hospital_name,last_updated_on,version,hospital_location,hospital_address,license_number|MO,"To the best of its knowledge and belief, the hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date indicated.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Pemiscot Memorial Health System,1/15/2025,2.0.0,Pemiscot Memorial Health System,"946 E Reed St, Hayti, MO 63851",15-67,TRUE,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SERVICE DESCRIPTION,CATEGORY,BILLING MSDRG | CPT | HCPCS,ITEM/SERVICE DESCRIPTION,BILLING REVENUE CODE,GROSS CHARGES,AETNA PLAN,AETNA REIMBURSEMENT METHOD,ANTHEM BCBS OTHER PLAN,ANTHEM BCBS OTHER REIMBURSEMENT METHOD,ANTHEM TRADITIONAL PLAN,ANTHEM TRADITIONAL REIMBURSEMENT METHOD,CIGNA PLAN,CIGNA REIMBURSEMENT METHOD,CONSOCIATE PLAN,CONSOCIATE REIMBURSEMENT METHOD,FIRST HEALTH PLAN,FIRST HEALTH REIMBURSEMENT METHOD,HEALTHLINK HMO PLAN,HEALTHLINK HMO REIMBURSEMENT METHOD,HEALTHLINK PPO PLAN,HEALTHLINK PPO REIMBURSEMENT METHOD,HEALTHPLAN MEDICAID PLAN,HEALTHPLAN MEDICAID REIMBURSEMENT METHOD,HEALTHSCOPE PLAN,HEALTHSCOPE REIMBURSEMENT METHOD,HEALTHYBLUE MEDICAID PLAN,HEALTHYBLUE MEDICAID REIMBURSEMENT METHOD,HOME STATE HEALTH PLAN PLAN,HOME STATE HEALTH PLAN REIMBURSEMENT METHOD,HOME STATE HEALTHPLAN MEDICAID PLAN,HOME STATE HEALTHPLAN MEDICAID REIMBURSEMENT METHOD,MEDICAID PLAN,MEDICAID REIMBURSEMENT METHOD,MEDICARE PLAN,MEDICARE REIMBURSEMENT METHOD,UHC PLAN,UHC REIMBURSEMENT METHOD,UHC MEDICAID PLAN,UHC MEDICAID REIMBURSEMENT METHOD,UHC MEDICARE PLAN,UHC MEDICARE REIMBURSEMENT METHOD,De-Identified Minimum Negotiated Rate,De-Identified Maximum Negotiated Rate,DISCOUNTED CASH PRICE,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,EMERGENCY ROOM,96372,INJECT THER DX SUBCU OR IM,331,181,13.09,Not Separately reimbursable,123.08,68% of total billed charges,137.56,76% of total billed charges,90.5,50% of total billed charges,26.26,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,86.01,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,63.71,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,63.71,Pays based on 100% of CMS OPPS Rate,300,Pays based on per visit rate,N/A,Not Separately reimbursable,63.71,Pays based on 100% of CMS OPPS Rate,26.26,300,126.7,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,EMERGENCY ROOM,99281,ER VISIT LEVEL 1,450,209.19,16.72,Not Separately reimbursable,142.25,68% of total billed charges,142.25,68% of total billed charges,104.6,50% of total billed charges,22.02,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,146.43,70% of total billed charges,156.89,75% of total Billed charges,N/A,Not Separately reimbursable,108.39,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,80.29,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,80.29,Pays based on 100% of CMS OPPS Rate,255,Pays based on per visit rate,N/A,Not Separately reimbursable,80.29,Pays based on 100% of CMS OPPS Rate,22.02,255,146.433,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,EMERGENCY ROOM,99282,ER VISIT LEVEL 2,450,384,32.39,Not Separately reimbursable,261.12,68% of total billed charges,261.12,68% of total billed charges,192,50% of total billed charges,80.4,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,268.8,70% of total billed charges,288,75% of total Billed charges,N/A,Not Separately reimbursable,199.69,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,147.91,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,147.91,Pays based on 100% of CMS OPPS Rate,255,Pays based on per visit rate,N/A,Not Separately reimbursable,147.91,Pays based on 100% of CMS OPPS Rate,80.4,288,268.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,EMERGENCY ROOM,99283,ER VISIT LEVEL 3,450,670,55.11,Not Separately reimbursable,443,68% of total billed charges,455.6,68% of total billed charges,335,50% of total billed charges,136.98,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,370,70% of total billed charges,400,75% of total Billed charges,N/A,Not Separately reimbursable,348.36,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,258.05,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,258.05,Pays based on 100% of CMS OPPS Rate,255,Pays based on per visit rate,N/A,Not Separately reimbursable,258.05,Pays based on 100% of CMS OPPS Rate,136.98,455.6,469,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,EMERGENCY ROOM,99284,ER VISIT LEVEL 4,450,1090,93.09,Not Separately reimbursable,443,68% of total billed charges,477,68% of total billed charges,545,50% of total billed charges,233.24,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,370,70% of total billed charges,400,75% of total Billed charges,N/A,Not Separately reimbursable,540.78,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,400.57,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,400.57,Pays based on 100% of CMS OPPS Rate,255,Pays based on per visit rate,N/A,Not Separately reimbursable,400.57,Pays based on 100% of CMS OPPS Rate,233.24,545,763,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,EMERGENCY ROOM,99285,ER VISIT LEVEL 5,450,1580,135.18,Not Separately reimbursable,443,68% of total billed charges,477,68% of total billed charges,650,50% of total billed charges,338.14,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,370,70% of total billed charges,400,75% of total Billed charges,N/A,Not Separately reimbursable,784.24,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,580.91,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,580.91,Pays based on 100% of CMS OPPS Rate,255,Pays based on per visit rate,N/A,Not Separately reimbursable,580.91,Pays based on 100% of CMS OPPS Rate,255,784.24,1106,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,EMERGENCY ROOM,99291,CRITCL CARE 1ST 30-74 MIN,450,2250,165.26,Not Separately reimbursable,443,68% of total billed charges,477,68% of total billed charges,650,50% of total billed charges,406.3,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,370,70% of total billed charges,400,75% of total Billed charges,N/A,Not Separately reimbursable,1083.45,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,802.56,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,802.56,Pays based on 100% of CMS OPPS Rate,255,Pays based on per visit rate,N/A,Not Separately reimbursable,802.56,Pays based on 100% of CMS OPPS Rate,255,1083.45,1575,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,EMERGENCY ROOM,X4011,CRITCL CARE EA ADD 30 MIN,450,350,N/A,Not Separately reimbursable,238,68% of total billed charges,238,68% of total billed charges,175,50% of total billed charges,227.5,65% of total Billed charges,N/A,Not Separately reimbursable,245,70% of total billed charges,262.5,75% of total Billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,0,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,255,Pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,175,262.5,245,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,EMERGENCY ROOM,12002,REP SMP SCP-NK-GN-TRNK XTRM 2.,450,529.35,50.88,Not Separately reimbursable,359.96,68% of total billed charges,359.96,68% of total billed charges,264.68,50% of total billed charges,113.02,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,370,70% of total billed charges,397.01,75% of total Billed charges,N/A,Not Separately reimbursable,244.44,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,181.06,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,181.06,Pays based on 100% of CMS OPPS Rate,255,Pays based on per visit rate,N/A,Not Separately reimbursable,181.06,Pays based on 100% of CMS OPPS Rate,113.02,397.01,370.545,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,EMERGENCY ROOM,12004,REP SMP SCP-NK-GN-TRNK-XTRM 7.,450,529.35,62.92,Not Separately reimbursable,359.96,68% of total billed charges,359.96,68% of total billed charges,264.68,50% of total billed charges,141.54,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,370,70% of total billed charges,397.01,75% of total Billed charges,N/A,Not Separately reimbursable,244.44,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,181.06,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,181.06,Pays based on 100% of CMS OPPS Rate,255,Pays based on per visit rate,N/A,Not Separately reimbursable,181.06,Pays based on 100% of CMS OPPS Rate,141.54,397.01,370.545,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,EMERGENCY ROOM,12011,REP SMP FACE < 2.5CM,450,529.35,47.65,Not Separately reimbursable,359.96,68% of total billed charges,359.96,68% of total billed charges,264.68,50% of total billed charges,106.58,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,370,70% of total billed charges,397.01,75% of total Billed charges,N/A,Not Separately reimbursable,244.44,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,181.06,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,181.06,Pays based on 100% of CMS OPPS Rate,255,Pays based on per visit rate,N/A,Not Separately reimbursable,181.06,Pays based on 100% of CMS OPPS Rate,106.58,397.01,370.545,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,EMERGENCY ROOM,96360,IV INFUS HYDRAT INIT 31 MIN TO,450,350,31.12,Not Separately reimbursable,238,68% of total billed charges,238,68% of total billed charges,175,50% of total billed charges,57.14,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,245,70% of total billed charges,262.5,75% of total Billed charges,N/A,Not Separately reimbursable,261.69,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,193.85,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,193.85,Pays based on 100% of CMS OPPS Rate,255,Pays based on per visit rate,N/A,Not Separately reimbursable,193.85,Pays based on 100% of CMS OPPS Rate,57.14,262.5,245,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,EMERGENCY ROOM,96361,IV INFUS HYDRATE EA ADDL HR,450,114,11.74,Not Separately reimbursable,77.52,68% of total billed charges,77.52,68% of total billed charges,57,50% of total billed charges,22.08,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,79.8,70% of total billed charges,85.5,75% of total Billed charges,N/A,Not Separately reimbursable,57.99,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,42.96,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,42.96,Pays based on 100% of CMS OPPS Rate,255,Pays based on per visit rate,N/A,Not Separately reimbursable,42.96,Pays based on 100% of CMS OPPS Rate,22.08,255,79.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,EMERGENCY ROOM,96365,IV INFUS THER PROPH DX INIT HR,450,350,61.42,Not Separately reimbursable,238,68% of total billed charges,238,68% of total billed charges,175,50% of total billed charges,109.78,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,245,70% of total billed charges,262.5,75% of total Billed charges,N/A,Not Separately reimbursable,261.69,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,193.85,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,193.85,Pays based on 100% of CMS OPPS Rate,255,Pays based on per visit rate,N/A,Not Separately reimbursable,193.85,Pays based on 100% of CMS OPPS Rate,109.78,262.5,245,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,EMERGENCY ROOM,96366,IV INFUS THX PROPH DX EA ADDL,450,114,19.23,Not Separately reimbursable,77.52,68% of total billed charges,77.52,68% of total billed charges,57,50% of total billed charges,36.64,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,79.8,70% of total billed charges,85.5,75% of total Billed charges,N/A,Not Separately reimbursable,57.99,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,42.96,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,42.96,Pays based on 100% of CMS OPPS Rate,255,Pays based on per visit rate,N/A,Not Separately reimbursable,42.96,Pays based on 100% of CMS OPPS Rate,36.64,255,79.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,EMERGENCY ROOM,96367,IV INFUS ADDL SEQ TO 1 HR,450,181,27.48,Not Separately reimbursable,123.08,68% of total billed charges,123.08,68% of total billed charges,90.5,50% of total billed charges,50.46,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,126.7,70% of total billed charges,135.75,75% of total Billed charges,N/A,Not Separately reimbursable,86.01,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,63.71,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,63.71,Pays based on 100% of CMS OPPS Rate,255,Pays based on per visit rate,N/A,Not Separately reimbursable,63.71,Pays based on 100% of CMS OPPS Rate,50.46,255,126.7,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,EMERGENCY ROOM,96368,IV INFUS CONCURRENT,450,390,18.6,Not Separately reimbursable,265.2,68% of total billed charges,265.2,68% of total billed charges,195,50% of total billed charges,35.4,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,273,70% of total billed charges,292.5,75% of total Billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,0,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,255,Pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,35.4,292.5,273,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,EMERGENCY ROOM,96374,INJ THER DX INTRV S/I DRUG,450,551,35.73,Not Separately reimbursable,374.68,68% of total billed charges,374.68,68% of total billed charges,275.5,50% of total billed charges,64.74,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,370,70% of total billed charges,400,75% of total Billed charges,N/A,Not Separately reimbursable,261.69,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,193.85,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,193.85,Pays based on 100% of CMS OPPS Rate,255,Pays based on per visit rate,N/A,Not Separately reimbursable,193.85,Pays based on 100% of CMS OPPS Rate,64.74,400,385.7,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,EMERGENCY ROOM,96375,IV PUSH EA ADDL SEQ DRUG,450,114,14.51,Not Separately reimbursable,77.52,68% of total billed charges,77.52,68% of total billed charges,57,50% of total billed charges,27.32,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,79.8,70% of total billed charges,85.5,75% of total Billed charges,N/A,Not Separately reimbursable,57.99,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,42.96,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,42.96,Pays based on 100% of CMS OPPS Rate,255,Pays based on per visit rate,N/A,Not Separately reimbursable,42.96,Pays based on 100% of CMS OPPS Rate,27.32,255,79.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,EMERGENCY ROOM,96376,EA ADD IVP SAME RX > 30 MIN,450,390,9.29,Not Separately reimbursable,265.2,68% of total billed charges,265.2,68% of total billed charges,195,50% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,273,70% of total billed charges,292.5,75% of total Billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,0,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,255,Pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,195,292.5,273,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,EMERGENCY ROOM,64400,INJ ANSTH TRIGEMINAL NERVE,450,785,43.2,Not Separately reimbursable,443,68% of total billed charges,477,68% of total billed charges,392.5,50% of total billed charges,97.28,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,370,70% of total billed charges,400,75% of total Billed charges,N/A,Not Separately reimbursable,361.63,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,267.87,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,267.87,Pays based on 100% of CMS OPPS Rate,255,Pays based on per visit rate,N/A,Not Separately reimbursable,267.87,Pays based on 100% of CMS OPPS Rate,97.28,477,549.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,EMERGENCY ROOM,51702,INSRT TEMP INDWL BLAD CATH SIM,450,327,22.77,Not Separately reimbursable,222.36,68% of total billed charges,222.36,68% of total billed charges,163.5,50% of total billed charges,48.04,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,228.9,70% of total billed charges,245.25,75% of total Billed charges,N/A,Not Separately reimbursable,155.96,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,115.53,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,115.53,Pays based on 100% of CMS OPPS Rate,255,Pays based on per visit rate,N/A,Not Separately reimbursable,115.53,Pays based on 100% of CMS OPPS Rate,48.04,255,228.9,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,EMERGENCY ROOM,92950,CARDIOPULMONARY RESUSCITATN,450,756.93,170.07,Not Separately reimbursable,443,68% of total billed charges,477,68% of total billed charges,378.47,50% of total billed charges,349.98,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,370,70% of total billed charges,400,75% of total Billed charges,N/A,Not Separately reimbursable,383.23,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,283.88,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,283.88,Pays based on 100% of CMS OPPS Rate,255,Pays based on per visit rate,N/A,Not Separately reimbursable,283.88,Pays based on 100% of CMS OPPS Rate,255,477,529.851,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,EMERGENCY ROOM,43752,NASAL/OROGASTRIC W/TUBE PLMT,450,125,36.72,Not Separately reimbursable,85,68% of total billed charges,85,68% of total billed charges,62.5,50% of total billed charges,75.84,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,87.5,70% of total billed charges,93.75,75% of total Billed charges,N/A,Not Separately reimbursable,486.48,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,360.35,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,360.35,Pays based on 100% of CMS OPPS Rate,255,Pays based on per visit rate,N/A,Not Separately reimbursable,360.35,Pays based on 100% of CMS OPPS Rate,62.5,486.48,87.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OPERATING ROOM,13122,CMPLX RPR SCALP ARM LG EA ADD,360,556,70.56,Not Separately reimbursable,1290.5,pays based on per visit rate,1444.4,68% of total billed charges,278,50% of total billed charges,155.3,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,389.2,70% of total billed charges,417,75% of total Billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,0,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,100,pays based on 100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,100,1444.4,389.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OPERATING ROOM,54360,PENIS PLASTIC SURGERY,360,6036,711.47,Not Separately reimbursable,1290.5,pays based on per visit rate,1444.4,68% of total billed charges,3018,50% of total billed charges,1364.88,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,1100,70% of total billed charges,1200,75% of total Billed charges,N/A,Not Separately reimbursable,4256.51,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,3152.97,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,3152.97,Pays based on 100% of CMS OPPS Rate,972,pays based on 100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,3152.97,Pays based on 100% of CMS OPPS Rate,972,4256.51,4225.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OPERATING ROOM,54405,INSRT MULTI CMPNT INFLAT PENL,360,35144,797.36,Not Separately reimbursable,1290.5,pays based on per visit rate,1444.4,68% of total billed charges,5000,50% of total billed charges,1529.14,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,1100,70% of total billed charges,1200,75% of total Billed charges,N/A,Not Separately reimbursable,24629.28,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,18243.91,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,18243.91,Pays based on 100% of CMS OPPS Rate,1103,pays based on 100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,18243.91,Pays based on 100% of CMS OPPS Rate,1100,24629.28,24600.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OPERATING ROOM,57282,COLPOPEXY EXTRAPERITONEAL,360,13406,589.78,Not Separately reimbursable,1290.5,pays based on per visit rate,1444.4,68% of total billed charges,5000,50% of total billed charges,1319.54,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,1100,70% of total billed charges,1200,75% of total Billed charges,N/A,Not Separately reimbursable,9226.35,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,6834.33,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,6834.33,Pays based on 100% of CMS OPPS Rate,972,pays based on 100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,6834.33,Pays based on 100% of CMS OPPS Rate,972,9226.35,9384.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OPERATING ROOM,41899,UNLISTED PROC DENTOALVEOLAR ST,360,407,N/A,Not Separately reimbursable,1290.5,pays based on per visit rate,1444.4,68% of total billed charges,203.5,50% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,284.9,70% of total billed charges,305.25,75% of total Billed charges,N/A,Not Separately reimbursable,298.23,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,220.91,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,220.91,Pays based on 100% of CMS OPPS Rate,100,pays based on 100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,220.91,Pays based on 100% of CMS OPPS Rate,100,1444.4,284.9,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OPERATING ROOM,24071,EXCIS TUM SFT TISS UPPR ARM SU,360,4637,371.69,Not Separately reimbursable,1290.5,pays based on per visit rate,1444.4,68% of total billed charges,2318.5,50% of total billed charges,767.92,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,1100,70% of total billed charges,1200,75% of total Billed charges,N/A,Not Separately reimbursable,3469.39,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,2569.92,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,2569.92,Pays based on 100% of CMS OPPS Rate,563,pays based on 100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,2569.92,Pays based on 100% of CMS OPPS Rate,563,3469.39,3245.9,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OPERATING ROOM,55250,VASECTOMY,360,1143,224.91,Not Separately reimbursable,1290.5,pays based on per visit rate,1444.4,68% of total billed charges,571.5,50% of total billed charges,431,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,800.1,70% of total billed charges,857.25,75% of total Billed charges,N/A,Not Separately reimbursable,2486.9,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,1842.15,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,1842.15,Pays based on 100% of CMS OPPS Rate,563,pays based on 100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,1842.15,Pays based on 100% of CMS OPPS Rate,431,2486.9,800.1,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OPERATING ROOM,47562,LAPAROSCOPIC CHOLECYSTECTOMY,360,9666,606.81,Not Separately reimbursable,1290.5,pays based on per visit rate,1444.4,68% of total billed charges,4833,50% of total billed charges,1257.66,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,1100,70% of total billed charges,1200,75% of total Billed charges,N/A,Not Separately reimbursable,7045.01,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,5218.53,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,5218.53,Pays based on 100% of CMS OPPS Rate,941,pays based on 100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,5218.53,Pays based on 100% of CMS OPPS Rate,941,7045.01,6766.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OPERATING ROOM,53440,SLING OPRATION CORRJ MALE URIN,360,2428,668.25,Not Separately reimbursable,1290.5,pays based on per visit rate,1444.4,68% of total billed charges,1214,50% of total billed charges,1424.6,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,1100,70% of total billed charges,1200,75% of total Billed charges,N/A,Not Separately reimbursable,15673.49,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,11609.99,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,11609.99,Pays based on 100% of CMS OPPS Rate,1098,pays based on 100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,11609.99,Pays based on 100% of CMS OPPS Rate,1098,15673.49,1699.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OPERATING ROOM,21931,"EXCIS SFT TUM BACK,FLANK SUBQ",360,2745,430.41,Not Separately reimbursable,1290.5,pays based on per visit rate,1444.4,68% of total billed charges,1372.5,50% of total billed charges,891.48,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,1100,70% of total billed charges,1200,75% of total Billed charges,N/A,Not Separately reimbursable,1979.55,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,1466.33,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,1466.33,Pays based on 100% of CMS OPPS Rate,563,pays based on 100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,1466.33,Pays based on 100% of CMS OPPS Rate,563,1979.55,1921.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OPERATING ROOM,54400,INSRTN PENL PROSTHES NON INFLA,360,35144,525.74,Not Separately reimbursable,1290.5,pays based on per visit rate,1444.4,68% of total billed charges,5000,50% of total billed charges,1007.44,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,1100,70% of total billed charges,1200,75% of total Billed charges,N/A,Not Separately reimbursable,15673.49,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,11609.99,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,11609.99,Pays based on 100% of CMS OPPS Rate,1098,pays based on 100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,11609.99,Pays based on 100% of CMS OPPS Rate,1007.44,15673.49,24600.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OPERATING ROOM,52630,TRURL RESCJ RESID REGROW OBST,360,1305,359.03,Not Separately reimbursable,1290.5,pays based on per visit rate,1444.4,68% of total billed charges,652.5,50% of total billed charges,765.22,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,913.5,70% of total billed charges,978.75,75% of total Billed charges,N/A,Not Separately reimbursable,6317.76,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,4679.82,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,4679.82,Pays based on 100% of CMS OPPS Rate,972,pays based on 100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,4679.82,Pays based on 100% of CMS OPPS Rate,652.5,6317.76,913.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OPERATING ROOM,54410,RMV RPLC CMPNT INFLATBLE PENL,360,35144,851.17,Not Separately reimbursable,1290.5,pays based on per visit rate,1444.4,68% of total billed charges,5000,50% of total billed charges,1632.66,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,1100,70% of total billed charges,1200,75% of total Billed charges,N/A,Not Separately reimbursable,24629.28,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,18243.91,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,18243.91,Pays based on 100% of CMS OPPS Rate,1103,pays based on 100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,18243.91,Pays based on 100% of CMS OPPS Rate,1100,24629.28,24600.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OPERATING ROOM,52353,CYSTOURETHRSCPY W LITHOTRIPSY,360,8462,345.29,Not Separately reimbursable,1290.5,pays based on per visit rate,1444.4,68% of total billed charges,4231,50% of total billed charges,737.38,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,1100,70% of total billed charges,1200,75% of total Billed charges,N/A,Not Separately reimbursable,6317.76,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,4679.82,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,4679.82,Pays based on 100% of CMS OPPS Rate,972,pays based on 100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,4679.82,Pays based on 100% of CMS OPPS Rate,737.38,6317.76,5923.4,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OPERATING ROOM,52601,TRANSURETHRAL RESECT PROSTATE,360,8462,646.14,Not Separately reimbursable,1290.5,pays based on per visit rate,1444.4,68% of total billed charges,4231,50% of total billed charges,1378.54,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,1100,70% of total billed charges,1200,75% of total Billed charges,N/A,Not Separately reimbursable,6317.76,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,4679.82,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,4679.82,Pays based on 100% of CMS OPPS Rate,972,pays based on 100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,4679.82,Pays based on 100% of CMS OPPS Rate,972,6317.76,5923.4,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OPERATING ROOM,57240,ANT COLPORRHAPHY RPR CYSTCEL W,360,8542,520.88,Not Separately reimbursable,1290.5,pays based on per visit rate,1444.4,68% of total billed charges,4271,50% of total billed charges,1165.18,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,1100,70% of total billed charges,1200,75% of total Billed charges,N/A,Not Separately reimbursable,6073.02,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,4498.54,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,4498.54,Pays based on 100% of CMS OPPS Rate,695,pays based on 100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,4498.54,Pays based on 100% of CMS OPPS Rate,695,6073.02,5979.4,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OPERATING ROOM,57288,SLING OPERATN FOR STRESS INCON,360,8542,630.23,Not Separately reimbursable,1290.5,pays based on per visit rate,1444.4,68% of total billed charges,4271,50% of total billed charges,1410.18,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,1100,70% of total billed charges,1200,75% of total Billed charges,N/A,Not Separately reimbursable,6073.02,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,4498.54,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,4498.54,Pays based on 100% of CMS OPPS Rate,972,pays based on 100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,4498.54,Pays based on 100% of CMS OPPS Rate,972,6073.02,5979.4,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OPERATING ROOM,11441,EXC FACE-MM B9+MARG 0.6-1 CM,360,555,113.07,Not Separately reimbursable,1290.5,pays based on per visit rate,1444.4,68% of total billed charges,277.5,50% of total billed charges,246.36,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,388.5,70% of total billed charges,416.25,75% of total Billed charges,N/A,Not Separately reimbursable,859.04,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,636.33,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,636.33,Pays based on 100% of CMS OPPS Rate,366,pays based on 100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,636.33,Pays based on 100% of CMS OPPS Rate,246.36,1444.4,388.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OPERATING ROOM,10120,INC&RMVL FB SUBQ TISS SMPL,360,484,88.5,Not Separately reimbursable,1290.5,pays based on per visit rate,1444.4,68% of total billed charges,242,50% of total billed charges,195.02,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,338.8,70% of total billed charges,363,75% of total Billed charges,N/A,Not Separately reimbursable,486.85,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,360.63,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,360.63,Pays based on 100% of CMS OPPS Rate,100,pays based on 100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,360.63,Pays based on 100% of CMS OPPS Rate,100,1444.4,338.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OPERATING ROOM,51705,CHANGE OF BLADDER TUBE,360,310,45.48,Not Separately reimbursable,1290.5,pays based on per visit rate,1444.4,68% of total billed charges,155,50% of total billed charges,97.34,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,217,70% of total billed charges,232.5,75% of total Billed charges,N/A,Not Separately reimbursable,301.75,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,223.52,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,223.52,Pays based on 100% of CMS OPPS Rate,100,pays based on 100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,223.52,Pays based on 100% of CMS OPPS Rate,97.34,1444.4,217,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OPERATING ROOM,23076,EXC SHOULDER TUM DEEP < 5 CM,360,1612,497.15,Not Separately reimbursable,1290.5,pays based on per visit rate,1444.4,68% of total billed charges,806,50% of total billed charges,1026.28,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,1100,70% of total billed charges,1200,75% of total Billed charges,N/A,Not Separately reimbursable,3469.39,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,2569.92,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,2569.92,Pays based on 100% of CMS OPPS Rate,492,pays based on 100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,2569.92,Pays based on 100% of CMS OPPS Rate,492,3469.39,1128.4,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OPERATING ROOM,21013,EXC FACE TUM DEEP < 2 CM,360,1711,365.58,Not Separately reimbursable,1290.5,pays based on per visit rate,1444.4,68% of total billed charges,855.5,50% of total billed charges,754.2,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,1100,70% of total billed charges,1200,75% of total Billed charges,N/A,Not Separately reimbursable,1979.55,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,1466.33,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,1466.33,Pays based on 100% of CMS OPPS Rate,366,pays based on 100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,1466.33,Pays based on 100% of CMS OPPS Rate,366,1979.55,1197.7,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OPERATING ROOM,11602,EXC TR-EXT MAL+MARG 1.1-2CM,360,779,137.5,Not Separately reimbursable,1290.5,pays based on per visit rate,1444.4,68% of total billed charges,389.5,50% of total billed charges,299.44,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,545.3,70% of total billed charges,584.25,75% of total Billed charges,N/A,Not Separately reimbursable,486.85,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,360.63,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,360.63,Pays based on 100% of CMS OPPS Rate,100,pays based on 100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,360.63,Pays based on 100% of CMS OPPS Rate,100,1444.4,545.3,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OPERATING ROOM,12031,INTMD RPR S/A/T/EXT 2.5 CM/<,360,833,128.8,Not Separately reimbursable,1290.5,pays based on per visit rate,1444.4,68% of total billed charges,416.5,50% of total billed charges,280.32,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,583.1,70% of total billed charges,624.75,75% of total Billed charges,N/A,Not Separately reimbursable,486.85,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,360.63,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,360.63,Pays based on 100% of CMS OPPS Rate,100,pays based on 100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,360.63,Pays based on 100% of CMS OPPS Rate,100,1444.4,583.1,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OPERATING ROOM,45378,COLONOSCOPY DIAGNOSTIC,360,1621,83.69,Not Separately reimbursable,1290.5,pays based on per visit rate,1444.4,68% of total billed charges,810.5,50% of total billed charges,345.48,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,1100,70% of total billed charges,1200,75% of total Billed charges,N/A,Not Separately reimbursable,1115.91,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,826.6,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,826.6,Pays based on 100% of CMS OPPS Rate,492,pays based on 100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,826.6,Pays based on 100% of CMS OPPS Rate,345.48,1444.4,1134.7,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OPERATING ROOM,51715,ENDOSCOPIC INJECTION/IMPLANT,360,4082,176.61,Not Separately reimbursable,1290.5,pays based on per visit rate,1444.4,68% of total billed charges,2041,50% of total billed charges,377.46,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,1100,70% of total billed charges,1200,75% of total Billed charges,N/A,Not Separately reimbursable,4256.51,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,3152.97,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,3152.97,Pays based on 100% of CMS OPPS Rate,695,pays based on 100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,3152.97,Pays based on 100% of CMS OPPS Rate,377.46,4256.51,2857.4,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OPERATING ROOM,21012,EXC FACE LES SBQ 2 CM/>,360,1108,309.14,Not Separately reimbursable,1290.5,pays based on per visit rate,1444.4,68% of total billed charges,554,50% of total billed charges,637.2,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,775.6,70% of total billed charges,831,75% of total Billed charges,N/A,Not Separately reimbursable,1979.55,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,1466.33,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,1466.33,Pays based on 100% of CMS OPPS Rate,366,pays based on 100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,1466.33,Pays based on 100% of CMS OPPS Rate,366,1979.55,775.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OPERATING ROOM,10061,I&D ABSCESS MULT OR COMP,361,691,157.32,Not Separately reimbursable,601.32,pays based on per visit rate,644.72,68% of total billed charges,345.5,50% of total billed charges,343.4,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,486.85,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,360.63,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,360.63,Pays based on 100% of CMS OPPS Rate,100,pays based on 100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,360.63,Pays based on 100% of CMS OPPS Rate,100,644.72,483.7,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OPERATING ROOM,52234,CYSTO W FULG AND RESECT TUMOR,361,6036,216.6,Not Separately reimbursable,601.32,pays based on per visit rate,644.72,68% of total billed charges,3018,50% of total billed charges,462.26,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,4256.51,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,3152.97,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,3152.97,Pays based on 100% of CMS OPPS Rate,563,pays based on 100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,3152.97,Pays based on 100% of CMS OPPS Rate,462.26,4256.51,4225.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OPERATING ROOM,52352,CYSTOURETERO W STONE REMOVAL,361,6036,311.59,Not Separately reimbursable,601.32,pays based on per visit rate,644.72,68% of total billed charges,3018,50% of total billed charges,666.1,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,4256.51,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,3152.97,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,3152.97,Pays based on 100% of CMS OPPS Rate,563,pays based on 100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,3152.97,Pays based on 100% of CMS OPPS Rate,563,4256.51,4225.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OPERATING ROOM,52354,CYSTO W URET PYELOSC BX FULG O,361,1322,367.23,Not Separately reimbursable,601.32,pays based on per visit rate,644.72,68% of total billed charges,661,50% of total billed charges,784.86,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,6317.76,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,4679.82,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,4679.82,Pays based on 100% of CMS OPPS Rate,563,pays based on 100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,4679.82,Pays based on 100% of CMS OPPS Rate,563,6317.76,925.4,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OPERATING ROOM,55700,BIOPSY PROSTATE NEEDLE PUNCH,361,3543,127.7,Not Separately reimbursable,601.32,pays based on per visit rate,644.72,68% of total billed charges,1771.5,50% of total billed charges,246.58,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,2486.9,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,1842.15,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,1842.15,Pays based on 100% of CMS OPPS Rate,492,pays based on 100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,1842.15,Pays based on 100% of CMS OPPS Rate,246.58,2486.9,2480.1,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OPERATING ROOM,43239,EGD FLIXIBLE TRANSORAL W BX SN,361,1572,125.24,Not Separately reimbursable,601.32,pays based on per visit rate,644.72,68% of total billed charges,786,50% of total billed charges,259.2,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,1106.79,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,819.84,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,819.84,Pays based on 100% of CMS OPPS Rate,492,pays based on 100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,819.84,Pays based on 100% of CMS OPPS Rate,259.2,1106.79,1100.4,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OPERATING ROOM,11042,DEBRID SKIN SBQ TISSUE<=20 SQ,361,639,51.54,Not Separately reimbursable,601.32,pays based on per visit rate,644.72,68% of total billed charges,319.5,50% of total billed charges,113.98,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,486.85,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,360.63,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,360.63,Pays based on 100% of CMS OPPS Rate,100,pays based on 100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,360.63,Pays based on 100% of CMS OPPS Rate,100,644.72,447.3,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OPERATING ROOM,10140,I & D HEMA SEROMA FLUID,361,2745,101.09,Not Separately reimbursable,601.32,pays based on per visit rate,644.72,68% of total billed charges,1372.5,50% of total billed charges,220.6,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,1979.55,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,1466.33,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,1466.33,Pays based on 100% of CMS OPPS Rate,492,pays based on 100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,1466.33,Pays based on 100% of CMS OPPS Rate,220.6,1979.55,1921.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OPERATING ROOM,52000,CYSTOURETHROSCOPY (SEPERATE PR,361,1113,71.38,Not Separately reimbursable,601.32,pays based on per visit rate,644.72,68% of total billed charges,556.5,50% of total billed charges,151.92,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,834.05,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,617.82,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,617.82,Pays based on 100% of CMS OPPS Rate,366,pays based on 100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,617.82,Pays based on 100% of CMS OPPS Rate,151.92,834.05,779.1,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OPERATING ROOM,52332,CYSTOURETHRSCPY W/INSERT INDW,361,6036,136.89,Not Separately reimbursable,601.32,pays based on per visit rate,644.72,68% of total billed charges,3018,50% of total billed charges,292.2,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,4256.51,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,3152.97,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,3152.97,Pays based on 100% of CMS OPPS Rate,563,pays based on 100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,3152.97,Pays based on 100% of CMS OPPS Rate,292.2,4256.51,4225.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OPERATING ROOM,52317,LITHOPLAXY CRUSH FRAG CALCULUS,361,2784,305.6,Not Separately reimbursable,601.32,pays based on per visit rate,644.72,68% of total billed charges,1392,50% of total billed charges,652.5,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,4256.51,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,3152.97,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,3152.97,Pays based on 100% of CMS OPPS Rate,563,pays based on 100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,3152.97,Pays based on 100% of CMS OPPS Rate,563,4256.51,1948.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OPERATING ROOM,45380,COLNSCPY FLEX SPLEN BX,361,2008,181.75,Not Separately reimbursable,601.32,pays based on per visit rate,644.72,68% of total billed charges,1004,50% of total billed charges,375.32,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,1440.83,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,1067.27,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,1067.27,Pays based on 100% of CMS OPPS Rate,492,pays based on 100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,1067.27,Pays based on 100% of CMS OPPS Rate,375.32,1440.83,1405.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OPERATING ROOM,45384,COLNSCPY FLEX SPLEN TUM BX,361,2008,207.41,Not Separately reimbursable,601.32,pays based on per visit rate,644.72,68% of total billed charges,1004,50% of total billed charges,428.38,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,1440.83,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,1067.27,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,1067.27,Pays based on 100% of CMS OPPS Rate,492,pays based on 100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,1067.27,Pays based on 100% of CMS OPPS Rate,428.38,1440.83,1405.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OPERATING ROOM,52281,CYSTOURETHROSCPY W CALIB DILAT,361,3543,133.85,Not Separately reimbursable,601.32,pays based on per visit rate,644.72,68% of total billed charges,1771.5,50% of total billed charges,285.76,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,2486.9,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,1842.15,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,1842.15,Pays based on 100% of CMS OPPS Rate,492,pays based on 100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,1842.15,Pays based on 100% of CMS OPPS Rate,285.76,2486.9,2480.1,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OPERATING ROOM,11444,EXCIS BEN LES FACE 3.1 4.0CM,361,2745,193.32,Not Separately reimbursable,601.32,pays based on per visit rate,644.72,68% of total billed charges,1372.5,50% of total billed charges,421.6,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,1979.55,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,1466.33,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,1466.33,Pays based on 100% of CMS OPPS Rate,366,pays based on 100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,1466.33,Pays based on 100% of CMS OPPS Rate,366,1979.55,1921.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OPERATING ROOM,45330,SIGMOID FLEX DIAGNOSTIC,361,1528,50.64,Not Separately reimbursable,601.32,pays based on per visit rate,644.72,68% of total billed charges,764,50% of total billed charges,105.44,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,1115.91,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,826.6,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,826.6,Pays based on 100% of CMS OPPS Rate,366,pays based on 100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,826.6,Pays based on 100% of CMS OPPS Rate,105.44,1115.91,1069.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OPERATING ROOM,11443,EXCIS BEN LES FACE 2.1 3.0 CM,361,2745,152.58,Not Separately reimbursable,601.32,pays based on per visit rate,644.72,68% of total billed charges,1372.5,50% of total billed charges,333.22,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,1979.55,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,1466.33,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,1466.33,Pays based on 100% of CMS OPPS Rate,366,pays based on 100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,1466.33,Pays based on 100% of CMS OPPS Rate,333.22,1979.55,1921.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OPERATING ROOM,11403,EXC B9 LESN MRGN XCP SK TG T/A,361,1907,126.56,Not Separately reimbursable,601.32,pays based on per visit rate,644.72,68% of total billed charges,953.5,50% of total billed charges,277.82,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,859.04,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,636.33,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,636.33,Pays based on 100% of CMS OPPS Rate,366,pays based on 100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,636.33,Pays based on 100% of CMS OPPS Rate,277.82,953.5,1334.9,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OPERATING ROOM,11404,EXC B9 LESN MRGN XCP SK TG T/A,361,4311,140.16,Not Separately reimbursable,601.32,pays based on per visit rate,644.72,68% of total billed charges,2155.5,50% of total billed charges,306.7,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,1979.55,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,1466.33,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,1466.33,Pays based on 100% of CMS OPPS Rate,492,pays based on 100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,1466.33,Pays based on 100% of CMS OPPS Rate,306.7,2155.5,3017.7,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OPERATING ROOM,51102,ASPIR BLAD WINSERT SUPRAP CATH,361,3543,127.97,Not Separately reimbursable,601.32,pays based on per visit rate,644.72,68% of total billed charges,1771.5,50% of total billed charges,269.04,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,2486.9,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,1842.15,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,1842.15,Pays based on 100% of CMS OPPS Rate,563,pays based on 100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,1842.15,Pays based on 100% of CMS OPPS Rate,269.04,2486.9,2480.1,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OPERATING ROOM,52224,CYSTO W FULG WO W BX,361,2444,179.77,Not Separately reimbursable,601.32,pays based on per visit rate,644.72,68% of total billed charges,1222,50% of total billed charges,382.6,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,4256.51,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,3152.97,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,3152.97,Pays based on 100% of CMS OPPS Rate,563,pays based on 100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,3152.97,Pays based on 100% of CMS OPPS Rate,382.6,4256.51,1710.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OPERATING ROOM,52351,CYSTOURETHROS W URETERSCOP DIA,361,6036,266.25,Not Separately reimbursable,601.32,pays based on per visit rate,644.72,68% of total billed charges,3018,50% of total billed charges,570.08,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,4256.51,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,3152.97,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,3152.97,Pays based on 100% of CMS OPPS Rate,563,pays based on 100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,3152.97,Pays based on 100% of CMS OPPS Rate,563,4256.51,4225.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OPERATING ROOM,54161,CIRCUMCISION/28 DAYS OR OLDER,361,3543,194.55,Not Separately reimbursable,601.32,pays based on per visit rate,644.72,68% of total billed charges,1771.5,50% of total billed charges,372.78,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,2486.9,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,1842.15,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,1842.15,Pays based on 100% of CMS OPPS Rate,563,pays based on 100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,1842.15,Pays based on 100% of CMS OPPS Rate,372.78,2486.9,2480.1,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OPERATING ROOM,11440,EXC FACE-MM B9+MARG 0.5 CM/<,361,448,89.71,Not Separately reimbursable,601.32,pays based on per visit rate,644.72,68% of total billed charges,224,50% of total billed charges,195.98,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,859.04,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,636.33,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,636.33,Pays based on 100% of CMS OPPS Rate,366,pays based on 100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,636.33,Pays based on 100% of CMS OPPS Rate,195.98,859.04,313.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,PHYSICAL THERAPY,97110,THERAPEUTIC EXERCISE (15 MIN),420,110,18.44,Not Separately reimbursable,74.8,68% of total billed charges,83.6,76% of total billed charges,150,pays based on per visit rate ,54.62,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,36.87,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,27.31,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,27.31,Pays based on 100% of CMS OPPS Rate,55,Pays based on per visit rate,N/A,Not Separately reimbursable,27.31,Pays based on 100% of CMS OPPS Rate,27.31,150,77,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,PHYSICAL THERAPY,97034,CONTRAST BATH,420,85,11.29,Not Separately reimbursable,57.8,68% of total billed charges,64.6,76% of total billed charges,150,pays based on per visit rate ,26.06,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,17.59,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,13.03,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,13.03,Pays based on 100% of CMS OPPS Rate,55,Pays based on per visit rate,N/A,Not Separately reimbursable,13.03,Pays based on 100% of CMS OPPS Rate,13.03,150,59.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,PHYSICAL THERAPY,97597,SELECTIVE DEBRIDEMENT A,420,275,33.45,Not Separately reimbursable,187,68% of total billed charges,209,76% of total billed charges,150,pays based on per visit rate ,67.72,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,244.43,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,181.06,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,181.06,Pays based on 100% of CMS OPPS Rate,55,Pays based on per visit rate,N/A,Not Separately reimbursable,181.06,Pays based on 100% of CMS OPPS Rate,55,244.43,192.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,PHYSICAL THERAPY,97598,SELECTIVE DEBRIDEMENT B,420,351,23.23,Not Separately reimbursable,238.68,68% of total billed charges,266.76,76% of total billed charges,150,pays based on per visit rate ,46.9,Pays based on 200% of CMS OPPS Rate,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,0,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,55,Pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,46.9,266.76,245.7,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,PHYSICAL THERAPY,97602,NON-SELECTIVE DEBRIDEMENT,420,367,82.4,Not Separately reimbursable,249.56,68% of total billed charges,278.92,76% of total billed charges,150,pays based on per visit rate ,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,244.44,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,181.06,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,181.06,Pays based on 100% of CMS OPPS Rate,55,Pays based on per visit rate,N/A,Not Separately reimbursable,181.06,Pays based on 100% of CMS OPPS Rate,55,278.92,256.9,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,PHYSICAL THERAPY,97032,ELECTRIC STIMULATION,420,106,10.42,Not Separately reimbursable,72.08,68% of total billed charges,80.56,76% of total billed charges,150,pays based on per visit rate ,27,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,18.23,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,13.5,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,13.5,Pays based on 100% of CMS OPPS Rate,55,Pays based on per visit rate,N/A,Not Separately reimbursable,13.5,Pays based on 100% of CMS OPPS Rate,13.5,150,74.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,PHYSICAL THERAPY,97014,E-STIM NON-WOUND UNATTENDED,420,74,6.56,Not Separately reimbursable,50.32,68% of total billed charges,56.24,76% of total billed charges,150,pays based on per visit rate ,22.92,Pays based on 200% of CMS OPPS Rate,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,0,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,55,Pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,22.92,150,51.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,PHYSICAL THERAPY,97116,GAIT TRAINING,420,96,22.88,Not Separately reimbursable,65.28,68% of total billed charges,72.96,76% of total billed charges,150,pays based on per visit rate ,54.62,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,36.87,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,27.31,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,27.31,Pays based on 100% of CMS OPPS Rate,55,Pays based on per visit rate,N/A,Not Separately reimbursable,27.31,Pays based on 100% of CMS OPPS Rate,27.31,150,67.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,PHYSICAL THERAPY,97535,SELF CARE/ HOME INSTRUCTION,420,119,25.44,Not Separately reimbursable,80.92,68% of total billed charges,90.44,76% of total billed charges,150,pays based on per visit rate ,60.34,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,40.73,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,30.17,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,30.17,Pays based on 100% of CMS OPPS Rate,55,Pays based on per visit rate,N/A,Not Separately reimbursable,30.17,Pays based on 100% of CMS OPPS Rate,30.17,150,83.3,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,PHYSICAL THERAPY,97033,IONTOPHORESIS (15 MIN),420,85,15.21,Not Separately reimbursable,57.8,68% of total billed charges,64.6,76% of total billed charges,150,pays based on per visit rate ,35.68,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,24.08,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,17.84,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,17.84,Pays based on 100% of CMS OPPS Rate,55,Pays based on per visit rate,N/A,Not Separately reimbursable,17.84,Pays based on 100% of CMS OPPS Rate,17.84,150,59.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,PHYSICAL THERAPY,97124,MASSAGE,420,106,13.56,Not Separately reimbursable,72.08,68% of total billed charges,80.56,76% of total billed charges,150,pays based on per visit rate ,55.4,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,37.4,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,27.7,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,27.7,Pays based on 100% of CMS OPPS Rate,55,Pays based on per visit rate,N/A,Not Separately reimbursable,27.7,Pays based on 100% of CMS OPPS Rate,27.7,150,74.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,PHYSICAL THERAPY,97140,MANUAL THERAPY,420,110,12.95,Not Separately reimbursable,74.8,68% of total billed charges,83.6,76% of total billed charges,150,pays based on per visit rate ,50.42,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,34.03,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,25.21,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,25.21,Pays based on 100% of CMS OPPS Rate,55,Pays based on per visit rate,N/A,Not Separately reimbursable,25.21,Pays based on 100% of CMS OPPS Rate,25.21,150,77,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,PHYSICAL THERAPY,97112,NEUROMUSCLE EXERCISE (15 MIN),420,110,26.54,Not Separately reimbursable,74.8,68% of total billed charges,83.6,76% of total billed charges,150,pays based on per visit rate ,62.52,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,42.2,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,31.26,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,31.26,Pays based on 100% of CMS OPPS Rate,55,Pays based on per visit rate,N/A,Not Separately reimbursable,31.26,Pays based on 100% of CMS OPPS Rate,31.26,150,77,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,PHYSICAL THERAPY,97760,ORTHOTIC FIT/TRAINING,420,85,37.58,Not Separately reimbursable,57.8,68% of total billed charges,64.6,76% of total billed charges,150,pays based on per visit rate ,86.54,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,58.41,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,43.27,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,43.27,Pays based on 100% of CMS OPPS Rate,55,Pays based on per visit rate,N/A,Not Separately reimbursable,43.27,Pays based on 100% of CMS OPPS Rate,43.27,150,59.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,PHYSICAL THERAPY,97018,PARAFIN BATH,420,106,4.42,Not Separately reimbursable,72.08,68% of total billed charges,80.56,76% of total billed charges,150,pays based on per visit rate ,10.36,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,6.99,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,5.18,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,5.18,Pays based on 100% of CMS OPPS Rate,55,Pays based on per visit rate,N/A,Not Separately reimbursable,5.18,Pays based on 100% of CMS OPPS Rate,5.18,150,74.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,PHYSICAL THERAPY,97761,PROSTHETIC TRAINING,420,117,32.18,Not Separately reimbursable,79.56,68% of total billed charges,88.92,76% of total billed charges,150,pays based on per visit rate ,76.24,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,51.46,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,38.12,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,38.12,Pays based on 100% of CMS OPPS Rate,55,Pays based on per visit rate,N/A,Not Separately reimbursable,38.12,Pays based on 100% of CMS OPPS Rate,38.12,150,81.9,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,PHYSICAL THERAPY,97022,STERILE WHIRLPOOL,420,181,13.29,Not Separately reimbursable,123.08,68% of total billed charges,137.56,76% of total billed charges,150,pays based on per visit rate ,30.82,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,20.8,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,15.41,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,15.41,Pays based on 100% of CMS OPPS Rate,55,Pays based on per visit rate,N/A,Not Separately reimbursable,15.41,Pays based on 100% of CMS OPPS Rate,15.41,150,126.7,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,PHYSICAL THERAPY,97035,ULTRASOUND (15 MIN),420,119,7.72,Not Separately reimbursable,80.92,68% of total billed charges,90.44,76% of total billed charges,150,pays based on per visit rate ,26.06,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,17.59,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,13.03,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,13.03,Pays based on 100% of CMS OPPS Rate,55,Pays based on per visit rate,N/A,Not Separately reimbursable,13.03,Pays based on 100% of CMS OPPS Rate,13.03,150,83.3,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,PHYSICAL THERAPY,97016,VASOPNEUMATIC TX,420,63,9.2,Not Separately reimbursable,42.84,68% of total billed charges,47.88,76% of total billed charges,150,pays based on per visit rate ,21.78,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,14.7,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,10.89,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,10.89,Pays based on 100% of CMS OPPS Rate,55,Pays based on per visit rate,N/A,Not Separately reimbursable,10.89,Pays based on 100% of CMS OPPS Rate,10.89,150,44.1,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,PHYSICAL THERAPY,97010,SM-HYDROCOLLATOR PKS,420,53,3.48,Not Separately reimbursable,36.04,68% of total billed charges,40.28,76% of total billed charges,150,pays based on per visit rate ,11.5,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,7.76,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,5.75,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,5.75,Pays based on 100% of CMS OPPS Rate,55,Pays based on per visit rate,N/A,Not Separately reimbursable,5.75,Pays based on 100% of CMS OPPS Rate,5.75,150,37.1,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,PHYSICAL THERAPY,97530,THER/FUNC ACTIVITIES (15 MIN),420,121,28.77,Not Separately reimbursable,82.28,68% of total billed charges,91.96,76% of total billed charges,150,pays based on per visit rate ,67.1,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,45.29,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,33.55,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,33.55,Pays based on 100% of CMS OPPS Rate,55,Pays based on per visit rate,N/A,Not Separately reimbursable,33.55,Pays based on 100% of CMS OPPS Rate,33.55,150,84.7,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,PHYSICAL THERAPY,97012,MECH TRACTION,420,85,5.22,Not Separately reimbursable,57.8,68% of total billed charges,64.6,76% of total billed charges,150,pays based on per visit rate ,26.44,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,17.85,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,13.22,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,13.22,Pays based on 100% of CMS OPPS Rate,55,Pays based on per visit rate,N/A,Not Separately reimbursable,13.22,Pays based on 100% of CMS OPPS Rate,13.22,150,59.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,PHYSICAL THERAPY,97039,UNLISTED MODALITIES (15 MIN),420,85,8,Not Separately reimbursable,57.8,68% of total billed charges,64.6,76% of total billed charges,150,pays based on per visit rate ,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,0,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,55,Pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,55,150,59.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,PHYSICAL THERAPY,97139,UNLISTED THER. PROCEDURE (15 M,420,106,13.51,Not Separately reimbursable,72.08,68% of total billed charges,80.56,76% of total billed charges,150,pays based on per visit rate ,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,0,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,55,Pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,55,150,74.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,PHYSICAL THERAPY,97542,WHEELCHAIR TRAINING (15 MIN),420,106,24.71,Not Separately reimbursable,72.08,68% of total billed charges,80.56,76% of total billed charges,150,pays based on per visit rate ,58.9,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,39.76,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,29.45,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,29.45,Pays based on 100% of CMS OPPS Rate,55,Pays based on per visit rate,N/A,Not Separately reimbursable,29.45,Pays based on 100% of CMS OPPS Rate,29.45,150,74.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,PHYSICAL THERAPY,97545,WORK HARDENING 1 (INITIAL 2HOU,420,210.5,130.16,Not Separately reimbursable,143.14,68% of total billed charges,159.98,76% of total billed charges,150,pays based on per visit rate ,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,0,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,55,Pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,55,159.98,147.35,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,PHYSICAL THERAPY,97546,WORK HARDENING 2 (EACH ADD'L H,420,106,51.46,Not Separately reimbursable,72.08,68% of total billed charges,80.56,76% of total billed charges,150,pays based on per visit rate ,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,0,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,55,Pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,55,150,74.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,PHYSICAL THERAPY,97164,PT RE-EVALUATION,424,226,53.54,Not Separately reimbursable,153.68,68% of total billed charges,171.76,76% of total billed charges,150,pays based on per visit rate ,128.76,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,86.91,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,64.38,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,64.38,Pays based on 100% of CMS OPPS Rate,55,Pays based on per visit rate,N/A,Not Separately reimbursable,64.38,Pays based on 100% of CMS OPPS Rate,55,171.76,158.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,PHYSICAL THERAPY,97001,EVALUATION TECH,424,210.5,N/A,Not Separately reimbursable,143.14,68% of total billed charges,159.98,76% of total billed charges,150,pays based on per visit rate ,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,0,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,55,Pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,55,159.98,147.35,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,PHYSICAL THERAPY,97161,PT EVALUATION-LOW,424,330,77.84,Not Separately reimbursable,224.4,68% of total billed charges,250.8,76% of total billed charges,150,pays based on per visit rate ,186.88,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,126.14,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,93.44,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,93.44,Pays based on 100% of CMS OPPS Rate,55,Pays based on per visit rate,N/A,Not Separately reimbursable,93.44,Pays based on 100% of CMS OPPS Rate,55,250.8,231,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,PHYSICAL THERAPY,97162,PT EVALUATION-MOD,424,330,77.84,Not Separately reimbursable,224.4,68% of total billed charges,250.8,76% of total billed charges,150,pays based on per visit rate ,186.88,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,126.14,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,93.44,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,93.44,Pays based on 100% of CMS OPPS Rate,55,Pays based on per visit rate,N/A,Not Separately reimbursable,93.44,Pays based on 100% of CMS OPPS Rate,55,250.8,231,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,PHYSICAL THERAPY,97163,PT EVALUATION-HIGH,424,330,77.84,Not Separately reimbursable,224.4,68% of total billed charges,250.8,76% of total billed charges,150,pays based on per visit rate ,186.88,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,126.14,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,93.44,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,93.44,Pays based on 100% of CMS OPPS Rate,55,Pays based on per visit rate,N/A,Not Separately reimbursable,93.44,Pays based on 100% of CMS OPPS Rate,55,250.8,231,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,70450,CT BRAIN W/O CONTRAST,351,556,48.16,Not Separately reimbursable,378.08,68% of total billed charges,378.08,68% of total billed charges,650,pays based on per visit rate ,118.44,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,89.49,Pays based on 100% of MO Medicaid Fee Schedule,134.22,Pays based on 135% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Rate,99.43,Pays based on 100% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Fee Schedule,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,300,Pays based on per visit rate,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,89.49,650,389.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,70460,CT BRAIN W/CONTRAST,351,912,64.36,Not Separately reimbursable,620.16,68% of total billed charges,620.16,68% of total billed charges,650,pays based on per visit rate ,169.92,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,149.56,Pays based on 100% of MO Medicaid Fee Schedule,224.33,Pays based on 135% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Rate,166.17,Pays based on 100% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Fee Schedule,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,300,Pays based on per visit rate,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,149.56,650,638.4,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,70490,CT NECK W/O CONTRAST,350,556,73.2,Not Separately reimbursable,378.08,68% of total billed charges,378.08,68% of total billed charges,650,pays based on per visit rate ,160.76,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,89.49,Pays based on 100% of MO Medicaid Fee Schedule,134.22,Pays based on 135% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Rate,99.43,Pays based on 100% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Fee Schedule,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,300,Pays based on per visit rate,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,89.49,650,389.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,70491,CT NECK W/CONTRAST,350,912,78.88,Not Separately reimbursable,620.16,68% of total billed charges,620.16,68% of total billed charges,650,pays based on per visit rate ,213.46,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,149.56,Pays based on 100% of MO Medicaid Fee Schedule,224.33,Pays based on 135% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Rate,166.17,Pays based on 100% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Fee Schedule,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,300,Pays based on per visit rate,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,149.56,650,638.4,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,71250,CT THORAX W/O CONTRAST,350,556,61.51,Not Separately reimbursable,378.08,68% of total billed charges,378.08,68% of total billed charges,650,pays based on per visit rate ,147.04,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,89.49,Pays based on 100% of MO Medicaid Fee Schedule,134.22,Pays based on 135% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Rate,99.43,Pays based on 100% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Fee Schedule,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,300,Pays based on per visit rate,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,89.49,650,389.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,71260,CT THORAX W/CONTRAST,350,912,65.98,Not Separately reimbursable,620.16,68% of total billed charges,620.16,68% of total billed charges,650,pays based on per visit rate ,200.3,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,149.56,Pays based on 100% of MO Medicaid Fee Schedule,224.33,Pays based on 135% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Rate,166.17,Pays based on 100% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Fee Schedule,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,300,Pays based on per visit rate,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,149.56,650,638.4,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,72131,CT LUMBAR SPINE W/O CONTRAST,350,556,57.04,Not Separately reimbursable,378.08,68% of total billed charges,378.08,68% of total billed charges,650,pays based on per visit rate ,147.04,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,89.49,Pays based on 100% of MO Medicaid Fee Schedule,134.22,Pays based on 135% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Rate,99.43,Pays based on 100% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Fee Schedule,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,300,Pays based on per visit rate,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,89.49,650,389.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,72192,CT PELVIS W/O CONTRAST,350,556,61.93,Not Separately reimbursable,378.08,68% of total billed charges,378.08,68% of total billed charges,650,pays based on per visit rate ,146.46,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,89.49,Pays based on 100% of MO Medicaid Fee Schedule,134.22,Pays based on 135% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Rate,99.43,Pays based on 100% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Fee Schedule,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,300,Pays based on per visit rate,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,89.49,650,389.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,72193,CT PELVIS W/CONTRAST,350,912,65.98,Not Separately reimbursable,620.16,68% of total billed charges,620.16,68% of total billed charges,650,pays based on per visit rate ,310.1,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,149.56,Pays based on 100% of MO Medicaid Fee Schedule,224.33,Pays based on 135% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Rate,166.17,Pays based on 100% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Fee Schedule,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,300,Pays based on per visit rate,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,149.56,650,638.4,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,73200,CT UPPER EXTREMITY W/O CONTRAS,350,556,57.04,Not Separately reimbursable,378.08,68% of total billed charges,378.08,68% of total billed charges,650,pays based on per visit rate ,203.66,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,89.49,Pays based on 100% of MO Medicaid Fee Schedule,134.22,Pays based on 135% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Rate,99.43,Pays based on 100% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Fee Schedule,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,300,Pays based on per visit rate,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,89.49,650,389.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,73201,CT UPPER EXTREMITY W/CONTRAST,340,1880,65.59,Not Separately reimbursable,1278.4,68% of total billed charges,1278.4,68% of total billed charges,940,50% of total billed charges,260.34,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,313.04,Pays based on 100% of MO Medicaid Fee Schedule,469.55,Pays based on 135% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Rate,347.82,Pays based on 100% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Fee Schedule,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,300,Pays based on per visit rate,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,260.34,1278.4,1316,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,73700,CT LOWER EXTREMITY W/O CONTRAS,350,556,57.04,Not Separately reimbursable,378.08,68% of total billed charges,378.08,68% of total billed charges,650,pays based on per visit rate ,147.62,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,89.49,Pays based on 100% of MO Medicaid Fee Schedule,134.22,Pays based on 135% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Rate,99.43,Pays based on 100% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Fee Schedule,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,300,Pays based on per visit rate,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,89.49,650,389.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,73701,CT LOWER EXTREMITY W/CONTRAST,340,912,65.98,Not Separately reimbursable,620.16,68% of total billed charges,620.16,68% of total billed charges,456,50% of total billed charges,200.3,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,149.56,Pays based on 100% of MO Medicaid Fee Schedule,224.33,Pays based on 135% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Rate,166.17,Pays based on 100% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Fee Schedule,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,300,Pays based on per visit rate,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,149.56,620.16,638.4,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,74150,CT ABDOMEN W/O CONTRAST,350,556,68.32,Not Separately reimbursable,378.08,68% of total billed charges,378.08,68% of total billed charges,650,pays based on per visit rate ,144.76,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,89.49,Pays based on 100% of MO Medicaid Fee Schedule,134.22,Pays based on 135% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Rate,99.43,Pays based on 100% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Fee Schedule,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,300,Pays based on per visit rate,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,89.49,650,389.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,74160,CT ABDOMEN W/CONTRAST,350,912,72.79,Not Separately reimbursable,620.16,68% of total billed charges,620.16,68% of total billed charges,650,pays based on per visit rate ,308.38,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,149.56,Pays based on 100% of MO Medicaid Fee Schedule,224.33,Pays based on 135% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Rate,166.17,Pays based on 100% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Fee Schedule,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,300,Pays based on per visit rate,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,149.56,650,638.4,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,77078,CT BONE DENSITY,340,319,14.17,Not Separately reimbursable,216.92,68% of total billed charges,216.92,68% of total billed charges,159.5,50% of total billed charges,157.34,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,73.96,Pays based on 100% of MO Medicaid Fee Schedule,110.94,Pays based on 135% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Rate,82.18,Pays based on 100% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Fee Schedule,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,300,Pays based on per visit rate,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,73.96,300,223.3,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,70480,CT ORBIT W/O CONTRAST,350,556,73.2,Not Separately reimbursable,378.08,68% of total billed charges,378.08,68% of total billed charges,650,pays based on per visit rate ,176.28,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,89.49,Pays based on 100% of MO Medicaid Fee Schedule,134.22,Pays based on 135% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Rate,99.43,Pays based on 100% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Fee Schedule,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,300,Pays based on per visit rate,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,89.49,650,389.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,70481,CT ORBIT W/CONTRAST,350,912,63.96,Not Separately reimbursable,620.16,68% of total billed charges,620.16,68% of total billed charges,650,pays based on per visit rate ,227.18,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,149.56,Pays based on 100% of MO Medicaid Fee Schedule,224.33,Pays based on 135% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Rate,166.17,Pays based on 100% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Fee Schedule,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,300,Pays based on per visit rate,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,149.56,650,638.4,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,74170,CT ABDOMEN W/WO CONTRAST,350,1000,80.06,Not Separately reimbursable,680,68% of total billed charges,680,68% of total billed charges,650,pays based on per visit rate ,349.56,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,149.56,Pays based on 100% of MO Medicaid Fee Schedule,224.33,Pays based on 135% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Rate,166.17,Pays based on 100% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Fee Schedule,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,300,Pays based on per visit rate,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,149.56,680,700,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,70470,CT BRAIN W/WO CONTRAST,351,1000,72.79,Not Separately reimbursable,680,68% of total billed charges,680,68% of total billed charges,650,pays based on per visit rate ,203.16,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,149.56,Pays based on 100% of MO Medicaid Fee Schedule,224.33,Pays based on 135% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Rate,166.17,Pays based on 100% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Fee Schedule,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,300,Pays based on per visit rate,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,149.56,680,700,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,70482,CT 0RBIT W/WO CONTRAST,350,1000,72.39,Not Separately reimbursable,680,68% of total billed charges,680,68% of total billed charges,650,pays based on per visit rate ,269.5,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,149.56,Pays based on 100% of MO Medicaid Fee Schedule,224.33,Pays based on 135% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Rate,166.17,Pays based on 100% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Fee Schedule,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,300,Pays based on per visit rate,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,149.56,680,700,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,73702,CT LOWER EXTREMITY W/WO CONTRA,340,912,69.55,Not Separately reimbursable,620.16,68% of total billed charges,620.16,68% of total billed charges,456,50% of total billed charges,246.62,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,149.56,Pays based on 100% of MO Medicaid Fee Schedule,224.33,Pays based on 135% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Rate,166.17,Pays based on 100% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Fee Schedule,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,300,Pays based on per visit rate,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,149.56,620.16,638.4,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,70488,CT MAXILLOFACIAL AREA W/WO CON,350,1000,72.39,Not Separately reimbursable,680,68% of total billed charges,680,68% of total billed charges,650,pays based on per visit rate ,222.6,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,149.56,Pays based on 100% of MO Medicaid Fee Schedule,224.33,Pays based on 135% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Rate,166.17,Pays based on 100% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Fee Schedule,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,300,Pays based on per visit rate,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,149.56,680,700,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,70486,CT MAXILLOFACIAL AREA W/O CONT,350,556,48.56,Not Separately reimbursable,378.08,68% of total billed charges,378.08,68% of total billed charges,650,pays based on per visit rate ,156.76,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,89.49,Pays based on 100% of MO Medicaid Fee Schedule,134.22,Pays based on 135% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Rate,99.43,Pays based on 100% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Fee Schedule,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,300,Pays based on per visit rate,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,89.49,650,389.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,70487,CT MAXILLOFACIAL AREA W/CONTRA,350,912,63.96,Not Separately reimbursable,620.16,68% of total billed charges,620.16,68% of total billed charges,650,pays based on per visit rate ,177.42,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,149.56,Pays based on 100% of MO Medicaid Fee Schedule,224.33,Pays based on 135% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Rate,166.17,Pays based on 100% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Fee Schedule,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,300,Pays based on per visit rate,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,149.56,650,638.4,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,70492,CT NECK W/WO CONTRAST,350,1000,92.21,Not Separately reimbursable,680,68% of total billed charges,680,68% of total billed charges,650,pays based on per visit rate ,259.78,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,149.56,Pays based on 100% of MO Medicaid Fee Schedule,224.33,Pays based on 135% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Rate,166.17,Pays based on 100% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Fee Schedule,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,300,Pays based on per visit rate,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,149.56,680,700,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,73202,CT UPPER EXTREMITY W/WO CONTRA,340,912,69.55,Not Separately reimbursable,620.16,68% of total billed charges,620.16,68% of total billed charges,456,50% of total billed charges,340.98,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,149.56,Pays based on 100% of MO Medicaid Fee Schedule,224.33,Pays based on 135% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Rate,166.17,Pays based on 100% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Fee Schedule,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,300,Pays based on per visit rate,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,149.56,620.16,638.4,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,71270,CT THORAX W/WO CONTRAST,350,1000,71.57,Not Separately reimbursable,680,68% of total billed charges,680,68% of total billed charges,650,pays based on per visit rate ,245.48,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,149.56,Pays based on 100% of MO Medicaid Fee Schedule,224.33,Pays based on 135% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Rate,166.17,Pays based on 100% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Fee Schedule,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,300,Pays based on per visit rate,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,149.56,680,700,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,77012,CT FOR NEEDLE BIOPSY,340,1281.5,83.75,Not Separately reimbursable,871.42,68% of total billed charges,871.42,68% of total billed charges,640.75,50% of total billed charges,121.3,Pays based on 200% of CMS OPPS Rate,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,0,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,300,Pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,121.3,871.42,897.05,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,74176,CT ABDOMEN & PELVIS W/O CONTRA,350,1175,99.11,Not Separately reimbursable,799,68% of total billed charges,799,68% of total billed charges,650,pays based on per visit rate ,182.58,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,199.45,Pays based on 100% of MO Medicaid Fee Schedule,299.18,Pays based on 135% of CMS OPPS Rate,203.44,Pays based on 102% of MO Medicaid Rate,221.61,Pays based on 100% of CMS OPPS Rate,203.44,Pays based on 102% of MO Medicaid Fee Schedule,199.45,Pays based on 100% of MO Medicaid Fee Schedule,221.61,Pays based on 100% of CMS OPPS Rate,300,Pays based on per visit rate,199.45,Pays based on 100% of MO Medicaid Fee Schedule,221.61,Pays based on 100% of CMS OPPS Rate,182.58,799,822.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,74177,CT ABDOMEN & PELVIS W/CONTRAST,350,1880,103.97,Not Separately reimbursable,1278.4,68% of total billed charges,1278.4,68% of total billed charges,650,pays based on per visit rate ,388.44,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,313.04,Pays based on 100% of MO Medicaid Fee Schedule,469.55,Pays based on 135% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Rate,347.82,Pays based on 100% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Fee Schedule,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,300,Pays based on per visit rate,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,300,1278.4,1316,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,70496,CTA HEAD,350,1200,99.53,Not Separately reimbursable,816,68% of total billed charges,816,68% of total billed charges,650,pays based on per visit rate ,345.64,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,149.56,Pays based on 100% of MO Medicaid Fee Schedule,224.33,Pays based on 135% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Rate,166.17,Pays based on 100% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Fee Schedule,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,300,Pays based on per visit rate,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,149.56,816,840,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,74178,CT ABDOMEN & PELVIS W/WO CONTR,350,1880,114.15,Not Separately reimbursable,1278.4,68% of total billed charges,1278.4,68% of total billed charges,650,pays based on per visit rate ,438.86,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,313.04,Pays based on 100% of MO Medicaid Fee Schedule,469.55,Pays based on 135% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Rate,347.82,Pays based on 100% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Fee Schedule,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,300,Pays based on per visit rate,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,300,1278.4,1316,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,72125,CT CERVICAL SPINE W/O CONTRAST,350,556,57.04,Not Separately reimbursable,378.08,68% of total billed charges,378.08,68% of total billed charges,650,pays based on per visit rate ,148.76,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,89.49,Pays based on 100% of MO Medicaid Fee Schedule,134.22,Pays based on 135% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Rate,99.43,Pays based on 100% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Fee Schedule,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,300,Pays based on per visit rate,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,89.49,650,389.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,72126,CT CERVICAL SPINE W/CONTRAST,350,1880,69.55,Not Separately reimbursable,1278.4,68% of total billed charges,1278.4,68% of total billed charges,650,pays based on per visit rate ,199.16,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,313.04,Pays based on 100% of MO Medicaid Fee Schedule,469.55,Pays based on 135% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Rate,347.82,Pays based on 100% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Fee Schedule,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,300,Pays based on per visit rate,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,199.16,1278.4,1316,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,72127,CT CERVICAL SPINE W/WO CONTRAS,350,912,72.75,Not Separately reimbursable,620.16,68% of total billed charges,620.16,68% of total billed charges,650,pays based on per visit rate ,246.06,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,149.56,Pays based on 100% of MO Medicaid Fee Schedule,224.33,Pays based on 135% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Rate,166.17,Pays based on 100% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Fee Schedule,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,300,Pays based on per visit rate,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,149.56,650,638.4,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,70498,CTA NECK,350,1200,99.53,Not Separately reimbursable,816,68% of total billed charges,816,68% of total billed charges,650,pays based on per visit rate ,345.06,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,149.56,Pays based on 100% of MO Medicaid Fee Schedule,224.33,Pays based on 135% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Rate,166.17,Pays based on 100% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Fee Schedule,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,300,Pays based on per visit rate,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,149.56,816,840,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,72128,CT THORACIC SPINE W/O CONTRAST,350,556,57.04,Not Separately reimbursable,378.08,68% of total billed charges,378.08,68% of total billed charges,650,pays based on per visit rate ,148.18,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,89.49,Pays based on 100% of MO Medicaid Fee Schedule,134.22,Pays based on 135% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Rate,99.43,Pays based on 100% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Fee Schedule,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,300,Pays based on per visit rate,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,89.49,650,389.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,75635,CTA ABDOMINAL AORTA W/RUNOFFS,350,1400,134.44,Not Separately reimbursable,952,68% of total billed charges,952,68% of total billed charges,650,pays based on per visit rate ,533.36,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,149.56,Pays based on 100% of MO Medicaid Fee Schedule,224.33,Pays based on 135% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Rate,166.17,Pays based on 100% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Fee Schedule,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,300,Pays based on per visit rate,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,149.56,952,980,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,73706,CTA LOWER EXT,350,1200,106.88,Not Separately reimbursable,816,68% of total billed charges,816,68% of total billed charges,650,pays based on per visit rate ,417.76,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,149.56,Pays based on 100% of MO Medicaid Fee Schedule,224.33,Pays based on 135% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Rate,166.17,Pays based on 100% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Fee Schedule,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,300,Pays based on per visit rate,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,149.56,816,840,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,71275,CT PE PROTOCOL,350,1175,103.58,Not Separately reimbursable,799,68% of total billed charges,799,68% of total billed charges,650,pays based on per visit rate ,349.64,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,149.56,Pays based on 100% of MO Medicaid Fee Schedule,224.33,Pays based on 135% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Rate,166.17,Pays based on 100% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Fee Schedule,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,300,Pays based on per visit rate,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,149.56,799,822.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,72194,CT PELVIS W/WO CONTRAST,350,1000,69.55,Not Separately reimbursable,680,68% of total billed charges,680,68% of total billed charges,650,pays based on per visit rate ,347.84,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,149.56,Pays based on 100% of MO Medicaid Fee Schedule,224.33,Pays based on 135% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Rate,166.17,Pays based on 100% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Fee Schedule,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,300,Pays based on per visit rate,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,149.56,680,700,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,51600,INJECTION FOR BLADDER XRAY,350,256,38.99,Not Separately reimbursable,174.08,68% of total billed charges,174.08,68% of total billed charges,650,pays based on per visit rate ,82.14,Pays based on 200% of CMS OPPS Rate,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,0,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,300,Pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,82.14,650,179.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,74175,ANGIOGRAM RENAL ARTERIES W/WO,350,1498.5,102.8,Not Separately reimbursable,1018.98,68% of total billed charges,1018.98,68% of total billed charges,650,pays based on per visit rate ,393.1,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,149.56,Pays based on 100% of MO Medicaid Fee Schedule,224.33,Pays based on 135% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Rate,166.17,Pays based on 100% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Fee Schedule,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,300,Pays based on per visit rate,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,149.56,1018.98,1048.95,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,72191,CT ANGIOGRAPHY-PELVIS,350,1498.5,102,Not Separately reimbursable,1018.98,68% of total billed charges,1018.98,68% of total billed charges,650,pays based on per visit rate ,392.52,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,149.56,Pays based on 100% of MO Medicaid Fee Schedule,224.33,Pays based on 135% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Rate,166.17,Pays based on 100% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Fee Schedule,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,300,Pays based on per visit rate,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,149.56,1018.98,1048.95,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,74320,T-TUBE CHOLANGIOGRAM,320,1661,N/A,Not Separately reimbursable,1129.48,68% of total billed charges,1129.48,68% of total billed charges,830.5,50% of total billed charges,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,0,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,75,Pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,75,1129.48,1162.7,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,72132,CT L-SPINE W/CONTRAST,350,1880,69.55,Not Separately reimbursable,1278.4,68% of total billed charges,1278.4,68% of total billed charges,650,pays based on per visit rate ,199.72,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,313.04,Pays based on 100% of MO Medicaid Fee Schedule,469.55,Pays based on 135% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Rate,347.82,Pays based on 100% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Fee Schedule,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,300,Pays based on per visit rate,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,199.72,1278.4,1316,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,72133,CT L-SPINE W/WO CONTRAST,350,912,72.75,Not Separately reimbursable,620.16,68% of total billed charges,620.16,68% of total billed charges,650,pays based on per visit rate ,246.62,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,149.56,Pays based on 100% of MO Medicaid Fee Schedule,224.33,Pays based on 135% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Rate,166.17,Pays based on 100% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Fee Schedule,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,300,Pays based on per visit rate,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,149.56,650,638.4,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,70549,MRA CAROTID ART W&W/O CONTRAST,610,2356.5,126,Not Separately reimbursable,1602.42,68% of total billed charges,1602.42,68% of total billed charges,1050,pays based on per visit rate ,465.8,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,313.04,Pays based on 100% of MO Medicaid Fee Schedule,469.55,Pays based on 135% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Rate,347.82,Pays based on 100% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Fee Schedule,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,313.04,1602.42,1649.55,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,73600,ANKLE; RIGHT; ANTER&LATERAL; X,320,248,8.04,Not Separately reimbursable,168.64,68% of total billed charges,168.64,68% of total billed charges,124,50% of total billed charges,42.38,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,73.96,Pays based on 100% of MO Medicaid Fee Schedule,110.95,Pays based on 135% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Rate,82.18,Pays based on 100% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Fee Schedule,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,42.38,168.64,173.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,73610,ANKLE; RIGHT; COMPLETE; X-RAY,320,248,8.74,Not Separately reimbursable,168.64,68% of total billed charges,168.64,68% of total billed charges,124,50% of total billed charges,48.68,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,73.96,Pays based on 100% of MO Medicaid Fee Schedule,110.95,Pays based on 135% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Rate,82.18,Pays based on 100% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Fee Schedule,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,48.68,168.64,173.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,72040,SPINE; CERVICAL; ANTER.&LATERA,320,248,11.2,Not Separately reimbursable,168.64,68% of total billed charges,168.64,68% of total billed charges,124,50% of total billed charges,49.82,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,73.96,Pays based on 100% of MO Medicaid Fee Schedule,110.95,Pays based on 135% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Rate,82.18,Pays based on 100% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Fee Schedule,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,49.82,168.64,173.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,73000,CLAVICLE; RIGHT; COMPLETE; X-R,320,248,8.38,Not Separately reimbursable,168.64,68% of total billed charges,168.64,68% of total billed charges,124,50% of total billed charges,42.38,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,73.96,Pays based on 100% of MO Medicaid Fee Schedule,110.95,Pays based on 135% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Rate,82.18,Pays based on 100% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Fee Schedule,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,42.38,168.64,173.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,73080,ELBOW; RIGHT; COMPLETE; X-RAY,320,248,8.74,Not Separately reimbursable,168.64,68% of total billed charges,168.64,68% of total billed charges,124,50% of total billed charges,42.38,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,73.96,Pays based on 100% of MO Medicaid Fee Schedule,110.95,Pays based on 135% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Rate,82.18,Pays based on 100% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Fee Schedule,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,42.38,168.64,173.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,70140,FACIAL BONES;RIGHT;LESS THAN 3,320,248,10.13,Not Separately reimbursable,168.64,68% of total billed charges,168.64,68% of total billed charges,124,50% of total billed charges,38.96,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,73.96,Pays based on 100% of MO Medicaid Fee Schedule,110.95,Pays based on 135% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Rate,82.18,Pays based on 100% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Fee Schedule,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,38.96,168.64,173.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,73070,ELBOW; RIGHT; ANTER&LATERAL; X,320,248,8.38,Not Separately reimbursable,168.64,68% of total billed charges,168.64,68% of total billed charges,124,50% of total billed charges,36.66,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,73.96,Pays based on 100% of MO Medicaid Fee Schedule,110.95,Pays based on 135% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Rate,82.18,Pays based on 100% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Fee Schedule,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,36.66,168.64,173.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,70150,FACIAL BONES;RIGHT;COMPLETE;X-,320,334,12.96,Not Separately reimbursable,227.12,68% of total billed charges,227.12,68% of total billed charges,167,50% of total billed charges,60.12,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,89.49,Pays based on 100% of MO Medicaid Fee Schedule,134.23,Pays based on 135% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Rate,99.43,Pays based on 100% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Fee Schedule,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,60.12,227.12,233.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,73551,FEMUR; RIGHT; ANTER&LATERAL; X,320,248,8.38,Not Separately reimbursable,168.64,68% of total billed charges,168.64,68% of total billed charges,124,50% of total billed charges,36.66,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,73.96,Pays based on 100% of MO Medicaid Fee Schedule,110.95,Pays based on 135% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Rate,82.18,Pays based on 100% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Fee Schedule,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,36.66,168.64,173.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,73140,FINGER; LEFT THUMB; MIN. 2 VIE,320,248,6.97,Not Separately reimbursable,168.64,68% of total billed charges,168.64,68% of total billed charges,124,50% of total billed charges,54.4,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,73.96,Pays based on 100% of MO Medicaid Fee Schedule,110.95,Pays based on 135% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Rate,82.18,Pays based on 100% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Fee Schedule,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,54.4,168.64,173.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,73630,FOOT; RIGHT; COMPLETE; X-RAY,320,248,8.4,Not Separately reimbursable,168.64,68% of total billed charges,168.64,68% of total billed charges,124,50% of total billed charges,45.24,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,73.96,Pays based on 100% of MO Medicaid Fee Schedule,110.95,Pays based on 135% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Rate,82.18,Pays based on 100% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Fee Schedule,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,45.24,168.64,173.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,73620,FOOT; RIGHT; ANTER&LATERAL; X-,320,248,7.7,Not Separately reimbursable,168.64,68% of total billed charges,168.64,68% of total billed charges,124,50% of total billed charges,36.66,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,73.96,Pays based on 100% of MO Medicaid Fee Schedule,110.95,Pays based on 135% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Rate,82.18,Pays based on 100% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Fee Schedule,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,36.66,168.64,173.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,73090,FOREARM; RIGHT; ANTER&LATERAL;,320,248,8.04,Not Separately reimbursable,168.64,68% of total billed charges,168.64,68% of total billed charges,124,50% of total billed charges,37.24,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,73.96,Pays based on 100% of MO Medicaid Fee Schedule,110.95,Pays based on 135% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Rate,82.18,Pays based on 100% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Fee Schedule,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,37.24,168.64,173.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,77076,FULL BODY INFANT,320,350,34.65,Not Separately reimbursable,238,68% of total billed charges,238,68% of total billed charges,175,50% of total billed charges,127.68,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,89.49,Pays based on 100% of MO Medicaid Fee Schedule,134.23,Pays based on 135% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Rate,99.43,Pays based on 100% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Fee Schedule,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,75,238,245,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,73130,HAND; RIGHT; MIN.3 VIEWS; X-RA,320,248,8.74,Not Separately reimbursable,168.64,68% of total billed charges,168.64,68% of total billed charges,124,50% of total billed charges,49.82,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,73.96,Pays based on 100% of MO Medicaid Fee Schedule,110.95,Pays based on 135% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Rate,82.18,Pays based on 100% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Fee Schedule,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,49.82,168.64,173.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,73120,HAND; RIGHT; 2 VIEWS; X-RAY,320,198,8.38,Not Separately reimbursable,134.64,68% of total billed charges,134.64,68% of total billed charges,99,50% of total billed charges,40.66,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,89.49,Pays based on 100% of MO Medicaid Fee Schedule,134.23,Pays based on 135% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Rate,99.43,Pays based on 100% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Fee Schedule,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,40.66,134.64,138.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,73650,CALCANEUS; RIGHT; MIN. 2 VIEWS,320,248,8.04,Not Separately reimbursable,168.64,68% of total billed charges,168.64,68% of total billed charges,124,50% of total billed charges,36.1,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,73.96,Pays based on 100% of MO Medicaid Fee Schedule,110.95,Pays based on 135% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Rate,82.18,Pays based on 100% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Fee Schedule,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,36.1,168.64,173.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,73502,HIP; RIGHT; COMPLETE;MIN. 2 VI,320,248,11.2,Not Separately reimbursable,168.64,68% of total billed charges,168.64,68% of total billed charges,124,50% of total billed charges,63.54,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,73.96,Pays based on 100% of MO Medicaid Fee Schedule,110.95,Pays based on 135% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Rate,82.18,Pays based on 100% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Fee Schedule,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,63.54,168.64,173.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,73521,HIPS; BILATERAL; MIN. 2 VIEWS,320,334,11.2,Not Separately reimbursable,227.12,68% of total billed charges,227.12,68% of total billed charges,167,50% of total billed charges,52.68,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,89.49,Pays based on 100% of MO Medicaid Fee Schedule,134.23,Pays based on 135% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Rate,99.43,Pays based on 100% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Fee Schedule,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,52.68,227.12,233.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,73501,HIP; RIGHT; DURING OP PROC; X-,320,331.5,9.43,Not Separately reimbursable,225.42,68% of total billed charges,225.42,68% of total billed charges,165.75,50% of total billed charges,41.24,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,73.96,Pays based on 100% of MO Medicaid Fee Schedule,110.95,Pays based on 135% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Rate,82.18,Pays based on 100% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Fee Schedule,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,41.24,225.42,232.05,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,73540,PELVIS&HIPS;INFANT/CHILD;MIN.2,320,198,N/A,Not Separately reimbursable,134.64,68% of total billed charges,134.64,68% of total billed charges,99,50% of total billed charges,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,0,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,75,Pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,75,134.64,138.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,73060,HUMERUS; RIGHT; MIN. 2 VIEWS;,320,248,8.04,Not Separately reimbursable,168.64,68% of total billed charges,168.64,68% of total billed charges,124,50% of total billed charges,41.82,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,73.96,Pays based on 100% of MO Medicaid Fee Schedule,110.95,Pays based on 135% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Rate,82.18,Pays based on 100% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Fee Schedule,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,41.82,168.64,173.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,73562,KNEE;RIGHT;ANT&LATW/OBLIQ;MIN.,320,198,9.43,Not Separately reimbursable,134.64,68% of total billed charges,134.64,68% of total billed charges,99,50% of total billed charges,54.96,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,73.96,Pays based on 100% of MO Medicaid Fee Schedule,110.95,Pays based on 135% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Rate,82.18,Pays based on 100% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Fee Schedule,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,54.96,134.64,138.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,73560,KNEE; RIGHT; ANTER&LATERAL; X-,320,248,8.38,Not Separately reimbursable,168.64,68% of total billed charges,168.64,68% of total billed charges,124,50% of total billed charges,45.24,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,73.96,Pays based on 100% of MO Medicaid Fee Schedule,110.95,Pays based on 135% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Rate,82.18,Pays based on 100% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Fee Schedule,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,45.24,168.64,173.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,73564,KNEE; RIGHT; COMPLETE W/OBLIQ;,320,334,11.2,Not Separately reimbursable,227.12,68% of total billed charges,227.12,68% of total billed charges,167,50% of total billed charges,62.4,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,89.49,Pays based on 100% of MO Medicaid Fee Schedule,134.23,Pays based on 135% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Rate,99.43,Pays based on 100% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Fee Schedule,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,62.4,227.12,233.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,73565,KNEE; BOTH; STANDING; ANTER; X,320,198,8.72,Not Separately reimbursable,134.64,68% of total billed charges,134.64,68% of total billed charges,99,50% of total billed charges,54.96,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,73.96,Pays based on 100% of MO Medicaid Fee Schedule,110.95,Pays based on 135% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Rate,82.18,Pays based on 100% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Fee Schedule,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,54.96,134.64,138.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,72110,SPINE;LUMBOSACRAL;COMPLETE;W/O,320,334,12.96,Not Separately reimbursable,227.12,68% of total billed charges,227.12,68% of total billed charges,167,50% of total billed charges,68.12,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,89.49,Pays based on 100% of MO Medicaid Fee Schedule,134.23,Pays based on 135% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Rate,99.43,Pays based on 100% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Fee Schedule,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,68.12,227.12,233.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,73592,LOWER EXTREMITY;INFANT;MIN.2 V,320,248,8.04,Not Separately reimbursable,168.64,68% of total billed charges,168.64,68% of total billed charges,124,50% of total billed charges,41.24,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,73.96,Pays based on 100% of MO Medicaid Fee Schedule,110.95,Pays based on 135% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Rate,82.18,Pays based on 100% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Fee Schedule,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,41.24,168.64,173.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,74710,PELVIMETRY,320,331.5,N/A,Not Separately reimbursable,225.42,68% of total billed charges,225.42,68% of total billed charges,165.75,50% of total billed charges,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,0,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,75,Pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,75,225.42,232.05,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,72170,PELVIS; ANTEROPOSTERIOR ONLY;,320,334,8.74,Not Separately reimbursable,227.12,68% of total billed charges,227.12,68% of total billed charges,167,50% of total billed charges,33.8,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,89.49,Pays based on 100% of MO Medicaid Fee Schedule,134.23,Pays based on 135% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Rate,99.43,Pays based on 100% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Fee Schedule,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,33.8,227.12,233.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,72190,PELVIS; COMPLETE; X-RAY,320,334,12.61,Not Separately reimbursable,227.12,68% of total billed charges,227.12,68% of total billed charges,167,50% of total billed charges,52.1,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,89.49,Pays based on 100% of MO Medicaid Fee Schedule,134.23,Pays based on 135% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Rate,99.43,Pays based on 100% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Fee Schedule,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,52.1,227.12,233.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,73010,SCAPULA; RIGHT; COMPLETE; X-RA,320,248,9.08,Not Separately reimbursable,168.64,68% of total billed charges,168.64,68% of total billed charges,124,50% of total billed charges,26.38,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,89.49,Pays based on 100% of MO Medicaid Fee Schedule,134.23,Pays based on 135% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Rate,99.43,Pays based on 100% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Fee Schedule,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,26.38,168.64,173.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,73030,SHOULDER; RIGHT; COMPLETE; X-R,320,248,9.43,Not Separately reimbursable,168.64,68% of total billed charges,168.64,68% of total billed charges,124,50% of total billed charges,44.68,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,73.96,Pays based on 100% of MO Medicaid Fee Schedule,110.95,Pays based on 135% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Rate,82.18,Pays based on 100% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Fee Schedule,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,44.68,168.64,173.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,73020,SHOULDER; RIGHT; ONE VIEW; X-R,320,248,7.69,Not Separately reimbursable,168.64,68% of total billed charges,168.64,68% of total billed charges,124,50% of total billed charges,24.66,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,73.96,Pays based on 100% of MO Medicaid Fee Schedule,110.95,Pays based on 135% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Rate,82.18,Pays based on 100% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Fee Schedule,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,24.66,168.64,173.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,74230,SWALLOWING FUNCTION,320,547,26.55,Not Separately reimbursable,371.96,68% of total billed charges,371.96,68% of total billed charges,273.5,50% of total billed charges,171.06,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,149.56,Pays based on 100% of MO Medicaid Fee Schedule,224.33,Pays based on 135% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Rate,166.17,Pays based on 100% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Fee Schedule,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,75,371.96,382.9,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,73590,TIBIA & FIBULA;RIGHT;ANTER&LAT,320,248,8.04,Not Separately reimbursable,168.64,68% of total billed charges,168.64,68% of total billed charges,124,50% of total billed charges,41.24,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,73.96,Pays based on 100% of MO Medicaid Fee Schedule,110.95,Pays based on 135% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Rate,82.18,Pays based on 100% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Fee Schedule,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,41.24,168.64,173.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,73660,TOE; LEFT GREAT; MIN. 2 VIEWS;,320,248,6.63,Not Separately reimbursable,168.64,68% of total billed charges,168.64,68% of total billed charges,124,50% of total billed charges,39.52,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,73.96,Pays based on 100% of MO Medicaid Fee Schedule,110.95,Pays based on 135% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Rate,82.18,Pays based on 100% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Fee Schedule,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,39.52,168.64,173.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,73110,WRIST; RIGHT; COMPLETE; X-RAY,320,248,8.74,Not Separately reimbursable,168.64,68% of total billed charges,168.64,68% of total billed charges,124,50% of total billed charges,56.68,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,73.96,Pays based on 100% of MO Medicaid Fee Schedule,110.95,Pays based on 135% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Rate,82.18,Pays based on 100% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Fee Schedule,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,56.68,168.64,173.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,74420,"UROGRAPHY, RETROGRADE; X-RAY",320,33,25.25,Not Separately reimbursable,22.44,68% of total billed charges,22.44,68% of total billed charges,16.5,50% of total billed charges,66,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,313.04,Pays based on 100% of MO Medicaid Fee Schedule,469.55,Pays based on 135% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Rate,347.82,Pays based on 100% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Fee Schedule,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,16.5,469.55,23.1,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,74430,"CYSTOGRAPHY, MIN. 3 VIEWS; S&I",320,755,15.44,Not Separately reimbursable,513.4,68% of total billed charges,513.4,68% of total billed charges,377.5,50% of total billed charges,45.24,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,313.04,Pays based on 100% of MO Medicaid Fee Schedule,469.55,Pays based on 135% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Rate,347.82,Pays based on 100% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Fee Schedule,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,45.24,513.4,528.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,74450,"URETHROCYSTOGRAPHY, RETROGRADE",320,755,16.14,Not Separately reimbursable,513.4,68% of total billed charges,513.4,68% of total billed charges,377.5,50% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,199.45,Pays based on 100% of MO Medicaid Fee Schedule,299.18,Pays based on 135% of CMS OPPS Rate,203.44,Pays based on 102% of MO Medicaid Rate,221.61,Pays based on 100% of CMS OPPS Rate,203.44,Pays based on 102% of MO Medicaid Fee Schedule,199.45,Pays based on 100% of MO Medicaid Fee Schedule,221.61,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,199.45,Pays based on 100% of MO Medicaid Fee Schedule,221.61,Pays based on 100% of CMS OPPS Rate,75,513.4,528.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,74455,"URETHROCYSTOGRAPHY, VOIDING,S&",320,755,15.8,Not Separately reimbursable,513.4,68% of total billed charges,513.4,68% of total billed charges,377.5,50% of total billed charges,152.18,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,199.45,Pays based on 100% of MO Medicaid Fee Schedule,299.18,Pays based on 135% of CMS OPPS Rate,203.44,Pays based on 102% of MO Medicaid Rate,221.61,Pays based on 100% of CMS OPPS Rate,203.44,Pays based on 102% of MO Medicaid Fee Schedule,199.45,Pays based on 100% of MO Medicaid Fee Schedule,221.61,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,199.45,Pays based on 100% of MO Medicaid Fee Schedule,221.61,Pays based on 100% of CMS OPPS Rate,75,513.4,528.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,77080,DXA BONE DENSITY STUDY,320,556,9.81,Not Separately reimbursable,378.08,68% of total billed charges,378.08,68% of total billed charges,278,50% of total billed charges,50.96,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,89.49,Pays based on 100% of MO Medicaid Fee Schedule,134.22,Pays based on 135% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Rate,99.43,Pays based on 100% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Fee Schedule,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,50.96,378.08,389.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,74018,ABDOMEN; SINGLE ANTER; X-RAY,320,248,9.09,Not Separately reimbursable,168.64,68% of total billed charges,168.64,68% of total billed charges,124,50% of total billed charges,37.24,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,73.96,Pays based on 100% of MO Medicaid Fee Schedule,110.95,Pays based on 135% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Rate,82.18,Pays based on 100% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Fee Schedule,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,37.24,168.64,173.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,74010,ABDOMEN; ANTER/OBLIQUE/CONE; X,320,198,N/A,Not Separately reimbursable,134.64,68% of total billed charges,134.64,68% of total billed charges,99,50% of total billed charges,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,0,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,75,Pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,75,134.64,138.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,74019,ABDOMEN; COMPLETE; X-RAY,320,334,11.55,Not Separately reimbursable,227.12,68% of total billed charges,227.12,68% of total billed charges,167,50% of total billed charges,44.68,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,89.49,Pays based on 100% of MO Medicaid Fee Schedule,134.23,Pays based on 135% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Rate,99.43,Pays based on 100% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Fee Schedule,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,44.68,227.12,233.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,73050,ACROMIOCLAVICULAR JOINTS;BILAT,320,198,9.43,Not Separately reimbursable,134.64,68% of total billed charges,134.64,68% of total billed charges,99,50% of total billed charges,34.38,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,73.96,Pays based on 100% of MO Medicaid Fee Schedule,110.95,Pays based on 135% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Rate,82.18,Pays based on 100% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Fee Schedule,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,34.38,134.64,138.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,74022,ABDOMEN; COMPLETE ACUTE SERIES,320,334,15.78,Not Separately reimbursable,227.12,68% of total billed charges,227.12,68% of total billed charges,167,50% of total billed charges,60.12,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,89.49,Pays based on 100% of MO Medicaid Fee Schedule,134.23,Pays based on 135% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Rate,99.43,Pays based on 100% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Fee Schedule,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,60.12,227.12,233.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,74280,COLON; AIR CONTR.W/ BARIUM; X-,320,623,62.3,Not Separately reimbursable,423.64,68% of total billed charges,423.64,68% of total billed charges,311.5,50% of total billed charges,275.78,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,149.56,Pays based on 100% of MO Medicaid Fee Schedule,224.33,Pays based on 135% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Rate,166.17,Pays based on 100% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Fee Schedule,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,75,423.64,436.1,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,74270,COLON; BARIUM ENEMA; X-RAY,320,385,51.14,Not Separately reimbursable,261.8,68% of total billed charges,261.8,68% of total billed charges,192.5,50% of total billed charges,180.2,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,149.56,Pays based on 100% of MO Medicaid Fee Schedule,224.33,Pays based on 135% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Rate,166.17,Pays based on 100% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Fee Schedule,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,75,261.8,269.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,74220,ESOPHAGUS; X-RAY,320,248,29.73,Not Separately reimbursable,168.64,68% of total billed charges,168.64,68% of total billed charges,124,50% of total billed charges,119.02,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,149.56,Pays based on 100% of MO Medicaid Fee Schedule,224.33,Pays based on 135% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Rate,166.17,Pays based on 100% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Fee Schedule,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,75,224.33,173.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,74210,PHARYNX &/OR CERVICAL ESOPHAGU,320,385,29.37,Not Separately reimbursable,261.8,68% of total billed charges,261.8,68% of total billed charges,192.5,50% of total billed charges,115.58,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,149.56,Pays based on 100% of MO Medicaid Fee Schedule,224.33,Pays based on 135% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Rate,166.17,Pays based on 100% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Fee Schedule,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,75,261.8,269.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,19081,BREAST-LOCALIZATION,320,535,141.64,Not Separately reimbursable,363.8,68% of total billed charges,363.8,68% of total billed charges,267.5,50% of total billed charges,307.34,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,1979.55,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,1466.33,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,1466.33,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,N/A,Not Separately reimbursable,1466.33,Pays based on 100% of CMS OPPS Rate,75,1979.55,374.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,76098,BREAST-SURG SPECIMEN,320,1661,15.73,Not Separately reimbursable,1129.48,68% of total billed charges,1129.48,68% of total billed charges,830.5,50% of total billed charges,47.54,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,449.05,Pays based on 100% of MO Medicaid Fee Schedule,673.58,Pays based on 135% of CMS OPPS Rate,458.03,Pays based on 102% of MO Medicaid Rate,498.94,Pays based on 100% of CMS OPPS Rate,458.03,Pays based on 102% of MO Medicaid Fee Schedule,449.05,Pays based on 100% of MO Medicaid Fee Schedule,498.94,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,449.05,Pays based on 100% of MO Medicaid Fee Schedule,498.94,Pays based on 100% of CMS OPPS Rate,47.54,1129.48,1162.7,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,72050,SPINE CERVICAL; MIN. 3 VIEWS;,320,334,13.66,Not Separately reimbursable,227.12,68% of total billed charges,227.12,68% of total billed charges,167,50% of total billed charges,70.4,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,89.49,Pays based on 100% of MO Medicaid Fee Schedule,134.23,Pays based on 135% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Rate,99.43,Pays based on 100% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Fee Schedule,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,70.4,227.12,233.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,71047,CHEST;2 VIEWS W/APICAL LORD.PR,324,248,13.32,Not Separately reimbursable,168.64,68% of total billed charges,168.64,68% of total billed charges,124,50% of total billed charges,50.4,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,73.96,Pays based on 100% of MO Medicaid Fee Schedule,110.95,Pays based on 135% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Rate,82.18,Pays based on 100% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Fee Schedule,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,50.4,168.64,173.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,71045,CHEST;SINGLE VIEW;FRONTAL;X-RA,324,248,9.09,Not Separately reimbursable,168.64,68% of total billed charges,168.64,68% of total billed charges,124,50% of total billed charges,29.8,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,73.96,Pays based on 100% of MO Medicaid Fee Schedule,110.94,Pays based on 135% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Rate,82.18,Pays based on 100% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Fee Schedule,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,29.8,168.64,173.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,71046,CHEST 2 VIEWS,324,248,10.86,Not Separately reimbursable,168.64,68% of total billed charges,168.64,68% of total billed charges,124,50% of total billed charges,40.1,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,73.96,Pays based on 100% of MO Medicaid Fee Schedule,110.94,Pays based on 135% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Rate,82.18,Pays based on 100% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Fee Schedule,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,40.1,168.64,173.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,72220,SACRUM & COCCYX; MIN. 2 VIEWS;,320,248,8.74,Not Separately reimbursable,168.64,68% of total billed charges,168.64,68% of total billed charges,124,50% of total billed charges,41.82,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,73.96,Pays based on 100% of MO Medicaid Fee Schedule,110.95,Pays based on 135% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Rate,82.18,Pays based on 100% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Fee Schedule,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,41.82,168.64,173.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,72070,SPINE; THORACIC; ANTER.&LATERA,320,334,10.15,Not Separately reimbursable,227.12,68% of total billed charges,227.12,68% of total billed charges,167,50% of total billed charges,40.1,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,89.49,Pays based on 100% of MO Medicaid Fee Schedule,134.23,Pays based on 135% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Rate,99.43,Pays based on 100% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Fee Schedule,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,40.1,227.12,233.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,76000,FLUOROSCOPY,320,16.5,15.64,Not Separately reimbursable,11.22,68% of total billed charges,11.22,68% of total billed charges,8.25,50% of total billed charges,33,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,199.45,Pays based on 100% of MO Medicaid Fee Schedule,299.18,Pays based on 135% of CMS OPPS Rate,203.44,Pays based on 102% of MO Medicaid Rate,221.61,Pays based on 100% of CMS OPPS Rate,203.44,Pays based on 102% of MO Medicaid Fee Schedule,199.45,Pays based on 100% of MO Medicaid Fee Schedule,221.61,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,199.45,Pays based on 100% of MO Medicaid Fee Schedule,221.61,Pays based on 100% of CMS OPPS Rate,8.25,299.18,11.55,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,77002,FLUOROSCOPIC LOCAL FOR NEEDLE,320,278.5,27.93,Not Separately reimbursable,189.38,68% of total billed charges,189.38,68% of total billed charges,139.25,50% of total billed charges,153.9,Pays based on 200% of CMS OPPS Rate,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,0,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,75,Pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,75,189.38,194.95,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,76010,RADIOL.EXAM FOR FOREIGN BODY;C,320,248,9.09,Not Separately reimbursable,168.64,68% of total billed charges,168.64,68% of total billed charges,124,50% of total billed charges,36.1,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,73.96,Pays based on 100% of MO Medicaid Fee Schedule,110.95,Pays based on 135% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Rate,82.18,Pays based on 100% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Fee Schedule,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,36.1,168.64,173.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,77072,BONE AGE STUDIES; X-RAY,320,198,9.45,Not Separately reimbursable,134.64,68% of total billed charges,134.64,68% of total billed charges,99,50% of total billed charges,29.24,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,89.49,Pays based on 100% of MO Medicaid Fee Schedule,134.23,Pays based on 135% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Rate,99.43,Pays based on 100% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Fee Schedule,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,29.24,134.64,138.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,77073,BONE LENGTH STUDIES; X-RAY,320,198,13.61,Not Separately reimbursable,134.64,68% of total billed charges,134.64,68% of total billed charges,99,50% of total billed charges,55.54,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,89.49,Pays based on 100% of MO Medicaid Fee Schedule,134.23,Pays based on 135% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Rate,99.43,Pays based on 100% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Fee Schedule,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,55.54,134.64,138.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,77003,FLUOROSCOPIC-LOCAL,320,71.5,29.73,Not Separately reimbursable,48.62,68% of total billed charges,48.62,68% of total billed charges,35.75,50% of total billed charges,132.18,Pays based on 200% of CMS OPPS Rate,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,0,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,75,Pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,35.75,132.18,50.05,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,74410,"UROGRAPHY, INFUSION, DRIP TECH",320,755,23.84,Not Separately reimbursable,513.4,68% of total billed charges,513.4,68% of total billed charges,377.5,50% of total billed charges,204.3,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,149.56,Pays based on 100% of MO Medicaid Fee Schedule,224.33,Pays based on 135% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Rate,166.17,Pays based on 100% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Fee Schedule,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,75,513.4,528.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,74400,"UROGRAPHY, INTRAVENOUS; X-RAY",320,755,23.84,Not Separately reimbursable,513.4,68% of total billed charges,513.4,68% of total billed charges,377.5,50% of total billed charges,192.3,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,149.56,Pays based on 100% of MO Medicaid Fee Schedule,224.33,Pays based on 135% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Rate,166.17,Pays based on 100% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Fee Schedule,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,75,513.4,528.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,74425,"UROGRAPHY, ANTERGRADE, S&I; X-",320,755,24.55,Not Separately reimbursable,513.4,68% of total billed charges,513.4,68% of total billed charges,377.5,50% of total billed charges,192.78,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,313.04,Pays based on 100% of MO Medicaid Fee Schedule,469.55,Pays based on 135% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Rate,347.82,Pays based on 100% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Fee Schedule,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,75,513.4,528.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,72100,SPINE; LUMBOSACRAL; ANTER.&LAT,320,334,11.2,Not Separately reimbursable,227.12,68% of total billed charges,227.12,68% of total billed charges,167,50% of total billed charges,50.4,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,89.49,Pays based on 100% of MO Medicaid Fee Schedule,134.23,Pays based on 135% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Rate,99.43,Pays based on 100% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Fee Schedule,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,50.4,227.12,233.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,70100,MANDIBLE; PARTIAL; X-RAY,320,248,9.09,Not Separately reimbursable,168.64,68% of total billed charges,168.64,68% of total billed charges,124,50% of total billed charges,52.1,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,73.96,Pays based on 100% of MO Medicaid Fee Schedule,110.95,Pays based on 135% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Rate,82.18,Pays based on 100% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Fee Schedule,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,52.1,168.64,173.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,70110,MANDIBLE; COMPLETE; X-RAY,320,248,12.27,Not Separately reimbursable,168.64,68% of total billed charges,168.64,68% of total billed charges,124,50% of total billed charges,54.96,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,89.49,Pays based on 100% of MO Medicaid Fee Schedule,134.23,Pays based on 135% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Rate,99.43,Pays based on 100% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Fee Schedule,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,54.96,168.64,173.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,70120,MASTOIDS;LESS THAN 3 VIEWS/SID,320,198,9.09,Not Separately reimbursable,134.64,68% of total billed charges,134.64,68% of total billed charges,99,50% of total billed charges,50.96,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,89.49,Pays based on 100% of MO Medicaid Fee Schedule,134.23,Pays based on 135% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Rate,99.43,Pays based on 100% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Fee Schedule,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,50.96,134.64,138.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,70130,MASTOIDS; RIGHT; COMPLETE; X-R,320,198,17.14,Not Separately reimbursable,134.64,68% of total billed charges,134.64,68% of total billed charges,99,50% of total billed charges,78.98,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,89.49,Pays based on 100% of MO Medicaid Fee Schedule,134.23,Pays based on 135% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Rate,99.43,Pays based on 100% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Fee Schedule,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,75,134.64,138.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,70360,"NECK,SOFT TISSUE X-RAY",320,248,9.09,Not Separately reimbursable,168.64,68% of total billed charges,168.64,68% of total billed charges,124,50% of total billed charges,38.96,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,73.96,Pays based on 100% of MO Medicaid Fee Schedule,110.95,Pays based on 135% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Rate,82.18,Pays based on 100% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Fee Schedule,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,38.96,168.64,173.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,70160,NASAL BONES;RIGHT;COMPLETE;X-R,320,198,8.74,Not Separately reimbursable,134.64,68% of total billed charges,134.64,68% of total billed charges,99,50% of total billed charges,50.96,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,73.96,Pays based on 100% of MO Medicaid Fee Schedule,110.95,Pays based on 135% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Rate,82.18,Pays based on 100% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Fee Schedule,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,50.96,134.64,138.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,70190,OPTIC FORAMINA;RIGHT;X-RAY,320,198,11.18,Not Separately reimbursable,134.64,68% of total billed charges,134.64,68% of total billed charges,99,50% of total billed charges,46.38,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,73.96,Pays based on 100% of MO Medicaid Fee Schedule,110.95,Pays based on 135% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Rate,82.18,Pays based on 100% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Fee Schedule,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,46.38,134.64,138.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,70200,ORBIT;RIGHT;X-RAY,320,248,14.01,Not Separately reimbursable,168.64,68% of total billed charges,168.64,68% of total billed charges,124,50% of total billed charges,59.54,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,89.49,Pays based on 100% of MO Medicaid Fee Schedule,134.23,Pays based on 135% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Rate,99.43,Pays based on 100% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Fee Schedule,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,59.54,168.64,173.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,71110,RIBS; BILATERAL; THREE VIEWS;,320,334,14.37,Not Separately reimbursable,227.12,68% of total billed charges,227.12,68% of total billed charges,167,50% of total billed charges,52.1,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,89.49,Pays based on 100% of MO Medicaid Fee Schedule,134.23,Pays based on 135% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Rate,99.43,Pays based on 100% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Fee Schedule,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,52.1,227.12,233.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,71111,RIBS W/CHEST;BILATERAL;MIN.4 V,320,334,15.78,Not Separately reimbursable,227.12,68% of total billed charges,227.12,68% of total billed charges,167,50% of total billed charges,64.12,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,89.49,Pays based on 100% of MO Medicaid Fee Schedule,134.23,Pays based on 135% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Rate,99.43,Pays based on 100% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Fee Schedule,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,64.12,227.12,233.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,71100,RIBS; RIGHT; X-RAY,320,248,11.2,Not Separately reimbursable,168.64,68% of total billed charges,168.64,68% of total billed charges,124,50% of total billed charges,45.24,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,73.96,Pays based on 100% of MO Medicaid Fee Schedule,110.95,Pays based on 135% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Rate,82.18,Pays based on 100% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Fee Schedule,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,45.24,168.64,173.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,71101,RIBS W/CHEST;RIGHT;MIN.3 VIEWS,320,334,13.32,Not Separately reimbursable,227.12,68% of total billed charges,227.12,68% of total billed charges,167,50% of total billed charges,50.96,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,89.49,Pays based on 100% of MO Medicaid Fee Schedule,134.23,Pays based on 135% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Rate,99.43,Pays based on 100% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Fee Schedule,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,50.96,227.12,233.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,72202,SACROILIAC JOINTS;RIGHT;MIN.3V,320,334,11.22,Not Separately reimbursable,227.12,68% of total billed charges,227.12,68% of total billed charges,167,50% of total billed charges,49.24,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,89.49,Pays based on 100% of MO Medicaid Fee Schedule,134.23,Pays based on 135% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Rate,99.43,Pays based on 100% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Fee Schedule,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,49.24,227.12,233.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,74740,"HYSTEROSALPINGOGRAPHY, S&I; X-",320,925.5,18.9,Not Separately reimbursable,629.34,68% of total billed charges,629.34,68% of total billed charges,462.75,50% of total billed charges,129.88,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,199.45,Pays based on 100% of MO Medicaid Fee Schedule,299.18,Pays based on 135% of CMS OPPS Rate,203.44,Pays based on 102% of MO Medicaid Rate,221.61,Pays based on 100% of CMS OPPS Rate,203.44,Pays based on 102% of MO Medicaid Fee Schedule,199.45,Pays based on 100% of MO Medicaid Fee Schedule,221.61,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,199.45,Pays based on 100% of MO Medicaid Fee Schedule,221.61,Pays based on 100% of CMS OPPS Rate,75,629.34,647.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,70220,SINUSES;COMPLETE;RIGHT;MIN.3VI,320,248,10.86,Not Separately reimbursable,168.64,68% of total billed charges,168.64,68% of total billed charges,124,50% of total billed charges,46.96,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,73.96,Pays based on 100% of MO Medicaid Fee Schedule,110.95,Pays based on 135% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Rate,82.18,Pays based on 100% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Fee Schedule,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,46.96,168.64,173.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,70260,SKULL; COMPLETE; X-RAY,320,331.5,14.01,Not Separately reimbursable,225.42,68% of total billed charges,225.42,68% of total billed charges,165.75,50% of total billed charges,53.82,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,89.49,Pays based on 100% of MO Medicaid Fee Schedule,134.23,Pays based on 135% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Rate,99.43,Pays based on 100% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Fee Schedule,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,53.82,225.42,232.05,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,70250,SKULL; LESS THAN 4 VIEWS; X-RA,320,334,9.09,Not Separately reimbursable,227.12,68% of total billed charges,227.12,68% of total billed charges,167,50% of total billed charges,46.96,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,89.49,Pays based on 100% of MO Medicaid Fee Schedule,134.23,Pays based on 135% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Rate,99.43,Pays based on 100% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Fee Schedule,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,46.96,227.12,233.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,74250,SMALL BOWEL SERIES,320,547,39.92,Not Separately reimbursable,371.96,68% of total billed charges,371.96,68% of total billed charges,273.5,50% of total billed charges,144.18,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,149.56,Pays based on 100% of MO Medicaid Fee Schedule,224.33,Pays based on 135% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Rate,166.17,Pays based on 100% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Fee Schedule,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,75,371.96,382.9,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,74251,SMALL BOWEL SERIES;ENTEROCLYSI,320,623,58.08,Not Separately reimbursable,423.64,68% of total billed charges,423.64,68% of total billed charges,311.5,50% of total billed charges,527.92,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,149.56,Pays based on 100% of MO Medicaid Fee Schedule,224.33,Pays based on 135% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Rate,166.17,Pays based on 100% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Fee Schedule,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,75,527.92,436.1,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,71130,STERNOCLAVICULAR JOINTS;RIGHT;,320,198,10.86,Not Separately reimbursable,134.64,68% of total billed charges,134.64,68% of total billed charges,99,50% of total billed charges,53.26,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,73.96,Pays based on 100% of MO Medicaid Fee Schedule,110.95,Pays based on 135% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Rate,82.18,Pays based on 100% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Fee Schedule,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,53.26,134.64,138.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,72010,SPINE; ENTIRE; ANTER.&LATERAL;,320,331.5,N/A,Not Separately reimbursable,225.42,68% of total billed charges,225.42,68% of total billed charges,165.75,50% of total billed charges,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,0,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,75,Pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,75,225.42,232.05,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,72020,SPINE; SINGLE VIEW; X-RAY,320,198,8.04,Not Separately reimbursable,134.64,68% of total billed charges,134.64,68% of total billed charges,99,50% of total billed charges,28.66,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,73.96,Pays based on 100% of MO Medicaid Fee Schedule,110.95,Pays based on 135% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Rate,82.18,Pays based on 100% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Fee Schedule,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,28.66,134.64,138.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,72052,SPINE; CERVICAL; COMPLETE; X-R,320,334,14.73,Not Separately reimbursable,227.12,68% of total billed charges,227.12,68% of total billed charges,167,50% of total billed charges,82.98,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,89.49,Pays based on 100% of MO Medicaid Fee Schedule,134.23,Pays based on 135% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Rate,99.43,Pays based on 100% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Fee Schedule,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,75,227.12,233.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,72081,SPINE; THORACOLUMBAR; STANDING,320,248,12.96,Not Separately reimbursable,168.64,68% of total billed charges,168.64,68% of total billed charges,124,50% of total billed charges,52.1,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,73.96,Pays based on 100% of MO Medicaid Fee Schedule,110.95,Pays based on 135% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Rate,82.18,Pays based on 100% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Fee Schedule,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,52.1,168.64,173.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,72072,SPINE;THORACIC;ANTER.&LAT.;W/S,320,334,11.22,Not Separately reimbursable,227.12,68% of total billed charges,227.12,68% of total billed charges,167,50% of total billed charges,49.82,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,89.49,Pays based on 100% of MO Medicaid Fee Schedule,134.23,Pays based on 135% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Rate,99.43,Pays based on 100% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Fee Schedule,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,49.82,227.12,233.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,72074,SPINE; THORACIC; COMPLETE; X-R,320,334,12.27,Not Separately reimbursable,227.12,68% of total billed charges,227.12,68% of total billed charges,167,50% of total billed charges,56.68,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,89.49,Pays based on 100% of MO Medicaid Fee Schedule,134.23,Pays based on 135% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Rate,99.43,Pays based on 100% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Fee Schedule,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,56.68,227.12,233.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,72090,SPINE; SCOLIOSIS STUDY; X-RAY,320,331.5,N/A,Not Separately reimbursable,225.42,68% of total billed charges,225.42,68% of total billed charges,165.75,50% of total billed charges,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,0,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,75,Pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,75,225.42,232.05,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,47531,CHOLANGIOGRAPHY;POSTOP; S&I; X,361,1382,63.16,Not Separately reimbursable,601.32,pays based on per visit rate,644.72,68% of total billed charges,691,50% of total billed charges,131,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,4224.17,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,3129.01,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,3129.01,Pays based on 100% of CMS OPPS Rate,695,pays based on 100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,3129.01,Pays based on 100% of CMS OPPS Rate,131,4224.17,967.4,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,71120,STERNUM; MIN. 2 VIEWS; X-RAY,320,248,9.81,Not Separately reimbursable,168.64,68% of total billed charges,168.64,68% of total billed charges,124,50% of total billed charges,41.82,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,73.96,Pays based on 100% of MO Medicaid Fee Schedule,110.95,Pays based on 135% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Rate,82.18,Pays based on 100% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Fee Schedule,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,41.82,168.64,173.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,70330,TMJ; BILATERAL; X-RAY,320,198,11.91,Not Separately reimbursable,134.64,68% of total billed charges,134.64,68% of total billed charges,99,50% of total billed charges,71.56,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,73.96,Pays based on 100% of MO Medicaid Fee Schedule,110.95,Pays based on 135% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Rate,82.18,Pays based on 100% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Fee Schedule,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,71.56,134.64,138.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,70328,TMJ; RIGHT; X-RAY,320,248,9.09,Not Separately reimbursable,168.64,68% of total billed charges,168.64,68% of total billed charges,124,50% of total billed charges,44.68,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,73.96,Pays based on 100% of MO Medicaid Fee Schedule,110.95,Pays based on 135% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Rate,82.18,Pays based on 100% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Fee Schedule,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,44.68,168.64,173.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,73092,UPPER EXTREMITY;INFANT;MIN.2 V,320,334,8.04,Not Separately reimbursable,227.12,68% of total billed charges,227.12,68% of total billed charges,167,50% of total billed charges,41.24,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,89.49,Pays based on 100% of MO Medicaid Fee Schedule,134.23,Pays based on 135% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Rate,99.43,Pays based on 100% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Fee Schedule,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,41.24,227.12,233.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,74240,UPPER GI W/O KUB; X-RAY,320,385,39.57,Not Separately reimbursable,261.8,68% of total billed charges,261.8,68% of total billed charges,192.5,50% of total billed charges,145.9,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,149.56,Pays based on 100% of MO Medicaid Fee Schedule,224.33,Pays based on 135% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Rate,166.17,Pays based on 100% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Fee Schedule,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,75,261.8,269.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,74241,UPPER GI WITH KUB; X-RAY,320,385,N/A,Not Separately reimbursable,261.8,68% of total billed charges,261.8,68% of total billed charges,192.5,50% of total billed charges,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,0,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,75,Pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,75,261.8,269.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,74245,UPPER GI W/ SMALL BOWEL; X-RAY,320,623,N/A,Not Separately reimbursable,423.64,68% of total billed charges,423.64,68% of total billed charges,311.5,50% of total billed charges,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,0,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,75,Pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,75,423.64,436.1,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,74246,UPPER GI AIR CONT.W/BARIUM W/O,320,385,44.15,Not Separately reimbursable,261.8,68% of total billed charges,261.8,68% of total billed charges,192.5,50% of total billed charges,166.48,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,149.56,Pays based on 100% of MO Medicaid Fee Schedule,224.33,Pays based on 135% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Rate,166.17,Pays based on 100% of CMS OPPS Rate,152.55,Pays based on 102% of MO Medicaid Fee Schedule,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,149.56,Pays based on 100% of MO Medicaid Fee Schedule,166.17,Pays based on 100% of CMS OPPS Rate,75,261.8,269.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,74247,UPPER GI AIR CONTR. W/BARIUM W,320,385,N/A,Not Separately reimbursable,261.8,68% of total billed charges,261.8,68% of total billed charges,192.5,50% of total billed charges,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,0,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,75,Pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,75,261.8,269.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,74249,"UPPER GI W/AIR,BARIUM & SM.BOW",320,623,N/A,Not Separately reimbursable,423.64,68% of total billed charges,423.64,68% of total billed charges,311.5,50% of total billed charges,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,0,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,75,Pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,75,423.64,436.1,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,75820,"VENOGRAPHY, EXTREMITY; RIGHT;",320,3055,51.36,Not Separately reimbursable,2077.4,68% of total billed charges,2077.4,68% of total billed charges,1527.5,50% of total billed charges,101.86,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,1303.62,Pays based on 100% of MO Medicaid Fee Schedule,1955.43,Pays based on 135% of CMS OPPS Rate,1329.69,Pays based on 102% of MO Medicaid Rate,1448.47,Pays based on 100% of CMS OPPS Rate,1329.69,Pays based on 102% of MO Medicaid Fee Schedule,1303.62,Pays based on 100% of MO Medicaid Fee Schedule,1448.47,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,1303.62,Pays based on 100% of MO Medicaid Fee Schedule,1448.47,Pays based on 100% of CMS OPPS Rate,75,2077.4,2138.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,75822,"VENOGRAPHY, EXTREMITY; BILATER",320,3055,66.75,Not Separately reimbursable,2077.4,68% of total billed charges,2077.4,68% of total billed charges,1527.5,50% of total billed charges,112.72,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,1303.62,Pays based on 100% of MO Medicaid Fee Schedule,1955.43,Pays based on 135% of CMS OPPS Rate,1329.69,Pays based on 102% of MO Medicaid Rate,1448.47,Pays based on 100% of CMS OPPS Rate,1329.69,Pays based on 102% of MO Medicaid Fee Schedule,1303.62,Pays based on 100% of MO Medicaid Fee Schedule,1448.47,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,1303.62,Pays based on 100% of MO Medicaid Fee Schedule,1448.47,Pays based on 100% of CMS OPPS Rate,75,2077.4,2138.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,70210,SINUSES;PARANASAL;RIGHT;>3 VIE,320,248,8.74,Not Separately reimbursable,168.64,68% of total billed charges,168.64,68% of total billed charges,124,50% of total billed charges,41.24,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,73.96,Pays based on 100% of MO Medicaid Fee Schedule,110.95,Pays based on 135% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Rate,82.18,Pays based on 100% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Fee Schedule,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,41.24,168.64,173.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,73100,WRIST; RIGHT; ANTER&LATERAL; X,320,198,8.38,Not Separately reimbursable,134.64,68% of total billed charges,134.64,68% of total billed charges,99,50% of total billed charges,44.68,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,73.96,Pays based on 100% of MO Medicaid Fee Schedule,110.95,Pays based on 135% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Rate,82.18,Pays based on 100% of CMS OPPS Rate,75.44,Pays based on 102% of MO Medicaid Fee Schedule,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,75,Pays based on per visit rate,73.96,Pays based on 100% of MO Medicaid Fee Schedule,82.18,Pays based on 100% of CMS OPPS Rate,44.68,134.64,138.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,76376,3D RENDERING W/INTERP & POSTPR,610,204,11.33,Not Separately reimbursable,138.72,68% of total billed charges,138.72,68% of total billed charges,1050,pays based on per visit rate ,26.94,Pays based on 200% of CMS OPPS Rate,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,0,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,26.94,1050,142.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,DIAGNOSTIC CENTER,74185,MRA ABDOMEN W/O CONTRAST,610,1538,126,Not Separately reimbursable,1045.84,68% of total billed charges,1045.84,68% of total billed charges,1050,pays based on per visit rate ,451.5,Pays based on 200% of CMS OPPS Rate,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,0,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,451.5,1050,1076.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,DIAGNOSTIC CENTER,70547,MRA CAROTID ART W/O CONTRAST,610,1538,126,Not Separately reimbursable,1045.84,68% of total billed charges,1045.84,68% of total billed charges,1050,pays based on per visit rate ,285.02,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,199.45,Pays based on 100% of MO Medicaid Fee Schedule,299.18,Pays based on 135% of CMS OPPS Rate,203.44,Pays based on 102% of MO Medicaid Rate,221.61,Pays based on 100% of CMS OPPS Rate,203.44,Pays based on 102% of MO Medicaid Fee Schedule,199.45,Pays based on 100% of MO Medicaid Fee Schedule,221.61,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,199.45,Pays based on 100% of MO Medicaid Fee Schedule,221.61,Pays based on 100% of CMS OPPS Rate,199.45,1050,1076.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,DIAGNOSTIC CENTER,70548,MRA CAROTID ART W/CONTRAST,610,1866,126,Not Separately reimbursable,1268.88,68% of total billed charges,1268.88,68% of total billed charges,1050,pays based on per visit rate ,313.6,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,313.04,Pays based on 100% of MO Medicaid Fee Schedule,469.55,Pays based on 135% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Rate,347.82,Pays based on 100% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Fee Schedule,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,313.04,1268.88,1306.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,DIAGNOSTIC CENTER,72141,MRI SPINAL CANAL CERV WO CON,610,1168,126,Not Separately reimbursable,794.24,68% of total billed charges,794.24,68% of total billed charges,1050,pays based on per visit rate ,217.46,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,199.45,Pays based on 100% of MO Medicaid Fee Schedule,299.18,Pays based on 135% of CMS OPPS Rate,203.44,Pays based on 102% of MO Medicaid Rate,221.61,Pays based on 100% of CMS OPPS Rate,203.44,Pays based on 102% of MO Medicaid Fee Schedule,199.45,Pays based on 100% of MO Medicaid Fee Schedule,221.61,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,199.45,Pays based on 100% of MO Medicaid Fee Schedule,221.61,Pays based on 100% of CMS OPPS Rate,199.45,1050,817.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,DIAGNOSTIC CENTER,72156,MRI SPINAL CANAL WO W CON CERV,610,2516,126,Not Separately reimbursable,1710.88,68% of total billed charges,1710.88,68% of total billed charges,1050,pays based on per visit rate ,380.52,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,313.04,Pays based on 100% of MO Medicaid Fee Schedule,469.55,Pays based on 135% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Rate,347.82,Pays based on 100% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Fee Schedule,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,313.04,1710.88,1761.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,DIAGNOSTIC CENTER,72142,MRI SPINAL CANAL CERV W CON,610,1842,126,Not Separately reimbursable,1252.56,68% of total billed charges,1252.56,68% of total billed charges,1050,pays based on per visit rate ,342.2,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,313.04,Pays based on 100% of MO Medicaid Fee Schedule,469.55,Pays based on 135% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Rate,347.82,Pays based on 100% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Fee Schedule,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,313.04,1252.56,1289.4,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,DIAGNOSTIC CENTER,71550,MRI CHEST W/O CONTRAST,610,1538,126,Not Separately reimbursable,1045.84,68% of total billed charges,1045.84,68% of total billed charges,1050,pays based on per visit rate ,479.46,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,199.45,Pays based on 100% of MO Medicaid Fee Schedule,299.18,Pays based on 135% of CMS OPPS Rate,203.44,Pays based on 102% of MO Medicaid Rate,221.61,Pays based on 100% of CMS OPPS Rate,203.44,Pays based on 102% of MO Medicaid Fee Schedule,199.45,Pays based on 100% of MO Medicaid Fee Schedule,221.61,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,199.45,Pays based on 100% of MO Medicaid Fee Schedule,221.61,Pays based on 100% of CMS OPPS Rate,199.45,1050,1076.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,DIAGNOSTIC CENTER,71555,MRA CHEST W/O CONTRAST,610,1538,126,Not Separately reimbursable,1045.84,68% of total billed charges,1045.84,68% of total billed charges,1050,pays based on per visit rate ,445.8,Pays based on 200% of CMS OPPS Rate,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,0,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,445.8,1050,1076.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,DIAGNOSTIC CENTER,74181,MRI ABD WO CON,610,1168,126,Not Separately reimbursable,794.24,68% of total billed charges,794.24,68% of total billed charges,1050,pays based on per visit rate ,228.32,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,199.45,Pays based on 100% of MO Medicaid Fee Schedule,299.18,Pays based on 135% of CMS OPPS Rate,203.44,Pays based on 102% of MO Medicaid Rate,221.61,Pays based on 100% of CMS OPPS Rate,203.44,Pays based on 102% of MO Medicaid Fee Schedule,199.45,Pays based on 100% of MO Medicaid Fee Schedule,221.61,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,199.45,Pays based on 100% of MO Medicaid Fee Schedule,221.61,Pays based on 100% of CMS OPPS Rate,199.45,1050,817.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,DIAGNOSTIC CENTER,73721,MRI ANY JNT LOW XT WO CON,610,1168,126,Not Separately reimbursable,794.24,68% of total billed charges,794.24,68% of total billed charges,1050,pays based on per visit rate ,248.34,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,199.45,Pays based on 100% of MO Medicaid Fee Schedule,299.18,Pays based on 135% of CMS OPPS Rate,203.44,Pays based on 102% of MO Medicaid Rate,221.61,Pays based on 100% of CMS OPPS Rate,203.44,Pays based on 102% of MO Medicaid Fee Schedule,199.45,Pays based on 100% of MO Medicaid Fee Schedule,221.61,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,199.45,Pays based on 100% of MO Medicaid Fee Schedule,221.61,Pays based on 100% of CMS OPPS Rate,199.45,1050,817.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,DIAGNOSTIC CENTER,71552,MRI CHEST W&W/O CONTRAST,610,2356.5,126,Not Separately reimbursable,1602.42,68% of total billed charges,1602.42,68% of total billed charges,1050,pays based on per visit rate ,651.1,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,313.04,Pays based on 100% of MO Medicaid Fee Schedule,469.55,Pays based on 135% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Rate,347.82,Pays based on 100% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Fee Schedule,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,313.04,1602.42,1649.55,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,DIAGNOSTIC CENTER,71551,MRI CHEST WITH CONTRAST,610,1866,126,Not Separately reimbursable,1268.88,68% of total billed charges,1268.88,68% of total billed charges,1050,pays based on per visit rate ,520.62,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,651.74,Pays based on 100% of MO Medicaid Fee Schedule,977.6,Pays based on 135% of CMS OPPS Rate,664.77,Pays based on 102% of MO Medicaid Rate,724.15,Pays based on 100% of CMS OPPS Rate,664.77,Pays based on 102% of MO Medicaid Fee Schedule,651.74,Pays based on 100% of MO Medicaid Fee Schedule,724.15,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,651.74,Pays based on 100% of MO Medicaid Fee Schedule,724.15,Pays based on 100% of CMS OPPS Rate,520.62,1268.88,1306.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,DIAGNOSTIC CENTER,74183,MRI ABDOMEN W&W/O CONTRAST,610,2356.5,126,Not Separately reimbursable,1602.42,68% of total billed charges,1602.42,68% of total billed charges,1050,pays based on per visit rate ,420.56,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,313.04,Pays based on 100% of MO Medicaid Fee Schedule,469.55,Pays based on 135% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Rate,347.82,Pays based on 100% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Fee Schedule,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,313.04,1602.42,1649.55,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,DIAGNOSTIC CENTER,74182,MRI ABDOMEN WITH CONTRAST,610,1866,126,Not Separately reimbursable,1268.88,68% of total billed charges,1268.88,68% of total billed charges,1050,pays based on per visit rate ,395.38,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,313.04,Pays based on 100% of MO Medicaid Fee Schedule,469.55,Pays based on 135% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Rate,347.82,Pays based on 100% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Fee Schedule,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,313.04,1268.88,1306.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,DIAGNOSTIC CENTER,73723,MRI ANY JNT LOW XT WO W CON,610,1842,126,Not Separately reimbursable,1252.56,68% of total billed charges,1252.56,68% of total billed charges,1050,pays based on per visit rate ,508.04,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,313.04,Pays based on 100% of MO Medicaid Fee Schedule,469.55,Pays based on 135% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Rate,347.82,Pays based on 100% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Fee Schedule,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,313.04,1252.56,1289.4,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,DIAGNOSTIC CENTER,73722,MRI ANY JNT LOW XT W CON,610,3704,126,Not Separately reimbursable,2518.72,68% of total billed charges,2518.72,68% of total billed charges,1050,pays based on per visit rate ,423.42,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,651.74,Pays based on 100% of MO Medicaid Fee Schedule,977.6,Pays based on 135% of CMS OPPS Rate,664.77,Pays based on 102% of MO Medicaid Rate,724.15,Pays based on 100% of CMS OPPS Rate,664.77,Pays based on 102% of MO Medicaid Fee Schedule,651.74,Pays based on 100% of MO Medicaid Fee Schedule,724.15,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,651.74,Pays based on 100% of MO Medicaid Fee Schedule,724.15,Pays based on 100% of CMS OPPS Rate,423.42,2518.72,2592.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,DIAGNOSTIC CENTER,72148,MRI SPINAL CANAL LUMB WO CON,610,1168,126,Not Separately reimbursable,794.24,68% of total billed charges,794.24,68% of total billed charges,1050,pays based on per visit rate ,218.02,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,199.45,Pays based on 100% of MO Medicaid Fee Schedule,299.18,Pays based on 135% of CMS OPPS Rate,203.44,Pays based on 102% of MO Medicaid Rate,221.61,Pays based on 100% of CMS OPPS Rate,203.44,Pays based on 102% of MO Medicaid Fee Schedule,199.45,Pays based on 100% of MO Medicaid Fee Schedule,221.61,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,199.45,Pays based on 100% of MO Medicaid Fee Schedule,221.61,Pays based on 100% of CMS OPPS Rate,199.45,1050,817.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,DIAGNOSTIC CENTER,72158,MRI SPINAL CANAL LUMB WO W CON,610,2516,126,Not Separately reimbursable,1710.88,68% of total billed charges,1710.88,68% of total billed charges,1050,pays based on per visit rate ,379.38,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,313.04,Pays based on 100% of MO Medicaid Fee Schedule,469.55,Pays based on 135% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Rate,347.82,Pays based on 100% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Fee Schedule,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,313.04,1710.88,1761.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,DIAGNOSTIC CENTER,72149,MRI SPINAL CANAL LUMB W CON,610,1842,126,Not Separately reimbursable,1252.56,68% of total billed charges,1252.56,68% of total billed charges,1050,pays based on per visit rate ,334.2,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,313.04,Pays based on 100% of MO Medicaid Fee Schedule,469.55,Pays based on 135% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Rate,347.82,Pays based on 100% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Fee Schedule,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,313.04,1252.56,1289.4,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,DIAGNOSTIC CENTER,70540,MRI ORBIT FACE NECK WO CON,610,1168,126,Not Separately reimbursable,794.24,68% of total billed charges,794.24,68% of total billed charges,1050,pays based on per visit rate ,291.22,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,199.45,Pays based on 100% of MO Medicaid Fee Schedule,299.18,Pays based on 135% of CMS OPPS Rate,203.44,Pays based on 102% of MO Medicaid Rate,221.61,Pays based on 100% of CMS OPPS Rate,203.44,Pays based on 102% of MO Medicaid Fee Schedule,199.45,Pays based on 100% of MO Medicaid Fee Schedule,221.61,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,199.45,Pays based on 100% of MO Medicaid Fee Schedule,221.61,Pays based on 100% of CMS OPPS Rate,199.45,1050,817.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,DIAGNOSTIC CENTER,70542,MRI ORBIT FACE NECK W CON,610,1842,126,Not Separately reimbursable,1252.56,68% of total billed charges,1252.56,68% of total billed charges,1050,pays based on per visit rate ,343.92,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,313.04,Pays based on 100% of MO Medicaid Fee Schedule,469.55,Pays based on 135% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Rate,347.82,Pays based on 100% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Fee Schedule,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,313.04,1252.56,1289.4,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,DIAGNOSTIC CENTER,70543,MRI ORBIT FACE NCK WO W CON,610,2516,126,Not Separately reimbursable,1710.88,68% of total billed charges,1710.88,68% of total billed charges,1050,pays based on per visit rate ,425.7,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,313.04,Pays based on 100% of MO Medicaid Fee Schedule,469.55,Pays based on 135% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Rate,347.82,Pays based on 100% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Fee Schedule,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,313.04,1710.88,1761.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,DIAGNOSTIC CENTER,73720,MRI LOWER XTR WO W CON,610,2516,126,Not Separately reimbursable,1710.88,68% of total billed charges,1710.88,68% of total billed charges,1050,pays based on per visit rate ,422.84,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,313.04,Pays based on 100% of MO Medicaid Fee Schedule,469.55,Pays based on 135% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Rate,347.82,Pays based on 100% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Fee Schedule,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,313.04,1710.88,1761.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,DIAGNOSTIC CENTER,73718,MRI LOWER XTR WO CON,610,1168,126,Not Separately reimbursable,794.24,68% of total billed charges,794.24,68% of total billed charges,1050,pays based on per visit rate ,286.08,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,199.45,Pays based on 100% of MO Medicaid Fee Schedule,299.18,Pays based on 135% of CMS OPPS Rate,203.44,Pays based on 102% of MO Medicaid Rate,221.61,Pays based on 100% of CMS OPPS Rate,203.44,Pays based on 102% of MO Medicaid Fee Schedule,199.45,Pays based on 100% of MO Medicaid Fee Schedule,221.61,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,199.45,Pays based on 100% of MO Medicaid Fee Schedule,221.61,Pays based on 100% of CMS OPPS Rate,199.45,1050,817.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,DIAGNOSTIC CENTER,73719,MRI LOWER XTR W CON,610,1842,126,Not Separately reimbursable,1252.56,68% of total billed charges,1252.56,68% of total billed charges,1050,pays based on per visit rate ,334.76,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,313.04,Pays based on 100% of MO Medicaid Fee Schedule,469.55,Pays based on 135% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Rate,347.82,Pays based on 100% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Fee Schedule,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,313.04,1252.56,1289.4,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,DIAGNOSTIC CENTER,72197,MRI PELVIS WO W CON FS,610,25.16,126,Not Separately reimbursable,17.11,68% of total billed charges,17.11,68% of total billed charges,1050,pays based on per visit rate ,50.32,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,313.04,Pays based on 100% of MO Medicaid Fee Schedule,469.55,Pays based on 135% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Rate,347.82,Pays based on 100% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Fee Schedule,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,17.11,1050,17.612,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,DIAGNOSTIC CENTER,72195,MRI PELVIS WO CON,610,1168,126,Not Separately reimbursable,794.24,68% of total billed charges,794.24,68% of total billed charges,1050,pays based on per visit rate ,286.66,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,199.45,Pays based on 100% of MO Medicaid Fee Schedule,299.18,Pays based on 135% of CMS OPPS Rate,203.44,Pays based on 102% of MO Medicaid Rate,221.61,Pays based on 100% of CMS OPPS Rate,203.44,Pays based on 102% of MO Medicaid Fee Schedule,199.45,Pays based on 100% of MO Medicaid Fee Schedule,221.61,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,199.45,Pays based on 100% of MO Medicaid Fee Schedule,221.61,Pays based on 100% of CMS OPPS Rate,199.45,1050,817.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,DIAGNOSTIC CENTER,72196,MRI PELVIS W CON,610,1842,126,Not Separately reimbursable,1252.56,68% of total billed charges,1252.56,68% of total billed charges,1050,pays based on per visit rate ,335.34,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,313.04,Pays based on 100% of MO Medicaid Fee Schedule,469.55,Pays based on 135% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Rate,347.82,Pays based on 100% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Fee Schedule,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,313.04,1252.56,1289.4,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,DIAGNOSTIC CENTER,73221,MRI ANY JNT UPP XT WO CON,610,1168,126,Not Separately reimbursable,794.24,68% of total billed charges,794.24,68% of total billed charges,1050,pays based on per visit rate ,248.92,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,199.45,Pays based on 100% of MO Medicaid Fee Schedule,299.18,Pays based on 135% of CMS OPPS Rate,203.44,Pays based on 102% of MO Medicaid Rate,221.61,Pays based on 100% of CMS OPPS Rate,203.44,Pays based on 102% of MO Medicaid Fee Schedule,199.45,Pays based on 100% of MO Medicaid Fee Schedule,221.61,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,199.45,Pays based on 100% of MO Medicaid Fee Schedule,221.61,Pays based on 100% of CMS OPPS Rate,199.45,1050,817.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,DIAGNOSTIC CENTER,73223,MRI ANY JNT UPP XT WO W CON FS,610,1842,126,Not Separately reimbursable,1252.56,68% of total billed charges,1252.56,68% of total billed charges,1050,pays based on per visit rate ,510.34,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,313.04,Pays based on 100% of MO Medicaid Fee Schedule,469.55,Pays based on 135% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Rate,347.82,Pays based on 100% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Fee Schedule,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,313.04,1252.56,1289.4,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,DIAGNOSTIC CENTER,73222,MRI ANY JNT UPP XT W CON,610,3704,126,Not Separately reimbursable,2518.72,68% of total billed charges,2518.72,68% of total billed charges,1050,pays based on per visit rate ,422.26,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,651.74,Pays based on 100% of MO Medicaid Fee Schedule,977.6,Pays based on 135% of CMS OPPS Rate,664.77,Pays based on 102% of MO Medicaid Rate,724.15,Pays based on 100% of CMS OPPS Rate,664.77,Pays based on 102% of MO Medicaid Fee Schedule,651.74,Pays based on 100% of MO Medicaid Fee Schedule,724.15,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,651.74,Pays based on 100% of MO Medicaid Fee Schedule,724.15,Pays based on 100% of CMS OPPS Rate,422.26,2518.72,2592.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,DIAGNOSTIC CENTER,73220,MRI UPPER XTR WO W CON FS,610,2516,126,Not Separately reimbursable,1710.88,68% of total billed charges,1710.88,68% of total billed charges,1050,pays based on per visit rate ,550.94,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,313.04,Pays based on 100% of MO Medicaid Fee Schedule,469.55,Pays based on 135% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Rate,347.82,Pays based on 100% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Fee Schedule,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,313.04,1710.88,1761.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,DIAGNOSTIC CENTER,73218,MRI UPPER XTR WO CON,610,1168,126,Not Separately reimbursable,794.24,68% of total billed charges,794.24,68% of total billed charges,1050,pays based on per visit rate ,426.84,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,199.45,Pays based on 100% of MO Medicaid Fee Schedule,299.18,Pays based on 135% of CMS OPPS Rate,203.44,Pays based on 102% of MO Medicaid Rate,221.61,Pays based on 100% of CMS OPPS Rate,203.44,Pays based on 102% of MO Medicaid Fee Schedule,199.45,Pays based on 100% of MO Medicaid Fee Schedule,221.61,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,199.45,Pays based on 100% of MO Medicaid Fee Schedule,221.61,Pays based on 100% of CMS OPPS Rate,199.45,1050,817.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,DIAGNOSTIC CENTER,73219,MRI UPPER XTR W CON,610,1842,126,Not Separately reimbursable,1252.56,68% of total billed charges,1252.56,68% of total billed charges,1050,pays based on per visit rate ,454.86,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,313.04,Pays based on 100% of MO Medicaid Fee Schedule,469.55,Pays based on 135% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Rate,347.82,Pays based on 100% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Fee Schedule,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,313.04,1252.56,1289.4,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,DIAGNOSTIC CENTER,70336,MRI TMJ W/O CONTRAST,610,1538,126,Not Separately reimbursable,1045.84,68% of total billed charges,1045.84,68% of total billed charges,1050,pays based on per visit rate ,347.84,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,199.45,Pays based on 100% of MO Medicaid Fee Schedule,299.18,Pays based on 135% of CMS OPPS Rate,203.44,Pays based on 102% of MO Medicaid Rate,221.61,Pays based on 100% of CMS OPPS Rate,203.44,Pays based on 102% of MO Medicaid Fee Schedule,199.45,Pays based on 100% of MO Medicaid Fee Schedule,221.61,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,199.45,Pays based on 100% of MO Medicaid Fee Schedule,221.61,Pays based on 100% of CMS OPPS Rate,199.45,1050,1076.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,DIAGNOSTIC CENTER,72146,MRI SPINAL CANAL THOR WO CON,610,1168,126,Not Separately reimbursable,794.24,68% of total billed charges,794.24,68% of total billed charges,1050,pays based on per visit rate ,216.88,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,199.45,Pays based on 100% of MO Medicaid Fee Schedule,299.18,Pays based on 135% of CMS OPPS Rate,203.44,Pays based on 102% of MO Medicaid Rate,221.61,Pays based on 100% of CMS OPPS Rate,203.44,Pays based on 102% of MO Medicaid Fee Schedule,199.45,Pays based on 100% of MO Medicaid Fee Schedule,221.61,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,199.45,Pays based on 100% of MO Medicaid Fee Schedule,221.61,Pays based on 100% of CMS OPPS Rate,199.45,1050,817.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,DIAGNOSTIC CENTER,72157,MRI SPINAL CANAL THOR WO W CON,610,2516,126,Not Separately reimbursable,1710.88,68% of total billed charges,1710.88,68% of total billed charges,1050,pays based on per visit rate ,381.66,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,313.04,Pays based on 100% of MO Medicaid Fee Schedule,469.55,Pays based on 135% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Rate,347.82,Pays based on 100% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Fee Schedule,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,313.04,1710.88,1761.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,DIAGNOSTIC CENTER,72147,MRI SPINAL CANAL THOR W CON,610,1842,126,Not Separately reimbursable,1252.56,68% of total billed charges,1252.56,68% of total billed charges,1050,pays based on per visit rate ,338.78,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,313.04,Pays based on 100% of MO Medicaid Fee Schedule,469.55,Pays based on 135% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Rate,347.82,Pays based on 100% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Fee Schedule,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,313.04,1252.56,1289.4,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,DIAGNOSTIC CENTER,70544,MRV BRAIN W/O CONTRAST,610,1538,126,Not Separately reimbursable,1045.84,68% of total billed charges,1045.84,68% of total billed charges,1050,pays based on per visit rate ,284.44,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,199.45,Pays based on 100% of MO Medicaid Fee Schedule,299.18,Pays based on 135% of CMS OPPS Rate,203.44,Pays based on 102% of MO Medicaid Rate,221.61,Pays based on 100% of CMS OPPS Rate,203.44,Pays based on 102% of MO Medicaid Fee Schedule,199.45,Pays based on 100% of MO Medicaid Fee Schedule,221.61,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,199.45,Pays based on 100% of MO Medicaid Fee Schedule,221.61,Pays based on 100% of CMS OPPS Rate,199.45,1050,1076.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,DIAGNOSTIC CENTER,70546,MRV BRAIN W&W/O CONTRAST,610,2356.5,126,Not Separately reimbursable,1602.42,68% of total billed charges,1602.42,68% of total billed charges,1050,pays based on per visit rate ,463.52,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,313.04,Pays based on 100% of MO Medicaid Fee Schedule,469.55,Pays based on 135% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Rate,347.82,Pays based on 100% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Fee Schedule,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,313.04,1602.42,1649.55,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,DIAGNOSTIC CENTER,70545,MRV BRAIN WITH CONTRAST,610,1866,126,Not Separately reimbursable,1268.88,68% of total billed charges,1268.88,68% of total billed charges,1050,pays based on per visit rate ,305.04,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,313.04,Pays based on 100% of MO Medicaid Fee Schedule,469.55,Pays based on 135% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Rate,347.82,Pays based on 100% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Fee Schedule,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,305.04,1268.88,1306.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,DIAGNOSTIC CENTER,70551,MRI BRAIN INC STEM WO CON,611,1168,126,Not Separately reimbursable,794.24,68% of total billed charges,794.24,68% of total billed charges,1050,pays based on per visit rate ,227.18,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,199.45,Pays based on 100% of MO Medicaid Fee Schedule,299.18,Pays based on 135% of CMS OPPS Rate,203.44,Pays based on 102% of MO Medicaid Rate,221.61,Pays based on 100% of CMS OPPS Rate,203.44,Pays based on 102% of MO Medicaid Fee Schedule,199.45,Pays based on 100% of MO Medicaid Fee Schedule,221.61,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,199.45,Pays based on 100% of MO Medicaid Fee Schedule,221.61,Pays based on 100% of CMS OPPS Rate,199.45,1050,817.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,DIAGNOSTIC CENTER,70553,MRI BRAIN INC STEM WO W CON FS,611,2516,126,Not Separately reimbursable,1710.88,68% of total billed charges,1710.88,68% of total billed charges,1050,pays based on per visit rate ,378.24,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,313.04,Pays based on 100% of MO Medicaid Fee Schedule,469.55,Pays based on 135% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Rate,347.82,Pays based on 100% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Fee Schedule,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,313.04,1710.88,1761.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,DIAGNOSTIC CENTER,70552,MRI BRAIN INC STEM W CON,611,1842,126,Not Separately reimbursable,1252.56,68% of total billed charges,1252.56,68% of total billed charges,1050,pays based on per visit rate ,334.2,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,313.04,Pays based on 100% of MO Medicaid Fee Schedule,469.55,Pays based on 135% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Rate,347.82,Pays based on 100% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Fee Schedule,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,313.04,1252.56,1289.4,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,DIAGNOSTIC CENTER,70549,MRA NECK W&W/O CONTRAST,615,2356.5,126,Not Separately reimbursable,1602.42,68% of total billed charges,1602.42,68% of total billed charges,1050,pays based on per visit rate ,465.8,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,313.04,Pays based on 100% of MO Medicaid Fee Schedule,469.55,Pays based on 135% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Rate,347.82,Pays based on 100% of CMS OPPS Rate,319.3,Pays based on 102% of MO Medicaid Fee Schedule,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,313.04,Pays based on 100% of MO Medicaid Fee Schedule,347.82,Pays based on 100% of CMS OPPS Rate,313.04,1602.42,1649.55,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RHC,10061,I & D ABSCESS MULT OR COMP,521,577,157.32,pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,288.5,50% of total billed charges,343.4,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,486.85,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,360.63,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,360.63,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,360.63,Pays based on 100% of CMS OPPS Rate,177.57,486.85,403.9,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RHC,11055,PARING CUTTING BEN LES 1,521,315,13.86,pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,157.5,50% of total billed charges,29.82,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,244.44,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,181.06,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,181.06,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,181.06,Pays based on 100% of CMS OPPS Rate,29.82,244.44,220.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RHC,11104,PUNCH BIOPSY SKIN SINGLE LESIO,521,333,40.2,pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,166.5,50% of total billed charges,88.04,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,486.85,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,360.63,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,360.63,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,360.63,Pays based on 100% of CMS OPPS Rate,88.04,486.85,233.1,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RHC,11400,PROC/EXC BENIGN LESION .5CM OR,521,153,71.17,pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,76.5,50% of total billed charges,155.18,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,859.04,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,636.33,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,636.33,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,636.33,Pays based on 100% of CMS OPPS Rate,76.5,859.04,107.1,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RHC,11750,PROC/EXC OF NAIL(INGROWN PERMA,521,353,81.03,pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,176.5,50% of total billed charges,190.82,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,486.85,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,360.63,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,360.63,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,360.63,Pays based on 100% of CMS OPPS Rate,176.5,486.85,247.1,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RHC,12001,PROC/SIMPLE LACERATION REPAIR,521,180,38.84,pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,90,50% of total billed charges,85.74,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,244.44,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,181.06,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,181.06,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,181.06,Pays based on 100% of CMS OPPS Rate,85.74,244.44,126,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RHC,17000,DESTR BEN PREMAL 1 LESION,521,179,46.8,pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,89.5,50% of total billed charges,101.1,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,244.44,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,181.06,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,181.06,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,181.06,Pays based on 100% of CMS OPPS Rate,89.5,244.44,125.3,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RHC,17003,DESTR BEN PREMAL 2 14 LESION,521,20,1.78,pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,10,50% of total billed charges,3.8,Pays based on 200% of CMS OPPS Rate,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,0,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,3.8,177.57,14,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RHC,17110,DESTR BEN 1 14 LESN NOT SKN TG,521,307,56.64,pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,153.5,50% of total billed charges,125.48,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,244.44,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,181.06,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,181.06,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,181.06,Pays based on 100% of CMS OPPS Rate,125.48,244.44,214.9,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RHC,20500,INJECTION OF SINUS TRACT,521,604,79.15,pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,302,50% of total billed charges,166.98,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,1862.03,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,1379.29,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,1379.29,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,1379.29,Pays based on 100% of CMS OPPS Rate,166.98,1862.03,422.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RHC,92551,SCREENING TEST PURE TONE AIR O,521,37,10.38,pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,18.5,50% of total billed charges,21.8,Pays based on 200% of CMS OPPS Rate,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,0,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,18.5,177.57,25.9,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RHC,95115,IMMUNO WO EXTRAC 1,521,26,8.54,pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,13,50% of total billed charges,17.8,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,57.99,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,42.96,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,42.96,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,42.96,Pays based on 100% of CMS OPPS Rate,13,177.57,18.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RHC,95117,INJ/ALLERGY INJ. 2 OR MORE,521,44,10.38,pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,22,50% of total billed charges,21.22,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,57.99,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,42.96,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,42.96,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,42.96,Pays based on 100% of CMS OPPS Rate,21.22,177.57,30.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RHC,96372,INJECT THER DX SUBCU OR IM,521,43,13.09,pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,21.5,50% of total billed charges,26.26,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,86.01,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,63.71,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,63.71,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,63.71,Pays based on 100% of CMS OPPS Rate,21.5,177.57,30.1,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RHC,99024,POSTOPERATIVE FOLLOW-UP VISIT,521,0.01,3.39,pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,0.01,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,0,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,0.01,177.57,0.007,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RHC,99201,OFF VISIT/NEW PT BRIEF,521,105,N/A,pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,52.5,50% of total billed charges,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,0,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,52.5,177.57,73.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RHC,99202,OFFICE OP NEW PT VISIT STRAIGH,521,135,37.23,pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,67.5,50% of total billed charges,89.96,Pays based on 200% of CMS OPPS Rate,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,0,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,67.5,177.57,94.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RHC,99203,OFFICE OP NEW PT VISIT LOW,521,208,63.5,pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,104,50% of total billed charges,155.78,Pays based on 200% of CMS OPPS Rate,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,0,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,104,177.57,145.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RHC,99204,OFFICE OP NEW PT VISIT MOD,521,313,102.89,pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,156.5,50% of total billed charges,253.26,Pays based on 200% of CMS OPPS Rate,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,0,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,156.5,253.26,219.1,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RHC,99205,OFFICE OP NEW PT VISIT HIGH,521,413,139.6,pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,206.5,50% of total billed charges,344.18,Pays based on 200% of CMS OPPS Rate,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,0,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,177.57,344.18,289.1,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RHC,99211,OFF OP ESTAB MAY X REQ PHY/QHP,521,103,6.8,pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,51.5,50% of total billed charges,16.62,Pays based on 200% of CMS OPPS Rate,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,0,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,16.62,177.57,72.1,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RHC,99212,OFFICE OP ESTAB VISIT STRAIGHT,521,105,27.6,pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,52.5,50% of total billed charges,67.06,Pays based on 200% of CMS OPPS Rate,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,0,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,52.5,177.57,73.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RHC,99213,OFFICE OP ESTAB VISIT LOW,521,170,50.86,pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,85,50% of total billed charges,125.04,Pays based on 200% of CMS OPPS Rate,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,0,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,85,177.57,119,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RHC,99214,OFFICE OP ESTAB VISIT MOD,521,240,74.68,pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,120,50% of total billed charges,184.36,Pays based on 200% of CMS OPPS Rate,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,0,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,120,184.36,168,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RHC,99215,OFFICE OP ESTAB VISIT HIGH,521,338,110.83,pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,169,50% of total billed charges,273.3,Pays based on 200% of CMS OPPS Rate,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,0,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,169,273.3,236.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RHC,99381,PREV/NEW OFF VISIT 0-1,521,157,54.95,pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,78.5,50% of total billed charges,138.86,Pays based on 200% of CMS OPPS Rate,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,0,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,78.5,177.57,109.9,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RHC,99382,NEW PT PREVENT MED 1 TO 4,521,228,58.71,pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,114,50% of total billed charges,148.46,Pays based on 200% of CMS OPPS Rate,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,0,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,114,177.57,159.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RHC,99383,NEW PT PREVENT MED 5 TO 11,521,237,62.24,pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,118.5,50% of total billed charges,157.4,Pays based on 200% of CMS OPPS Rate,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,0,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,118.5,177.57,165.9,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RHC,99384,NEW PT PREVENT MED 12 TO 17,521,267,73.92,pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,133.5,50% of total billed charges,185.52,Pays based on 200% of CMS OPPS Rate,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,0,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,133.5,185.52,186.9,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RHC,99385,NEW PT PREVENT MED 18 TO 39,521,259,70.92,pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,129.5,50% of total billed charges,177.92,Pays based on 200% of CMS OPPS Rate,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,0,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,129.5,177.92,181.3,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RHC,99386,NEW PT PREVENT MED 40 TO 64,521,299,85.98,pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,149.5,50% of total billed charges,215.66,Pays based on 200% of CMS OPPS Rate,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,0,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,149.5,215.66,209.3,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RHC,99387,NEW PT PREVENT MED 65PLUS,521,325,92.25,pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,162.5,50% of total billed charges,231.62,Pays based on 200% of CMS OPPS Rate,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,0,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,162.5,231.62,227.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RHC,99391,PREV/EST OFF VISIT 0-1,521,130,50.41,pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,65,50% of total billed charges,126.7,Pays based on 200% of CMS OPPS Rate,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,0,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,65,177.57,91,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RHC,99392,EST PT PREVENT MED 1 TO 4,521,210,54.95,pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,105,50% of total billed charges,138.86,Pays based on 200% of CMS OPPS Rate,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,0,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,105,177.57,147,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RHC,99393,EST PT PREVENT MED 5 T0 11,521,210,54.95,pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,105,50% of total billed charges,138.86,Pays based on 200% of CMS OPPS Rate,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,0,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,105,177.57,147,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RHC,99394,EST PT PREVENT MED 12 TO 17,521,228,62.24,pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,114,50% of total billed charges,157.4,Pays based on 200% of CMS OPPS Rate,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,0,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,114,177.57,159.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RHC,99395,EST PT PREVENT MED 18 TO 39,521,234,64.01,pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,117,50% of total billed charges,162.52,Pays based on 200% of CMS OPPS Rate,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,0,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,117,177.57,163.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RHC,99396,EST PT PREVENT MED 40 TO 64,521,248,70.17,pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,124,50% of total billed charges,176.58,Pays based on 200% of CMS OPPS Rate,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,0,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,124,177.57,173.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RHC,99397,EST PT PREVENT MED 65PLUS,521,268,73.92,pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,134,50% of total billed charges,185.52,Pays based on 200% of CMS OPPS Rate,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,0,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,134,185.52,187.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RHC,99490,CHRONIC CARE MANAGEMENT,521,202,38.89,pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,101,50% of total billed charges,95.12,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,108.83,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,80.61,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,80.61,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,80.61,Pays based on 100% of CMS OPPS Rate,80.61,177.57,141.4,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RHC,99499,DOT PHYSICAL EXAMINATION,521,125,N/A,pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,62.5,50% of total billed charges,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,0,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,62.5,177.57,87.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,ULTRASOUND,76641,US BREAST,402,336,36.06,Not Separately reimbursable,228.48,68% of total billed charges,228.48,68% of total billed charges,168,50% of total billed charges,117.3,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,89.49,Pays based on 100% of MO Medicaid Fee Schedule,134.23,Pays based on 135% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Rate,99.43,Pays based on 100% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Fee Schedule,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,105,Pays based on per visit rate,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,89.49,228.48,235.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,ULTRASOUND,76604,US CHEST B SCAN,402,275,28.69,Not Separately reimbursable,187,68% of total billed charges,187,68% of total billed charges,137.5,50% of total billed charges,52.1,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,89.49,Pays based on 100% of MO Medicaid Fee Schedule,134.23,Pays based on 135% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Rate,99.43,Pays based on 100% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Fee Schedule,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,105,Pays based on per visit rate,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,52.1,187,192.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,ULTRASOUND,76801,US OB 1ST TRIMESTER <14 WKS,402,440,48.71,Not Separately reimbursable,299.2,68% of total billed charges,299.2,68% of total billed charges,220,50% of total billed charges,121.88,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,89.49,Pays based on 100% of MO Medicaid Fee Schedule,134.22,Pays based on 135% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Rate,99.43,Pays based on 100% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Fee Schedule,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,105,Pays based on per visit rate,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,89.49,299.2,308,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,ULTRASOUND,76815,US OB LIMITED,402,413,32.19,Not Separately reimbursable,280.84,68% of total billed charges,280.84,68% of total billed charges,206.5,50% of total billed charges,87,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,89.49,Pays based on 100% of MO Medicaid Fee Schedule,134.23,Pays based on 135% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Rate,99.43,Pays based on 100% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Fee Schedule,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,105,Pays based on per visit rate,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,87,280.84,289.1,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,ULTRASOUND,76700,US ABDOMEN TECH,402,103.5,39.92,Not Separately reimbursable,70.38,68% of total billed charges,70.38,68% of total billed charges,51.75,50% of total billed charges,135.1,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,89.49,Pays based on 100% of MO Medicaid Fee Schedule,134.22,Pays based on 135% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Rate,99.43,Pays based on 100% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Fee Schedule,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,105,Pays based on per visit rate,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,51.75,135.1,72.45,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,ULTRASOUND,76705,US ABDOMINAL LIMITED,402,428,29.37,Not Separately reimbursable,291.04,68% of total billed charges,291.04,68% of total billed charges,214,50% of total billed charges,102.44,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,89.49,Pays based on 100% of MO Medicaid Fee Schedule,134.22,Pays based on 135% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Rate,99.43,Pays based on 100% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Fee Schedule,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,105,Pays based on per visit rate,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,89.49,291.04,299.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,ULTRASOUND,76706,US ABDOMINAL AORTA,402,120,27.27,Not Separately reimbursable,81.6,68% of total billed charges,81.6,68% of total billed charges,60,50% of total billed charges,139.04,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,89.49,Pays based on 100% of MO Medicaid Fee Schedule,134.22,Pays based on 135% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Rate,99.43,Pays based on 100% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Fee Schedule,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,105,Pays based on per visit rate,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,60,139.04,84,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,ULTRASOUND,93931,US ARTERIAL UPPER EXTR UNILATE,402,398,22.06,Not Separately reimbursable,270.64,68% of total billed charges,270.64,68% of total billed charges,199,50% of total billed charges,172.86,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,89.49,Pays based on 100% of MO Medicaid Fee Schedule,134.22,Pays based on 135% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Rate,99.43,Pays based on 100% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Fee Schedule,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,105,Pays based on per visit rate,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,89.49,270.64,278.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,ULTRASOUND,76811,US OB 2ND TRIMESTER W/ ANATOMY,402,572,84.61,Not Separately reimbursable,388.96,68% of total billed charges,388.96,68% of total billed charges,286,50% of total billed charges,151.76,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,199.45,Pays based on 100% of MO Medicaid Fee Schedule,299.18,Pays based on 135% of CMS OPPS Rate,203.44,Pays based on 102% of MO Medicaid Rate,221.61,Pays based on 100% of CMS OPPS Rate,203.44,Pays based on 102% of MO Medicaid Fee Schedule,199.45,Pays based on 100% of MO Medicaid Fee Schedule,221.61,Pays based on 100% of CMS OPPS Rate,105,Pays based on per visit rate,199.45,Pays based on 100% of MO Medicaid Fee Schedule,221.61,Pays based on 100% of CMS OPPS Rate,105,388.96,400.4,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,ULTRASOUND,76812,US OB ADD'L 2ND TRIMESTER W/ A,402,623,88.64,Not Separately reimbursable,423.64,68% of total billed charges,423.64,68% of total billed charges,311.5,50% of total billed charges,185.44,Pays based on 200% of CMS OPPS Rate,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,0,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,105,Pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,105,423.64,436.1,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,ULTRASOUND,76805,US OB 2ND TRIMESTER >14 WEEKS,402,482,49.05,Not Separately reimbursable,327.76,68% of total billed charges,327.76,68% of total billed charges,241,50% of total billed charges,152.84,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,89.49,Pays based on 100% of MO Medicaid Fee Schedule,134.22,Pays based on 135% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Rate,99.43,Pays based on 100% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Fee Schedule,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,105,Pays based on per visit rate,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,89.49,327.76,337.4,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,ULTRASOUND,76770,US RETROPERITONEAL;COMPLETE,402,428,36.41,Not Separately reimbursable,291.04,68% of total billed charges,291.04,68% of total billed charges,214,50% of total billed charges,126.46,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,89.49,Pays based on 100% of MO Medicaid Fee Schedule,134.22,Pays based on 135% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Rate,99.43,Pays based on 100% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Fee Schedule,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,105,Pays based on per visit rate,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,89.49,291.04,299.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,ULTRASOUND,76856,US PELVIC-NON OB,402,428,34.29,Not Separately reimbursable,291.04,68% of total billed charges,291.04,68% of total billed charges,214,50% of total billed charges,125.88,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,89.49,Pays based on 100% of MO Medicaid Fee Schedule,134.22,Pays based on 135% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Rate,99.43,Pays based on 100% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Fee Schedule,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,105,Pays based on per visit rate,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,89.49,291.04,299.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,ULTRASOUND,76870,US ECHO SCROTUM AND CONTENTS,402,428,31.83,Not Separately reimbursable,291.04,68% of total billed charges,291.04,68% of total billed charges,214,50% of total billed charges,120.74,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,89.49,Pays based on 100% of MO Medicaid Fee Schedule,134.23,Pays based on 135% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Rate,99.43,Pays based on 100% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Fee Schedule,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,105,Pays based on per visit rate,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,89.49,291.04,299.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,ULTRASOUND,76536,US SOFT TISSUE OF HEAD & NECK,402,428,28.3,Not Separately reimbursable,291.04,68% of total billed charges,291.04,68% of total billed charges,214,50% of total billed charges,144.18,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,89.49,Pays based on 100% of MO Medicaid Fee Schedule,134.23,Pays based on 135% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Rate,99.43,Pays based on 100% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Fee Schedule,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,105,Pays based on per visit rate,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,89.49,291.04,299.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,ULTRASOUND,76830,US TRANSVAGINAL,402,428,34.29,Not Separately reimbursable,291.04,68% of total billed charges,291.04,68% of total billed charges,214,50% of total billed charges,149.4,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,89.49,Pays based on 100% of MO Medicaid Fee Schedule,134.22,Pays based on 135% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Rate,99.43,Pays based on 100% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Fee Schedule,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,105,Pays based on per visit rate,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,89.49,291.04,299.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,ULTRASOUND,76857,US BLADDER,402,275,24.2,Not Separately reimbursable,187,68% of total billed charges,187,68% of total billed charges,137.5,50% of total billed charges,45.24,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,89.49,Pays based on 100% of MO Medicaid Fee Schedule,134.22,Pays based on 135% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Rate,99.43,Pays based on 100% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Fee Schedule,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,105,Pays based on per visit rate,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,45.24,187,192.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,ULTRASOUND,76942,US W/GUIDANCE - TECH,402,880,27.76,Not Separately reimbursable,598.4,68% of total billed charges,598.4,68% of total billed charges,440,50% of total billed charges,48.68,Pays based on 200% of CMS OPPS Rate,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,0,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,105,Pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,48.68,598.4,616,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,ULTRASOUND,76881,"US ECHO OF EXTREMITY, NON VASC",402,428,28.78,Not Separately reimbursable,291.04,68% of total billed charges,291.04,68% of total billed charges,214,50% of total billed charges,18.94,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,89.49,Pays based on 100% of MO Medicaid Fee Schedule,134.22,Pays based on 135% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Rate,99.43,Pays based on 100% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Fee Schedule,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,105,Pays based on per visit rate,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,18.94,291.04,299.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,ULTRASOUND,76937,US GUIDANCE VAS ACCESS,402,482,14.02,Not Separately reimbursable,327.76,68% of total billed charges,327.76,68% of total billed charges,241,50% of total billed charges,42.38,Pays based on 200% of CMS OPPS Rate,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,0,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,105,Pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,42.38,327.76,337.4,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,ULTRASOUND,76872,US TRANSRECTAL TECH,402,428,33.34,Not Separately reimbursable,291.04,68% of total billed charges,291.04,68% of total billed charges,214,50% of total billed charges,290.66,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,89.49,Pays based on 100% of MO Medicaid Fee Schedule,134.22,Pays based on 135% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Rate,99.43,Pays based on 100% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Fee Schedule,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,105,Pays based on per visit rate,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,89.49,291.04,299.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,ULTRASOUND,76810,US OB ADD'L 3RD TRIMESTER; COM,402,428,42.34,Not Separately reimbursable,291.04,68% of total billed charges,291.04,68% of total billed charges,214,50% of total billed charges,70.98,Pays based on 200% of CMS OPPS Rate,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,0,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,105,Pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,70.98,291.04,299.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,ULTRASOUND,76802,US OB ADD'L 1ST TRIMESTER <14,402,200,21.69,Not Separately reimbursable,136,68% of total billed charges,136,68% of total billed charges,100,50% of total billed charges,36.02,Pays based on 200% of CMS OPPS Rate,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,0,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,105,Pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,36.02,136,140,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,ULTRASOUND,76816,US OB FOLLOW UP,402,372,42.37,Not Separately reimbursable,252.96,68% of total billed charges,252.96,68% of total billed charges,186,50% of total billed charges,120.16,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,89.49,Pays based on 100% of MO Medicaid Fee Schedule,134.23,Pays based on 135% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Rate,99.43,Pays based on 100% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Fee Schedule,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,105,Pays based on per visit rate,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,89.49,252.96,260.4,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,ULTRASOUND,76818,US FETAL BIOPHYSICAL PROFILE,402,428,52.21,Not Separately reimbursable,291.04,68% of total billed charges,291.04,68% of total billed charges,214,50% of total billed charges,119.18,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,89.49,Pays based on 100% of MO Medicaid Fee Schedule,134.22,Pays based on 135% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Rate,99.43,Pays based on 100% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Fee Schedule,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,105,Pays based on per visit rate,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,89.49,291.04,299.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,ULTRASOUND,76819,US FETAL BIOPHYSICAL W/O NON S,402,357.5,38.5,Not Separately reimbursable,243.1,68% of total billed charges,243.1,68% of total billed charges,178.75,50% of total billed charges,85.36,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,89.49,Pays based on 100% of MO Medicaid Fee Schedule,134.22,Pays based on 135% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Rate,99.43,Pays based on 100% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Fee Schedule,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,105,Pays based on per visit rate,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,85.36,243.1,250.25,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,ULTRASOUND,76775,US KIDNEY,402,428,28.68,Not Separately reimbursable,291.04,68% of total billed charges,291.04,68% of total billed charges,214,50% of total billed charges,56.12,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,89.49,Pays based on 100% of MO Medicaid Fee Schedule,134.23,Pays based on 135% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Rate,99.43,Pays based on 100% of CMS OPPS Rate,91.28,Pays based on 102% of MO Medicaid Fee Schedule,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,105,Pays based on per visit rate,89.49,Pays based on 100% of MO Medicaid Fee Schedule,99.43,Pays based on 100% of CMS OPPS Rate,56.12,291.04,299.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,ULTRASOUND,93307,ECHO 2D,480,1284,40.81,Not Separately reimbursable,873.12,68% of total billed charges,975.84,76% of total billed charges,642,50% of total billed charges,161.42,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,199.45,Pays based on 100% of MO Medicaid Fee Schedule,299.18,Pays based on 135% of CMS OPPS Rate,203.44,Pays based on 102% of MO Medicaid Rate,221.61,Pays based on 100% of CMS OPPS Rate,203.44,Pays based on 102% of MO Medicaid Fee Schedule,199.45,Pays based on 100% of MO Medicaid Fee Schedule,221.61,Pays based on 100% of CMS OPPS Rate,150,Pays based on per visit rate,199.45,Pays based on 100% of MO Medicaid Fee Schedule,221.61,Pays based on 100% of CMS OPPS Rate,150,975.84,898.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,ULTRASOUND,93320,DOPPLER ECHOCARDIOGRAM,480,428,16.48,Not Separately reimbursable,291.04,68% of total billed charges,325.28,76% of total billed charges,214,50% of total billed charges,57.26,Pays based on 200% of CMS OPPS Rate,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,0,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,150,Pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,57.26,325.28,299.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,ULTRASOUND,93325,DOPPLER COLOR FLOW,480,321.5,2.86,Not Separately reimbursable,218.62,68% of total billed charges,244.34,76% of total billed charges,160.75,50% of total billed charges,34.88,Pays based on 200% of CMS OPPS Rate,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,0,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,150,Pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,34.88,244.34,225.05,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,ULTRASOUND,93306,ECHOCARDIOGRAPHY COMPLETE GLOB,480,1480,64.28,Not Separately reimbursable,1006.4,68% of total billed charges,1124.8,76% of total billed charges,740,50% of total billed charges,221.54,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,449.05,Pays based on 100% of MO Medicaid Fee Schedule,673.58,Pays based on 135% of CMS OPPS Rate,458.03,Pays based on 102% of MO Medicaid Rate,498.94,Pays based on 100% of CMS OPPS Rate,458.03,Pays based on 102% of MO Medicaid Fee Schedule,449.05,Pays based on 100% of MO Medicaid Fee Schedule,498.94,Pays based on 100% of CMS OPPS Rate,150,Pays based on per visit rate,449.05,Pays based on 100% of MO Medicaid Fee Schedule,498.94,Pays based on 100% of CMS OPPS Rate,150,1124.8,1036,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,ULTRASOUND,93308,ECHOCARDIOGRAPHY LIMITED,480,1248.5,23.12,Not Separately reimbursable,848.98,68% of total billed charges,948.86,76% of total billed charges,624.25,50% of total billed charges,127.68,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,199.45,Pays based on 100% of MO Medicaid Fee Schedule,299.18,Pays based on 135% of CMS OPPS Rate,203.44,Pays based on 102% of MO Medicaid Rate,221.61,Pays based on 100% of CMS OPPS Rate,203.44,Pays based on 102% of MO Medicaid Fee Schedule,199.45,Pays based on 100% of MO Medicaid Fee Schedule,221.61,Pays based on 100% of CMS OPPS Rate,150,Pays based on per visit rate,199.45,Pays based on 100% of MO Medicaid Fee Schedule,221.61,Pays based on 100% of CMS OPPS Rate,127.68,948.86,873.95,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,SPEECH THERAPY,97129,COGNITIVE FUNCTION INTERVENTIO,440,108,17.81,Not Separately reimbursable,73.44,68% of total billed charges,82.08,76% of total billed charges,150,pays based on per visit rate ,42.5,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,28.69,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,21.25,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,21.25,Pays based on 100% of CMS OPPS Rate,55,Pays based on per visit rate,N/A,Not Separately reimbursable,21.25,Pays based on 100% of CMS OPPS Rate,21.25,150,75.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,SPEECH THERAPY,96125,COGNITIVE SKILLS EVAL 15 MIN,440,333,96.07,Not Separately reimbursable,226.44,68% of total billed charges,253.08,76% of total billed charges,150,pays based on per visit rate ,191.98,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,129.59,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,95.99,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,95.99,Pays based on 100% of CMS OPPS Rate,55,Pays based on per visit rate,N/A,Not Separately reimbursable,95.99,Pays based on 100% of CMS OPPS Rate,55,253.08,233.1,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,SPEECH THERAPY,96105,ASSESS OF APHASIA,440,75,90.91,Not Separately reimbursable,51,68% of total billed charges,57,76% of total billed charges,150,pays based on per visit rate ,150,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,101.25,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,75,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,75,Pays based on 100% of CMS OPPS Rate,55,Pays based on per visit rate,N/A,Not Separately reimbursable,75,Pays based on 100% of CMS OPPS Rate,51,150,52.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,SPEECH THERAPY,92510,AURAL REHABILITATION W/ COCHLE,440,80.5,N/A,Not Separately reimbursable,54.74,68% of total billed charges,61.18,76% of total billed charges,150,pays based on per visit rate ,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,0,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,55,Pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,54.74,150,56.35,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,SPEECH THERAPY,92522,SPEECH PATH EVAL,444,362,92.33,Not Separately reimbursable,246.16,68% of total billed charges,275.12,76% of total billed charges,150,pays based on per visit rate ,209.56,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,141.45,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,104.78,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,104.78,Pays based on 100% of CMS OPPS Rate,55,Pays based on per visit rate,N/A,Not Separately reimbursable,104.78,Pays based on 100% of CMS OPPS Rate,55,275.12,253.4,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,SPEECH THERAPY,92508,SPEECH THERAPY GROUP 15 MIN,443,77,19.56,Not Separately reimbursable,52.36,68% of total billed charges,58.52,76% of total billed charges,150,pays based on per visit rate ,44.92,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,30.32,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,22.46,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,22.46,Pays based on 100% of CMS OPPS Rate,55,Pays based on per visit rate,N/A,Not Separately reimbursable,22.46,Pays based on 100% of CMS OPPS Rate,22.46,150,53.9,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,SPEECH THERAPY,92507,SPEECH THERAPY- ADULT,440,250,63.43,Not Separately reimbursable,170,68% of total billed charges,190,76% of total billed charges,150,pays based on per visit rate ,143.38,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,96.78,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,71.69,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,71.69,Pays based on 100% of CMS OPPS Rate,55,Pays based on per visit rate,N/A,Not Separately reimbursable,71.69,Pays based on 100% of CMS OPPS Rate,55,190,175,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,SPEECH THERAPY,92526,SWALLOWING TREAT,440,276,78.78,Not Separately reimbursable,187.68,68% of total billed charges,209.76,76% of total billed charges,150,pays based on per visit rate ,158.06,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,106.69,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,79.03,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,79.03,Pays based on 100% of CMS OPPS Rate,55,Pays based on per visit rate,N/A,Not Separately reimbursable,79.03,Pays based on 100% of CMS OPPS Rate,55,209.76,193.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,SPEECH THERAPY,92610,BEDSIDE SWALLOWING EVAL,444,75,64.89,Not Separately reimbursable,51,68% of total billed charges,57,76% of total billed charges,150,pays based on per visit rate ,132.6,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,89.51,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,66.3,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,66.3,Pays based on 100% of CMS OPPS Rate,55,Pays based on per visit rate,N/A,Not Separately reimbursable,66.3,Pays based on 100% of CMS OPPS Rate,51,150,52.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,SPEECH THERAPY,92611,VIDEO FLUOROSCOPIC SWALLOWING,444,75,84.79,Not Separately reimbursable,51,68% of total billed charges,57,76% of total billed charges,150,pays based on per visit rate ,150,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,101.25,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,75,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,75,Pays based on 100% of CMS OPPS Rate,55,Pays based on per visit rate,N/A,Not Separately reimbursable,75,Pays based on 100% of CMS OPPS Rate,51,150,52.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,SPEECH THERAPY,92609,THER SVC/SPEECH GEN DEV (15 MI,440,53,96.12,Not Separately reimbursable,36.04,68% of total billed charges,40.28,76% of total billed charges,150,pays based on per visit rate ,191.66,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,129.37,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,95.83,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,95.83,Pays based on 100% of CMS OPPS Rate,55,Pays based on per visit rate,N/A,Not Separately reimbursable,95.83,Pays based on 100% of CMS OPPS Rate,36.04,191.66,37.1,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,SPEECH THERAPY,92597,EVAL FOR SPEECH GEN DEVICE,440,1237.5,66.97,Not Separately reimbursable,841.5,68% of total billed charges,940.5,76% of total billed charges,150,pays based on per visit rate ,136.22,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,91.95,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,68.11,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,68.11,Pays based on 100% of CMS OPPS Rate,55,Pays based on per visit rate,N/A,Not Separately reimbursable,68.11,Pays based on 100% of CMS OPPS Rate,55,940.5,866.25,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,SPEECH THERAPY,92506,SPEECH PATHOLOGY EVALUATION,444,299.5,N/A,Not Separately reimbursable,203.66,68% of total billed charges,227.62,76% of total billed charges,150,pays based on per visit rate ,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,0,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,55,Pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,55,227.62,209.65,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,SPEECH THERAPY,92521,EVALUATION OF SPEECH FLUENCY,444,121,109.99,Not Separately reimbursable,82.28,68% of total billed charges,91.96,76% of total billed charges,150,pays based on per visit rate ,249.66,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,168.52,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,124.83,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,124.83,Pays based on 100% of CMS OPPS Rate,55,Pays based on per visit rate,N/A,Not Separately reimbursable,124.83,Pays based on 100% of CMS OPPS Rate,55,249.66,84.7,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,SPEECH THERAPY,92523,EVAL OF SP SOUND PRO WITH EVAL,444,742,187.82,Not Separately reimbursable,504.56,68% of total billed charges,563.92,76% of total billed charges,150,pays based on per visit rate ,427.96,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,288.87,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,213.98,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,213.98,Pays based on 100% of CMS OPPS Rate,55,Pays based on per visit rate,N/A,Not Separately reimbursable,213.98,Pays based on 100% of CMS OPPS Rate,55,563.92,519.4,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,SPEECH THERAPY,92524,EVALUATION OF VOICE,444,358,90.96,Not Separately reimbursable,243.44,68% of total billed charges,272.08,76% of total billed charges,150,pays based on per visit rate ,206.7,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,139.52,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,103.35,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,103.35,Pays based on 100% of CMS OPPS Rate,55,Pays based on per visit rate,N/A,Not Separately reimbursable,103.35,Pays based on 100% of CMS OPPS Rate,55,272.08,250.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,87077,ADDITIONAL ID-AEROBIC,300,25.5,5.49,Not Separately reimbursable,17.34,68% of total billed charges,17.34,68% of total billed charges,12.75,50% of total billed charges,16.16,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,10.91,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,8.08,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,8.08,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,8.08,Pays based on 100% of CMS OPPS Rate,8.08,17.34,17.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,87186,ANTIBIOTIC SENSITIVITY (MIC),300,27.5,5.88,Not Separately reimbursable,18.7,68% of total billed charges,18.7,68% of total billed charges,13.75,50% of total billed charges,17.3,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,11.68,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,8.65,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,8.65,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,8.65,Pays based on 100% of CMS OPPS Rate,8.65,18.7,19.25,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,87040,BLOOD CULTURE,300,33,7.02,Not Separately reimbursable,22.44,68% of total billed charges,22.44,68% of total billed charges,16.5,50% of total billed charges,20.64,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,13.93,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,10.32,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,10.32,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,10.32,Pays based on 100% of CMS OPPS Rate,10.32,22.44,23.1,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,87070,BORDETELLA CULTURE,300,27.5,5.86,Not Separately reimbursable,18.7,68% of total billed charges,18.7,68% of total billed charges,13.75,50% of total billed charges,17.23,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,11.64,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,8.62,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,8.62,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,8.62,Pays based on 100% of CMS OPPS Rate,8.62,18.7,19.25,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,82274,FECAL OCCULT BLOOD IA,300,49.5,10.83,Not Separately reimbursable,33.66,68% of total billed charges,33.66,68% of total billed charges,24.75,50% of total billed charges,31.84,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,21.49,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,15.92,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,15.92,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,15.92,Pays based on 100% of CMS OPPS Rate,15.92,33.66,34.65,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,87804,INFLUENZA A/B OIA,300,37.5,11.25,Not Separately reimbursable,25.5,68% of total billed charges,25.5,68% of total billed charges,18.75,50% of total billed charges,33.1,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,22.34,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,16.55,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,16.55,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,16.55,Pays based on 100% of CMS OPPS Rate,16.55,33.1,26.25,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,87880,RAPID STREP A,300,37.5,11.24,Not Separately reimbursable,25.5,68% of total billed charges,25.5,68% of total billed charges,18.75,50% of total billed charges,33.06,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,22.32,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,16.53,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,16.53,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,16.53,Pays based on 100% of CMS OPPS Rate,16.53,33.06,26.25,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,87086,URINE CULTURE,300,22,5.49,Not Separately reimbursable,14.96,68% of total billed charges,14.96,68% of total billed charges,11,50% of total billed charges,16.14,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,10.89,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,8.07,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,8.07,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,8.07,Pays based on 100% of CMS OPPS Rate,8.07,16.14,15.4,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,P9016,BLOOD PROCESSING & STORAGE-EA,390,100.5,9.6,Not Separately reimbursable,68.34,68% of total billed charges,76.38,76% of total billed charges,50.25,50% of total billed charges,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,244.1,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,180.82,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,180.82,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,180.82,Pays based on 100% of CMS OPPS Rate,50.25,244.1,70.35,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,P9035,PLATELETS PHERESIS LEUKOCYTE R,390,1490.73,40,Not Separately reimbursable,1013.7,68% of total billed charges,1132.95,76% of total billed charges,745.37,50% of total billed charges,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,637.64,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,472.33,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,472.33,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,472.33,Pays based on 100% of CMS OPPS Rate,472.33,1132.95,1043.511,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,36430,TRANSFUSION-BLOOD /DAY,391,291.5,37.87,Not Separately reimbursable,198.22,68% of total billed charges,221.54,76% of total billed charges,145.75,50% of total billed charges,72.84,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,530.02,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,392.61,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,392.61,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,392.61,Pays based on 100% of CMS OPPS Rate,72.84,530.02,204.05,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,86900,ABO TYPE,300,32,2.03,Not Separately reimbursable,21.76,68% of total billed charges,21.76,68% of total billed charges,16,50% of total billed charges,5.98,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,155.96,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,115.53,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,115.53,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,115.53,Pays based on 100% of CMS OPPS Rate,5.98,155.96,22.4,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,82803,ARTERIAL BLOOD GAS,300,60.5,17.73,Not Separately reimbursable,41.14,68% of total billed charges,41.14,68% of total billed charges,30.25,50% of total billed charges,52.14,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,35.19,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,26.07,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,26.07,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,26.07,Pays based on 100% of CMS OPPS Rate,26.07,52.14,42.35,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,P9017,FRESH FROZEN PLASMA PER UNIT,390,253.2,33.52,Not Separately reimbursable,172.18,68% of total billed charges,192.43,76% of total billed charges,126.6,50% of total billed charges,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,107.94,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,79.95,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,79.95,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,79.95,Pays based on 100% of CMS OPPS Rate,79.95,192.43,177.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,86901,RH TYPE,300,32,2.03,Not Separately reimbursable,21.76,68% of total billed charges,21.76,68% of total billed charges,16,50% of total billed charges,5.98,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,48.96,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,36.27,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,36.27,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,36.27,Pays based on 100% of CMS OPPS Rate,5.98,48.96,22.4,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,86920,COMP TEST-IMMEDIATE SPIN,300,103.5,22.83,Not Separately reimbursable,70.38,68% of total billed charges,70.38,68% of total billed charges,51.75,50% of total billed charges,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,208.54,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,154.47,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,154.47,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,154.47,Pays based on 100% of CMS OPPS Rate,51.75,208.54,72.45,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,80143,ACETAMINOPHEN,301,56,12.68,Not Separately reimbursable,38.08,68% of total billed charges,38.08,68% of total billed charges,28,50% of total billed charges,37.28,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,25.16,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,18.64,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,18.64,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,18.64,Pays based on 100% of CMS OPPS Rate,18.64,38.08,39.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,80320,SERUM ETHANOL,300,34.5,0.01,Not Separately reimbursable,23.46,68% of total billed charges,23.46,68% of total billed charges,17.25,50% of total billed charges,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,0,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,17.25,23.46,24.15,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,82150,AMYLASE,300,21,4.41,Not Separately reimbursable,14.28,68% of total billed charges,14.28,68% of total billed charges,10.5,50% of total billed charges,12.96,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,8.75,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,6.48,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,6.48,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,6.48,Pays based on 100% of CMS OPPS Rate,6.48,14.28,14.7,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,83880,B-NATRUIRETIC PEPTIDE-PLASMA,300,88,26.7,Not Separately reimbursable,59.84,68% of total billed charges,59.84,68% of total billed charges,44,50% of total billed charges,78.52,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,53,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,39.26,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,39.26,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,39.26,Pays based on 100% of CMS OPPS Rate,39.26,78.52,61.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,80048,BAS. METABOLIC PANEL,300,26.5,5.75,Not Separately reimbursable,18.02,68% of total billed charges,18.02,68% of total billed charges,13.25,50% of total billed charges,16.92,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,11.42,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,8.46,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,8.46,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,8.46,Pays based on 100% of CMS OPPS Rate,8.46,18.02,18.55,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,82248,BILIRUBIN DIR.,300,15.5,3.41,Not Separately reimbursable,10.54,68% of total billed charges,10.54,68% of total billed charges,7.75,50% of total billed charges,10.03,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,6.78,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,5.02,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,5.02,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,5.02,Pays based on 100% of CMS OPPS Rate,5.02,10.54,10.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,82247,BILIRUBIN TOTAL,300,15.5,3.41,Not Separately reimbursable,10.54,68% of total billed charges,10.54,68% of total billed charges,7.75,50% of total billed charges,10.03,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,6.78,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,5.02,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,5.02,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,5.02,Pays based on 100% of CMS OPPS Rate,5.02,10.54,10.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,82140,AMMONIA (SERUM),300,46.5,9.91,Not Separately reimbursable,31.62,68% of total billed charges,31.62,68% of total billed charges,23.25,50% of total billed charges,29.14,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,19.67,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,14.57,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,14.57,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,14.57,Pays based on 100% of CMS OPPS Rate,14.57,31.62,32.55,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,80156,CARBAMAZEPINE,300,46.5,9.91,Not Separately reimbursable,31.62,68% of total billed charges,31.62,68% of total billed charges,23.25,50% of total billed charges,29.14,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,19.67,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,14.57,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,14.57,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,14.57,Pays based on 100% of CMS OPPS Rate,14.57,31.62,32.55,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,80053,COM. METABOLIC PANEL,300,33,7.18,Not Separately reimbursable,22.44,68% of total billed charges,22.44,68% of total billed charges,16.5,50% of total billed charges,21.12,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,14.26,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,10.56,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,10.56,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,10.56,Pays based on 100% of CMS OPPS Rate,10.56,22.44,23.1,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,82533,CORTISOL (TOTAL),300,52,11.08,Not Separately reimbursable,35.36,68% of total billed charges,35.36,68% of total billed charges,26,50% of total billed charges,32.6,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,22.01,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,16.3,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,16.3,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,16.3,Pays based on 100% of CMS OPPS Rate,16.3,35.36,36.4,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,82550,CREATINE KINASE (CK),300,21,4.43,Not Separately reimbursable,14.28,68% of total billed charges,14.28,68% of total billed charges,10.5,50% of total billed charges,13.02,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,8.79,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,6.51,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,6.51,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,6.51,Pays based on 100% of CMS OPPS Rate,6.51,14.28,14.7,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,82553,CK-MB,300,36.5,7.85,Not Separately reimbursable,24.82,68% of total billed charges,24.82,68% of total billed charges,18.25,50% of total billed charges,23.1,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,15.59,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,11.55,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,11.55,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,11.55,Pays based on 100% of CMS OPPS Rate,11.55,24.82,25.55,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,82570,CREATININE-URINE (RANDOM),300,16.5,3.52,Not Separately reimbursable,11.22,68% of total billed charges,11.22,68% of total billed charges,8.25,50% of total billed charges,10.36,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,6.99,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,5.18,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,5.18,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,5.18,Pays based on 100% of CMS OPPS Rate,5.18,11.22,11.55,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,82565,CREATININE-SERUM,300,16.5,3.48,Not Separately reimbursable,11.22,68% of total billed charges,11.22,68% of total billed charges,8.25,50% of total billed charges,10.24,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,6.91,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,5.12,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,5.12,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,5.12,Pays based on 100% of CMS OPPS Rate,5.12,11.22,11.55,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,80185,DILANTIN,300,42,9.01,Not Separately reimbursable,28.56,68% of total billed charges,28.56,68% of total billed charges,21,50% of total billed charges,26.5,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,17.89,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,13.25,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,13.25,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,13.25,Pays based on 100% of CMS OPPS Rate,13.25,28.56,29.4,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,82948,ACCU-CHECK BLOOD SUGAR,300,10,3.43,Not Separately reimbursable,6.8,68% of total billed charges,6.8,68% of total billed charges,5,50% of total billed charges,10.08,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,6.8,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,5.04,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,5.04,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,5.04,Pays based on 100% of CMS OPPS Rate,5,10.08,7,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,82728,FERRITIN,300,43,9.27,Not Separately reimbursable,29.24,68% of total billed charges,29.24,68% of total billed charges,21.5,50% of total billed charges,27.26,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,18.4,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,13.63,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,13.63,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,13.63,Pays based on 100% of CMS OPPS Rate,13.63,29.24,30.1,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,84439,FREE T-4,300,29,6.13,Not Separately reimbursable,19.72,68% of total billed charges,19.72,68% of total billed charges,14.5,50% of total billed charges,18.04,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,12.18,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,9.02,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,9.02,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,9.02,Pays based on 100% of CMS OPPS Rate,9.02,19.72,20.3,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,82977,GAMMA GLUTAMUL TRAN.,300,23.5,4.9,Not Separately reimbursable,15.98,68% of total billed charges,15.98,68% of total billed charges,11.75,50% of total billed charges,14.4,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,9.72,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,7.2,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,7.2,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,7.2,Pays based on 100% of CMS OPPS Rate,7.2,15.98,16.45,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,84703,SERUM PREGNANCY TEST,300,24.5,5.11,Not Separately reimbursable,16.66,68% of total billed charges,16.66,68% of total billed charges,12.25,50% of total billed charges,15.04,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,10.15,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,7.52,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,7.52,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,7.52,Pays based on 100% of CMS OPPS Rate,7.52,16.66,17.15,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,83036,HEMOGLOBIN A I C,300,31,6.6,Not Separately reimbursable,21.08,68% of total billed charges,21.08,68% of total billed charges,15.5,50% of total billed charges,19.42,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,13.11,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,9.71,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,9.71,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,9.71,Pays based on 100% of CMS OPPS Rate,9.71,21.08,21.7,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,80076,HEPATIC FUNCTION-LFT,300,25.5,5.56,Not Separately reimbursable,17.34,68% of total billed charges,17.34,68% of total billed charges,12.75,50% of total billed charges,16.34,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,11.03,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,8.17,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,8.17,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,8.17,Pays based on 100% of CMS OPPS Rate,8.17,17.34,17.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,80074,HEPATITIS PANEL,300,150,32.39,Not Separately reimbursable,102,68% of total billed charges,102,68% of total billed charges,75,50% of total billed charges,95.26,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,64.3,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,47.63,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,47.63,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,47.63,Pays based on 100% of CMS OPPS Rate,47.63,102,105,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,83550,IRON BINDING CAPACI.,300,27.5,5.94,Not Separately reimbursable,18.7,68% of total billed charges,18.7,68% of total billed charges,13.75,50% of total billed charges,17.48,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,11.8,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,8.74,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,8.74,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,8.74,Pays based on 100% of CMS OPPS Rate,8.74,18.7,19.25,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,83605,LACTIC ACID,300,52,7.87,Not Separately reimbursable,35.36,68% of total billed charges,35.36,68% of total billed charges,26,50% of total billed charges,23.14,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,15.62,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,11.57,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,11.57,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,11.57,Pays based on 100% of CMS OPPS Rate,11.57,35.36,36.4,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,83690,LIPASE,300,22,4.69,Not Separately reimbursable,14.96,68% of total billed charges,14.96,68% of total billed charges,11,50% of total billed charges,13.78,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,9.3,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,6.89,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,6.89,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,6.89,Pays based on 100% of CMS OPPS Rate,6.89,14.96,15.4,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,80061,LIPID PANEL,300,42,9.11,Not Separately reimbursable,28.56,68% of total billed charges,28.56,68% of total billed charges,21,50% of total billed charges,26.78,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,18.08,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,13.39,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,13.39,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,13.39,Pays based on 100% of CMS OPPS Rate,13.39,28.56,29.4,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,82172,APOLIPOPROTEIN,300,48.5,14.34,Not Separately reimbursable,32.98,68% of total billed charges,32.98,68% of total billed charges,24.25,50% of total billed charges,42.18,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,28.47,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,21.09,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,21.09,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,21.09,Pays based on 100% of CMS OPPS Rate,21.09,42.18,33.95,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,83735,MAGNESIUM,300,21,4.56,Not Separately reimbursable,14.28,68% of total billed charges,14.28,68% of total billed charges,10.5,50% of total billed charges,13.4,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,9.05,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,6.7,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,6.7,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,6.7,Pays based on 100% of CMS OPPS Rate,6.7,14.28,14.7,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,82542,OXCARBAZEPINE (TRILEPTAL),300,57.5,16.38,Not Separately reimbursable,39.1,68% of total billed charges,39.1,68% of total billed charges,28.75,50% of total billed charges,48.18,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,32.52,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,24.09,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,24.09,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,24.09,Pays based on 100% of CMS OPPS Rate,24.09,48.18,40.25,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,84100,PHOSPHOROUS,300,15.5,3.22,Not Separately reimbursable,10.54,68% of total billed charges,10.54,68% of total billed charges,7.75,50% of total billed charges,9.48,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,6.4,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,4.74,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,4.74,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,4.74,Pays based on 100% of CMS OPPS Rate,4.74,10.54,10.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,84132,POTASSIUM-SERUM,300,14.5,3.24,Not Separately reimbursable,9.86,68% of total billed charges,9.86,68% of total billed charges,7.25,50% of total billed charges,9.52,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,6.43,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,4.76,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,4.76,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,4.76,Pays based on 100% of CMS OPPS Rate,4.76,9.86,10.15,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,84153,PSA TOTAL (DIAGNOSTIC),300,58.5,12.51,Not Separately reimbursable,39.78,68% of total billed charges,39.78,68% of total billed charges,29.25,50% of total billed charges,36.78,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,24.83,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,18.39,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,18.39,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,18.39,Pays based on 100% of CMS OPPS Rate,18.39,39.78,40.95,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,G0103,PSA SCREENING,300,58.5,13.13,Not Separately reimbursable,39.78,68% of total billed charges,39.78,68% of total billed charges,29.25,50% of total billed charges,38.61,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,26.07,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,19.31,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,19.31,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,19.31,Pays based on 100% of CMS OPPS Rate,19.31,39.78,40.95,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,80179,SALICYLATE,301,56,12.68,Not Separately reimbursable,38.08,68% of total billed charges,38.08,68% of total billed charges,28,50% of total billed charges,37.28,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,25.16,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,18.64,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,18.64,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,18.64,Pays based on 100% of CMS OPPS Rate,18.64,38.08,39.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,83540,SERUM IRON,300,21,4.4,Not Separately reimbursable,14.28,68% of total billed charges,14.28,68% of total billed charges,10.5,50% of total billed charges,12.94,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,8.73,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,6.47,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,6.47,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,6.47,Pays based on 100% of CMS OPPS Rate,6.47,14.28,14.7,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,80069,RENAL FUNCTION PANEL,300,27.5,5.9,Not Separately reimbursable,18.7,68% of total billed charges,18.7,68% of total billed charges,13.75,50% of total billed charges,17.36,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,11.72,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,8.68,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,8.68,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,8.68,Pays based on 100% of CMS OPPS Rate,8.68,18.7,19.25,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,84410,TESTOSTERONE-TOTAL,300,81.5,34.87,Not Separately reimbursable,55.42,68% of total billed charges,55.42,68% of total billed charges,40.75,50% of total billed charges,102.56,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,69.23,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,51.28,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,51.28,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,51.28,Pays based on 100% of CMS OPPS Rate,40.75,102.56,57.05,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,80197,TACROLIMUS,300,43,9.34,Not Separately reimbursable,29.24,68% of total billed charges,29.24,68% of total billed charges,21.5,50% of total billed charges,27.46,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,18.54,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,13.73,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,13.73,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,13.73,Pays based on 100% of CMS OPPS Rate,13.73,29.24,30.1,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,84484,TROPONIN I-QUANT,300,31,8.48,Not Separately reimbursable,21.08,68% of total billed charges,21.08,68% of total billed charges,15.5,50% of total billed charges,24.94,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,16.83,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,12.47,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,12.47,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,12.47,Pays based on 100% of CMS OPPS Rate,12.47,24.94,21.7,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,87491,URINE-GC&CHLAMYDIA W/TRICH,300,88,23.86,Not Separately reimbursable,59.84,68% of total billed charges,59.84,68% of total billed charges,44,50% of total billed charges,70.18,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,47.37,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,35.09,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,35.09,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,35.09,Pays based on 100% of CMS OPPS Rate,35.09,70.18,61.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,80164,VALPROIC ACID LEVEL,300,43,9.21,Not Separately reimbursable,29.24,68% of total billed charges,29.24,68% of total billed charges,21.5,50% of total billed charges,27.08,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,18.28,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,13.54,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,13.54,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,13.54,Pays based on 100% of CMS OPPS Rate,13.54,29.24,30.1,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,80202,VANCOMYCIN LEVEL,300,43,9.21,Not Separately reimbursable,29.24,68% of total billed charges,29.24,68% of total billed charges,21.5,50% of total billed charges,27.08,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,18.28,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,13.54,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,13.54,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,13.54,Pays based on 100% of CMS OPPS Rate,13.54,29.24,30.1,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,36415,VENOUS COLLECTION,300,54,2.04,Not Separately reimbursable,36.72,68% of total billed charges,36.72,68% of total billed charges,27,50% of total billed charges,17.66,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,11.92,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,8.83,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,8.83,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,8.83,Pays based on 100% of CMS OPPS Rate,8.83,36.72,37.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,82608,VIT B12 UNSAT. BIND,300,45.5,9.74,Not Separately reimbursable,30.94,68% of total billed charges,30.94,68% of total billed charges,22.75,50% of total billed charges,28.64,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,19.33,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,14.32,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,14.32,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,14.32,Pays based on 100% of CMS OPPS Rate,14.32,30.94,31.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,82306,VIT D 25-HYDROXY (CALCIFEDIOL),300,93.5,20.13,Not Separately reimbursable,63.58,68% of total billed charges,63.58,68% of total billed charges,46.75,50% of total billed charges,59.2,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,39.96,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,29.6,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,29.6,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,29.6,Pays based on 100% of CMS OPPS Rate,29.6,63.58,65.45,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,82652,VIT D 1.25 DIHYDROXY,300,121,26.18,Not Separately reimbursable,82.28,68% of total billed charges,82.28,68% of total billed charges,60.5,50% of total billed charges,77,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,51.98,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,38.5,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,38.5,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,38.5,Pays based on 100% of CMS OPPS Rate,38.5,82.28,84.7,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,87661,NU SWAB VAGINITIS PLUS,300,673,23.86,Not Separately reimbursable,457.64,68% of total billed charges,457.64,68% of total billed charges,336.5,50% of total billed charges,70.18,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,47.37,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,35.09,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,35.09,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,35.09,Pays based on 100% of CMS OPPS Rate,35.09,457.64,471.1,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,85025,CBC W/AUTO DIFF,300,24.5,5.28,Not Separately reimbursable,16.66,68% of total billed charges,16.66,68% of total billed charges,12.25,50% of total billed charges,15.54,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,10.49,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,7.77,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,7.77,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,7.77,Pays based on 100% of CMS OPPS Rate,7.77,16.66,17.15,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,85027,CBC W/MANUAL DIFF,300,21,4.4,Not Separately reimbursable,14.28,68% of total billed charges,14.28,68% of total billed charges,10.5,50% of total billed charges,12.94,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,8.73,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,6.47,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,6.47,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,6.47,Pays based on 100% of CMS OPPS Rate,6.47,14.28,14.7,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,85610,PROTHROMBIN TIME,300,,2.92,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,0,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,N/A,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,85730,THROMBOPLASTIN INHIBITION,300,,4.09,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,0,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,N/A,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,85651,SEDIMENTATION RATE,300,11,2.9,Not Separately reimbursable,7.48,68% of total billed charges,7.48,68% of total billed charges,5.5,50% of total billed charges,8.53,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,5.76,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,4.27,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,4.27,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,4.27,Pays based on 100% of CMS OPPS Rate,4.27,8.53,7.7,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,82746,SERUM FOLATE,300,46.5,10,Not Separately reimbursable,31.62,68% of total billed charges,31.62,68% of total billed charges,23.25,50% of total billed charges,29.4,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,19.85,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,14.7,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,14.7,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,14.7,Pays based on 100% of CMS OPPS Rate,14.7,31.62,32.55,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,80198,THEOPHYLLIN LEVEL,300,45.5,9.62,Not Separately reimbursable,30.94,68% of total billed charges,30.94,68% of total billed charges,22.75,50% of total billed charges,28.28,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,19.09,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,14.14,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,14.14,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,14.14,Pays based on 100% of CMS OPPS Rate,14.14,30.94,31.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,84443,THYROID STIM.HORMONE,300,53,11.42,Not Separately reimbursable,36.04,68% of total billed charges,36.04,68% of total billed charges,26.5,50% of total billed charges,33.6,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,22.68,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,16.8,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,16.8,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,16.8,Pays based on 100% of CMS OPPS Rate,16.8,36.04,37.1,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,87591,N GONORR.-DNA PROBE,300,111.5,23.86,Not Separately reimbursable,75.82,68% of total billed charges,75.82,68% of total billed charges,55.75,50% of total billed charges,70.18,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,47.37,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,35.09,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,35.09,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,35.09,Pays based on 100% of CMS OPPS Rate,35.09,75.82,78.05,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,87635,INFECT AGNT DETECTION COVID-19,306,130,51.31,Not Separately reimbursable,88.4,68% of total billed charges,88.4,68% of total billed charges,65,50% of total billed charges,102.62,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,36.94,Pays based on 100% of MO Medicaid Fee Schedule,69.27,Pays based on 135% of CMS OPPS Rate,37.68,Pays based on 102% of MO Medicaid Rate,51.31,Pays based on 100% of CMS OPPS Rate,37.68,Pays based on 102% of MO Medicaid Fee Schedule,36.94,Pays based on 100% of MO Medicaid Fee Schedule,51.31,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,36.94,Pays based on 100% of MO Medicaid Fee Schedule,51.31,Pays based on 100% of CMS OPPS Rate,36.94,102.62,91,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,82043,MICROALBUMIN,300,19,3.93,Not Separately reimbursable,12.92,68% of total billed charges,12.92,68% of total billed charges,9.5,50% of total billed charges,11.56,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,7.8,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,5.78,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,5.78,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,5.78,Pays based on 100% of CMS OPPS Rate,5.78,12.92,13.3,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,86592,RAPID PLASMA REAGIN,300,13.5,2.9,Not Separately reimbursable,9.18,68% of total billed charges,9.18,68% of total billed charges,6.75,50% of total billed charges,8.53,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,5.76,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,4.27,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,4.27,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,4.27,Pays based on 100% of CMS OPPS Rate,4.27,9.18,9.45,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,87807,RSV-RESP SYNCYTIAL V,300,37.5,8.91,Not Separately reimbursable,25.5,68% of total billed charges,25.5,68% of total billed charges,18.75,50% of total billed charges,26.2,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,17.69,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,13.1,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,13.1,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,13.1,Pays based on 100% of CMS OPPS Rate,13.1,26.2,26.25,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,86922,TYPE & CROSSMATCH-AHG,300,111.5,24.39,Not Separately reimbursable,75.82,68% of total billed charges,75.82,68% of total billed charges,55.75,50% of total billed charges,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,208.54,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,154.47,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,154.47,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,154.47,Pays based on 100% of CMS OPPS Rate,55.75,208.54,78.05,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,80307,TOXOCOLOGY PANEL SCREENING,300,734,42.26,Not Separately reimbursable,499.12,68% of total billed charges,499.12,68% of total billed charges,367,50% of total billed charges,124.28,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,83.89,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,62.14,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,62.14,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,62.14,Pays based on 100% of CMS OPPS Rate,62.14,499.12,513.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,80305,DRUG TEST OPTICAL OBSRVTN IN H,300,734,8.57,Not Separately reimbursable,499.12,68% of total billed charges,499.12,68% of total billed charges,367,50% of total billed charges,25.2,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,17.01,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,12.6,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,12.6,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,12.6,Pays based on 100% of CMS OPPS Rate,12.6,499.12,513.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OCCUPATIONAL THERAPY,97165,OT EVALUATION-LOW COMPLEXITY,434,330,78.36,Not Separately reimbursable,224.4,68% of total billed charges,250.8,76% of total billed charges,150,pays based on per visit rate ,188.6,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,127.31,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,94.3,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,94.3,Pays based on 100% of CMS OPPS Rate,55,Pays based on per visit rate,N/A,Not Separately reimbursable,94.3,Pays based on 100% of CMS OPPS Rate,55,250.8,231,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OCCUPATIONAL THERAPY,97166,OT EVALUATION-MODERATE COMPLEX,434,330,78.36,Not Separately reimbursable,224.4,68% of total billed charges,250.8,76% of total billed charges,150,pays based on per visit rate ,188.6,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,127.31,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,94.3,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,94.3,Pays based on 100% of CMS OPPS Rate,55,Pays based on per visit rate,N/A,Not Separately reimbursable,94.3,Pays based on 100% of CMS OPPS Rate,55,250.8,231,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OCCUPATIONAL THERAPY,97167,OT EVALUATION-HIGH COMPLEXITY,434,330,78.36,Not Separately reimbursable,224.4,68% of total billed charges,250.8,76% of total billed charges,150,pays based on per visit rate ,188.6,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,127.31,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,94.3,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,94.3,Pays based on 100% of CMS OPPS Rate,55,Pays based on per visit rate,N/A,Not Separately reimbursable,94.3,Pays based on 100% of CMS OPPS Rate,55,250.8,231,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OCCUPATIONAL THERAPY,97168,OT RE-EVALUATION,434,136.5,53.79,Not Separately reimbursable,92.82,68% of total billed charges,103.74,76% of total billed charges,150,pays based on per visit rate ,129.32,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,87.29,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,64.66,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,64.66,Pays based on 100% of CMS OPPS Rate,55,Pays based on per visit rate,N/A,Not Separately reimbursable,64.66,Pays based on 100% of CMS OPPS Rate,55,150,95.55,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OCCUPATIONAL THERAPY,97532,COGNITIVE TRAINING/15 MIN,430,35,N/A,Not Separately reimbursable,23.8,68% of total billed charges,26.6,76% of total billed charges,150,pays based on per visit rate ,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,0,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,55,Pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,23.8,150,24.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OCCUPATIONAL THERAPY,97535,COMMUNITY/WORK RE-INTEGRATION,430,106,25.44,Not Separately reimbursable,72.08,68% of total billed charges,80.56,76% of total billed charges,150,pays based on per visit rate ,60.34,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,40.73,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,30.17,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,30.17,Pays based on 100% of CMS OPPS Rate,55,Pays based on per visit rate,N/A,Not Separately reimbursable,30.17,Pays based on 100% of CMS OPPS Rate,30.17,150,74.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OCCUPATIONAL THERAPY,97703,DEVELOPMENTAL TESTING,430,275,N/A,Not Separately reimbursable,187,68% of total billed charges,209,76% of total billed charges,150,pays based on per visit rate ,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,0,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,55,Pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,55,209,192.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OCCUPATIONAL THERAPY,97032,E-STIMULATION,430,106,10.42,Not Separately reimbursable,72.08,68% of total billed charges,80.56,76% of total billed charges,150,pays based on per visit rate ,27,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,18.23,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,13.5,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,13.5,Pays based on 100% of CMS OPPS Rate,55,Pays based on per visit rate,N/A,Not Separately reimbursable,13.5,Pays based on 100% of CMS OPPS Rate,13.5,150,74.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OCCUPATIONAL THERAPY,97750,PHYSICAL PERFORMANCE TEST,430,275,25.96,Not Separately reimbursable,187,68% of total billed charges,209,76% of total billed charges,150,pays based on per visit rate ,62.62,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,42.27,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,31.31,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,31.31,Pays based on 100% of CMS OPPS Rate,55,Pays based on per visit rate,N/A,Not Separately reimbursable,31.31,Pays based on 100% of CMS OPPS Rate,31.31,209,192.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OCCUPATIONAL THERAPY,97016,VASOPNEUMATIC DEVICE,430,65,9.2,Not Separately reimbursable,44.2,68% of total billed charges,49.4,76% of total billed charges,150,pays based on per visit rate ,21.78,Pays based on 200% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,14.7,Pays based on 135% of CMS OPPS Rate,N/A,Not Separately reimbursable,10.89,Pays based on 100% of CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,10.89,Pays based on 100% of CMS OPPS Rate,55,Pays based on per visit rate,N/A,Not Separately reimbursable,10.89,Pays based on 100% of CMS OPPS Rate,10.89,150,45.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OCCUPATIONAL THERAPY,97545,WORK HARDENING,430,210.5,130.16,Not Separately reimbursable,143.14,68% of total billed charges,159.98,76% of total billed charges,150,pays based on per visit rate ,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,0,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,55,Pays based on per visit rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,55,159.98,147.35,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,BEHAVIORAL,90832,"Psychotherapy, 30 minute",900,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,BEHAVIORAL,90834,"Psychotherapy, 45 minutes",900,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,BEHAVIORAL,90837,"Psychotherapy, 60 minutes",900,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,BEHAVIORAL,90846,"Family psychotherapy, not including patient, 50 minutes",900,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,BEHAVIORAL,90847,"Family psychotherapy, including patient, 50 min",900,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,BEHAVIORAL,90853,Group psychotherapy,900,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OFFICE VISIT,99243,"Patient office consultation, typically 40 min",761,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OFFICE VISIT,99244,"Patient office consultation, typically 60 min",761,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,80055,Obstetric blood test panel,300,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,81000,Manual urinalysis test with examination using microscope,300,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,81001,Manual urinalysis test with examination using microscope,300,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,81002,Automated urinalysis test,300,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,LAB,81003,Prostate specific antigen,300,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,77065,Mammography of one breast,403,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,77066,Mammography of both breasts,403,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,77067,"Mammography, screening, bilateral",403,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,RADIOLOGY,19120,"Removal of 1 or more breast growth, open procedure",360,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OUTPATIENT SERVICES,29826,Shaving of shoulder bone using an endoscope,360,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OUTPATIENT SERVICES,29881,Removal of one knee cartilage using an endoscope,360,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OUTPATIENT SERVICES,42820,Removal of tonsils and adenoid glands patient younger than age 12,360,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OUTPATIENT SERVICES,43235,"Diagnostic examination of esophagus, stomach, and/or upper small bowel using an endoscop",360,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OUTPATIENT SERVICES,45385,Removal of polyps or growths of large bowel using an endoscope,360,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OUTPATIENT SERVICES,45391,Ultrasound examination of lower large bowel using an endoscope,360,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OUTPATIENT SERVICES,49505,Repair of groin hernia patient age 5 or older,360,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OUTPATIENT SERVICES,55866,Surgical removal of prostate and surrounding lymph nodes using an endoscope,360,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OUTPATIENT SERVICES,59400,"Routine obstetric care for vaginal delivery, including pre-and post-delivery care",720,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OUTPATIENT SERVICES,59510,"Routine obstetric care for cesarean delivery, including pre-and post-delivery care",720,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OUTPATIENT SERVICES,59610,Routine obstetric care for vaginal delivery after prior cesarean delivery including pre-and post-delivery care,720,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OUTPATIENT SERVICES,62323,Injection of substance into spinal canal of lower back or sacrum using imaging guidanc,360,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OUTPATIENT SERVICES,62322,Injection of substance into spinal canal of lower back or sacrum using imaging guidanc,360,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OUTPATIENT SERVICES,64483,Injections of anesthetic and/or steroid drug into lower or sacral spine nerve root using imaging guidance,360,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OUTPATIENT SERVICES,66821,Removal of recurring cataract in lens capsule using laser,360,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,OUTPATIENT SERVICES,66984,Removal of cataract with insertion of lens,360,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,ECCG,93000,"Electrocardiogram, routine, with interpretation and report",730,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,CARDIOLOGY,93452,Insertion of catheter into left heart for diagnosis,480,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Outpatient Medical Services,SLEEP STUDY,95810,Sleep study,920,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Inpatient Medical Services,INPATIENT PROCEDURES,216,Cardiac valve and other major cardiothoracic procedures with cardiac catheterization with major complications or comorbidities,100,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Inpatient Medical Services,INPATIENT PROCEDURES,460,Spinal fusion except cervical without major comorbid conditions or complications,100,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Inpatient Medical Services,INPATIENT PROCEDURES,470,Major joint replacement or reattachment of lower extremity without major comorbid conditions or complications,100,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Inpatient Medical Services,INPATIENT PROCEDURES,473,Cervical spinal fusion without comorbid conditions or major comorbid conditions or complications,100,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
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,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,