 |
Benefit Utilization |  |
| By Group Code | Report Date: 12/18/2003 |
| By Plan | Report Period: 11/01/2003 - 11/30/2003 Paid |
| By Location |
Procedure
Description
Mem
Cnt
Days
Chrgs
Disallowed
Allowable
PPO Disc
Deduct
CoPays
Coins OOP
Reimb
Sav
Other
Paid
Chrg
Pd
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Procedure |
Description |
Mem |
Cnt |
Days |
Chrgs |
Disallowed |
Allowable |
PPO Disc |
Deduct |
CoPays |
Coins OOP |
COB Reimb |
COB Sav |
Other |
Paid |
Avg Chrg |
Avg Pd |
||||||
| Group: 999999 | |||||||||||||||||||||||
| Benefit Type: D | |||||||||||||||||||||||
| D0120 | PERIODIC ORAL EXAMINATION | enr | 5 | 12 | $235.00 | $63.00 | $172.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $172.00 | $47.00 | $34.40 | ||||||
| sps | 1 | 1 | $50.00 | $50.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $50.00 | $.00 | ||||||||
| Total D0120 | 6 | 13 | $285.00 | $113.00 | $172.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $172.00 | $47.50 | $28.67 | ||||||||
| D0130 | CONVERSION ADDED | dep | 1 | 1 | $50.00 | $.00 | $50.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $50.00 | $50.00 | $50.00 | ||||||
| enr | 2 | 19 | $100.00 | $100.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $50.00 | $.00 | ||||||||
| sps | 1 | 1 | $75.00 | $.00 | $75.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $75.00 | $75.00 | $75.00 | ||||||||
| Total D0130 | 4 | 21 | $225.00 | $100.00 | $125.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $125.00 | $56.25 | $31.25 | ||||||||
| D0150 | COMP ORAL EVALUATION - NEW/ESTABLISHED PATIENT | enr | 1 | 10 | $50.00 | $50.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $50.00 | $.00 | ||||||
| sps | 2 | 21 | $125.00 | $75.00 | $50.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $50.00 | $62.50 | $25.00 | ||||||||
| Total D0150 | 3 | 31 | $175.00 | $125.00 | $50.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $50.00 | $58.33 | $16.67 | ||||||||
| D0210 | INTRAORAL - COMPLETE SERIES SEE ALSO CODE 70320 | enr | 2 | 2 | $173.00 | $.00 | $173.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $173.00 | $86.50 | $86.50 | ||||||
| sps | 1 | 20 | $150.00 | $5.00 | $145.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $145.00 | $150.00 | $145.00 | ||||||||
| Total D0210 | 3 | 22 | $323.00 | $5.00 | $318.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $318.00 | $107.67 | $106.00 | ||||||||
| D0220 | INTRAORL - PERIAPICAL 1 FILM SEE ALSO CODE 70300 | dep | 2 | 2 | $55.00 | $30.00 | $25.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $25.00 | $27.50 | $12.50 | ||||||
| enr | 3 | 28 | $75.00 | $50.00 | $25.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $25.00 | $25.00 | $8.33 | ||||||||
| sps | 2 | 2 | $64.00 | $36.00 | $28.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $28.00 | $32.00 | $14.00 | ||||||||
| Total D0220 | 7 | 32 | $194.00 | $116.00 | $78.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $78.00 | $27.71 | $11.14 | ||||||||
| D0230 | INTRAORL - PERIAPICAL EA ADD FILM SEE CODE 70310 | dep | 1 | 1 | $15.00 | $15.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $15.00 | $.00 | ||||||
| enr | 3 | 19 | $60.00 | $29.00 | $31.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $31.00 | $20.00 | $10.33 | ||||||||
| sps | 1 | 1 | $10.00 | $10.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $10.00 | $.00 | ||||||||
| Total D0230 | 5 | 21 | $85.00 | $54.00 | $31.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $31.00 | $17.00 | $6.20 | ||||||||
| D0270 | BITEWING - SINGLE FILM | enr | 1 | 10 | $20.00 | $20.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $20.00 | $.00 | ||||||
| Total D0270 | 1 | 10 | $20.00 | $20.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $20.00 | $.00 | ||||||||
| D0274 | BITEWINGS - FOUR FILMS | enr | 3 | 19 | $170.00 | $60.00 | $110.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $110.00 | $56.67 | $36.67 | ||||||
| sps | 1 | 1 | $60.00 | $60.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $60.00 | $.00 | ||||||||
| Total D0274 | 4 | 20 | $230.00 | $120.00 | $110.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $110.00 | $57.50 | $27.50 | ||||||||
| D0330 | PANORAMIC FILM SEE ALSO CODE 70320 | sps | 1 | 1 | $90.00 | $90.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $90.00 | $.00 | ||||||
| Total D0330 | 1 | 1 | $90.00 | $90.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $90.00 | $.00 | ||||||||
| D1110 | PROPHYLAXIS - ADULT | enr | 6 | 22 | $437.00 | $140.00 | $297.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $297.00 | $72.83 | $49.50 | ||||||
| sps | 3 | 22 | $200.00 | $65.00 | $135.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $51.97 | $.00 | $83.03 | $66.67 | $27.68 | ||||||||
| Total D1110 | 9 | 44 | $637.00 | $205.00 | $432.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $51.97 | $.00 | $380.03 | $70.78 | $42.23 | ||||||||
| D1204 | TOPICAL APPLICATION OF FLUORIDE - ADULT | enr | 1 | 1 | $10.00 | $10.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $10.00 | $.00 | ||||||
| Total D1204 | 1 | 1 | $10.00 | $10.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $10.00 | $.00 | ||||||||
| D2120 | AMALGAM TWO SURFACES PRIMARY | dep | 3 | 3 | $305.00 | $90.00 | $215.00 | $.00 | $25.00 | $.00 | $38.00 | $.00 | $.00 | $.00 | $152.00 | $101.67 | $50.67 | ||||||
| Total D2120 | 3 | 3 | $305.00 | $90.00 | $215.00 | $.00 | $25.00 | $.00 | $38.00 | $.00 | $.00 | $.00 | $152.00 | $101.67 | $50.67 | ||||||||
| D2140 | AMALGAM-ONE SURFACE PRIMARY OR PERMANENT | sps | 4 | 80 | $360.00 | $180.00 | $180.00 | $.00 | $25.00 | $.00 | $31.00 | $.00 | $.00 | $.00 | $124.00 | $90.00 | $31.00 | ||||||
| Total D2140 | 4 | 80 | $360.00 | $180.00 | $180.00 | $.00 | $25.00 | $.00 | $31.00 | $.00 | $.00 | $.00 | $124.00 | $90.00 | $31.00 | ||||||||
| D2150 | AMALGAM-TWO SURFACES PRIMARY OR PERMANENT | enr | 3 | 17 | $315.00 | $.00 | $315.00 | $.00 | $50.00 | $.00 | $53.00 | $.00 | $.00 | $.00 | $212.00 | $105.00 | $70.67 | ||||||
| Total D2150 | 3 | 17 | $315.00 | $.00 | $315.00 | $.00 | $50.00 | $.00 | $53.00 | $.00 | $.00 | $.00 | $212.00 | $105.00 | $70.67 | ||||||||
| D2330 | RESIN-BASED COMPOSITE - ONE SURFACE ANTERIOR | enr | 4 | 4 | $500.00 | $.00 | $500.00 | $.00 | $25.00 | $.00 | $95.00 | $.00 | $.00 | $.00 | $380.00 | $125.00 | $95.00 | ||||||
| Total D2330 | 4 | 4 | $500.00 | $.00 | $500.00 | $.00 | $25.00 | $.00 | $95.00 | $.00 | $.00 | $.00 | $380.00 | $125.00 | $95.00 | ||||||||
| D2332 | RESIN-BASED COMPOSITE - THREE SURFACES ANTERIOR | sps | 1 | 20 | $150.00 | $.00 | $150.00 | $.00 | $.00 | $.00 | $30.00 | $.00 | $.00 | $.00 | $120.00 | $150.00 | $120.00 | ||||||
| Total D2332 | 1 | 20 | $150.00 | $.00 | $150.00 | $.00 | $.00 | $.00 | $30.00 | $.00 | $.00 | $.00 | $120.00 | $150.00 | $120.00 | ||||||||
| D2335 | RESIN COMPOS - 4/MORE SURFACES/INVLV INCISAL ANG | sps | 1 | 1 | $150.00 | $.00 | $150.00 | $.00 | $25.00 | $.00 | $25.00 | $.00 | $.00 | $.00 | $100.00 | $150.00 | $100.00 | ||||||
| Total D2335 | 1 | 1 | $150.00 | $.00 | $150.00 | $.00 | $25.00 | $.00 | $25.00 | $.00 | $.00 | $.00 | $100.00 | $150.00 | $100.00 | ||||||||
| D3220 | TX PULP-REMV PULP CORONAL DENTINOCEMENTL JUNC | dep | 2 | 2 | $360.00 | $205.00 | $155.00 | $.00 | $25.00 | $.00 | $26.00 | $.00 | $.00 | $.00 | $104.00 | $180.00 | $52.00 | ||||||
| Total D3220 | 2 | 2 | $360.00 | $205.00 | $155.00 | $.00 | $25.00 | $.00 | $26.00 | $.00 | $.00 | $.00 | $104.00 | $180.00 | $52.00 | ||||||||
| D3310 | ANTERIOR | enr | 1 | 9 | $475.00 | $191.25 | $283.75 | $.00 | $.00 | $.00 | $56.75 | $.00 | $.00 | $.00 | $227.00 | $475.00 | $227.00 | ||||||
| Total D3310 | 1 | 9 | $475.00 | $191.25 | $283.75 | $.00 | $.00 | $.00 | $56.75 | $.00 | $.00 | $.00 | $227.00 | $475.00 | $227.00 | ||||||||
| D3320 | BICUSPID | enr | 1 | 1 | $702.00 | $126.25 | $575.75 | $.00 | $.00 | $.00 | $115.15 | $.00 | $.00 | $.00 | $460.60 | $702.00 | $460.60 | ||||||
| Total D3320 | 1 | 1 | $702.00 | $126.25 | $575.75 | $.00 | $.00 | $.00 | $115.15 | $.00 | $.00 | $.00 | $460.60 | $702.00 | $460.60 | ||||||||
| D4341 | PRDONTAL SCAL&ROOT PLAN 4/>CONT/BOUND TEETH-QUAD | enr | 8 | 36 | $1,160.00 | $580.00 | $580.00 | $.00 | $.00 | $.00 | $116.00 | $.00 | $.00 | $.00 | $464.00 | $145.00 | $58.00 | ||||||
| sps | 4 | 80 | $580.00 | $.00 | $580.00 | $.00 | $.00 | $.00 | $116.00 | $.00 | $.00 | $.00 | $464.00 | $145.00 | $116.00 | ||||||||
| Total D4341 | 12 | 116 | $1,740.00 | $580.00 | $1,160.00 | $.00 | $.00 | $.00 | $232.00 | $.00 | $.00 | $.00 | $928.00 | $145.00 | $77.33 | ||||||||
| D4910 | PERIODONTAL MAINTENANCE | enr | 1 | 1 | $150.00 | $21.00 | $129.00 | $.00 | $.00 | $.00 | $25.80 | $.00 | $.00 | $.00 | $103.20 | $150.00 | $103.20 | ||||||
| Total D4910 | 1 | 1 | $150.00 | $21.00 | $129.00 | $.00 | $.00 | $.00 | $25.80 | $.00 | $.00 | $.00 | $103.20 | $150.00 | $103.20 | ||||||||
| D7110 | SINGLE TOOTH | enr | 1 | 10 | $105.00 | $105.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $105.00 | $.00 | ||||||
| sps | 1 | 20 | $105.00 | $65.00 | $40.00 | $.00 | $.00 | $.00 | $8.00 | $.00 | $.00 | $.00 | $32.00 | $105.00 | $32.00 | ||||||||
| Total D7110 | 2 | 30 | $210.00 | $170.00 | $40.00 | $.00 | $.00 | $.00 | $8.00 | $.00 | $.00 | $.00 | $32.00 | $105.00 | $16.00 | ||||||||
| D7210 | SURG REMV ERUPTED TOOTH RQR ELEV FLP&REMV BONE | sps | 1 | 1 | $195.00 | $195.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $195.00 | $.00 | ||||||
| Total D7210 | 1 | 1 | $195.00 | $195.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $195.00 | $.00 | ||||||||
| D9110 | PALLIATIVE TREATMENT DENTAL PAIN - MINOR PROC | enr | 1 | 9 | $110.00 | $110.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $110.00 | $.00 | ||||||
| Total D9110 | 1 | 9 | $110.00 | $110.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $110.00 | $.00 | ||||||||
| Total Ben Type: D | 81 | 510 | $7,996.00 | $2,826.50 | $5,169.50 | $.00 | $175.00 | $.00 | $735.70 | $.00 | $51.97 | $.00 | $4,206.83 | $98.72 | $51.94 | ||||||||
| Benefit Type: M | |||||||||||||||||||||||
| 00160 | ANESTHESIA PROC NOSE&ACCESSORY SINUSES; NOS | enr | 1 | 1 | $910.00 | $.00 | $910.00 | $55.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $855.00 | $910.00 | $855.00 | ||||||
| Total 00160 | 1 | 1 | $910.00 | $.00 | $910.00 | $55.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $855.00 | $910.00 | $855.00 | ||||||||
| 11042 | DEBRIDEMENT; SKIN AND SUBCUTANEOUS TISSUE | enr | 1 | 1 | $435.00 | $200.00 | $235.00 | $.00 | $.00 | $.00 | $94.00 | $.00 | $.00 | $.00 | $141.00 | $435.00 | $141.00 | ||||||
| Total 11042 | 1 | 1 | $435.00 | $200.00 | $235.00 | $.00 | $.00 | $.00 | $94.00 | $.00 | $.00 | $.00 | $141.00 | $435.00 | $141.00 | ||||||||
| 11730 | AVUL NAIL PLATE PARTIAL/COMPLETE SIMPLE; SINGLE | enr | 1 | 1 | $121.00 | $.00 | $121.00 | $.00 | $.00 | $15.00 | $.00 | $.00 | $.00 | $.00 | $106.00 | $121.00 | $106.00 | ||||||
| Total 11730 | 1 | 1 | $121.00 | $.00 | $121.00 | $.00 | $.00 | $15.00 | $.00 | $.00 | $.00 | $.00 | $106.00 | $121.00 | $106.00 | ||||||||
| 27619 | EXCISION TUMOR LEG OR ANKLE AREA; DEEP | enr | 2 | 2 | $1,940.00 | $150.00 | $1,790.00 | $128.00 | $.00 | $.00 | $562.40 | $.00 | $.00 | $.00 | $1,099.60 | $970.00 | $549.80 | ||||||
| Total 27619 | 2 | 2 | $1,940.00 | $150.00 | $1,790.00 | $128.00 | $.00 | $.00 | $562.40 | $.00 | $.00 | $.00 | $1,099.60 | $970.00 | $549.80 | ||||||||
| 27620 | ARTHROTOMY ANK W/JNT EXPL W/WO BX REMV LOOSE/FB | enr | 1 | 1 | $1,932.00 | $.00 | $1,932.00 | $.00 | $.00 | $.00 | $772.80 | $.00 | $.00 | $.00 | $1,159.20 | $1,932.00 | $1,159.20 | ||||||
| Total 27620 | 1 | 1 | $1,932.00 | $.00 | $1,932.00 | $.00 | $.00 | $.00 | $772.80 | $.00 | $.00 | $.00 | $1,159.20 | $1,932.00 | $1,159.20 | ||||||||
| 28043 | EXCISION TUMOR FOOT; SUBCUTANEOUS TISSUE | enr | 1 | 1 | $1,000.00 | $203.00 | $797.00 | $.00 | $.00 | $.00 | $318.80 | $.00 | $.00 | $.00 | $478.20 | $1,000.00 | $478.20 | ||||||
| Total 28043 | 1 | 1 | $1,000.00 | $203.00 | $797.00 | $.00 | $.00 | $.00 | $318.80 | $.00 | $.00 | $.00 | $478.20 | $1,000.00 | $478.20 | ||||||||
| 31237 | NASL/SINUS ENDO; W/BX POLYPECT/DEBRID SEP PROC | enr | 1 | 1 | $705.00 | $.00 | $705.00 | $162.93 | $.00 | $15.00 | $.00 | $.00 | $.00 | $.00 | $527.07 | $705.00 | $527.07 | ||||||
| Total 31237 | 1 | 1 | $705.00 | $.00 | $705.00 | $162.93 | $.00 | $15.00 | $.00 | $.00 | $.00 | $.00 | $527.07 | $705.00 | $527.07 | ||||||||
| 36415 | COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE | sps | 2 | 2 | $20.00 | $.00 | $20.00 | $8.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $12.00 | $10.00 | $6.00 | ||||||
| Total 36415 | 2 | 2 | $20.00 | $.00 | $20.00 | $8.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $12.00 | $10.00 | $6.00 | ||||||||
| 47562 | LAPAROSCOPY SURGICAL; CHOLECYSTECTOMY | sps | 1 | 1 | $1,563.30 | $1,563.30 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $1,563.30 | $.00 | ||||||
| Total 47562 | 1 | 1 | $1,563.30 | $1,563.30 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $1,563.30 | $.00 | ||||||||
| 71010 | RADIOLOGIC EXAMINATION CHST; SINGLE VIEW FRONTAL | enr | 1 | 1 | $156.00 | $.00 | $156.00 | $90.22 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $65.78 | $156.00 | $65.78 | ||||||
| Total 71010 | 1 | 1 | $156.00 | $.00 | $156.00 | $90.22 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $65.78 | $156.00 | $65.78 | ||||||||
| 71020 | RADIOLOGIC EXAMINATION CHST 2 VIEWS FRNTL⪫ | enr | 1 | 1 | $128.00 | $.00 | $128.00 | $61.50 | $.00 | $15.00 | $.00 | $.00 | $.00 | $.00 | $51.50 | $128.00 | $51.50 | ||||||
| Total 71020 | 1 | 1 | $128.00 | $.00 | $128.00 | $61.50 | $.00 | $15.00 | $.00 | $.00 | $.00 | $.00 | $51.50 | $128.00 | $51.50 | ||||||||
| 73110 | RADIOLOGIC EXAM WRST; COMPLETE MINI 3 VIEWS | dep | 1 | 1 | $156.00 | $.00 | $156.00 | $89.37 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $66.63 | $156.00 | $66.63 | ||||||
| Total 73110 | 1 | 1 | $156.00 | $.00 | $156.00 | $89.37 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $66.63 | $156.00 | $66.63 | ||||||||
| 73562 | RADIOLOGIC EXAMINATION KNEE; THREE VIEWS | enr | 1 | 1 | $130.00 | $.00 | $130.00 | $57.21 | $.00 | $15.00 | $.00 | $.00 | $.00 | $.00 | $57.79 | $130.00 | $57.79 | ||||||
| Total 73562 | 1 | 1 | $130.00 | $.00 | $130.00 | $57.21 | $.00 | $15.00 | $.00 | $.00 | $.00 | $.00 | $57.79 | $130.00 | $57.79 | ||||||||
| 73564 | RADIOLOGIC EXAM KNEE; COMPLETE 4/MORE VIEWS | enr | 1 | 1 | $132.00 | $.00 | $132.00 | $65.01 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $66.99 | $132.00 | $66.99 | ||||||
| Total 73564 | 1 | 1 | $132.00 | $.00 | $132.00 | $65.01 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $66.99 | $132.00 | $66.99 | ||||||||
| 73610 | RADIOLOGIC EXAM ANK; COMPLETE MINI 3 VIEWS | enr | 1 | 1 | $98.00 | $.00 | $98.00 | $.00 | $.00 | $.00 | $39.20 | $.00 | $.00 | $.00 | $58.80 | $98.00 | $58.80 | ||||||
| Total 73610 | 1 | 1 | $98.00 | $.00 | $98.00 | $.00 | $.00 | $.00 | $39.20 | $.00 | $.00 | $.00 | $58.80 | $98.00 | $58.80 | ||||||||
| 73721 | MR IMAG ANY JNT LOW EXTREM; W/O CONTRST MATERIAL | enr | 1 | 1 | $100.00 | $.00 | $100.00 | $.00 | $.00 | $.00 | $40.00 | $.00 | $.00 | $.00 | $60.00 | $100.00 | $60.00 | ||||||
| Total 73721 | 1 | 1 | $100.00 | $.00 | $100.00 | $.00 | $.00 | $.00 | $40.00 | $.00 | $.00 | $.00 | $60.00 | $100.00 | $60.00 | ||||||||
| 76075 | DEXA BONE DNSITY STUDY 1/MORE SITES; AXIAL SKEL | enr | 1 | 1 | $200.00 | $.00 | $200.00 | $.00 | $.00 | $15.00 | $.00 | $.00 | $.00 | $.00 | $185.00 | $200.00 | $185.00 | ||||||
| Total 76075 | 1 | 1 | $200.00 | $.00 | $200.00 | $.00 | $.00 | $15.00 | $.00 | $.00 | $.00 | $.00 | $185.00 | $200.00 | $185.00 | ||||||||
| 76085 | DIGITIZ FILM RAD IMAG CMPT ANALY LES DETECT MAM | enr | 1 | 1 | $40.00 | $.00 | $40.00 | $10.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $30.00 | $40.00 | $30.00 | ||||||
| Total 76085 | 1 | 1 | $40.00 | $.00 | $40.00 | $10.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $30.00 | $40.00 | $30.00 | ||||||||
| 76091 | MAMMOGRAPHY; BILATERAL | enr | 2 | 2 | $250.00 | $.00 | $250.00 | $.00 | $.00 | $30.00 | $.00 | $.00 | $.00 | $.00 | $220.00 | $125.00 | $110.00 | ||||||
| Total 76091 | 2 | 2 | $250.00 | $.00 | $250.00 | $.00 | $.00 | $30.00 | $.00 | $.00 | $.00 | $.00 | $220.00 | $125.00 | $110.00 | ||||||||
| 76092 | SCREENING MAMMOGRAPHY BILATERAL | enr | 1 | 1 | $145.50 | $.00 | $145.50 | $70.53 | $.00 | $15.00 | $.00 | $.00 | $.00 | $.00 | $59.97 | $145.50 | $59.97 | ||||||
| Total 76092 | 1 | 1 | $145.50 | $.00 | $145.50 | $70.53 | $.00 | $15.00 | $.00 | $.00 | $.00 | $.00 | $59.97 | $145.50 | $59.97 | ||||||||
| 78465 | MYOCARDIAL PERFUS IMAG; TOMO MX STUDIES | enr | 1 | 1 | $1,500.00 | $.00 | $1,500.00 | $307.10 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $1,192.90 | $1,500.00 | $1,192.90 | ||||||
| Total 78465 | 1 | 1 | $1,500.00 | $.00 | $1,500.00 | $307.10 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $1,192.90 | $1,500.00 | $1,192.90 | ||||||||
| 78478 | MYOCARD PERFUS STDY W/WALL MOTION QUAL/QUAN STDY | enr | 1 | 1 | $265.00 | $.00 | $265.00 | $55.60 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $209.40 | $265.00 | $209.40 | ||||||
| Total 78478 | 1 | 1 | $265.00 | $.00 | $265.00 | $55.60 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $209.40 | $265.00 | $209.40 | ||||||||
| 78480 | MYOCARDIAL PERFUSION STUDY W/EJECTION FRACTION | enr | 1 | 1 | $265.00 | $.00 | $265.00 | $55.60 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $209.40 | $265.00 | $209.40 | ||||||
| Total 78480 | 1 | 1 | $265.00 | $.00 | $265.00 | $55.60 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $209.40 | $265.00 | $209.40 | ||||||||
| 80050 | GENERAL HEALTH PANEL | enr | 1 | 1 | $63.51 | $.00 | $63.51 | $22.23 | $.00 | $15.00 | $.00 | $.00 | $.00 | $.00 | $26.28 | $63.51 | $26.28 | ||||||
| Total 80050 | 1 | 1 | $63.51 | $.00 | $63.51 | $22.23 | $.00 | $15.00 | $.00 | $.00 | $.00 | $.00 | $26.28 | $63.51 | $26.28 | ||||||||
| 80061 | LIPID PANEL | sps | 2 | 2 | $100.00 | $.00 | $100.00 | $28.60 | $.00 | $15.00 | $.00 | $.00 | $.00 | $.00 | $56.40 | $50.00 | $28.20 | ||||||
| Total 80061 | 2 | 2 | $100.00 | $.00 | $100.00 | $28.60 | $.00 | $15.00 | $.00 | $.00 | $.00 | $.00 | $56.40 | $50.00 | $28.20 | ||||||||
| 80076 | HEPATIC FUNCTION PANEL | sps | 1 | 1 | $73.29 | $.00 | $73.29 | $51.61 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $21.68 | $73.29 | $21.68 | ||||||
| Total 80076 | 1 | 1 | $73.29 | $.00 | $73.29 | $51.61 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $21.68 | $73.29 | $21.68 | ||||||||
| 81000 | UA DIP STICK/TABLET REAGENT; NON-AUTO W/MICRO | sps | 2 | 2 | $40.00 | $40.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $20.00 | $.00 | ||||||
| Total 81000 | 2 | 2 | $40.00 | $40.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $20.00 | $.00 | ||||||||
| 82270 | BLD OCCLT PEROX ACTV QUAL; FECES 1-3 SIMXAN DTRM | enr | 4 | 4 | $73.00 | $.00 | $73.00 | $24.30 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $48.70 | $18.25 | $12.17 | ||||||
| sps | 2 | 2 | $21.00 | $6.00 | $15.00 | $.00 | $.00 | $15.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $10.50 | $.00 | ||||||||
| Total 82270 | 6 | 6 | $94.00 | $6.00 | $88.00 | $24.30 | $.00 | $15.00 | $.00 | $.00 | $.00 | $.00 | $48.70 | $15.67 | $8.12 | ||||||||
| 82565 | CREATININE; BLOOD | sps | 2 | 2 | $34.88 | $.00 | $34.88 | $9.11 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $25.77 | $17.44 | $12.89 | ||||||
| Total 82565 | 2 | 2 | $34.88 | $.00 | $34.88 | $9.11 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $25.77 | $17.44 | $12.89 | ||||||||
| 82947 | GLUCOSE; QUANTITATIVE BLOOD | sps | 2 | 2 | $57.50 | $.00 | $57.50 | $32.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $25.50 | $28.75 | $12.75 | ||||||
| Total 82947 | 2 | 2 | $57.50 | $.00 | $57.50 | $32.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $25.50 | $28.75 | $12.75 | ||||||||
| 82962 | GLU BLD GLU MON DEVICE CLEARED FDA SPEC HOME USE | enr | 1 | 1 | $12.00 | $.00 | $12.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $12.00 | $12.00 | $12.00 | ||||||
| Total 82962 | 1 | 1 | $12.00 | $.00 | $12.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $12.00 | $12.00 | $12.00 | ||||||||
| 83036 | HEMOGLOBIN; GLYCATED | sps | 2 | 2 | $90.00 | $.00 | $90.00 | $54.30 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $35.70 | $45.00 | $17.85 | ||||||
| Total 83036 | 2 | 2 | $90.00 | $.00 | $90.00 | $54.30 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $35.70 | $45.00 | $17.85 | ||||||||
| 84153 | PROSTATE SPECIFIC ANTIGEN; TOTAL | sps | 1 | 1 | $65.00 | $.00 | $65.00 | $26.75 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $38.25 | $65.00 | $38.25 | ||||||
| Total 84153 | 1 | 1 | $65.00 | $.00 | $65.00 | $26.75 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $38.25 | $65.00 | $38.25 | ||||||||
| 84460 | TRANSFERASE; ALANINE AMINO | sps | 1 | 1 | $24.41 | $.00 | $24.41 | $9.11 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $15.30 | $24.41 | $15.30 | ||||||
| Total 84460 | 1 | 1 | $24.41 | $.00 | $24.41 | $9.11 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $15.30 | $24.41 | $15.30 | ||||||||
| 84520 | UREA NITROGEN; QUANTITATIVE | sps | 2 | 2 | $34.92 | $.00 | $34.92 | $10.40 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $24.52 | $17.46 | $12.26 | ||||||
| Total 84520 | 2 | 2 | $34.92 | $.00 | $34.92 | $10.40 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $24.52 | $17.46 | $12.26 | ||||||||
| 85018 | BLOOD COUNT; HEMOGLOBIN | dep | 1 | 1 | $10.00 | $.00 | $10.00 | $4.25 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $5.75 | $10.00 | $5.75 | ||||||
| Total 85018 | 1 | 1 | $10.00 | $.00 | $10.00 | $4.25 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $5.75 | $10.00 | $5.75 | ||||||||
| 85025 | BLD COUNT; CMPL AUTO & AUTO DIFF WBC COUNT | sps | 1 | 1 | $30.00 | $.00 | $30.00 | $4.50 | $.00 | $15.00 | $.00 | $.00 | $.00 | $.00 | $10.50 | $30.00 | $10.50 | ||||||
| Total 85025 | 1 | 1 | $30.00 | $.00 | $30.00 | $4.50 | $.00 | $15.00 | $.00 | $.00 | $.00 | $.00 | $10.50 | $30.00 | $10.50 | ||||||||
| 85610 | PROTHROMBIN TIME; | enr | 2 | 2 | $13.00 | $.00 | $13.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $13.00 | $6.50 | $6.50 | ||||||
| Total 85610 | 2 | 2 | $13.00 | $.00 | $13.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $13.00 | $6.50 | $6.50 | ||||||||
| 87880 | INF AGT-IMMUNOASSAY W/DIR OBS; STREP GRP A | dep | 1 | 1 | $25.00 | $.00 | $25.00 | $2.41 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $22.59 | $25.00 | $22.59 | ||||||
| sps | 2 | 2 | $110.00 | $.00 | $110.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $110.00 | $55.00 | $55.00 | ||||||||
| Total 87880 | 3 | 3 | $135.00 | $.00 | $135.00 | $2.41 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $132.59 | $45.00 | $44.20 | ||||||||
| 88150 | CYTOPATH SLIDES CERV/VAG; MNL SCR UND PHYS SUPV | enr | 1 | 1 | $30.00 | $.00 | $30.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $30.00 | $30.00 | $30.00 | ||||||
| Total 88150 | 1 | 1 | $30.00 | $.00 | $30.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $30.00 | $30.00 | $30.00 | ||||||||
| 88304 | LEVEL III - SURGICAL PATH GROSS & MICRO EXAM | enr | 1 | 1 | $148.00 | $.00 | $148.00 | $29.60 | $.00 | $.00 | $23.68 | $.00 | $.00 | $.00 | $94.72 | $148.00 | $94.72 | ||||||
| Total 88304 | 1 | 1 | $148.00 | $.00 | $148.00 | $29.60 | $.00 | $.00 | $23.68 | $.00 | $.00 | $.00 | $94.72 | $148.00 | $94.72 | ||||||||
| 88305 | LEVEL IV - SURGICAL PATHOLOGY GROSS & MICRO EXAM | enr | 1 | 1 | $217.00 | $.00 | $217.00 | $43.40 | $.00 | $.00 | $34.72 | $.00 | $.00 | $.00 | $138.88 | $217.00 | $138.88 | ||||||
| Total 88305 | 1 | 1 | $217.00 | $.00 | $217.00 | $43.40 | $.00 | $.00 | $34.72 | $.00 | $.00 | $.00 | $138.88 | $217.00 | $138.88 | ||||||||
| 88307 | LEVEL V- SURG PATH GROSS/MICRO EXAM | enr | 1 | 1 | $356.00 | $.00 | $356.00 | $71.20 | $.00 | $.00 | $56.96 | $.00 | $.00 | $.00 | $227.84 | $356.00 | $227.84 | ||||||
| Total 88307 | 1 | 1 | $356.00 | $.00 | $356.00 | $71.20 | $.00 | $.00 | $56.96 | $.00 | $.00 | $.00 | $227.84 | $356.00 | $227.84 | ||||||||
| 88331 | PATH CNSLT DUR SURG; 1ST TISS BLK W/FZ-SNGL SPEC | enr | 1 | 1 | $262.00 | $.00 | $262.00 | $52.40 | $.00 | $.00 | $41.92 | $.00 | $.00 | $.00 | $167.68 | $262.00 | $167.68 | ||||||
| Total 88331 | 1 | 1 | $262.00 | $.00 | $262.00 | $52.40 | $.00 | $.00 | $41.92 | $.00 | $.00 | $.00 | $167.68 | $262.00 | $167.68 | ||||||||
| 90472 | IMMUNIZATION ADMINISTRATION; EA ADD VACCINE | dep | 1 | 1 | $60.00 | $60.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $60.00 | $.00 | ||||||
| Total 90472 | 1 | 1 | $60.00 | $60.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $60.00 | $.00 | ||||||||
| 90659 | FLU VIRUS VACC WHOLE VIRUS IM/JET INJECTION USE | sps | 1 | 1 | $20.00 | $.00 | $20.00 | $.00 | $.00 | $15.00 | $.00 | $.00 | $.00 | $.00 | $5.00 | $20.00 | $5.00 | ||||||
| Total 90659 | 1 | 1 | $20.00 | $.00 | $20.00 | $.00 | $.00 | $15.00 | $.00 | $.00 | $.00 | $.00 | $5.00 | $20.00 | $5.00 | ||||||||
| 90782 | THERAPEUTIC PROPHYLACTIC/DX INJECTION; SUBQ/IM | dep | 1 | 1 | $26.00 | $.00 | $26.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $26.00 | $26.00 | $26.00 | ||||||
| enr | 1 | 1 | $10.00 | $.00 | $10.00 | $1.82 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $8.18 | $10.00 | $8.18 | ||||||||
| Total 90782 | 2 | 2 | $36.00 | $.00 | $36.00 | $1.82 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $34.18 | $18.00 | $17.09 | ||||||||
| 92004 | OPHTH SERV: MED EXAM; COMP NEW PT 1/MORE VISITS | enr | 1 | 1 | $148.00 | $.00 | $148.00 | $.00 | $.00 | $15.00 | $.00 | $.00 | $.00 | $.00 | $133.00 | $148.00 | $133.00 | ||||||
| Total 92004 | 1 | 1 | $148.00 | $.00 | $148.00 | $.00 | $.00 | $15.00 | $.00 | $.00 | $.00 | $.00 | $133.00 | $148.00 | $133.00 | ||||||||
| 92015 | DETERMINATION OF REFRACTIVE STATE | enr | 1 | 1 | $50.00 | $50.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $50.00 | $.00 | ||||||
| Total 92015 | 1 | 1 | $50.00 | $50.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $50.00 | $.00 | ||||||||
| 92557 | COMP AUD THRESHOLD EVALUATION&SPEECH RECOGNITION | enr | 1 | 1 | $95.00 | $.00 | $95.00 | $29.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $66.00 | $95.00 | $66.00 | ||||||
| Total 92557 | 1 | 1 | $95.00 | $.00 | $95.00 | $29.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $66.00 | $95.00 | $66.00 | ||||||||
| 93000 | ECG ROUTINE ECG W/AT LEAST 12 LEADS; W/I&R | sps | 1 | 1 | $65.00 | $65.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $65.00 | $.00 | ||||||
| Total 93000 | 1 | 1 | $65.00 | $65.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $65.00 | $.00 | ||||||||
| 93015 | CV STRESS TEST W/TREADMILL-PHARM; INTRPT & REPRT | enr | 1 | 1 | $400.00 | $.00 | $400.00 | $155.18 | $.00 | $15.00 | $.00 | $.00 | $.00 | $.00 | $229.82 | $400.00 | $229.82 | ||||||
| Total 93015 | 1 | 1 | $400.00 | $.00 | $400.00 | $155.18 | $.00 | $15.00 | $.00 | $.00 | $.00 | $.00 | $229.82 | $400.00 | $229.82 | ||||||||
| 97001 | PHYSICAL THERAPY EVALUATION | enr | 1 | 3 | $85.00 | $.00 | $85.00 | $39.40 | $.00 | $.00 | $9.12 | $.00 | $.00 | $.00 | $36.48 | $85.00 | $36.48 | ||||||
| Total 97001 | 1 | 3 | $85.00 | $.00 | $85.00 | $39.40 | $.00 | $.00 | $9.12 | $.00 | $.00 | $.00 | $36.48 | $85.00 | $36.48 | ||||||||
| 97010 | APPLICATION MODAL 1/MORE AREAS; HOT/COLD PACKS | enr | 6 | 25 | $104.00 | $104.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $17.33 | $.00 | ||||||
| Total 97010 | 6 | 25 | $104.00 | $104.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $17.33 | $.00 | ||||||||
| 97110 | THERAP PROC 1/> AREAS EA 15 MIN; EXERCISES | enr | 7 | 26 | $480.00 | $.00 | $480.00 | $.00 | $140.00 | $.00 | $68.00 | $.00 | $.00 | $.00 | $272.00 | $68.57 | $38.86 | ||||||
| Total 97110 | 7 | 26 | $480.00 | $.00 | $480.00 | $.00 | $140.00 | $.00 | $68.00 | $.00 | $.00 | $.00 | $272.00 | $68.57 | $38.86 | ||||||||
| 97112 | THERAP PROC 1/> AREAS EA 15 MIN; BALANCE/COORDIN | enr | 1 | 3 | $35.00 | $.00 | $35.00 | $4.50 | $.00 | $.00 | $6.10 | $.00 | $.00 | $.00 | $24.40 | $35.00 | $24.40 | ||||||
| Total 97112 | 1 | 3 | $35.00 | $.00 | $35.00 | $4.50 | $.00 | $.00 | $6.10 | $.00 | $.00 | $.00 | $24.40 | $35.00 | $24.40 | ||||||||
| 97140 | MANUAL THERAPY TECH 1/MORE REGIONS EA 15 MIN | enr | 6 | 45 | $310.00 | $90.00 | $220.00 | $.00 | $110.00 | $.00 | $22.00 | $.00 | $.00 | $.00 | $88.00 | $51.67 | $14.67 | ||||||
| Total 97140 | 6 | 45 | $310.00 | $90.00 | $220.00 | $.00 | $110.00 | $.00 | $22.00 | $.00 | $.00 | $.00 | $88.00 | $51.67 | $14.67 | ||||||||
| 97530 | THERAPEUTIC ACTV DIR PT CNTC PROVIDER EA 15 MIN | enr | 2 | 4 | $110.00 | $.00 | $110.00 | $48.36 | $.00 | $.00 | $12.33 | $.00 | $.00 | $.00 | $49.31 | $55.00 | $24.66 | ||||||
| Total 97530 | 2 | 4 | $110.00 | $.00 | $110.00 | $48.36 | $.00 | $.00 | $12.33 | $.00 | $.00 | $.00 | $49.31 | $55.00 | $24.66 | ||||||||
| 98940 | CHIROPRACTIC MANIPULATIVE TX; SPINAL 1-2 REGIONS | enr | 2 | 26 | $100.00 | $100.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $50.00 | $.00 | ||||||
| Total 98940 | 2 | 26 | $100.00 | $100.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $50.00 | $.00 | ||||||||
| 99000 | HNDLING &OR CONVEYANCE SPEC TRNSF PHYS OFC LAB | dep | 1 | 1 | $10.00 | $.00 | $10.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $10.00 | $10.00 | $10.00 | ||||||
| enr | 3 | 3 | $73.00 | $48.00 | $25.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $25.00 | $24.33 | $8.33 | ||||||||
| sps | 1 | 1 | $20.00 | $20.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $20.00 | $.00 | ||||||||
| Total 99000 | 5 | 5 | $103.00 | $68.00 | $35.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $35.00 | $20.60 | $7.00 | ||||||||
| 99201 | OFC/OUTPT VISIT E&M NEW SELF LIMIT/MINOR 10 MIN | dep | 2 | 2 | $150.00 | $75.00 | $75.00 | $11.36 | $.00 | $15.00 | $.00 | $.00 | $.00 | $.00 | $48.64 | $75.00 | $24.32 | ||||||
| Total 99201 | 2 | 2 | $150.00 | $75.00 | $75.00 | $11.36 | $.00 | $15.00 | $.00 | $.00 | $.00 | $.00 | $48.64 | $75.00 | $24.32 | ||||||||
| 99202 | OFC/OUTPT VISIT E&M NEW LOW-MOD SEVERITY 20 MIN | enr | 4 | 4 | $429.00 | $.00 | $429.00 | $29.68 | $.00 | $60.00 | $14.68 | $.00 | $.00 | $.00 | $324.64 | $107.25 | $81.16 | ||||||
| sps | 1 | 1 | $124.00 | $.00 | $124.00 | $13.68 | $.00 | $15.00 | $.00 | $.00 | $.00 | $.00 | $95.32 | $124.00 | $95.32 | ||||||||
| Total 99202 | 5 | 5 | $553.00 | $.00 | $553.00 | $43.36 | $.00 | $75.00 | $14.68 | $.00 | $.00 | $.00 | $419.96 | $110.60 | $83.99 | ||||||||
| 99203 | OFC/OUTPT VISIT E&M NEW MODERATE SEVERITY 30 MIN | enr | 3 | 3 | $412.00 | $.00 | $412.00 | $12.47 | $.00 | $45.00 | $.00 | $.00 | $.00 | $.00 | $354.53 | $137.33 | $118.18 | ||||||
| sps | 1 | 1 | $130.00 | $.00 | $130.00 | $.00 | $.00 | $15.00 | $.00 | $.00 | $.00 | $.00 | $115.00 | $130.00 | $115.00 | ||||||||
| Total 99203 | 4 | 4 | $542.00 | $.00 | $542.00 | $12.47 | $.00 | $60.00 | $.00 | $.00 | $.00 | $.00 | $469.53 | $135.50 | $117.38 | ||||||||
| 99205 | OFC/OUTPT VISIT E&M NEW MOD-HI SEVERITY 60 MIN | sps | 1 | 1 | $200.00 | $200.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $200.00 | $.00 | ||||||
| Total 99205 | 1 | 1 | $200.00 | $200.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $200.00 | $.00 | ||||||||
| 99211 | OFC/OUTPT VISIT E&M ESTAB NO PHYS PRES 5 MIN | enr | 2 | 2 | $62.00 | $.00 | $62.00 | $.00 | $.00 | $30.00 | $.00 | $.00 | $.00 | $.00 | $32.00 | $31.00 | $16.00 | ||||||
| Total 99211 | 2 | 2 | $62.00 | $.00 | $62.00 | $.00 | $.00 | $30.00 | $.00 | $.00 | $.00 | $.00 | $32.00 | $31.00 | $16.00 | ||||||||
| 99212 | OFC/OUTPT VISIT E&M EST SELF-LIMIT/MINOR 10 MIN | dep | 3 | 3 | $205.00 | $65.00 | $140.00 | $11.34 | $.00 | $30.00 | $.00 | $.00 | $.00 | $.00 | $98.66 | $68.33 | $32.89 | ||||||
| enr | 4 | 4 | $273.00 | $.00 | $273.00 | $9.34 | $.00 | $60.00 | $.00 | $.00 | $.00 | $.00 | $203.66 | $68.25 | $50.92 | ||||||||
| sps | 1 | 1 | $50.00 | $50.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $50.00 | $.00 | ||||||||
| Total 99212 | 8 | 8 | $528.00 | $115.00 | $413.00 | $20.68 | $.00 | $90.00 | $.00 | $.00 | $.00 | $.00 | $302.32 | $66.00 | $37.79 | ||||||||
| 99213 | OFC/OUTPT VISIT E&M EST LOW-MOD SEVERITY 15 MIN | dep | 9 | 9 | $677.00 | $266.00 | $411.00 | $.00 | $.00 | $90.00 | $.00 | $.00 | $.00 | $.00 | $321.00 | $75.22 | $35.67 | ||||||
| enr | 17 | 17 | $1,381.00 | $.00 | $1,381.00 | $69.12 | $131.00 | $210.00 | $80.00 | $.00 | $.00 | $.00 | $890.88 | $81.24 | $52.40 | ||||||||
| sps | 9 | 9 | $736.00 | $170.00 | $566.00 | $20.21 | $.00 | $75.00 | $.00 | $.00 | $.00 | $.00 | $470.79 | $81.78 | $52.31 | ||||||||
| Total 99213 | 35 | 35 | $2,794.00 | $436.00 | $2,358.00 | $89.33 | $131.00 | $375.00 | $80.00 | $.00 | $.00 | $.00 | $1,682.67 | $79.83 | $48.08 | ||||||||
| 99214 | OFC/OUTPT VISIT E&M EST MOD-HI SEVERITY 25 MIN | dep | 2 | 2 | $302.00 | $.00 | $302.00 | $.00 | $.00 | $15.00 | $60.40 | $.00 | $.00 | $.00 | $226.60 | $151.00 | $113.30 | ||||||
| enr | 8 | 8 | $710.00 | $.00 | $710.00 | $22.00 | $.00 | $105.00 | $.00 | $.00 | $.00 | $.00 | $583.00 | $88.75 | $72.88 | ||||||||
| sps | 2 | 2 | $255.00 | $95.00 | $160.00 | $70.00 | $.00 | $15.00 | $.00 | $.00 | $.00 | $.00 | $75.00 | $127.50 | $37.50 | ||||||||
| Total 99214 | 12 | 12 | $1,267.00 | $95.00 | $1,172.00 | $92.00 | $.00 | $135.00 | $60.40 | $.00 | $.00 | $.00 | $884.60 | $105.58 | $73.72 | ||||||||
| 99215 | OFC/OUTPT VISIT E&M ESTAB MOD-HI SEVRTY 40 MIN | enr | 1 | 1 | $180.00 | $.00 | $180.00 | $.00 | $.00 | $15.00 | $.00 | $.00 | $.00 | $.00 | $165.00 | $180.00 | $165.00 | ||||||
| Total 99215 | 1 | 1 | $180.00 | $.00 | $180.00 | $.00 | $.00 | $15.00 | $.00 | $.00 | $.00 | $.00 | $165.00 | $180.00 | $165.00 | ||||||||
| 99231 | SUBSQT HOSP CARE-DAY E&M STABLE/RECOVER 15 MIN | sps | 2 | 4 | $126.00 | $.00 | $126.00 | $39.90 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $86.10 | $63.00 | $43.05 | ||||||
| Total 99231 | 2 | 4 | $126.00 | $.00 | $126.00 | $39.90 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $86.10 | $63.00 | $43.05 | ||||||||
| 99244 | OFFICE CNSLT NEW/ESTAB MOD-HIGH SEVERITY 60 MIN | enr | 1 | 1 | $450.00 | $29.00 | $421.00 | $.00 | $.00 | $.00 | $168.40 | $.00 | $.00 | $.00 | $252.60 | $450.00 | $252.60 | ||||||
| Total 99244 | 1 | 1 | $450.00 | $29.00 | $421.00 | $.00 | $.00 | $.00 | $168.40 | $.00 | $.00 | $.00 | $252.60 | $450.00 | $252.60 | ||||||||
| 99283 | EMERG DEPT VISIT E&M MODERATE SEVERITY | sps | 1 | 1 | $170.00 | $.00 | $170.00 | $17.00 | $.00 | $.00 | $30.60 | $.00 | $.00 | $.00 | $122.40 | $170.00 | $122.40 | ||||||
| Total 99283 | 1 | 1 | $170.00 | $.00 | $170.00 | $17.00 | $.00 | $.00 | $30.60 | $.00 | $.00 | $.00 | $122.40 | $170.00 | $122.40 | ||||||||
| 99392 | PRD PREVENTATIVE MED E&M ESTAB PT; 1-4 YRS | dep | 1 | 1 | $147.00 | $.00 | $147.00 | $.00 | $.00 | $15.00 | $.00 | $.00 | $.00 | $.00 | $132.00 | $147.00 | $132.00 | ||||||
| Total 99392 | 1 | 1 | $147.00 | $.00 | $147.00 | $.00 | $.00 | $15.00 | $.00 | $.00 | $.00 | $.00 | $132.00 | $147.00 | $132.00 | ||||||||
| 99396 | PRD PREVENTATIVE MED E&M ESTAB PT; 40-64 YRS | enr | 6 | 6 | $1,179.00 | $624.00 | $555.00 | $25.96 | $.00 | $45.00 | $.00 | $.00 | $.00 | $.00 | $484.04 | $196.50 | $80.67 | ||||||
| sps | 1 | 1 | $135.00 | $135.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $135.00 | $.00 | ||||||||
| Total 99396 | 7 | 7 | $1,314.00 | $759.00 | $555.00 | $25.96 | $.00 | $45.00 | $.00 | $.00 | $.00 | $.00 | $484.04 | $187.71 | $69.15 | ||||||||
| A4402 | LUBRICANT,PER OUNCE | sps | 1 | 1 | $20.00 | $20.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $20.00 | $.00 | ||||||
| Total A4402 | 1 | 1 | $20.00 | $20.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $20.00 | $.00 | ||||||||
| A4712 | WATER,STERILE | dep | 2 | 2 | $1.29 | $.00 | $1.29 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $1.29 | $.65 | $.65 | ||||||
| Total A4712 | 2 | 2 | $1.29 | $.00 | $1.29 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $1.29 | $.65 | $.65 | ||||||||
| A4927 | GLOVES,STERILE OR NONSTERILE,/PAIR | sps | 1 | 1 | $20.00 | $20.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $20.00 | $.00 | ||||||
| Total A4927 | 1 | 1 | $20.00 | $20.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $20.00 | $.00 | ||||||||
| A6209 | FOAM DRESSING, WOUND COVER, PAD SIZ | enr | 1 | 1 | $5.00 | $.00 | $5.00 | $1.25 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $3.75 | $5.00 | $3.75 | ||||||
| Total A6209 | 1 | 1 | $5.00 | $.00 | $5.00 | $1.25 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $3.75 | $5.00 | $3.75 | ||||||||
| A6260 | WOUND CLEANSERS, ANY TYPE/SIZE | enr | 1 | 1 | $4.00 | $.00 | $4.00 | $1.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $3.00 | $4.00 | $3.00 | ||||||
| Total A6260 | 1 | 1 | $4.00 | $.00 | $4.00 | $1.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $3.00 | $4.00 | $3.00 | ||||||||
| A9500 | SPLY-OF RADIOPHARM DIAG IMAGING AGE | enr | 1 | 1 | $244.00 | $.00 | $244.00 | $24.40 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $219.60 | $244.00 | $219.60 | ||||||
| Total A9500 | 1 | 1 | $244.00 | $.00 | $244.00 | $24.40 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $219.60 | $244.00 | $219.60 | ||||||||
| J1030 | INJ METHYLPREDNISOLONE 40MG | enr | 1 | 1 | $20.00 | $.00 | $20.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $20.00 | $20.00 | $20.00 | ||||||
| Total J1030 | 1 | 1 | $20.00 | $.00 | $20.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $20.00 | $20.00 | $20.00 | ||||||||
| J1040 | INJ METHYLPREDNISOLONE 80MG | enr | 1 | 1 | $40.00 | $.00 | $40.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $40.00 | $40.00 | $40.00 | ||||||
| Total J1040 | 1 | 1 | $40.00 | $.00 | $40.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $.00 | $40.00 | $40.00 | $40.00 | ||||||||
| J1100 | INJ, DEXAMETHOSONE SOD PHOS | dep | 1 | 1 | $48.00 | $.00 | $48.00 | $.00 | $.00 | $.00 | $.00 | ||||||||||||