 |
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 |
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 |
$.00 |
$.00 |
$.00 |
$48.00 |
$48.00 |
$48.00 |
| |
| Total J1100 |
1 |
1 |
$48.00 |
$.00 |
$48.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$48.00 |
$48.00 |
$48.00 |
| |
| J1565 |
INJ, RESSPIRATORY SYNCYTIAL VIRUS |
dep |
4 |
4 |
$6,018.46 |
$.00 |
$6,018.46 |
$.00 |
$.00 |
$30.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$5,988.46 |
$1,504.62 |
$1,497.12 |
| |
| Total J1565 |
4 |
4 |
$6,018.46 |
$.00 |
$6,018.46 |
$.00 |
$.00 |
$30.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$5,988.46 |
$1,504.62 |
$1,497.12 |
| |
| J7050 |
INF NORMAL SALINE SOL 250CC |
enr |
1 |
1 |
$11.03 |
$.00 |
$11.03 |
$1.11 |
$.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$9.92 |
$11.03 |
$9.92 |
| |
| Total J7050 |
1 |
1 |
$11.03 |
$.00 |
$11.03 |
$1.11 |
$.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$9.92 |
$11.03 |
$9.92 |
| |
| L1902 |
AFO ANKLE GAUNTLET |
enr |
1 |
1 |
$65.00 |
$.00 |
$65.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$65.00 |
$65.00 |
$65.00 |
| |
| Total L1902 |
1 |
1 |
$65.00 |
$.00 |
$65.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$65.00 |
$65.00 |
$65.00 |
| |
| L3908 |
WHO-WRIST EXTCNTL COCKUP |
dep |
1 |
1 |
$28.00 |
$.00 |
$28.00 |
$2.80 |
$.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$25.20 |
$28.00 |
$25.20 |
| |
| Total L3908 |
1 |
1 |
$28.00 |
$.00 |
$28.00 |
$2.80 |
$.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$25.20 |
$28.00 |
$25.20 |
| |
| R250 |
Pharmacy |
enr |
1 |
1 |
$16,877.67 |
$16,877.67 |
$.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$16,877.67 |
$.00 |
| |
| Total R250 |
1 |
1 |
$16,877.67 |
$16,877.67 |
$.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$16,877.67 |
$.00 |
| |
| R300 |
Laboratory |
dep |
1 |
1 |
$411.12 |
$411.12 |
$.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$411.12 |
$.00 |
|
|
enr |
3 |
3 |
$379.80 |
$.00 |
$379.80 |
$.00 |
$332.30 |
$.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$47.50 |
$126.60 |
$15.83 |
|
|
sps |
1 |
1 |
$148.50 |
$.00 |
$148.50 |
$.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$148.50 |
$148.50 |
$148.50 |
| |
| Total R300 |
5 |
5 |
$939.42 |
$411.12 |
$528.30 |
$.00 |
$332.30 |
$.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$196.00 |
$187.88 |
$39.20 |
| |
| R306 |
Lab Bacteriology/Microbiology |
enr |
1 |
1 |
$32.75 |
$.00 |
$32.75 |
$.00 |
$.00 |
$.00 |
$6.55 |
$.00 |
$.00 |
$.00 |
$26.20 |
$32.75 |
$26.20 |
|
|
sps |
3 |
3 |
$223.45 |
$.00 |
$223.45 |
$.00 |
$.00 |
$.00 |
$44.69 |
$.00 |
$.00 |
$.00 |
$178.76 |
$74.48 |
$59.59 |
| |
| Total R306 |
4 |
4 |
$256.20 |
$.00 |
$256.20 |
$.00 |
$.00 |
$.00 |
$51.24 |
$.00 |
$.00 |
$.00 |
$204.96 |
$64.05 |
$51.24 |
| |
| R320 |
Radiology/Diagnostic |
enr |
1 |
1 |
$200.00 |
$.00 |
$200.00 |
$.00 |
$81.95 |
$.00 |
$23.61 |
$.00 |
$.00 |
$.00 |
$94.44 |
$200.00 |
$94.44 |
| |
| Total R320 |
1 |
1 |
$200.00 |
$.00 |
$200.00 |
$.00 |
$81.95 |
$.00 |
$23.61 |
$.00 |
$.00 |
$.00 |
$94.44 |
$200.00 |
$94.44 |
| |
| R360 |
Operating Room |
enr |
2 |
6 |
$14,572.36 |
$11,279.36 |
$3,293.00 |
$.00 |
$.00 |
$.00 |
$587.09 |
$.00 |
$.00 |
$.00 |
$2,705.91 |
$7,286.18 |
$1,352.96 |
| |
| Total R360 |
2 |
6 |
$14,572.36 |
$11,279.36 |
$3,293.00 |
$.00 |
$.00 |
$.00 |
$587.09 |
$.00 |
$.00 |
$.00 |
$2,705.91 |
$7,286.18 |
$1,352.96 |
| |
| R402 |
Ultrasound |
enr |
1 |
1 |
$351.00 |
$.00 |
$351.00 |
$.00 |
$.00 |
$.00 |
$70.20 |
$.00 |
$.00 |
$.00 |
$280.80 |
$351.00 |
$280.80 |
| |
| Total R402 |
1 |
1 |
$351.00 |
$.00 |
$351.00 |
$.00 |
$.00 |
$.00 |
$70.20 |
$.00 |
$.00 |
$.00 |
$280.80 |
$351.00 |
$280.80 |
| |
| R403 |
SCREENING MAMMOGRAPHY |
enr |
2 |
2 |
$166.00 |
$.00 |
$166.00 |
$.00 |
$.00 |
$15.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$151.00 |
$83.00 |
$75.50 |
| |
| Total R403 |
2 |
2 |
$166.00 |
$.00 |
$166.00 |
$.00 |
$.00 |
$15.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$151.00 |
$83.00 |
$75.50 |
| |
| R424 |
Phys Ther Evaluation |
enr |
1 |
1 |
$176.00 |
$.00 |
$176.00 |
$44.00 |
$.00 |
$.00 |
$26.40 |
$.00 |
$.00 |
$.00 |
$105.60 |
$176.00 |
$105.60 |
| |
| Total R424 |
1 |
1 |
$176.00 |
$.00 |
$176.00 |
$44.00 |
$.00 |
$.00 |
$26.40 |
$.00 |
$.00 |
$.00 |
$105.60 |
$176.00 |
$105.60 |
| |
| R450 |
Emergency Room |
sps |
1 |
2 |
$1,125.65 |
$.00 |
$1,125.65 |
$.00 |
$250.00 |
$.00 |
$175.13 |
$.00 |
$.00 |
$.00 |
$700.52 |
$1,125.65 |
$700.52 |
| |
| Total R450 |
1 |
2 |
$1,125.65 |
$.00 |
$1,125.65 |
$.00 |
$250.00 |
$.00 |
$175.13 |
$.00 |
$.00 |
$.00 |
$700.52 |
$1,125.65 |
$700.52 |
| |
| R490 |
Ambulatory Surgery |
sps |
1 |
1 |
$5,589.00 |
$.00 |
$5,589.00 |
$.00 |
$250.00 |
$.00 |
$1,067.80 |
$.00 |
$.00 |
$.00 |
$4,271.20 |
$5,589.00 |
$4,271.20 |
| |
| Total R490 |
1 |
1 |
$5,589.00 |
$.00 |
$5,589.00 |
$.00 |
$250.00 |
$.00 |
$1,067.80 |
$.00 |
$.00 |
$.00 |
$4,271.20 |
$5,589.00 |
$4,271.20 |
| |
| R551 |
Skilled Nursing Visit Chg |
enr |
1 |
16 |
$10.00 |
$.00 |
$10.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$10.00 |
$10.00 |
$10.00 |
| |
| Total R551 |
1 |
16 |
$10.00 |
$.00 |
$10.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$10.00 |
$10.00 |
$10.00 |
| |
| R923 |
Pap Smear |
enr |
6 |
6 |
$133.00 |
$.00 |
$133.00 |
$.00 |
$66.50 |
$15.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$51.50 |
$22.17 |
$8.58 |
| |
| Total R923 |
6 |
6 |
$133.00 |
$.00 |
$133.00 |
$.00 |
$66.50 |
$15.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$51.50 |
$22.17 |
$8.58 |
| |
| R942 |
Education/Training |
enr |
1 |
1 |
$100.00 |
$100.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$100.00 |
$.00 |
| |
| Total R942 |
1 |
1 |
$100.00 |
$100.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$100.00 |
$.00 |
| Total Ben Type: M |
226 |
355 |
$71,787.39 |
$33,116.45 |
$38,670.94 |
$2,397.12 |
$1,361.75 |
$1,140.00 |
$4,457.58 |
$.00 |
$.00 |
$.00 |
$29,314.49 |
$317.64 |
$129.71 |
| |
| Benefit Type: >P |
| . |
. |
enr |
3 |
70 |
$5,587.33 |
$.00 |
$5,587.33 |
$.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$5,587.33 |
$1,862.44 |
$1,862.44 |
| |
| Total . |
3 |
70 |
$5,587.33 |
$.00 |
$5,587.33 |
$.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$5,587.33 |
$1,862.44 |
$1,862.44 |
| Total Ben Type: P |
3 |
70 |
$5,587.33 |
$.00 |
$5,587.33 |
$.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$.00 |
$5,587.33 |
$1,862.44 |
$1,862.44 |
| Total Group: 999999 |
310 |
935 |
$85,370.72 |
$35,942.95 |
$49,427.77 |
$2,397.12 |
$1,536.75 |
$1,140.00 |
$5,193.28 |
$.00 |
$51.97 |
$.00 |
$39,108.65 |
$275.39 |
$126.16 |
| |
| |
| |
| |
Procedure |
Description |
Mem |
Cnt |
Days |
Chrgs |
Disallowed |
Allowable |
PPO Disc |
Deduct |
CoPays |
Coins OOP |
COB
Reimb |
COB
Sav |
Other |
Paid |
Avg
Chrg |
Avg
Pd |
| |
| TOTAL |
310 |
935 |
$85,370.72 |
$35,942.95 |
$49,427.77 |
$2,397.12 |
$1,536.75 |
$1,140.00 |
$5,193.28 |
$.00 |
$51.97 |
$.00 |
$39,108.65 |
$275.39 |
$126.16 |
| |
| Benefit Utilization |
| Requestor: John Employer |
| Report Date: 12/18/2003 |
| Sort fields: Selected values: |
| Group 999999 |
| Procedure Codes: From: To: |
| Benefit Type(s): ALL |
| Date: Paid |
| Report Period: 11/01/2003 - 11/30/2003 |
|