of total billed charges,$64.60 ,pays at 80% of total billed charges,$6.47 ,pays at MCR OPPS,$34.00 ,pays at MCR OPPS,$72.25 ,pays at 85% of total billed charges,$7.45 ,pays at MCD OPPS,$34.00 ,pays at MCR OPPS,$68.00 ,pays at 80% of total billed charges,$6.28 ,pays at 97% of MCR OPPS,$72.25 ,pays at 85% of total billed charges,$7.45 ,pays at MCD OPPS,$6.08 ,$80.75 ,$72.25 
Outpatient Medical Services,LABORATORY & PATHOLOGY,85046,"Blood Count; Reticulocytes, Automated, Including 1 Or More Cellular Parameters (Eg, Reticulocyte Hemoglobin Content [Chr], Immature Reticulocyte Fract",300,$60.00 ,$45.00 ,pays at 75% of total billed charges,$48.00 ,pays at 80% of total billed charges,$5.57 ,pays at MCR OPPS,$47.52 ,pays at 79.2% of total billed charges,$47.52 ,pays at 79.2% of total billed charges,$47.52 ,pays at 79.2% of total billed charges,$47.52 ,pays at 79.2% of total billed charges,$51.00 ,pays at 85% of total billed charges,$7.45 ,pays at MCD O/P rates,$24.00 ,pays at MCR OPPS,$57.00 ,pays at 95% of total billed charges,$48.00 ,pays at 80% total billed charges,$51.00 ,pays at 85% of total billed charges,$54.00 ,pays at 90% of total billed charges,$24.00 ,pays at MCR OPPS,$7.45 ,pays at 100% of MCD OPPS,$5.24 ,pays at 100% of MCD OPPS,$24.00 ,pays at MCR OPPS,$54.00 ,pays at 90% of total billed charges,$45.60 ,pays at 80% of total billed charges,$5.57 ,pays at MCR OPPS,$24.00 ,pays at MCR OPPS,$51.00 ,pays at 85% of total billed charges,$7.45 ,pays at MCD OPPS,$24.00 ,pays at MCR OPPS,$48.00 ,pays at 80% of total billed charges,$5.40 ,pays at 97% of MCR OPPS,$51.00 ,pays at 85% of total billed charges,$7.45 ,pays at MCD OPPS,$5.24 ,$57.00 ,$51.00 
Outpatient Medical Services,LABORATORY & PATHOLOGY,85379,"Fibrin Degradation Products, D-Dimer; Quantitative",300,$243.00 ,$182.25 ,pays at 75% of total billed charges,$194.40 ,pays at 80% of total billed charges,$10.18 ,pays at MCR OPPS,$192.46 ,pays at 79.2% of total billed charges,$192.46 ,pays at 79.2% of total billed charges,$192.46 ,pays at 79.2% of total billed charges,$192.46 ,pays at 79.2% of total billed charges,$206.55 ,pays at 85% of total billed charges,$4.89 ,pays at MCD O/P rates,$97.20 ,pays at MCR OPPS,$230.85 ,pays at 95% of total billed charges,$194.40 ,pays at 80% total billed charges,$206.55 ,pays at 85% of total billed charges,$218.70 ,pays at 90% of total billed charges,$97.20 ,pays at MCR OPPS,$4.89 ,pays at 100% of MCD OPPS,$9.57 ,pays at 100% of MCD OPPS,$97.20 ,pays at MCR OPPS,$218.70 ,pays at 90% of total billed charges,$184.68 ,pays at 80% of total billed charges,$10.18 ,pays at MCR OPPS,$97.20 ,pays at MCR OPPS,$206.55 ,pays at 85% of total billed charges,$4.89 ,pays at MCD OPPS,$97.20 ,pays at MCR OPPS,$194.40 ,pays at 80% of total billed charges,$9.87 ,pays at 97% of MCR OPPS,$206.55 ,pays at 85% of total billed charges,$4.89 ,pays at MCD OPPS,$4.89 ,$230.85 ,$206.55 
Outpatient Medical Services,LABORATORY & PATHOLOGY,85384,Fibrinogen; Activity,300,$123.00 ,$92.25 ,pays at 75% of total billed charges,$98.40 ,pays at 80% of total billed charges,$9.72 ,pays at MCR OPPS,$97.42 ,pays at 79.2% of total billed charges,$97.42 ,pays at 79.2% of total billed charges,$97.42 ,pays at 79.2% of total billed charges,$97.42 ,pays at 79.2% of total billed charges,$104.55 ,pays at 85% of total billed charges,$4.89 ,pays at MCD O/P rates,$49.20 ,pays at MCR OPPS,$116.85 ,pays at 95% of total billed charges,$98.40 ,pays at 80% total billed charges,$104.55 ,pays at 85% of total billed charges,$110.70 ,pays at 90% of total billed charges,$49.20 ,pays at MCR OPPS,$4.89 ,pays at 100% of MCD OPPS,$9.14 ,pays at 100% of MCD OPPS,$49.20 ,pays at MCR OPPS,$110.70 ,pays at 90% of total billed charges,$93.48 ,pays at 80% of total billed charges,$9.72 ,pays at MCR OPPS,$49.20 ,pays at MCR OPPS,$104.55 ,pays at 85% of total billed charges,$4.89 ,pays at MCD OPPS,$49.20 ,pays at MCR OPPS,$98.40 ,pays at 80% of total billed charges,$9.43 ,pays at 97% of MCR OPPS,$104.55 ,pays at 85% of total billed charges,$4.89 ,pays at MCD OPPS,$4.89 ,$116.85 ,$104.55 
Outpatient Medical Services,LABORATORY & PATHOLOGY,85610,"Blood test, clotting time",300,$57.00 ,$42.75 ,pays at 75% of total billed charges,$45.60 ,pays at 80% of total billed charges,$4.29 ,pays at MCR OPPS,$45.14 ,pays at 79.2% of total billed charges,$45.14 ,pays at 79.2% of total billed charges,$45.14 ,pays at 79.2% of total billed charges,$45.14 ,pays at 79.2% of total billed charges,$48.45 ,pays at 85% of total billed charges,$4.89 ,pays at MCD O/P rates,$22.80 ,pays at MCR OPPS,$54.15 ,pays at 95% of total billed charges,$45.60 ,pays at 80% total billed charges,$48.45 ,pays at 85% of total billed charges,$51.30 ,pays at 90% of total billed charges,$22.80 ,pays at MCR OPPS,$4.89 ,pays at 100% of MCD OPPS,$4.03 ,pays at 100% of MCD OPPS,$22.80 ,pays at MCR OPPS,$51.30 ,pays at 90% of total billed charges,$43.32 ,pays at 80% of total billed charges,$4.29 ,pays at MCR OPPS,$22.80 ,pays at MCR OPPS,$48.45 ,pays at 85% of total billed charges,$4.89 ,pays at MCD OPPS,$22.80 ,pays at MCR OPPS,$45.60 ,pays at 80% of total billed charges,$4.16 ,pays at 97% of MCR OPPS,$48.45 ,pays at 85% of total billed charges,$4.89 ,pays at MCD OPPS,$4.03 ,$54.15 ,$48.45 
Outpatient Medical Services,LABORATORY & PATHOLOGY,85652,"Sedimentation Rate, Erythrocyte; Automated",300,$42.00 ,$31.50 ,pays at 75% of total billed charges,$33.60 ,pays at 80% of total billed charges,$2.70 ,pays at MCR OPPS,$33.26 ,pays at 79.2% of total billed charges,$33.26 ,pays at 79.2% of total billed charges,$33.26 ,pays at 79.2% of total billed charges,$33.26 ,pays at 79.2% of total billed charges,$35.70 ,pays at 85% of total billed charges,$7.45 ,pays at MCD O/P rates,$16.80 ,pays at MCR OPPS,$39.90 ,pays at 95% of total billed charges,$33.60 ,pays at 80% total billed charges,$35.70 ,pays at 85% of total billed charges,$37.80 ,pays at 90% of total billed charges,$16.80 ,pays at MCR OPPS,$7.45 ,pays at 100% of MCD OPPS,$2.54 ,pays at 100% of MCD OPPS,$16.80 ,pays at MCR OPPS,$37.80 ,pays at 90% of total billed charges,$31.92 ,pays at 80% of total billed charges,$2.70 ,pays at MCR OPPS,$16.80 ,pays at MCR OPPS,$35.70 ,pays at 85% of total billed charges,$7.45 ,pays at MCD OPPS,$16.80 ,pays at MCR OPPS,$33.60 ,pays at 80% of total billed charges,$2.62 ,pays at 97% of MCR OPPS,$35.70 ,pays at 85% of total billed charges,$7.45 ,pays at MCD OPPS,$2.54 ,$39.90 ,$35.70 
Outpatient Medical Services,LABORATORY & PATHOLOGY,85730,Coagulation assessment blood test,300,$68.00 ,$51.00 ,pays at 75% of total billed charges,$54.40 ,pays at 80% of total billed charges,$6.01 ,pays at MCR OPPS,$53.86 ,pays at 79.2% of total billed charges,$53.86 ,pays at 79.2% of total billed charges,$53.86 ,pays at 79.2% of total billed charges,$53.86 ,pays at 79.2% of total billed charges,$57.80 ,pays at 85% of total billed charges,$4.89 ,pays at MCD O/P rates,$27.20 ,pays at MCR OPPS,$64.60 ,pays at 95% of total billed charges,$54.40 ,pays at 80% total billed charges,$57.80 ,pays at 85% of total billed charges,$61.20 ,pays at 90% of total billed charges,$27.20 ,pays at MCR OPPS,$4.89 ,pays at 100% of MCD OPPS,$5.65 ,pays at 100% of MCD OPPS,$27.20 ,pays at MCR OPPS,$61.20 ,pays at 90% of total billed charges,$51.68 ,pays at 80% of total billed charges,$6.01 ,pays at MCR OPPS,$27.20 ,pays at MCR OPPS,$57.80 ,pays at 85% of total billed charges,$4.89 ,pays at MCD OPPS,$27.20 ,pays at MCR OPPS,$54.40 ,pays at 80% of total billed charges,$5.83 ,pays at 97% of MCR OPPS,$57.80 ,pays at 85% of total billed charges,$4.89 ,pays at MCD OPPS,$4.89 ,$64.60 ,$57.80 
Outpatient Medical Services,LABORATORY & PATHOLOGY,86038,Antinuclear Antibodies (Ana);,300,$93.00 ,$69.75 ,pays at 75% of total billed charges,$74.40 ,pays at 80% of total billed charges,$12.09 ,pays at MCR OPPS,$73.66 ,pays at 79.2% of total billed charges,$73.66 ,pays at 79.2% of total billed charges,$73.66 ,pays at 79.2% of total billed charges,$73.66 ,pays at 79.2% of total billed charges,$79.05 ,pays at 85% of total billed charges,$13.74 ,pays at MCD O/P rates,$37.20 ,pays at MCR OPPS,$88.35 ,pays at 95% of total billed charges,$74.40 ,pays at 80% total billed charges,$79.05 ,pays at 85% of total billed charges,$83.70 ,pays at 90% of total billed charges,$37.20 ,pays at MCR OPPS,$13.74 ,pays at 100% of MCD OPPS,$11.36 ,pays at 100% of MCD OPPS,$37.20 ,pays at MCR OPPS,$83.70 ,pays at 90% of total billed charges,$70.68 ,pays at 80% of total billed charges,$12.09 ,pays at MCR OPPS,$37.20 ,pays at MCR OPPS,$79.05 ,pays at 85% of total billed charges,$13.74 ,pays at MCD OPPS,$37.20 ,pays at MCR OPPS,$74.40 ,pays at 80% of total billed charges,$11.73 ,pays at 97% of MCR OPPS,$79.05 ,pays at 85% of total billed charges,$13.74 ,pays at MCD OPPS,$11.36 ,$88.35 ,$79.05 
Outpatient Medical Services,LABORATORY & PATHOLOGY,86140,C-Reactive Protein;,300,$94.00 ,$70.50 ,pays at 75% of total billed charges,$75.20 ,pays at 80% of total billed charges,$5.18 ,pays at MCR OPPS,$74.45 ,pays at 79.2% of total billed charges,$74.45 ,pays at 79.2% of total billed charges,$74.45 ,pays at 79.2% of total billed charges,$74.45 ,pays at 79.2% of total billed charges,$79.90 ,pays at 85% of total billed charges,$13.74 ,pays at MCD O/P rates,$37.60 ,pays at MCR OPPS,$89.30 ,pays at 95% of total billed charges,$75.20 ,pays at 80% total billed charges,$79.90 ,pays at 85% of total billed charges,$84.60 ,pays at 90% of total billed charges,$37.60 ,pays at MCR OPPS,$13.74 ,pays at 100% of MCD OPPS,$4.87 ,pays at 100% of MCD OPPS,$37.60 ,pays at MCR OPPS,$84.60 ,pays at 90% of total billed charges,$71.44 ,pays at 80% of total billed charges,$5.18 ,pays at MCR OPPS,$37.60 ,pays at MCR OPPS,$79.90 ,pays at 85% of total billed charges,$13.74 ,pays at MCD OPPS,$37.60 ,pays at MCR OPPS,$75.20 ,pays at 80% of total billed charges,$5.02 ,pays at 97% of MCR OPPS,$79.90 ,pays at 85% of total billed charges,$13.74 ,pays at MCD OPPS,$4.87 ,$89.30 ,$79.90 
Outpatient Medical Services,LABORATORY & PATHOLOGY,86147,Blood test to determine cause of inappropriate blood clot formation,300,$119.00 ,$89.25 ,pays at 75% of total billed charges,$95.20 ,pays at 80% of total billed charges,$25.45 ,pays at MCR OPPS,$94.25 ,pays at 79.2% of total billed charges,$94.25 ,pays at 79.2% of total billed charges,$94.25 ,pays at 79.2% of total billed charges,$94.25 ,pays at 79.2% of total billed charges,$101.15 ,pays at 85% of total billed charges,$13.74 ,pays at MCD O/P rates,$47.60 ,pays at MCR OPPS,$113.05 ,pays at 95% of total billed charges,$95.20 ,pays at 80% total billed charges,$101.15 ,pays at 85% of total billed charges,$107.10 ,pays at 90% of total billed charges,$47.60 ,pays at MCR OPPS,$13.74 ,pays at 100% of MCD OPPS,$23.92 ,pays at 100% of MCD OPPS,$47.60 ,pays at MCR OPPS,$107.10 ,pays at 90% of total billed charges,$90.44 ,pays at 80% of total billed charges,$25.45 ,pays at MCR OPPS,$47.60 ,pays at MCR OPPS,$101.15 ,pays at 85% of total billed charges,$13.74 ,pays at MCD OPPS,$47.60 ,pays at MCR OPPS,$95.20 ,pays at 80% of total billed charges,$24.69 ,pays at 97% of MCR OPPS,$101.15 ,pays at 85% of total billed charges,$13.74 ,pays at MCD OPPS,$13.74 ,$113.05 ,$101.15 
Outpatient Medical Services,LABORATORY & PATHOLOGY,86148,Anti-Phosphatidylserine (Phospholipid) Antibody,300,$66.00 ,$49.50 ,pays at 75% of total billed charges,$52.80 ,pays at 80% of total billed charges,$16.07 ,pays at MCR OPPS,$52.27 ,pays at 79.2% of total billed charges,$52.27 ,pays at 79.2% of total billed charges,$52.27 ,pays at 79.2% of total billed charges,$52.27 ,pays at 79.2% of total billed charges,$56.10 ,pays at 85% of total billed charges,$13.74 ,pays at MCD O/P rates,$26.40 ,pays at MCR OPPS,$62.70 ,pays at 95% of total billed charges,$52.80 ,pays at 80% total billed charges,$56.10 ,pays at 85% of total billed charges,$59.40 ,pays at 90% of total billed charges,$26.40 ,pays at MCR OPPS,$13.74 ,pays at 100% of MCD OPPS,$15.11 ,pays at 100% of MCD OPPS,$26.40 ,pays at MCR OPPS,$59.40 ,pays at 90% of total billed charges,$50.16 ,pays at 80% of total billed charges,$16.07 ,pays at MCR OPPS,$26.40 ,pays at MCR OPPS,$56.10 ,pays at 85% of total billed charges,$13.74 ,pays at MCD OPPS,$26.40 ,pays at MCR OPPS,$52.80 ,pays at 80% of total billed charges,$15.59 ,pays at 97% of MCR OPPS,$56.10 ,pays at 85% of total billed charges,$13.74 ,pays at MCD OPPS,$13.74 ,$62.70 ,$56.10 
Outpatient Medical Services,LABORATORY & PATHOLOGY,86200,Blood test to diagnose rheumatoid arthritis,300,$103.00 ,$77.25 ,pays at 75% of total billed charges,$82.40 ,pays at 80% of total billed charges,$12.95 ,pays at MCR OPPS,$81.58 ,pays at 79.2% of total billed charges,$81.58 ,pays at 79.2% of total billed charges,$81.58 ,pays at 79.2% of total billed charges,$81.58 ,pays at 79.2% of total billed charges,$87.55 ,pays at 85% of total billed charges,$13.74 ,pays at MCD O/P rates,$41.20 ,pays at MCR OPPS,$97.85 ,pays at 95% of total billed charges,$82.40 ,pays at 80% total billed charges,$87.55 ,pays at 85% of total billed charges,$92.70 ,pays at 90% of total billed charges,$41.20 ,pays at MCR OPPS,$13.74 ,pays at 100% of MCD OPPS,$12.17 ,pays at 100% of MCD OPPS,$41.20 ,pays at MCR OPPS,$92.70 ,pays at 90% of total billed charges,$78.28 ,pays at 80% of total billed charges,$12.95 ,pays at MCR OPPS,$41.20 ,pays at MCR OPPS,$87.55 ,pays at 85% of total billed charges,$13.74 ,pays at MCD OPPS,$41.20 ,pays at MCR OPPS,$82.40 ,pays at 80% of total billed charges,$12.56 ,pays at 97% of MCR OPPS,$87.55 ,pays at 85% of total billed charges,$13.74 ,pays at MCD OPPS,$12.17 ,$97.85 ,$87.55 
Outpatient Medical Services,LABORATORY & PATHOLOGY,86300,Blood test to monitor breast cancer,300,$157.00 ,$117.75 ,pays at 75% of total billed charges,$125.60 ,pays at 80% of total billed charges,$20.81 ,pays at MCR OPPS,$124.34 ,pays at 79.2% of total billed charges,$124.34 ,pays at 79.2% of total billed charges,$124.34 ,pays at 79.2% of total billed charges,$124.34 ,pays at 79.2% of total billed charges,$133.45 ,pays at 85% of total billed charges,$13.74 ,pays at MCD O/P rates,$62.80 ,pays at MCR OPPS,$149.15 ,pays at 95% of total billed charges,$125.60 ,pays at 80% total billed charges,$133.45 ,pays at 85% of total billed charges,$141.30 ,pays at 90% of total billed charges,$62.80 ,pays at MCR OPPS,$13.74 ,pays at 100% of MCD OPPS,$19.55 ,pays at 100% of MCD OPPS,$62.80 ,pays at MCR OPPS,$141.30 ,pays at 90% of total billed charges,$119.32 ,pays at 80% of total billed charges,$20.81 ,pays at MCR OPPS,$62.80 ,pays at MCR OPPS,$133.45 ,pays at 85% of total billed charges,$13.74 ,pays at MCD OPPS,$62.80 ,pays at MCR OPPS,$125.60 ,pays at 80% of total billed charges,$20.19 ,pays at 97% of MCR OPPS,$133.45 ,pays at 85% of total billed charges,$13.74 ,pays at MCD OPPS,$13.74 ,$149.15 ,$133.45 
Outpatient Medical Services,LABORATORY & PATHOLOGY,86304,Blood test to monitor for cancer,300,$177.00 ,$132.75 ,pays at 75% of total billed charges,$141.60 ,pays at 80% of total billed charges,$20.81 ,pays at MCR OPPS,$140.18 ,pays at 79.2% of total billed charges,$140.18 ,pays at 79.2% of total billed charges,$140.18 ,pays at 79.2% of total billed charges,$140.18 ,pays at 79.2% of total billed charges,$150.45 ,pays at 85% of total billed charges,$13.74 ,pays at MCD O/P rates,$70.80 ,pays at MCR OPPS,$168.15 ,pays at 95% of total billed charges,$141.60 ,pays at 80% total billed charges,$150.45 ,pays at 85% of total billed charges,$159.30 ,pays at 90% of total billed charges,$70.80 ,pays at MCR OPPS,$13.74 ,pays at 100% of MCD OPPS,$19.55 ,pays at 100% of MCD OPPS,$70.80 ,pays at MCR OPPS,$159.30 ,pays at 90% of total billed charges,$134.52 ,pays at 80% of total billed charges,$20.81 ,pays at MCR OPPS,$70.80 ,pays at MCR OPPS,$150.45 ,pays at 85% of total billed charges,$13.74 ,pays at MCD OPPS,$70.80 ,pays at MCR OPPS,$141.60 ,pays at 80% of total billed charges,$20.19 ,pays at 97% of MCR OPPS,$150.45 ,pays at 85% of total billed charges,$13.74 ,pays at MCD OPPS,$13.74 ,$168.15 ,$150.45 
Outpatient Medical Services,LABORATORY & PATHOLOGY,86431,Rheumatoid Factor; Quantitative,300,$68.00 ,$51.00 ,pays at 75% of total billed charges,$54.40 ,pays at 80% of total billed charges,$5.67 ,pays at MCR OPPS,$53.86 ,pays at 79.2% of total billed charges,$53.86 ,pays at 79.2% of total billed charges,$53.86 ,pays at 79.2% of total billed charges,$53.86 ,pays at 79.2% of total billed charges,$57.80 ,pays at 85% of total billed charges,$13.74 ,pays at MCD O/P rates,$27.20 ,pays at MCR OPPS,$64.60 ,pays at 95% of total billed charges,$54.40 ,pays at 80% total billed charges,$57.80 ,pays at 85% of total billed charges,$61.20 ,pays at 90% of total billed charges,$27.20 ,pays at MCR OPPS,$13.74 ,pays at 100% of MCD OPPS,$5.33 ,pays at 100% of MCD OPPS,$27.20 ,pays at MCR OPPS,$61.20 ,pays at 90% of total billed charges,$51.68 ,pays at 80% of total billed charges,$5.67 ,pays at MCR OPPS,$27.20 ,pays at MCR OPPS,$57.80 ,pays at 85% of total billed charges,$13.74 ,pays at MCD OPPS,$27.20 ,pays at MCR OPPS,$54.40 ,pays at 80% of total billed charges,$5.50 ,pays at 97% of MCR OPPS,$57.80 ,pays at 85% of total billed charges,$13.74 ,pays at MCD OPPS,$5.33 ,$64.60 ,$57.80 
Outpatient Medical Services,LABORATORY & PATHOLOGY,86592,Blood test to screen for syphilis,300,$103.00 ,$77.25 ,pays at 75% of total billed charges,$82.40 ,pays at 80% of total billed charges,$4.27 ,pays at MCR OPPS,$81.58 ,pays at 79.2% of total billed charges,$81.58 ,pays at 79.2% of total billed charges,$81.58 ,pays at 79.2% of total billed charges,$81.58 ,pays at 79.2% of total billed charges,$87.55 ,pays at 85% of total billed charges,$13.74 ,pays at MCD O/P rates,$41.20 ,pays at MCR OPPS,$97.85 ,pays at 95% of total billed charges,$82.40 ,pays at 80% total billed charges,$87.55 ,pays at 85% of total billed charges,$92.70 ,pays at 90% of total billed charges,$41.20 ,pays at MCR OPPS,$13.74 ,pays at 100% of MCD OPPS,$4.01 ,pays at 100% of MCD OPPS,$41.20 ,pays at MCR OPPS,$92.70 ,pays at 90% of total billed charges,$78.28 ,pays at 80% of total billed charges,$4.27 ,pays at MCR OPPS,$41.20 ,pays at MCR OPPS,$87.55 ,pays at 85% of total billed charges,$13.74 ,pays at MCD OPPS,$41.20 ,pays at MCR OPPS,$82.40 ,pays at 80% of total billed charges,$4.14 ,pays at 97% of MCR OPPS,$87.55 ,pays at 85% of total billed charges,$13.74 ,pays at MCD OPPS,$4.01 ,$97.85 ,$87.55 
Outpatient Medical Services,LABORATORY & PATHOLOGY,86677,Blood test to if peptic ulcers are caused by a certain bacterium,300,$125.00 ,$93.75 ,pays at 75% of total billed charges,$100.00 ,pays at 80% of total billed charges,$16.85 ,pays at MCR OPPS,$99.00 ,pays at 79.2% of total billed charges,$99.00 ,pays at 79.2% of total billed charges,$99.00 ,pays at 79.2% of total billed charges,$99.00 ,pays at 79.2% of total billed charges,$106.25 ,pays at 85% of total billed charges,$13.74 ,pays at MCD O/P rates,$50.00 ,pays at MCR OPPS,$118.75 ,pays at 95% of total billed charges,$100.00 ,pays at 80% total billed charges,$106.25 ,pays at 85% of total billed charges,$112.50 ,pays at 90% of total billed charges,$50.00 ,pays at MCR OPPS,$13.74 ,pays at 100% of MCD OPPS,$15.84 ,pays at 100% of MCD OPPS,$50.00 ,pays at MCR OPPS,$112.50 ,pays at 90% of total billed charges,$95.00 ,pays at 80% of total billed charges,$16.85 ,pays at MCR OPPS,$50.00 ,pays at MCR OPPS,$106.25 ,pays at 85% of total billed charges,$13.74 ,pays at MCD OPPS,$50.00 ,pays at MCR OPPS,$100.00 ,pays at 80% of total billed charges,$16.34 ,pays at 97% of MCR OPPS,$106.25 ,pays at 85% of total billed charges,$13.74 ,pays at MCD OPPS,$13.74 ,$118.75 ,$106.25 
Outpatient Medical Services,LABORATORY & PATHOLOGY,86703,Blood test to diagnose HIV,300,$80.00 ,$60.00 ,pays at 75% of total billed charges,$64.00 ,pays at 80% of total billed charges,$13.71 ,pays at MCR OPPS,$63.36 ,pays at 79.2% of total billed charges,$63.36 ,pays at 79.2% of total billed charges,$63.36 ,pays at 79.2% of total billed charges,$63.36 ,pays at 79.2% of total billed charges,$68.00 ,pays at 85% of total billed charges,$13.74 ,pays at MCD O/P rates,$32.00 ,pays at MCR OPPS,$76.00 ,pays at 95% of total billed charges,$64.00 ,pays at 80% total billed charges,$68.00 ,pays at 85% of total billed charges,$72.00 ,pays at 90% of total billed charges,$32.00 ,pays at MCR OPPS,$13.74 ,pays at 100% of MCD OPPS,$12.89 ,pays at 100% of MCD OPPS,$32.00 ,pays at MCR OPPS,$72.00 ,pays at 90% of total billed charges,$60.80 ,pays at 80% of total billed charges,$13.71 ,pays at MCR OPPS,$32.00 ,pays at MCR OPPS,$68.00 ,pays at 85% of total billed charges,$13.74 ,pays at MCD OPPS,$32.00 ,pays at MCR OPPS,$64.00 ,pays at 80% of total billed charges,$13.30 ,pays at 97% of MCR OPPS,$68.00 ,pays at 85% of total billed charges,$13.74 ,pays at MCD OPPS,$12.89 ,$76.00 ,$68.00 
Outpatient Medical Services,LABORATORY & PATHOLOGY,86769,Antibody; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]),300,$60.00 ,$45.00 ,pays at 75% of total billed charges,$48.00 ,pays at 80% of total billed charges,$42.13 ,pays at MCR OPPS,$47.52 ,pays at 79.2% of total billed charges,$47.52 ,pays at 79.2% of total billed charges,$47.52 ,pays at 79.2% of total billed charges,$47.52 ,pays at 79.2% of total billed charges,$51.00 ,pays at 85% of total billed charges,$13.74 ,pays at MCD O/P rates,$24.00 ,pays at MCR OPPS,$57.00 ,pays at 95% of total billed charges,$48.00 ,pays at 80% total billed charges,$51.00 ,pays at 85% of total billed charges,$54.00 ,pays at 90% of total billed charges,$24.00 ,pays at MCR OPPS,$13.74 ,pays at 100% of MCD OPPS,$39.60 ,pays at 100% of MCD OPPS,$24.00 ,pays at MCR OPPS,$54.00 ,pays at 90% of total billed charges,$45.60 ,pays at 80% of total billed charges,$42.13 ,pays at MCR OPPS,$24.00 ,pays at MCR OPPS,$51.00 ,pays at 85% of total billed charges,$13.74 ,pays at MCD OPPS,$24.00 ,pays at MCR OPPS,$48.00 ,pays at 80% of total billed charges,$40.87 ,pays at 97% of MCR OPPS,$51.00 ,pays at 85% of total billed charges,$13.74 ,pays at MCD OPPS,$13.74 ,$57.00 ,$51.00 
Outpatient Medical Services,LABORATORY & PATHOLOGY,86803,Blood test to determine infection with Hepatitis C,300,$120.00 ,$90.00 ,pays at 75% of total billed charges,$96.00 ,pays at 80% of total billed charges,$14.27 ,pays at MCR OPPS,$95.04 ,pays at 79.2% of total billed charges,$95.04 ,pays at 79.2% of total billed charges,$95.04 ,pays at 79.2% of total billed charges,$95.04 ,pays at 79.2% of total billed charges,$102.00 ,pays at 85% of total billed charges,$13.74 ,pays at MCD O/P rates,$48.00 ,pays at MCR OPPS,$114.00 ,pays at 95% of total billed charges,$96.00 ,pays at 80% total billed charges,$102.00 ,pays at 85% of total billed charges,$108.00 ,pays at 90% of total billed charges,$48.00 ,pays at MCR OPPS,$13.74 ,pays at 100% of MCD OPPS,$13.41 ,pays at 100% of MCD OPPS,$48.00 ,pays at MCR OPPS,$108.00 ,pays at 90% of total billed charges,$91.20 ,pays at 80% of total billed charges,$14.27 ,pays at MCR OPPS,$48.00 ,pays at MCR OPPS,$102.00 ,pays at 85% of total billed charges,$13.74 ,pays at MCD OPPS,$48.00 ,pays at MCR OPPS,$96.00 ,pays at 80% of total billed charges,$13.84 ,pays at 97% of MCR OPPS,$102.00 ,pays at 85% of total billed charges,$13.74 ,pays at MCD OPPS,$13.41 ,$114.00 ,$102.00 
Outpatient Medical Services,LABORATORY & PATHOLOGY,86850,Blood test to screen for antibodies that could harm red blood cells,300,$102.00 ,$76.50 ,pays at 75% of total billed charges,$81.60 ,pays at 80% of total billed charges,$9.77 ,pays at MCR OPPS,$80.78 ,pays at 79.2% of total billed charges,$80.78 ,pays at 79.2% of total billed charges,$80.78 ,pays at 79.2% of total billed charges,$80.78 ,pays at 79.2% of total billed charges,$86.70 ,pays at 85% of total billed charges,$5.65 ,pays at MCD O/P rates,$40.80 ,pays at MCR OPPS,$96.90 ,pays at 95% of total billed charges,$81.60 ,pays at 80% total billed charges,$86.70 ,pays at 85% of total billed charges,$91.80 ,pays at 90% of total billed charges,$40.80 ,pays at MCR OPPS,$5.65 ,pays at 100% of MCD OPPS,$50.14 ,pays at 100% of MCD OPPS,$40.80 ,pays at MCR OPPS,$91.80 ,pays at 90% of total billed charges,$77.52 ,pays at 80% of total billed charges,$9.77 ,pays at MCR OPPS,$40.80 ,pays at MCR OPPS,$86.70 ,pays at 85% of total billed charges,$5.65 ,pays at MCD OPPS,$40.80 ,pays at MCR OPPS,$81.60 ,pays at 80% of total billed charges,$9.48 ,pays at 97% of MCR OPPS,$86.70 ,pays at 85% of total billed charges,$5.65 ,pays at MCD OPPS,$5.65 ,$96.90 ,$86.70 
Outpatient Medical Services,LABORATORY & PATHOLOGY,86900,"Blood typing, serologic; ABO",300,$61.00 ,$45.75 ,pays at 75% of total billed charges,$48.80 ,pays at 80% of total billed charges,$2.99 ,pays at MCR OPPS,$48.31 ,pays at 79.2% of total billed charges,$48.31 ,pays at 79.2% of total billed charges,$48.31 ,pays at 79.2% of total billed charges,$48.31 ,pays at 79.2% of total billed charges,$51.85 ,pays at 85% of total billed charges,$5.65 ,pays at MCD O/P rates,$24.40 ,pays at MCR OPPS,$57.95 ,pays at 95% of total billed charges,$48.80 ,pays at 80% total billed charges,$51.85 ,pays at 85% of total billed charges,$54.90 ,pays at 90% of total billed charges,$24.40 ,pays at MCR OPPS,$5.65 ,pays at 100% of MCD OPPS,$61.00 ,pays at 100% of MCD OPPS,$24.40 ,pays at MCR OPPS,$54.90 ,pays at 90% of total billed charges,$46.36 ,pays at 80% of total billed charges,$2.99 ,pays at MCR OPPS,$24.40 ,pays at MCR OPPS,$51.85 ,pays at 85% of total billed charges,$5.65 ,pays at MCD OPPS,$24.40 ,pays at MCR OPPS,$48.80 ,pays at 80% of total billed charges,$2.90 ,pays at 97% of MCR OPPS,$51.85 ,pays at 85% of total billed charges,$5.65 ,pays at MCD OPPS,$2.90 ,$61.00 ,$51.85 
Outpatient Medical Services,LABORATORY & PATHOLOGY,86901,"Blood typing, serologic; Rh (D)",300,$63.00 ,$47.25 ,pays at 75% of total billed charges,$50.40 ,pays at 80% of total billed charges,$2.99 ,pays at MCR OPPS,$49.90 ,pays at 79.2% of total billed charges,$49.90 ,pays at 79.2% of total billed charges,$49.90 ,pays at 79.2% of total billed charges,$49.90 ,pays at 79.2% of total billed charges,$53.55 ,pays at 85% of total billed charges,$5.65 ,pays at MCD O/P rates,$25.20 ,pays at MCR OPPS,$59.85 ,pays at 95% of total billed charges,$50.40 ,pays at 80% total billed charges,$53.55 ,pays at 85% of total billed charges,$56.70 ,pays at 90% of total billed charges,$25.20 ,pays at MCR OPPS,$5.65 ,pays at 100% of MCD OPPS,$33.96 ,pays at 100% of MCD OPPS,$25.20 ,pays at MCR OPPS,$56.70 ,pays at 90% of total billed charges,$47.88 ,pays at 80% of total billed charges,$2.99 ,pays at MCR OPPS,$25.20 ,pays at MCR OPPS,$53.55 ,pays at 85% of total billed charges,$5.65 ,pays at MCD OPPS,$25.20 ,pays at MCR OPPS,$50.40 ,pays at 80% of total billed charges,$2.90 ,pays at 97% of MCR OPPS,$53.55 ,pays at 85% of total billed charges,$5.65 ,pays at MCD OPPS,$2.90 ,$59.85 ,$53.55 
Outpatient Medical Services,LABORATORY & PATHOLOGY,86922,Compatibility test each unit; antiglobulin technique,300,$214.00 ,$160.50 ,pays at 75% of total billed charges,$171.20 ,pays at 80% of total billed charges,N/A,AUDIT: // Allowable RM =  Physician Fee Schedule (outpatient):(86922) $0.00 * 1 * 115% = $0.00,$169.49 ,pays at 79.2% of total billed charges,$169.49 ,pays at 79.2% of total billed charges,$169.49 ,pays at 79.2% of total billed charges,$169.49 ,pays at 79.2% of total billed charges,$181.90 ,pays at 85% of total billed charges,$214.00 ,pays at MCD O/P rates,$85.60 ,pays at MCR OPPS,$203.30 ,pays at 95% of total billed charges,$171.20 ,pays at 80% total billed charges,$181.90 ,pays at 85% of total billed charges,$192.60 ,pays at 90% of total billed charges,$85.60 ,pays at MCR OPPS,$214.00 ,pays at 100% of MCD OPPS,$157.25 ,pays at 100% of MCD OPPS,$85.60 ,pays at MCR OPPS,$192.60 ,pays at 90% of total billed charges,$162.64 ,pays at 80% of total billed charges,N/A,AUDIT: // Allowable RM =  Physician Fee Schedule (outpatient):(86922) $0.00 * 1 * 115% = $0.00,$85.60 ,pays at MCR OPPS,$181.90 ,pays at 85% of total billed charges,$214.00 ,pays at MCD OPPS,$85.60 ,pays at MCR OPPS,$171.20 ,pays at 80% of total billed charges,N/A,not reimburseable per contract,$181.90 ,pays at 85% of total billed charges,$214.00 ,pays at MCD OPPS,$85.60 ,$214.00 ,$181.90 
Outpatient Medical Services,LABORATORY & PATHOLOGY,86923,Compatibility test each unit; electronic,300,$350.00 ,$262.50 ,pays at 75% of total billed charges,$280.00 ,pays at 80% of total billed charges,N/A,AUDIT: // Allowable RM =  Physician Fee Schedule (outpatient):(86923) $0.00 * 1 * 115% = $0.00,$277.20 ,pays at 79.2% of total billed charges,$277.20 ,pays at 79.2% of total billed charges,$277.20 ,pays at 79.2% of total billed charges,$277.20 ,pays at 79.2% of total billed charges,$297.50 ,pays at 85% of total billed charges,$350.00 ,pays at MCD O/P rates,$140.00 ,pays at MCR OPPS,$332.50 ,pays at 95% of total billed charges,$280.00 ,pays at 80% total billed charges,$297.50 ,pays at 85% of total billed charges,$315.00 ,pays at 90% of total billed charges,$140.00 ,pays at MCR OPPS,$350.00 ,pays at 100% of MCD OPPS,$157.25 ,pays at 100% of MCD OPPS,$140.00 ,pays at MCR OPPS,$315.00 ,pays at 90% of total billed charges,$266.00 ,pays at 80% of total billed charges,N/A,AUDIT: // Allowable RM =  Physician Fee Schedule (outpatient):(86923) $0.00 * 1 * 115% = $0.00,$140.00 ,pays at MCR OPPS,$297.50 ,pays at 85% of total billed charges,$350.00 ,pays at MCD OPPS,$140.00 ,pays at MCR OPPS,$280.00 ,pays at 80% of total billed charges,N/A,not reimburseable per contract,$297.50 ,pays at 85% of total billed charges,$350.00 ,pays at MCD OPPS,$140.00 ,$350.00 ,$297.50 
Outpatient Medical Services,LABORATORY & PATHOLOGY,87040,Blood test to screen for bacteria in the blood,300,$98.00 ,$73.50 ,pays at 75% of total billed charges,$78.40 ,pays at 80% of total billed charges,$10.32 ,pays at MCR OPPS,$77.62 ,pays at 79.2% of total billed charges,$77.62 ,pays at 79.2% of total billed charges,$77.62 ,pays at 79.2% of total billed charges,$77.62 ,pays at 79.2% of total billed charges,$83.30 ,pays at 85% of total billed charges,$9.49 ,pays at MCD O/P rates,$39.20 ,pays at MCR OPPS,$93.10 ,pays at 95% of total billed charges,$78.40 ,pays at 80% total billed charges,$83.30 ,pays at 85% of total billed charges,$88.20 ,pays at 90% of total billed charges,$39.20 ,pays at MCR OPPS,$9.49 ,pays at 100% of MCD OPPS,$9.69 ,pays at 100% of MCD OPPS,$39.20 ,pays at MCR OPPS,$88.20 ,pays at 90% of total billed charges,$74.48 ,pays at 80% of total billed charges,$10.32 ,pays at MCR OPPS,$39.20 ,pays at MCR OPPS,$83.30 ,pays at 85% of total billed charges,$9.49 ,pays at MCD OPPS,$39.20 ,pays at MCR OPPS,$78.40 ,pays at 80% of total billed charges,$10.01 ,pays at 97% of MCR OPPS,$83.30 ,pays at 85% of total billed charges,$9.49 ,pays at MCD OPPS,$9.49 ,$93.10 ,$83.30 
Outpatient Medical Services,LABORATORY & PATHOLOGY,87070,Test of body fluid other than blood to assess for bacteria,300,$135.81 ,$101.86 ,pays at 75% of total billed charges,$108.65 ,pays at 80% of total billed charges,$8.62 ,pays at MCR OPPS,$107.56 ,pays at 79.2% of total billed charges,$107.56 ,pays at 79.2% of total billed charges,$107.56 ,pays at 79.2% of total billed charges,$107.56 ,pays at 79.2% of total billed charges,$115.44 ,pays at 85% of total billed charges,$9.49 ,pays at MCD O/P rates,$54.32 ,pays at MCR OPPS,$129.02 ,pays at 95% of total billed charges,$108.65 ,pays at 80% total billed charges,$115.44 ,pays at 85% of total billed charges,$122.23 ,pays at 90% of total billed charges,$54.32 ,pays at MCR OPPS,$9.49 ,pays at 100% of MCD OPPS,$8.10 ,pays at 100% of MCD OPPS,$54.32 ,pays at MCR OPPS,$122.23 ,pays at 90% of total billed charges,$103.22 ,pays at 80% of total billed charges,$8.62 ,pays at MCR OPPS,$54.32 ,pays at MCR OPPS,$115.44 ,pays at 85% of total billed charges,$9.49 ,pays at MCD OPPS,$54.32 ,pays at MCR OPPS,$108.65 ,pays at 80% of total billed charges,$8.36 ,pays at 97% of MCR OPPS,$115.44 ,pays at 85% of total billed charges,$9.49 ,pays at MCD OPPS,$8.10 ,$129.02 ,$115.44 
Outpatient Medical Services,LABORATORY & PATHOLOGY,87075,"Culture, Bacterial; Any Source, Except Blood, Anaerobic With Isolation And Presumptive Identification Of Isolates",300,$149.00 ,$111.75 ,pays at 75% of total billed charges,$119.20 ,pays at 80% of total billed charges,$9.47 ,pays at MCR OPPS,$118.01 ,pays at 79.2% of total billed charges,$118.01 ,pays at 79.2% of total billed charges,$118.01 ,pays at 79.2% of total billed charges,$118.01 ,pays at 79.2% of total billed charges,$126.65 ,pays at 85% of total billed charges,$9.49 ,pays at MCD O/P rates,$59.60 ,pays at MCR OPPS,$141.55 ,pays at 95% of total billed charges,$119.20 ,pays at 80% total billed charges,$126.65 ,pays at 85% of total billed charges,$134.10 ,pays at 90% of total billed charges,$59.60 ,pays at MCR OPPS,$9.49 ,pays at 100% of MCD OPPS,$8.90 ,pays at 100% of MCD OPPS,$59.60 ,pays at MCR OPPS,$134.10 ,pays at 90% of total billed charges,$113.24 ,pays at 80% of total billed charges,$9.47 ,pays at MCR OPPS,$59.60 ,pays at MCR OPPS,$126.65 ,pays at 85% of total billed charges,$9.49 ,pays at MCD OPPS,$59.60 ,pays at MCR OPPS,$119.20 ,pays at 80% of total billed charges,$9.19 ,pays at 97% of MCR OPPS,$126.65 ,pays at 85% of total billed charges,$9.49 ,pays at MCD OPPS,$8.90 ,$141.55 ,$126.65 
Outpatient Medical Services,LABORATORY & PATHOLOGY,87076,"Culture, Bacterial; Anaerobic Isolate, Additional Methods Required For Definitive Identification, Each Isolate",300,$50.00 ,$37.50 ,pays at 75% of total billed charges,$40.00 ,pays at 80% of total billed charges,$8.08 ,pays at MCR OPPS,$39.60 ,pays at 79.2% of total billed charges,$39.60 ,pays at 79.2% of total billed charges,$39.60 ,pays at 79.2% of total billed charges,$39.60 ,pays at 79.2% of total billed charges,$42.50 ,pays at 85% of total billed charges,$9.49 ,pays at MCD O/P rates,$20.00 ,pays at MCR OPPS,$47.50 ,pays at 95% of total billed charges,$40.00 ,pays at 80% total billed charges,$42.50 ,pays at 85% of total billed charges,$45.00 ,pays at 90% of total billed charges,$20.00 ,pays at MCR OPPS,$9.49 ,pays at 100% of MCD OPPS,$7.60 ,pays at 100% of MCD OPPS,$20.00 ,pays at MCR OPPS,$45.00 ,pays at 90% of total billed charges,$38.00 ,pays at 80% of total billed charges,$8.08 ,pays at MCR OPPS,$20.00 ,pays at MCR OPPS,$42.50 ,pays at 85% of total billed charges,$9.49 ,pays at MCD OPPS,$20.00 ,pays at MCR OPPS,$40.00 ,pays at 80% of total billed charges,$7.84 ,pays at 97% of MCR OPPS,$42.50 ,pays at 85% of total billed charges,$9.49 ,pays at MCD OPPS,$7.60 ,$47.50 ,$42.50 
Outpatient Medical Services,LABORATORY & PATHOLOGY,87077,Test of a wound for type of bacterial infection,300,$56.00 ,$42.00 ,pays at 75% of total billed charges,$44.80 ,pays at 80% of total billed charges,$8.08 ,pays at MCR OPPS,$44.35 ,pays at 79.2% of total billed charges,$44.35 ,pays at 79.2% of total billed charges,$44.35 ,pays at 79.2% of total billed charges,$44.35 ,pays at 79.2% of total billed charges,$47.60 ,pays at 85% of total billed charges,$9.49 ,pays at MCD O/P rates,$22.40 ,pays at MCR OPPS,$53.20 ,pays at 95% of total billed charges,$44.80 ,pays at 80% total billed charges,$47.60 ,pays at 85% of total billed charges,$50.40 ,pays at 90% of total billed charges,$22.40 ,pays at MCR OPPS,$9.49 ,pays at 100% of MCD OPPS,$7.60 ,pays at 100% of MCD OPPS,$22.40 ,pays at MCR OPPS,$50.40 ,pays at 90% of total billed charges,$42.56 ,pays at 80% of total billed charges,$8.08 ,pays at MCR OPPS,$22.40 ,pays at MCR OPPS,$47.60 ,pays at 85% of total billed charges,$9.49 ,pays at MCD OPPS,$22.40 ,pays at MCR OPPS,$44.80 ,pays at 80% of total billed charges,$7.84 ,pays at 97% of MCR OPPS,$47.60 ,pays at 85% of total billed charges,$9.49 ,pays at MCD OPPS,$7.60 ,$53.20 ,$47.60 
Outpatient Medical Services,LABORATORY & PATHOLOGY,87086,Culture of the urine to determine number of bacteria,300,$73.00 ,$54.75 ,pays at 75% of total billed charges,$58.40 ,pays at 80% of total billed charges,$8.07 ,pays at MCR OPPS,$57.82 ,pays at 79.2% of total billed charges,$57.82 ,pays at 79.2% of total billed charges,$57.82 ,pays at 79.2% of total billed charges,$57.82 ,pays at 79.2% of total billed charges,$62.05 ,pays at 85% of total billed charges,$9.49 ,pays at MCD O/P rates,$29.20 ,pays at MCR OPPS,$69.35 ,pays at 95% of total billed charges,$58.40 ,pays at 80% total billed charges,$62.05 ,pays at 85% of total billed charges,$65.70 ,pays at 90% of total billed charges,$29.20 ,pays at MCR OPPS,$9.49 ,pays at 100% of MCD OPPS,$7.59 ,pays at 100% of MCD OPPS,$29.20 ,pays at MCR OPPS,$65.70 ,pays at 90% of total billed charges,$55.48 ,pays at 80% of total billed charges,$8.07 ,pays at MCR OPPS,$29.20 ,pays at MCR OPPS,$62.05 ,pays at 85% of total billed charges,$9.49 ,pays at MCD OPPS,$29.20 ,pays at MCR OPPS,$58.40 ,pays at 80% of total billed charges,$7.83 ,pays at 97% of MCR OPPS,$62.05 ,pays at 85% of total billed charges,$9.49 ,pays at MCD OPPS,$7.59 ,$69.35 ,$62.05 
Outpatient Medical Services,LABORATORY & PATHOLOGY,87150,"Culture, Typing; Identification By Nucleic Acid (Dna Or Rna) Probe, Amplified Probe Technique, Per Culture Or Isolate, Each Organism Probed",300,$62.00 ,$46.50 ,pays at 75% of total billed charges,$49.60 ,pays at 80% of total billed charges,$35.09 ,pays at MCR OPPS,$49.10 ,pays at 79.2% of total billed charges,$49.10 ,pays at 79.2% of total billed charges,$49.10 ,pays at 79.2% of total billed charges,$49.10 ,pays at 79.2% of total billed charges,$52.70 ,pays at 85% of total billed charges,$36.19 ,pays at MCD O/P rates,$24.80 ,pays at MCR OPPS,$58.90 ,pays at 95% of total billed charges,$49.60 ,pays at 80% total billed charges,$52.70 ,pays at 85% of total billed charges,$55.80 ,pays at 90% of total billed charges,$24.80 ,pays at MCR OPPS,$36.19 ,pays at 100% of MCD OPPS,$32.97 ,pays at 100% of MCD OPPS,$24.80 ,pays at MCR OPPS,$55.80 ,pays at 90% of total billed charges,$47.12 ,pays at 80% of total billed charges,$35.09 ,pays at MCR OPPS,$24.80 ,pays at MCR OPPS,$52.70 ,pays at 85% of total billed charges,$36.19 ,pays at MCD OPPS,$24.80 ,pays at MCR OPPS,$49.60 ,pays at 80% of total billed charges,$34.04 ,pays at 97% of MCR OPPS,$52.70 ,pays at 85% of total billed charges,$36.19 ,pays at MCD OPPS,$24.80 ,$58.90 ,$52.70 
Outpatient Medical Services,LABORATORY & PATHOLOGY,87186,A test used to determine which medications work on bacteria for fungi,300,$208.00 ,$156.00 ,pays at 75% of total billed charges,$166.40 ,pays at 80% of total billed charges,$8.65 ,pays at MCR OPPS,$164.74 ,pays at 79.2% of total billed charges,$164.74 ,pays at 79.2% of total billed charges,$164.74 ,pays at 79.2% of total billed charges,$164.74 ,pays at 79.2% of total billed charges,$176.80 ,pays at 85% of total billed charges,$9.49 ,pays at MCD O/P rates,$83.20 ,pays at MCR OPPS,$197.60 ,pays at 95% of total billed charges,$166.40 ,pays at 80% total billed charges,$176.80 ,pays at 85% of total billed charges,$187.20 ,pays at 90% of total billed charges,$83.20 ,pays at MCR OPPS,$9.49 ,pays at 100% of MCD OPPS,$8.13 ,pays at 100% of MCD OPPS,$83.20 ,pays at MCR OPPS,$187.20 ,pays at 90% of total billed charges,$158.08 ,pays at 80% of total billed charges,$8.65 ,pays at MCR OPPS,$83.20 ,pays at MCR OPPS,$176.80 ,pays at 85% of total billed charges,$9.49 ,pays at MCD OPPS,$83.20 ,pays at MCR OPPS,$166.40 ,pays at 80% of total billed charges,$8.39 ,pays at 97% of MCR OPPS,$176.80 ,pays at 85% of total billed charges,$9.49 ,pays at MCD OPPS,$8.13 ,$197.60 ,$176.80 
Outpatient Medical Services,LABORATORY & PATHOLOGY,87210,A lab test to screen for evidence of vaginal infection,300,$31.00 ,$23.25 ,pays at 75% of total billed charges,$24.80 ,pays at 80% of total billed charges,$5.82 ,pays at MCR OPPS,$24.55 ,pays at 79.2% of total billed charges,$24.55 ,pays at 79.2% of total billed charges,$24.55 ,pays at 79.2% of total billed charges,$24.55 ,pays at 79.2% of total billed charges,$26.35 ,pays at 85% of total billed charges,$9.49 ,pays at MCD O/P rates,$12.40 ,pays at MCR OPPS,$29.45 ,pays at 95% of total billed charges,$24.80 ,pays at 80% total billed charges,$26.35 ,pays at 85% of total billed charges,$27.90 ,pays at 90% of total billed charges,$12.40 ,pays at MCR OPPS,$9.49 ,pays at 100% of MCD OPPS,$5.47 ,pays at 100% of MCD OPPS,$12.40 ,pays at MCR OPPS,$27.90 ,pays at 90% of total billed charges,$23.56 ,pays at 80% of total billed charges,$5.82 ,pays at MCR OPPS,$12.40 ,pays at MCR OPPS,$26.35 ,pays at 85% of total billed charges,$9.49 ,pays at MCD OPPS,$12.40 ,pays at MCR OPPS,$24.80 ,pays at 80% of total billed charges,$5.65 ,pays at 97% of MCR OPPS,$26.35 ,pays at 85% of total billed charges,$9.49 ,pays at MCD OPPS,$5.47 ,$29.45 ,$26.35 
Outpatient Medical Services,LABORATORY & PATHOLOGY,87340,"Infectious Agent Antigen Detection By Enzyme Immunoassay Technique, Qualitative Or Semiquantitative, Multiple-Step Method; Hepatitis B Surface Antigen",300,$93.00 ,$69.75 ,pays at 75% of total billed charges,$74.40 ,pays at 80% of total billed charges,$10.33 ,pays at MCR OPPS,$73.66 ,pays at 79.2% of total billed charges,$73.66 ,pays at 79.2% of total billed charges,$73.66 ,pays at 79.2% of total billed charges,$73.66 ,pays at 79.2% of total billed charges,$79.05 ,pays at 85% of total billed charges,$9.49 ,pays at MCD O/P rates,$37.20 ,pays at MCR OPPS,$88.35 ,pays at 95% of total billed charges,$74.40 ,pays at 80% total billed charges,$79.05 ,pays at 85% of total billed charges,$83.70 ,pays at 90% of total billed charges,$37.20 ,pays at MCR OPPS,$9.49 ,pays at 100% of MCD OPPS,$9.71 ,pays at 100% of MCD OPPS,$37.20 ,pays at MCR OPPS,$83.70 ,pays at 90% of total billed charges,$70.68 ,pays at 80% of total billed charges,$10.33 ,pays at MCR OPPS,$37.20 ,pays at MCR OPPS,$79.05 ,pays at 85% of total billed charges,$9.49 ,pays at MCD OPPS,$37.20 ,pays at MCR OPPS,$74.40 ,pays at 80% of total billed charges,$10.02 ,pays at 97% of MCR OPPS,$79.05 ,pays at 85% of total billed charges,$9.49 ,pays at MCD OPPS,$9.49 ,$88.35 ,$79.05 
Outpatient Medical Services,LABORATORY & PATHOLOGY,87420,"Infectious Agent Antigen Detection By Enzyme Immunoassay Technique, Qualitative Or Semiquantitative, Multiple-Step Method; Respiratory Syncytial Virus",300,$84.00 ,$63.00 ,pays at 75% of total billed charges,$67.20 ,pays at 80% of total billed charges,$13.91 ,pays at MCR OPPS,$66.53 ,pays at 79.2% of total billed charges,$66.53 ,pays at 79.2% of total billed charges,$66.53 ,pays at 79.2% of total billed charges,$66.53 ,pays at 79.2% of total billed charges,$71.40 ,pays at 85% of total billed charges,$9.49 ,pays at MCD O/P rates,$33.60 ,pays at MCR OPPS,$79.80 ,pays at 95% of total billed charges,$67.20 ,pays at 80% total billed charges,$71.40 ,pays at 85% of total billed charges,$75.60 ,pays at 90% of total billed charges,$33.60 ,pays at MCR OPPS,$9.49 ,pays at 100% of MCD OPPS,$13.08 ,pays at 100% of MCD OPPS,$33.60 ,pays at MCR OPPS,$75.60 ,pays at 90% of total billed charges,$63.84 ,pays at 80% of total billed charges,$13.91 ,pays at MCR OPPS,$33.60 ,pays at MCR OPPS,$71.40 ,pays at 85% of total billed charges,$9.49 ,pays at MCD OPPS,$33.60 ,pays at MCR OPPS,$67.20 ,pays at 80% of total billed charges,$13.49 ,pays at 97% of MCR OPPS,$71.40 ,pays at 85% of total billed charges,$9.49 ,pays at MCD OPPS,$9.49 ,$79.80 ,$71.40 
Outpatient Medical Services,LABORATORY & PATHOLOGY,87491,Test that detects Chlamydia,300,$241.50 ,$181.13 ,pays at 75% of total billed charges,$193.20 ,pays at 80% of total billed charges,$35.09 ,pays at MCR OPPS,$191.27 ,pays at 79.2% of total billed charges,$191.27 ,pays at 79.2% of total billed charges,$191.27 ,pays at 79.2% of total billed charges,$191.27 ,pays at 79.2% of total billed charges,$205.28 ,pays at 85% of total billed charges,$36.19 ,pays at MCD O/P rates,$96.60 ,pays at MCR OPPS,$229.43 ,pays at 95% of total billed charges,$193.20 ,pays at 80% total billed charges,$205.28 ,pays at 85% of total billed charges,$217.35 ,pays at 90% of total billed charges,$96.60 ,pays at MCR OPPS,$36.19 ,pays at 100% of MCD OPPS,$32.97 ,pays at 100% of MCD OPPS,$96.60 ,pays at MCR OPPS,$217.35 ,pays at 90% of total billed charges,$183.54 ,pays at 80% of total billed charges,$35.09 ,pays at MCR OPPS,$96.60 ,pays at MCR OPPS,$205.28 ,pays at 85% of total billed charges,$36.19 ,pays at MCD OPPS,$96.60 ,pays at MCR OPPS,$193.20 ,pays at 80% of total billed charges,$34.04 ,pays at 97% of MCR OPPS,$205.28 ,pays at 85% of total billed charges,$36.19 ,pays at MCD OPPS,$32.97 ,$229.43 ,$205.28 
Outpatient Medical Services,LABORATORY & PATHOLOGY,87502,"Infectious Agent Detection By Nucleic Acid (Dna Or Rna); Influenza Virus, For Multiple Types Or Sub-Types, Multiplex Reverse Transcription And Amplifi",300,$348.00 ,$261.00 ,pays at 75% of total billed charges,$278.40 ,pays at 80% of total billed charges,$95.80 ,pays at MCR OPPS,$275.62 ,pays at 79.2% of total billed charges,$275.62 ,pays at 79.2% of total billed charges,$275.62 ,pays at 79.2% of total billed charges,$275.62 ,pays at 79.2% of total billed charges,$295.80 ,pays at 85% of total billed charges,$142.76 ,pays at MCD O/P rates,$139.20 ,pays at MCR OPPS,$330.60 ,pays at 95% of total billed charges,$278.40 ,pays at 80% total billed charges,$295.80 ,pays at 85% of total billed charges,$313.20 ,pays at 90% of total billed charges,$139.20 ,pays at MCR OPPS,$142.76 ,pays at 100% of MCD OPPS,$90.05 ,pays at 100% of MCD OPPS,$139.20 ,pays at MCR OPPS,$313.20 ,pays at 90% of total billed charges,$264.48 ,pays at 80% of total billed charges,$95.80 ,pays at MCR OPPS,$139.20 ,pays at MCR OPPS,$295.80 ,pays at 85% of total billed charges,$142.76 ,pays at MCD OPPS,$139.20 ,pays at MCR OPPS,$278.40 ,pays at 80% of total billed charges,$92.93 ,pays at 97% of MCR OPPS,$295.80 ,pays at 85% of total billed charges,$142.76 ,pays at MCD OPPS,$90.05 ,$330.60 ,$295.80 
Outpatient Medical Services,LABORATORY & PATHOLOGY,87506,"Infectious Agent Detection By Nucleic Acid (Dna Or Rna); Gastrointestinal Pathogen (Eg, Clostridium Difficile, E. Coli, Salmonella, Shigella, Noroviru",300,$800.00 ,$600.00 ,pays at 75% of total billed charges,$640.00 ,pays at 80% of total billed charges,$262.99 ,pays at MCR OPPS,$633.60 ,pays at 79.2% of total billed charges,$633.60 ,pays at 79.2% of total billed charges,$633.60 ,pays at 79.2% of total billed charges,$633.60 ,pays at 79.2% of total billed charges,$680.00 ,pays at 85% of total billed charges,$142.76 ,pays at MCD O/P rates,$320.00 ,pays at MCR OPPS,$760.00 ,pays at 95% of total billed charges,$640.00 ,pays at 80% total billed charges,$680.00 ,pays at 85% of total billed charges,$720.00 ,pays at 90% of total billed charges,$320.00 ,pays at MCR OPPS,$142.76 ,pays at 100% of MCD OPPS,$800.00 ,pays at 100% of MCD OPPS,$320.00 ,pays at MCR OPPS,$720.00 ,pays at 90% of total billed charges,$608.00 ,pays at 80% of total billed charges,$262.99 ,pays at MCR OPPS,$320.00 ,pays at MCR OPPS,$680.00 ,pays at 85% of total billed charges,$142.76 ,pays at MCD OPPS,$320.00 ,pays at MCR OPPS,$640.00 ,pays at 80% of total billed charges,$255.10 ,pays at 97% of MCR OPPS,$680.00 ,pays at 85% of total billed charges,$142.76 ,pays at MCD OPPS,$142.76 ,$800.00 ,$680.00 
Outpatient Medical Services,LABORATORY & PATHOLOGY,87529,"Infectious Agent Detection By Nucleic Acid (Dna Or Rna); Herpes Simplex Virus, Amplified Probe Technique",300,$219.00 ,$164.25 ,pays at 75% of total billed charges,$175.20 ,pays at 80% of total billed charges,$35.09 ,pays at MCR OPPS,$173.45 ,pays at 79.2% of total billed charges,$173.45 ,pays at 79.2% of total billed charges,$173.45 ,pays at 79.2% of total billed charges,$173.45 ,pays at 79.2% of total billed charges,$186.15 ,pays at 85% of total billed charges,$36.19 ,pays at MCD O/P rates,$87.60 ,pays at MCR OPPS,$208.05 ,pays at 95% of total billed charges,$175.20 ,pays at 80% total billed charges,$186.15 ,pays at 85% of total billed charges,$197.10 ,pays at 90% of total billed charges,$87.60 ,pays at MCR OPPS,$36.19 ,pays at 100% of MCD OPPS,$32.97 ,pays at 100% of MCD OPPS,$87.60 ,pays at MCR OPPS,$197.10 ,pays at 90% of total billed charges,$166.44 ,pays at 80% of total billed charges,$35.09 ,pays at MCR OPPS,$87.60 ,pays at MCR OPPS,$186.15 ,pays at 85% of total billed charges,$36.19 ,pays at MCD OPPS,$87.60 ,pays at MCR OPPS,$175.20 ,pays at 80% of total billed charges,$34.04 ,pays at 97% of MCR OPPS,$186.15 ,pays at 85% of total billed charges,$36.19 ,pays at MCD OPPS,$32.97 ,$208.05 ,$186.15 
Outpatient Medical Services,LABORATORY & PATHOLOGY,87591,Blood test for an STD,300,$241.50 ,$181.13 ,pays at 75% of total billed charges,$193.20 ,pays at 80% of total billed charges,$35.09 ,pays at MCR OPPS,$191.27 ,pays at 79.2% of total billed charges,$191.27 ,pays at 79.2% of total billed charges,$191.27 ,pays at 79.2% of total billed charges,$191.27 ,pays at 79.2% of total billed charges,$205.28 ,pays at 85% of total billed charges,$36.19 ,pays at MCD O/P rates,$96.60 ,pays at MCR OPPS,$229.43 ,pays at 95% of total billed charges,$193.20 ,pays at 80% total billed charges,$205.28 ,pays at 85% of total billed charges,$217.35 ,pays at 90% of total billed charges,$96.60 ,pays at MCR OPPS,$36.19 ,pays at 100% of MCD OPPS,$32.97 ,pays at 100% of MCD OPPS,$96.60 ,pays at MCR OPPS,$217.35 ,pays at 90% of total billed charges,$183.54 ,pays at 80% of total billed charges,$35.09 ,pays at MCR OPPS,$96.60 ,pays at MCR OPPS,$205.28 ,pays at 85% of total billed charges,$36.19 ,pays at MCD OPPS,$96.60 ,pays at MCR OPPS,$193.20 ,pays at 80% of total billed charges,$34.04 ,pays at 97% of MCR OPPS,$205.28 ,pays at 85% of total billed charges,$36.19 ,pays at MCD OPPS,$32.97 ,$229.43 ,$205.28 
Outpatient Medical Services,LABORATORY & PATHOLOGY,87624,Detection test for human papillomavirus (hpv),300,$150.00 ,$112.50 ,pays at 75% of total billed charges,$120.00 ,pays at 80% of total billed charges,$35.09 ,pays at MCR OPPS,$118.80 ,pays at 79.2% of total billed charges,$118.80 ,pays at 79.2% of total billed charges,$118.80 ,pays at 79.2% of total billed charges,$118.80 ,pays at 79.2% of total billed charges,$127.50 ,pays at 85% of total billed charges,$36.19 ,pays at MCD O/P rates,$60.00 ,pays at MCR OPPS,$142.50 ,pays at 95% of total billed charges,$120.00 ,pays at 80% total billed charges,$127.50 ,pays at 85% of total billed charges,$135.00 ,pays at 90% of total billed charges,$60.00 ,pays at MCR OPPS,$36.19 ,pays at 100% of MCD OPPS,$150.00 ,pays at 100% of MCD OPPS,$60.00 ,pays at MCR OPPS,$135.00 ,pays at 90% of total billed charges,$114.00 ,pays at 80% of total billed charges,$35.09 ,pays at MCR OPPS,$60.00 ,pays at MCR OPPS,$127.50 ,pays at 85% of total billed charges,$36.19 ,pays at MCD OPPS,$60.00 ,pays at MCR OPPS,$120.00 ,pays at 80% of total billed charges,$34.04 ,pays at 97% of MCR OPPS,$127.50 ,pays at 85% of total billed charges,$36.19 ,pays at MCD OPPS,$34.04 ,$150.00 ,$127.50 
Outpatient Medical Services,LABORATORY & PATHOLOGY,87635,Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]),300,$62.00 ,$46.50 ,pays at 75% of total billed charges,$49.60 ,pays at 80% of total billed charges,$51.31 ,pays at MCR OPPS,$49.10 ,pays at 79.2% of total billed charges,$49.10 ,pays at 79.2% of total billed charges,$49.10 ,pays at 79.2% of total billed charges,$49.10 ,pays at 79.2% of total billed charges,$52.70 ,pays at 85% of total billed charges,$36.19 ,pays at MCD O/P rates,$24.80 ,pays at MCR OPPS,$58.90 ,pays at 95% of total billed charges,$49.60 ,pays at 80% total billed charges,$52.70 ,pays at 85% of total billed charges,$55.80 ,pays at 90% of total billed charges,$24.80 ,pays at MCR OPPS,$36.19 ,pays at 100% of MCD OPPS,$48.23 ,pays at 100% of MCD OPPS,$24.80 ,pays at MCR OPPS,$55.80 ,pays at 90% of total billed charges,$47.12 ,pays at 80% of total billed charges,$51.31 ,pays at MCR OPPS,$24.80 ,pays at MCR OPPS,$52.70 ,pays at 85% of total billed charges,$36.19 ,pays at MCD OPPS,$24.80 ,pays at MCR OPPS,$49.60 ,pays at 80% of total billed charges,$49.77 ,pays at 97% of MCR OPPS,$52.70 ,pays at 85% of total billed charges,$36.19 ,pays at MCD OPPS,$24.80 ,$58.90 ,$52.70 
Outpatient Medical Services,LABORATORY & PATHOLOGY,87651,"Infectious Agent Detection By Nucleic Acid (Dna Or Rna); Streptococcus, Group A, Amplified Probe Technique",300,$65.00 ,$48.75 ,pays at 75% of total billed charges,$52.00 ,pays at 80% of total billed charges,$35.09 ,pays at MCR OPPS,$51.48 ,pays at 79.2% of total billed charges,$51.48 ,pays at 79.2% of total billed charges,$51.48 ,pays at 79.2% of total billed charges,$51.48 ,pays at 79.2% of total billed charges,$55.25 ,pays at 85% of total billed charges,$36.19 ,pays at MCD O/P rates,$26.00 ,pays at MCR OPPS,$61.75 ,pays at 95% of total billed charges,$52.00 ,pays at 80% total billed charges,$55.25 ,pays at 85% of total billed charges,$58.50 ,pays at 90% of total billed charges,$26.00 ,pays at MCR OPPS,$36.19 ,pays at 100% of MCD OPPS,$32.97 ,pays at 100% of MCD OPPS,$26.00 ,pays at MCR OPPS,$58.50 ,pays at 90% of total billed charges,$49.40 ,pays at 80% of total billed charges,$35.09 ,pays at MCR OPPS,$26.00 ,pays at MCR OPPS,$55.25 ,pays at 85% of total billed charges,$36.19 ,pays at MCD OPPS,$26.00 ,pays at MCR OPPS,$52.00 ,pays at 80% of total billed charges,$34.04 ,pays at 97% of MCR OPPS,$55.25 ,pays at 85% of total billed charges,$36.19 ,pays at MCD OPPS,$26.00 ,$61.75 ,$55.25 
Outpatient Medical Services,LABORATORY & PATHOLOGY,87804,Flu test,300,$106.00 ,$79.50 ,pays at 75% of total billed charges,$84.80 ,pays at 80% of total billed charges,$16.55 ,pays at MCR OPPS,$83.95 ,pays at 79.2% of total billed charges,$83.95 ,pays at 79.2% of total billed charges,$83.95 ,pays at 79.2% of total billed charges,$83.95 ,pays at 79.2% of total billed charges,$90.10 ,pays at 85% of total billed charges,$9.49 ,pays at MCD O/P rates,$42.40 ,pays at MCR OPPS,$100.70 ,pays at 95% of total billed charges,$84.80 ,pays at 80% total billed charges,$90.10 ,pays at 85% of total billed charges,$95.40 ,pays at 90% of total billed charges,$42.40 ,pays at MCR OPPS,$9.49 ,pays at 100% of MCD OPPS,$15.56 ,pays at 100% of MCD OPPS,$42.40 ,pays at MCR OPPS,$95.40 ,pays at 90% of total billed charges,$80.56 ,pays at 80% of total billed charges,$16.55 ,pays at MCR OPPS,$42.40 ,pays at MCR OPPS,$90.10 ,pays at 85% of total billed charges,$9.49 ,pays at MCD OPPS,$42.40 ,pays at MCR OPPS,$84.80 ,pays at 80% of total billed charges,$16.05 ,pays at 97% of MCR OPPS,$90.10 ,pays at 85% of total billed charges,$9.49 ,pays at MCD OPPS,$9.49 ,$100.70 ,$90.10 
Outpatient Medical Services,LABORATORY & PATHOLOGY,87880,Test for strep A,300,$57.00 ,$42.75 ,pays at 75% of total billed charges,$45.60 ,pays at 80% of total billed charges,$16.53 ,pays at MCR OPPS,$45.14 ,pays at 79.2% of total billed charges,$45.14 ,pays at 79.2% of total billed charges,$45.14 ,pays at 79.2% of total billed charges,$45.14 ,pays at 79.2% of total billed charges,$48.45 ,pays at 85% of total billed charges,$9.49 ,pays at MCD O/P rates,$22.80 ,pays at MCR OPPS,$54.15 ,pays at 95% of total billed charges,$45.60 ,pays at 80% total billed charges,$48.45 ,pays at 85% of total billed charges,$51.30 ,pays at 90% of total billed charges,$22.80 ,pays at MCR OPPS,$9.49 ,pays at 100% of MCD OPPS,$15.54 ,pays at 100% of MCD OPPS,$22.80 ,pays at MCR OPPS,$51.30 ,pays at 90% of total billed charges,$43.32 ,pays at 80% of total billed charges,$16.53 ,pays at MCR OPPS,$22.80 ,pays at MCR OPPS,$48.45 ,pays at 85% of total billed charges,$9.49 ,pays at MCD OPPS,$22.80 ,pays at MCR OPPS,$45.60 ,pays at 80% of total billed charges,$16.03 ,pays at 97% of MCR OPPS,$48.45 ,pays at 85% of total billed charges,$9.49 ,pays at MCD OPPS,$9.49 ,$54.15 ,$48.45 
Outpatient Medical Services,LABORATORY & PATHOLOGY,88175,PAP smear,300,$80.00 ,$60.00 ,pays at 75% of total billed charges,$64.00 ,pays at 80% of total billed charges,$26.61 ,pays at MCR OPPS,$63.36 ,pays at 79.2% of total billed charges,$63.36 ,pays at 79.2% of total billed charges,$63.36 ,pays at 79.2% of total billed charges,$63.36 ,pays at 79.2% of total billed charges,$68.00 ,pays at 85% of total billed charges,$22.75 ,pays at MCD O/P rates,$32.00 ,pays at MCR OPPS,$76.00 ,pays at 95% of total billed charges,$64.00 ,pays at 80% total billed charges,$68.00 ,pays at 85% of total billed charges,$72.00 ,pays at 90% of total billed charges,$32.00 ,pays at MCR OPPS,$22.75 ,pays at 100% of MCD OPPS,$25.01 ,pays at 100% of MCD OPPS,$32.00 ,pays at MCR OPPS,$72.00 ,pays at 90% of total billed charges,$60.80 ,pays at 80% of total billed charges,$26.61 ,pays at MCR OPPS,$32.00 ,pays at MCR OPPS,$68.00 ,pays at 85% of total billed charges,$22.75 ,pays at MCD OPPS,$32.00 ,pays at MCR OPPS,$64.00 ,pays at 80% of total billed charges,$25.81 ,pays at 97% of MCR OPPS,$68.00 ,pays at 85% of total billed charges,$22.75 ,pays at MCD OPPS,$22.75 ,$76.00 ,$68.00 
Outpatient Medical Services,LABORATORY & PATHOLOGY,88304,"Level III - Surgical pathology, gross and microscopic examination Abortion, induced Abscess Aneurysm - arterial/ventricular Anus, tag Appendix, other",300,$90.00 ,$67.50 ,pays at 75% of total billed charges,$72.00 ,pays at 80% of total billed charges,$51.38 ,pays at MCR OPPS,$71.28 ,pays at 79.2% of total billed charges,$71.28 ,pays at 79.2% of total billed charges,$71.28 ,pays at 79.2% of total billed charges,$71.28 ,pays at 79.2% of total billed charges,$76.50 ,pays at 85% of total billed charges,$29.14 ,pays at MCD O/P rates,$36.00 ,pays at MCR OPPS,$85.50 ,pays at 95% of total billed charges,$72.00 ,pays at 80% total billed charges,$76.50 ,pays at 85% of total billed charges,$81.00 ,pays at 90% of total billed charges,$36.00 ,pays at MCR OPPS,$29.14 ,pays at 100% of MCD OPPS,$50.14 ,pays at 100% of MCD OPPS,$36.00 ,pays at MCR OPPS,$81.00 ,pays at 90% of total billed charges,$68.40 ,pays at 80% of total billed charges,$51.38 ,pays at MCR OPPS,$36.00 ,pays at MCR OPPS,$76.50 ,pays at 85% of total billed charges,$29.14 ,pays at MCD OPPS,$36.00 ,pays at MCR OPPS,$72.00 ,pays at 80% of total billed charges,$49.84 ,pays at 97% of MCR OPPS,$76.50 ,pays at 85% of total billed charges,$29.14 ,pays at MCD OPPS,$29.14 ,$85.50 ,$76.50 
Outpatient Medical Services,LABORATORY & PATHOLOGY,88305,Test of tissues for diagnosis of abnormalities,300,$92.00 ,$69.00 ,pays at 75% of total billed charges,$73.60 ,pays at 80% of total billed charges,$85.23 ,pays at MCR OPPS,$72.86 ,pays at 79.2% of total billed charges,$72.86 ,pays at 79.2% of total billed charges,$72.86 ,pays at 79.2% of total billed charges,$72.86 ,pays at 79.2% of total billed charges,$78.20 ,pays at 85% of total billed charges,$29.14 ,pays at MCD O/P rates,$36.80 ,pays at MCR OPPS,$87.40 ,pays at 95% of total billed charges,$73.60 ,pays at 80% total billed charges,$78.20 ,pays at 85% of total billed charges,$82.80 ,pays at 90% of total billed charges,$36.80 ,pays at MCR OPPS,$29.14 ,pays at 100% of MCD OPPS,$50.14 ,pays at 100% of MCD OPPS,$36.80 ,pays at MCR OPPS,$82.80 ,pays at 90% of total billed charges,$69.92 ,pays at 80% of total billed charges,$85.23 ,pays at MCR OPPS,$36.80 ,pays at MCR OPPS,$78.20 ,pays at 85% of total billed charges,$29.14 ,pays at MCD OPPS,$36.80 ,pays at MCR OPPS,$73.60 ,pays at 80% of total billed charges,$82.67 ,pays at 97% of MCR OPPS,$78.20 ,pays at 85% of total billed charges,$29.14 ,pays at MCD OPPS,$29.14 ,$87.40 ,$78.20 
Outpatient Medical Services,LABORATORY & PATHOLOGY,88312,Blood test to assist with diagnosis,300,$218.00 ,$163.50 ,pays at 75% of total billed charges,$174.40 ,pays at 80% of total billed charges,$135.93 ,pays at MCR OPPS,$172.66 ,pays at 79.2% of total billed charges,$172.66 ,pays at 79.2% of total billed charges,$172.66 ,pays at 79.2% of total billed charges,$172.66 ,pays at 79.2% of total billed charges,$185.30 ,pays at 85% of total billed charges,$29.14 ,pays at MCD O/P rates,$87.20 ,pays at MCR OPPS,$207.10 ,pays at 95% of total billed charges,$174.40 ,pays at 80% total billed charges,$185.30 ,pays at 85% of total billed charges,$196.20 ,pays at 90% of total billed charges,$87.20 ,pays at MCR OPPS,$29.14 ,pays at 100% of MCD OPPS,$50.14 ,pays at 100% of MCD OPPS,$87.20 ,pays at MCR OPPS,$196.20 ,pays at 90% of total billed charges,$165.68 ,pays at 80% of total billed charges,$135.93 ,pays at MCR OPPS,$87.20 ,pays at MCR OPPS,$185.30 ,pays at 85% of total billed charges,$29.14 ,pays at MCD OPPS,$87.20 ,pays at MCR OPPS,$174.40 ,pays at 80% of total billed charges,$131.85 ,pays at 97% of MCR OPPS,$185.30 ,pays at 85% of total billed charges,$29.14 ,pays at MCD OPPS,$29.14 ,$207.10 ,$185.30 
Outpatient Medical Services,MEDICINE SERVICES,10060,Incision and drainage of abscess; simple or single and complex or multiple,360,$542.80 ,$407.10 ,pays at 75% of total billed charges,$434.24 ,pays at 80% of total billed charges,$125.15 ,pays at MCR OPPS,$429.90 ,pays at 79.2% of total billed charges,$429.90 ,pays at 79.2% of total billed charges,$429.90 ,pays at 79.2% of total billed charges,$429.90 ,pays at 79.2% of total billed charges,$461.38 ,pays at 85% of total billed charges,$215.49 ,pays at MCD O/P rates,$217.12 ,pays at MCR OPPS,$515.66 ,pays at 95% of total billed charges,$434.24 ,pays at 80% total billed charges,$461.38 ,pays at 85% of total billed charges,$488.52 ,pays at 90% of total billed charges,$217.12 ,pays at MCR OPPS,$215.49 ,pays at 100% of MCD OPPS,$180.58 ,pays at 100% of MCD OPPS,$217.12 ,pays at MCR OPPS,$488.52 ,pays at 90% of total billed charges,$412.53 ,pays at 80% of total billed charges,$125.15 ,pays at MCR OPPS,$217.12 ,pays at MCR OPPS,$461.38 ,pays at 85% of total billed charges,$215.49 ,pays at MCD OPPS,$217.12 ,pays at MCR OPPS,$434.24 ,pays at 80% of total billed charges,$121.40 ,pays at 97% of MCR OPPS,$461.38 ,pays at 85% of total billed charges,$215.49 ,pays at MCD OPPS,$121.40 ,$515.66 ,$461.38 
Outpatient Medical Services,MEDICINE SERVICES,12001,"Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities",360,$542.80 ,$407.10 ,pays at 75% of total billed charges,$434.24 ,pays at 80% of total billed charges,$51.68 ,pays at MCR OPPS,$429.90 ,pays at 79.2% of total billed charges,$429.90 ,pays at 79.2% of total billed charges,$429.90 ,pays at 79.2% of total billed charges,$429.90 ,pays at 79.2% of total billed charges,$461.38 ,pays at 85% of total billed charges,$246.34 ,pays at MCD O/P rates,$217.12 ,pays at MCR OPPS,$515.66 ,pays at 95% of total billed charges,$434.24 ,pays at 80% total billed charges,$461.38 ,pays at 85% of total billed charges,$488.52 ,pays at 90% of total billed charges,$217.12 ,pays at MCR OPPS,$246.34 ,pays at 100% of MCD OPPS,$180.58 ,pays at 100% of MCD OPPS,$217.12 ,pays at MCR OPPS,$488.52 ,pays at 90% of total billed charges,$412.53 ,pays at 80% of total billed charges,$51.68 ,pays at MCR OPPS,$217.12 ,pays at MCR OPPS,$461.38 ,pays at 85% of total billed charges,$246.34 ,pays at MCD OPPS,$217.12 ,pays at MCR OPPS,$434.24 ,pays at 80% of total billed charges,$50.13 ,pays at 97% of MCR OPPS,$461.38 ,pays at 85% of total billed charges,$246.34 ,pays at MCD OPPS,$50.13 ,$515.66 ,$461.38 
Outpatient Medical Services,MEDICINE SERVICES,12002,"Simple Repair Of Superficial Wounds Of Scalp, Neck, Axillae, External Genitalia, Trunk And/Or Extremities (Including Hands And Feet); 2.6 Cm To 7.5 Cm",360,$472.80 ,$354.60 ,pays at 75% of total billed charges,$378.24 ,pays at 80% of total billed charges,$67.44 ,pays at MCR OPPS,$374.46 ,pays at 79.2% of total billed charges,$374.46 ,pays at 79.2% of total billed charges,$374.46 ,pays at 79.2% of total billed charges,$374.46 ,pays at 79.2% of total billed charges,$401.88 ,pays at 85% of total billed charges,$246.34 ,pays at MCD O/P rates,$189.12 ,pays at MCR OPPS,$449.16 ,pays at 95% of total billed charges,$378.24 ,pays at 80% total billed charges,$401.88 ,pays at 85% of total billed charges,$425.52 ,pays at 90% of total billed charges,$189.12 ,pays at MCR OPPS,$246.34 ,pays at 100% of MCD OPPS,$180.58 ,pays at 100% of MCD OPPS,$189.12 ,pays at MCR OPPS,$425.52 ,pays at 90% of total billed charges,$359.33 ,pays at 80% of total billed charges,$67.44 ,pays at MCR OPPS,$189.12 ,pays at MCR OPPS,$401.88 ,pays at 85% of total billed charges,$246.34 ,pays at MCD OPPS,$189.12 ,pays at MCR OPPS,$378.24 ,pays at 80% of total billed charges,$65.41 ,pays at 97% of MCR OPPS,$401.88 ,pays at 85% of total billed charges,$246.34 ,pays at MCD OPPS,$65.41 ,$449.16 ,$401.88 
Outpatient Medical Services,MEDICINE SERVICES,12011,"Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes",360,$472.80 ,$354.60 ,pays at 75% of total billed charges,$378.24 ,pays at 80% of total billed charges,$63.25 ,pays at MCR OPPS,$374.46 ,pays at 79.2% of total billed charges,$374.46 ,pays at 79.2% of total billed charges,$374.46 ,pays at 79.2% of total billed charges,$374.46 ,pays at 79.2% of total billed charges,$401.88 ,pays at 85% of total billed charges,$246.34 ,pays at MCD O/P rates,$189.12 ,pays at MCR OPPS,$449.16 ,pays at 95% of total billed charges,$378.24 ,pays at 80% total billed charges,$401.88 ,pays at 85% of total billed charges,$425.52 ,pays at 90% of total billed charges,$189.12 ,pays at MCR OPPS,$246.34 ,pays at 100% of MCD OPPS,$180.58 ,pays at 100% of MCD OPPS,$189.12 ,pays at MCR OPPS,$425.52 ,pays at 90% of total billed charges,$359.33 ,pays at 80% of total billed charges,$63.25 ,pays at MCR OPPS,$189.12 ,pays at MCR OPPS,$401.88 ,pays at 85% of total billed charges,$246.34 ,pays at MCD OPPS,$189.12 ,pays at MCR OPPS,$378.24 ,pays at 80% of total billed charges,$61.35 ,pays at 97% of MCR OPPS,$401.88 ,pays at 85% of total billed charges,$246.34 ,pays at MCD OPPS,$61.35 ,$449.16 ,$401.88 
Outpatient Medical Services,MEDICINE SERVICES,17000,Destruction of pre-cancerous lesion,360,$426.30 ,$319.73 ,pays at 75% of total billed charges,$341.04 ,pays at 80% of total billed charges,$65.03 ,pays at MCR OPPS,$337.63 ,pays at 79.2% of total billed charges,$337.63 ,pays at 79.2% of total billed charges,$337.63 ,pays at 79.2% of total billed charges,$337.63 ,pays at 79.2% of total billed charges,$362.36 ,pays at 85% of total billed charges,$215.49 ,pays at MCD O/P rates,$170.52 ,pays at MCR OPPS,$404.99 ,pays at 95% of total billed charges,$341.04 ,pays at 80% total billed charges,$362.36 ,pays at 85% of total billed charges,$383.67 ,pays at 90% of total billed charges,$170.52 ,pays at MCR OPPS,$215.49 ,pays at 100% of MCD OPPS,$180.58 ,pays at 100% of MCD OPPS,$170.52 ,pays at MCR OPPS,$383.67 ,pays at 90% of total billed charges,$323.99 ,pays at 80% of total billed charges,$65.03 ,pays at MCR OPPS,$170.52 ,pays at MCR OPPS,$362.36 ,pays at 85% of total billed charges,$215.49 ,pays at MCD OPPS,$170.52 ,pays at MCR OPPS,$341.04 ,pays at 80% of total billed charges,$63.08 ,pays at 97% of MCR OPPS,$362.36 ,pays at 85% of total billed charges,$215.49 ,pays at MCD OPPS,$63.08 ,$404.99 ,$362.36 
Outpatient Medical Services,MEDICINE SERVICES,17003,Destruction of 2-14 pre-cancerous lesions,360,$15.00 ,$11.25 ,pays at 75% of total billed charges,$12.00 ,pays at 80% of total billed charges,$2.38 ,pays at MCR OPPS,$11.88 ,pays at 79.2% of total billed charges,$11.88 ,pays at 79.2% of total billed charges,$11.88 ,pays at 79.2% of total billed charges,$11.88 ,pays at 79.2% of total billed charges,$12.75 ,pays at 85% of total billed charges,$15.00 ,pays at MCD O/P rates,$6.00 ,pays at MCR OPPS,$14.25 ,pays at 95% of total billed charges,$12.00 ,pays at 80% total billed charges,$12.75 ,pays at 85% of total billed charges,$13.50 ,pays at 90% of total billed charges,$6.00 ,pays at MCR OPPS,$215.49 ,pays at 100% of MCD OPPS,$15.00 ,pays at 100% of MCD OPPS,$6.00 ,pays at MCR OPPS,$13.50 ,pays at 90% of total billed charges,$11.40 ,pays at 80% of total billed charges,$2.38 ,pays at MCR OPPS,$6.00 ,pays at MCR OPPS,$12.75 ,pays at 85% of total billed charges,$215.49 ,pays at MCD OPPS,$6.00 ,pays at MCR OPPS,$12.00 ,pays at 80% of total billed charges,$2.31 ,pays at 97% of MCR OPPS,$12.75 ,pays at 85% of total billed charges,$215.49 ,pays at MCD OPPS,$2.31 ,$215.49 ,$12.75 
Outpatient Medical Services,MEDICINE SERVICES,17110,Destruction of 1-14 common or plantar warts,360,$409.90 ,$307.43 ,pays at 75% of total billed charges,$327.92 ,pays at 80% of total billed charges,$79.91 ,pays at MCR OPPS,$324.64 ,pays at 79.2% of total billed charges,$324.64 ,pays at 79.2% of total billed charges,$324.64 ,pays at 79.2% of total billed charges,$324.64 ,pays at 79.2% of total billed charges,$348.42 ,pays at 85% of total billed charges,$215.49 ,pays at MCD O/P rates,$163.96 ,pays at MCR OPPS,$389.41 ,pays at 95% of total billed charges,$327.92 ,pays at 80% total billed charges,$348.42 ,pays at 85% of total billed charges,$368.91 ,pays at 90% of total billed charges,$163.96 ,pays at MCR OPPS,$215.49 ,pays at 100% of MCD OPPS,$180.58 ,pays at 100% of MCD OPPS,$163.96 ,pays at MCR OPPS,$368.91 ,pays at 90% of total billed charges,$311.52 ,pays at 80% of total billed charges,$79.91 ,pays at MCR OPPS,$163.96 ,pays at MCR OPPS,$348.42 ,pays at 85% of total billed charges,$215.49 ,pays at MCD OPPS,$163.96 ,pays at MCR OPPS,$327.92 ,pays at 80% of total billed charges,$77.52 ,pays at 97% of MCR OPPS,$348.42 ,pays at 85% of total billed charges,$215.49 ,pays at MCD OPPS,$77.52 ,$389.41 ,$348.42 
Outpatient Medical Services,MEDICINE SERVICES,95117,Multiple allergy shots,924,$35.00 ,$26.25 ,pays at 75% of total billed charges,$28.00 ,pays at 80% of total billed charges,$14.21 ,pays at MCR OPPS,$27.72 ,pays at 79.2% of total billed charges,$27.72 ,pays at 79.2% of total billed charges,$27.72 ,pays at 79.2% of total billed charges,$27.72 ,pays at 79.2% of total billed charges,$29.75 ,pays at 85% of total billed charges,$30.60 ,pays at MCD O/P rates,$14.00 ,pays at MCR OPPS,$33.25 ,pays at 95% of total billed charges,$28.00 ,pays at 80% total billed charges,$29.75 ,pays at 85% of total billed charges,$31.50 ,pays at 90% of total billed charges,$14.00 ,pays at MCR OPPS,$30.60 ,pays at 100% of MCD OPPS,$35.00 ,pays at 100% of MCD OPPS,$14.00 ,pays at MCR OPPS,$31.50 ,pays at 90% of total billed charges,$26.60 ,pays at 80% of total billed charges,$14.21 ,pays at MCR OPPS,$14.00 ,pays at MCR OPPS,$29.75 ,pays at 85% of total billed charges,$30.60 ,pays at MCD OPPS,$14.00 ,pays at MCR OPPS,$28.00 ,pays at 80% of total billed charges,$13.79 ,pays at 97% of MCR OPPS,$29.75 ,pays at 85% of total billed charges,$30.60 ,pays at MCD OPPS,$13.79 ,$35.00 ,$29.75 
Outpatient Medical Services,MEDICINE SERVICES,95115,Allergy shot-1 shot,924,$29.00 ,$21.75 ,pays at 75% of total billed charges,$23.20 ,pays at 80% of total billed charges,$12.17 ,pays at MCR OPPS,$22.97 ,pays at 79.2% of total billed charges,$22.97 ,pays at 79.2% of total billed charges,$22.97 ,pays at 79.2% of total billed charges,$22.97 ,pays at 79.2% of total billed charges,$24.65 ,pays at 85% of total billed charges,$29.00 ,pays at MCD O/P rates,$11.60 ,pays at MCR OPPS,$27.55 ,pays at 95% of total billed charges,$23.20 ,pays at 80% total billed charges,$24.65 ,pays at 85% of total billed charges,$26.10 ,pays at 90% of total billed charges,$11.60 ,pays at MCR OPPS,$30.60 ,pays at 100% of MCD OPPS,$29.00 ,pays at 100% of MCD OPPS,$11.60 ,pays at MCR OPPS,$26.10 ,pays at 90% of total billed charges,$22.04 ,pays at 80% of total billed charges,$12.17 ,pays at MCR OPPS,$11.60 ,pays at MCR OPPS,$24.65 ,pays at 85% of total billed charges,$30.60 ,pays at MCD OPPS,$11.60 ,pays at MCR OPPS,$23.20 ,pays at 80% of total billed charges,$11.80 ,pays at 97% of MCR OPPS,$24.65 ,pays at 85% of total billed charges,$30.60 ,pays at MCD OPPS,$11.60 ,$30.60 ,$24.65 
Outpatient Medical Services,MEDICINE SERVICES,99195,"Phlebotomy, Therapeutic (Separate Procedure)",300,$253.00 ,$189.75 ,pays at 75% of total billed charges,$202.40 ,pays at 80% of total billed charges,$118.07 ,pays at MCR OPPS,$200.38 ,pays at 79.2% of total billed charges,$200.38 ,pays at 79.2% of total billed charges,$200.38 ,pays at 79.2% of total billed charges,$200.38 ,pays at 79.2% of total billed charges,$215.05 ,pays at 85% of total billed charges,$77.32 ,pays at MCD O/P rates,$101.20 ,pays at MCR OPPS,$240.35 ,pays at 95% of total billed charges,$202.40 ,pays at 80% total billed charges,$215.05 ,pays at 85% of total billed charges,$227.70 ,pays at 90% of total billed charges,$101.20 ,pays at MCR OPPS,$77.32 ,pays at 100% of MCD OPPS,$116.11 ,pays at 100% of MCD OPPS,$101.20 ,pays at MCR OPPS,$227.70 ,pays at 90% of total billed charges,$192.28 ,pays at 80% of total billed charges,$118.07 ,pays at MCR OPPS,$101.20 ,pays at MCR OPPS,$215.05 ,pays at 85% of total billed charges,$77.32 ,pays at MCD OPPS,$101.20 ,pays at MCR OPPS,$202.40 ,pays at 80% of total billed charges,$114.53 ,pays at 97% of MCR OPPS,$215.05 ,pays at 85% of total billed charges,$77.32 ,pays at MCD OPPS,$77.32 ,$240.35 ,$215.05 
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,$63.00 ,$47.25 ,pays at 75% of total billed charges,$50.40 ,pays at 80% of total billed charges,$13.90 ,pays at MCR OPPS,$49.90 ,pays at 79.2% of total billed charges,$49.90 ,pays at 79.2% of total billed charges,$49.90 ,pays at 79.2% of total billed charges,$49.90 ,pays at 79.2% of total billed charges,$53.55 ,pays at 85% of total billed charges,$42.55 ,pays at MCD O/P rates,$25.20 ,pays at MCR OPPS,$59.85 ,pays at 95% of total billed charges,$50.40 ,pays at 80% total billed charges,$53.55 ,pays at 85% of total billed charges,$56.70 ,pays at 90% of total billed charges,$25.20 ,pays at MCR OPPS,$42.55 ,pays at 100% of MCD OPPS,$13.45 ,pays at 100% of MCD OPPS,$25.20 ,pays at MCR OPPS,$56.70 ,pays at 90% of total billed charges,$47.88 ,pays at 80% of total billed charges,$13.90 ,pays at MCR OPPS,$25.20 ,pays at MCR OPPS,$53.55 ,pays at 85% of total billed charges,$42.55 ,pays at MCD OPPS,$25.20 ,pays at MCR OPPS,$50.40 ,pays at 80% of total billed charges,$13.49 ,pays at 97% of MCR OPPS,$53.55 ,pays at 85% of total billed charges,$42.55 ,pays at MCD OPPS,$13.45 ,$59.85 ,$53.55 
Outpatient Medical Services,PHYSICAL THERAPY,97110,"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",420,$106.00 ,$79.50 ,pays at 75% of total billed charges,$84.80 ,pays at 80% of total billed charges,$35.11 ,pays at MCR OPPS,$83.95 ,pays at 79.2% of total billed charges,$83.95 ,pays at 79.2% of total billed charges,$83.95 ,pays at 79.2% of total billed charges,$83.95 ,pays at 79.2% of total billed charges,$90.10 ,pays at 85% of total billed charges,$50.89 ,pays at MCD O/P rates,$42.40 ,pays at MCR OPPS,$100.70 ,pays at 95% of total billed charges,$84.80 ,pays at 80% total billed charges,$90.10 ,pays at 85% of total billed charges,$95.40 ,pays at 90% of total billed charges,$42.40 ,pays at MCR OPPS,$50.89 ,pays at 100% of MCD OPPS,$27.31 ,pays at 100% of MCD OPPS,$42.40 ,pays at MCR OPPS,$95.40 ,pays at 90% of total billed charges,$80.56 ,pays at 80% of total billed charges,$35.11 ,pays at MCR OPPS,$42.40 ,pays at MCR OPPS,$90.10 ,pays at 85% of total billed charges,$50.89 ,pays at MCD OPPS,$42.40 ,pays at MCR OPPS,$84.80 ,pays at 80% of total billed charges,$34.06 ,pays at 97% of MCR OPPS,$90.10 ,pays at 85% of total billed charges,$50.89 ,pays at MCD OPPS,$27.31 ,$100.70 ,$90.10 
Outpatient Medical Services,PHYSICAL THERAPY,97140,Manipulation of 1 or more regions of the body,420,$99.00 ,$74.25 ,pays at 75% of total billed charges,$79.20 ,pays at 80% of total billed charges,$32.28 ,pays at MCR OPPS,$78.41 ,pays at 79.2% of total billed charges,$78.41 ,pays at 79.2% of total billed charges,$78.41 ,pays at 79.2% of total billed charges,$78.41 ,pays at 79.2% of total billed charges,$84.15 ,pays at 85% of total billed charges,$50.89 ,pays at MCD O/P rates,$39.60 ,pays at MCR OPPS,$94.05 ,pays at 95% of total billed charges,$79.20 ,pays at 80% total billed charges,$84.15 ,pays at 85% of total billed charges,$89.10 ,pays at 90% of total billed charges,$39.60 ,pays at MCR OPPS,$50.89 ,pays at 100% of MCD OPPS,$25.50 ,pays at 100% of MCD OPPS,$39.60 ,pays at MCR OPPS,$89.10 ,pays at 90% of total billed charges,$75.24 ,pays at 80% of total billed charges,$32.28 ,pays at MCR OPPS,$39.60 ,pays at MCR OPPS,$84.15 ,pays at 85% of total billed charges,$50.89 ,pays at MCD OPPS,$39.60 ,pays at MCR OPPS,$79.20 ,pays at 80% of total billed charges,$31.31 ,pays at 97% of MCR OPPS,$84.15 ,pays at 85% of total billed charges,$50.89 ,pays at MCD OPPS,$25.50 ,$94.05 ,$84.15 
Outpatient Medical Services,PHYSICAL THERAPY,97161,"Physical therapy evaluation: low complexity, requiring these components: A history with no personal factors and/or comorbidities that impact the plan",420,$258.00 ,$193.50 ,pays at 75% of total billed charges,$206.40 ,pays at 80% of total billed charges,$119.66 ,pays at MCR OPPS,$204.34 ,pays at 79.2% of total billed charges,$204.34 ,pays at 79.2% of total billed charges,$204.34 ,pays at 79.2% of total billed charges,$204.34 ,pays at 79.2% of total billed charges,$219.30 ,pays at 85% of total billed charges,$258.00 ,pays at MCD O/P rates,$103.20 ,pays at MCR OPPS,$245.10 ,pays at 95% of total billed charges,$206.40 ,pays at 80% total billed charges,$219.30 ,pays at 85% of total billed charges,$232.20 ,pays at 90% of total billed charges,$103.20 ,pays at MCR OPPS,$315.42 ,pays at 100% of MCD OPPS,$22.77 ,pays at 100% of MCD OPPS,$103.20 ,pays at MCR OPPS,$232.20 ,pays at 90% of total billed charges,$196.08 ,pays at 80% of total billed charges,$119.66 ,pays at MCR OPPS,$103.20 ,pays at MCR OPPS,$219.30 ,pays at 85% of total billed charges,$315.42 ,pays at MCD OPPS,$103.20 ,pays at MCR OPPS,$206.40 ,pays at 80% of total billed charges,$116.07 ,pays at 97% of MCR OPPS,$219.30 ,pays at 85% of total billed charges,$315.42 ,pays at MCD OPPS,$22.77 ,$315.42 ,$219.30 
Outpatient Medical Services,PHYSICAL THERAPY,97163,"Physical therapy evaluation: high complexity, requiring these components: A history of present problem with 3 or more personal factors and/or comorbid",420,$258.00 ,$193.50 ,pays at 75% of total billed charges,$206.40 ,pays at 80% of total billed charges,$119.66 ,pays at MCR OPPS,$204.34 ,pays at 79.2% of total billed charges,$204.34 ,pays at 79.2% of total billed charges,$204.34 ,pays at 79.2% of total billed charges,$204.34 ,pays at 79.2% of total billed charges,$219.30 ,pays at 85% of total billed charges,$258.00 ,pays at MCD O/P rates,$103.20 ,pays at MCR OPPS,$245.10 ,pays at 95% of total billed charges,$206.40 ,pays at 80% total billed charges,$219.30 ,pays at 85% of total billed charges,$232.20 ,pays at 90% of total billed charges,$103.20 ,pays at MCR OPPS,$315.42 ,pays at 100% of MCD OPPS,$68.98 ,pays at 100% of MCD OPPS,$103.20 ,pays at MCR OPPS,$232.20 ,pays at 90% of total billed charges,$196.08 ,pays at 80% of total billed charges,$119.66 ,pays at MCR OPPS,$103.20 ,pays at MCR OPPS,$219.30 ,pays at 85% of total billed charges,$315.42 ,pays at MCD OPPS,$103.20 ,pays at MCR OPPS,$206.40 ,pays at 80% of total billed charges,$116.07 ,pays at 97% of MCR OPPS,$219.30 ,pays at 85% of total billed charges,$315.42 ,pays at MCD OPPS,$68.98 ,$315.42 ,$219.30 
Outpatient Medical Services,RADIOLOGY,70450,CT scan head or brain without dye,350,"$1,193.00 ",$894.75 ,pays at 75% of total billed charges,$954.40 ,pays at 80% of total billed charges,$132.63 ,pays at MCR OPPS,$514.00 ,pays at 79.2% of total billed charges,$514.00 ,pays at 79.2% of total billed charges,$514.00 ,pays at 79.2% of total billed charges,$514.00 ,pays at 79.2% of total billed charges,"$1,014.05 ",pays at 85% of total billed charges,$416.44 ,pays at MCD O/P rates,$477.20 ,pays at MCR OPPS,"$1,133.35 ",pays at 95% of total billed charges,$954.40 ,pays at 80% total billed charges,"$1,014.05 ",pays at 85% of total billed charges,"$1,073.70 ",pays at 90% of total billed charges,$477.20 ,pays at MCR OPPS,$416.44 ,pays at 100% of MCD OPPS,$106.88 ,pays at 100% of MCD OPPS,$477.20 ,pays at MCR OPPS,"$1,073.70 ",pays at 90% of total billed charges,$906.68 ,pays at 80% of total billed charges,$132.63 ,pays at MCR OPPS,$477.20 ,pays at MCR OPPS,"$1,014.05 ",pays at 85% of total billed charges,$416.44 ,pays at MCD OPPS,$477.20 ,pays at MCR OPPS,$954.40 ,pays at 80% of total billed charges,$128.65 ,pays at 97% of MCR OPPS,"$1,014.05 ",pays at 85% of total billed charges,$416.44 ,pays at MCD OPPS,$106.88 ,"$1,133.35 ","$1,014.05 "
Outpatient Medical Services,RADIOLOGY,70486,CT Scan of the face and jaw without dye,350,"$1,262.00 ",$946.50 ,pays at 75% of total billed charges,"$1,009.60 ",pays at 80% of total billed charges,$160.86 ,pays at MCR OPPS,$514.00 ,pays at 79.2% of total billed charges,$514.00 ,pays at 79.2% of total billed charges,$514.00 ,pays at 79.2% of total billed charges,$514.00 ,pays at 79.2% of total billed charges,"$1,072.70 ",pays at 85% of total billed charges,$153.71 ,pays at MCD O/P rates,$504.80 ,pays at MCR OPPS,"$1,198.90 ",pays at 95% of total billed charges,"$1,009.60 ",pays at 80% total billed charges,"$1,072.70 ",pays at 85% of total billed charges,"$1,135.80 ",pays at 90% of total billed charges,$504.80 ,pays at MCR OPPS,$153.71 ,pays at 100% of MCD OPPS,$106.88 ,pays at 100% of MCD OPPS,$504.80 ,pays at MCR OPPS,"$1,135.80 ",pays at 90% of total billed charges,$959.12 ,pays at 80% of total billed charges,$160.86 ,pays at MCR OPPS,$504.80 ,pays at MCR OPPS,"$1,072.70 ",pays at 85% of total billed charges,$153.71 ,pays at MCD OPPS,$504.80 ,pays at MCR OPPS,"$1,009.60 ",pays at 80% of total billed charges,$156.04 ,pays at 97% of MCR OPPS,"$1,072.70 ",pays at 85% of total billed charges,$153.71 ,pays at MCD OPPS,$106.88 ,"$1,198.90 ","$1,072.70 "
Outpatient Medical Services,RADIOLOGY,70491,CT scan of neck with dye,350,"$1,377.00 ","$1,032.75 ",pays at 75% of total billed charges,"$1,101.60 ",pays at 80% of total billed charges,$231.56 ,pays at MCR OPPS,$514.00 ,pays at 79.2% of total billed charges,$514.00 ,pays at 79.2% of total billed charges,$514.00 ,pays at 79.2% of total billed charges,$514.00 ,pays at 79.2% of total billed charges,"$1,170.45 ",pays at 85% of total billed charges,$416.44 ,pays at MCD O/P rates,$550.80 ,pays at MCR OPPS,"$1,308.15 ",pays at 95% of total billed charges,"$1,101.60 ",pays at 80% total billed charges,"$1,170.45 ",pays at 85% of total billed charges,"$1,239.30 ",pays at 90% of total billed charges,$550.80 ,pays at MCR OPPS,$416.44 ,pays at 100% of MCD OPPS,$180.34 ,pays at 100% of MCD OPPS,$550.80 ,pays at MCR OPPS,"$1,239.30 ",pays at 90% of total billed charges,"$1,046.52 ",pays at 80% of total billed charges,$231.56 ,pays at MCR OPPS,$550.80 ,pays at MCR OPPS,"$1,170.45 ",pays at 85% of total billed charges,$416.44 ,pays at MCD OPPS,$550.80 ,pays at MCR OPPS,"$1,101.60 ",pays at 80% of total billed charges,$224.62 ,pays at 97% of MCR OPPS,"$1,170.45 ",pays at 85% of total billed charges,$416.44 ,pays at MCD OPPS,$180.34 ,"$1,308.15 ","$1,170.45 "
Outpatient Medical Services,RADIOLOGY,70496,"Computed Tomographic Angiography, Head, With Contrast Material(S), Including Noncontrast Images, If Performed, And Image Postprocessing",350,"$2,594.00 ","$1,945.50 ",pays at 75% of total billed charges,"$2,075.20 ",pays at 80% of total billed charges,$273.75 ,pays at MCR OPPS,$514.00 ,pays at 79.2% of total billed charges,$514.00 ,pays at 79.2% of total billed charges,$514.00 ,pays at 79.2% of total billed charges,$514.00 ,pays at 79.2% of total billed charges,"$2,204.90 ",pays at 85% of total billed charges,$509.86 ,pays at MCD O/P rates,"$1,037.60 ",pays at MCR OPPS,"$2,464.30 ",pays at 95% of total billed charges,"$2,075.20 ",pays at 80% total billed charges,"$2,204.90 ",pays at 85% of total billed charges,"$2,334.60 ",pays at 90% of total billed charges,"$1,037.60 ",pays at MCR OPPS,$509.86 ,pays at 100% of MCD OPPS,$180.34 ,pays at 100% of MCD OPPS,"$1,037.60 ",pays at MCR OPPS,"$2,334.60 ",pays at 90% of total billed charges,"$1,971.44 ",pays at 80% of total billed charges,$273.75 ,pays at MCR OPPS,"$1,037.60 ",pays at MCR OPPS,"$2,204.90 ",pays at 85% of total billed charges,$509.86 ,pays at MCD OPPS,"$1,037.60 ",pays at MCR OPPS,"$2,075.20 ",pays at 80% of total billed charges,$273.75 ,pays at 97% of MCR OPPS,"$2,204.90 ",pays at 85% of total billed charges,$509.86 ,pays at MCD OPPS,$180.34 ,"$2,464.30 ","$2,204.90 "
Outpatient Medical Services,RADIOLOGY,70498,"Computed Tomographic Angiography, Neck, With Contrast Material(S), Including Noncontrast Images, If Performed, And Image Postprocessing",350,$721.00 ,$540.75 ,pays at 75% of total billed charges,$576.80 ,pays at 80% of total billed charges,$273.75 ,pays at MCR OPPS,$514.00 ,pays at 79.2% of total billed charges,$514.00 ,pays at 79.2% of total billed charges,$514.00 ,pays at 79.2% of total billed charges,$514.00 ,pays at 79.2% of total billed charges,$612.85 ,pays at 85% of total billed charges,$509.86 ,pays at MCD O/P rates,$288.40 ,pays at MCR OPPS,$684.95 ,pays at 95% of total billed charges,$576.80 ,pays at 80% total billed charges,$612.85 ,pays at 85% of total billed charges,$648.90 ,pays at 90% of total billed charges,$288.40 ,pays at MCR OPPS,$509.86 ,pays at 100% of MCD OPPS,$180.34 ,pays at 100% of MCD OPPS,$288.40 ,pays at MCR OPPS,$648.90 ,pays at 90% of total billed charges,$547.96 ,pays at 80% of total billed charges,$273.75 ,pays at MCR OPPS,$288.40 ,pays at MCR OPPS,$612.85 ,pays at 85% of total billed charges,$509.86 ,pays at MCD OPPS,$288.40 ,pays at MCR OPPS,$576.80 ,pays at 80% of total billed charges,$273.75 ,pays at 97% of MCR OPPS,$612.85 ,pays at 85% of total billed charges,$509.86 ,pays at MCD OPPS,$180.34 ,$684.95 ,$612.85 
Outpatient Medical Services,RADIOLOGY,70551,MRI of brain stem without dye,610,"$2,134.00 ","$1,600.50 ",pays at 75% of total billed charges,"$1,707.20 ",pays at 80% of total billed charges,$246.42 ,pays at MCR OPPS,$730.00 ,pays at 79.2% of total billed charges,$730.00 ,pays at 79.2% of total billed charges,$730.00 ,pays at 79.2% of total billed charges,$730.00 ,pays at 79.2% of total billed charges,"$1,813.90 ",pays at 85% of total billed charges,$335.59 ,pays at MCD O/P rates,$853.60 ,pays at MCR OPPS,"$2,027.30 ",pays at 95% of total billed charges,"$1,707.20 ",pays at 80% total billed charges,"$1,813.90 ",pays at 85% of total billed charges,"$1,920.60 ",pays at 90% of total billed charges,$853.60 ,pays at MCR OPPS,$335.59 ,pays at 100% of MCD OPPS,$233.52 ,pays at 100% of MCD OPPS,$853.60 ,pays at MCR OPPS,"$1,920.60 ",pays at 90% of total billed charges,"$1,621.84 ",pays at 80% of total billed charges,$246.42 ,pays at MCR OPPS,$853.60 ,pays at MCR OPPS,"$1,813.90 ",pays at 85% of total billed charges,$335.59 ,pays at MCD OPPS,$853.60 ,pays at MCR OPPS,"$1,707.20 ",pays at 80% of total billed charges,$239.03 ,pays at 97% of MCR OPPS,"$1,813.90 ",pays at 85% of total billed charges,$335.59 ,pays at MCD OPPS,$233.52 ,"$2,027.30 ","$1,813.90 "
Outpatient Medical Services,RADIOLOGY,70553,MRI scan of brain before and after contrast,610,"$2,731.00 ","$2,048.25 ",pays at 75% of total billed charges,"$2,184.80 ",pays at 80% of total billed charges,$401.95 ,pays at MCR OPPS,$730.00 ,pays at 79.2% of total billed charges,$730.00 ,pays at 79.2% of total billed charges,$730.00 ,pays at 79.2% of total billed charges,$730.00 ,pays at 79.2% of total billed charges,"$2,321.35 ",pays at 85% of total billed charges,$588.01 ,pays at MCD O/P rates,"$1,092.40 ",pays at MCR OPPS,"$2,594.45 ",pays at 95% of total billed charges,"$2,184.80 ",pays at 80% total billed charges,"$2,321.35 ",pays at 85% of total billed charges,"$2,457.90 ",pays at 90% of total billed charges,"$1,092.40 ",pays at MCR OPPS,$588.01 ,pays at 100% of MCD OPPS,$368.43 ,pays at 100% of MCD OPPS,"$1,092.40 ",pays at MCR OPPS,"$2,457.90 ",pays at 90% of total billed charges,"$2,075.56 ",pays at 80% of total billed charges,$401.95 ,pays at MCR OPPS,"$1,092.40 ",pays at MCR OPPS,"$2,321.35 ",pays at 85% of total billed charges,$588.01 ,pays at MCD OPPS,"$1,092.40 ",pays at MCR OPPS,"$2,184.80 ",pays at 80% of total billed charges,$389.89 ,pays at 97% of MCR OPPS,"$2,321.35 ",pays at 85% of total billed charges,$588.01 ,pays at MCD OPPS,$368.43 ,"$2,594.45 ","$2,321.35 "
Outpatient Medical Services,RADIOLOGY,71045,Single view,324,$738.00 ,$553.50 ,pays at 75% of total billed charges,$590.40 ,pays at 80% of total billed charges,$31.40 ,pays at MCR OPPS,$584.50 ,pays at 79.2% of total billed charges,$584.50 ,pays at 79.2% of total billed charges,$584.50 ,pays at 79.2% of total billed charges,$584.50 ,pays at 79.2% of total billed charges,$627.30 ,pays at 85% of total billed charges,$75.44 ,pays at MCD O/P rates,$295.20 ,pays at MCR OPPS,$701.10 ,pays at 95% of total billed charges,$590.40 ,pays at 80% total billed charges,$627.30 ,pays at 85% of total billed charges,$664.20 ,pays at 90% of total billed charges,$295.20 ,pays at MCR OPPS,$75.44 ,pays at 100% of MCD OPPS,$86.88 ,pays at 100% of MCD OPPS,$295.20 ,pays at MCR OPPS,$664.20 ,pays at 90% of total billed charges,$560.88 ,pays at 80% of total billed charges,$31.40 ,pays at MCR OPPS,$295.20 ,pays at MCR OPPS,$627.30 ,pays at 85% of total billed charges,$75.44 ,pays at MCD OPPS,$295.20 ,pays at MCR OPPS,$590.40 ,pays at 80% of total billed charges,$30.45 ,pays at 97% of MCR OPPS,$627.30 ,pays at 85% of total billed charges,$75.44 ,pays at MCD OPPS,$30.45 ,$701.10 ,$627.30 
Outpatient Medical Services,RADIOLOGY,71046,"2 views, front and back",324,$270.00 ,$202.50 ,pays at 75% of total billed charges,$216.00 ,pays at 80% of total billed charges,$40.74 ,pays at MCR OPPS,$213.84 ,pays at 79.2% of total billed charges,$213.84 ,pays at 79.2% of total billed charges,$213.84 ,pays at 79.2% of total billed charges,$213.84 ,pays at 79.2% of total billed charges,$229.50 ,pays at 85% of total billed charges,$75.44 ,pays at MCD O/P rates,$108.00 ,pays at MCR OPPS,$256.50 ,pays at 95% of total billed charges,$216.00 ,pays at 80% total billed charges,$229.50 ,pays at 85% of total billed charges,$243.00 ,pays at 90% of total billed charges,$108.00 ,pays at MCR OPPS,$75.44 ,pays at 100% of MCD OPPS,$86.88 ,pays at 100% of MCD OPPS,$108.00 ,pays at MCR OPPS,$243.00 ,pays at 90% of total billed charges,$205.20 ,pays at 80% of total billed charges,$40.74 ,pays at MCR OPPS,$108.00 ,pays at MCR OPPS,$229.50 ,pays at 85% of total billed charges,$75.44 ,pays at MCD OPPS,$108.00 ,pays at MCR OPPS,$216.00 ,pays at 80% of total billed charges,$39.52 ,pays at 97% of MCR OPPS,$229.50 ,pays at 85% of total billed charges,$75.44 ,pays at MCD OPPS,$39.52 ,$256.50 ,$229.50 
Outpatient Medical Services,RADIOLOGY,71101,Radiologic examination of one side of the chest/ribs,324,$282.00 ,$211.50 ,pays at 75% of total billed charges,$225.60 ,pays at 80% of total billed charges,$51.29 ,pays at MCR OPPS,$223.34 ,pays at 79.2% of total billed charges,$223.34 ,pays at 79.2% of total billed charges,$223.34 ,pays at 79.2% of total billed charges,$223.34 ,pays at 79.2% of total billed charges,$239.70 ,pays at 85% of total billed charges,$75.44 ,pays at MCD O/P rates,$112.80 ,pays at MCR OPPS,$267.90 ,pays at 95% of total billed charges,$225.60 ,pays at 80% total billed charges,$239.70 ,pays at 85% of total billed charges,$253.80 ,pays at 90% of total billed charges,$112.80 ,pays at MCR OPPS,$75.44 ,pays at 100% of MCD OPPS,$106.88 ,pays at 100% of MCD OPPS,$112.80 ,pays at MCR OPPS,$253.80 ,pays at 90% of total billed charges,$214.32 ,pays at 80% of total billed charges,$51.29 ,pays at MCR OPPS,$112.80 ,pays at MCR OPPS,$239.70 ,pays at 85% of total billed charges,$75.44 ,pays at MCD OPPS,$112.80 ,pays at MCR OPPS,$225.60 ,pays at 80% of total billed charges,$49.75 ,pays at 97% of MCR OPPS,$239.70 ,pays at 85% of total billed charges,$75.44 ,pays at MCD OPPS,$49.75 ,$267.90 ,$239.70 
Outpatient Medical Services,RADIOLOGY,71250,CT scan of the thorax without dye,350,"$1,575.00 ","$1,181.25 ",pays at 75% of total billed charges,"$1,260.00 ",pays at 80% of total billed charges,$166.41 ,pays at MCR OPPS,$514.00 ,pays at 79.2% of total billed charges,$514.00 ,pays at 79.2% of total billed charges,$514.00 ,pays at 79.2% of total billed charges,$514.00 ,pays at 79.2% of total billed charges,"$1,338.75 ",pays at 85% of total billed charges,$153.71 ,pays at MCD O/P rates,$630.00 ,pays at MCR OPPS,"$1,496.25 ",pays at 95% of total billed charges,"$1,260.00 ",pays at 80% total billed charges,"$1,338.75 ",pays at 85% of total billed charges,"$1,417.50 ",pays at 90% of total billed charges,$630.00 ,pays at MCR OPPS,$153.71 ,pays at 100% of MCD OPPS,$106.88 ,pays at 100% of MCD OPPS,$630.00 ,pays at MCR OPPS,"$1,417.50 ",pays at 90% of total billed charges,"$1,197.00 ",pays at 80% of total billed charges,$166.41 ,pays at MCR OPPS,$630.00 ,pays at MCR OPPS,"$1,338.75 ",pays at 85% of total billed charges,$153.71 ,pays at MCD OPPS,$630.00 ,pays at MCR OPPS,"$1,260.00 ",pays at 80% of total billed charges,$161.41 ,pays at 97% of MCR OPPS,"$1,338.75 ",pays at 85% of total billed charges,$153.71 ,pays at MCD OPPS,$106.88 ,"$1,496.25 ","$1,338.75 "
Outpatient Medical Services,RADIOLOGY,71260,CT scan of the thorax with dye,350,"$1,503.00 ","$1,127.25 ",pays at 75% of total billed charges,"$1,202.40 ",pays at 80% of total billed charges,$209.13 ,pays at MCR OPPS,$514.00 ,pays at 79.2% of total billed charges,$514.00 ,pays at 79.2% of total billed charges,$514.00 ,pays at 79.2% of total billed charges,$514.00 ,pays at 79.2% of total billed charges,"$1,277.55 ",pays at 85% of total billed charges,$416.44 ,pays at MCD O/P rates,$601.20 ,pays at MCR OPPS,"$1,427.85 ",pays at 95% of total billed charges,"$1,202.40 ",pays at 80% total billed charges,"$1,277.55 ",pays at 85% of total billed charges,"$1,352.70 ",pays at 90% of total billed charges,$601.20 ,pays at MCR OPPS,$416.44 ,pays at 100% of MCD OPPS,$180.34 ,pays at 100% of MCD OPPS,$601.20 ,pays at MCR OPPS,"$1,352.70 ",pays at 90% of total billed charges,"$1,142.28 ",pays at 80% of total billed charges,$209.13 ,pays at MCR OPPS,$601.20 ,pays at MCR OPPS,"$1,277.55 ",pays at 85% of total billed charges,$416.44 ,pays at MCD OPPS,$601.20 ,pays at MCR OPPS,"$1,202.40 ",pays at 80% of total billed charges,$202.85 ,pays at 97% of MCR OPPS,"$1,277.55 ",pays at 85% of total billed charges,$416.44 ,pays at MCD OPPS,$180.34 ,"$1,427.85 ","$1,277.55 "
Outpatient Medical Services,RADIOLOGY,71275,Diagnostic Radiology (Diagnostic Imaging) Procedures of the Chest,350,"$2,594.00 ","$1,945.50 ",pays at 75% of total billed charges,"$2,075.20 ",pays at 80% of total billed charges,$276.85 ,pays at MCR OPPS,$514.00 ,pays at 79.2% of total billed charges,$514.00 ,pays at 79.2% of total billed charges,$514.00 ,pays at 79.2% of total billed charges,$514.00 ,pays at 79.2% of total billed charges,"$2,204.90 ",pays at 85% of total billed charges,$509.86 ,pays at MCD O/P rates,"$1,037.60 ",pays at MCR OPPS,"$2,464.30 ",pays at 95% of total billed charges,"$2,075.20 ",pays at 80% total billed charges,"$2,204.90 ",pays at 85% of total billed charges,"$2,334.60 ",pays at 90% of total billed charges,"$1,037.60 ",pays at MCR OPPS,$509.86 ,pays at 100% of MCD OPPS,$180.34 ,pays at 100% of MCD OPPS,"$1,037.60 ",pays at MCR OPPS,"$2,334.60 ",pays at 90% of total billed charges,"$1,971.44 ",pays at 80% of total billed charges,$276.85 ,pays at MCR OPPS,"$1,037.60 ",pays at MCR OPPS,"$2,204.90 ",pays at 85% of total billed charges,$509.86 ,pays at MCD OPPS,"$1,037.60 ",pays at MCR OPPS,"$2,075.20 ",pays at 80% of total billed charges,$276.85 ,pays at 97% of MCR OPPS,"$2,204.90 ",pays at 85% of total billed charges,$509.86 ,pays at MCD OPPS,$180.34 ,"$2,464.30 ","$2,204.90 "
Outpatient Medical Services,RADIOLOGY,72040,"Radiologic examination of the neck/spine, 2-3 views",324,$261.00 ,$195.75 ,pays at 75% of total billed charges,$208.80 ,pays at 80% of total billed charges,$48.10 ,pays at MCR OPPS,$206.71 ,pays at 79.2% of total billed charges,$206.71 ,pays at 79.2% of total billed charges,$206.71 ,pays at 79.2% of total billed charges,$206.71 ,pays at 79.2% of total billed charges,$221.85 ,pays at 85% of total billed charges,$75.44 ,pays at MCD O/P rates,$104.40 ,pays at MCR OPPS,$247.95 ,pays at 95% of total billed charges,$208.80 ,pays at 80% total billed charges,$221.85 ,pays at 85% of total billed charges,$234.90 ,pays at 90% of total billed charges,$104.40 ,pays at MCR OPPS,$75.44 ,pays at 100% of MCD OPPS,$86.88 ,pays at 100% of MCD OPPS,$104.40 ,pays at MCR OPPS,$234.90 ,pays at 90% of total billed charges,$198.36 ,pays at 80% of total billed charges,$48.10 ,pays at MCR OPPS,$104.40 ,pays at MCR OPPS,$221.85 ,pays at 85% of total billed charges,$75.44 ,pays at MCD OPPS,$104.40 ,pays at MCR OPPS,$208.80 ,pays at 80% of total billed charges,$46.66 ,pays at 97% of MCR OPPS,$221.85 ,pays at 85% of total billed charges,$75.44 ,pays at MCD OPPS,$46.66 ,$247.95 ,$221.85 
Outpatient Medical Services,RADIOLOGY,72100,X-ray of the lower spine 2-3 views,324,$261.00 ,$195.75 ,pays at 75% of total billed charges,$208.80 ,pays at 80% of total billed charges,$48.52 ,pays at MCR OPPS,$206.71 ,pays at 79.2% of total billed charges,$206.71 ,pays at 79.2% of total billed charges,$206.71 ,pays at 79.2% of total billed charges,$206.71 ,pays at 79.2% of total billed charges,$221.85 ,pays at 85% of total billed charges,$75.44 ,pays at MCD O/P rates,$104.40 ,pays at MCR OPPS,$247.95 ,pays at 95% of total billed charges,$208.80 ,pays at 80% total billed charges,$221.85 ,pays at 85% of total billed charges,$234.90 ,pays at 90% of total billed charges,$104.40 ,pays at MCR OPPS,$75.44 ,pays at 100% of MCD OPPS,$106.88 ,pays at 100% of MCD OPPS,$104.40 ,pays at MCR OPPS,$234.90 ,pays at 90% of total billed charges,$198.36 ,pays at 80% of total billed charges,$48.52 ,pays at MCR OPPS,$104.40 ,pays at MCR OPPS,$221.85 ,pays at 85% of total billed charges,$75.44 ,pays at MCD OPPS,$104.40 ,pays at MCR OPPS,$208.80 ,pays at 80% of total billed charges,$47.06 ,pays at 97% of MCR OPPS,$221.85 ,pays at 85% of total billed charges,$75.44 ,pays at MCD OPPS,$47.06 ,$247.95 ,$221.85 
Outpatient Medical Services,RADIOLOGY,72110,"X-ray of lower and sacral spine, minimum of 4 views",324,$415.00 ,$311.25 ,pays at 75% of total billed charges,$332.00 ,pays at 80% of total billed charges,$62.35 ,pays at MCR OPPS,$328.68 ,pays at 79.2% of total billed charges,$328.68 ,pays at 79.2% of total billed charges,$328.68 ,pays at 79.2% of total billed charges,$328.68 ,pays at 79.2% of total billed charges,$352.75 ,pays at 85% of total billed charges,$75.44 ,pays at MCD O/P rates,$166.00 ,pays at MCR OPPS,$394.25 ,pays at 95% of total billed charges,$332.00 ,pays at 80% total billed charges,$352.75 ,pays at 85% of total billed charges,$373.50 ,pays at 90% of total billed charges,$166.00 ,pays at MCR OPPS,$75.44 ,pays at 100% of MCD OPPS,$106.88 ,pays at 100% of MCD OPPS,$166.00 ,pays at MCR OPPS,$373.50 ,pays at 90% of total billed charges,$315.40 ,pays at 80% of total billed charges,$62.35 ,pays at MCR OPPS,$166.00 ,pays at MCR OPPS,$352.75 ,pays at 85% of total billed charges,$75.44 ,pays at MCD OPPS,$166.00 ,pays at MCR OPPS,$332.00 ,pays at 80% of total billed charges,$60.48 ,pays at 97% of MCR OPPS,$352.75 ,pays at 85% of total billed charges,$75.44 ,pays at MCD OPPS,$60.48 ,$394.25 ,$352.75 
Outpatient Medical Services,RADIOLOGY,72125,"Computed Tomography, Cervical Spine; Without Contrast Material",350,"$1,262.00 ",$946.50 ,pays at 75% of total billed charges,"$1,009.60 ",pays at 80% of total billed charges,$162.24 ,pays at MCR OPPS,$514.00 ,pays at 79.2% of total billed charges,$514.00 ,pays at 79.2% of total billed charges,$514.00 ,pays at 79.2% of total billed charges,$514.00 ,pays at 79.2% of total billed charges,"$1,072.70 ",pays at 85% of total billed charges,$153.71 ,pays at MCD O/P rates,$504.80 ,pays at MCR OPPS,"$1,198.90 ",pays at 95% of total billed charges,"$1,009.60 ",pays at 80% total billed charges,"$1,072.70 ",pays at 85% of total billed charges,"$1,135.80 ",pays at 90% of total billed charges,$504.80 ,pays at MCR OPPS,$153.71 ,pays at 100% of MCD OPPS,$106.88 ,pays at 100% of MCD OPPS,$504.80 ,pays at MCR OPPS,"$1,135.80 ",pays at 90% of total billed charges,$959.12 ,pays at 80% of total billed charges,$162.24 ,pays at MCR OPPS,$504.80 ,pays at MCR OPPS,"$1,072.70 ",pays at 85% of total billed charges,$153.71 ,pays at MCD OPPS,$504.80 ,pays at MCR OPPS,"$1,009.60 ",pays at 80% of total billed charges,$157.37 ,pays at 97% of MCR OPPS,"$1,072.70 ",pays at 85% of total billed charges,$153.71 ,pays at MCD OPPS,$106.88 ,"$1,198.90 ","$1,072.70 "
Outpatient Medical Services,RADIOLOGY,72131,CT scan of lower spine without dye,350,"$1,262.00 ",$946.50 ,pays at 75% of total billed charges,"$1,009.60 ",pays at 80% of total billed charges,$161.43 ,pays at MCR OPPS,$514.00 ,pays at 79.2% of total billed charges,$514.00 ,pays at 79.2% of total billed charges,$514.00 ,pays at 79.2% of total billed charges,$514.00 ,pays at 79.2% of total billed charges,"$1,072.70 ",pays at 85% of total billed charges,$153.71 ,pays at MCD O/P rates,$504.80 ,pays at MCR OPPS,"$1,198.90 ",pays at 95% of total billed charges,"$1,009.60 ",pays at 80% total billed charges,"$1,072.70 ",pays at 85% of total billed charges,"$1,135.80 ",pays at 90% of total billed charges,$504.80 ,pays at MCR OPPS,$153.71 ,pays at 100% of MCD OPPS,$106.88 ,pays at 100% of MCD OPPS,$504.80 ,pays at MCR OPPS,"$1,135.80 ",pays at 90% of total billed charges,$959.12 ,pays at 80% of total billed charges,$161.43 ,pays at MCR OPPS,$504.80 ,pays at MCR OPPS,"$1,072.70 ",pays at 85% of total billed charges,$153.71 ,pays at MCD OPPS,$504.80 ,pays at MCR OPPS,"$1,009.60 ",pays at 80% of total billed charges,$156.58 ,pays at 97% of MCR OPPS,"$1,072.70 ",pays at 85% of total billed charges,$153.71 ,pays at MCD OPPS,$106.88 ,"$1,198.90 ","$1,072.70 "
Outpatient Medical Services,RADIOLOGY,72141,MRI of the neck or spine without dye,610,"$2,134.00 ","$1,600.50 ",pays at 75% of total billed charges,"$1,707.20 ",pays at 80% of total billed charges,$239.48 ,pays at MCR OPPS,$730.00 ,pays at 79.2% of total billed charges,$730.00 ,pays at 79.2% of total billed charges,$730.00 ,pays at 79.2% of total billed charges,$730.00 ,pays at 79.2% of total billed charges,"$1,813.90 ",pays at 85% of total billed charges,$335.59 ,pays at MCD O/P rates,$853.60 ,pays at MCR OPPS,"$2,027.30 ",pays at 95% of total billed charges,"$1,707.20 ",pays at 80% total billed charges,"$1,813.90 ",pays at 85% of total billed charges,"$1,920.60 ",pays at 90% of total billed charges,$853.60 ,pays at MCR OPPS,$335.59 ,pays at 100% of MCD OPPS,$233.52 ,pays at 100% of MCD OPPS,$853.60 ,pays at MCR OPPS,"$1,920.60 ",pays at 90% of total billed charges,"$1,621.84 ",pays at 80% of total billed charges,$239.48 ,pays at MCR OPPS,$853.60 ,pays at MCR OPPS,"$1,813.90 ",pays at 85% of total billed charges,$335.59 ,pays at MCD OPPS,$853.60 ,pays at MCR OPPS,"$1,707.20 ",pays at 80% of total billed charges,$232.29 ,pays at 97% of MCR OPPS,"$1,813.90 ",pays at 85% of total billed charges,$335.59 ,pays at MCD OPPS,$232.29 ,"$2,027.30 ","$1,813.90 "
Outpatient Medical Services,RADIOLOGY,72148,MRI scan of lower spinal canal,610,"$2,134.00 ","$1,600.50 ",pays at 75% of total billed charges,"$1,707.20 ",pays at 80% of total billed charges,$240.29 ,pays at MCR OPPS,$730.00 ,pays at 79.2% of total billed charges,$730.00 ,pays at 79.2% of total billed charges,$730.00 ,pays at 79.2% of total billed charges,$730.00 ,pays at 79.2% of total billed charges,"$1,813.90 ",pays at 85% of total billed charges,$335.59 ,pays at MCD O/P rates,$853.60 ,pays at MCR OPPS,"$2,027.30 ",pays at 95% of total billed charges,"$1,707.20 ",pays at 80% total billed charges,"$1,813.90 ",pays at 85% of total billed charges,"$1,920.60 ",pays at 90% of total billed charges,$853.60 ,pays at MCR OPPS,$335.59 ,pays at 100% of MCD OPPS,$233.52 ,pays at 100% of MCD OPPS,$853.60 ,pays at MCR OPPS,"$1,920.60 ",pays at 90% of total billed charges,"$1,621.84 ",pays at 80% of total billed charges,$240.29 ,pays at MCR OPPS,$853.60 ,pays at MCR OPPS,"$1,813.90 ",pays at 85% of total billed charges,$335.59 ,pays at MCD OPPS,$853.60 ,pays at MCR OPPS,"$1,707.20 ",pays at 80% of total billed charges,$233.08 ,pays at 97% of MCR OPPS,"$1,813.90 ",pays at 85% of total billed charges,$335.59 ,pays at MCD OPPS,$233.08 ,"$2,027.30 ","$1,813.90 "
Outpatient Medical Services,RADIOLOGY,72193,"CT scan, pelvis, with contrast",350,"$1,513.00 ","$1,134.75 ",pays at 75% of total billed charges,"$1,210.40 ",pays at 80% of total billed charges,$245.19 ,pays at MCR OPPS,$514.00 ,pays at 79.2% of total billed charges,$514.00 ,pays at 79.2% of total billed charges,$514.00 ,pays at 79.2% of total billed charges,$514.00 ,pays at 79.2% of total billed charges,"$1,286.05 ",pays at 85% of total billed charges,$416.44 ,pays at MCD O/P rates,$605.20 ,pays at MCR OPPS,"$1,437.35 ",pays at 95% of total billed charges,"$1,210.40 ",pays at 80% total billed charges,"$1,286.05 ",pays at 85% of total billed charges,"$1,361.70 ",pays at 90% of total billed charges,$605.20 ,pays at MCR OPPS,$416.44 ,pays at 100% of MCD OPPS,$180.34 ,pays at 100% of MCD OPPS,$605.20 ,pays at MCR OPPS,"$1,361.70 ",pays at 90% of total billed charges,"$1,149.88 ",pays at 80% of total billed charges,$245.19 ,pays at MCR OPPS,$605.20 ,pays at MCR OPPS,"$1,286.05 ",pays at 85% of total billed charges,$416.44 ,pays at MCD OPPS,$605.20 ,pays at MCR OPPS,"$1,210.40 ",pays at 80% of total billed charges,$245.19 ,pays at 97% of MCR OPPS,"$1,286.05 ",pays at 85% of total billed charges,$416.44 ,pays at MCD OPPS,$180.34 ,"$1,437.35 ","$1,286.05 "
Outpatient Medical Services,RADIOLOGY,73000,Radiologic examination of the collar bone,324,$240.00 ,$180.00 ,pays at 75% of total billed charges,$192.00 ,pays at 80% of total billed charges,$39.20 ,pays at MCR OPPS,$190.08 ,pays at 79.2% of total billed charges,$190.08 ,pays at 79.2% of total billed charges,$190.08 ,pays at 79.2% of total billed charges,$190.08 ,pays at 79.2% of total billed charges,$204.00 ,pays at 85% of total billed charges,$75.44 ,pays at MCD O/P rates,$96.00 ,pays at MCR OPPS,$228.00 ,pays at 95% of total billed charges,$192.00 ,pays at 80% total billed charges,$204.00 ,pays at 85% of total billed charges,$216.00 ,pays at 90% of total billed charges,$96.00 ,pays at MCR OPPS,$75.44 ,pays at 100% of MCD OPPS,$86.88 ,pays at 100% of MCD OPPS,$96.00 ,pays at MCR OPPS,$216.00 ,pays at 90% of total billed charges,$182.40 ,pays at 80% of total billed charges,$39.20 ,pays at MCR OPPS,$96.00 ,pays at MCR OPPS,$204.00 ,pays at 85% of total billed charges,$75.44 ,pays at MCD OPPS,$96.00 ,pays at MCR OPPS,$192.00 ,pays at 80% of total billed charges,$38.03 ,pays at 97% of MCR OPPS,$204.00 ,pays at 85% of total billed charges,$75.44 ,pays at MCD OPPS,$38.03 ,$228.00 ,$204.00 
Outpatient Medical Services,RADIOLOGY,73030,Radiologic examination of the shoulder,324,$254.00 ,$190.50 ,pays at 75% of total billed charges,$203.20 ,pays at 80% of total billed charges,$42.03 ,pays at MCR OPPS,$201.17 ,pays at 79.2% of total billed charges,$201.17 ,pays at 79.2% of total billed charges,$201.17 ,pays at 79.2% of total billed charges,$201.17 ,pays at 79.2% of total billed charges,$215.90 ,pays at 85% of total billed charges,$75.44 ,pays at MCD O/P rates,$101.60 ,pays at MCR OPPS,$241.30 ,pays at 95% of total billed charges,$203.20 ,pays at 80% total billed charges,$215.90 ,pays at 85% of total billed charges,$228.60 ,pays at 90% of total billed charges,$101.60 ,pays at MCR OPPS,$75.44 ,pays at 100% of MCD OPPS,$86.88 ,pays at 100% of MCD OPPS,$101.60 ,pays at MCR OPPS,$228.60 ,pays at 90% of total billed charges,$193.04 ,pays at 80% of total billed charges,$42.03 ,pays at MCR OPPS,$101.60 ,pays at MCR OPPS,$215.90 ,pays at 85% of total billed charges,$75.44 ,pays at MCD OPPS,$101.60 ,pays at MCR OPPS,$203.20 ,pays at 80% of total billed charges,$40.77 ,pays at 97% of MCR OPPS,$215.90 ,pays at 85% of total billed charges,$75.44 ,pays at MCD OPPS,$40.77 ,$241.30 ,$215.90 
Outpatient Medical Services,RADIOLOGY,73060,"Radiologic Examination; Humerus, Minimum Of 2 Views",324,$240.00 ,$180.00 ,pays at 75% of total billed charges,$192.00 ,pays at 80% of total billed charges,$39.20 ,pays at MCR OPPS,$190.08 ,pays at 79.2% of total billed charges,$190.08 ,pays at 79.2% of total billed charges,$190.08 ,pays at 79.2% of total billed charges,$190.08 ,pays at 79.2% of total billed charges,$204.00 ,pays at 85% of total billed charges,$75.44 ,pays at MCD O/P rates,$96.00 ,pays at MCR OPPS,$228.00 ,pays at 95% of total billed charges,$192.00 ,pays at 80% total billed charges,$204.00 ,pays at 85% of total billed charges,$216.00 ,pays at 90% of total billed charges,$96.00 ,pays at MCR OPPS,$75.44 ,pays at 100% of MCD OPPS,$86.88 ,pays at 100% of MCD OPPS,$96.00 ,pays at MCR OPPS,$216.00 ,pays at 90% of total billed charges,$182.40 ,pays at 80% of total billed charges,$39.20 ,pays at MCR OPPS,$96.00 ,pays at MCR OPPS,$204.00 ,pays at 85% of total billed charges,$75.44 ,pays at MCD OPPS,$96.00 ,pays at MCR OPPS,$192.00 ,pays at 80% of total billed charges,$38.03 ,pays at 97% of MCR OPPS,$204.00 ,pays at 85% of total billed charges,$75.44 ,pays at MCD OPPS,$38.03 ,$228.00 ,$204.00 
Outpatient Medical Services,RADIOLOGY,73080,"Radiologic examination, elbow; 3 or more views",324,$254.00 ,$190.50 ,pays at 75% of total billed charges,$203.20 ,pays at 80% of total billed charges,$39.59 ,pays at MCR OPPS,$201.17 ,pays at 79.2% of total billed charges,$201.17 ,pays at 79.2% of total billed charges,$201.17 ,pays at 79.2% of total billed charges,$201.17 ,pays at 79.2% of total billed charges,$215.90 ,pays at 85% of total billed charges,$75.44 ,pays at MCD O/P rates,$101.60 ,pays at MCR OPPS,$241.30 ,pays at 95% of total billed charges,$203.20 ,pays at 80% total billed charges,$215.90 ,pays at 85% of total billed charges,$228.60 ,pays at 90% of total billed charges,$101.60 ,pays at MCR OPPS,$75.44 ,pays at 100% of MCD OPPS,$86.88 ,pays at 100% of MCD OPPS,$101.60 ,pays at MCR OPPS,$228.60 ,pays at 90% of total billed charges,$193.04 ,pays at 80% of total billed charges,$39.59 ,pays at MCR OPPS,$101.60 ,pays at MCR OPPS,$215.90 ,pays at 85% of total billed charges,$75.44 ,pays at MCD OPPS,$101.60 ,pays at MCR OPPS,$203.20 ,pays at 80% of total billed charges,$38.41 ,pays at 97% of MCR OPPS,$215.90 ,pays at 85% of total billed charges,$75.44 ,pays at MCD OPPS,$38.41 ,$241.30 ,$215.90 
Outpatient Medical Services,RADIOLOGY,73090,Radiologic examination of the forearm,324,$240.00 ,$180.00 ,pays at 75% of total billed charges,$192.00 ,pays at 80% of total billed charges,$35.52 ,pays at MCR OPPS,$190.08 ,pays at 79.2% of total billed charges,$190.08 ,pays at 79.2% of total billed charges,$190.08 ,pays at 79.2% of total billed charges,$190.08 ,pays at 79.2% of total billed charges,$204.00 ,pays at 85% of total billed charges,$75.44 ,pays at MCD O/P rates,$96.00 ,pays at MCR OPPS,$228.00 ,pays at 95% of total billed charges,$192.00 ,pays at 80% total billed charges,$204.00 ,pays at 85% of total billed charges,$216.00 ,pays at 90% of total billed charges,$96.00 ,pays at MCR OPPS,$75.44 ,pays at 100% of MCD OPPS,$86.88 ,pays at 100% of MCD OPPS,$96.00 ,pays at MCR OPPS,$216.00 ,pays at 90% of total billed charges,$182.40 ,pays at 80% of total billed charges,$35.52 ,pays at MCR OPPS,$96.00 ,pays at MCR OPPS,$204.00 ,pays at 85% of total billed charges,$75.44 ,pays at MCD OPPS,$96.00 ,pays at MCR OPPS,$192.00 ,pays at 80% of total billed charges,$34.46 ,pays at 97% of MCR OPPS,$204.00 ,pays at 85% of total billed charges,$75.44 ,pays at MCD OPPS,$34.46 ,$228.00 ,$204.00 
Outpatient Medical Services,RADIOLOGY,73100,3 or more views,324,$240.00 ,$180.00 ,pays at 75% of total billed charges,$192.00 ,pays at 80% of total billed charges,$41.25 ,pays at MCR OPPS,$190.08 ,pays at 79.2% of total billed charges,$190.08 ,pays at 79.2% of total billed charges,$190.08 ,pays at 79.2% of total billed charges,$190.08 ,pays at 79.2% of total billed charges,$204.00 ,pays at 85% of total billed charges,$75.44 ,pays at MCD O/P rates,$96.00 ,pays at MCR OPPS,$228.00 ,pays at 95% of total billed charges,$192.00 ,pays at 80% total billed charges,$204.00 ,pays at 85% of total billed charges,$216.00 ,pays at 90% of total billed charges,$96.00 ,pays at MCR OPPS,$75.44 ,pays at 100% of MCD OPPS,$86.88 ,pays at 100% of MCD OPPS,$96.00 ,pays at MCR OPPS,$216.00 ,pays at 90% of total billed charges,$182.40 ,pays at 80% of total billed charges,$41.25 ,pays at MCR OPPS,$96.00 ,pays at MCR OPPS,$204.00 ,pays at 85% of total billed charges,$75.44 ,pays at MCD OPPS,$96.00 ,pays at MCR OPPS,$192.00 ,pays at 80% of total billed charges,$40.01 ,pays at 97% of MCR OPPS,$204.00 ,pays at 85% of total billed charges,$75.44 ,pays at MCD OPPS,$40.01 ,$228.00 ,$204.00 
Outpatient Medical Services,RADIOLOGY,73110,Up to 3 views,324,$254.00 ,$190.50 ,pays at 75% of total billed charges,$203.20 ,pays at 80% of total billed charges,$49.83 ,pays at MCR OPPS,$201.17 ,pays at 79.2% of total billed charges,$201.17 ,pays at 79.2% of total billed charges,$201.17 ,pays at 79.2% of total billed charges,$201.17 ,pays at 79.2% of total billed charges,$215.90 ,pays at 85% of total billed charges,$75.44 ,pays at MCD O/P rates,$101.60 ,pays at MCR OPPS,$241.30 ,pays at 95% of total billed charges,$203.20 ,pays at 80% total billed charges,$215.90 ,pays at 85% of total billed charges,$228.60 ,pays at 90% of total billed charges,$101.60 ,pays at MCR OPPS,$75.44 ,pays at 100% of MCD OPPS,$86.88 ,pays at 100% of MCD OPPS,$101.60 ,pays at MCR OPPS,$228.60 ,pays at 90% of total billed charges,$193.04 ,pays at 80% of total billed charges,$49.83 ,pays at MCR OPPS,$101.60 ,pays at MCR OPPS,$215.90 ,pays at 85% of total billed charges,$75.44 ,pays at MCD OPPS,$101.60 ,pays at MCR OPPS,$203.20 ,pays at 80% of total billed charges,$48.33 ,pays at 97% of MCR OPPS,$215.90 ,pays at 85% of total billed charges,$75.44 ,pays at MCD OPPS,$48.33 ,$241.30 ,$215.90 
Outpatient Medical Services,RADIOLOGY,73130,X-ray of the hand with 3 or more views,324,$254.00 ,$190.50 ,pays at 75% of total billed charges,$203.20 ,pays at 80% of total billed charges,$44.92 ,pays at MCR OPPS,$201.17 ,pays at 79.2% of total billed charges,$201.17 ,pays at 79.2% of total billed charges,$201.17 ,pays at 79.2% of total billed charges,$201.17 ,pays at 79.2% of total billed charges,$215.90 ,pays at 85% of total billed charges,$75.44 ,pays at MCD O/P rates,$101.60 ,pays at MCR OPPS,$241.30 ,pays at 95% of total billed charges,$203.20 ,pays at 80% total billed charges,$215.90 ,pays at 85% of total billed charges,$228.60 ,pays at 90% of total billed charges,$101.60 ,pays at MCR OPPS,$75.44 ,pays at 100% of MCD OPPS,$86.88 ,pays at 100% of MCD OPPS,$101.60 ,pays at MCR OPPS,$228.60 ,pays at 90% of total billed charges,$193.04 ,pays at 80% of total billed charges,$44.92 ,pays at MCR OPPS,$101.60 ,pays at MCR OPPS,$215.90 ,pays at 85% of total billed charges,$75.44 ,pays at MCD OPPS,$101.60 ,pays at MCR OPPS,$203.20 ,pays at 80% of total billed charges,$43.57 ,pays at 97% of MCR OPPS,$215.90 ,pays at 85% of total billed charges,$75.44 ,pays at MCD OPPS,$43.57 ,$241.30 ,$215.90 
Outpatient Medical Services,RADIOLOGY,73140,Radiologic examination of the finger(s),324,$240.00 ,$180.00 ,pays at 75% of total billed charges,$192.00 ,pays at 80% of total billed charges,$46.22 ,pays at MCR OPPS,$190.08 ,pays at 79.2% of total billed charges,$190.08 ,pays at 79.2% of total billed charges,$190.08 ,pays at 79.2% of total billed charges,$190.08 ,pays at 79.2% of total billed charges,$204.00 ,pays at 85% of total billed charges,$75.44 ,pays at MCD O/P rates,$96.00 ,pays at MCR OPPS,$228.00 ,pays at 95% of total billed charges,$192.00 ,pays at 80% total billed charges,$204.00 ,pays at 85% of total billed charges,$216.00 ,pays at 90% of total billed charges,$96.00 ,pays at MCR OPPS,$75.44 ,pays at 100% of MCD OPPS,$86.88 ,pays at 100% of MCD OPPS,$96.00 ,pays at MCR OPPS,$216.00 ,pays at 90% of total billed charges,$182.40 ,pays at 80% of total billed charges,$46.22 ,pays at MCR OPPS,$96.00 ,pays at MCR OPPS,$204.00 ,pays at 85% of total billed charges,$75.44 ,pays at MCD OPPS,$96.00 ,pays at MCR OPPS,$192.00 ,pays at 80% of total billed charges,$44.83 ,pays at 97% of MCR OPPS,$204.00 ,pays at 85% of total billed charges,$75.44 ,pays at MCD OPPS,$44.83 ,$228.00 ,$204.00 
Outpatient Medical Services,RADIOLOGY,73221,MRI of upper extremity without dye,610,"$2,134.00 ","$1,600.50 ",pays at 75% of total billed charges,"$1,707.20 ",pays at 80% of total billed charges,$255.35 ,pays at MCR OPPS,$730.00 ,pays at 79.2% of total billed charges,$730.00 ,pays at 79.2% of total billed charges,$730.00 ,pays at 79.2% of total billed charges,$730.00 ,pays at 79.2% of total billed charges,"$1,813.90 ",pays at 85% of total billed charges,$335.59 ,pays at MCD O/P rates,$853.60 ,pays at MCR OPPS,"$2,027.30 ",pays at 95% of total billed charges,"$1,707.20 ",pays at 80% total billed charges,"$1,813.90 ",pays at 85% of total billed charges,"$1,920.60 ",pays at 90% of total billed charges,$853.60 ,pays at MCR OPPS,$335.59 ,pays at 100% of MCD OPPS,$233.52 ,pays at 100% of MCD OPPS,$853.60 ,pays at MCR OPPS,"$1,920.60 ",pays at 90% of total billed charges,"$1,621.84 ",pays at 80% of total billed charges,$255.35 ,pays at MCR OPPS,$853.60 ,pays at MCR OPPS,"$1,813.90 ",pays at 85% of total billed charges,$335.59 ,pays at MCD OPPS,$853.60 ,pays at MCR OPPS,"$1,707.20 ",pays at 80% of total billed charges,$247.69 ,pays at 97% of MCR OPPS,"$1,813.90 ",pays at 85% of total billed charges,$335.59 ,pays at MCD OPPS,$233.52 ,"$2,027.30 ","$1,813.90 "
Outpatient Medical Services,RADIOLOGY,73502,"Radiologic Examination, Hip, Unilateral, With Pelvis When Performed; 2-3 Views",324,$240.00 ,$180.00 ,pays at 75% of total billed charges,$192.00 ,pays at 80% of total billed charges,$57.11 ,pays at MCR OPPS,$190.08 ,pays at 79.2% of total billed charges,$190.08 ,pays at 79.2% of total billed charges,$190.08 ,pays at 79.2% of total billed charges,$190.08 ,pays at 79.2% of total billed charges,$204.00 ,pays at 85% of total billed charges,$75.44 ,pays at MCD O/P rates,$96.00 ,pays at MCR OPPS,$228.00 ,pays at 95% of total billed charges,$192.00 ,pays at 80% total billed charges,$204.00 ,pays at 85% of total billed charges,$216.00 ,pays at 90% of total billed charges,$96.00 ,pays at MCR OPPS,$75.44 ,pays at 100% of MCD OPPS,$86.88 ,pays at 100% of MCD OPPS,$96.00 ,pays at MCR OPPS,$216.00 ,pays at 90% of total billed charges,$182.40 ,pays at 80% of total billed charges,$57.11 ,pays at MCR OPPS,$96.00 ,pays at MCR OPPS,$204.00 ,pays at 85% of total billed charges,$75.44 ,pays at MCD OPPS,$96.00 ,pays at MCR OPPS,$192.00 ,pays at 80% of total billed charges,$55.40 ,pays at 97% of MCR OPPS,$204.00 ,pays at 85% of total billed charges,$75.44 ,pays at MCD OPPS,$55.40 ,$228.00 ,$204.00 
Outpatient Medical Services,RADIOLOGY,73521,"Radiologic Examination, Hips, Bilateral, With Pelvis When Performed; 2 Views",324,$415.00 ,$311.25 ,pays at 75% of total billed charges,$332.00 ,pays at 80% of total billed charges,$50.15 ,pays at MCR OPPS,$328.68 ,pays at 79.2% of total billed charges,$328.68 ,pays at 79.2% of total billed charges,$328.68 ,pays at 79.2% of total billed charges,$328.68 ,pays at 79.2% of total billed charges,$352.75 ,pays at 85% of total billed charges,$75.44 ,pays at MCD O/P rates,$166.00 ,pays at MCR OPPS,$394.25 ,pays at 95% of total billed charges,$332.00 ,pays at 80% total billed charges,$352.75 ,pays at 85% of total billed charges,$373.50 ,pays at 90% of total billed charges,$166.00 ,pays at MCR OPPS,$75.44 ,pays at 100% of MCD OPPS,$106.88 ,pays at 100% of MCD OPPS,$166.00 ,pays at MCR OPPS,$373.50 ,pays at 90% of total billed charges,$315.40 ,pays at 80% of total billed charges,$50.15 ,pays at MCR OPPS,$166.00 ,pays at MCR OPPS,$352.75 ,pays at 85% of total billed charges,$75.44 ,pays at MCD OPPS,$166.00 ,pays at MCR OPPS,$332.00 ,pays at 80% of total billed charges,$48.65 ,pays at 97% of MCR OPPS,$352.75 ,pays at 85% of total billed charges,$75.44 ,pays at MCD OPPS,$48.65 ,$394.25 ,$352.75 
Outpatient Medical Services,RADIOLOGY,73560,Radiologic examination of the knee with 1 or 2 views,324,$186.00 ,$139.50 ,pays at 75% of total billed charges,$148.80 ,pays at 80% of total billed charges,$41.66 ,pays at MCR OPPS,$147.31 ,pays at 79.2% of total billed charges,$147.31 ,pays at 79.2% of total billed charges,$147.31 ,pays at 79.2% of total billed charges,$147.31 ,pays at 79.2% of total billed charges,$158.10 ,pays at 85% of total billed charges,$75.44 ,pays at MCD O/P rates,$74.40 ,pays at MCR OPPS,$176.70 ,pays at 95% of total billed charges,$148.80 ,pays at 80% total billed charges,$158.10 ,pays at 85% of total billed charges,$167.40 ,pays at 90% of total billed charges,$74.40 ,pays at MCR OPPS,$75.44 ,pays at 100% of MCD OPPS,$86.88 ,pays at 100% of MCD OPPS,$74.40 ,pays at MCR OPPS,$167.40 ,pays at 90% of total billed charges,$141.36 ,pays at 80% of total billed charges,$41.66 ,pays at MCR OPPS,$74.40 ,pays at MCR OPPS,$158.10 ,pays at 85% of total billed charges,$75.44 ,pays at MCD OPPS,$74.40 ,pays at MCR OPPS,$148.80 ,pays at 80% of total billed charges,$40.41 ,pays at 97% of MCR OPPS,$158.10 ,pays at 85% of total billed charges,$75.44 ,pays at MCD OPPS,$40.41 ,$176.70 ,$158.10 
Outpatient Medical Services,RADIOLOGY,73562,Radiologic examination of the knee with 3 views,324,$186.00 ,$139.50 ,pays at 75% of total billed charges,$148.80 ,pays at 80% of total billed charges,$49.40 ,pays at MCR OPPS,$147.31 ,pays at 79.2% of total billed charges,$147.31 ,pays at 79.2% of total billed charges,$147.31 ,pays at 79.2% of total billed charges,$147.31 ,pays at 79.2% of total billed charges,$158.10 ,pays at 85% of total billed charges,$75.44 ,pays at MCD O/P rates,$74.40 ,pays at MCR OPPS,$176.70 ,pays at 95% of total billed charges,$148.80 ,pays at 80% total billed charges,$158.10 ,pays at 85% of total billed charges,$167.40 ,pays at 90% of total billed charges,$74.40 ,pays at MCR OPPS,$75.44 ,pays at 100% of MCD OPPS,$86.88 ,pays at 100% of MCD OPPS,$74.40 ,pays at MCR OPPS,$167.40 ,pays at 90% of total billed charges,$141.36 ,pays at 80% of total billed charges,$49.40 ,pays at MCR OPPS,$74.40 ,pays at MCR OPPS,$158.10 ,pays at 85% of total billed charges,$75.44 ,pays at MCD OPPS,$74.40 ,pays at MCR OPPS,$148.80 ,pays at 80% of total billed charges,$47.92 ,pays at 97% of MCR OPPS,$158.10 ,pays at 85% of total billed charges,$75.44 ,pays at MCD OPPS,$47.92 ,$176.70 ,$158.10 
Outpatient Medical Services,RADIOLOGY,73564,Radiologic examination of the knee with 4 or more views,324,$268.00 ,$201.00 ,pays at 75% of total billed charges,$214.40 ,pays at 80% of total billed charges,$56.70 ,pays at MCR OPPS,$212.26 ,pays at 79.2% of total billed charges,$212.26 ,pays at 79.2% of total billed charges,$212.26 ,pays at 79.2% of total billed charges,$212.26 ,pays at 79.2% of total billed charges,$227.80 ,pays at 85% of total billed charges,$75.44 ,pays at MCD O/P rates,$107.20 ,pays at MCR OPPS,$254.60 ,pays at 95% of total billed charges,$214.40 ,pays at 80% total billed charges,$227.80 ,pays at 85% of total billed charges,$241.20 ,pays at 90% of total billed charges,$107.20 ,pays at MCR OPPS,$75.44 ,pays at 100% of MCD OPPS,$106.88 ,pays at 100% of MCD OPPS,$107.20 ,pays at MCR OPPS,$241.20 ,pays at 90% of total billed charges,$203.68 ,pays at 80% of total billed charges,$56.70 ,pays at MCR OPPS,$107.20 ,pays at MCR OPPS,$227.80 ,pays at 85% of total billed charges,$75.44 ,pays at MCD OPPS,$107.20 ,pays at MCR OPPS,$214.40 ,pays at 80% of total billed charges,$54.99 ,pays at 97% of MCR OPPS,$227.80 ,pays at 85% of total billed charges,$75.44 ,pays at MCD OPPS,$54.99 ,$254.60 ,$227.80 
Outpatient Medical Services,RADIOLOGY,73565,Radiologic examination of both knees,324,$240.00 ,$180.00 ,pays at 75% of total billed charges,$192.00 ,pays at 80% of total billed charges,$48.62 ,pays at MCR OPPS,$190.08 ,pays at 79.2% of total billed charges,$190.08 ,pays at 79.2% of total billed charges,$190.08 ,pays at 79.2% of total billed charges,$190.08 ,pays at 79.2% of total billed charges,$204.00 ,pays at 85% of total billed charges,$75.44 ,pays at MCD O/P rates,$96.00 ,pays at MCR OPPS,$228.00 ,pays at 95% of total billed charges,$192.00 ,pays at 80% total billed charges,$204.00 ,pays at 85% of total billed charges,$216.00 ,pays at 90% of total billed charges,$96.00 ,pays at MCR OPPS,$75.44 ,pays at 100% of MCD OPPS,$86.88 ,pays at 100% of MCD OPPS,$96.00 ,pays at MCR OPPS,$216.00 ,pays at 90% of total billed charges,$182.40 ,pays at 80% of total billed charges,$48.62 ,pays at MCR OPPS,$96.00 ,pays at MCR OPPS,$204.00 ,pays at 85% of total billed charges,$75.44 ,pays at MCD OPPS,$96.00 ,pays at MCR OPPS,$192.00 ,pays at 80% of total billed charges,$47.16 ,pays at 97% of MCR OPPS,$204.00 ,pays at 85% of total billed charges,$75.44 ,pays at MCD OPPS,$47.16 ,$228.00 ,$204.00 
Outpatient Medical Services,RADIOLOGY,73590,Radiologic examination of the lower leg,324,$240.00 ,$180.00 ,pays at 75% of total billed charges,$192.00 ,pays at 80% of total billed charges,$38.39 ,pays at MCR OPPS,$190.08 ,pays at 79.2% of total billed charges,$190.08 ,pays at 79.2% of total billed charges,$190.08 ,pays at 79.2% of total billed charges,$190.08 ,pays at 79.2% of total billed charges,$204.00 ,pays at 85% of total billed charges,$75.44 ,pays at MCD O/P rates,$96.00 ,pays at MCR OPPS,$228.00 ,pays at 95% of total billed charges,$192.00 ,pays at 80% total billed charges,$204.00 ,pays at 85% of total billed charges,$216.00 ,pays at 90% of total billed charges,$96.00 ,pays at MCR OPPS,$75.44 ,pays at 100% of MCD OPPS,$86.88 ,pays at 100% of MCD OPPS,$96.00 ,pays at MCR OPPS,$216.00 ,pays at 90% of total billed charges,$182.40 ,pays at 80% of total billed charges,$38.39 ,pays at MCR OPPS,$96.00 ,pays at MCR OPPS,$204.00 ,pays at 85% of total billed charges,$75.44 ,pays at MCD OPPS,$96.00 ,pays at MCR OPPS,$192.00 ,pays at 80% of total billed charges,$37.24 ,pays at 97% of MCR OPPS,$204.00 ,pays at 85% of total billed charges,$75.44 ,pays at MCD OPPS,$37.24 ,$228.00 ,$204.00 
Outpatient Medical Services,RADIOLOGY,73600,Radiologic examination of the ankle with 2 views,324,$240.00 ,$180.00 ,pays at 75% of total billed charges,$192.00 ,pays at 80% of total billed charges,$39.62 ,pays at MCR OPPS,$190.08 ,pays at 79.2% of total billed charges,$190.08 ,pays at 79.2% of total billed charges,$190.08 ,pays at 79.2% of total billed charges,$190.08 ,pays at 79.2% of total billed charges,$204.00 ,pays at 85% of total billed charges,$75.44 ,pays at MCD O/P rates,$96.00 ,pays at MCR OPPS,$228.00 ,pays at 95% of total billed charges,$192.00 ,pays at 80% total billed charges,$204.00 ,pays at 85% of total billed charges,$216.00 ,pays at 90% of total billed charges,$96.00 ,pays at MCR OPPS,$75.44 ,pays at 100% of MCD OPPS,$86.88 ,pays at 100% of MCD OPPS,$96.00 ,pays at MCR OPPS,$216.00 ,pays at 90% of total billed charges,$182.40 ,pays at 80% of total billed charges,$39.62 ,pays at MCR OPPS,$96.00 ,pays at MCR OPPS,$204.00 ,pays at 85% of total billed charges,$75.44 ,pays at MCD OPPS,$96.00 ,pays at MCR OPPS,$192.00 ,pays at 80% of total billed charges,$38.43 ,pays at 97% of MCR OPPS,$204.00 ,pays at 85% of total billed charges,$75.44 ,pays at MCD OPPS,$38.43 ,$228.00 ,$204.00 
Outpatient Medical Services,RADIOLOGY,73610,Radiologic examination of the ankle with 3 views,324,$254.00 ,$190.50 ,pays at 75% of total billed charges,$203.20 ,pays at 80% of total billed charges,$44.92 ,pays at MCR OPPS,$201.17 ,pays at 79.2% of total billed charges,$201.17 ,pays at 79.2% of total billed charges,$201.17 ,pays at 79.2% of total billed charges,$201.17 ,pays at 79.2% of total billed charges,$215.90 ,pays at 85% of total billed charges,$75.44 ,pays at MCD O/P rates,$101.60 ,pays at MCR OPPS,$241.30 ,pays at 95% of total billed charges,$203.20 ,pays at 80% total billed charges,$215.90 ,pays at 85% of total billed charges,$228.60 ,pays at 90% of total billed charges,$101.60 ,pays at MCR OPPS,$75.44 ,pays at 100% of MCD OPPS,$86.88 ,pays at 100% of MCD OPPS,$101.60 ,pays at MCR OPPS,$228.60 ,pays at 90% of total billed charges,$193.04 ,pays at 80% of total billed charges,$44.92 ,pays at MCR OPPS,$101.60 ,pays at MCR OPPS,$215.90 ,pays at 85% of total billed charges,$75.44 ,pays at MCD OPPS,$101.60 ,pays at MCR OPPS,$203.20 ,pays at 80% of total billed charges,$43.57 ,pays at 97% of MCR OPPS,$215.90 ,pays at 85% of total billed charges,$75.44 ,pays at MCD OPPS,$43.57 ,$241.30 ,$215.90 
Outpatient Medical Services,RADIOLOGY,73620,"Radiologic examination, foot; 2 views",324,$240.00 ,$180.00 ,pays at 75% of total billed charges,$192.00 ,pays at 80% of total billed charges,$34.29 ,pays at MCR OPPS,$190.08 ,pays at 79.2% of total billed charges,$190.08 ,pays at 79.2% of total billed charges,$190.08 ,pays at 79.2% of total billed charges,$190.08 ,pays at 79.2% of total billed charges,$204.00 ,pays at 85% of total billed charges,$75.44 ,pays at MCD O/P rates,$96.00 ,pays at MCR OPPS,$228.00 ,pays at 95% of total billed charges,$192.00 ,pays at 80% total billed charges,$204.00 ,pays at 85% of total billed charges,$216.00 ,pays at 90% of total billed charges,$96.00 ,pays at MCR OPPS,$75.44 ,pays at 100% of MCD OPPS,$86.88 ,pays at 100% of MCD OPPS,$96.00 ,pays at MCR OPPS,$216.00 ,pays at 90% of total billed charges,$182.40 ,pays at 80% of total billed charges,$34.29 ,pays at MCR OPPS,$96.00 ,pays at MCR OPPS,$204.00 ,pays at 85% of total billed charges,$75.44 ,pays at MCD OPPS,$96.00 ,pays at MCR OPPS,$192.00 ,pays at 80% of total billed charges,$33.26 ,pays at 97% of MCR OPPS,$204.00 ,pays at 85% of total billed charges,$75.44 ,pays at MCD OPPS,$33.26 ,$228.00 ,$204.00 
Outpatient Medical Services,RADIOLOGY,73630,Radiologic examination of the foot with 3 or more views,324,$254.00 ,$190.50 ,pays at 75% of total billed charges,$203.20 ,pays at 80% of total billed charges,$41.64 ,pays at MCR OPPS,$201.17 ,pays at 79.2% of total billed charges,$201.17 ,pays at 79.2% of total billed charges,$201.17 ,pays at 79.2% of total billed charges,$201.17 ,pays at 79.2% of total billed charges,$215.90 ,pays at 85% of total billed charges,$75.44 ,pays at MCD O/P rates,$101.60 ,pays at MCR OPPS,$241.30 ,pays at 95% of total billed charges,$203.20 ,pays at 80% total billed charges,$215.90 ,pays at 85% of total billed charges,$228.60 ,pays at 90% of total billed charges,$101.60 ,pays at MCR OPPS,$75.44 ,pays at 100% of MCD OPPS,$86.88 ,pays at 100% of MCD OPPS,$101.60 ,pays at MCR OPPS,$228.60 ,pays at 90% of total billed charges,$193.04 ,pays at 80% of total billed charges,$41.64 ,pays at MCR OPPS,$101.60 ,pays at MCR OPPS,$215.90 ,pays at 85% of total billed charges,$75.44 ,pays at MCD OPPS,$101.60 ,pays at MCR OPPS,$203.20 ,pays at 80% of total billed charges,$40.39 ,pays at 97% of MCR OPPS,$215.90 ,pays at 85% of total billed charges,$75.44 ,pays at MCD OPPS,$40.39 ,$241.30 ,$215.90 
Outpatient Medical Services,RADIOLOGY,73650,Radiologic examination of the heel,324,$240.00 ,$180.00 ,pays at 75% of total billed charges,$192.00 ,pays at 80% of total billed charges,$34.71 ,pays at MCR OPPS,$190.08 ,pays at 79.2% of total billed charges,$190.08 ,pays at 79.2% of total billed charges,$190.08 ,pays at 79.2% of total billed charges,$190.08 ,pays at 79.2% of total billed charges,$204.00 ,pays at 85% of total billed charges,$75.44 ,pays at MCD O/P rates,$96.00 ,pays at MCR OPPS,$228.00 ,pays at 95% of total billed charges,$192.00 ,pays at 80% total billed charges,$204.00 ,pays at 85% of total billed charges,$216.00 ,pays at 90% of total billed charges,$96.00 ,pays at MCR OPPS,$75.44 ,pays at 100% of MCD OPPS,$86.88 ,pays at 100% of MCD OPPS,$96.00 ,pays at MCR OPPS,$216.00 ,pays at 90% of total billed charges,$182.40 ,pays at 80% of total billed charges,$34.71 ,pays at MCR OPPS,$96.00 ,pays at MCR OPPS,$204.00 ,pays at 85% of total billed charges,$75.44 ,pays at MCD OPPS,$96.00 ,pays at MCR OPPS,$192.00 ,pays at 80% of total billed charges,$33.67 ,pays at 97% of MCR OPPS,$204.00 ,pays at 85% of total billed charges,$75.44 ,pays at MCD OPPS,$33.67 ,$228.00 ,$204.00 
Outpatient Medical Services,RADIOLOGY,73700,CT scan of leg without dye,350,"$1,193.00 ",$894.75 ,pays at 75% of total billed charges,$954.40 ,pays at 80% of total billed charges,$161.83 ,pays at MCR OPPS,$514.00 ,pays at 79.2% of total billed charges,$514.00 ,pays at 79.2% of total billed charges,$514.00 ,pays at 79.2% of total billed charges,$514.00 ,pays at 79.2% of total billed charges,"$1,014.05 ",pays at 85% of total billed charges,$153.71 ,pays at MCD O/P rates,$477.20 ,pays at MCR OPPS,"$1,133.35 ",pays at 95% of total billed charges,$954.40 ,pays at 80% total billed charges,"$1,014.05 ",pays at 85% of total billed charges,"$1,073.70 ",pays at 90% of total billed charges,$477.20 ,pays at MCR OPPS,$153.71 ,pays at 100% of MCD OPPS,$106.88 ,pays at 100% of MCD OPPS,$477.20 ,pays at MCR OPPS,"$1,073.70 ",pays at 90% of total billed charges,$906.68 ,pays at 80% of total billed charges,$161.83 ,pays at MCR OPPS,$477.20 ,pays at MCR OPPS,"$1,014.05 ",pays at 85% of total billed charges,$153.71 ,pays at MCD OPPS,$477.20 ,pays at MCR OPPS,$954.40 ,pays at 80% of total billed charges,$156.97 ,pays at 97% of MCR OPPS,"$1,014.05 ",pays at 85% of total billed charges,$153.71 ,pays at MCD OPPS,$106.88 ,"$1,133.35 ","$1,014.05 "
Outpatient Medical Services,RADIOLOGY,73721,MRI of lower extremity joint (knee/ankle) without dye,610,"$2,134.00 ","$1,600.50 ",pays at 75% of total billed charges,"$1,707.20 ",pays at 80% of total billed charges,$254.93 ,pays at MCR OPPS,$730.00 ,pays at 79.2% of total billed charges,$730.00 ,pays at 79.2% of total billed charges,$730.00 ,pays at 79.2% of total billed charges,$730.00 ,pays at 79.2% of total billed charges,"$1,813.90 ",pays at 85% of total billed charges,$335.59 ,pays at MCD O/P rates,$853.60 ,pays at MCR OPPS,"$2,027.30 ",pays at 95% of total billed charges,"$1,707.20 ",pays at 80% total billed charges,"$1,813.90 ",pays at 85% of total billed charges,"$1,920.60 ",pays at 90% of total billed charges,$853.60 ,pays at MCR OPPS,$335.59 ,pays at 100% of MCD OPPS,$233.52 ,pays at 100% of MCD OPPS,$853.60 ,pays at MCR OPPS,"$1,920.60 ",pays at 90% of total billed charges,"$1,621.84 ",pays at 80% of total billed charges,$254.93 ,pays at MCR OPPS,$853.60 ,pays at MCR OPPS,"$1,813.90 ",pays at 85% of total billed charges,$335.59 ,pays at MCD OPPS,$853.60 ,pays at MCR OPPS,"$1,707.20 ",pays at 80% of total billed charges,$247.28 ,pays at 97% of MCR OPPS,"$1,813.90 ",pays at 85% of total billed charges,$335.59 ,pays at MCD OPPS,$233.52 ,"$2,027.30 ","$1,813.90 "
Outpatient Medical Services,RADIOLOGY,74018,"Radiologic examination, abdomen; 1 view",324,$240.00 ,$180.00 ,pays at 75% of total billed charges,$192.00 ,pays at 80% of total billed charges,$36.31 ,pays at MCR OPPS,$190.08 ,pays at 79.2% of total billed charges,$190.08 ,pays at 79.2% of total billed charges,$190.08 ,pays at 79.2% of total billed charges,$190.08 ,pays at 79.2% of total billed charges,$204.00 ,pays at 85% of total billed charges,$75.44 ,pays at MCD O/P rates,$96.00 ,pays at MCR OPPS,$228.00 ,pays at 95% of total billed charges,$192.00 ,pays at 80% total billed charges,$204.00 ,pays at 85% of total billed charges,$216.00 ,pays at 90% of total billed charges,$96.00 ,pays at MCR OPPS,$75.44 ,pays at 100% of MCD OPPS,$86.88 ,pays at 100% of MCD OPPS,$96.00 ,pays at MCR OPPS,$216.00 ,pays at 90% of total billed charges,$182.40 ,pays at 80% of total billed charges,$36.31 ,pays at MCR OPPS,$96.00 ,pays at MCR OPPS,$204.00 ,pays at 85% of total billed charges,$75.44 ,pays at MCD OPPS,$96.00 ,pays at MCR OPPS,$192.00 ,pays at 80% of total billed charges,$35.22 ,pays at 97% of MCR OPPS,$204.00 ,pays at 85% of total billed charges,$75.44 ,pays at MCD OPPS,$35.22 ,$228.00 ,$204.00 
Outpatient Medical Services,RADIOLOGY,74019,"Radiologic examination, abdomen; 2 views",324,$332.00 ,$249.00 ,pays at 75% of total billed charges,$265.60 ,pays at 80% of total billed charges,$44.82 ,pays at MCR OPPS,$262.94 ,pays at 79.2% of total billed charges,$262.94 ,pays at 79.2% of total billed charges,$262.94 ,pays at 79.2% of total billed charges,$262.94 ,pays at 79.2% of total billed charges,$282.20 ,pays at 85% of total billed charges,$75.44 ,pays at MCD O/P rates,$132.80 ,pays at MCR OPPS,$315.40 ,pays at 95% of total billed charges,$265.60 ,pays at 80% total billed charges,$282.20 ,pays at 85% of total billed charges,$298.80 ,pays at 90% of total billed charges,$132.80 ,pays at MCR OPPS,$75.44 ,pays at 100% of MCD OPPS,$106.88 ,pays at 100% of MCD OPPS,$132.80 ,pays at MCR OPPS,$298.80 ,pays at 90% of total billed charges,$252.32 ,pays at 80% of total billed charges,$44.82 ,pays at MCR OPPS,$132.80 ,pays at MCR OPPS,$282.20 ,pays at 85% of total billed charges,$75.44 ,pays at MCD OPPS,$132.80 ,pays at MCR OPPS,$265.60 ,pays at 80% of total billed charges,$43.47 ,pays at 97% of MCR OPPS,$282.20 ,pays at 85% of total billed charges,$75.44 ,pays at MCD OPPS,$43.47 ,$315.40 ,$282.20 
Outpatient Medical Services,RADIOLOGY,74022,Serial radiologic examination of the abdomen,350,$415.00 ,$311.25 ,pays at 75% of total billed charges,$332.00 ,pays at 80% of total billed charges,$60.51 ,pays at MCR OPPS,$514.00 ,pays at 79.2% of total billed charges,$514.00 ,pays at 79.2% of total billed charges,$514.00 ,pays at 79.2% of total billed charges,$514.00 ,pays at 79.2% of total billed charges,$352.75 ,pays at 85% of total billed charges,$75.44 ,pays at MCD O/P rates,$166.00 ,pays at MCR OPPS,$394.25 ,pays at 95% of total billed charges,$332.00 ,pays at 80% total billed charges,$352.75 ,pays at 85% of total billed charges,$373.50 ,pays at 90% of total billed charges,$166.00 ,pays at MCR OPPS,$75.44 ,pays at 100% of MCD OPPS,$106.88 ,pays at 100% of MCD OPPS,$166.00 ,pays at MCR OPPS,$373.50 ,pays at 90% of total billed charges,$315.40 ,pays at 80% of total billed charges,$60.51 ,pays at MCR OPPS,$166.00 ,pays at MCR OPPS,$352.75 ,pays at 85% of total billed charges,$75.44 ,pays at MCD OPPS,$166.00 ,pays at MCR OPPS,$332.00 ,pays at 80% of total billed charges,$58.70 ,pays at 97% of MCR OPPS,$352.75 ,pays at 85% of total billed charges,$75.44 ,pays at MCD OPPS,$58.70 ,$514.00 ,$352.75 
Outpatient Medical Services,RADIOLOGY,74174,"Computed Tomographic Angiography, Abdomen And Pelvis, With Contrast Material(S), Including Noncontrast Images, If Performed, And Image Postprocessing",350,"$1,909.00 ","$1,431.75 ",pays at 75% of total billed charges,"$1,527.20 ",pays at 80% of total billed charges,$479.86 ,pays at MCR OPPS,$514.00 ,pays at 79.2% of total billed charges,$514.00 ,pays at 79.2% of total billed charges,$514.00 ,pays at 79.2% of total billed charges,$514.00 ,pays at 79.2% of total billed charges,"$1,622.65 ",pays at 85% of total billed charges,$509.86 ,pays at MCD O/P rates,$763.60 ,pays at MCR OPPS,"$1,813.55 ",pays at 95% of total billed charges,"$1,527.20 ",pays at 80% total billed charges,"$1,622.65 ",pays at 85% of total billed charges,"$1,718.10 ",pays at 90% of total billed charges,$763.60 ,pays at MCR OPPS,$509.86 ,pays at 100% of MCD OPPS,$368.43 ,pays at 100% of MCD OPPS,$763.60 ,pays at MCR OPPS,"$1,718.10 ",pays at 90% of total billed charges,"$1,450.84 ",pays at 80% of total billed charges,$479.86 ,pays at MCR OPPS,$763.60 ,pays at MCR OPPS,"$1,622.65 ",pays at 85% of total billed charges,$509.86 ,pays at MCD OPPS,$763.60 ,pays at MCR OPPS,"$1,527.20 ",pays at 80% of total billed charges,$465.46 ,pays at 97% of MCR OPPS,"$1,622.65 ",pays at 85% of total billed charges,$509.86 ,pays at MCD OPPS,$368.43 ,"$1,813.55 ","$1,622.65 "
Outpatient Medical Services,RADIOLOGY,74176,CT of abdomen and pelvis without dye,350,"$1,241.00 ",$930.75 ,pays at 75% of total billed charges,$992.80 ,pays at 80% of total billed charges,$228.18 ,pays at MCR OPPS,$514.00 ,pays at 79.2% of total billed charges,$514.00 ,pays at 79.2% of total billed charges,$514.00 ,pays at 79.2% of total billed charges,$514.00 ,pays at 79.2% of total billed charges,"$1,054.85 ",pays at 85% of total billed charges,$416.44 ,pays at MCD O/P rates,$496.40 ,pays at MCR OPPS,"$1,178.95 ",pays at 95% of total billed charges,$992.80 ,pays at 80% total billed charges,"$1,054.85 ",pays at 85% of total billed charges,"$1,116.90 ",pays at 90% of total billed charges,$496.40 ,pays at MCR OPPS,$416.44 ,pays at 100% of MCD OPPS,$233.52 ,pays at 100% of MCD OPPS,$496.40 ,pays at MCR OPPS,"$1,116.90 ",pays at 90% of total billed charges,$943.16 ,pays at 80% of total billed charges,$228.18 ,pays at MCR OPPS,$496.40 ,pays at MCR OPPS,"$1,054.85 ",pays at 85% of total billed charges,$416.44 ,pays at MCD OPPS,$496.40 ,pays at MCR OPPS,$992.80 ,pays at 80% of total billed charges,$221.34 ,pays at 97% of MCR OPPS,"$1,054.85 ",pays at 85% of total billed charges,$416.44 ,pays at MCD OPPS,$221.34 ,"$1,178.95 ","$1,054.85 "
Outpatient Medical Services,RADIOLOGY,74177,CT scan of abdomen and pelvis with contrast,350,"$1,513.00 ","$1,134.75 ",pays at 75% of total billed charges,"$1,210.40 ",pays at 80% of total billed charges,$385.17 ,pays at MCR OPPS,$514.00 ,pays at 79.2% of total billed charges,$514.00 ,pays at 79.2% of total billed charges,$514.00 ,pays at 79.2% of total billed charges,$514.00 ,pays at 79.2% of total billed charges,"$1,286.05 ",pays at 85% of total billed charges,$416.44 ,pays at MCD O/P rates,$605.20 ,pays at MCR OPPS,"$1,437.35 ",pays at 95% of total billed charges,"$1,210.40 ",pays at 80% total billed charges,"$1,286.05 ",pays at 85% of total billed charges,"$1,361.70 ",pays at 90% of total billed charges,$605.20 ,pays at MCR OPPS,$416.44 ,pays at 100% of MCD OPPS,$368.43 ,pays at 100% of MCD OPPS,$605.20 ,pays at MCR OPPS,"$1,361.70 ",pays at 90% of total billed charges,"$1,149.88 ",pays at 80% of total billed charges,$385.17 ,pays at MCR OPPS,$605.20 ,pays at MCR OPPS,"$1,286.05 ",pays at 85% of total billed charges,$416.44 ,pays at MCD OPPS,$605.20 ,pays at MCR OPPS,"$1,210.40 ",pays at 80% of total billed charges,$373.61 ,pays at 97% of MCR OPPS,"$1,286.05 ",pays at 85% of total billed charges,$416.44 ,pays at MCD OPPS,$368.43 ,"$1,437.35 ","$1,286.05 "
Outpatient Medical Services,RADIOLOGY,76536,Ultrasound of head and neck,402,$475.00 ,$356.25 ,pays at 75% of total billed charges,$380.00 ,pays at 80% of total billed charges,$135.60 ,pays at MCR OPPS,$376.20 ,pays at 79.2% of total billed charges,$376.20 ,pays at 79.2% of total billed charges,$376.20 ,pays at 79.2% of total billed charges,$376.20 ,pays at 79.2% of total billed charges,$403.75 ,pays at 85% of total billed charges,$145.77 ,pays at MCD O/P rates,$190.00 ,pays at MCR OPPS,$451.25 ,pays at 95% of total billed charges,$380.00 ,pays at 80% total billed charges,$403.75 ,pays at 85% of total billed charges,$427.50 ,pays at 90% of total billed charges,$190.00 ,pays at MCR OPPS,$145.77 ,pays at 100% of MCD OPPS,$106.88 ,pays at 100% of MCD OPPS,$190.00 ,pays at MCR OPPS,$427.50 ,pays at 90% of total billed charges,$361.00 ,pays at 80% of total billed charges,$135.60 ,pays at MCR OPPS,$190.00 ,pays at MCR OPPS,$403.75 ,pays at 85% of total billed charges,$145.77 ,pays at MCD OPPS,$190.00 ,pays at MCR OPPS,$380.00 ,pays at 80% of total billed charges,$131.53 ,pays at 97% of MCR OPPS,$403.75 ,pays at 85% of total billed charges,$145.77 ,pays at MCD OPPS,$106.88 ,$451.25 ,$403.75 
Outpatient Medical Services,RADIOLOGY,76641,"Ultrasound, Breast, Unilateral, Real Time With Image Documentation, Including Axilla When Performed; Complete",402,$357.00 ,$267.75 ,pays at 75% of total billed charges,$285.60 ,pays at 80% of total billed charges,$125.48 ,pays at MCR OPPS,$282.74 ,pays at 79.2% of total billed charges,$282.74 ,pays at 79.2% of total billed charges,$282.74 ,pays at 79.2% of total billed charges,$282.74 ,pays at 79.2% of total billed charges,$303.45 ,pays at 85% of total billed charges,$145.77 ,pays at MCD O/P rates,$142.80 ,pays at MCR OPPS,$339.15 ,pays at 95% of total billed charges,$285.60 ,pays at 80% total billed charges,$303.45 ,pays at 85% of total billed charges,$321.30 ,pays at 90% of total billed charges,$142.80 ,pays at MCR OPPS,$145.77 ,pays at 100% of MCD OPPS,$106.88 ,pays at 100% of MCD OPPS,$142.80 ,pays at MCR OPPS,$321.30 ,pays at 90% of total billed charges,$271.32 ,pays at 80% of total billed charges,$125.48 ,pays at MCR OPPS,$142.80 ,pays at MCR OPPS,$303.45 ,pays at 85% of total billed charges,$145.77 ,pays at MCD OPPS,$142.80 ,pays at MCR OPPS,$285.60 ,pays at 80% of total billed charges,$121.71 ,pays at 97% of MCR OPPS,$303.45 ,pays at 85% of total billed charges,$145.77 ,pays at MCD OPPS,$106.88 ,$339.15 ,$303.45 
Outpatient Medical Services,RADIOLOGY,76700,Ultrasound of abdomen with all areas scanned,402,$555.00 ,$416.25 ,pays at 75% of total billed charges,$444.00 ,pays at 80% of total billed charges,$141.70 ,pays at MCR OPPS,$439.56 ,pays at 79.2% of total billed charges,$439.56 ,pays at 79.2% of total billed charges,$439.56 ,pays at 79.2% of total billed charges,$439.56 ,pays at 79.2% of total billed charges,$471.75 ,pays at 85% of total billed charges,$221.27 ,pays at MCD O/P rates,$222.00 ,pays at MCR OPPS,$527.25 ,pays at 95% of total billed charges,$444.00 ,pays at 80% total billed charges,$471.75 ,pays at 85% of total billed charges,$499.50 ,pays at 90% of total billed charges,$222.00 ,pays at MCR OPPS,$221.27 ,pays at 100% of MCD OPPS,$106.88 ,pays at 100% of MCD OPPS,$222.00 ,pays at MCR OPPS,$499.50 ,pays at 90% of total billed charges,$421.80 ,pays at 80% of total billed charges,$141.70 ,pays at MCR OPPS,$222.00 ,pays at MCR OPPS,$471.75 ,pays at 85% of total billed charges,$221.27 ,pays at MCD OPPS,$222.00 ,pays at MCR OPPS,$444.00 ,pays at 80% of total billed charges,$137.45 ,pays at 97% of MCR OPPS,$471.75 ,pays at 85% of total billed charges,$221.27 ,pays at MCD OPPS,$106.88 ,$527.25 ,$471.75 
Outpatient Medical Services,RADIOLOGY,76705,A diagnostic procedure that allows a provider to see the organs and other structures in the abdomen,402,$430.00 ,$322.50 ,pays at 75% of total billed charges,$344.00 ,pays at 80% of total billed charges,$106.90 ,pays at MCR OPPS,$340.56 ,pays at 79.2% of total billed charges,$340.56 ,pays at 79.2% of total billed charges,$340.56 ,pays at 79.2% of total billed charges,$340.56 ,pays at 79.2% of total billed charges,$365.50 ,pays at 85% of total billed charges,$145.77 ,pays at MCD O/P rates,$172.00 ,pays at MCR OPPS,$408.50 ,pays at 95% of total billed charges,$344.00 ,pays at 80% total billed charges,$365.50 ,pays at 85% of total billed charges,$387.00 ,pays at 90% of total billed charges,$172.00 ,pays at MCR OPPS,$145.77 ,pays at 100% of MCD OPPS,$106.88 ,pays at 100% of MCD OPPS,$172.00 ,pays at MCR OPPS,$387.00 ,pays at 90% of total billed charges,$326.80 ,pays at 80% of total billed charges,$106.90 ,pays at MCR OPPS,$172.00 ,pays at MCR OPPS,$365.50 ,pays at 85% of total billed charges,$145.77 ,pays at MCD OPPS,$172.00 ,pays at MCR OPPS,$344.00 ,pays at 80% of total billed charges,$103.70 ,pays at 97% of MCR OPPS,$365.50 ,pays at 85% of total billed charges,$145.77 ,pays at MCD OPPS,$103.70 ,$408.50 ,$365.50 
Outpatient Medical Services,RADIOLOGY,76770,Ultrasound of back wall of the abdomen with all areas viewed,402,$526.00 ,$394.50 ,pays at 75% of total billed charges,$420.80 ,pays at 80% of total billed charges,$132.01 ,pays at MCR OPPS,$416.59 ,pays at 79.2% of total billed charges,$416.59 ,pays at 79.2% of total billed charges,$416.59 ,pays at 79.2% of total billed charges,$416.59 ,pays at 79.2% of total billed charges,$447.10 ,pays at 85% of total billed charges,$221.27 ,pays at MCD O/P rates,$210.40 ,pays at MCR OPPS,$499.70 ,pays at 95% of total billed charges,$420.80 ,pays at 80% total billed charges,$447.10 ,pays at 85% of total billed charges,$473.40 ,pays at 90% of total billed charges,$210.40 ,pays at MCR OPPS,$221.27 ,pays at 100% of MCD OPPS,$106.88 ,pays at 100% of MCD OPPS,$210.40 ,pays at MCR OPPS,$473.40 ,pays at 90% of total billed charges,$399.76 ,pays at 80% of total billed charges,$132.01 ,pays at MCR OPPS,$210.40 ,pays at MCR OPPS,$447.10 ,pays at 85% of total billed charges,$221.27 ,pays at MCD OPPS,$210.40 ,pays at MCR OPPS,$420.80 ,pays at 80% of total billed charges,$128.05 ,pays at 97% of MCR OPPS,$447.10 ,pays at 85% of total billed charges,$221.27 ,pays at MCD OPPS,$106.88 ,$499.70 ,$447.10 
Outpatient Medical Services,RADIOLOGY,76805,Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus,402,$591.00 ,$443.25 ,pays at 75% of total billed charges,$472.80 ,pays at 80% of total billed charges,$164.61 ,pays at MCR OPPS,$468.07 ,pays at 79.2% of total billed charges,$468.07 ,pays at 79.2% of total billed charges,$468.07 ,pays at 79.2% of total billed charges,$468.07 ,pays at 79.2% of total billed charges,$502.35 ,pays at 85% of total billed charges,$134.00 ,pays at MCD O/P rates,$236.40 ,pays at MCR OPPS,$561.45 ,pays at 95% of total billed charges,$472.80 ,pays at 80% total billed charges,$502.35 ,pays at 85% of total billed charges,$531.90 ,pays at 90% of total billed charges,$236.40 ,pays at MCR OPPS,$134.00 ,pays at 100% of MCD OPPS,$106.88 ,pays at 100% of MCD OPPS,$236.40 ,pays at MCR OPPS,$531.90 ,pays at 90% of total billed charges,$449.16 ,pays at 80% of total billed charges,$164.61 ,pays at MCR OPPS,$236.40 ,pays at MCR OPPS,$502.35 ,pays at 85% of total billed charges,$134.00 ,pays at MCD OPPS,$236.40 ,pays at MCR OPPS,$472.80 ,pays at 80% of total billed charges,$159.67 ,pays at 97% of MCR OPPS,$502.35 ,pays at 85% of total billed charges,$134.00 ,pays at MCD OPPS,$106.88 ,$561.45 ,$502.35 
Outpatient Medical Services,RADIOLOGY,76830,Ultrasound of the pelvis through vagina,402,$502.00 ,$376.50 ,pays at 75% of total billed charges,$401.60 ,pays at 80% of total billed charges,$146.00 ,pays at MCR OPPS,$397.58 ,pays at 79.2% of total billed charges,$397.58 ,pays at 79.2% of total billed charges,$397.58 ,pays at 79.2% of total billed charges,$397.58 ,pays at 79.2% of total billed charges,$426.70 ,pays at 85% of total billed charges,$145.77 ,pays at MCD O/P rates,$200.80 ,pays at MCR OPPS,$476.90 ,pays at 95% of total billed charges,$401.60 ,pays at 80% total billed charges,$426.70 ,pays at 85% of total billed charges,$451.80 ,pays at 90% of total billed charges,$200.80 ,pays at MCR OPPS,$145.77 ,pays at 100% of MCD OPPS,$106.88 ,pays at 100% of MCD OPPS,$200.80 ,pays at MCR OPPS,$451.80 ,pays at 90% of total billed charges,$381.52 ,pays at 80% of total billed charges,$146.00 ,pays at MCR OPPS,$200.80 ,pays at MCR OPPS,$426.70 ,pays at 85% of total billed charges,$145.77 ,pays at MCD OPPS,$200.80 ,pays at MCR OPPS,$401.60 ,pays at 80% of total billed charges,$141.62 ,pays at 97% of MCR OPPS,$426.70 ,pays at 85% of total billed charges,$145.77 ,pays at MCD OPPS,$106.88 ,$476.90 ,$426.70 
Outpatient Medical Services,RADIOLOGY,76856,Complete ultrasound of the pelvis,402,$502.00 ,$376.50 ,pays at 75% of total billed charges,$401.60 ,pays at 80% of total billed charges,$128.41 ,pays at MCR OPPS,$397.58 ,pays at 79.2% of total billed charges,$397.58 ,pays at 79.2% of total billed charges,$397.58 ,pays at 79.2% of total billed charges,$397.58 ,pays at 79.2% of total billed charges,$426.70 ,pays at 85% of total billed charges,$221.27 ,pays at MCD O/P rates,$200.80 ,pays at MCR OPPS,$476.90 ,pays at 95% of total billed charges,$401.60 ,pays at 80% total billed charges,$426.70 ,pays at 85% of total billed charges,$451.80 ,pays at 90% of total billed charges,$200.80 ,pays at MCR OPPS,$221.27 ,pays at 100% of MCD OPPS,$106.88 ,pays at 100% of MCD OPPS,$200.80 ,pays at MCR OPPS,$451.80 ,pays at 90% of total billed charges,$381.52 ,pays at 80% of total billed charges,$128.41 ,pays at MCR OPPS,$200.80 ,pays at MCR OPPS,$426.70 ,pays at 85% of total billed charges,$221.27 ,pays at MCD OPPS,$200.80 ,pays at MCR OPPS,$401.60 ,pays at 80% of total billed charges,$124.56 ,pays at 97% of MCR OPPS,$426.70 ,pays at 85% of total billed charges,$221.27 ,pays at MCD OPPS,$106.88 ,$476.90 ,$426.70 
Outpatient Medical Services,RADIOLOGY,77065,"Diagnostic mammography, including computer-aided detection (cad) when performed; unilateral",401,$322.00 ,$241.50 ,pays at 75% of total billed charges,$257.60 ,pays at 80% of total billed charges,$151.94 ,pays at MCR OPPS,$255.02 ,pays at 79.2% of total billed charges,$255.02 ,pays at 79.2% of total billed charges,$255.02 ,pays at 79.2% of total billed charges,$255.02 ,pays at 79.2% of total billed charges,$273.70 ,pays at 85% of total billed charges,$66.74 ,pays at MCD O/P rates,$128.80 ,pays at MCR OPPS,$305.90 ,pays at 95% of total billed charges,$257.60 ,pays at 80% total billed charges,$273.70 ,pays at 85% of total billed charges,$289.80 ,pays at 90% of total billed charges,$128.80 ,pays at MCR OPPS,$66.74 ,pays at 100% of MCD OPPS,$125.59 ,pays at 100% of MCD OPPS,$128.80 ,pays at MCR OPPS,$289.80 ,pays at 90% of total billed charges,$244.72 ,pays at 80% of total billed charges,$151.94 ,pays at MCR OPPS,$128.80 ,pays at MCR OPPS,$273.70 ,pays at 85% of total billed charges,$66.74 ,pays at MCD OPPS,$128.80 ,pays at MCR OPPS,$257.60 ,pays at 80% of total billed charges,$147.38 ,pays at 97% of MCR OPPS,$273.70 ,pays at 85% of total billed charges,$66.74 ,pays at MCD OPPS,$66.74 ,$305.90 ,$273.70 
Outpatient Medical Services,RADIOLOGY,77066,"Diagnostic mammography, including computer-aided detection (cad) when performed; bilateral",401,$412.00 ,$309.00 ,pays at 75% of total billed charges,$329.60 ,pays at 80% of total billed charges,$191.71 ,pays at MCR OPPS,$326.30 ,pays at 79.2% of total billed charges,$326.30 ,pays at 79.2% of total billed charges,$326.30 ,pays at 79.2% of total billed charges,$326.30 ,pays at 79.2% of total billed charges,$350.20 ,pays at 85% of total billed charges,$66.74 ,pays at MCD O/P rates,$164.80 ,pays at MCR OPPS,$391.40 ,pays at 95% of total billed charges,$329.60 ,pays at 80% total billed charges,$350.20 ,pays at 85% of total billed charges,$370.80 ,pays at 90% of total billed charges,$164.80 ,pays at MCR OPPS,$66.74 ,pays at 100% of MCD OPPS,$158.59 ,pays at 100% of MCD OPPS,$164.80 ,pays at MCR OPPS,$370.80 ,pays at 90% of total billed charges,$313.12 ,pays at 80% of total billed charges,$191.71 ,pays at MCR OPPS,$164.80 ,pays at MCR OPPS,$350.20 ,pays at 85% of total billed charges,$66.74 ,pays at MCD OPPS,$164.80 ,pays at MCR OPPS,$329.60 ,pays at 80% of total billed charges,$185.95 ,pays at 97% of MCR OPPS,$350.20 ,pays at 85% of total billed charges,$66.74 ,pays at MCD OPPS,$66.74 ,$391.40 ,$350.20 
Outpatient Medical Services,RADIOLOGY,77067,Mammography of both breasts-2 or more views,401,$341.00 ,$255.75 ,pays at 75% of total billed charges,$272.80 ,pays at 80% of total billed charges,$155.71 ,pays at MCR OPPS,$270.07 ,pays at 79.2% of total billed charges,$270.07 ,pays at 79.2% of total billed charges,$270.07 ,pays at 79.2% of total billed charges,$270.07 ,pays at 79.2% of total billed charges,$289.85 ,pays at 85% of total billed charges,$66.74 ,pays at MCD O/P rates,$136.40 ,pays at MCR OPPS,$323.95 ,pays at 95% of total billed charges,$272.80 ,pays at 80% total billed charges,$289.85 ,pays at 85% of total billed charges,$306.90 ,pays at 90% of total billed charges,$136.40 ,pays at MCR OPPS,$66.74 ,pays at 100% of MCD OPPS,$127.61 ,pays at 100% of MCD OPPS,$136.40 ,pays at MCR OPPS,$306.90 ,pays at 90% of total billed charges,$259.16 ,pays at 80% of total billed charges,$155.71 ,pays at MCR OPPS,$136.40 ,pays at MCR OPPS,$289.85 ,pays at 85% of total billed charges,$66.74 ,pays at MCD OPPS,$136.40 ,pays at MCR OPPS,$272.80 ,pays at 80% of total billed charges,$151.04 ,pays at 97% of MCR OPPS,$289.85 ,pays at 85% of total billed charges,$66.74 ,pays at MCD OPPS,$66.74 ,$323.95 ,$289.85 
Outpatient Medical Services,RADIOLOGY,77080,Scan to measure bone mineral density (BMD) at the spine and hip,324,$506.00 ,$379.50 ,pays at 75% of total billed charges,$404.80 ,pays at 80% of total billed charges,$46.09 ,pays at MCR OPPS,$400.75 ,pays at 79.2% of total billed charges,$400.75 ,pays at 79.2% of total billed charges,$400.75 ,pays at 79.2% of total billed charges,$400.75 ,pays at 79.2% of total billed charges,$430.10 ,pays at 85% of total billed charges,$104.58 ,pays at MCD O/P rates,$202.40 ,pays at MCR OPPS,$480.70 ,pays at 95% of total billed charges,$404.80 ,pays at 80% total billed charges,$430.10 ,pays at 85% of total billed charges,$455.40 ,pays at 90% of total billed charges,$202.40 ,pays at MCR OPPS,$104.58 ,pays at 100% of MCD OPPS,$106.88 ,pays at 100% of MCD OPPS,$202.40 ,pays at MCR OPPS,$455.40 ,pays at 90% of total billed charges,$384.56 ,pays at 80% of total billed charges,$46.09 ,pays at MCR OPPS,$202.40 ,pays at MCR OPPS,$430.10 ,pays at 85% of total billed charges,$104.58 ,pays at MCD OPPS,$202.40 ,pays at MCR OPPS,$404.80 ,pays at 80% of total billed charges,$44.71 ,pays at 97% of MCR OPPS,$430.10 ,pays at 85% of total billed charges,$104.58 ,pays at MCD OPPS,$44.71 ,$480.70 ,$430.10 
Outpatient Medical Services,RADIOLOGY,93880,Study of vessels on both sides of the head and neck,324,$572.00 ,$429.00 ,pays at 75% of total billed charges,$457.60 ,pays at 80% of total billed charges,$231.97 ,pays at MCR OPPS,$453.02 ,pays at 79.2% of total billed charges,$453.02 ,pays at 79.2% of total billed charges,$453.02 ,pays at 79.2% of total billed charges,$453.02 ,pays at 79.2% of total billed charges,$486.20 ,pays at 85% of total billed charges,$221.27 ,pays at MCD O/P rates,$228.80 ,pays at MCR OPPS,$543.40 ,pays at 95% of total billed charges,$457.60 ,pays at 80% total billed charges,$486.20 ,pays at 85% of total billed charges,$514.80 ,pays at 90% of total billed charges,$228.80 ,pays at MCR OPPS,$221.27 ,pays at 100% of MCD OPPS,$233.52 ,pays at 100% of MCD OPPS,$228.80 ,pays at MCR OPPS,$514.80 ,pays at 90% of total billed charges,$434.72 ,pays at 80% of total billed charges,$231.97 ,pays at MCR OPPS,$228.80 ,pays at MCR OPPS,$486.20 ,pays at 85% of total billed charges,$221.27 ,pays at MCD OPPS,$228.80 ,pays at MCR OPPS,$457.60 ,pays at 80% of total billed charges,$225.01 ,pays at 97% of MCR OPPS,$486.20 ,pays at 85% of total billed charges,$221.27 ,pays at MCD OPPS,$221.27 ,$543.40 ,$486.20 
Outpatient Medical Services,RADIOLOGY,93970,Complete bilateral study of the extremities,324,$780.00 ,$585.00 ,pays at 75% of total billed charges,$624.00 ,pays at 80% of total billed charges,$228.98 ,pays at MCR OPPS,$617.76 ,pays at 79.2% of total billed charges,$617.76 ,pays at 79.2% of total billed charges,$617.76 ,pays at 79.2% of total billed charges,$617.76 ,pays at 79.2% of total billed charges,$663.00 ,pays at 85% of total billed charges,$221.27 ,pays at MCD O/P rates,$312.00 ,pays at MCR OPPS,$741.00 ,pays at 95% of total billed charges,$624.00 ,pays at 80% total billed charges,$663.00 ,pays at 85% of total billed charges,$702.00 ,pays at 90% of total billed charges,$312.00 ,pays at MCR OPPS,$221.27 ,pays at 100% of MCD OPPS,$233.52 ,pays at 100% of MCD OPPS,$312.00 ,pays at MCR OPPS,$702.00 ,pays at 90% of total billed charges,$592.80 ,pays at 80% of total billed charges,$228.98 ,pays at MCR OPPS,$312.00 ,pays at MCR OPPS,$663.00 ,pays at 85% of total billed charges,$221.27 ,pays at MCD OPPS,$312.00 ,pays at MCR OPPS,$624.00 ,pays at 80% of total billed charges,$222.11 ,pays at 97% of MCR OPPS,$663.00 ,pays at 85% of total billed charges,$221.27 ,pays at MCD OPPS,$221.27 ,$741.00 ,$663.00 
Outpatient Medical Services,RADIOLOGY,93971,One sided or limited bilateral study,324,$495.00 ,$371.25 ,pays at 75% of total billed charges,$396.00 ,pays at 80% of total billed charges,$145.11 ,pays at MCR OPPS,$392.04 ,pays at 79.2% of total billed charges,$392.04 ,pays at 79.2% of total billed charges,$392.04 ,pays at 79.2% of total billed charges,$392.04 ,pays at 79.2% of total billed charges,$420.75 ,pays at 85% of total billed charges,$145.77 ,pays at MCD O/P rates,$198.00 ,pays at MCR OPPS,$470.25 ,pays at 95% of total billed charges,$396.00 ,pays at 80% total billed charges,$420.75 ,pays at 85% of total billed charges,$445.50 ,pays at 90% of total billed charges,$198.00 ,pays at MCR OPPS,$145.77 ,pays at 100% of MCD OPPS,$106.88 ,pays at 100% of MCD OPPS,$198.00 ,pays at MCR OPPS,$445.50 ,pays at 90% of total billed charges,$376.20 ,pays at 80% of total billed charges,$145.11 ,pays at MCR OPPS,$198.00 ,pays at MCR OPPS,$420.75 ,pays at 85% of total billed charges,$145.77 ,pays at MCD OPPS,$198.00 ,pays at MCR OPPS,$396.00 ,pays at 80% of total billed charges,$140.75 ,pays at 97% of MCR OPPS,$420.75 ,pays at 85% of total billed charges,$145.77 ,pays at MCD OPPS,$106.88 ,$470.25 ,$420.75 
Outpatient Medical Services,RESPIRATORY THERAPY,94640,Pressurized or nonpressurized inhalation treatment for acute airway obstruction for therapeutic purposes and/or for diagnostic purposes such as sputum,410,$89.00 ,$66.75 ,pays at 75% of total billed charges,$71.20 ,pays at 80% of total billed charges,$10.95 ,pays at MCR OPPS,$70.49 ,pays at 79.2% of total billed charges,$70.49 ,pays at 79.2% of total billed charges,$70.49 ,pays at 79.2% of total billed charges,$70.49 ,pays at 79.2% of total billed charges,$75.65 ,pays at 85% of total billed charges,$68.59 ,pays at MCD O/P rates,$35.60 ,pays at MCR OPPS,$84.55 ,pays at 95% of total billed charges,$71.20 ,pays at 80% total billed charges,$75.65 ,pays at 85% of total billed charges,$80.10 ,pays at 90% of total billed charges,$35.60 ,pays at MCR OPPS,$68.59 ,pays at 100% of MCD OPPS,$89.00 ,pays at 100% of MCD OPPS,$35.60 ,pays at MCR OPPS,$80.10 ,pays at 90% of total billed charges,$67.64 ,pays at 80% of total billed charges,$10.95 ,pays at MCR OPPS,$35.60 ,pays at MCR OPPS,$75.65 ,pays at 85% of total billed charges,$68.59 ,pays at MCD OPPS,$35.60 ,pays at MCR OPPS,$71.20 ,pays at 80% of total billed charges,$10.62 ,pays at 97% of MCR OPPS,$75.65 ,pays at 85% of total billed charges,$68.59 ,pays at MCD OPPS,$10.62 ,$89.00 ,$75.65 
Outpatient Medical Services,RESPIRATORY THERAPY,94667,"Manipulation chest wall, such as cupping, percussing, and vibration to facilitate lung function; initial demonstration and/or evaluation",410,$315.00 ,$236.25 ,pays at 75% of total billed charges,$252.00 ,pays at 80% of total billed charges,$28.44 ,pays at MCR OPPS,$249.48 ,pays at 79.2% of total billed charges,$249.48 ,pays at 79.2% of total billed charges,$249.48 ,pays at 79.2% of total billed charges,$249.48 ,pays at 79.2% of total billed charges,$267.75 ,pays at 85% of total billed charges,$68.59 ,pays at MCD O/P rates,$126.00 ,pays at MCR OPPS,$299.25 ,pays at 95% of total billed charges,$252.00 ,pays at 80% total billed charges,$267.75 ,pays at 85% of total billed charges,$283.50 ,pays at 90% of total billed charges,$126.00 ,pays at MCR OPPS,$68.59 ,pays at 100% of MCD OPPS,$116.11 ,pays at 100% of MCD OPPS,$126.00 ,pays at MCR OPPS,$283.50 ,pays at 90% of total billed charges,$239.40 ,pays at 80% of total billed charges,$28.44 ,pays at MCR OPPS,$126.00 ,pays at MCR OPPS,$267.75 ,pays at 85% of total billed charges,$68.59 ,pays at MCD OPPS,$126.00 ,pays at MCR OPPS,$252.00 ,pays at 80% of total billed charges,$27.59 ,pays at 97% of MCR OPPS,$267.75 ,pays at 85% of total billed charges,$68.59 ,pays at MCD OPPS,$27.59 ,$299.25 ,$267.75 
Outpatient Medical Services,RESPIRATORY THERAPY,94668,"Manipulation chest wall, such as cupping, percussing, and vibration to facilitate lung function; subsequent",410,$315.00 ,$236.25 ,pays at 75% of total billed charges,$252.00 ,pays at 80% of total billed charges,$44.40 ,pays at MCR OPPS,$249.48 ,pays at 79.2% of total billed charges,$249.48 ,pays at 79.2% of total billed charges,$249.48 ,pays at 79.2% of total billed charges,$249.48 ,pays at 79.2% of total billed charges,$267.75 ,pays at 85% of total billed charges,$68.59 ,pays at MCD O/P rates,$126.00 ,pays at MCR OPPS,$299.25 ,pays at 95% of total billed charges,$252.00 ,pays at 80% total billed charges,$267.75 ,pays at 85% of total billed charges,$283.50 ,pays at 90% of total billed charges,$126.00 ,pays at MCR OPPS,$68.59 ,pays at 100% of MCD OPPS,$116.11 ,pays at 100% of MCD OPPS,$126.00 ,pays at MCR OPPS,$283.50 ,pays at 90% of total billed charges,$239.40 ,pays at 80% of total billed charges,$44.40 ,pays at MCR OPPS,$126.00 ,pays at MCR OPPS,$267.75 ,pays at 85% of total billed charges,$68.59 ,pays at MCD OPPS,$126.00 ,pays at MCR OPPS,$252.00 ,pays at 80% of total billed charges,$43.07 ,pays at 97% of MCR OPPS,$267.75 ,pays at 85% of total billed charges,$68.59 ,pays at MCD OPPS,$43.07 ,$299.25 ,$267.75 
Outpatient Medical Services,VACCINE ADMIN,90471,Immunization administration by a medical assistant or nurse,771,$40.00 ,$30.00 ,pays at 75% of total billed charges,$32.00 ,pays at 80% of total billed charges,$24.15 ,pays at MCR OPPS,$31.68 ,pays at 79.2% of total billed charges,$31.68 ,pays at 79.2% of total billed charges,$31.68 ,pays at 79.2% of total billed charges,$31.68 ,pays at 79.2% of total billed charges,$34.00 ,pays at 85% of total billed charges,$40.00 ,pays at MCD O/P rates,$16.00 ,pays at MCR OPPS,$38.00 ,pays at 95% of total billed charges,$32.00 ,pays at 80% total billed charges,$34.00 ,pays at 85% of total billed charges,$36.00 ,pays at 90% of total billed charges,$16.00 ,pays at MCR OPPS,$50.67 ,pays at 100% of MCD OPPS,$40.00 ,pays at 100% of MCD OPPS,$16.00 ,pays at MCR OPPS,$36.00 ,pays at 90% of total billed charges,$30.40 ,pays at 80% of total billed charges,$24.15 ,pays at MCR OPPS,$16.00 ,pays at MCR OPPS,$34.00 ,pays at 85% of total billed charges,$50.67 ,pays at MCD OPPS,$16.00 ,pays at MCR OPPS,$32.00 ,pays at 80% of total billed charges,$23.43 ,pays at 97% of MCR OPPS,$34.00 ,pays at 85% of total billed charges,$50.67 ,pays at MCD OPPS,$16.00 ,$50.67 ,$34.00 
Outpatient Medical Services,VACCINE ADMIN,90472,"Immunization Administration (Includes Percutaneous, Intradermal, Subcutaneous, Or Intramuscular Injections); Each Additional Vaccine (Single Or Combin",771,$40.00 ,$30.00 ,pays at 75% of total billed charges,$32.00 ,pays at 80% of total billed charges,$17.23 ,pays at MCR OPPS,$31.68 ,pays at 79.2% of total billed charges,$31.68 ,pays at 79.2% of total billed charges,$31.68 ,pays at 79.2% of total billed charges,$31.68 ,pays at 79.2% of total billed charges,$34.00 ,pays at 85% of total billed charges,$40.00 ,pays at MCD O/P rates,$16.00 ,pays at MCR OPPS,$38.00 ,pays at 95% of total billed charges,$32.00 ,pays at 80% total billed charges,$34.00 ,pays at 85% of total billed charges,$36.00 ,pays at 90% of total billed charges,$16.00 ,pays at MCR OPPS,$50.67 ,pays at 100% of MCD OPPS,$40.00 ,pays at 100% of MCD OPPS,$16.00 ,pays at MCR OPPS,$36.00 ,pays at 90% of total billed charges,$30.40 ,pays at 80% of total billed charges,$17.23 ,pays at MCR OPPS,$16.00 ,pays at MCR OPPS,$34.00 ,pays at 85% of total billed charges,$50.67 ,pays at MCD OPPS,$16.00 ,pays at MCR OPPS,$32.00 ,pays at 80% of total billed charges,$16.71 ,pays at 97% of MCR OPPS,$34.00 ,pays at 85% of total billed charges,$50.67 ,pays at MCD OPPS,$16.00 ,$50.67 ,$34.00 
Outpatient Medical Services,VACCINE ADMIN,90474,Immunization administered orally or nasally,771,$21.00 ,$15.75 ,pays at 75% of total billed charges,$16.80 ,pays at 80% of total billed charges,$13.95 ,pays at MCR OPPS,$16.63 ,pays at 79.2% of total billed charges,$16.63 ,pays at 79.2% of total billed charges,$16.63 ,pays at 79.2% of total billed charges,$16.63 ,pays at 79.2% of total billed charges,$17.85 ,pays at 85% of total billed charges,$21.00 ,pays at MCD O/P rates,$8.40 ,pays at MCR OPPS,$19.95 ,pays at 95% of total billed charges,$16.80 ,pays at 80% total billed charges,$17.85 ,pays at 85% of total billed charges,$18.90 ,pays at 90% of total billed charges,$8.40 ,pays at MCR OPPS,$50.67 ,pays at 100% of MCD OPPS,$21.00 ,pays at 100% of MCD OPPS,$8.40 ,pays at MCR OPPS,$18.90 ,pays at 90% of total billed charges,$15.96 ,pays at 80% of total billed charges,$13.95 ,pays at MCR OPPS,$8.40 ,pays at MCR OPPS,$17.85 ,pays at 85% of total billed charges,$50.67 ,pays at MCD OPPS,$8.40 ,pays at MCR OPPS,$16.80 ,pays at 80% of total billed charges,$13.53 ,pays at 97% of MCR OPPS,$17.85 ,pays at 85% of total billed charges,$50.67 ,pays at MCD OPPS,$8.40 ,$50.67 ,$17.85 
Outpatient Medical Services,VACCINE ADMIN,90633,Hepatitis A vaccination for adolescents and children,771,$74.00 ,$55.50 ,pays at 75% of total billed charges,$59.20 ,pays at 80% of total billed charges,N/A,not reimburseable per contract,$58.61 ,pays at 79.2% of total billed charges,$58.61 ,pays at 79.2% of total billed charges,$58.61 ,pays at 79.2% of total billed charges,$58.61 ,pays at 79.2% of total billed charges,$62.90 ,pays at 85% of total billed charges,$35.65 ,pays at MCD O/P rates,$29.60 ,pays at MCR OPPS,$70.30 ,pays at 95% of total billed charges,$59.20 ,pays at 80% total billed charges,$62.90 ,pays at 85% of total billed charges,$66.60 ,pays at 90% of total billed charges,$29.60 ,pays at MCR OPPS,$35.65 ,pays at 100% of MCD OPPS,$74.00 ,pays at 100% of MCD OPPS,$29.60 ,pays at MCR OPPS,$66.60 ,pays at 90% of total billed charges,$56.24 ,pays at 80% of total billed charges,N/A,not reimburseable per contract,$29.60 ,pays at MCR OPPS,$62.90 ,pays at 85% of total billed charges,$35.65 ,pays at MCD OPPS,$29.60 ,pays at MCR OPPS,$59.20 ,pays at 80% of total billed charges,N/A,not reimburseable per contract,$62.90 ,pays at 85% of total billed charges,$35.65 ,pays at MCD OPPS,$29.60 ,$74.00 ,$62.90 
Outpatient Medical Services,VACCINE ADMIN,90651,"Human Papillomavirus Vaccine Types 6, 11, 16, 18, 31, 33, 45, 52, 58, Nonavalent (Hpv), 3 Dose Schedule, For Intramuscular Use",771,$474.00 ,$355.50 ,pays at 75% of total billed charges,$379.20 ,pays at 80% of total billed charges,N/A,not reimburseable per contract,$375.41 ,pays at 79.2% of total billed charges,$375.41 ,pays at 79.2% of total billed charges,$375.41 ,pays at 79.2% of total billed charges,$375.41 ,pays at 79.2% of total billed charges,$402.90 ,pays at 85% of total billed charges,$144.61 ,pays at MCD O/P rates,$189.60 ,pays at MCR OPPS,$450.30 ,pays at 95% of total billed charges,$379.20 ,pays at 80% total billed charges,$402.90 ,pays at 85% of total billed charges,$426.60 ,pays at 90% of total billed charges,$189.60 ,pays at MCR OPPS,$144.61 ,pays at 100% of MCD OPPS,$176.95 ,pays at 100% of MCD OPPS,$189.60 ,pays at MCR OPPS,$426.60 ,pays at 90% of total billed charges,$360.24 ,pays at 80% of total billed charges,N/A,not reimburseable per contract,$189.60 ,pays at MCR OPPS,$402.90 ,pays at 85% of total billed charges,$144.61 ,pays at MCD OPPS,$189.60 ,pays at MCR OPPS,$379.20 ,pays at 80% of total billed charges,N/A,not reimburseable per contract,$402.90 ,pays at 85% of total billed charges,$144.61 ,pays at MCD OPPS,$144.61 ,$450.30 ,$402.90 
Outpatient Medical Services,VACCINE ADMIN,90654,"Influenza Virus Vaccine, Split Virus, Preservative-Free, For Intradermal Use",771,$65.00 ,$48.75 ,pays at 75% of total billed charges,$52.00 ,pays at 80% of total billed charges,N/A,not reimburseable per contract,$51.48 ,pays at 79.2% of total billed charges,$51.48 ,pays at 79.2% of total billed charges,$51.48 ,pays at 79.2% of total billed charges,$51.48 ,pays at 79.2% of total billed charges,$55.25 ,pays at 85% of total billed charges,$35.65 ,pays at MCD O/P rates,$26.00 ,pays at MCR OPPS,$61.75 ,pays at 95% of total billed charges,$52.00 ,pays at 80% total billed charges,$55.25 ,pays at 85% of total billed charges,$58.50 ,pays at 90% of total billed charges,$26.00 ,pays at MCR OPPS,$35.65 ,pays at 100% of MCD OPPS,$65.00 ,pays at 100% of MCD OPPS,$26.00 ,pays at MCR OPPS,$58.50 ,pays at 90% of total billed charges,$49.40 ,pays at 80% of total billed charges,N/A,not reimburseable per contract,$26.00 ,pays at MCR OPPS,$55.25 ,pays at 85% of total billed charges,$35.65 ,pays at MCD OPPS,$26.00 ,pays at MCR OPPS,$52.00 ,pays at 80% of total billed charges,N/A,not reimburseable per contract,$55.25 ,pays at 85% of total billed charges,$35.65 ,pays at MCD OPPS,$26.00 ,$65.00 ,$55.25 
Outpatient Medical Services,VACCINE ADMIN,90670,"Pneumococcal Conjugate Vaccine, 13 Valent, For Intramuscular Use",771,$292.00 ,$219.00 ,pays at 75% of total billed charges,$233.60 ,pays at 80% of total billed charges,N/A,not reimburseable per contract,$231.26 ,pays at 79.2% of total billed charges,$231.26 ,pays at 79.2% of total billed charges,$231.26 ,pays at 79.2% of total billed charges,$231.26 ,pays at 79.2% of total billed charges,$248.20 ,pays at 85% of total billed charges,$144.61 ,pays at MCD O/P rates,$116.80 ,pays at MCR OPPS,$277.40 ,pays at 95% of total billed charges,$233.60 ,pays at 80% total billed charges,$248.20 ,pays at 85% of total billed charges,$262.80 ,pays at 90% of total billed charges,$116.80 ,pays at MCR OPPS,$144.61 ,pays at 100% of MCD OPPS,$292.00 ,pays at 100% of MCD OPPS,$116.80 ,pays at MCR OPPS,$262.80 ,pays at 90% of total billed charges,$221.92 ,pays at 80% of total billed charges,N/A,not reimburseable per contract,$116.80 ,pays at MCR OPPS,$248.20 ,pays at 85% of total billed charges,$144.61 ,pays at MCD OPPS,$116.80 ,pays at MCR OPPS,$233.60 ,pays at 80% of total billed charges,N/A,not reimburseable per contract,$248.20 ,pays at 85% of total billed charges,$144.61 ,pays at MCD OPPS,$116.80 ,$292.00 ,$248.20 
Outpatient Medical Services,VACCINE ADMIN,90680,"Rotavirus Vaccine, Pentavalent, 3 Dose Schedule, Live, For Oral Use",771,$187.00 ,$140.25 ,pays at 75% of total billed charges,$149.60 ,pays at 80% of total billed charges,N/A,not reimburseable per contract,$148.10 ,pays at 79.2% of total billed charges,$148.10 ,pays at 79.2% of total billed charges,$148.10 ,pays at 79.2% of total billed charges,$148.10 ,pays at 79.2% of total billed charges,$158.95 ,pays at 85% of total billed charges,$144.61 ,pays at MCD O/P rates,$74.80 ,pays at MCR OPPS,$177.65 ,pays at 95% of total billed charges,$149.60 ,pays at 80% total billed charges,$158.95 ,pays at 85% of total billed charges,$168.30 ,pays at 90% of total billed charges,$74.80 ,pays at MCR OPPS,$144.61 ,pays at 100% of MCD OPPS,$187.00 ,pays at 100% of MCD OPPS,$74.80 ,pays at MCR OPPS,$168.30 ,pays at 90% of total billed charges,$142.12 ,pays at 80% of total billed charges,N/A,not reimburseable per contract,$74.80 ,pays at MCR OPPS,$158.95 ,pays at 85% of total billed charges,$144.61 ,pays at MCD OPPS,$74.80 ,pays at MCR OPPS,$149.60 ,pays at 80% of total billed charges,N/A,not reimburseable per contract,$158.95 ,pays at 85% of total billed charges,$144.61 ,pays at MCD OPPS,$74.80 ,$187.00 ,$158.95 
Outpatient Medical Services,VACCINE ADMIN,90686,Flu shot-high dose for 2019-2020 flu season given by injection for people >65,771,$40.00 ,$30.00 ,pays at 75% of total billed charges,$32.00 ,pays at 80% of total billed charges,N/A,not reimburseable per contract,$31.68 ,pays at 79.2% of total billed charges,$31.68 ,pays at 79.2% of total billed charges,$31.68 ,pays at 79.2% of total billed charges,$31.68 ,pays at 79.2% of total billed charges,$34.00 ,pays at 85% of total billed charges,$35.65 ,pays at MCD O/P rates,$16.00 ,pays at MCR OPPS,$38.00 ,pays at 95% of total billed charges,$32.00 ,pays at 80% total billed charges,$34.00 ,pays at 85% of total billed charges,$36.00 ,pays at 90% of total billed charges,$16.00 ,pays at MCR OPPS,$35.65 ,pays at 100% of MCD OPPS,$40.00 ,pays at 100% of MCD OPPS,$16.00 ,pays at MCR OPPS,$36.00 ,pays at 90% of total billed charges,$30.40 ,pays at 80% of total billed charges,N/A,not reimburseable per contract,$16.00 ,pays at MCR OPPS,$34.00 ,pays at 85% of total billed charges,$35.65 ,pays at MCD OPPS,$16.00 ,pays at MCR OPPS,$32.00 ,pays at 80% of total billed charges,N/A,not reimburseable per contract,$34.00 ,pays at 85% of total billed charges,$35.65 ,pays at MCD OPPS,$16.00 ,$40.00 ,$34.00 
Outpatient Medical Services,VACCINE ADMIN,90694,"Influenza virus vaccine, quadrivalent (aIIV4), inactivated, adjuvanted, preservative free, 0.5 mL dosage, for intramuscular use",771,$65.00 ,$48.75 ,pays at 75% of total billed charges,$52.00 ,pays at 80% of total billed charges,N/A,not reimburseable per contract,$51.48 ,pays at 79.2% of total billed charges,$51.48 ,pays at 79.2% of total billed charges,$51.48 ,pays at 79.2% of total billed charges,$51.48 ,pays at 79.2% of total billed charges,$55.25 ,pays at 85% of total billed charges,$35.65 ,pays at MCD O/P rates,$26.00 ,pays at MCR OPPS,$61.75 ,pays at 95% of total billed charges,$52.00 ,pays at 80% total billed charges,$55.25 ,pays at 85% of total billed charges,$58.50 ,pays at 90% of total billed charges,$26.00 ,pays at MCR OPPS,$35.65 ,pays at 100% of MCD OPPS,$65.00 ,pays at 100% of MCD OPPS,$26.00 ,pays at MCR OPPS,$58.50 ,pays at 90% of total billed charges,$49.40 ,pays at 80% of total billed charges,N/A,not reimburseable per contract,$26.00 ,pays at MCR OPPS,$55.25 ,pays at 85% of total billed charges,$35.65 ,pays at MCD OPPS,$26.00 ,pays at MCR OPPS,$52.00 ,pays at 80% of total billed charges,N/A,not reimburseable per contract,$55.25 ,pays at 85% of total billed charges,$35.65 ,pays at MCD OPPS,$26.00 ,$65.00 ,$55.25 
Outpatient Medical Services,VACCINE ADMIN,90698,"Diphtheria, Tetanus Toxoids, Acellular Pertussis Vaccine, Haemophilus Influenza Type B, And Poliovirus Vaccine, Inactivated (Dtap - Hib - Ipv), For In",771,$192.00 ,$144.00 ,pays at 75% of total billed charges,$153.60 ,pays at 80% of total billed charges,N/A,not reimburseable per contract,$152.06 ,pays at 79.2% of total billed charges,$152.06 ,pays at 79.2% of total billed charges,$152.06 ,pays at 79.2% of total billed charges,$152.06 ,pays at 79.2% of total billed charges,$163.20 ,pays at 85% of total billed charges,$35.65 ,pays at MCD O/P rates,$76.80 ,pays at MCR OPPS,$182.40 ,pays at 95% of total billed charges,$153.60 ,pays at 80% total billed charges,$163.20 ,pays at 85% of total billed charges,$172.80 ,pays at 90% of total billed charges,$76.80 ,pays at MCR OPPS,$35.65 ,pays at 100% of MCD OPPS,$192.00 ,pays at 100% of MCD OPPS,$76.80 ,pays at MCR OPPS,$172.80 ,pays at 90% of total billed charges,$145.92 ,pays at 80% of total billed charges,N/A,not reimburseable per contract,$76.80 ,pays at MCR OPPS,$163.20 ,pays at 85% of total billed charges,$35.65 ,pays at MCD OPPS,$76.80 ,pays at MCR OPPS,$153.60 ,pays at 80% of total billed charges,N/A,not reimburseable per contract,$163.20 ,pays at 85% of total billed charges,$35.65 ,pays at MCD OPPS,$35.65 ,$192.00 ,$163.20 
Outpatient Medical Services,VACCINE ADMIN,90710,"measlesMeasles, mumps, rubella and varicella vaccine",771,$344.00 ,$258.00 ,pays at 75% of total billed charges,$275.20 ,pays at 80% of total billed charges,N/A,not reimburseable per contract,$272.45 ,pays at 79.2% of total billed charges,$272.45 ,pays at 79.2% of total billed charges,$272.45 ,pays at 79.2% of total billed charges,$272.45 ,pays at 79.2% of total billed charges,$292.40 ,pays at 85% of total billed charges,$35.65 ,pays at MCD O/P rates,$137.60 ,pays at MCR OPPS,$326.80 ,pays at 95% of total billed charges,$275.20 ,pays at 80% total billed charges,$292.40 ,pays at 85% of total billed charges,$309.60 ,pays at 90% of total billed charges,$137.60 ,pays at MCR OPPS,$35.65 ,pays at 100% of MCD OPPS,$344.00 ,pays at 100% of MCD OPPS,$137.60 ,pays at MCR OPPS,$309.60 ,pays at 90% of total billed charges,$261.44 ,pays at 80% of total billed charges,N/A,not reimburseable per contract,$137.60 ,pays at MCR OPPS,$292.40 ,pays at 85% of total billed charges,$35.65 ,pays at MCD OPPS,$137.60 ,pays at MCR OPPS,$275.20 ,pays at 80% of total billed charges,N/A,not reimburseable per contract,$292.40 ,pays at 85% of total billed charges,$35.65 ,pays at MCD OPPS,$35.65 ,$344.00 ,$292.40 
Outpatient Medical Services,VACCINE ADMIN,90715,"Diphtheria, tetanus acellular, and pertussis vaccine for adults",771,$86.00 ,$64.50 ,pays at 75% of total billed charges,$68.80 ,pays at 80% of total billed charges,N/A,not reimburseable per contract,$68.11 ,pays at 79.2% of total billed charges,$68.11 ,pays at 79.2% of total billed charges,$68.11 ,pays at 79.2% of total billed charges,$68.11 ,pays at 79.2% of total billed charges,$73.10 ,pays at 85% of total billed charges,$35.65 ,pays at MCD O/P rates,$34.40 ,pays at MCR OPPS,$81.70 ,pays at 95% of total billed charges,$68.80 ,pays at 80% total billed charges,$73.10 ,pays at 85% of total billed charges,$77.40 ,pays at 90% of total billed charges,$34.40 ,pays at MCR OPPS,$35.65 ,pays at 100% of MCD OPPS,$86.00 ,pays at 100% of MCD OPPS,$34.40 ,pays at MCR OPPS,$77.40 ,pays at 90% of total billed charges,$65.36 ,pays at 80% of total billed charges,N/A,not reimburseable per contract,$34.40 ,pays at MCR OPPS,$73.10 ,pays at 85% of total billed charges,$35.65 ,pays at MCD OPPS,$34.40 ,pays at MCR OPPS,$68.80 ,pays at 80% of total billed charges,N/A,not reimburseable per contract,$73.10 ,pays at 85% of total billed charges,$35.65 ,pays at MCD OPPS,$34.40 ,$86.00 ,$73.10 
Outpatient Medical Services,VACCINE ADMIN,90732,pneumococcal Pneumococcal vaccine,771,$132.00 ,$99.00 ,pays at 75% of total billed charges,$105.60 ,pays at 80% of total billed charges,N/A,not reimburseable per contract,$104.54 ,pays at 79.2% of total billed charges,$104.54 ,pays at 79.2% of total billed charges,$104.54 ,pays at 79.2% of total billed charges,$104.54 ,pays at 79.2% of total billed charges,$112.20 ,pays at 85% of total billed charges,$35.65 ,pays at MCD O/P rates,$52.80 ,pays at MCR OPPS,$125.40 ,pays at 95% of total billed charges,$105.60 ,pays at 80% total billed charges,$112.20 ,pays at 85% of total billed charges,$118.80 ,pays at 90% of total billed charges,$52.80 ,pays at MCR OPPS,$35.65 ,pays at 100% of MCD OPPS,$132.00 ,pays at 100% of MCD OPPS,$52.80 ,pays at MCR OPPS,$118.80 ,pays at 90% of total billed charges,$100.32 ,pays at 80% of total billed charges,N/A,not reimburseable per contract,$52.80 ,pays at MCR OPPS,$112.20 ,pays at 85% of total billed charges,$35.65 ,pays at MCD OPPS,$52.80 ,pays at MCR OPPS,$105.60 ,pays at 80% of total billed charges,N/A,not reimburseable per contract,$112.20 ,pays at 85% of total billed charges,$35.65 ,pays at MCD OPPS,$35.65 ,$132.00 ,$112.20 
Outpatient Medical Services,VACCINE ADMIN,90734,meningococcal Meningococcal conjugate vaccine,771,$271.00 ,$203.25 ,pays at 75% of total billed charges,$216.80 ,pays at 80% of total billed charges,N/A,not reimburseable per contract,$214.63 ,pays at 79.2% of total billed charges,$214.63 ,pays at 79.2% of total billed charges,$214.63 ,pays at 79.2% of total billed charges,$214.63 ,pays at 79.2% of total billed charges,$230.35 ,pays at 85% of total billed charges,$144.61 ,pays at MCD O/P rates,$108.40 ,pays at MCR OPPS,$257.45 ,pays at 95% of total billed charges,$216.80 ,pays at 80% total billed charges,$230.35 ,pays at 85% of total billed charges,$243.90 ,pays at 90% of total billed charges,$108.40 ,pays at MCR OPPS,$144.61 ,pays at 100% of MCD OPPS,$271.00 ,pays at 100% of MCD OPPS,$108.40 ,pays at MCR OPPS,$243.90 ,pays at 90% of total billed charges,$205.96 ,pays at 80% of total billed charges,N/A,not reimburseable per contract,$108.40 ,pays at MCR OPPS,$230.35 ,pays at 85% of total billed charges,$144.61 ,pays at MCD OPPS,$108.40 ,pays at MCR OPPS,$216.80 ,pays at 80% of total billed charges,N/A,not reimburseable per contract,$230.35 ,pays at 85% of total billed charges,$144.61 ,pays at MCD OPPS,$108.40 ,$271.00 ,$230.35 
Outpatient Medical Services,VACCINE ADMIN,90744,"Hepatitis B Vaccine, Pediatric/Adolescent Dosage (3 Dose Schedule), For Intramuscular Use",771,$31.00 ,$23.25 ,pays at 75% of total billed charges,$24.80 ,pays at 80% of total billed charges,N/A,not reimburseable per contract,$24.55 ,pays at 79.2% of total billed charges,$24.55 ,pays at 79.2% of total billed charges,$24.55 ,pays at 79.2% of total billed charges,$24.55 ,pays at 79.2% of total billed charges,$26.35 ,pays at 85% of total billed charges,$31.00 ,pays at MCD O/P rates,$12.40 ,pays at MCR OPPS,$29.45 ,pays at 95% of total billed charges,$24.80 ,pays at 80% total billed charges,$26.35 ,pays at 85% of total billed charges,$27.90 ,pays at 90% of total billed charges,$12.40 ,pays at MCR OPPS,$35.65 ,pays at 100% of MCD OPPS,$31.00 ,pays at 100% of MCD OPPS,$12.40 ,pays at MCR OPPS,$27.90 ,pays at 90% of total billed charges,$23.56 ,pays at 80% of total billed charges,N/A,not reimburseable per contract,$12.40 ,pays at MCR OPPS,$26.35 ,pays at 85% of total billed charges,$35.65 ,pays at MCD OPPS,$12.40 ,pays at MCR OPPS,$24.80 ,pays at 80% of total billed charges,N/A,not reimburseable per contract,$26.35 ,pays at 85% of total billed charges,$35.65 ,pays at MCD OPPS,$12.40 ,$35.65 ,$26.35 
Physician Medical Services,EVALUATION & MGMT PROFESSIONAL,99212,Outpatient visit of established patient requiring a physician,960,$105.10 ,$78.83 ,75% of charges,$78.83 ,75% of charges,$41.14 ,40% of charges which is 100% of the Medicare rate,$83.24 ,79.2% of total billed charges,$83.24 ,79.2% of total billed charges,$83.24 ,79.2% of total billed charges,$83.24 ,79.2% of total billed charges,$89.34 ,85% of total billed charges,N/A,Not separately reimbursable,$41.14 ,40% of charges which is 100% of the Medicare rate,$99.85 ,95% of total billed charges,$84.08 ,80% of total billed charges,$89.34 ,85% of total billed charges,$94.59 ,90% of total billed charges,$41.14 ,40% of charges which is 100% of the Medicare rate,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$41.14 ,40% of charges which is 100% of the Medicare rate,$94.59 ,90% of total billed charges,$79.88 ,76% of total billed charges,$41.14 ,40% of charges which is 100% of the Medicare rate,$41.14 ,40% of charges which is 100% of the Medicare rate,$89.34 ,85% of total billed charges,N/A,Not separately reimbursable,$41.14 ,40% of charges which is 100% of the Medicare rate,$84.08 ,80% of total billed charges,$39.90 ,38.8% of charges which is 100% of the Medicare rate,$89.34 ,85% of total billed charges,N/A,Not separately reimbursable,$39.90 ,$94.59 ,
Physician Medical Services,EVALUATION & MGMT PROFESSIONAL,99213,"Established patient office or other outpatient visit, typically 15 minutes",960,$139.10 ,$104.33 ,75% of charges,$104.33 ,75% of charges,$76.52 ,115% CMS RBRVS fee schedule,$110.17 ,79.2% of total billed charges,$110.17 ,79.2% of total billed charges,$110.17 ,79.2% of total billed charges,$110.17 ,79.2% of total billed charges,$118.24 ,85% of total billed charges,N/A,Not separately reimbursable,$76.52 ,115% CMS RBRVS fee schedule,$132.15 ,95% of total billed charges,$111.28 ,80% of total billed charges,$118.24 ,85% of total billed charges,$125.19 ,90% of total billed charges,$76.52 ,115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$76.52 ,115% CMS RBRVS fee schedule,$125.19 ,90% of total billed charges,$105.72 ,76% of total billed charges,$76.52 ,115% CMS RBRVS fee schedule,$76.52 ,115% CMS RBRVS fee schedule,$118.24 ,85% of total billed charges,N/A,Not separately reimbursable,$76.52 ,115% CMS RBRVS fee schedule,$111.28 ,80% of total billed charges,$74.23 ,111.55% CMS RBRVS fee schedule,$118.24 ,85% of total billed charges,N/A,Not separately reimbursable,$74.23 ,$125.19 ,
Physician Medical Services,EVALUATION & MGMT PROFESSIONAL,99214,"Established patient office or other outpatient visit, typically 25 minutes",960,$196.70 ,$147.53 ,75% of charges,$147.53 ,75% of charges,$113.09 ,115% CMS RBRVS fee schedule,$155.79 ,79.2% of total billed charges,$155.79 ,79.2% of total billed charges,$155.79 ,79.2% of total billed charges,$155.79 ,79.2% of total billed charges,$167.20 ,85% of total billed charges,N/A,Not separately reimbursable,$113.09 ,115% CMS RBRVS fee schedule,$186.87 ,95% of total billed charges,$157.36 ,80% of total billed charges,$167.20 ,85% of total billed charges,$177.03 ,90% of total billed charges,$113.09 ,115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$113.09 ,115% CMS RBRVS fee schedule,$177.03 ,90% of total billed charges,$149.49 ,76% of total billed charges,$113.09 ,115% CMS RBRVS fee schedule,$113.09 ,115% CMS RBRVS fee schedule,$167.20 ,85% of total billed charges,N/A,Not separately reimbursable,$113.09 ,115% CMS RBRVS fee schedule,$157.36 ,80% of total billed charges,$109.70 ,111.55% CMS RBRVS fee schedule,$167.20 ,85% of total billed charges,N/A,Not separately reimbursable,$109.70 ,$177.03 ,
Physician Medical Services,EVALUATION & MGMT PROFESSIONAL,99215,"Established patient office or other outpatient, visit typically 40 minutes",960,$284.30 ,$213.23 ,75% of charges,$213.23 ,75% of charges,$166.20 ,115% CMS RBRVS fee schedule,$225.17 ,79.2% of total billed charges,$225.17 ,79.2% of total billed charges,$225.17 ,79.2% of total billed charges,$225.17 ,79.2% of total billed charges,$241.66 ,85% of total billed charges,N/A,Not separately reimbursable,$166.20 ,115% CMS RBRVS fee schedule,$270.09 ,95% of total billed charges,$227.44 ,80% of total billed charges,$241.66 ,85% of total billed charges,$255.87 ,90% of total billed charges,$166.20 ,115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$166.20 ,115% CMS RBRVS fee schedule,$255.87 ,90% of total billed charges,$216.07 ,76% of total billed charges,$166.20 ,115% CMS RBRVS fee schedule,$166.20 ,115% CMS RBRVS fee schedule,$241.66 ,85% of total billed charges,N/A,Not separately reimbursable,$166.20 ,115% CMS RBRVS fee schedule,$227.44 ,80% of total billed charges,$161.21 ,111.55% CMS RBRVS fee schedule,$241.66 ,85% of total billed charges,N/A,Not separately reimbursable,$161.21 ,$255.87 ,
Physician Medical Services,EVALUATION & MGMT PROFESSIONAL,99243,"Patient office consultation, typically 40 min",960,$239.00 ,$179.25 ,75% of charges,$179.25 ,75% of charges,$102.96 ,115% CMS RBRVS fee schedule,$189.29 ,79.2% of total billed charges,$189.29 ,79.2% of total billed charges,$189.29 ,79.2% of total billed charges,$189.29 ,79.2% of total billed charges,$203.15 ,85% of total billed charges,N/A,Not separately reimbursable,$102.96 ,115% CMS RBRVS fee schedule,$227.05 ,95% of total billed charges,$191.20 ,80% of total billed charges,$203.15 ,85% of total billed charges,$215.10 ,90% of total billed charges,$102.96 ,115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$102.96 ,115% CMS RBRVS fee schedule,$215.10 ,90% of total billed charges,$181.64 ,76% of total billed charges,$102.96 ,115% CMS RBRVS fee schedule,$102.96 ,115% CMS RBRVS fee schedule,$203.15 ,85% of total billed charges,N/A,Not separately reimbursable,$102.96 ,115% CMS RBRVS fee schedule,$191.20 ,80% of total billed charges,$99.87 ,111.55% CMS RBRVS fee schedule,$203.15 ,85% of total billed charges,N/A,Not separately reimbursable,$99.87 ,$215.10 ,
Physician Medical Services,EVALUATION & MGMT PROFESSIONAL,99244,"Patient office consultation, typically 60 min",960,$339.90 ,$254.93 ,75% of charges,$254.93 ,75% of charges,$157.27 ,115% CMS RBRVS fee schedule,$269.20 ,79.2% of total billed charges,$269.20 ,79.2% of total billed charges,$269.20 ,79.2% of total billed charges,$269.20 ,79.2% of total billed charges,$288.92 ,85% of total billed charges,N/A,Not separately reimbursable,$157.27 ,115% CMS RBRVS fee schedule,$322.91 ,95% of total billed charges,$271.92 ,80% of total billed charges,$288.92 ,85% of total billed charges,$305.91 ,90% of total billed charges,$157.27 ,115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$157.27 ,115% CMS RBRVS fee schedule,$305.91 ,90% of total billed charges,$258.32 ,76% of total billed charges,$157.27 ,115% CMS RBRVS fee schedule,$157.27 ,115% CMS RBRVS fee schedule,$288.92 ,85% of total billed charges,N/A,Not separately reimbursable,$157.27 ,115% CMS RBRVS fee schedule,$271.92 ,80% of total billed charges,$152.56 ,111.55% CMS RBRVS fee schedule,$288.92 ,85% of total billed charges,N/A,Not separately reimbursable,$152.56 ,$305.91 ,
Physician Medical Services,EVALUATION & MGMT PROFESSIONAL,99381,Initial visit for an infant,960,$270.90 ,$203.18 ,75% of charges,$203.18 ,75% of charges,$85.58 ,115% CMS RBRVS fee schedule,$214.55 ,79.2% of total billed charges,$214.55 ,79.2% of total billed charges,$214.55 ,79.2% of total billed charges,$214.55 ,79.2% of total billed charges,$230.27 ,85% of total billed charges,N/A,Not separately reimbursable,$85.58 ,115% CMS RBRVS fee schedule,$257.36 ,95% of total billed charges,$216.72 ,80% of total billed charges,$230.27 ,85% of total billed charges,$243.81 ,90% of total billed charges,$85.58 ,115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$85.58 ,115% CMS RBRVS fee schedule,$243.81 ,90% of total billed charges,$205.88 ,76% of total billed charges,$85.58 ,115% CMS RBRVS fee schedule,$85.58 ,115% CMS RBRVS fee schedule,$230.27 ,85% of total billed charges,N/A,Not separately reimbursable,$85.58 ,115% CMS RBRVS fee schedule,$216.72 ,80% of total billed charges,$83.02 ,111.55% CMS RBRVS fee schedule,$230.27 ,85% of total billed charges,N/A,Not separately reimbursable,$83.02 ,$243.81 ,
Physician Medical Services,EVALUATION & MGMT PROFESSIONAL,99385,Initial new patient preventive medicine evaluation (18?39 years),960,$270.90 ,$203.18 ,75% of charges,$203.18 ,75% of charges,$109.20 ,40% of charges which is 100% of the Medicare rate,$214.55 ,79.2% of total billed charges,$214.55 ,79.2% of total billed charges,$214.55 ,79.2% of total billed charges,$214.55 ,79.2% of total billed charges,$230.27 ,85% of total billed charges,N/A,Not separately reimbursable,$109.20 ,40% of charges which is 100% of the Medicare rate,$257.36 ,95% of total billed charges,$216.72 ,80% of total billed charges,$230.27 ,85% of total billed charges,$243.81 ,90% of total billed charges,$109.20 ,40% of charges which is 100% of the Medicare rate,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$109.20 ,40% of charges which is 100% of the Medicare rate,$243.81 ,90% of total billed charges,$205.88 ,76% of total billed charges,$109.20 ,40% of charges which is 100% of the Medicare rate,$109.20 ,40% of charges which is 100% of the Medicare rate,$230.27 ,85% of total billed charges,N/A,Not separately reimbursable,$109.20 ,40% of charges which is 100% of the Medicare rate,$216.72 ,80% of total billed charges,$105.93 ,38.8% of charges which is 100% of the Medicare rate,$230.27 ,85% of total billed charges,N/A,Not separately reimbursable,$105.93 ,$243.81 ,
Physician Medical Services,EVALUATION & MGMT PROFESSIONAL,99386,Initial new patient preventive medicine evaluation (40?64 years),960,$270.90 ,$203.18 ,75% of charges,$203.18 ,75% of charges,$132.42 ,115% CMS RBRVS fee schedule,$214.55 ,79.2% of total billed charges,$214.55 ,79.2% of total billed charges,$214.55 ,79.2% of total billed charges,$214.55 ,79.2% of total billed charges,$230.27 ,85% of total billed charges,N/A,Not separately reimbursable,$132.42 ,115% CMS RBRVS fee schedule,$257.36 ,95% of total billed charges,$216.72 ,80% of total billed charges,$230.27 ,85% of total billed charges,$243.81 ,90% of total billed charges,$132.42 ,115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$132.42 ,115% CMS RBRVS fee schedule,$243.81 ,90% of total billed charges,$205.88 ,76% of total billed charges,$132.42 ,115% CMS RBRVS fee schedule,$132.42 ,115% CMS RBRVS fee schedule,$230.27 ,85% of total billed charges,N/A,Not separately reimbursable,$132.42 ,115% CMS RBRVS fee schedule,$216.72 ,80% of total billed charges,$128.45 ,111.55% CMS RBRVS fee schedule,$230.27 ,85% of total billed charges,N/A,Not separately reimbursable,$128.45 ,$243.81 ,
Physician Medical Services,EVALUATION & MGMT PROFESSIONAL,99391,Periodic primary re-evaluation for an established infant patient,960,$202.90 ,$152.18 ,75% of charges,$152.18 ,75% of charges,$77.82 ,40% of charges which is 100% of the Medicare rate,$160.70 ,79.2% of total billed charges,$160.70 ,79.2% of total billed charges,$160.70 ,79.2% of total billed charges,$160.70 ,79.2% of total billed charges,$172.47 ,85% of total billed charges,N/A,Not separately reimbursable,$77.82 ,40% of charges which is 100% of the Medicare rate,$192.76 ,95% of total billed charges,$162.32 ,80% of total billed charges,$172.47 ,85% of total billed charges,$182.61 ,90% of total billed charges,$77.82 ,40% of charges which is 100% of the Medicare rate,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$77.82 ,40% of charges which is 100% of the Medicare rate,$182.61 ,90% of total billed charges,$154.20 ,76% of total billed charges,$77.82 ,40% of charges which is 100% of the Medicare rate,$77.82 ,40% of charges which is 100% of the Medicare rate,$172.47 ,85% of total billed charges,N/A,Not separately reimbursable,$77.82 ,40% of charges which is 100% of the Medicare rate,$162.32 ,80% of total billed charges,$75.49 ,38.8% of charges which is 100% of the Medicare rate,$172.47 ,85% of total billed charges,N/A,Not separately reimbursable,$75.49 ,$182.61 ,
Physician Medical Services,EVALUATION & MGMT PROFESSIONAL,99392,Initial visit for new patients 1-4 years old,960,$202.90 ,$152.18 ,75% of charges,$152.18 ,75% of charges,$85.58 ,115% CMS RBRVS fee schedule,$160.70 ,79.2% of total billed charges,$160.70 ,79.2% of total billed charges,$160.70 ,79.2% of total billed charges,$160.70 ,79.2% of total billed charges,$172.47 ,85% of total billed charges,N/A,Not separately reimbursable,$85.58 ,115% CMS RBRVS fee schedule,$192.76 ,95% of total billed charges,$162.32 ,80% of total billed charges,$172.47 ,85% of total billed charges,$182.61 ,90% of total billed charges,$85.58 ,115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$85.58 ,115% CMS RBRVS fee schedule,$182.61 ,90% of total billed charges,$154.20 ,76% of total billed charges,$85.58 ,115% CMS RBRVS fee schedule,$85.58 ,115% CMS RBRVS fee schedule,$172.47 ,85% of total billed charges,N/A,Not separately reimbursable,$85.58 ,115% CMS RBRVS fee schedule,$162.32 ,80% of total billed charges,$83.02 ,111.55% CMS RBRVS fee schedule,$172.47 ,85% of total billed charges,N/A,Not separately reimbursable,$83.02 ,$182.61 ,
Physician Medical Services,EVALUATION & MGMT PROFESSIONAL,99393,New preventative visit in new patients 5-11 years old,960,$202.90 ,$152.18 ,75% of charges,$152.18 ,75% of charges,$85.58 ,115% CMS RBRVS fee schedule,$160.70 ,79.2% of total billed charges,$160.70 ,79.2% of total billed charges,$160.70 ,79.2% of total billed charges,$160.70 ,79.2% of total billed charges,$172.47 ,85% of total billed charges,N/A,Not separately reimbursable,$85.58 ,115% CMS RBRVS fee schedule,$192.76 ,95% of total billed charges,$162.32 ,80% of total billed charges,$172.47 ,85% of total billed charges,$182.61 ,90% of total billed charges,$85.58 ,115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$85.58 ,115% CMS RBRVS fee schedule,$182.61 ,90% of total billed charges,$154.20 ,76% of total billed charges,$85.58 ,115% CMS RBRVS fee schedule,$85.58 ,115% CMS RBRVS fee schedule,$172.47 ,85% of total billed charges,N/A,Not separately reimbursable,$85.58 ,115% CMS RBRVS fee schedule,$162.32 ,80% of total billed charges,$83.02 ,111.55% CMS RBRVS fee schedule,$172.47 ,85% of total billed charges,N/A,Not separately reimbursable,$83.02 ,$182.61 ,
Physician Medical Services,EVALUATION & MGMT PROFESSIONAL,99394,New preventative visit in new patients 12-17 years old,960,$202.90 ,$152.18 ,75% of charges,$152.18 ,75% of charges,$96.69 ,115% CMS RBRVS fee schedule,$160.70 ,79.2% of total billed charges,$160.70 ,79.2% of total billed charges,$160.70 ,79.2% of total billed charges,$160.70 ,79.2% of total billed charges,$172.47 ,85% of total billed charges,N/A,Not separately reimbursable,$96.69 ,115% CMS RBRVS fee schedule,$192.76 ,95% of total billed charges,$162.32 ,80% of total billed charges,$172.47 ,85% of total billed charges,$182.61 ,90% of total billed charges,$96.69 ,115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$96.69 ,115% CMS RBRVS fee schedule,$182.61 ,90% of total billed charges,$154.20 ,76% of total billed charges,$96.69 ,115% CMS RBRVS fee schedule,$96.69 ,115% CMS RBRVS fee schedule,$172.47 ,85% of total billed charges,N/A,Not separately reimbursable,$96.69 ,115% CMS RBRVS fee schedule,$162.32 ,80% of total billed charges,$93.79 ,111.55% CMS RBRVS fee schedule,$172.47 ,85% of total billed charges,N/A,Not separately reimbursable,$93.79 ,$182.61 ,
Physician Medical Services,EVALUATION & MGMT PROFESSIONAL,99395,Established patient periodic preventive medicine examination age 18-39 years,960,$202.90 ,$152.18 ,75% of charges,$152.18 ,75% of charges,$99.77 ,115% CMS RBRVS fee schedule,$160.70 ,79.2% of total billed charges,$160.70 ,79.2% of total billed charges,$160.70 ,79.2% of total billed charges,$160.70 ,79.2% of total billed charges,$172.47 ,85% of total billed charges,N/A,Not separately reimbursable,$99.77 ,115% CMS RBRVS fee schedule,$192.76 ,95% of total billed charges,$162.32 ,80% of total billed charges,$172.47 ,85% of total billed charges,$182.61 ,90% of total billed charges,$99.77 ,115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$99.77 ,115% CMS RBRVS fee schedule,$182.61 ,90% of total billed charges,$154.20 ,76% of total billed charges,$99.77 ,115% CMS RBRVS fee schedule,$99.77 ,115% CMS RBRVS fee schedule,$172.47 ,85% of total billed charges,N/A,Not separately reimbursable,$99.77 ,115% CMS RBRVS fee schedule,$162.32 ,80% of total billed charges,$96.78 ,111.55% CMS RBRVS fee schedule,$172.47 ,85% of total billed charges,N/A,Not separately reimbursable,$96.78 ,$182.61 ,
Physician Medical Services,EVALUATION & MGMT PROFESSIONAL,99396,Established patient periodic preventive medicine examination age 40-64 years,960,$202.90 ,$152.18 ,75% of charges,$152.18 ,75% of charges,$108.10 ,115% CMS RBRVS fee schedule,$160.70 ,79.2% of total billed charges,$160.70 ,79.2% of total billed charges,$160.70 ,79.2% of total billed charges,$160.70 ,79.2% of total billed charges,$172.47 ,85% of total billed charges,N/A,Not separately reimbursable,$108.10 ,115% CMS RBRVS fee schedule,$192.76 ,95% of total billed charges,$162.32 ,80% of total billed charges,$172.47 ,85% of total billed charges,$182.61 ,90% of total billed charges,$108.10 ,115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$108.10 ,115% CMS RBRVS fee schedule,$182.61 ,90% of total billed charges,$154.20 ,76% of total billed charges,$108.10 ,115% CMS RBRVS fee schedule,$108.10 ,115% CMS RBRVS fee schedule,$172.47 ,85% of total billed charges,N/A,Not separately reimbursable,$108.10 ,115% CMS RBRVS fee schedule,$162.32 ,80% of total billed charges,$104.86 ,111.55% CMS RBRVS fee schedule,$172.47 ,85% of total billed charges,N/A,Not separately reimbursable,$104.86 ,$182.61 ,
Physician Medical Services,EVALUATION & MGMT PROFESSIONAL,99441,"Physician telephone patient service, 5-10 minutes of medical discussion",960,$105.10 ,$78.83 ,75% of charges,$78.83 ,75% of charges,$40.51 ,40% of charges which is 100% of the Medicare rate,$83.24 ,79.2% of total billed charges,$83.24 ,79.2% of total billed charges,$83.24 ,79.2% of total billed charges,$83.24 ,79.2% of total billed charges,$89.34 ,85% of total billed charges,N/A,Not separately reimbursable,$40.51 ,40% of charges which is 100% of the Medicare rate,$99.85 ,95% of total billed charges,$84.08 ,80% of total billed charges,$89.34 ,85% of total billed charges,$94.59 ,90% of total billed charges,$40.51 ,40% of charges which is 100% of the Medicare rate,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$40.51 ,40% of charges which is 100% of the Medicare rate,$94.59 ,90% of total billed charges,$79.88 ,76% of total billed charges,$40.51 ,40% of charges which is 100% of the Medicare rate,$40.51 ,40% of charges which is 100% of the Medicare rate,$89.34 ,85% of total billed charges,N/A,Not separately reimbursable,$40.51 ,40% of charges which is 100% of the Medicare rate,$84.08 ,80% of total billed charges,$39.30 ,38.8% of charges which is 100% of the Medicare rate,$89.34 ,85% of total billed charges,N/A,Not separately reimbursable,$39.30 ,$94.59 ,
Physician Medical Services,EVALUATION & MGMT PROFESSIONAL,99442,"Physician telephone patient service, 11-20 minutes of medical discussion",960,$139.10 ,$104.33 ,75% of charges,$104.33 ,75% of charges,$76.52 ,115% CMS RBRVS fee schedule,$110.17 ,79.2% of total billed charges,$110.17 ,79.2% of total billed charges,$110.17 ,79.2% of total billed charges,$110.17 ,79.2% of total billed charges,$118.24 ,85% of total billed charges,N/A,Not separately reimbursable,$76.52 ,115% CMS RBRVS fee schedule,$132.15 ,95% of total billed charges,$111.28 ,80% of total billed charges,$118.24 ,85% of total billed charges,$125.19 ,90% of total billed charges,$76.52 ,115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$76.52 ,115% CMS RBRVS fee schedule,$125.19 ,90% of total billed charges,$105.72 ,76% of total billed charges,$76.52 ,115% CMS RBRVS fee schedule,$76.52 ,115% CMS RBRVS fee schedule,$118.24 ,85% of total billed charges,N/A,Not separately reimbursable,$76.52 ,115% CMS RBRVS fee schedule,$111.28 ,80% of total billed charges,$74.23 ,111.55% CMS RBRVS fee schedule,$118.24 ,85% of total billed charges,N/A,Not separately reimbursable,$74.23 ,$125.19 ,
Physician Medical Services,EVALUATION & MGMT PROFESSIONAL,99443,"Physician telephone patient service, 21-30 minutes of medical discussion",960,$196.70 ,$147.53 ,75% of charges,$147.53 ,75% of charges,$112.47 ,115% CMS RBRVS fee schedule,$155.79 ,79.2% of total billed charges,$155.79 ,79.2% of total billed charges,$155.79 ,79.2% of total billed charges,$155.79 ,79.2% of total billed charges,$167.20 ,85% of total billed charges,N/A,Not separately reimbursable,$112.47 ,115% CMS RBRVS fee schedule,$186.87 ,95% of total billed charges,$157.36 ,80% of total billed charges,$167.20 ,85% of total billed charges,$177.03 ,90% of total billed charges,$112.47 ,115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$112.47 ,115% CMS RBRVS fee schedule,$177.03 ,90% of total billed charges,$149.49 ,76% of total billed charges,$112.47 ,115% CMS RBRVS fee schedule,$112.47 ,115% CMS RBRVS fee schedule,$167.20 ,85% of total billed charges,N/A,Not separately reimbursable,$112.47 ,115% CMS RBRVS fee schedule,$157.36 ,80% of total billed charges,$109.10 ,111.55% CMS RBRVS fee schedule,$167.20 ,85% of total billed charges,N/A,Not separately reimbursable,$109.10 ,$177.03 ,
Physician Medical Services,EVALUATION & MGMT PROFESSIONAL,90853,Group psychotherapy,960,$215.00 ,$161.25 ,75% of charges,$161.25 ,75% of charges,$27.00 ,115% CMS RBRVS fee schedule,$170.28 ,79.2% of total billed charges,$170.28 ,79.2% of total billed charges,$170.28 ,79.2% of total billed charges,$170.28 ,79.2% of total billed charges,$182.75 ,85% of total billed charges,N/A,Not separately reimbursable,$27.00 ,115% CMS RBRVS fee schedule,$204.25 ,95% of total billed charges,$172.00 ,80% of total billed charges,$182.75 ,85% of total billed charges,$193.50 ,90% of total billed charges,$27.00 ,115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$27.00 ,115% CMS RBRVS fee schedule,$193.50 ,90% of total billed charges,$163.40 ,76% of total billed charges,$27.00 ,115% CMS RBRVS fee schedule,$27.00 ,115% CMS RBRVS fee schedule,$182.75 ,85% of total billed charges,N/A,Not separately reimbursable,$27.00 ,115% CMS RBRVS fee schedule,$172.00 ,80% of total billed charges,$26.19 ,111.55% CMS RBRVS fee schedule,$182.75 ,85% of total billed charges,N/A,Not separately reimbursable,$26.19 ,$193.50 ,
Physician Medical Services,EVALUATION & MGMT PROFESSIONAL,90847,"Family psychotherapy, including patient, 50 min",960,$207.00 ,$155.25 ,75% of charges,$155.25 ,75% of charges,$114.82 ,115% CMS RBRVS fee schedule,$163.94 ,79.2% of total billed charges,$163.94 ,79.2% of total billed charges,$163.94 ,79.2% of total billed charges,$163.94 ,79.2% of total billed charges,$175.95 ,85% of total billed charges,N/A,Not separately reimbursable,$114.82 ,115% CMS RBRVS fee schedule,$196.65 ,95% of total billed charges,$165.60 ,80% of total billed charges,$175.95 ,85% of total billed charges,$186.30 ,90% of total billed charges,$114.82 ,115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$114.82 ,115% CMS RBRVS fee schedule,$186.30 ,90% of total billed charges,$157.32 ,76% of total billed charges,$114.82 ,115% CMS RBRVS fee schedule,$114.82 ,115% CMS RBRVS fee schedule,$175.95 ,85% of total billed charges,N/A,Not separately reimbursable,$114.82 ,115% CMS RBRVS fee schedule,$165.60 ,80% of total billed charges,$111.37 ,111.55% CMS RBRVS fee schedule,$175.95 ,85% of total billed charges,N/A,Not separately reimbursable,$111.37 ,$186.30 ,
Physician Medical Services,EVALUATION & MGMT PROFESSIONAL,90846,"Family psychotherapy, not including patient, 50 min",960,$310.00 ,$232.50 ,75% of charges,$232.50 ,75% of charges,$110.08 ,115% CMS RBRVS fee schedule,$245.52 ,79.2% of total billed charges,$245.52 ,79.2% of total billed charges,$245.52 ,79.2% of total billed charges,$245.52 ,79.2% of total billed charges,$263.50 ,85% of total billed charges,N/A,Not separately reimbursable,$110.08 ,115% CMS RBRVS fee schedule,$294.50 ,95% of total billed charges,$248.00 ,80% of total billed charges,$263.50 ,85% of total billed charges,$279.00 ,90% of total billed charges,$110.08 ,115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$110.08 ,115% CMS RBRVS fee schedule,$279.00 ,90% of total billed charges,$235.60 ,76% of total billed charges,$110.08 ,115% CMS RBRVS fee schedule,$110.08 ,115% CMS RBRVS fee schedule,$263.50 ,85% of total billed charges,N/A,Not separately reimbursable,$110.08 ,115% CMS RBRVS fee schedule,$248.00 ,80% of total billed charges,$106.78 ,111.55% CMS RBRVS fee schedule,$263.50 ,85% of total billed charges,N/A,Not separately reimbursable,$106.78 ,$279.00 ,
Physician Medical Services,EVALUATION & MGMT PROFESSIONAL,90837,"Psychotherapy, 60 min",960,$229.70 ,$172.28 ,75% of charges,$172.28 ,75% of charges,$149.71 ,115% CMS RBRVS fee schedule,$181.92 ,79.2% of total billed charges,$181.92 ,79.2% of total billed charges,$181.92 ,79.2% of total billed charges,$181.92 ,79.2% of total billed charges,$195.25 ,85% of total billed charges,N/A,Not separately reimbursable,$149.71 ,115% CMS RBRVS fee schedule,$218.22 ,95% of total billed charges,$183.76 ,80% of total billed charges,$195.25 ,85% of total billed charges,$206.73 ,90% of total billed charges,$149.71 ,115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$149.71 ,115% CMS RBRVS fee schedule,$206.73 ,90% of total billed charges,$174.57 ,76% of total billed charges,$149.71 ,115% CMS RBRVS fee schedule,$149.71 ,115% CMS RBRVS fee schedule,$195.25 ,85% of total billed charges,N/A,Not separately reimbursable,$149.71 ,115% CMS RBRVS fee schedule,$183.76 ,80% of total billed charges,$145.22 ,111.55% CMS RBRVS fee schedule,$195.25 ,85% of total billed charges,N/A,Not separately reimbursable,$145.22 ,$206.73 ,
Physician Medical Services,EVALUATION & MGMT PROFESSIONAL,90834,"Psychotherapy, 45 min",960,$197.80 ,$148.35 ,75% of charges,$148.35 ,75% of charges,$101.87 ,115% CMS RBRVS fee schedule,$156.66 ,79.2% of total billed charges,$156.66 ,79.2% of total billed charges,$156.66 ,79.2% of total billed charges,$156.66 ,79.2% of total billed charges,$168.13 ,85% of total billed charges,N/A,Not separately reimbursable,$101.87 ,115% CMS RBRVS fee schedule,$187.91 ,95% of total billed charges,$158.24 ,80% of total billed charges,$168.13 ,85% of total billed charges,$178.02 ,90% of total billed charges,$101.87 ,115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$101.87 ,115% CMS RBRVS fee schedule,$178.02 ,90% of total billed charges,$150.33 ,76% of total billed charges,$101.87 ,115% CMS RBRVS fee schedule,$101.87 ,115% CMS RBRVS fee schedule,$168.13 ,85% of total billed charges,N/A,Not separately reimbursable,$101.87 ,115% CMS RBRVS fee schedule,$158.24 ,80% of total billed charges,$98.81 ,111.55% CMS RBRVS fee schedule,$168.13 ,85% of total billed charges,N/A,Not separately reimbursable,$98.81 ,$178.02 ,
Physician Medical Services,EVALUATION & MGMT PROFESSIONAL,90832,"Psychotherapy, 30 min",960,$128.80 ,$96.60 ,75% of charges,$96.60 ,75% of charges,$76.82 ,115% CMS RBRVS fee schedule,$102.01 ,79.2% of total billed charges,$102.01 ,79.2% of total billed charges,$102.01 ,79.2% of total billed charges,$102.01 ,79.2% of total billed charges,$109.48 ,85% of total billed charges,N/A,Not separately reimbursable,$76.82 ,115% CMS RBRVS fee schedule,$122.36 ,95% of total billed charges,$103.04 ,80% of total billed charges,$109.48 ,85% of total billed charges,$115.92 ,90% of total billed charges,$76.82 ,115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$76.82 ,115% CMS RBRVS fee schedule,$115.92 ,90% of total billed charges,$97.89 ,76% of total billed charges,$76.82 ,115% CMS RBRVS fee schedule,$76.82 ,115% CMS RBRVS fee schedule,$109.48 ,85% of total billed charges,N/A,Not separately reimbursable,$76.82 ,115% CMS RBRVS fee schedule,$103.04 ,80% of total billed charges,$74.52 ,111.55% CMS RBRVS fee schedule,$109.48 ,85% of total billed charges,N/A,Not separately reimbursable,$74.52 ,$115.92 ,
Physician Medical Services,EVALUATION & MGMT PROFESSIONAL,90791,"A diagnostic tool employed by a psychiatrist to diagnose problems with memory, thought processes, and behaviors",960,$360.50 ,$270.38 ,75% of charges,$270.38 ,75% of charges,$174.36 ,115% CMS RBRVS fee schedule,$285.52 ,79.2% of total billed charges,$285.52 ,79.2% of total billed charges,$285.52 ,79.2% of total billed charges,$285.52 ,79.2% of total billed charges,$306.43 ,85% of total billed charges,N/A,Not separately reimbursable,$174.36 ,115% CMS RBRVS fee schedule,$342.48 ,95% of total billed charges,$288.40 ,80% of total billed charges,$306.43 ,85% of total billed charges,$324.45 ,90% of total billed charges,$174.36 ,115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$174.36 ,115% CMS RBRVS fee schedule,$324.45 ,90% of total billed charges,$273.98 ,76% of total billed charges,$174.36 ,115% CMS RBRVS fee schedule,$174.36 ,115% CMS RBRVS fee schedule,$306.43 ,85% of total billed charges,N/A,Not separately reimbursable,$174.36 ,115% CMS RBRVS fee schedule,$288.40 ,80% of total billed charges,$169.13 ,111.55% CMS RBRVS fee schedule,$306.43 ,85% of total billed charges,N/A,Not separately reimbursable,$169.13 ,$324.45 ,
Physician Medical Services,PHYSICIAN SURGERY SERVICES,19101,"19101 - Biopsy Of Breast; Open, Incisional",960,"$1,201.30 ",$900.98 ,75% of charges,$900.98 ,75% of charges,$261.30 ,115% CMS RBRVS fee schedule,$951.43 ,79.2% of total billed charges,$951.43 ,79.2% of total billed charges,$951.43 ,79.2% of total billed charges,$951.43 ,79.2% of total billed charges,"$1,021.11 ",85% of total billed charges,N/A,Not separately reimbursable,$261.30 ,115% CMS RBRVS fee schedule,"$1,141.24 ",95% of total billed charges,$961.04 ,80% of total billed charges,"$1,021.11 ",85% of total billed charges,"$1,081.17 ",90% of total billed charges,$261.30 ,115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$261.30 ,115% CMS RBRVS fee schedule,"$1,081.17 ",90% of total billed charges,$912.99 ,76% of total billed charges,$261.30 ,115% CMS RBRVS fee schedule,$261.30 ,115% CMS RBRVS fee schedule,"$1,021.11 ",85% of total billed charges,N/A,Not separately reimbursable,$261.30 ,115% CMS RBRVS fee schedule,$961.04 ,80% of total billed charges,$253.46 ,111.55% CMS RBRVS fee schedule,"$1,021.11 ",85% of total billed charges,N/A,Not separately reimbursable,$253.46 ,"$1,081.17 ",
Physician Medical Services,PHYSICIAN SURGERY SERVICES,19120,REMOVAL OF BREAST LESION,960,"$1,316.40 ",$987.30 ,75% of charges,$987.30 ,75% of charges,$488.53 ,40% of charges which is 100% of the Medicare rate,"$1,042.59 ",79.2% of total billed charges,"$1,042.59 ",79.2% of total billed charges,"$1,042.59 ",79.2% of total billed charges,"$1,042.59 ",79.2% of total billed charges,"$1,118.94 ",85% of total billed charges,N/A,Not separately reimbursable,$488.53 ,40% of charges which is 100% of the Medicare rate,"$1,250.58 ",95% of total billed charges,"$1,053.12 ",80% of total billed charges,"$1,118.94 ",85% of total billed charges,"$1,184.76 ",90% of total billed charges,$488.53 ,40% of charges which is 100% of the Medicare rate,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$488.53 ,40% of charges which is 100% of the Medicare rate,"$1,184.76 ",90% of total billed charges,"$1,000.46 ",76% of total billed charges,$488.53 ,40% of charges which is 100% of the Medicare rate,$488.53 ,40% of charges which is 100% of the Medicare rate,"$1,118.94 ",85% of total billed charges,N/A,Not separately reimbursable,$488.53 ,40% of charges which is 100% of the Medicare rate,"$1,053.12 ",80% of total billed charges,$473.88 ,38.8% of charges which is 100% of the Medicare rate,"$1,118.94 ",85% of total billed charges,N/A,Not separately reimbursable,$473.88 ,"$1,184.76 ",
Physician Medical Services,PHYSICIAN SURGERY SERVICES,19301,"19301 - Mastectomy, Partial (Eg, Lumpectomy, Tylectomy, Quadrantectomy, Segmentectomy);",960,"$2,551.10 ","$1,913.33 ",75% of charges,"$1,913.33 ",75% of charges,$767.56 ,115% CMS RBRVS fee schedule,"$2,020.47 ",79.2% of total billed charges,"$2,020.47 ",79.2% of total billed charges,"$2,020.47 ",79.2% of total billed charges,"$2,020.47 ",79.2% of total billed charges,"$2,168.44 ",85% of total billed charges,N/A,Not separately reimbursable,$767.56 ,115% CMS RBRVS fee schedule,"$2,423.55 ",95% of total billed charges,"$2,040.88 ",80% of total billed charges,"$2,168.44 ",85% of total billed charges,"$2,295.99 ",90% of total billed charges,$767.56 ,115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$767.56 ,115% CMS RBRVS fee schedule,"$2,295.99 ",90% of total billed charges,"$1,938.84 ",76% of total billed charges,$767.56 ,115% CMS RBRVS fee schedule,$767.56 ,115% CMS RBRVS fee schedule,"$2,168.44 ",85% of total billed charges,N/A,Not separately reimbursable,$767.56 ,115% CMS RBRVS fee schedule,"$2,040.88 ",80% of total billed charges,$744.53 ,111.55% CMS RBRVS fee schedule,"$2,168.44 ",85% of total billed charges,N/A,Not separately reimbursable,$744.53 ,"$2,295.99 ",
Physician Medical Services,PHYSICIAN SURGERY SERVICES,20240,"20240 - Biopsy, Bone, Open; Superficial (Eg, Ilium, Sternum, Spinous Process, Ribs, Trochanter Of Femur)",960,$457.08 ,$342.81 ,75% of charges,$342.81 ,75% of charges,$161.97 ,115% CMS RBRVS fee schedule,$362.01 ,79.2% of total billed charges,$362.01 ,79.2% of total billed charges,$362.01 ,79.2% of total billed charges,$362.01 ,79.2% of total billed charges,$388.52 ,85% of total billed charges,N/A,Not separately reimbursable,$161.97 ,115% CMS RBRVS fee schedule,$434.23 ,95% of total billed charges,$365.66 ,80% of total billed charges,$388.52 ,85% of total billed charges,$411.37 ,90% of total billed charges,$161.97 ,115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$161.97 ,115% CMS RBRVS fee schedule,$411.37 ,90% of total billed charges,$347.38 ,76% of total billed charges,$161.97 ,115% CMS RBRVS fee schedule,$161.97 ,115% CMS RBRVS fee schedule,$388.52 ,85% of total billed charges,N/A,Not separately reimbursable,$161.97 ,115% CMS RBRVS fee schedule,$365.66 ,80% of total billed charges,$157.11 ,111.55% CMS RBRVS fee schedule,$388.52 ,85% of total billed charges,N/A,Not separately reimbursable,$157.11 ,$411.37 ,
Physician Medical Services,PHYSICIAN SURGERY SERVICES,20610,Draining or injecting medication into a major joint/bursa without ultrasound,960,$197.80 ,$148.35 ,75% of charges,$148.35 ,75% of charges,$52.26 ,115% CMS RBRVS fee schedule,$156.66 ,79.2% of total billed charges,$156.66 ,79.2% of total billed charges,$156.66 ,79.2% of total billed charges,$156.66 ,79.2% of total billed charges,$168.13 ,85% of total billed charges,N/A,Not separately reimbursable,$52.26 ,115% CMS RBRVS fee schedule,$187.91 ,95% of total billed charges,$158.24 ,80% of total billed charges,$168.13 ,85% of total billed charges,$178.02 ,90% of total billed charges,$52.26 ,115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$52.26 ,115% CMS RBRVS fee schedule,$178.02 ,90% of total billed charges,$150.33 ,76% of total billed charges,$52.26 ,115% CMS RBRVS fee schedule,$52.26 ,115% CMS RBRVS fee schedule,$168.13 ,85% of total billed charges,N/A,Not separately reimbursable,$52.26 ,115% CMS RBRVS fee schedule,$158.24 ,80% of total billed charges,$50.69 ,111.55% CMS RBRVS fee schedule,$168.13 ,85% of total billed charges,N/A,Not separately reimbursable,$50.69 ,$178.02 ,
Physician Medical Services,PHYSICIAN SURGERY SERVICES,20680,"20680 - Removal Of Implant; Deep (Eg, Buried Wire, Pin, Screw, Metal Band, Nail, Rod Or Plate)",960,"$1,504.90 ","$1,128.68 ",75% of charges,"$1,128.68 ",75% of charges,$493.43 ,115% CMS RBRVS fee schedule,"$1,191.88 ",79.2% of total billed charges,"$1,191.88 ",79.2% of total billed charges,"$1,191.88 ",79.2% of total billed charges,"$1,191.88 ",79.2% of total billed charges,"$1,279.17 ",85% of total billed charges,N/A,Not separately reimbursable,$493.43 ,115% CMS RBRVS fee schedule,"$1,429.66 ",95% of total billed charges,"$1,203.92 ",80% of total billed charges,"$1,279.17 ",85% of total billed charges,"$1,354.41 ",90% of total billed charges,$493.43 ,115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$493.43 ,115% CMS RBRVS fee schedule,"$1,354.41 ",90% of total billed charges,"$1,143.72 ",76% of total billed charges,$493.43 ,115% CMS RBRVS fee schedule,$493.43 ,115% CMS RBRVS fee schedule,"$1,279.17 ",85% of total billed charges,N/A,Not separately reimbursable,$493.43 ,115% CMS RBRVS fee schedule,"$1,203.92 ",80% of total billed charges,$478.63 ,111.55% CMS RBRVS fee schedule,"$1,279.17 ",85% of total billed charges,N/A,Not separately reimbursable,$478.63 ,"$1,354.41 ",
Physician Medical Services,PHYSICIAN SURGERY SERVICES,21556,"21556 - Excision, Tumor, Soft Tissue Of Neck Or Anterior Thorax, Subfascial (Eg, Intramuscular); Less Than 5 Cm",960,"$1,320.50 ",$990.38 ,75% of charges,$990.38 ,75% of charges,$625.44 ,115% CMS RBRVS fee schedule,"$1,045.84 ",79.2% of total billed charges,"$1,045.84 ",79.2% of total billed charges,"$1,045.84 ",79.2% of total billed charges,"$1,045.84 ",79.2% of total billed charges,"$1,122.43 ",85% of total billed charges,N/A,Not separately reimbursable,$625.44 ,115% CMS RBRVS fee schedule,"$1,254.48 ",95% of total billed charges,"$1,056.40 ",80% of total billed charges,"$1,122.43 ",85% of total billed charges,"$1,188.45 ",90% of total billed charges,$625.44 ,115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$625.44 ,115% CMS RBRVS fee schedule,"$1,188.45 ",90% of total billed charges,"$1,003.58 ",76% of total billed charges,$625.44 ,115% CMS RBRVS fee schedule,$625.44 ,115% CMS RBRVS fee schedule,"$1,122.43 ",85% of total billed charges,N/A,Not separately reimbursable,$625.44 ,115% CMS RBRVS fee schedule,"$1,056.40 ",80% of total billed charges,$606.68 ,111.55% CMS RBRVS fee schedule,"$1,122.43 ",85% of total billed charges,N/A,Not separately reimbursable,$606.68 ,"$1,188.45 ",
Physician Medical Services,PHYSICIAN SURGERY SERVICES,23700,"23700 - Manipulation Under Anesthesia, Shoulder Joint, Including Application Of Fixation Apparatus (Dislocation Excluded)",960,$686.00 ,$514.50 ,75% of charges,$514.50 ,75% of charges,$232.39 ,115% CMS RBRVS fee schedule,$543.31 ,79.2% of total billed charges,$543.31 ,79.2% of total billed charges,$543.31 ,79.2% of total billed charges,$543.31 ,79.2% of total billed charges,$583.10 ,85% of total billed charges,N/A,Not separately reimbursable,$232.39 ,115% CMS RBRVS fee schedule,$651.70 ,95% of total billed charges,$548.80 ,80% of total billed charges,$583.10 ,85% of total billed charges,$617.40 ,90% of total billed charges,$232.39 ,115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$232.39 ,115% CMS RBRVS fee schedule,$617.40 ,90% of total billed charges,$521.36 ,76% of total billed charges,$232.39 ,115% CMS RBRVS fee schedule,$232.39 ,115% CMS RBRVS fee schedule,$583.10 ,85% of total billed charges,N/A,Not separately reimbursable,$232.39 ,115% CMS RBRVS fee schedule,$548.80 ,80% of total billed charges,$225.42 ,111.55% CMS RBRVS fee schedule,$583.10 ,85% of total billed charges,N/A,Not separately reimbursable,$225.42 ,$617.40 ,
Physician Medical Services,PHYSICIAN SURGERY SERVICES,24341,"24341 - Repair, Tendon Or Muscle, Upper Arm Or Elbow, Each Tendon Or Muscle, Primary Or Secondary (Excludes Rotator Cuff)",960,"$2,543.40 ","$1,907.55 ",75% of charges,"$1,907.55 ",75% of charges,$889.04 ,115% CMS RBRVS fee schedule,"$2,014.37 ",79.2% of total billed charges,"$2,014.37 ",79.2% of total billed charges,"$2,014.37 ",79.2% of total billed charges,"$2,014.37 ",79.2% of total billed charges,"$2,161.89 ",85% of total billed charges,N/A,Not separately reimbursable,$889.04 ,115% CMS RBRVS fee schedule,"$2,416.23 ",95% of total billed charges,"$2,034.72 ",80% of total billed charges,"$2,161.89 ",85% of total billed charges,"$2,289.06 ",90% of total billed charges,$889.04 ,115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$889.04 ,115% CMS RBRVS fee schedule,"$2,289.06 ",90% of total billed charges,"$1,932.98 ",76% of total billed charges,$889.04 ,115% CMS RBRVS fee schedule,$889.04 ,115% CMS RBRVS fee schedule,"$2,161.89 ",85% of total billed charges,N/A,Not separately reimbursable,$889.04 ,115% CMS RBRVS fee schedule,"$2,034.72 ",80% of total billed charges,$862.37 ,111.55% CMS RBRVS fee schedule,"$2,161.89 ",85% of total billed charges,N/A,Not separately reimbursable,$862.37 ,"$2,289.06 ",
Physician Medical Services,PHYSICIAN SURGERY SERVICES,24342,"24342 - Reinsertion Of Ruptured Biceps Or Triceps Tendon, Distal, With Or Without Tendon Graft",960,"$2,600.80 ","$1,950.60 ",75% of charges,"$1,950.60 ",75% of charges,$915.08 ,115% CMS RBRVS fee schedule,"$2,059.83 ",79.2% of total billed charges,"$2,059.83 ",79.2% of total billed charges,"$2,059.83 ",79.2% of total billed charges,"$2,059.83 ",79.2% of total billed charges,"$2,210.68 ",85% of total billed charges,N/A,Not separately reimbursable,$915.08 ,115% CMS RBRVS fee schedule,"$2,470.76 ",95% of total billed charges,"$2,080.64 ",80% of total billed charges,"$2,210.68 ",85% of total billed charges,"$2,340.72 ",90% of total billed charges,$915.08 ,115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$915.08 ,115% CMS RBRVS fee schedule,"$2,340.72 ",90% of total billed charges,"$1,976.61 ",76% of total billed charges,$915.08 ,115% CMS RBRVS fee schedule,$915.08 ,115% CMS RBRVS fee schedule,"$2,210.68 ",85% of total billed charges,N/A,Not separately reimbursable,$915.08 ,115% CMS RBRVS fee schedule,"$2,080.64 ",80% of total billed charges,$887.63 ,111.55% CMS RBRVS fee schedule,"$2,210.68 ",85% of total billed charges,N/A,Not separately reimbursable,$887.63 ,"$2,340.72 ",
Physician Medical Services,PHYSICIAN SURGERY SERVICES,24358,"24358 - Tenotomy, Elbow, Lateral Or Medial (Eg, Epicondylitis, Tennis Elbow, Golfer'S Elbow); Debridement, Soft Tissue And/Or Bone, Open",960,"$1,889.00 ","$1,416.75 ",75% of charges,"$1,416.75 ",75% of charges,$631.82 ,115% CMS RBRVS fee schedule,"$1,496.09 ",79.2% of total billed charges,"$1,496.09 ",79.2% of total billed charges,"$1,496.09 ",79.2% of total billed charges,"$1,496.09 ",79.2% of total billed charges,"$1,605.65 ",85% of total billed charges,N/A,Not separately reimbursable,$631.82 ,115% CMS RBRVS fee schedule,"$1,794.55 ",95% of total billed charges,"$1,511.20 ",80% of total billed charges,"$1,605.65 ",85% of total billed charges,"$1,700.10 ",90% of total billed charges,$631.82 ,115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$631.82 ,115% CMS RBRVS fee schedule,"$1,700.10 ",90% of total billed charges,"$1,435.64 ",76% of total billed charges,$631.82 ,115% CMS RBRVS fee schedule,$631.82 ,115% CMS RBRVS fee schedule,"$1,605.65 ",85% of total billed charges,N/A,Not separately reimbursable,$631.82 ,115% CMS RBRVS fee schedule,"$1,511.20 ",80% of total billed charges,$612.87 ,111.55% CMS RBRVS fee schedule,"$1,605.65 ",85% of total billed charges,N/A,Not separately reimbursable,$612.87 ,"$1,700.10 ",
Physician Medical Services,PHYSICIAN SURGERY SERVICES,25000,"25000 - Incision, Extensor Tendon Sheath, Wrist (Eg, Dequervains Disease)",960,$781.80 ,$586.35 ,75% of charges,$586.35 ,75% of charges,$418.14 ,115% CMS RBRVS fee schedule,$619.19 ,79.2% of total billed charges,$619.19 ,79.2% of total billed charges,$619.19 ,79.2% of total billed charges,$619.19 ,79.2% of total billed charges,$664.53 ,85% of total billed charges,N/A,Not separately reimbursable,$418.14 ,115% CMS RBRVS fee schedule,$742.71 ,95% of total billed charges,$625.44 ,80% of total billed charges,$664.53 ,85% of total billed charges,$703.62 ,90% of total billed charges,$418.14 ,115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$418.14 ,115% CMS RBRVS fee schedule,$703.62 ,90% of total billed charges,$594.17 ,76% of total billed charges,$418.14 ,115% CMS RBRVS fee schedule,$418.14 ,115% CMS RBRVS fee schedule,$664.53 ,85% of total billed charges,N/A,Not separately reimbursable,$418.14 ,115% CMS RBRVS fee schedule,$625.44 ,80% of total billed charges,$405.60 ,111.55% CMS RBRVS fee schedule,$664.53 ,85% of total billed charges,N/A,Not separately reimbursable,$405.60 ,$703.62 ,
Physician Medical Services,PHYSICIAN SURGERY SERVICES,26055,"26055 - Tendon Sheath Incision (Eg, For Trigger Finger)",960,"$1,126.45 ",$844.84 ,75% of charges,$844.84 ,75% of charges,$351.36 ,115% CMS RBRVS fee schedule,$892.15 ,79.2% of total billed charges,$892.15 ,79.2% of total billed charges,$892.15 ,79.2% of total billed charges,$892.15 ,79.2% of total billed charges,$957.48 ,85% of total billed charges,N/A,Not separately reimbursable,$351.36 ,115% CMS RBRVS fee schedule,"$1,070.13 ",95% of total billed charges,$901.16 ,80% of total billed charges,$957.48 ,85% of total billed charges,"$1,013.81 ",90% of total billed charges,$351.36 ,115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$351.36 ,115% CMS RBRVS fee schedule,"$1,013.81 ",90% of total billed charges,$856.10 ,76% of total billed charges,$351.36 ,115% CMS RBRVS fee schedule,$351.36 ,115% CMS RBRVS fee schedule,$957.48 ,85% of total billed charges,N/A,Not separately reimbursable,$351.36 ,115% CMS RBRVS fee schedule,$901.16 ,80% of total billed charges,$340.82 ,111.55% CMS RBRVS fee schedule,$957.48 ,85% of total billed charges,N/A,Not separately reimbursable,$340.82 ,"$1,013.81 ",
Physician Medical Services,PHYSICIAN SURGERY SERVICES,26111,"26111 - Excision, Tumor Or Vascular Malformation, Soft Tissue Of Hand Or Finger, Subcutaneous; 1.5 Cm Or Greater",960,$958.90 ,$719.18 ,75% of charges,$719.18 ,75% of charges,$494.37 ,115% CMS RBRVS fee schedule,$759.45 ,79.2% of total billed charges,$759.45 ,79.2% of total billed charges,$759.45 ,79.2% of total billed charges,$759.45 ,79.2% of total billed charges,$815.07 ,85% of total billed charges,N/A,Not separately reimbursable,$494.37 ,115% CMS RBRVS fee schedule,$910.96 ,95% of total billed charges,$767.12 ,80% of total billed charges,$815.07 ,85% of total billed charges,$863.01 ,90% of total billed charges,$494.37 ,115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$494.37 ,115% CMS RBRVS fee schedule,$863.01 ,90% of total billed charges,$728.76 ,76% of total billed charges,$494.37 ,115% CMS RBRVS fee schedule,$494.37 ,115% CMS RBRVS fee schedule,$815.07 ,85% of total billed charges,N/A,Not separately reimbursable,$494.37 ,115% CMS RBRVS fee schedule,$767.12 ,80% of total billed charges,$479.54 ,111.55% CMS RBRVS fee schedule,$815.07 ,85% of total billed charges,N/A,Not separately reimbursable,$479.54 ,$863.01 ,
Physician Medical Services,PHYSICIAN SURGERY SERVICES,26160,"26160 - Excision Of Lesion Of Tendon Sheath Or Joint Capsule (Eg, Cyst, Mucous Cyst, Or Ganglion), Hand Or Finger",960,"$1,308.10 ",$981.08 ,75% of charges,$981.08 ,75% of charges,$380.45 ,115% CMS RBRVS fee schedule,"$1,036.02 ",79.2% of total billed charges,"$1,036.02 ",79.2% of total billed charges,"$1,036.02 ",79.2% of total billed charges,"$1,036.02 ",79.2% of total billed charges,"$1,111.89 ",85% of total billed charges,N/A,Not separately reimbursable,$380.45 ,115% CMS RBRVS fee schedule,"$1,242.70 ",95% of total billed charges,"$1,046.48 ",80% of total billed charges,"$1,111.89 ",85% of total billed charges,"$1,177.29 ",90% of total billed charges,$380.45 ,115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$380.45 ,115% CMS RBRVS fee schedule,"$1,177.29 ",90% of total billed charges,$994.16 ,76% of total billed charges,$380.45 ,115% CMS RBRVS fee schedule,$380.45 ,115% CMS RBRVS fee schedule,"$1,111.89 ",85% of total billed charges,N/A,Not separately reimbursable,$380.45 ,115% CMS RBRVS fee schedule,"$1,046.48 ",80% of total billed charges,$369.04 ,111.55% CMS RBRVS fee schedule,"$1,111.89 ",85% of total billed charges,N/A,Not separately reimbursable,$369.04 ,"$1,177.29 ",
Physician Medical Services,PHYSICIAN SURGERY SERVICES,26410,"26410 - Repair, Extensor Tendon, Hand, Primary Or Secondary; Without Free Graft, Each Tendon",960,"$2,330.00 ","$1,747.50 ",75% of charges,"$1,747.50 ",75% of charges,$734.13 ,115% CMS RBRVS fee schedule,"$1,845.36 ",79.2% of total billed charges,"$1,845.36 ",79.2% of total billed charges,"$1,845.36 ",79.2% of total billed charges,"$1,845.36 ",79.2% of total billed charges,"$1,980.50 ",85% of total billed charges,N/A,Not separately reimbursable,$734.13 ,115% CMS RBRVS fee schedule,"$2,213.50 ",95% of total billed charges,"$1,864.00 ",80% of total billed charges,"$1,980.50 ",85% of total billed charges,"$2,097.00 ",90% of total billed charges,$734.13 ,115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$734.13 ,115% CMS RBRVS fee schedule,"$2,097.00 ",90% of total billed charges,"$1,770.80 ",76% of total billed charges,$734.13 ,115% CMS RBRVS fee schedule,$734.13 ,115% CMS RBRVS fee schedule,"$1,980.50 ",85% of total billed charges,N/A,Not separately reimbursable,$734.13 ,115% CMS RBRVS fee schedule,"$1,864.00 ",80% of total billed charges,$712.10 ,111.55% CMS RBRVS fee schedule,"$1,980.50 ",85% of total billed charges,N/A,Not separately reimbursable,$712.10 ,"$2,097.00 ",
Physician Medical Services,PHYSICIAN SURGERY SERVICES,26951,"26951 - Amputation, Finger Or Thumb, Primary Or Secondary, Any Joint Or Phalanx, Single, Including Neurectomies; With Direct Closure",960,"$2,093.60 ","$1,570.20 ",75% of charges,"$1,570.20 ",75% of charges,$850.97 ,40% of charges which is 100% of the Medicare rate,"$1,658.13 ",79.2% of total billed charges,"$1,658.13 ",79.2% of total billed charges,"$1,658.13 ",79.2% of total billed charges,"$1,658.13 ",79.2% of total billed charges,"$1,779.56 ",85% of total billed charges,N/A,Not separately reimbursable,$850.97 ,40% of charges which is 100% of the Medicare rate,"$1,988.92 ",95% of total billed charges,"$1,674.88 ",80% of total billed charges,"$1,779.56 ",85% of total billed charges,"$1,884.24 ",90% of total billed charges,$850.97 ,40% of charges which is 100% of the Medicare rate,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$850.97 ,40% of charges which is 100% of the Medicare rate,"$1,884.24 ",90% of total billed charges,"$1,591.14 ",76% of total billed charges,$850.97 ,40% of charges which is 100% of the Medicare rate,$850.97 ,40% of charges which is 100% of the Medicare rate,"$1,779.56 ",85% of total billed charges,N/A,Not separately reimbursable,$850.97 ,40% of charges which is 100% of the Medicare rate,"$1,674.88 ",80% of total billed charges,$825.44 ,38.8% of charges which is 100% of the Medicare rate,"$1,779.56 ",85% of total billed charges,N/A,Not separately reimbursable,$825.44 ,"$1,884.24 ",
Physician Medical Services,PHYSICIAN SURGERY SERVICES,27096,"27096 - Injection Procedure For Sacroiliac Joint, Anesthetic/Steroid, With Image Guidance (Fluoroscopy Or Ct) Including Arthrography When Performed",960,$627.68 ,$470.76 ,75% of charges,$470.76 ,75% of charges,$96.27 ,115% CMS RBRVS fee schedule,$497.12 ,79.2% of total billed charges,$497.12 ,79.2% of total billed charges,$497.12 ,79.2% of total billed charges,$497.12 ,79.2% of total billed charges,$533.53 ,85% of total billed charges,N/A,Not separately reimbursable,$96.27 ,115% CMS RBRVS fee schedule,$596.30 ,95% of total billed charges,$502.14 ,80% of total billed charges,$533.53 ,85% of total billed charges,$564.91 ,90% of total billed charges,$96.27 ,115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$96.27 ,115% CMS RBRVS fee schedule,$564.91 ,90% of total billed charges,$477.04 ,76% of total billed charges,$96.27 ,115% CMS RBRVS fee schedule,$96.27 ,115% CMS RBRVS fee schedule,$533.53 ,85% of total billed charges,N/A,Not separately reimbursable,$96.27 ,115% CMS RBRVS fee schedule,$502.14 ,80% of total billed charges,$93.38 ,111.55% CMS RBRVS fee schedule,$533.53 ,85% of total billed charges,N/A,Not separately reimbursable,$93.38 ,$564.91 ,
Physician Medical Services,PHYSICIAN SURGERY SERVICES,27130,"27130 - Arthroplasty, Acetabular And Proximal Femoral Prosthetic Replacement (Total Hip Arthroplasty), With Or Without Autograft Or Allograft",960,"$4,781.99 ","$3,586.49 ",75% of charges,"$3,586.49 ",75% of charges,"$1,497.65 ",115% CMS RBRVS fee schedule,"$3,787.34 ",79.2% of total billed charges,"$3,787.34 ",79.2% of total billed charges,"$3,787.34 ",79.2% of total billed charges,"$3,787.34 ",79.2% of total billed charges,"$4,064.69 ",85% of total billed charges,N/A,Not separately reimbursable,"$1,497.65 ",115% CMS RBRVS fee schedule,"$4,542.89 ",95% of total billed charges,"$3,825.59 ",80% of total billed charges,"$4,064.69 ",85% of total billed charges,"$4,303.79 ",90% of total billed charges,"$1,497.65 ",115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,"$1,497.65 ",115% CMS RBRVS fee schedule,"$4,303.79 ",90% of total billed charges,"$3,634.31 ",76% of total billed charges,"$1,497.65 ",115% CMS RBRVS fee schedule,"$1,497.65 ",115% CMS RBRVS fee schedule,"$4,064.69 ",85% of total billed charges,N/A,Not separately reimbursable,"$1,497.65 ",115% CMS RBRVS fee schedule,"$3,825.59 ",80% of total billed charges,"$1,452.72 ",111.55% CMS RBRVS fee schedule,"$4,064.69 ",85% of total billed charges,N/A,Not separately reimbursable,"$1,452.72 ","$4,303.79 ",
Physician Medical Services,PHYSICIAN SURGERY SERVICES,27420,"27420 - Reconstruction Of Dislocating Patella; (Eg, Hauser Type Procedure)",960,"$4,902.50 ","$3,676.88 ",75% of charges,"$3,676.88 ",75% of charges,$882.56 ,115% CMS RBRVS fee schedule,"$3,882.78 ",79.2% of total billed charges,"$3,882.78 ",79.2% of total billed charges,"$3,882.78 ",79.2% of total billed charges,"$3,882.78 ",79.2% of total billed charges,"$4,167.13 ",85% of total billed charges,N/A,Not separately reimbursable,$882.56 ,115% CMS RBRVS fee schedule,"$4,657.38 ",95% of total billed charges,"$3,922.00 ",80% of total billed charges,"$4,167.13 ",85% of total billed charges,"$4,412.25 ",90% of total billed charges,$882.56 ,115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$882.56 ,115% CMS RBRVS fee schedule,"$4,412.25 ",90% of total billed charges,"$3,725.90 ",76% of total billed charges,$882.56 ,115% CMS RBRVS fee schedule,$882.56 ,115% CMS RBRVS fee schedule,"$4,167.13 ",85% of total billed charges,N/A,Not separately reimbursable,$882.56 ,115% CMS RBRVS fee schedule,"$3,922.00 ",80% of total billed charges,$856.08 ,111.55% CMS RBRVS fee schedule,"$4,167.13 ",85% of total billed charges,N/A,Not separately reimbursable,$856.08 ,"$4,412.25 ",
Physician Medical Services,PHYSICIAN SURGERY SERVICES,27427,"27427 - Ligamentous Reconstruction (Augmentation), Knee; Extra-Articular",960,"$2,589.40 ","$1,942.05 ",75% of charges,"$1,942.05 ",75% of charges,$840.45 ,115% CMS RBRVS fee schedule,"$2,050.80 ",79.2% of total billed charges,"$2,050.80 ",79.2% of total billed charges,"$2,050.80 ",79.2% of total billed charges,"$2,050.80 ",79.2% of total billed charges,"$2,200.99 ",85% of total billed charges,N/A,Not separately reimbursable,$840.45 ,115% CMS RBRVS fee schedule,"$2,459.93 ",95% of total billed charges,"$2,071.52 ",80% of total billed charges,"$2,200.99 ",85% of total billed charges,"$2,330.46 ",90% of total billed charges,$840.45 ,115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$840.45 ,115% CMS RBRVS fee schedule,"$2,330.46 ",90% of total billed charges,"$1,967.94 ",76% of total billed charges,$840.45 ,115% CMS RBRVS fee schedule,$840.45 ,115% CMS RBRVS fee schedule,"$2,200.99 ",85% of total billed charges,N/A,Not separately reimbursable,$840.45 ,115% CMS RBRVS fee schedule,"$2,071.52 ",80% of total billed charges,$815.24 ,111.55% CMS RBRVS fee schedule,"$2,200.99 ",85% of total billed charges,N/A,Not separately reimbursable,$815.24 ,"$2,330.46 ",
Physician Medical Services,PHYSICIAN SURGERY SERVICES,27447,"27447 - Arthroplasty, Knee, Condyle And Plateau; Medial And Lateral Compartments With Or Without Patella Resurfacing (Total Knee Arthroplasty)",960,"$4,989.22 ","$3,741.92 ",75% of charges,"$3,741.92 ",75% of charges,"$1,496.12 ",115% CMS RBRVS fee schedule,"$3,951.46 ",79.2% of total billed charges,"$3,951.46 ",79.2% of total billed charges,"$3,951.46 ",79.2% of total billed charges,"$3,951.46 ",79.2% of total billed charges,"$4,240.84 ",85% of total billed charges,N/A,Not separately reimbursable,"$1,496.12 ",115% CMS RBRVS fee schedule,"$4,739.76 ",95% of total billed charges,"$3,991.38 ",80% of total billed charges,"$4,240.84 ",85% of total billed charges,"$4,490.30 ",90% of total billed charges,"$1,496.12 ",115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,"$1,496.12 ",115% CMS RBRVS fee schedule,"$4,490.30 ",90% of total billed charges,"$3,791.81 ",76% of total billed charges,"$1,496.12 ",115% CMS RBRVS fee schedule,"$1,496.12 ",115% CMS RBRVS fee schedule,"$4,240.84 ",85% of total billed charges,N/A,Not separately reimbursable,"$1,496.12 ",115% CMS RBRVS fee schedule,"$3,991.38 ",80% of total billed charges,"$1,451.23 ",111.55% CMS RBRVS fee schedule,"$4,240.84 ",85% of total billed charges,N/A,Not separately reimbursable,"$1,451.23 ","$4,490.30 ",
Physician Medical Services,PHYSICIAN SURGERY SERVICES,27486,"27486 - Revision Of Total Knee Arthroplasty, With Or Without Allograft; 1 Component",960,"$1,081.50 ",$811.13 ,75% of charges,$811.13 ,75% of charges,"$1,243.73 ",115% CMS RBRVS fee schedule,$856.55 ,79.2% of total billed charges,$856.55 ,79.2% of total billed charges,$856.55 ,79.2% of total billed charges,$856.55 ,79.2% of total billed charges,$919.28 ,85% of total billed charges,N/A,Not separately reimbursable,"$1,243.73 ",115% CMS RBRVS fee schedule,"$1,027.43 ",95% of total billed charges,$865.20 ,80% of total billed charges,$919.28 ,85% of total billed charges,$973.35 ,90% of total billed charges,"$1,243.73 ",115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,"$1,243.73 ",115% CMS RBRVS fee schedule,$973.35 ,90% of total billed charges,$821.94 ,76% of total billed charges,"$1,243.73 ",115% CMS RBRVS fee schedule,"$1,243.73 ",115% CMS RBRVS fee schedule,$919.28 ,85% of total billed charges,N/A,Not separately reimbursable,"$1,243.73 ",115% CMS RBRVS fee schedule,$865.20 ,80% of total billed charges,"$1,206.41 ",111.55% CMS RBRVS fee schedule,$919.28 ,85% of total billed charges,N/A,Not separately reimbursable,$821.94 ,"$1,243.73 ",
Physician Medical Services,PHYSICIAN SURGERY SERVICES,27658,"27658 - Repair, Flexor Tendon, Leg; Primary, Without Graft, Each Tendon",960,"$2,279.51 ","$1,709.63 ",75% of charges,"$1,709.63 ",75% of charges,$438.43 ,115% CMS RBRVS fee schedule,"$1,805.37 ",79.2% of total billed charges,"$1,805.37 ",79.2% of total billed charges,"$1,805.37 ",79.2% of total billed charges,"$1,805.37 ",79.2% of total billed charges,"$1,937.58 ",85% of total billed charges,N/A,Not separately reimbursable,$438.43 ,115% CMS RBRVS fee schedule,"$2,165.53 ",95% of total billed charges,"$1,823.61 ",80% of total billed charges,"$1,937.58 ",85% of total billed charges,"$2,051.56 ",90% of total billed charges,$438.43 ,115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$438.43 ,115% CMS RBRVS fee schedule,"$2,051.56 ",90% of total billed charges,"$1,732.43 ",76% of total billed charges,$438.43 ,115% CMS RBRVS fee schedule,$438.43 ,115% CMS RBRVS fee schedule,"$1,937.58 ",85% of total billed charges,N/A,Not separately reimbursable,$438.43 ,115% CMS RBRVS fee schedule,"$1,823.61 ",80% of total billed charges,$425.27 ,111.55% CMS RBRVS fee schedule,"$1,937.58 ",85% of total billed charges,N/A,Not separately reimbursable,$425.27 ,"$2,051.56 ",
Physician Medical Services,PHYSICIAN SURGERY SERVICES,27814,"27814 - Open Treatment Of Bimalleolar Ankle Fracture (Eg, Lateral And Medial Malleoli, Or Lateral And Posterior Malleoli, Or Medial And Posterior Mall",960,"$2,348.95 ","$1,761.71 ",75% of charges,"$1,761.71 ",75% of charges,$903.51 ,40% of charges which is 100% of the Medicare rate,"$1,860.37 ",79.2% of total billed charges,"$1,860.37 ",79.2% of total billed charges,"$1,860.37 ",79.2% of total billed charges,"$1,860.37 ",79.2% of total billed charges,"$1,996.61 ",85% of total billed charges,N/A,Not separately reimbursable,$903.51 ,40% of charges which is 100% of the Medicare rate,"$2,231.50 ",95% of total billed charges,"$1,879.16 ",80% of total billed charges,"$1,996.61 ",85% of total billed charges,"$2,114.06 ",90% of total billed charges,$903.51 ,40% of charges which is 100% of the Medicare rate,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$903.51 ,40% of charges which is 100% of the Medicare rate,"$2,114.06 ",90% of total billed charges,"$1,785.20 ",76% of total billed charges,$903.51 ,40% of charges which is 100% of the Medicare rate,$903.51 ,40% of charges which is 100% of the Medicare rate,"$1,996.61 ",85% of total billed charges,N/A,Not separately reimbursable,$903.51 ,40% of charges which is 100% of the Medicare rate,"$1,879.16 ",80% of total billed charges,$876.40 ,38.8% of charges which is 100% of the Medicare rate,"$1,996.61 ",85% of total billed charges,N/A,Not separately reimbursable,$876.40 ,"$2,114.06 ",
Physician Medical Services,PHYSICIAN SURGERY SERVICES,28090,"28090 - Excision Of Lesion, Tendon, Tendon Sheath, Or Capsule (Including Synovectomy) (Eg, Cyst Or Ganglion); Foot",960,"$1,032.00 ",$774.00 ,75% of charges,$774.00 ,75% of charges,$363.93 ,115% CMS RBRVS fee schedule,$817.34 ,79.2% of total billed charges,$817.34 ,79.2% of total billed charges,$817.34 ,79.2% of total billed charges,$817.34 ,79.2% of total billed charges,$877.20 ,85% of total billed charges,N/A,Not separately reimbursable,$363.93 ,115% CMS RBRVS fee schedule,$980.40 ,95% of total billed charges,$825.60 ,80% of total billed charges,$877.20 ,85% of total billed charges,$928.80 ,90% of total billed charges,$363.93 ,115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$363.93 ,115% CMS RBRVS fee schedule,$928.80 ,90% of total billed charges,$784.32 ,76% of total billed charges,$363.93 ,115% CMS RBRVS fee schedule,$363.93 ,115% CMS RBRVS fee schedule,$877.20 ,85% of total billed charges,N/A,Not separately reimbursable,$363.93 ,115% CMS RBRVS fee schedule,$825.60 ,80% of total billed charges,$353.01 ,111.55% CMS RBRVS fee schedule,$877.20 ,85% of total billed charges,N/A,Not separately reimbursable,$353.01 ,$928.80 ,
Physician Medical Services,PHYSICIAN SURGERY SERVICES,28119,"28119 - Ostectomy, Calcaneus; For Spur, With Or Without Plantar Fascial Release",960,"$1,905.50 ","$1,429.13 ",75% of charges,"$1,429.13 ",75% of charges,$428.28 ,115% CMS RBRVS fee schedule,"$1,509.16 ",79.2% of total billed charges,"$1,509.16 ",79.2% of total billed charges,"$1,509.16 ",79.2% of total billed charges,"$1,509.16 ",79.2% of total billed charges,"$1,619.68 ",85% of total billed charges,N/A,Not separately reimbursable,$428.28 ,115% CMS RBRVS fee schedule,"$1,810.23 ",95% of total billed charges,"$1,524.40 ",80% of total billed charges,"$1,619.68 ",85% of total billed charges,"$1,714.95 ",90% of total billed charges,$428.28 ,115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$428.28 ,115% CMS RBRVS fee schedule,"$1,714.95 ",90% of total billed charges,"$1,448.18 ",76% of total billed charges,$428.28 ,115% CMS RBRVS fee schedule,$428.28 ,115% CMS RBRVS fee schedule,"$1,619.68 ",85% of total billed charges,N/A,Not separately reimbursable,$428.28 ,115% CMS RBRVS fee schedule,"$1,524.40 ",80% of total billed charges,$415.43 ,111.55% CMS RBRVS fee schedule,"$1,619.68 ",85% of total billed charges,N/A,Not separately reimbursable,$415.43 ,"$1,714.95 ",
Physician Medical Services,PHYSICIAN SURGERY SERVICES,28285,"28285 - Correction, Hammertoe (Eg, Interphalangeal Fusion, Partial Or Total Phalangectomy)",960,"$1,940.50 ","$1,455.38 ",75% of charges,"$1,455.38 ",75% of charges,$454.17 ,115% CMS RBRVS fee schedule,"$1,536.88 ",79.2% of total billed charges,"$1,536.88 ",79.2% of total billed charges,"$1,536.88 ",79.2% of total billed charges,"$1,536.88 ",79.2% of total billed charges,"$1,649.43 ",85% of total billed charges,N/A,Not separately reimbursable,$454.17 ,115% CMS RBRVS fee schedule,"$1,843.48 ",95% of total billed charges,"$1,552.40 ",80% of total billed charges,"$1,649.43 ",85% of total billed charges,"$1,746.45 ",90% of total billed charges,$454.17 ,115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$454.17 ,115% CMS RBRVS fee schedule,"$1,746.45 ",90% of total billed charges,"$1,474.78 ",76% of total billed charges,$454.17 ,115% CMS RBRVS fee schedule,$454.17 ,115% CMS RBRVS fee schedule,"$1,649.43 ",85% of total billed charges,N/A,Not separately reimbursable,$454.17 ,115% CMS RBRVS fee schedule,"$1,552.40 ",80% of total billed charges,$440.54 ,111.55% CMS RBRVS fee schedule,"$1,649.43 ",85% of total billed charges,N/A,Not separately reimbursable,$440.54 ,"$1,746.45 ",
Physician Medical Services,PHYSICIAN SURGERY SERVICES,28820,"28820 - Amputation, Toe; Metatarsophalangeal Joint",960,"$2,913.20 ","$2,184.90 ",75% of charges,"$2,184.90 ",75% of charges,$205.75 ,115% CMS RBRVS fee schedule,"$2,307.25 ",79.2% of total billed charges,"$2,307.25 ",79.2% of total billed charges,"$2,307.25 ",79.2% of total billed charges,"$2,307.25 ",79.2% of total billed charges,"$2,476.22 ",85% of total billed charges,N/A,Not separately reimbursable,$205.75 ,115% CMS RBRVS fee schedule,"$2,767.54 ",95% of total billed charges,"$2,330.56 ",80% of total billed charges,"$2,476.22 ",85% of total billed charges,"$2,621.88 ",90% of total billed charges,$205.75 ,115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$205.75 ,115% CMS RBRVS fee schedule,"$2,621.88 ",90% of total billed charges,"$2,214.03 ",76% of total billed charges,$205.75 ,115% CMS RBRVS fee schedule,$205.75 ,115% CMS RBRVS fee schedule,"$2,476.22 ",85% of total billed charges,N/A,Not separately reimbursable,$205.75 ,115% CMS RBRVS fee schedule,"$2,330.56 ",80% of total billed charges,$199.57 ,111.55% CMS RBRVS fee schedule,"$2,476.22 ",85% of total billed charges,N/A,Not separately reimbursable,$199.57 ,"$2,621.88 ",
Physician Medical Services,PHYSICIAN SURGERY SERVICES,29806,"29806 - Arthroscopy, Shoulder, Surgical; Capsulorrhaphy",960,"$2,859.40 ","$2,144.55 ",75% of charges,"$2,144.55 ",75% of charges,"$1,242.81 ",115% CMS RBRVS fee schedule,"$2,264.64 ",79.2% of total billed charges,"$2,264.64 ",79.2% of total billed charges,"$2,264.64 ",79.2% of total billed charges,"$2,264.64 ",79.2% of total billed charges,"$2,430.49 ",85% of total billed charges,N/A,Not separately reimbursable,"$1,242.81 ",115% CMS RBRVS fee schedule,"$2,716.43 ",95% of total billed charges,"$2,287.52 ",80% of total billed charges,"$2,430.49 ",85% of total billed charges,"$2,573.46 ",90% of total billed charges,"$1,242.81 ",115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,"$1,242.81 ",115% CMS RBRVS fee schedule,"$2,573.46 ",90% of total billed charges,"$2,173.14 ",76% of total billed charges,"$1,242.81 ",115% CMS RBRVS fee schedule,"$1,242.81 ",115% CMS RBRVS fee schedule,"$2,430.49 ",85% of total billed charges,N/A,Not separately reimbursable,"$1,242.81 ",115% CMS RBRVS fee schedule,"$2,287.52 ",80% of total billed charges,"$1,205.52 ",111.55% CMS RBRVS fee schedule,"$2,430.49 ",85% of total billed charges,N/A,Not separately reimbursable,"$1,205.52 ","$2,573.46 ",
Physician Medical Services,PHYSICIAN SURGERY SERVICES,29822,"29822 - Arthroscopy, Shoulder, Surgical; Debridement, Limited",960,"$1,595.10 ","$1,196.33 ",75% of charges,"$1,196.33 ",75% of charges,$642.46 ,40% of charges which is 100% of the Medicare rate,"$1,263.32 ",79.2% of total billed charges,"$1,263.32 ",79.2% of total billed charges,"$1,263.32 ",79.2% of total billed charges,"$1,263.32 ",79.2% of total billed charges,"$1,355.84 ",85% of total billed charges,N/A,Not separately reimbursable,$642.46 ,40% of charges which is 100% of the Medicare rate,"$1,515.35 ",95% of total billed charges,"$1,276.08 ",80% of total billed charges,"$1,355.84 ",85% of total billed charges,"$1,435.59 ",90% of total billed charges,$642.46 ,40% of charges which is 100% of the Medicare rate,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$642.46 ,40% of charges which is 100% of the Medicare rate,"$1,435.59 ",90% of total billed charges,"$1,212.28 ",76% of total billed charges,$642.46 ,40% of charges which is 100% of the Medicare rate,$642.46 ,40% of charges which is 100% of the Medicare rate,"$1,355.84 ",85% of total billed charges,N/A,Not separately reimbursable,$642.46 ,40% of charges which is 100% of the Medicare rate,"$1,276.08 ",80% of total billed charges,$623.19 ,38.8% of charges which is 100% of the Medicare rate,"$1,355.84 ",85% of total billed charges,N/A,Not separately reimbursable,$623.19 ,"$1,435.59 ",
Physician Medical Services,PHYSICIAN SURGERY SERVICES,29827,"29827 - Arthroscopy, Shoulder, Surgical; With Rotator Cuff Repair",960,"$3,987.21 ","$2,990.41 ",75% of charges,"$2,990.41 ",75% of charges,"$1,254.42 ",115% CMS RBRVS fee schedule,"$3,157.87 ",79.2% of total billed charges,"$3,157.87 ",79.2% of total billed charges,"$3,157.87 ",79.2% of total billed charges,"$3,157.87 ",79.2% of total billed charges,"$3,389.13 ",85% of total billed charges,N/A,Not separately reimbursable,"$1,254.42 ",115% CMS RBRVS fee schedule,"$3,787.85 ",95% of total billed charges,"$3,189.77 ",80% of total billed charges,"$3,389.13 ",85% of total billed charges,"$3,588.49 ",90% of total billed charges,"$1,254.42 ",115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,"$1,254.42 ",115% CMS RBRVS fee schedule,"$3,588.49 ",90% of total billed charges,"$3,030.28 ",76% of total billed charges,"$1,254.42 ",115% CMS RBRVS fee schedule,"$1,254.42 ",115% CMS RBRVS fee schedule,"$3,389.13 ",85% of total billed charges,N/A,Not separately reimbursable,"$1,254.42 ",115% CMS RBRVS fee schedule,"$3,189.77 ",80% of total billed charges,"$1,216.79 ",111.55% CMS RBRVS fee schedule,"$3,389.13 ",85% of total billed charges,N/A,Not separately reimbursable,"$1,216.79 ","$3,588.49 ",
Physician Medical Services,PHYSICIAN SURGERY SERVICES,29877,"29877 - Arthroscopy, Knee, Surgical; Debridement/Shaving Of Articular Cartilage (Chondroplasty)",960,"$2,000.30 ","$1,500.23 ",75% of charges,"$1,500.23 ",75% of charges,$735.37 ,115% CMS RBRVS fee schedule,"$1,584.24 ",79.2% of total billed charges,"$1,584.24 ",79.2% of total billed charges,"$1,584.24 ",79.2% of total billed charges,"$1,584.24 ",79.2% of total billed charges,"$1,700.26 ",85% of total billed charges,N/A,Not separately reimbursable,$735.37 ,115% CMS RBRVS fee schedule,"$1,900.29 ",95% of total billed charges,"$1,600.24 ",80% of total billed charges,"$1,700.26 ",85% of total billed charges,"$1,800.27 ",90% of total billed charges,$735.37 ,115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$735.37 ,115% CMS RBRVS fee schedule,"$1,800.27 ",90% of total billed charges,"$1,520.23 ",76% of total billed charges,$735.37 ,115% CMS RBRVS fee schedule,$735.37 ,115% CMS RBRVS fee schedule,"$1,700.26 ",85% of total billed charges,N/A,Not separately reimbursable,$735.37 ,115% CMS RBRVS fee schedule,"$1,600.24 ",80% of total billed charges,$713.31 ,111.55% CMS RBRVS fee schedule,"$1,700.26 ",85% of total billed charges,N/A,Not separately reimbursable,$713.31 ,"$1,800.27 ",
Physician Medical Services,PHYSICIAN SURGERY SERVICES,29879,"29879 - Arthroscopy, Knee, Surgical; Abrasion Arthroplasty (Includes Chondroplasty Where Necessary) Or Multiple Drilling Or Microfracture",960,"$2,410.20 ","$1,807.65 ",75% of charges,"$1,807.65 ",75% of charges,$781.89 ,115% CMS RBRVS fee schedule,"$1,908.88 ",79.2% of total billed charges,"$1,908.88 ",79.2% of total billed charges,"$1,908.88 ",79.2% of total billed charges,"$1,908.88 ",79.2% of total billed charges,"$2,048.67 ",85% of total billed charges,N/A,Not separately reimbursable,$781.89 ,115% CMS RBRVS fee schedule,"$2,289.69 ",95% of total billed charges,"$1,928.16 ",80% of total billed charges,"$2,048.67 ",85% of total billed charges,"$2,169.18 ",90% of total billed charges,$781.89 ,115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$781.89 ,115% CMS RBRVS fee schedule,"$2,169.18 ",90% of total billed charges,"$1,831.75 ",76% of total billed charges,$781.89 ,115% CMS RBRVS fee schedule,$781.89 ,115% CMS RBRVS fee schedule,"$2,048.67 ",85% of total billed charges,N/A,Not separately reimbursable,$781.89 ,115% CMS RBRVS fee schedule,"$1,928.16 ",80% of total billed charges,$758.43 ,111.55% CMS RBRVS fee schedule,"$2,048.67 ",85% of total billed charges,N/A,Not separately reimbursable,$758.43 ,"$2,169.18 ",
Physician Medical Services,PHYSICIAN SURGERY SERVICES,29880,Surgery to remove of all or part of a torn meniscus in both medial and lateral compartments,960,"$1,253.50 ",$940.13 ,75% of charges,$940.13 ,75% of charges,$666.72 ,115% CMS RBRVS fee schedule,$992.77 ,79.2% of total billed charges,$992.77 ,79.2% of total billed charges,$992.77 ,79.2% of total billed charges,$992.77 ,79.2% of total billed charges,"$1,065.48 ",85% of total billed charges,N/A,Not separately reimbursable,$666.72 ,115% CMS RBRVS fee schedule,"$1,190.83 ",95% of total billed charges,"$1,002.80 ",80% of total billed charges,"$1,065.48 ",85% of total billed charges,"$1,128.15 ",90% of total billed charges,$666.72 ,115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$666.72 ,115% CMS RBRVS fee schedule,"$1,128.15 ",90% of total billed charges,$952.66 ,76% of total billed charges,$666.72 ,115% CMS RBRVS fee schedule,$666.72 ,115% CMS RBRVS fee schedule,"$1,065.48 ",85% of total billed charges,N/A,Not separately reimbursable,$666.72 ,115% CMS RBRVS fee schedule,"$1,002.80 ",80% of total billed charges,$646.72 ,111.55% CMS RBRVS fee schedule,"$1,065.48 ",85% of total billed charges,N/A,Not separately reimbursable,$646.72 ,"$1,128.15 ",
Physician Medical Services,PHYSICIAN SURGERY SERVICES,29881,Surgery to remove of all or part of a torn meniscus in one compartment,960,"$1,770.49 ","$1,327.87 ",75% of charges,"$1,327.87 ",75% of charges,$642.46 ,115% CMS RBRVS fee schedule,"$1,402.23 ",79.2% of total billed charges,"$1,402.23 ",79.2% of total billed charges,"$1,402.23 ",79.2% of total billed charges,"$1,402.23 ",79.2% of total billed charges,"$1,504.92 ",85% of total billed charges,N/A,Not separately reimbursable,$642.46 ,115% CMS RBRVS fee schedule,"$1,681.97 ",95% of total billed charges,"$1,416.39 ",80% of total billed charges,"$1,504.92 ",85% of total billed charges,"$1,593.44 ",90% of total billed charges,$642.46 ,115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$642.46 ,115% CMS RBRVS fee schedule,"$1,593.44 ",90% of total billed charges,"$1,345.57 ",76% of total billed charges,$642.46 ,115% CMS RBRVS fee schedule,$642.46 ,115% CMS RBRVS fee schedule,"$1,504.92 ",85% of total billed charges,N/A,Not separately reimbursable,$642.46 ,115% CMS RBRVS fee schedule,"$1,416.39 ",80% of total billed charges,$623.19 ,111.55% CMS RBRVS fee schedule,"$1,504.92 ",85% of total billed charges,N/A,Not separately reimbursable,$623.19 ,"$1,593.44 ",
Physician Medical Services,PHYSICIAN SURGERY SERVICES,29882,"29882 - Arthroscopy, Knee, Surgical; With Meniscus Repair (Medial Or Lateral)",960,"$2,428.23 ","$1,821.17 ",75% of charges,"$1,821.17 ",75% of charges,$813.98 ,115% CMS RBRVS fee schedule,"$1,923.16 ",79.2% of total billed charges,"$1,923.16 ",79.2% of total billed charges,"$1,923.16 ",79.2% of total billed charges,"$1,923.16 ",79.2% of total billed charges,"$2,064.00 ",85% of total billed charges,N/A,Not separately reimbursable,$813.98 ,115% CMS RBRVS fee schedule,"$2,306.82 ",95% of total billed charges,"$1,942.58 ",80% of total billed charges,"$2,064.00 ",85% of total billed charges,"$2,185.41 ",90% of total billed charges,$813.98 ,115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$813.98 ,115% CMS RBRVS fee schedule,"$2,185.41 ",90% of total billed charges,"$1,845.45 ",76% of total billed charges,$813.98 ,115% CMS RBRVS fee schedule,$813.98 ,115% CMS RBRVS fee schedule,"$2,064.00 ",85% of total billed charges,N/A,Not separately reimbursable,$813.98 ,115% CMS RBRVS fee schedule,"$1,942.58 ",80% of total billed charges,$789.56 ,111.55% CMS RBRVS fee schedule,"$2,064.00 ",85% of total billed charges,N/A,Not separately reimbursable,$789.56 ,"$2,185.41 ",
Physician Medical Services,PHYSICIAN SURGERY SERVICES,29888,ACL reconstruction,960,"$2,272.20 ","$1,704.15 ",75% of charges,"$1,704.15 ",75% of charges,"$1,144.66 ",115% CMS RBRVS fee schedule,"$1,799.58 ",79.2% of total billed charges,"$1,799.58 ",79.2% of total billed charges,"$1,799.58 ",79.2% of total billed charges,"$1,799.58 ",79.2% of total billed charges,"$1,931.37 ",85% of total billed charges,N/A,Not separately reimbursable,"$1,144.66 ",115% CMS RBRVS fee schedule,"$2,158.59 ",95% of total billed charges,"$1,817.76 ",80% of total billed charges,"$1,931.37 ",85% of total billed charges,"$2,044.98 ",90% of total billed charges,"$1,144.66 ",115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,"$1,144.66 ",115% CMS RBRVS fee schedule,"$2,044.98 ",90% of total billed charges,"$1,726.87 ",76% of total billed charges,"$1,144.66 ",115% CMS RBRVS fee schedule,"$1,144.66 ",115% CMS RBRVS fee schedule,"$1,931.37 ",85% of total billed charges,N/A,Not separately reimbursable,"$1,144.66 ",115% CMS RBRVS fee schedule,"$1,817.76 ",80% of total billed charges,"$1,110.32 ",111.55% CMS RBRVS fee schedule,"$1,931.37 ",85% of total billed charges,N/A,Not separately reimbursable,"$1,110.32 ","$2,044.98 ",
Physician Medical Services,PHYSICIAN SURGERY SERVICES,30520,Repair procedures of the nose,960,"$5,119.61 ","$3,839.71 ",75% of charges,"$3,839.71 ",75% of charges,$815.04 ,115% CMS RBRVS fee schedule,"$4,054.73 ",79.2% of total billed charges,"$4,054.73 ",79.2% of total billed charges,"$4,054.73 ",79.2% of total billed charges,"$4,054.73 ",79.2% of total billed charges,"$4,351.67 ",85% of total billed charges,N/A,Not separately reimbursable,$815.04 ,115% CMS RBRVS fee schedule,"$4,863.63 ",95% of total billed charges,"$4,095.69 ",80% of total billed charges,"$4,351.67 ",85% of total billed charges,"$4,607.65 ",90% of total billed charges,$815.04 ,115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$815.04 ,115% CMS RBRVS fee schedule,"$4,607.65 ",90% of total billed charges,"$3,890.90 ",76% of total billed charges,$815.04 ,115% CMS RBRVS fee schedule,$815.04 ,115% CMS RBRVS fee schedule,"$4,351.67 ",85% of total billed charges,N/A,Not separately reimbursable,$815.04 ,115% CMS RBRVS fee schedule,"$4,095.69 ",80% of total billed charges,$790.59 ,111.55% CMS RBRVS fee schedule,"$4,351.67 ",85% of total billed charges,N/A,Not separately reimbursable,$790.59 ,"$4,607.65 ",
Physician Medical Services,PHYSICIAN SURGERY SERVICES,31254,"31254 - Nasal/Sinus Endoscopy, Surgical; With Ethmoidectomy, Partial (Anterior)",960,"$5,015.90 ","$3,761.93 ",75% of charges,"$3,761.93 ",75% of charges,$282.53 ,115% CMS RBRVS fee schedule,"$3,972.59 ",79.2% of total billed charges,"$3,972.59 ",79.2% of total billed charges,"$3,972.59 ",79.2% of total billed charges,"$3,972.59 ",79.2% of total billed charges,"$4,263.52 ",85% of total billed charges,N/A,Not separately reimbursable,$282.53 ,115% CMS RBRVS fee schedule,"$4,765.11 ",95% of total billed charges,"$4,012.72 ",80% of total billed charges,"$4,263.52 ",85% of total billed charges,"$4,514.31 ",90% of total billed charges,$282.53 ,115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$282.53 ,115% CMS RBRVS fee schedule,"$4,514.31 ",90% of total billed charges,"$3,812.08 ",76% of total billed charges,$282.53 ,115% CMS RBRVS fee schedule,$282.53 ,115% CMS RBRVS fee schedule,"$4,263.52 ",85% of total billed charges,N/A,Not separately reimbursable,$282.53 ,115% CMS RBRVS fee schedule,"$4,012.72 ",80% of total billed charges,$274.06 ,111.55% CMS RBRVS fee schedule,"$4,263.52 ",85% of total billed charges,N/A,Not separately reimbursable,$274.06 ,"$4,514.31 ",
Physician Medical Services,PHYSICIAN SURGERY SERVICES,36561,"36561 - Insertion Of Tunneled Centrally Inserted Central Venous Access Device, With Subcutaneous Port; Age 5 Years Or Older",960,"$1,199.64 ",$899.73 ,75% of charges,$899.73 ,75% of charges,$381.98 ,115% CMS RBRVS fee schedule,$950.11 ,79.2% of total billed charges,$950.11 ,79.2% of total billed charges,$950.11 ,79.2% of total billed charges,$950.11 ,79.2% of total billed charges,"$1,019.69 ",85% of total billed charges,N/A,Not separately reimbursable,$381.98 ,115% CMS RBRVS fee schedule,"$1,139.66 ",95% of total billed charges,$959.71 ,80% of total billed charges,"$1,019.69 ",85% of total billed charges,"$1,079.68 ",90% of total billed charges,$381.98 ,115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$381.98 ,115% CMS RBRVS fee schedule,"$1,079.68 ",90% of total billed charges,$911.73 ,76% of total billed charges,$381.98 ,115% CMS RBRVS fee schedule,$381.98 ,115% CMS RBRVS fee schedule,"$1,019.69 ",85% of total billed charges,N/A,Not separately reimbursable,$381.98 ,115% CMS RBRVS fee schedule,$959.71 ,80% of total billed charges,$370.52 ,111.55% CMS RBRVS fee schedule,"$1,019.69 ",85% of total billed charges,N/A,Not separately reimbursable,$370.52 ,"$1,079.68 ",
Physician Medical Services,PHYSICIAN SURGERY SERVICES,42820,Removal of tonsils and adenoid glands patient younger than age 12,960,"$1,022.80 ",$767.10 ,75% of charges,$767.10 ,75% of charges,$345.23 ,115% CMS RBRVS fee schedule,$810.06 ,79.2% of total billed charges,$810.06 ,79.2% of total billed charges,$810.06 ,79.2% of total billed charges,$810.06 ,79.2% of total billed charges,$869.38 ,85% of total billed charges,N/A,Not separately reimbursable,$345.23 ,115% CMS RBRVS fee schedule,$971.66 ,95% of total billed charges,$818.24 ,80% of total billed charges,$869.38 ,85% of total billed charges,$920.52 ,90% of total billed charges,$345.23 ,115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$345.23 ,115% CMS RBRVS fee schedule,$920.52 ,90% of total billed charges,$777.33 ,76% of total billed charges,$345.23 ,115% CMS RBRVS fee schedule,$345.23 ,115% CMS RBRVS fee schedule,$869.38 ,85% of total billed charges,N/A,Not separately reimbursable,$345.23 ,115% CMS RBRVS fee schedule,$818.24 ,80% of total billed charges,$334.87 ,111.55% CMS RBRVS fee schedule,$869.38 ,85% of total billed charges,N/A,Not separately reimbursable,$334.87 ,$920.52 ,
Physician Medical Services,PHYSICIAN SURGERY SERVICES,42825,"42825 - Tonsillectomy, Primary Or Secondary; Younger Than Age 12",960,$922.90 ,$692.18 ,75% of charges,$692.18 ,75% of charges,$320.36 ,115% CMS RBRVS fee schedule,$730.94 ,79.2% of total billed charges,$730.94 ,79.2% of total billed charges,$730.94 ,79.2% of total billed charges,$730.94 ,79.2% of total billed charges,$784.47 ,85% of total billed charges,N/A,Not separately reimbursable,$320.36 ,115% CMS RBRVS fee schedule,$876.76 ,95% of total billed charges,$738.32 ,80% of total billed charges,$784.47 ,85% of total billed charges,$830.61 ,90% of total billed charges,$320.36 ,115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$320.36 ,115% CMS RBRVS fee schedule,$830.61 ,90% of total billed charges,$701.40 ,76% of total billed charges,$320.36 ,115% CMS RBRVS fee schedule,$320.36 ,115% CMS RBRVS fee schedule,$784.47 ,85% of total billed charges,N/A,Not separately reimbursable,$320.36 ,115% CMS RBRVS fee schedule,$738.32 ,80% of total billed charges,$310.74 ,111.55% CMS RBRVS fee schedule,$784.47 ,85% of total billed charges,N/A,Not separately reimbursable,$310.74 ,$830.61 ,
Physician Medical Services,PHYSICIAN SURGERY SERVICES,42826,Primary or secondary removal of tonsils,960,$885.80 ,$664.35 ,75% of charges,$664.35 ,75% of charges,$304.50 ,115% CMS RBRVS fee schedule,$701.55 ,79.2% of total billed charges,$701.55 ,79.2% of total billed charges,$701.55 ,79.2% of total billed charges,$701.55 ,79.2% of total billed charges,$752.93 ,85% of total billed charges,N/A,Not separately reimbursable,$304.50 ,115% CMS RBRVS fee schedule,$841.51 ,95% of total billed charges,$708.64 ,80% of total billed charges,$752.93 ,85% of total billed charges,$797.22 ,90% of total billed charges,$304.50 ,115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$304.50 ,115% CMS RBRVS fee schedule,$797.22 ,90% of total billed charges,$673.21 ,76% of total billed charges,$304.50 ,115% CMS RBRVS fee schedule,$304.50 ,115% CMS RBRVS fee schedule,$752.93 ,85% of total billed charges,N/A,Not separately reimbursable,$304.50 ,115% CMS RBRVS fee schedule,$708.64 ,80% of total billed charges,$295.36 ,111.55% CMS RBRVS fee schedule,$752.93 ,85% of total billed charges,N/A,Not separately reimbursable,$295.36 ,$797.22 ,
Physician Medical Services,PHYSICIAN SURGERY SERVICES,43235,"Diagnostic examination of esophagus, stomach, and/or upper small bowel using an endoscope",960,$451.48 ,$338.61 ,75% of charges,$338.61 ,75% of charges,$141.07 ,115% CMS RBRVS fee schedule,$357.57 ,79.2% of total billed charges,$357.57 ,79.2% of total billed charges,$357.57 ,79.2% of total billed charges,$357.57 ,79.2% of total billed charges,$383.76 ,85% of total billed charges,N/A,Not separately reimbursable,$141.07 ,115% CMS RBRVS fee schedule,$428.91 ,95% of total billed charges,$361.18 ,80% of total billed charges,$383.76 ,85% of total billed charges,$406.33 ,90% of total billed charges,$141.07 ,115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$141.07 ,115% CMS RBRVS fee schedule,$406.33 ,90% of total billed charges,$343.12 ,76% of total billed charges,$141.07 ,115% CMS RBRVS fee schedule,$141.07 ,115% CMS RBRVS fee schedule,$383.76 ,85% of total billed charges,N/A,Not separately reimbursable,$141.07 ,115% CMS RBRVS fee schedule,$361.18 ,80% of total billed charges,$136.84 ,111.55% CMS RBRVS fee schedule,$383.76 ,85% of total billed charges,N/A,Not separately reimbursable,$136.84 ,$406.33 ,
Physician Medical Services,PHYSICIAN SURGERY SERVICES,43239,"Biopsy of the esophagus, stomach, and/or upper small bowel using an endoscope",960,"$1,156.56 ",$867.42 ,75% of charges,$867.42 ,75% of charges,$159.08 ,115% CMS RBRVS fee schedule,$916.00 ,79.2% of total billed charges,$916.00 ,79.2% of total billed charges,$916.00 ,79.2% of total billed charges,$916.00 ,79.2% of total billed charges,$983.08 ,85% of total billed charges,N/A,Not separately reimbursable,$159.08 ,115% CMS RBRVS fee schedule,"$1,098.73 ",95% of total billed charges,$925.25 ,80% of total billed charges,$983.08 ,85% of total billed charges,"$1,040.90 ",90% of total billed charges,$159.08 ,115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$159.08 ,115% CMS RBRVS fee schedule,"$1,040.90 ",90% of total billed charges,$878.99 ,76% of total billed charges,$159.08 ,115% CMS RBRVS fee schedule,$159.08 ,115% CMS RBRVS fee schedule,$983.08 ,85% of total billed charges,N/A,Not separately reimbursable,$159.08 ,115% CMS RBRVS fee schedule,$925.25 ,80% of total billed charges,$154.31 ,111.55% CMS RBRVS fee schedule,$983.08 ,85% of total billed charges,N/A,Not separately reimbursable,$154.31 ,"$1,040.90 ",
Physician Medical Services,PHYSICIAN SURGERY SERVICES,44970,"44970 - Laparoscopy, Surgical, Appendectomy",960,"$2,410.10 ","$1,807.58 ",75% of charges,"$1,807.58 ",75% of charges,$699.83 ,115% CMS RBRVS fee schedule,"$1,908.80 ",79.2% of total billed charges,"$1,908.80 ",79.2% of total billed charges,"$1,908.80 ",79.2% of total billed charges,"$1,908.80 ",79.2% of total billed charges,"$2,048.59 ",85% of total billed charges,N/A,Not separately reimbursable,$699.83 ,115% CMS RBRVS fee schedule,"$2,289.60 ",95% of total billed charges,"$1,928.08 ",80% of total billed charges,"$2,048.59 ",85% of total billed charges,"$2,169.09 ",90% of total billed charges,$699.83 ,115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$699.83 ,115% CMS RBRVS fee schedule,"$2,169.09 ",90% of total billed charges,"$1,831.68 ",76% of total billed charges,$699.83 ,115% CMS RBRVS fee schedule,$699.83 ,115% CMS RBRVS fee schedule,"$2,048.59 ",85% of total billed charges,N/A,Not separately reimbursable,$699.83 ,115% CMS RBRVS fee schedule,"$1,928.08 ",80% of total billed charges,$678.84 ,111.55% CMS RBRVS fee schedule,"$2,048.59 ",85% of total billed charges,N/A,Not separately reimbursable,$678.84 ,"$2,169.09 ",
Physician Medical Services,PHYSICIAN SURGERY SERVICES,45330,"45330 - Sigmoidoscopy, Flexible; Diagnostic, With Or Without Collection Of Specimen(S) By Brushing Or Washing (Separate Procedure)",960,N/A,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,N/A,
Physician Medical Services,PHYSICIAN SURGERY SERVICES,45331,"45331 - Sigmoidoscopy, Flexible; With Biopsy, Single Or Multiple",960,N/A,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,N/A,
Physician Medical Services,PHYSICIAN SURGERY SERVICES,45378,Diagnostic examination of large bowel using an endoscope,960,N/A,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,N/A,
Physician Medical Services,PHYSICIAN SURGERY SERVICES,45380,Biopsy of large bowel using an endoscope,960,N/A,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,N/A,
Physician Medical Services,PHYSICIAN SURGERY SERVICES,45384,Removal of polyps or growths in large bowel using an endoscope,960,N/A,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,N/A,
Physician Medical Services,PHYSICIAN SURGERY SERVICES,45385,Removal of polyps or growths of large bowel using an endoscope,960,N/A,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,N/A,
Physician Medical Services,PHYSICIAN SURGERY SERVICES,45388,Destruction of large bowel growths using an endoscope,960,N/A,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,N/A,
Physician Medical Services,PHYSICIAN SURGERY SERVICES,45990,"45990 - Anorectal Exam, Surgical, Requiring Anesthesia (General, Spinal, Or Epidural), Diagnostic",960,$305.90 ,$229.43 ,75% of charges,$229.43 ,75% of charges,$121.14 ,40% of charges which is 100% of the Medicare rate,$242.27 ,79.2% of total billed charges,$242.27 ,79.2% of total billed charges,$242.27 ,79.2% of total billed charges,$242.27 ,79.2% of total billed charges,$260.02 ,85% of total billed charges,N/A,Not separately reimbursable,$121.14 ,40% of charges which is 100% of the Medicare rate,$290.61 ,95% of total billed charges,$244.72 ,80% of total billed charges,$260.02 ,85% of total billed charges,$275.31 ,90% of total billed charges,$121.14 ,40% of charges which is 100% of the Medicare rate,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$121.14 ,40% of charges which is 100% of the Medicare rate,$275.31 ,90% of total billed charges,$232.48 ,76% of total billed charges,$121.14 ,40% of charges which is 100% of the Medicare rate,$121.14 ,40% of charges which is 100% of the Medicare rate,$260.02 ,85% of total billed charges,N/A,Not separately reimbursable,$121.14 ,40% of charges which is 100% of the Medicare rate,$244.72 ,80% of total billed charges,$117.51 ,38.8% of charges which is 100% of the Medicare rate,$260.02 ,85% of total billed charges,N/A,Not separately reimbursable,$117.51 ,$275.31 ,
Physician Medical Services,PHYSICIAN SURGERY SERVICES,46221,"46221 - Hemorrhoidectomy, Internal, By Rubber Band Ligation(S)",960,$620.90 ,$465.68 ,75% of charges,$465.68 ,75% of charges,$228.51 ,115% CMS RBRVS fee schedule,$491.75 ,79.2% of total billed charges,$491.75 ,79.2% of total billed charges,$491.75 ,79.2% of total billed charges,$491.75 ,79.2% of total billed charges,$527.77 ,85% of total billed charges,N/A,Not separately reimbursable,$228.51 ,115% CMS RBRVS fee schedule,$589.86 ,95% of total billed charges,$496.72 ,80% of total billed charges,$527.77 ,85% of total billed charges,$558.81 ,90% of total billed charges,$228.51 ,115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$228.51 ,115% CMS RBRVS fee schedule,$558.81 ,90% of total billed charges,$471.88 ,76% of total billed charges,$228.51 ,115% CMS RBRVS fee schedule,$228.51 ,115% CMS RBRVS fee schedule,$527.77 ,85% of total billed charges,N/A,Not separately reimbursable,$228.51 ,115% CMS RBRVS fee schedule,$496.72 ,80% of total billed charges,$221.65 ,111.55% CMS RBRVS fee schedule,$527.77 ,85% of total billed charges,N/A,Not separately reimbursable,$221.65 ,$558.81 ,
Physician Medical Services,PHYSICIAN SURGERY SERVICES,46922,"46922 - Destruction Of Lesion(S), Anus (Eg, Condyloma, Papilloma, Molluscum Contagiosum, Herpetic Vesicle), Simple; Surgical Excision",960,$409.90 ,$307.43 ,75% of charges,$307.43 ,75% of charges,$162.18 ,40% of charges which is 100% of the Medicare rate,$324.64 ,79.2% of total billed charges,$324.64 ,79.2% of total billed charges,$324.64 ,79.2% of total billed charges,$324.64 ,79.2% of total billed charges,$348.42 ,85% of total billed charges,N/A,Not separately reimbursable,$162.18 ,40% of charges which is 100% of the Medicare rate,$389.41 ,95% of total billed charges,$327.92 ,80% of total billed charges,$348.42 ,85% of total billed charges,$368.91 ,90% of total billed charges,$162.18 ,40% of charges which is 100% of the Medicare rate,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$162.18 ,40% of charges which is 100% of the Medicare rate,$368.91 ,90% of total billed charges,$311.52 ,76% of total billed charges,$162.18 ,40% of charges which is 100% of the Medicare rate,$162.18 ,40% of charges which is 100% of the Medicare rate,$348.42 ,85% of total billed charges,N/A,Not separately reimbursable,$162.18 ,40% of charges which is 100% of the Medicare rate,$327.92 ,80% of total billed charges,$157.32 ,38.8% of charges which is 100% of the Medicare rate,$348.42 ,85% of total billed charges,N/A,Not separately reimbursable,$157.32 ,$368.91 ,
Physician Medical Services,PHYSICIAN SURGERY SERVICES,46945,"46945 - Hemorrhoidectomy, Internal, By Ligation Other Than Rubber Band; Single Hemorrhoid Column/Group",960,"$1,250.20 ",$937.65 ,75% of charges,$937.65 ,75% of charges,$404.67 ,115% CMS RBRVS fee schedule,$990.16 ,79.2% of total billed charges,$990.16 ,79.2% of total billed charges,$990.16 ,79.2% of total billed charges,$990.16 ,79.2% of total billed charges,"$1,062.67 ",85% of total billed charges,N/A,Not separately reimbursable,$404.67 ,115% CMS RBRVS fee schedule,"$1,187.69 ",95% of total billed charges,"$1,000.16 ",80% of total billed charges,"$1,062.67 ",85% of total billed charges,"$1,125.18 ",90% of total billed charges,$404.67 ,115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$404.67 ,115% CMS RBRVS fee schedule,"$1,125.18 ",90% of total billed charges,$950.15 ,76% of total billed charges,$404.67 ,115% CMS RBRVS fee schedule,$404.67 ,115% CMS RBRVS fee schedule,"$1,062.67 ",85% of total billed charges,N/A,Not separately reimbursable,$404.67 ,115% CMS RBRVS fee schedule,"$1,000.16 ",80% of total billed charges,$392.53 ,111.55% CMS RBRVS fee schedule,"$1,062.67 ",85% of total billed charges,N/A,Not separately reimbursable,$392.53 ,"$1,125.18 ",
Physician Medical Services,PHYSICIAN SURGERY SERVICES,47562,Removal of gallbladder using an endoscope,960,"$2,096.00 ","$1,572.00 ",75% of charges,"$1,572.00 ",75% of charges,$764.95 ,115% CMS RBRVS fee schedule,"$1,660.03 ",79.2% of total billed charges,"$1,660.03 ",79.2% of total billed charges,"$1,660.03 ",79.2% of total billed charges,"$1,660.03 ",79.2% of total billed charges,"$1,781.60 ",85% of total billed charges,N/A,Not separately reimbursable,$764.95 ,115% CMS RBRVS fee schedule,"$1,991.20 ",95% of total billed charges,"$1,676.80 ",80% of total billed charges,"$1,781.60 ",85% of total billed charges,"$1,886.40 ",90% of total billed charges,$764.95 ,115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$764.95 ,115% CMS RBRVS fee schedule,"$1,886.40 ",90% of total billed charges,"$1,592.96 ",76% of total billed charges,$764.95 ,115% CMS RBRVS fee schedule,$764.95 ,115% CMS RBRVS fee schedule,"$1,781.60 ",85% of total billed charges,N/A,Not separately reimbursable,$764.95 ,115% CMS RBRVS fee schedule,"$1,676.80 ",80% of total billed charges,$742.00 ,111.55% CMS RBRVS fee schedule,"$1,781.60 ",85% of total billed charges,N/A,Not separately reimbursable,$742.00 ,"$1,886.40 ",
Physician Medical Services,PHYSICIAN SURGERY SERVICES,49321,"49321 - Laparoscopy, Surgical; With Biopsy (Single Or Multiple)",960,"$1,531.00 ","$1,148.25 ",75% of charges,"$1,148.25 ",75% of charges,$400.50 ,115% CMS RBRVS fee schedule,"$1,212.55 ",79.2% of total billed charges,"$1,212.55 ",79.2% of total billed charges,"$1,212.55 ",79.2% of total billed charges,"$1,212.55 ",79.2% of total billed charges,"$1,301.35 ",85% of total billed charges,N/A,Not separately reimbursable,$400.50 ,115% CMS RBRVS fee schedule,"$1,454.45 ",95% of total billed charges,"$1,224.80 ",80% of total billed charges,"$1,301.35 ",85% of total billed charges,"$1,377.90 ",90% of total billed charges,$400.50 ,115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$400.50 ,115% CMS RBRVS fee schedule,"$1,377.90 ",90% of total billed charges,"$1,163.56 ",76% of total billed charges,$400.50 ,115% CMS RBRVS fee schedule,$400.50 ,115% CMS RBRVS fee schedule,"$1,301.35 ",85% of total billed charges,N/A,Not separately reimbursable,$400.50 ,115% CMS RBRVS fee schedule,"$1,224.80 ",80% of total billed charges,$388.48 ,111.55% CMS RBRVS fee schedule,"$1,301.35 ",85% of total billed charges,N/A,Not separately reimbursable,$388.48 ,"$1,377.90 ",
Physician Medical Services,PHYSICIAN SURGERY SERVICES,49505,Repair of groin hernia patient age 5 years or older,960,"$1,813.84 ","$1,360.38 ",75% of charges,"$1,360.38 ",75% of charges,$609.44 ,115% CMS RBRVS fee schedule,"$1,436.56 ",79.2% of total billed charges,"$1,436.56 ",79.2% of total billed charges,"$1,436.56 ",79.2% of total billed charges,"$1,436.56 ",79.2% of total billed charges,"$1,541.76 ",85% of total billed charges,N/A,Not separately reimbursable,$609.44 ,115% CMS RBRVS fee schedule,"$1,723.15 ",95% of total billed charges,"$1,451.07 ",80% of total billed charges,"$1,541.76 ",85% of total billed charges,"$1,632.46 ",90% of total billed charges,$609.44 ,115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$609.44 ,115% CMS RBRVS fee schedule,"$1,632.46 ",90% of total billed charges,"$1,378.52 ",76% of total billed charges,$609.44 ,115% CMS RBRVS fee schedule,$609.44 ,115% CMS RBRVS fee schedule,"$1,541.76 ",85% of total billed charges,N/A,Not separately reimbursable,$609.44 ,115% CMS RBRVS fee schedule,"$1,451.07 ",80% of total billed charges,$591.16 ,111.55% CMS RBRVS fee schedule,"$1,541.76 ",85% of total billed charges,N/A,Not separately reimbursable,$591.16 ,"$1,632.46 ",
Physician Medical Services,PHYSICIAN SURGERY SERVICES,49585,Repair of umbilical hernia in patients over 5 years old,960,"$1,586.40 ","$1,189.80 ",75% of charges,"$1,189.80 ",75% of charges,N/A,Not separately reimbursable,"$1,256.43 ",79.2% of total billed charges,"$1,256.43 ",79.2% of total billed charges,"$1,256.43 ",79.2% of total billed charges,"$1,256.43 ",79.2% of total billed charges,"$1,348.44 ",85% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,"$1,507.08 ",95% of total billed charges,"$1,269.12 ",80% of total billed charges,"$1,348.44 ",85% of total billed charges,"$1,427.76 ",90% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,"$1,427.76 ",90% of total billed charges,"$1,205.66 ",76% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,"$1,348.44 ",85% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,"$1,269.12 ",80% of total billed charges,N/A,Not separately reimbursable,"$1,348.44 ",85% of total billed charges,N/A,Not separately reimbursable,N/A,"$1,427.76 ",
Physician Medical Services,PHYSICIAN SURGERY SERVICES,58661,"Removal of either benign or malignant tissue from the uterus, ovaries, fallopian tubes, or any of the surrounding tissues using a laparoscope",960,N/A,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,N/A,
Physician Medical Services,PHYSICIAN SURGERY SERVICES,58662,"Removal of lesions of the ovary, pelvic viscera, or peritoneal surface",960,N/A,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,N/A,
Physician Medical Services,PHYSICIAN SURGERY SERVICES,58670,"58670 - Laparoscopy, Surgical; With Fulguration Of Oviducts (With Or Without Transection)",960,N/A,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,N/A,
Physician Medical Services,PHYSICIAN SURGERY SERVICES,60500,60500 - Parathyroidectomy Or Exploration Of Parathyroid(S);,960,"$2,991.60 ","$2,243.70 ",75% of charges,"$2,243.70 ",75% of charges,"$1,128.09 ",40% of charges which is 100% of the Medicare rate,"$2,369.35 ",79.2% of total billed charges,"$2,369.35 ",79.2% of total billed charges,"$2,369.35 ",79.2% of total billed charges,"$2,369.35 ",79.2% of total billed charges,"$2,542.86 ",85% of total billed charges,N/A,Not separately reimbursable,"$1,128.09 ",40% of charges which is 100% of the Medicare rate,"$2,842.02 ",95% of total billed charges,"$2,393.28 ",80% of total billed charges,"$2,542.86 ",85% of total billed charges,"$2,692.44 ",90% of total billed charges,"$1,128.09 ",40% of charges which is 100% of the Medicare rate,N/A,Not separately reimbursable,N/A,Not separately reimbursable,"$1,128.09 ",40% of charges which is 100% of the Medicare rate,"$2,692.44 ",90% of total billed charges,"$2,273.62 ",76% of total billed charges,"$1,128.09 ",40% of charges which is 100% of the Medicare rate,"$1,128.09 ",40% of charges which is 100% of the Medicare rate,"$2,542.86 ",85% of total billed charges,N/A,Not separately reimbursable,"$1,128.09 ",40% of charges which is 100% of the Medicare rate,"$2,393.28 ",80% of total billed charges,"$1,094.25 ",38.8% of charges which is 100% of the Medicare rate,"$2,542.86 ",85% of total billed charges,N/A,Not separately reimbursable,"$1,094.25 ","$2,692.44 ",
Physician Medical Services,PHYSICIAN SURGERY SERVICES,62323,Injection of substance into spinal canal of lower back or sacrum using imaging guidance,960,$878.15 ,$658.61 ,75% of charges,$658.61 ,75% of charges,$114.55 ,115% CMS RBRVS fee schedule,$695.49 ,79.2% of total billed charges,$695.49 ,79.2% of total billed charges,$695.49 ,79.2% of total billed charges,$695.49 ,79.2% of total billed charges,$746.43 ,85% of total billed charges,N/A,Not separately reimbursable,$114.55 ,115% CMS RBRVS fee schedule,$834.24 ,95% of total billed charges,$702.52 ,80% of total billed charges,$746.43 ,85% of total billed charges,$790.34 ,90% of total billed charges,$114.55 ,115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$114.55 ,115% CMS RBRVS fee schedule,$790.34 ,90% of total billed charges,$667.39 ,76% of total billed charges,$114.55 ,115% CMS RBRVS fee schedule,$114.55 ,115% CMS RBRVS fee schedule,$746.43 ,85% of total billed charges,N/A,Not separately reimbursable,$114.55 ,115% CMS RBRVS fee schedule,$702.52 ,80% of total billed charges,$111.11 ,111.55% CMS RBRVS fee schedule,$746.43 ,85% of total billed charges,N/A,Not separately reimbursable,$111.11 ,$790.34 ,
Physician Medical Services,PHYSICIAN SURGERY SERVICES,64483,Injections of anesthetic and/or steroid drug into lower or sacral spine nerve root using imaging guidance,960,$537.93 ,$403.45 ,75% of charges,$403.45 ,75% of charges,$128.70 ,115% CMS RBRVS fee schedule,$426.04 ,79.2% of total billed charges,$426.04 ,79.2% of total billed charges,$426.04 ,79.2% of total billed charges,$426.04 ,79.2% of total billed charges,$457.24 ,85% of total billed charges,N/A,Not separately reimbursable,$128.70 ,115% CMS RBRVS fee schedule,$511.03 ,95% of total billed charges,$430.34 ,80% of total billed charges,$457.24 ,85% of total billed charges,$484.14 ,90% of total billed charges,$128.70 ,115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$128.70 ,115% CMS RBRVS fee schedule,$484.14 ,90% of total billed charges,$408.83 ,76% of total billed charges,$128.70 ,115% CMS RBRVS fee schedule,$128.70 ,115% CMS RBRVS fee schedule,$457.24 ,85% of total billed charges,N/A,Not separately reimbursable,$128.70 ,115% CMS RBRVS fee schedule,$430.34 ,80% of total billed charges,$124.84 ,111.55% CMS RBRVS fee schedule,$457.24 ,85% of total billed charges,N/A,Not separately reimbursable,$124.84 ,$484.14 ,
Physician Medical Services,PHYSICIAN SURGERY SERVICES,64721,Release of the transverse carpal ligament,960,$994.00 ,$745.50 ,75% of charges,$745.50 ,75% of charges,$521.85 ,115% CMS RBRVS fee schedule,$787.25 ,79.2% of total billed charges,$787.25 ,79.2% of total billed charges,$787.25 ,79.2% of total billed charges,$787.25 ,79.2% of total billed charges,$844.90 ,85% of total billed charges,N/A,Not separately reimbursable,$521.85 ,115% CMS RBRVS fee schedule,$944.30 ,95% of total billed charges,$795.20 ,80% of total billed charges,$844.90 ,85% of total billed charges,$894.60 ,90% of total billed charges,$521.85 ,115% CMS RBRVS fee schedule,N/A,Not separately reimbursable,N/A,Not separately reimbursable,$521.85 ,115% CMS RBRVS fee schedule,$894.60 ,90% of total billed charges,$755.44 ,76% of total billed charges,$521.85 ,115% CMS RBRVS fee schedule,$521.85 ,115% CMS RBRVS fee schedule,$844.90 ,85% of total billed charges,N/A,Not separately reimbursable,$521.85 ,115% CMS RBRVS fee schedule,$795.20 ,80% of total billed charges,$506.19 ,111.55% CMS RBRVS fee schedule,$844.90 ,85% of total billed charges,N/A,Not separately reimbursable,$506.19 ,$894.60 ,
Outpatient Medical Services,OFFICE VISIT,99203,"New patient office or other outpatient visit, typically 30 min",761,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,OFFICE VISIT,99204,"New patient office of other outpatient visit, typically 45 min",761,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,OFFICE VISIT,99205,"New patient office of other outpatient visit, typically 60 min",761,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,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,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,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,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,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,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,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,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,OUTPATIENT SERVICES,55866,Surgical removal of prostate and surrounding lymph nodes using an endoscope,360,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,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,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,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,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,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,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,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,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,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,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,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,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,CARDIOLOGY,93452,Insertion of catheter into left heart for diagnosis,480,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,SLEEP STUDY,95810,Sleep study,920,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Inpatient Medical Services,INPATIENT PROCEDURES,216,Cardiac valve and other major cardiothoracic procedures with cardiac catheterization with major complications or comorbidities,100,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Inpatient Medical Services,INPATIENT PROCEDURES,460,Spinal fusion except cervical without major comorbid conditions or complications,100,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,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,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Inpatient Medical Services,INPATIENT PROCEDURES,473,Cervical spinal fusion without comorbid conditions or major comorbid conditions or complications,100,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,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,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A