hospital_name,last_updated_on,version,hospital_location,hospital_address,license_number|[state],"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.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
yuma_disctrict_hospital,1/1/2024,2.0.0,yuma_disctrict_hospital,"1000 W 8th Ave Yuma, CO 80759",84-0420041 | CO,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SERVICE DESCRIPTION,CATEGORY,BILLING MSDRG | CPT | HCPCS,ITEM/SERVICE DESCRIPTION,BILLING REVENUE CODE,GROSS CHARGES,AETNA PLAN,REIMBURSEMENT METHOD,AETNA MEDICARE PLAN,REIMBURSEMENT METHOD,ALIGN NETWORKS PLAN,REIMBURSEMENT METHOD,ANTHEM BLUE CROSS PLAN,REIMBURSEMENT METHOD,ANTHEM BLUE CROSS WORKERS COMP PLAN,REIMBURSEMENT METHOD,ANTHEM BLUE MEDICARE PLAN,REIMBURSEMENT METHOD,CIGNA PLAN,REIMBURSEMENT METHOD,COFINITY PREFERRED PLAN,REIMBURSEMENT METHOD,CORVEL PLAN,REIMBURSEMENT METHOD,FRIDAY HEALTH PLAN PLAN,REIMBURSEMENT METHOD,HUMANA CHOICECARE PLAN,REIMBURSEMENT METHOD,MEDICARE PLAN,REIMBURSEMENT METHOD,MEDRISK PREFERRED PLAN,REIMBURSEMENT METHOD,MIDLANDS CHOICE PLAN,REIMBURSEMENT METHOD,MULTIPLAN OPEN ACCESS PLAN,REIMBURSEMENT METHOD,MULTIPLAN PPO PLAN,REIMBURSEMENT METHOD,ROCKY MOUNTAIN HEALTH PLAN PLAN,REIMBURSEMENT METHOD,THREE RIVERS PLAN,REIMBURSEMENT METHOD,TRIWEST PLAN,REIMBURSEMENT METHOD,UC HEALTH PLAN PLAN,REIMBURSEMENT METHOD,UHC MEDICARE PLAN,REIMBURSEMENT METHOD,UNITED HEALTHCARE PLAN,REIMBURSEMENT METHOD,De-Identified Minimum Negotiated Rate,De-Identified Maximum Negotiated Rate,DISCOUNTED CASH PRICE 
Outpatient Medical Services,Physician Services,65205,"REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL SUPERFICIAL ProFee",981,$120.00 ,$58.79 ,135% of 2011 CMS physician fee schedule,$29.64 ,100% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$46.39 ,100% of the Blue Cross physician fee schedule,$58.10 ,100% of Work Comp physician fee schedule. Multiple discount rules may apply,$29.64 ,100% CMS Medicare physician fee schedule ,$42.98 ,145% CMS Medicare physician fee schedule ,$114.00 ,95% of total billed charges for physician setting,,Not separately reimbursible. Not contracted for physician rates,$37.01 ,100% CMS Medicare physician fee schedule ,$42.38 ,100% Humana physician fee schedule,$29.64 ,100% CMS Medicare physician fee schedule ,$120.00 ,Not separately reimbursible. Not contracted for physician rates,,Not separately reimbursable per contract terms,$72.00 ,60% of total billed charges for physician settings,$72.00 ,60% of total billed charges for physician settings,$41.50 ,140% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$29.64 ,100% CMS Medicare physician fee schedule ,$114.00 ,95% of total billed charges,$29.64 ,100% CMS Medicare physician fee schedule ,$36.98 ,124.753% CMS Medicare physician fee schedule ,$29.64 ,$120.00 ,$90.00 
Outpatient Medical Services,Physician Services,69209,"REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL ProFee",981,$64.00 ,,Not separately reimbursable per contract terms,$16.04 ,100% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$17.61 ,100% of the Blue Cross physician fee schedule,$28.00 ,100% of Work Comp physician fee schedule. Multiple discount rules may apply,$16.04 ,100% CMS Medicare physician fee schedule ,$23.26 ,145% CMS Medicare physician fee schedule ,$60.80 ,95% of total billed charges for physician setting,,Not separately reimbursible. Not contracted for physician rates,$20.25 ,100% CMS Medicare physician fee schedule ,$20.82 ,100% Humana physician fee schedule,$16.04 ,100% CMS Medicare physician fee schedule ,$64.00 ,Not separately reimbursible. Not contracted for physician rates,,Not separately reimbursable per contract terms,$38.40 ,60% of total billed charges for physician settings,$38.40 ,60% of total billed charges for physician settings,$22.46 ,140% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$16.04 ,100% CMS Medicare physician fee schedule ,$60.80 ,95% of total billed charges,$16.04 ,100% CMS Medicare physician fee schedule ,$20.01 ,124.753% CMS Medicare physician fee schedule ,$16.04 ,$64.00 ,$48.00 
Outpatient Medical Services,Physician Services,99282,EMERGENCY ROOM LIMITED SERVICE ProFee,981,$450.00 ,$54.76 ,135% of 2011 CMS physician fee schedule,$42.82 ,100% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$52.83 ,100% of the Blue Cross physician fee schedule,$68.88 ,100% of Work Comp physician fee schedule. Multiple discount rules may apply,$42.82 ,100% CMS Medicare physician fee schedule ,$62.09 ,145% CMS Medicare physician fee schedule ,$427.50 ,95% of total billed charges for physician setting,,Not separately reimbursible. Not contracted for physician rates,$53.05 ,100% CMS Medicare physician fee schedule ,$62.06 ,100% Humana physician fee schedule,$42.82 ,100% CMS Medicare physician fee schedule ,$450.00 ,Not separately reimbursible. Not contracted for physician rates,$69.22 ,100% Midlands Choice physician fee schedule,$42.00 ,100% Multiplan physician fee schedule,$42.00 ,100% Multiplan physician fee schedule,$59.95 ,140% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$42.82 ,100% CMS Medicare physician fee schedule ,$427.50 ,95% of total billed charges,$42.82 ,100% CMS Medicare physician fee schedule ,$53.42 ,124.753% CMS Medicare physician fee schedule ,$42.00 ,$450.00 ,$337.50 
Outpatient Medical Services,Physician Services,99283,"Emergency department visit, moderately severe problem",981,$450.00 ,$82.22 ,135% of 2011 CMS physician fee schedule,$72.80 ,100% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$79.03 ,100% of the Blue Cross physician fee schedule,$103.04 ,100% of Work Comp physician fee schedule. Multiple discount rules may apply,$72.80 ,100% CMS Medicare physician fee schedule ,$105.56 ,145% CMS Medicare physician fee schedule ,$427.50 ,95% of total billed charges for physician setting,,Not separately reimbursible. Not contracted for physician rates,$90.13 ,100% CMS Medicare physician fee schedule ,$92.82 ,100% Humana physician fee schedule,$72.80 ,100% CMS Medicare physician fee schedule ,$450.00 ,Not separately reimbursible. Not contracted for physician rates,$103.66 ,100% Midlands Choice physician fee schedule,$62.81 ,100% Multiplan physician fee schedule,$62.81 ,100% Multiplan physician fee schedule,$101.92 ,140% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$72.80 ,100% CMS Medicare physician fee schedule ,$427.50 ,95% of total billed charges,$72.80 ,100% CMS Medicare physician fee schedule ,$90.82 ,124.753% CMS Medicare physician fee schedule ,$62.81 ,$450.00 ,$337.50 
Outpatient Medical Services,Physician Services,99284,"Emergency department visit, problem of high severity",981,$450.00 ,$154.49 ,135% of 2011 CMS physician fee schedule,$122.89 ,100% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$144.74 ,100% of the Blue Cross physician fee schedule,$189.28 ,100% of Work Comp physician fee schedule. Multiple discount rules may apply,$122.89 ,100% CMS Medicare physician fee schedule ,$178.19 ,145% CMS Medicare physician fee schedule ,$427.50 ,95% of total billed charges for physician setting,,Not separately reimbursible. Not contracted for physician rates,$152.26 ,100% CMS Medicare physician fee schedule ,$170.32 ,100% Humana physician fee schedule,$122.89 ,100% CMS Medicare physician fee schedule ,$450.00 ,Not separately reimbursible. Not contracted for physician rates,$196.66 ,100% Midlands Choice physician fee schedule,$119.14 ,100% Multiplan physician fee schedule,$119.14 ,100% Multiplan physician fee schedule,$172.05 ,140% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$122.89 ,100% CMS Medicare physician fee schedule ,$427.50 ,95% of total billed charges,$122.89 ,100% CMS Medicare physician fee schedule ,$153.31 ,124.753% CMS Medicare physician fee schedule ,$119.14 ,$450.00 ,$337.50 
Outpatient Medical Services,Physician Services,99285,"Emergency department visit, problem with significant threat to life or function",981,$450.00 ,$224.68 ,135% of 2011 CMS physician fee schedule,$178.38 ,100% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$210.46 ,100% of the Blue Cross physician fee schedule,$274.95 ,100% of Work Comp physician fee schedule. Multiple discount rules may apply,$178.38 ,100% CMS Medicare physician fee schedule ,$258.65 ,145% CMS Medicare physician fee schedule ,$427.50 ,95% of total billed charges for physician setting,,Not separately reimbursible. Not contracted for physician rates,$220.93 ,100% CMS Medicare physician fee schedule ,$247.34 ,100% Humana physician fee schedule,$178.38 ,100% CMS Medicare physician fee schedule ,$450.00 ,Not separately reimbursible. Not contracted for physician rates,$289.40 ,100% Midlands Choice physician fee schedule,$175.47 ,100% Multiplan physician fee schedule,$175.47 ,100% Multiplan physician fee schedule,$249.73 ,140% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$178.38 ,100% CMS Medicare physician fee schedule ,$427.50 ,95% of total billed charges,$178.38 ,100% CMS Medicare physician fee schedule ,$222.53 ,124.753% CMS Medicare physician fee schedule ,$175.47 ,$450.00 ,$337.50 
Outpatient Medical Services,Physician Services,99222,Physician Fee- LEVEL 2 ADMIT HOSPTIAL CARE,987,$987.00 ,$180.99 ,135% of 2011 CMS physician fee schedule,$135.82 ,100% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$167.51 ,100% of the Blue Cross physician fee schedule,$217.84 ,100% of Work Comp physician fee schedule. Multiple discount rules may apply,$135.82 ,100% CMS Medicare physician fee schedule ,$196.94 ,145% CMS Medicare physician fee schedule ,$937.65 ,95% of total billed charges for physician setting,,Not separately reimbursible. Not contracted for physician rates,$169.11 ,100% CMS Medicare physician fee schedule ,$197.26 ,100% Humana physician fee schedule,$135.82 ,100% CMS Medicare physician fee schedule ,$987.00 ,Not separately reimbursible. Not contracted for physician rates,$228.72 ,100% Midlands Choice physician fee schedule,$138.70 ,100% Multiplan physician fee schedule,$138.70 ,100% Multiplan physician fee schedule,$190.15 ,140% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$135.82 ,100% CMS Medicare physician fee schedule ,$937.65 ,95% of total billed charges,$135.82 ,100% CMS Medicare physician fee schedule ,$169.44 ,124.753% CMS Medicare physician fee schedule ,$135.82 ,$987.00 ,$740.25 
Outpatient Medical Services,Physician Services,99231,Physician FeeHospital Subsequent Care LEVEL 1 VISIT STABLE IMPROVING,987,$175.00 ,$51.85 ,135% of 2011 CMS physician fee schedule,$38.85 ,100% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$47.67 ,100% of the Blue Cross physician fee schedule,$123.76 ,100% of Work Comp physician fee schedule. Multiple discount rules may apply,$38.85 ,100% CMS Medicare physician fee schedule ,$56.33 ,145% CMS Medicare physician fee schedule ,$166.25 ,95% of total billed charges for physician setting,,Not separately reimbursible. Not contracted for physician rates,$48.33 ,100% CMS Medicare physician fee schedule ,$56.28 ,100% Humana physician fee schedule,$38.85 ,100% CMS Medicare physician fee schedule ,$175.00 ,Not separately reimbursible. Not contracted for physician rates,$65.85 ,100% Midlands Choice physician fee schedule,$39.88 ,100% Multiplan physician fee schedule,$39.88 ,100% Multiplan physician fee schedule,$54.39 ,140% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$38.85 ,100% CMS Medicare physician fee schedule ,$166.25 ,95% of total billed charges,$38.85 ,100% CMS Medicare physician fee schedule ,$48.47 ,124.753% CMS Medicare physician fee schedule ,$38.85 ,$175.00 ,$131.25 
Outpatient Medical Services,Physician Services,99232,Physician Fee-LEVEL 2 VISIT SUBSEQUENT HOSPITAL CARE,987,$292.00 ,$94.88 ,135% of 2011 CMS physician fee schedule,$71.61 ,100% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$88.05 ,100% of the Blue Cross physician fee schedule,$176.40 ,100% of Work Comp physician fee schedule. Multiple discount rules may apply,$71.61 ,100% CMS Medicare physician fee schedule ,$103.83 ,145% CMS Medicare physician fee schedule ,$277.40 ,95% of total billed charges for physician setting,,Not separately reimbursible. Not contracted for physician rates,$89.25 ,100% CMS Medicare physician fee schedule ,$103.57 ,100% Humana physician fee schedule,$71.61 ,100% CMS Medicare physician fee schedule ,$292.00 ,Not separately reimbursible. Not contracted for physician rates,$121.93 ,100% Midlands Choice physician fee schedule,$73.65 ,100% Multiplan physician fee schedule,$73.65 ,100% Multiplan physician fee schedule,$100.25 ,140% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$71.61 ,100% CMS Medicare physician fee schedule ,$277.40 ,95% of total billed charges,$71.61 ,100% CMS Medicare physician fee schedule ,$89.34 ,124.753% CMS Medicare physician fee schedule ,$71.61 ,$292.00 ,$219.00 
Outpatient Medical Services,Physician Services,99238,Physician FeeHOSPITAL  DISCHARGE DAY MGMT,987,$307.00 ,$94.57 ,135% of 2011 CMS physician fee schedule,$72.49 ,100% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$88.91 ,100% of the Blue Cross physician fee schedule,$115.36 ,100% of Work Comp physician fee schedule. Multiple discount rules may apply,$72.49 ,100% CMS Medicare physician fee schedule ,$105.11 ,145% CMS Medicare physician fee schedule ,$291.65 ,95% of total billed charges for physician setting,,Not separately reimbursible. Not contracted for physician rates,$90.51 ,100% CMS Medicare physician fee schedule ,$104.80 ,100% Humana physician fee schedule,$72.49 ,100% CMS Medicare physician fee schedule ,$307.00 ,Not separately reimbursible. Not contracted for physician rates,$122.24 ,100% Midlands Choice physician fee schedule,$74.07 ,100% Multiplan physician fee schedule,$74.07 ,100% Multiplan physician fee schedule,$101.49 ,140% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$72.49 ,100% CMS Medicare physician fee schedule ,$291.65 ,95% of total billed charges,$72.49 ,100% CMS Medicare physician fee schedule ,$90.43 ,124.753% CMS Medicare physician fee schedule ,$72.49 ,$307.00 ,$230.25 
Outpatient Medical Services,Physician Services,99203,"New patient office or other outpatient visit, typically 30 min",510,$983.00 ,$904.36 ,92% of total billed charges for outpatient setting,$540.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,,Not seperately reimbursible per contract terms,$786.40 ,80% of total billed charges for outpatient setting,$540.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$96.95 ,100% of Cigna Behavioral Health fee schedule,$933.85 ,95% of total billed charges for outpatient setting,$737.25 ,75% of total billed charges for outpatient setting,$835.55 ,85% of total billed charges for outpatient setting,$953.51 ,97% of total billed charges for outpatient setting,$540.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$884.70 ,90% of total billed charges for outpatient setting,$953.51 ,97% of total billed charges for outpatient setting,$953.51 ,97% of total billed charges for outpatient setting,$953.51 ,97% of total billed charges for outpatient setting,$35.00 ,100% case rate for treatment room,$884.70 ,90% of total billed charges for outpatient setting,$835.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$933.85 ,90% of total billed charges for outpatient setting,$540.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$914.19 ,93% of total billed charges for outpatient setting,$35.00 ,$953.51 ,$737.25 
Outpatient Medical Services,Physician Services,99204,"New patient office of other outpatient visit, typically 45 min",510,$983.00 ,$904.36 ,92% of total billed charges for outpatient setting,$540.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,,Not seperately reimbursible per contract terms,$786.40 ,80% of total billed charges for outpatient setting,$540.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$137.09 ,100% of Cigna Behavioral Health fee schedule,$933.85 ,95% of total billed charges for outpatient setting,$737.25 ,75% of total billed charges for outpatient setting,$835.55 ,85% of total billed charges for outpatient setting,$953.51 ,97% of total billed charges for outpatient setting,$540.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$884.70 ,90% of total billed charges for outpatient setting,$953.51 ,97% of total billed charges for outpatient setting,$953.51 ,97% of total billed charges for outpatient setting,$953.51 ,97% of total billed charges for outpatient setting,$35.00 ,100% case rate for treatment room,$884.70 ,90% of total billed charges for outpatient setting,$835.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$933.85 ,90% of total billed charges for outpatient setting,$540.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$914.19 ,93% of total billed charges for outpatient setting,$35.00 ,$953.51 ,$737.25 
Outpatient Medical Services,Physician Services,99205,"New patient office of other outpatient visit, typically 60 min",510,$983.00 ,$904.36 ,92% of total billed charges for outpatient setting,$540.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,,Not seperately reimbursible per contract terms,$786.40 ,80% of total billed charges for outpatient setting,$540.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$174.15 ,100% of Cigna Behavioral Health fee schedule,$933.85 ,95% of total billed charges for outpatient setting,$737.25 ,75% of total billed charges for outpatient setting,$835.55 ,85% of total billed charges for outpatient setting,$953.51 ,97% of total billed charges for outpatient setting,$540.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$884.70 ,90% of total billed charges for outpatient setting,$953.51 ,97% of total billed charges for outpatient setting,$953.51 ,97% of total billed charges for outpatient setting,$953.51 ,97% of total billed charges for outpatient setting,$35.00 ,100% case rate for treatment room,$884.70 ,90% of total billed charges for outpatient setting,$835.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$933.85 ,90% of total billed charges for outpatient setting,$540.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$914.19 ,93% of total billed charges for outpatient setting,$35.00 ,$953.51 ,$737.25 
Outpatient Medical Services,SLEEP STUDY,95810,Sleep monitoring of patient (6 years or older) in sleep lab,920,"$3,185.00 ","$2,930.20 ",92% of total billed charges for outpatient setting,"$1,751.75 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,"$2,739.10 ",86% of total billed charges for outpatient setting,"$2,548.00 ",80% of total billed charges for outpatient setting,"$1,751.75 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$3,025.75 ",95% of total billed charges for outpatient setting,"$3,025.75 ",95% of total billed charges for outpatient setting,"$2,388.75 ",75% of total billed charges for outpatient setting,"$2,707.25 ",85% of total billed charges for outpatient setting,"$3,089.45 ",97% of total billed charges for outpatient setting,"$1,751.75 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$2,866.50 ",90% of total billed charges for outpatient setting,"$3,089.45 ",97% of total billed charges for outpatient setting,"$3,089.45 ",97% of total billed charges for outpatient setting,"$3,089.45 ",97% of total billed charges for outpatient setting,"$2,707.25 ",85% of total billed charges for outpatient setting,"$2,866.50 ",90% of total billed charges for outpatient setting,"$2,707.25 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$3,025.75 ",90% of total billed charges for outpatient setting,"$1,751.75 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$2,962.05 ",93% of total billed charges for outpatient setting,"$1,751.75 ","$3,089.45 ","$2,388.75 "
Outpatient Medical Services,RADIOLOGY,23350,YUMA Shoulder Arthrogram Inj,320,$451.00 ,$414.92 ,92% of total billed charges for outpatient setting,$248.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$387.86 ,86% of total billed charges for outpatient setting,$360.80 ,80% of total billed charges for outpatient setting,$248.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$428.45 ,95% of total billed charges for outpatient setting,$428.45 ,95% of total billed charges for outpatient setting,$338.25 ,75% of total billed charges for outpatient setting,$383.35 ,85% of total billed charges for outpatient setting,$437.47 ,97% of total billed charges for outpatient setting,$248.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$405.90 ,90% of total billed charges for outpatient setting,$437.47 ,97% of total billed charges for outpatient setting,$437.47 ,97% of total billed charges for outpatient setting,$437.47 ,97% of total billed charges for outpatient setting,$383.35 ,85% of total billed charges for outpatient setting,$405.90 ,90% of total billed charges for outpatient setting,$383.35 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$428.45 ,90% of total billed charges for outpatient setting,$248.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$419.43 ,93% of total billed charges for outpatient setting,$248.05 ,$437.47 ,$338.25 
Outpatient Medical Services,RADIOLOGY,27093,YUMA Hip Arthrogram Inj,320,$241.00 ,$221.72 ,92% of total billed charges for outpatient setting,$132.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$207.26 ,86% of total billed charges for outpatient setting,$192.80 ,80% of total billed charges for outpatient setting,$132.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$228.95 ,95% of total billed charges for outpatient setting,$228.95 ,95% of total billed charges for outpatient setting,$180.75 ,75% of total billed charges for outpatient setting,$204.85 ,85% of total billed charges for outpatient setting,$233.77 ,97% of total billed charges for outpatient setting,$132.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$216.90 ,90% of total billed charges for outpatient setting,$233.77 ,97% of total billed charges for outpatient setting,$233.77 ,97% of total billed charges for outpatient setting,$233.77 ,97% of total billed charges for outpatient setting,$204.85 ,85% of total billed charges for outpatient setting,$216.90 ,90% of total billed charges for outpatient setting,$204.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$228.95 ,90% of total billed charges for outpatient setting,$132.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$224.13 ,93% of total billed charges for outpatient setting,$132.55 ,$233.77 ,$180.75 
Outpatient Medical Services,RADIOLOGY,62282,YUMA Lumbar Epidural Steroid Injection (ESI),320,"$2,071.00 ","$1,905.32 ",92% of total billed charges for outpatient setting,"$1,139.05 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,"$1,781.06 ",86% of total billed charges for outpatient setting,"$1,656.80 ",80% of total billed charges for outpatient setting,"$1,139.05 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$1,967.45 ",95% of total billed charges for outpatient setting,"$1,967.45 ",95% of total billed charges for outpatient setting,"$1,553.25 ",75% of total billed charges for outpatient setting,"$1,760.35 ",85% of total billed charges for outpatient setting,"$2,008.87 ",97% of total billed charges for outpatient setting,"$1,139.05 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$1,863.90 ",90% of total billed charges for outpatient setting,"$2,008.87 ",97% of total billed charges for outpatient setting,"$2,008.87 ",97% of total billed charges for outpatient setting,"$2,008.87 ",97% of total billed charges for outpatient setting,"$1,760.35 ",85% of total billed charges for outpatient setting,"$1,863.90 ",90% of total billed charges for outpatient setting,"$1,760.35 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$1,967.45 ",90% of total billed charges for outpatient setting,"$1,139.05 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$1,926.03 ",93% of total billed charges for outpatient setting,"$1,139.05 ","$2,008.87 ","$1,553.25 "
Outpatient Medical Services,RADIOLOGY,70150,XR Facial Bones 3+ Views,320,$430.00 ,$395.60 ,92% of total billed charges for outpatient setting,$236.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$369.80 ,86% of total billed charges for outpatient setting,$344.00 ,80% of total billed charges for outpatient setting,$236.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$408.50 ,95% of total billed charges for outpatient setting,$408.50 ,95% of total billed charges for outpatient setting,$322.50 ,75% of total billed charges for outpatient setting,$365.50 ,85% of total billed charges for outpatient setting,$417.10 ,97% of total billed charges for outpatient setting,$236.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$387.00 ,90% of total billed charges for outpatient setting,$417.10 ,97% of total billed charges for outpatient setting,$417.10 ,97% of total billed charges for outpatient setting,$417.10 ,97% of total billed charges for outpatient setting,$365.50 ,85% of total billed charges for outpatient setting,$387.00 ,90% of total billed charges for outpatient setting,$365.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$408.50 ,90% of total billed charges for outpatient setting,$236.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$399.90 ,93% of total billed charges for outpatient setting,$236.50 ,$417.10 ,$322.50 
Outpatient Medical Services,RADIOLOGY,71045,Single view,320,$316.00 ,$290.72 ,92% of total billed charges for outpatient setting,$173.80 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$271.76 ,86% of total billed charges for outpatient setting,$252.80 ,80% of total billed charges for outpatient setting,$173.80 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$300.20 ,95% of total billed charges for outpatient setting,$300.20 ,95% of total billed charges for outpatient setting,$237.00 ,75% of total billed charges for outpatient setting,$268.60 ,85% of total billed charges for outpatient setting,$306.52 ,97% of total billed charges for outpatient setting,$173.80 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$284.40 ,90% of total billed charges for outpatient setting,$306.52 ,97% of total billed charges for outpatient setting,$306.52 ,97% of total billed charges for outpatient setting,$306.52 ,97% of total billed charges for outpatient setting,$268.60 ,85% of total billed charges for outpatient setting,$284.40 ,90% of total billed charges for outpatient setting,$268.60 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$300.20 ,90% of total billed charges for outpatient setting,$173.80 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$293.88 ,93% of total billed charges for outpatient setting,$173.80 ,$306.52 ,$237.00 
Outpatient Medical Services,RADIOLOGY,71046,"2 views, front and back",320,$471.00 ,$433.32 ,92% of total billed charges for outpatient setting,$259.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$405.06 ,86% of total billed charges for outpatient setting,$376.80 ,80% of total billed charges for outpatient setting,$259.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$447.45 ,95% of total billed charges for outpatient setting,$447.45 ,95% of total billed charges for outpatient setting,$353.25 ,75% of total billed charges for outpatient setting,$400.35 ,85% of total billed charges for outpatient setting,$456.87 ,97% of total billed charges for outpatient setting,$259.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$423.90 ,90% of total billed charges for outpatient setting,$456.87 ,97% of total billed charges for outpatient setting,$456.87 ,97% of total billed charges for outpatient setting,$456.87 ,97% of total billed charges for outpatient setting,$400.35 ,85% of total billed charges for outpatient setting,$423.90 ,90% of total billed charges for outpatient setting,$400.35 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$447.45 ,90% of total billed charges for outpatient setting,$259.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$438.03 ,93% of total billed charges for outpatient setting,$259.05 ,$456.87 ,$353.25 
Outpatient Medical Services,RADIOLOGY,71100,XR Ribs 2 Views,320,$405.00 ,$372.60 ,92% of total billed charges for outpatient setting,$222.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$348.30 ,86% of total billed charges for outpatient setting,$324.00 ,80% of total billed charges for outpatient setting,$222.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$384.75 ,95% of total billed charges for outpatient setting,$384.75 ,95% of total billed charges for outpatient setting,$303.75 ,75% of total billed charges for outpatient setting,$344.25 ,85% of total billed charges for outpatient setting,$392.85 ,97% of total billed charges for outpatient setting,$222.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$364.50 ,90% of total billed charges for outpatient setting,$392.85 ,97% of total billed charges for outpatient setting,$392.85 ,97% of total billed charges for outpatient setting,$392.85 ,97% of total billed charges for outpatient setting,$344.25 ,85% of total billed charges for outpatient setting,$364.50 ,90% of total billed charges for outpatient setting,$344.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$384.75 ,90% of total billed charges for outpatient setting,$222.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$376.65 ,93% of total billed charges for outpatient setting,$222.75 ,$392.85 ,$303.75 
Outpatient Medical Services,RADIOLOGY,71101,Radiologic examination of one side of the chest/ribs,320,$621.00 ,$571.32 ,92% of total billed charges for outpatient setting,$341.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$534.06 ,86% of total billed charges for outpatient setting,$496.80 ,80% of total billed charges for outpatient setting,$341.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$589.95 ,95% of total billed charges for outpatient setting,$589.95 ,95% of total billed charges for outpatient setting,$465.75 ,75% of total billed charges for outpatient setting,$527.85 ,85% of total billed charges for outpatient setting,$602.37 ,97% of total billed charges for outpatient setting,$341.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$558.90 ,90% of total billed charges for outpatient setting,$602.37 ,97% of total billed charges for outpatient setting,$602.37 ,97% of total billed charges for outpatient setting,$602.37 ,97% of total billed charges for outpatient setting,$527.85 ,85% of total billed charges for outpatient setting,$558.90 ,90% of total billed charges for outpatient setting,$527.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$589.95 ,90% of total billed charges for outpatient setting,$341.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$577.53 ,93% of total billed charges for outpatient setting,$341.55 ,$602.37 ,$465.75 
Outpatient Medical Services,RADIOLOGY,71111,XR Ribs w/ PA Chest Bilateral,320,$595.00 ,$547.40 ,92% of total billed charges for outpatient setting,$327.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$511.70 ,86% of total billed charges for outpatient setting,$476.00 ,80% of total billed charges for outpatient setting,$327.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$565.25 ,95% of total billed charges for outpatient setting,$565.25 ,95% of total billed charges for outpatient setting,$446.25 ,75% of total billed charges for outpatient setting,$505.75 ,85% of total billed charges for outpatient setting,$577.15 ,97% of total billed charges for outpatient setting,$327.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$535.50 ,90% of total billed charges for outpatient setting,$577.15 ,97% of total billed charges for outpatient setting,$577.15 ,97% of total billed charges for outpatient setting,$577.15 ,97% of total billed charges for outpatient setting,$505.75 ,85% of total billed charges for outpatient setting,$535.50 ,90% of total billed charges for outpatient setting,$505.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$565.25 ,90% of total billed charges for outpatient setting,$327.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$553.35 ,93% of total billed charges for outpatient setting,$327.25 ,$577.15 ,$446.25 
Outpatient Medical Services,RADIOLOGY,72040,"Radiologic examination of the neck/spine, 2-3 views",320,$437.00 ,$402.04 ,92% of total billed charges for outpatient setting,$240.35 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$375.82 ,86% of total billed charges for outpatient setting,$349.60 ,80% of total billed charges for outpatient setting,$240.35 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$415.15 ,95% of total billed charges for outpatient setting,$415.15 ,95% of total billed charges for outpatient setting,$327.75 ,75% of total billed charges for outpatient setting,$371.45 ,85% of total billed charges for outpatient setting,$423.89 ,97% of total billed charges for outpatient setting,$240.35 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$393.30 ,90% of total billed charges for outpatient setting,$423.89 ,97% of total billed charges for outpatient setting,$423.89 ,97% of total billed charges for outpatient setting,$423.89 ,97% of total billed charges for outpatient setting,$371.45 ,85% of total billed charges for outpatient setting,$393.30 ,90% of total billed charges for outpatient setting,$371.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$415.15 ,90% of total billed charges for outpatient setting,$240.35 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$406.41 ,93% of total billed charges for outpatient setting,$240.35 ,$423.89 ,$327.75 
Outpatient Medical Services,RADIOLOGY,72050,"Radiologic examination of the neck/spine, 4-5 views",320,$746.00 ,$686.32 ,92% of total billed charges for outpatient setting,$410.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$641.56 ,86% of total billed charges for outpatient setting,$596.80 ,80% of total billed charges for outpatient setting,$410.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$708.70 ,95% of total billed charges for outpatient setting,$708.70 ,95% of total billed charges for outpatient setting,$559.50 ,75% of total billed charges for outpatient setting,$634.10 ,85% of total billed charges for outpatient setting,$723.62 ,97% of total billed charges for outpatient setting,$410.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$671.40 ,90% of total billed charges for outpatient setting,$723.62 ,97% of total billed charges for outpatient setting,$723.62 ,97% of total billed charges for outpatient setting,$723.62 ,97% of total billed charges for outpatient setting,$634.10 ,85% of total billed charges for outpatient setting,$671.40 ,90% of total billed charges for outpatient setting,$634.10 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$708.70 ,90% of total billed charges for outpatient setting,$410.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$693.78 ,93% of total billed charges for outpatient setting,$410.30 ,$723.62 ,$559.50 
Outpatient Medical Services,RADIOLOGY,72070,"Radiologic examination of the middle spine, 2 views",320,$504.00 ,$463.68 ,92% of total billed charges for outpatient setting,$277.20 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$433.44 ,86% of total billed charges for outpatient setting,$403.20 ,80% of total billed charges for outpatient setting,$277.20 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$478.80 ,95% of total billed charges for outpatient setting,$478.80 ,95% of total billed charges for outpatient setting,$378.00 ,75% of total billed charges for outpatient setting,$428.40 ,85% of total billed charges for outpatient setting,$488.88 ,97% of total billed charges for outpatient setting,$277.20 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$453.60 ,90% of total billed charges for outpatient setting,$488.88 ,97% of total billed charges for outpatient setting,$488.88 ,97% of total billed charges for outpatient setting,$488.88 ,97% of total billed charges for outpatient setting,$428.40 ,85% of total billed charges for outpatient setting,$453.60 ,90% of total billed charges for outpatient setting,$428.40 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$478.80 ,90% of total billed charges for outpatient setting,$277.20 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$468.72 ,93% of total billed charges for outpatient setting,$277.20 ,$488.88 ,$378.00 
Outpatient Medical Services,RADIOLOGY,72072,"Radiologic examination of the middle spine, 3 views",320,$555.00 ,$510.60 ,92% of total billed charges for outpatient setting,$305.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$477.30 ,86% of total billed charges for outpatient setting,$444.00 ,80% of total billed charges for outpatient setting,$305.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$527.25 ,95% of total billed charges for outpatient setting,$527.25 ,95% of total billed charges for outpatient setting,$416.25 ,75% of total billed charges for outpatient setting,$471.75 ,85% of total billed charges for outpatient setting,$538.35 ,97% of total billed charges for outpatient setting,$305.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$499.50 ,90% of total billed charges for outpatient setting,$538.35 ,97% of total billed charges for outpatient setting,$538.35 ,97% of total billed charges for outpatient setting,$538.35 ,97% of total billed charges for outpatient setting,$471.75 ,85% of total billed charges for outpatient setting,$499.50 ,90% of total billed charges for outpatient setting,$471.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$527.25 ,90% of total billed charges for outpatient setting,$305.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$516.15 ,93% of total billed charges for outpatient setting,$305.25 ,$538.35 ,$416.25 
Outpatient Medical Services,RADIOLOGY,72100,X-ray of the lower spine 2-3 views,320,$559.00 ,$514.28 ,92% of total billed charges for outpatient setting,$307.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$480.74 ,86% of total billed charges for outpatient setting,$447.20 ,80% of total billed charges for outpatient setting,$307.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$531.05 ,95% of total billed charges for outpatient setting,$531.05 ,95% of total billed charges for outpatient setting,$419.25 ,75% of total billed charges for outpatient setting,$475.15 ,85% of total billed charges for outpatient setting,$542.23 ,97% of total billed charges for outpatient setting,$307.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$503.10 ,90% of total billed charges for outpatient setting,$542.23 ,97% of total billed charges for outpatient setting,$542.23 ,97% of total billed charges for outpatient setting,$542.23 ,97% of total billed charges for outpatient setting,$475.15 ,85% of total billed charges for outpatient setting,$503.10 ,90% of total billed charges for outpatient setting,$475.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$531.05 ,90% of total billed charges for outpatient setting,$307.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$519.87 ,93% of total billed charges for outpatient setting,$307.45 ,$542.23 ,$419.25 
Outpatient Medical Services,RADIOLOGY,72170,Radiologic examination of the pelvis,320,$482.00 ,$443.44 ,92% of total billed charges for outpatient setting,$265.10 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$414.52 ,86% of total billed charges for outpatient setting,$385.60 ,80% of total billed charges for outpatient setting,$265.10 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$457.90 ,95% of total billed charges for outpatient setting,$457.90 ,95% of total billed charges for outpatient setting,$361.50 ,75% of total billed charges for outpatient setting,$409.70 ,85% of total billed charges for outpatient setting,$467.54 ,97% of total billed charges for outpatient setting,$265.10 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$433.80 ,90% of total billed charges for outpatient setting,$467.54 ,97% of total billed charges for outpatient setting,$467.54 ,97% of total billed charges for outpatient setting,$467.54 ,97% of total billed charges for outpatient setting,$409.70 ,85% of total billed charges for outpatient setting,$433.80 ,90% of total billed charges for outpatient setting,$409.70 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$457.90 ,90% of total billed charges for outpatient setting,$265.10 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$448.26 ,93% of total billed charges for outpatient setting,$265.10 ,$467.54 ,$361.50 
Outpatient Medical Services,RADIOLOGY,72200,XR Sacroiliac Joints 1 or 2 Views,320,$393.00 ,$361.56 ,92% of total billed charges for outpatient setting,$216.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$337.98 ,86% of total billed charges for outpatient setting,$314.40 ,80% of total billed charges for outpatient setting,$216.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$373.35 ,95% of total billed charges for outpatient setting,$373.35 ,95% of total billed charges for outpatient setting,$294.75 ,75% of total billed charges for outpatient setting,$334.05 ,85% of total billed charges for outpatient setting,$381.21 ,97% of total billed charges for outpatient setting,$216.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$353.70 ,90% of total billed charges for outpatient setting,$381.21 ,97% of total billed charges for outpatient setting,$381.21 ,97% of total billed charges for outpatient setting,$381.21 ,97% of total billed charges for outpatient setting,$334.05 ,85% of total billed charges for outpatient setting,$353.70 ,90% of total billed charges for outpatient setting,$334.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$373.35 ,90% of total billed charges for outpatient setting,$216.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$365.49 ,93% of total billed charges for outpatient setting,$216.15 ,$381.21 ,$294.75 
Outpatient Medical Services,RADIOLOGY,72220,XR Sacrum/Coccyx 2+ Views,320,$528.00 ,$485.76 ,92% of total billed charges for outpatient setting,$290.40 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$454.08 ,86% of total billed charges for outpatient setting,$422.40 ,80% of total billed charges for outpatient setting,$290.40 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$501.60 ,95% of total billed charges for outpatient setting,$501.60 ,95% of total billed charges for outpatient setting,$396.00 ,75% of total billed charges for outpatient setting,$448.80 ,85% of total billed charges for outpatient setting,$512.16 ,97% of total billed charges for outpatient setting,$290.40 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$475.20 ,90% of total billed charges for outpatient setting,$512.16 ,97% of total billed charges for outpatient setting,$512.16 ,97% of total billed charges for outpatient setting,$512.16 ,97% of total billed charges for outpatient setting,$448.80 ,85% of total billed charges for outpatient setting,$475.20 ,90% of total billed charges for outpatient setting,$448.80 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$501.60 ,90% of total billed charges for outpatient setting,$290.40 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$491.04 ,93% of total billed charges for outpatient setting,$290.40 ,$512.16 ,$396.00 
Outpatient Medical Services,RADIOLOGY,73000,Radiologic examination of the collar bone,320,$345.00 ,$317.40 ,92% of total billed charges for outpatient setting,$189.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$296.70 ,86% of total billed charges for outpatient setting,$276.00 ,80% of total billed charges for outpatient setting,$189.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$327.75 ,95% of total billed charges for outpatient setting,$327.75 ,95% of total billed charges for outpatient setting,$258.75 ,75% of total billed charges for outpatient setting,$293.25 ,85% of total billed charges for outpatient setting,$334.65 ,97% of total billed charges for outpatient setting,$189.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$310.50 ,90% of total billed charges for outpatient setting,$334.65 ,97% of total billed charges for outpatient setting,$334.65 ,97% of total billed charges for outpatient setting,$334.65 ,97% of total billed charges for outpatient setting,$293.25 ,85% of total billed charges for outpatient setting,$310.50 ,90% of total billed charges for outpatient setting,$293.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$327.75 ,90% of total billed charges for outpatient setting,$189.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$320.85 ,93% of total billed charges for outpatient setting,$189.75 ,$334.65 ,$258.75 
Outpatient Medical Services,RADIOLOGY,73010,XR Scapula,320,$360.00 ,$331.20 ,92% of total billed charges for outpatient setting,$198.00 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$309.60 ,86% of total billed charges for outpatient setting,$288.00 ,80% of total billed charges for outpatient setting,$198.00 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$342.00 ,95% of total billed charges for outpatient setting,$342.00 ,95% of total billed charges for outpatient setting,$270.00 ,75% of total billed charges for outpatient setting,$306.00 ,85% of total billed charges for outpatient setting,$349.20 ,97% of total billed charges for outpatient setting,$198.00 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$324.00 ,90% of total billed charges for outpatient setting,$349.20 ,97% of total billed charges for outpatient setting,$349.20 ,97% of total billed charges for outpatient setting,$349.20 ,97% of total billed charges for outpatient setting,$306.00 ,85% of total billed charges for outpatient setting,$324.00 ,90% of total billed charges for outpatient setting,$306.00 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$342.00 ,90% of total billed charges for outpatient setting,$198.00 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$334.80 ,93% of total billed charges for outpatient setting,$198.00 ,$349.20 ,$270.00 
Outpatient Medical Services,RADIOLOGY,73030,Radiologic examination of the shoulder,320,$379.00 ,$348.68 ,92% of total billed charges for outpatient setting,$208.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$325.94 ,86% of total billed charges for outpatient setting,$303.20 ,80% of total billed charges for outpatient setting,$208.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$360.05 ,95% of total billed charges for outpatient setting,$360.05 ,95% of total billed charges for outpatient setting,$284.25 ,75% of total billed charges for outpatient setting,$322.15 ,85% of total billed charges for outpatient setting,$367.63 ,97% of total billed charges for outpatient setting,$208.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$341.10 ,90% of total billed charges for outpatient setting,$367.63 ,97% of total billed charges for outpatient setting,$367.63 ,97% of total billed charges for outpatient setting,$367.63 ,97% of total billed charges for outpatient setting,$322.15 ,85% of total billed charges for outpatient setting,$341.10 ,90% of total billed charges for outpatient setting,$322.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$360.05 ,90% of total billed charges for outpatient setting,$208.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$352.47 ,93% of total billed charges for outpatient setting,$208.45 ,$367.63 ,$284.25 
Outpatient Medical Services,RADIOLOGY,73040,XR Arthrogram Shoulder,320,"$1,556.00 ","$1,431.52 ",92% of total billed charges for outpatient setting,$855.80 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,"$1,338.16 ",86% of total billed charges for outpatient setting,"$1,244.80 ",80% of total billed charges for outpatient setting,$855.80 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$1,478.20 ",95% of total billed charges for outpatient setting,"$1,478.20 ",95% of total billed charges for outpatient setting,"$1,167.00 ",75% of total billed charges for outpatient setting,"$1,322.60 ",85% of total billed charges for outpatient setting,"$1,509.32 ",97% of total billed charges for outpatient setting,$855.80 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$1,400.40 ",90% of total billed charges for outpatient setting,"$1,509.32 ",97% of total billed charges for outpatient setting,"$1,509.32 ",97% of total billed charges for outpatient setting,"$1,509.32 ",97% of total billed charges for outpatient setting,"$1,322.60 ",85% of total billed charges for outpatient setting,"$1,400.40 ",90% of total billed charges for outpatient setting,"$1,322.60 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$1,478.20 ",90% of total billed charges for outpatient setting,$855.80 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$1,447.08 ",93% of total billed charges for outpatient setting,$855.80 ,"$1,509.32 ","$1,167.00 "
Outpatient Medical Services,RADIOLOGY,73070,"Radiologic examination, elbow; 2 views",320,$379.00 ,$348.68 ,92% of total billed charges for outpatient setting,$208.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$325.94 ,86% of total billed charges for outpatient setting,$303.20 ,80% of total billed charges for outpatient setting,$208.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$360.05 ,95% of total billed charges for outpatient setting,$360.05 ,95% of total billed charges for outpatient setting,$284.25 ,75% of total billed charges for outpatient setting,$322.15 ,85% of total billed charges for outpatient setting,$367.63 ,97% of total billed charges for outpatient setting,$208.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$341.10 ,90% of total billed charges for outpatient setting,$367.63 ,97% of total billed charges for outpatient setting,$367.63 ,97% of total billed charges for outpatient setting,$367.63 ,97% of total billed charges for outpatient setting,$322.15 ,85% of total billed charges for outpatient setting,$341.10 ,90% of total billed charges for outpatient setting,$322.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$360.05 ,90% of total billed charges for outpatient setting,$208.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$352.47 ,93% of total billed charges for outpatient setting,$208.45 ,$367.63 ,$284.25 
Outpatient Medical Services,RADIOLOGY,73080,"Radiologic examination, elbow; 3 or more views",320,$379.00 ,$348.68 ,92% of total billed charges for outpatient setting,$208.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$325.94 ,86% of total billed charges for outpatient setting,$303.20 ,80% of total billed charges for outpatient setting,$208.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$360.05 ,95% of total billed charges for outpatient setting,$360.05 ,95% of total billed charges for outpatient setting,$284.25 ,75% of total billed charges for outpatient setting,$322.15 ,85% of total billed charges for outpatient setting,$367.63 ,97% of total billed charges for outpatient setting,$208.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$341.10 ,90% of total billed charges for outpatient setting,$367.63 ,97% of total billed charges for outpatient setting,$367.63 ,97% of total billed charges for outpatient setting,$367.63 ,97% of total billed charges for outpatient setting,$322.15 ,85% of total billed charges for outpatient setting,$341.10 ,90% of total billed charges for outpatient setting,$322.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$360.05 ,90% of total billed charges for outpatient setting,$208.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$352.47 ,93% of total billed charges for outpatient setting,$208.45 ,$367.63 ,$284.25 
Outpatient Medical Services,RADIOLOGY,73090,Radiologic examination of the forearm,320,$379.00 ,$348.68 ,92% of total billed charges for outpatient setting,$208.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$325.94 ,86% of total billed charges for outpatient setting,$303.20 ,80% of total billed charges for outpatient setting,$208.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$360.05 ,95% of total billed charges for outpatient setting,$360.05 ,95% of total billed charges for outpatient setting,$284.25 ,75% of total billed charges for outpatient setting,$322.15 ,85% of total billed charges for outpatient setting,$367.63 ,97% of total billed charges for outpatient setting,$208.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$341.10 ,90% of total billed charges for outpatient setting,$367.63 ,97% of total billed charges for outpatient setting,$367.63 ,97% of total billed charges for outpatient setting,$367.63 ,97% of total billed charges for outpatient setting,$322.15 ,85% of total billed charges for outpatient setting,$341.10 ,90% of total billed charges for outpatient setting,$322.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$360.05 ,90% of total billed charges for outpatient setting,$208.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$352.47 ,93% of total billed charges for outpatient setting,$208.45 ,$367.63 ,$284.25 
Outpatient Medical Services,RADIOLOGY,73110,Up to 3 views,320,$379.00 ,$348.68 ,92% of total billed charges for outpatient setting,$208.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$325.94 ,86% of total billed charges for outpatient setting,$303.20 ,80% of total billed charges for outpatient setting,$208.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$360.05 ,95% of total billed charges for outpatient setting,$360.05 ,95% of total billed charges for outpatient setting,$284.25 ,75% of total billed charges for outpatient setting,$322.15 ,85% of total billed charges for outpatient setting,$367.63 ,97% of total billed charges for outpatient setting,$208.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$341.10 ,90% of total billed charges for outpatient setting,$367.63 ,97% of total billed charges for outpatient setting,$367.63 ,97% of total billed charges for outpatient setting,$367.63 ,97% of total billed charges for outpatient setting,$322.15 ,85% of total billed charges for outpatient setting,$341.10 ,90% of total billed charges for outpatient setting,$322.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$360.05 ,90% of total billed charges for outpatient setting,$208.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$352.47 ,93% of total billed charges for outpatient setting,$208.45 ,$367.63 ,$284.25 
Outpatient Medical Services,RADIOLOGY,73120,X-ray of the hand with 2 views,320,$379.00 ,$348.68 ,92% of total billed charges for outpatient setting,$208.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$325.94 ,86% of total billed charges for outpatient setting,$303.20 ,80% of total billed charges for outpatient setting,$208.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$360.05 ,95% of total billed charges for outpatient setting,$360.05 ,95% of total billed charges for outpatient setting,$284.25 ,75% of total billed charges for outpatient setting,$322.15 ,85% of total billed charges for outpatient setting,$367.63 ,97% of total billed charges for outpatient setting,$208.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$341.10 ,90% of total billed charges for outpatient setting,$367.63 ,97% of total billed charges for outpatient setting,$367.63 ,97% of total billed charges for outpatient setting,$367.63 ,97% of total billed charges for outpatient setting,$322.15 ,85% of total billed charges for outpatient setting,$341.10 ,90% of total billed charges for outpatient setting,$322.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$360.05 ,90% of total billed charges for outpatient setting,$208.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$352.47 ,93% of total billed charges for outpatient setting,$208.45 ,$367.63 ,$284.25 
Outpatient Medical Services,RADIOLOGY,73130,X-ray of the hand with 3 or more views,320,$379.00 ,$348.68 ,92% of total billed charges for outpatient setting,$208.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$325.94 ,86% of total billed charges for outpatient setting,$303.20 ,80% of total billed charges for outpatient setting,$208.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$360.05 ,95% of total billed charges for outpatient setting,$360.05 ,95% of total billed charges for outpatient setting,$284.25 ,75% of total billed charges for outpatient setting,$322.15 ,85% of total billed charges for outpatient setting,$367.63 ,97% of total billed charges for outpatient setting,$208.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$341.10 ,90% of total billed charges for outpatient setting,$367.63 ,97% of total billed charges for outpatient setting,$367.63 ,97% of total billed charges for outpatient setting,$367.63 ,97% of total billed charges for outpatient setting,$322.15 ,85% of total billed charges for outpatient setting,$341.10 ,90% of total billed charges for outpatient setting,$322.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$360.05 ,90% of total billed charges for outpatient setting,$208.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$352.47 ,93% of total billed charges for outpatient setting,$208.45 ,$367.63 ,$284.25 
Outpatient Medical Services,RADIOLOGY,73140,Radiologic examination of the finger(s),320,$379.00 ,$348.68 ,92% of total billed charges for outpatient setting,$208.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$325.94 ,86% of total billed charges for outpatient setting,$303.20 ,80% of total billed charges for outpatient setting,$208.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$360.05 ,95% of total billed charges for outpatient setting,$360.05 ,95% of total billed charges for outpatient setting,$284.25 ,75% of total billed charges for outpatient setting,$322.15 ,85% of total billed charges for outpatient setting,$367.63 ,97% of total billed charges for outpatient setting,$208.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$341.10 ,90% of total billed charges for outpatient setting,$367.63 ,97% of total billed charges for outpatient setting,$367.63 ,97% of total billed charges for outpatient setting,$367.63 ,97% of total billed charges for outpatient setting,$322.15 ,85% of total billed charges for outpatient setting,$341.10 ,90% of total billed charges for outpatient setting,$322.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$360.05 ,90% of total billed charges for outpatient setting,$208.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$352.47 ,93% of total billed charges for outpatient setting,$208.45 ,$367.63 ,$284.25 
Outpatient Medical Services,RADIOLOGY,73502,XR Hip 2-3 Views w/AP Pelvis,320,$494.00 ,$454.48 ,92% of total billed charges for outpatient setting,$271.70 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$424.84 ,86% of total billed charges for outpatient setting,$395.20 ,80% of total billed charges for outpatient setting,$271.70 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$469.30 ,95% of total billed charges for outpatient setting,$469.30 ,95% of total billed charges for outpatient setting,$370.50 ,75% of total billed charges for outpatient setting,$419.90 ,85% of total billed charges for outpatient setting,$479.18 ,97% of total billed charges for outpatient setting,$271.70 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$444.60 ,90% of total billed charges for outpatient setting,$479.18 ,97% of total billed charges for outpatient setting,$479.18 ,97% of total billed charges for outpatient setting,$479.18 ,97% of total billed charges for outpatient setting,$419.90 ,85% of total billed charges for outpatient setting,$444.60 ,90% of total billed charges for outpatient setting,$419.90 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$469.30 ,90% of total billed charges for outpatient setting,$271.70 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$459.42 ,93% of total billed charges for outpatient setting,$271.70 ,$479.18 ,$370.50 
Outpatient Medical Services,RADIOLOGY,73560,Radiologic examination of the knee with 1 or 2 views,320,$475.00 ,$437.00 ,92% of total billed charges for outpatient setting,$261.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$408.50 ,86% of total billed charges for outpatient setting,$380.00 ,80% of total billed charges for outpatient setting,$261.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$451.25 ,95% of total billed charges for outpatient setting,$451.25 ,95% of total billed charges for outpatient setting,$356.25 ,75% of total billed charges for outpatient setting,$403.75 ,85% of total billed charges for outpatient setting,$460.75 ,97% of total billed charges for outpatient setting,$261.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$427.50 ,90% of total billed charges for outpatient setting,$460.75 ,97% of total billed charges for outpatient setting,$460.75 ,97% of total billed charges for outpatient setting,$460.75 ,97% of total billed charges for outpatient setting,$403.75 ,85% of total billed charges for outpatient setting,$427.50 ,90% of total billed charges for outpatient setting,$403.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$451.25 ,90% of total billed charges for outpatient setting,$261.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$441.75 ,93% of total billed charges for outpatient setting,$261.25 ,$460.75 ,$356.25 
Outpatient Medical Services,RADIOLOGY,73562,Radiologic examination of the knee with 3 views,320,$495.00 ,$455.40 ,92% of total billed charges for outpatient setting,$272.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$425.70 ,86% of total billed charges for outpatient setting,$396.00 ,80% of total billed charges for outpatient setting,$272.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$470.25 ,95% of total billed charges for outpatient setting,$470.25 ,95% of total billed charges for outpatient setting,$371.25 ,75% of total billed charges for outpatient setting,$420.75 ,85% of total billed charges for outpatient setting,$480.15 ,97% of total billed charges for outpatient setting,$272.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$445.50 ,90% of total billed charges for outpatient setting,$480.15 ,97% of total billed charges for outpatient setting,$480.15 ,97% of total billed charges for outpatient setting,$480.15 ,97% of total billed charges for outpatient setting,$420.75 ,85% of total billed charges for outpatient setting,$445.50 ,90% of total billed charges for outpatient setting,$420.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$470.25 ,90% of total billed charges for outpatient setting,$272.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$460.35 ,93% of total billed charges for outpatient setting,$272.25 ,$480.15 ,$371.25 
Outpatient Medical Services,RADIOLOGY,73564,Radiologic examination of the knee with 4 or more views,320,$555.00 ,$510.60 ,92% of total billed charges for outpatient setting,$305.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$477.30 ,86% of total billed charges for outpatient setting,$444.00 ,80% of total billed charges for outpatient setting,$305.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$527.25 ,95% of total billed charges for outpatient setting,$527.25 ,95% of total billed charges for outpatient setting,$416.25 ,75% of total billed charges for outpatient setting,$471.75 ,85% of total billed charges for outpatient setting,$538.35 ,97% of total billed charges for outpatient setting,$305.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$499.50 ,90% of total billed charges for outpatient setting,$538.35 ,97% of total billed charges for outpatient setting,$538.35 ,97% of total billed charges for outpatient setting,$538.35 ,97% of total billed charges for outpatient setting,$471.75 ,85% of total billed charges for outpatient setting,$499.50 ,90% of total billed charges for outpatient setting,$471.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$527.25 ,90% of total billed charges for outpatient setting,$305.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$516.15 ,93% of total billed charges for outpatient setting,$305.25 ,$538.35 ,$416.25 
Outpatient Medical Services,RADIOLOGY,73610,Radiologic examination of the ankle with 3 views,320,$435.00 ,$400.20 ,92% of total billed charges for outpatient setting,$239.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$374.10 ,86% of total billed charges for outpatient setting,$348.00 ,80% of total billed charges for outpatient setting,$239.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$413.25 ,95% of total billed charges for outpatient setting,$413.25 ,95% of total billed charges for outpatient setting,$326.25 ,75% of total billed charges for outpatient setting,$369.75 ,85% of total billed charges for outpatient setting,$421.95 ,97% of total billed charges for outpatient setting,$239.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$391.50 ,90% of total billed charges for outpatient setting,$421.95 ,97% of total billed charges for outpatient setting,$421.95 ,97% of total billed charges for outpatient setting,$421.95 ,97% of total billed charges for outpatient setting,$369.75 ,85% of total billed charges for outpatient setting,$391.50 ,90% of total billed charges for outpatient setting,$369.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$413.25 ,90% of total billed charges for outpatient setting,$239.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$404.55 ,93% of total billed charges for outpatient setting,$239.25 ,$421.95 ,$326.25 
Outpatient Medical Services,RADIOLOGY,73630,Radiologic examination of the foot with 3 or more views,320,$435.00 ,$400.20 ,92% of total billed charges for outpatient setting,$239.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$374.10 ,86% of total billed charges for outpatient setting,$348.00 ,80% of total billed charges for outpatient setting,$239.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$413.25 ,95% of total billed charges for outpatient setting,$413.25 ,95% of total billed charges for outpatient setting,$326.25 ,75% of total billed charges for outpatient setting,$369.75 ,85% of total billed charges for outpatient setting,$421.95 ,97% of total billed charges for outpatient setting,$239.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$391.50 ,90% of total billed charges for outpatient setting,$421.95 ,97% of total billed charges for outpatient setting,$421.95 ,97% of total billed charges for outpatient setting,$421.95 ,97% of total billed charges for outpatient setting,$369.75 ,85% of total billed charges for outpatient setting,$391.50 ,90% of total billed charges for outpatient setting,$369.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$413.25 ,90% of total billed charges for outpatient setting,$239.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$404.55 ,93% of total billed charges for outpatient setting,$239.25 ,$421.95 ,$326.25 
Outpatient Medical Services,RADIOLOGY,74019,XR Abdomen 2 Views,320,$401.00 ,$368.92 ,92% of total billed charges for outpatient setting,$220.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$344.86 ,86% of total billed charges for outpatient setting,$320.80 ,80% of total billed charges for outpatient setting,$220.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$380.95 ,95% of total billed charges for outpatient setting,$380.95 ,95% of total billed charges for outpatient setting,$300.75 ,75% of total billed charges for outpatient setting,$340.85 ,85% of total billed charges for outpatient setting,$388.97 ,97% of total billed charges for outpatient setting,$220.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$360.90 ,90% of total billed charges for outpatient setting,$388.97 ,97% of total billed charges for outpatient setting,$388.97 ,97% of total billed charges for outpatient setting,$388.97 ,97% of total billed charges for outpatient setting,$340.85 ,85% of total billed charges for outpatient setting,$360.90 ,90% of total billed charges for outpatient setting,$340.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$380.95 ,90% of total billed charges for outpatient setting,$220.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$372.93 ,93% of total billed charges for outpatient setting,$220.55 ,$388.97 ,$300.75 
Outpatient Medical Services,RADIOLOGY,77080,Scan to measure bone mineral density (BMD) at the spine and hip,320,$561.00 ,$516.12 ,92% of total billed charges for outpatient setting,$308.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$482.46 ,86% of total billed charges for outpatient setting,$448.80 ,80% of total billed charges for outpatient setting,$308.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$532.95 ,95% of total billed charges for outpatient setting,$532.95 ,95% of total billed charges for outpatient setting,$420.75 ,75% of total billed charges for outpatient setting,$476.85 ,85% of total billed charges for outpatient setting,$544.17 ,97% of total billed charges for outpatient setting,$308.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$504.90 ,90% of total billed charges for outpatient setting,$544.17 ,97% of total billed charges for outpatient setting,$544.17 ,97% of total billed charges for outpatient setting,$544.17 ,97% of total billed charges for outpatient setting,$476.85 ,85% of total billed charges for outpatient setting,$504.90 ,90% of total billed charges for outpatient setting,$476.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$532.95 ,90% of total billed charges for outpatient setting,$308.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$521.73 ,93% of total billed charges for outpatient setting,$308.55 ,$544.17 ,$420.75 
Outpatient Medical Services,RADIOLOGY,96401,Chemotherapy Subcutaneous Injection Charge,331,$198.00 ,$182.16 ,92% of total billed charges for outpatient setting,$108.90 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$170.28 ,86% of total billed charges for outpatient setting,$158.40 ,80% of total billed charges for outpatient setting,$108.90 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$188.10 ,95% of total billed charges for outpatient setting,$188.10 ,95% of total billed charges for outpatient setting,$148.50 ,75% of total billed charges for outpatient setting,$168.30 ,85% of total billed charges for outpatient setting,$192.06 ,97% of total billed charges for outpatient setting,$108.90 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$178.20 ,90% of total billed charges for outpatient setting,$192.06 ,97% of total billed charges for outpatient setting,$192.06 ,97% of total billed charges for outpatient setting,$192.06 ,97% of total billed charges for outpatient setting,$168.30 ,85% of total billed charges for outpatient setting,$178.20 ,90% of total billed charges for outpatient setting,$168.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$188.10 ,90% of total billed charges for outpatient setting,$108.90 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$184.14 ,93% of total billed charges for outpatient setting,$108.90 ,$192.06 ,$148.50 
Outpatient Medical Services,RADIOLOGY,96411,CHEMO ADMIN IVP ADD'L CHARGE,331,$202.00 ,$185.84 ,92% of total billed charges for outpatient setting,$111.10 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$173.72 ,86% of total billed charges for outpatient setting,$161.60 ,80% of total billed charges for outpatient setting,$111.10 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$191.90 ,95% of total billed charges for outpatient setting,$191.90 ,95% of total billed charges for outpatient setting,$151.50 ,75% of total billed charges for outpatient setting,$171.70 ,85% of total billed charges for outpatient setting,$195.94 ,97% of total billed charges for outpatient setting,$111.10 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$181.80 ,90% of total billed charges for outpatient setting,$195.94 ,97% of total billed charges for outpatient setting,$195.94 ,97% of total billed charges for outpatient setting,$195.94 ,97% of total billed charges for outpatient setting,$171.70 ,85% of total billed charges for outpatient setting,$181.80 ,90% of total billed charges for outpatient setting,$171.70 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$191.90 ,90% of total billed charges for outpatient setting,$111.10 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$187.86 ,93% of total billed charges for outpatient setting,$111.10 ,$195.94 ,$151.50 
Outpatient Medical Services,RADIOLOGY,96413,CHEMOTHERAPY ADMN IV NFS TQ UP 1 HR 1/1ST SBST/DRUG,331,$834.00 ,$767.28 ,92% of total billed charges for outpatient setting,$458.70 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$717.24 ,86% of total billed charges for outpatient setting,$667.20 ,80% of total billed charges for outpatient setting,$458.70 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$792.30 ,95% of total billed charges for outpatient setting,$792.30 ,95% of total billed charges for outpatient setting,$625.50 ,75% of total billed charges for outpatient setting,$708.90 ,85% of total billed charges for outpatient setting,$808.98 ,97% of total billed charges for outpatient setting,$458.70 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$750.60 ,90% of total billed charges for outpatient setting,$808.98 ,97% of total billed charges for outpatient setting,$808.98 ,97% of total billed charges for outpatient setting,$808.98 ,97% of total billed charges for outpatient setting,$708.90 ,85% of total billed charges for outpatient setting,$750.60 ,90% of total billed charges for outpatient setting,$708.90 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$792.30 ,90% of total billed charges for outpatient setting,$458.70 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$775.62 ,93% of total billed charges for outpatient setting,$458.70 ,$808.98 ,$625.50 
Outpatient Medical Services,RADIOLOGY,96415,Chemotherapy infusion-each additional hour,331,$253.00 ,$232.76 ,92% of total billed charges for outpatient setting,$139.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$217.58 ,86% of total billed charges for outpatient setting,$202.40 ,80% of total billed charges for outpatient setting,$139.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$240.35 ,95% of total billed charges for outpatient setting,$240.35 ,95% of total billed charges for outpatient setting,$189.75 ,75% of total billed charges for outpatient setting,$215.05 ,85% of total billed charges for outpatient setting,$245.41 ,97% of total billed charges for outpatient setting,$139.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$227.70 ,90% of total billed charges for outpatient setting,$245.41 ,97% of total billed charges for outpatient setting,$245.41 ,97% of total billed charges for outpatient setting,$245.41 ,97% of total billed charges for outpatient setting,$215.05 ,85% of total billed charges for outpatient setting,$227.70 ,90% of total billed charges for outpatient setting,$215.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$240.35 ,90% of total billed charges for outpatient setting,$139.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$235.29 ,93% of total billed charges for outpatient setting,$139.15 ,$245.41 ,$189.75 
Outpatient Medical Services,RADIOLOGY,78452,Image of the heart to assess perfusion,341,"$4,102.00 ","$3,773.84 ",92% of total billed charges for outpatient setting,"$2,256.10 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,"$3,527.72 ",86% of total billed charges for outpatient setting,"$3,281.60 ",80% of total billed charges for outpatient setting,"$2,256.10 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$3,896.90 ",95% of total billed charges for outpatient setting,"$3,896.90 ",95% of total billed charges for outpatient setting,"$3,076.50 ",75% of total billed charges for outpatient setting,"$3,486.70 ",85% of total billed charges for outpatient setting,"$3,978.94 ",97% of total billed charges for outpatient setting,"$2,256.10 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$3,691.80 ",90% of total billed charges for outpatient setting,"$3,978.94 ",97% of total billed charges for outpatient setting,"$3,978.94 ",97% of total billed charges for outpatient setting,"$3,978.94 ",97% of total billed charges for outpatient setting,"$3,486.70 ",85% of total billed charges for outpatient setting,"$3,691.80 ",90% of total billed charges for outpatient setting,"$3,486.70 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$3,896.90 ",90% of total billed charges for outpatient setting,"$2,256.10 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$3,814.86 ",93% of total billed charges for outpatient setting,"$2,256.10 ","$3,978.94 ","$3,076.50 "
Outpatient Medical Services,RADIOLOGY,70491,CT scan of neck with dye,351,"$2,063.00 ","$1,897.96 ",92% of total billed charges for outpatient setting,"$1,134.65 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,"$1,774.18 ",86% of total billed charges for outpatient setting,"$1,650.40 ",80% of total billed charges for outpatient setting,"$1,134.65 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$1,959.85 ",95% of total billed charges for outpatient setting,"$1,959.85 ",95% of total billed charges for outpatient setting,"$1,547.25 ",75% of total billed charges for outpatient setting,"$1,753.55 ",85% of total billed charges for outpatient setting,"$2,001.11 ",97% of total billed charges for outpatient setting,"$1,134.65 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$1,856.70 ",90% of total billed charges for outpatient setting,"$2,001.11 ",97% of total billed charges for outpatient setting,"$2,001.11 ",97% of total billed charges for outpatient setting,"$2,001.11 ",97% of total billed charges for outpatient setting,"$1,753.55 ",85% of total billed charges for outpatient setting,"$1,856.70 ",90% of total billed charges for outpatient setting,"$1,753.55 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$1,959.85 ",90% of total billed charges for outpatient setting,"$1,134.65 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$1,918.59 ",93% of total billed charges for outpatient setting,"$1,134.65 ","$2,001.11 ","$1,547.25 "
Outpatient Medical Services,RADIOLOGY,70492,CT Neck Soft Tissue w/ + w/o Contrast,351,"$2,475.00 ","$2,277.00 ",92% of total billed charges for outpatient setting,"$1,361.25 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,"$2,128.50 ",86% of total billed charges for outpatient setting,"$1,980.00 ",80% of total billed charges for outpatient setting,"$1,361.25 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$2,351.25 ",95% of total billed charges for outpatient setting,"$2,351.25 ",95% of total billed charges for outpatient setting,"$1,856.25 ",75% of total billed charges for outpatient setting,"$2,103.75 ",85% of total billed charges for outpatient setting,"$2,400.75 ",97% of total billed charges for outpatient setting,"$1,361.25 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$2,227.50 ",90% of total billed charges for outpatient setting,"$2,400.75 ",97% of total billed charges for outpatient setting,"$2,400.75 ",97% of total billed charges for outpatient setting,"$2,400.75 ",97% of total billed charges for outpatient setting,"$2,103.75 ",85% of total billed charges for outpatient setting,"$2,227.50 ",90% of total billed charges for outpatient setting,"$2,103.75 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$2,351.25 ",90% of total billed charges for outpatient setting,"$1,361.25 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$2,301.75 ",93% of total billed charges for outpatient setting,"$1,361.25 ","$2,400.75 ","$1,856.25 "
Outpatient Medical Services,RADIOLOGY,70496,CTA HEAD,351,"$2,888.00 ","$2,656.96 ",92% of total billed charges for outpatient setting,"$1,588.40 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,"$2,483.68 ",86% of total billed charges for outpatient setting,"$2,310.40 ",80% of total billed charges for outpatient setting,"$1,588.40 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$2,743.60 ",95% of total billed charges for outpatient setting,"$2,743.60 ",95% of total billed charges for outpatient setting,"$2,166.00 ",75% of total billed charges for outpatient setting,"$2,454.80 ",85% of total billed charges for outpatient setting,"$2,801.36 ",97% of total billed charges for outpatient setting,"$1,588.40 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$2,599.20 ",90% of total billed charges for outpatient setting,"$2,801.36 ",97% of total billed charges for outpatient setting,"$2,801.36 ",97% of total billed charges for outpatient setting,"$2,801.36 ",97% of total billed charges for outpatient setting,"$2,454.80 ",85% of total billed charges for outpatient setting,"$2,599.20 ",90% of total billed charges for outpatient setting,"$2,454.80 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$2,743.60 ",90% of total billed charges for outpatient setting,"$1,588.40 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$2,685.84 ",93% of total billed charges for outpatient setting,"$1,588.40 ","$2,801.36 ","$2,166.00 "
Outpatient Medical Services,RADIOLOGY,70498,CTA NECK,352,"$2,750.00 ","$2,530.00 ",92% of total billed charges for outpatient setting,"$1,512.50 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,"$2,365.00 ",86% of total billed charges for outpatient setting,"$2,200.00 ",80% of total billed charges for outpatient setting,"$1,512.50 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$2,612.50 ",95% of total billed charges for outpatient setting,"$2,612.50 ",95% of total billed charges for outpatient setting,"$2,062.50 ",75% of total billed charges for outpatient setting,"$2,337.50 ",85% of total billed charges for outpatient setting,"$2,667.50 ",97% of total billed charges for outpatient setting,"$1,512.50 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$2,475.00 ",90% of total billed charges for outpatient setting,"$2,667.50 ",97% of total billed charges for outpatient setting,"$2,667.50 ",97% of total billed charges for outpatient setting,"$2,667.50 ",97% of total billed charges for outpatient setting,"$2,337.50 ",85% of total billed charges for outpatient setting,"$2,475.00 ",90% of total billed charges for outpatient setting,"$2,337.50 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$2,612.50 ",90% of total billed charges for outpatient setting,"$1,512.50 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$2,557.50 ",93% of total billed charges for outpatient setting,"$1,512.50 ","$2,667.50 ","$2,062.50 "
Outpatient Medical Services,RADIOLOGY,71250,CT scan of the thorax without dye,352,"$2,105.00 ","$1,936.60 ",92% of total billed charges for outpatient setting,"$1,157.75 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,"$1,810.30 ",86% of total billed charges for outpatient setting,"$1,684.00 ",80% of total billed charges for outpatient setting,"$1,157.75 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$1,999.75 ",95% of total billed charges for outpatient setting,"$1,999.75 ",95% of total billed charges for outpatient setting,"$1,578.75 ",75% of total billed charges for outpatient setting,"$1,789.25 ",85% of total billed charges for outpatient setting,"$2,041.85 ",97% of total billed charges for outpatient setting,"$1,157.75 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$1,894.50 ",90% of total billed charges for outpatient setting,"$2,041.85 ",97% of total billed charges for outpatient setting,"$2,041.85 ",97% of total billed charges for outpatient setting,"$2,041.85 ",97% of total billed charges for outpatient setting,"$1,789.25 ",85% of total billed charges for outpatient setting,"$1,894.50 ",90% of total billed charges for outpatient setting,"$1,789.25 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$1,999.75 ",90% of total billed charges for outpatient setting,"$1,157.75 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$1,957.65 ",93% of total billed charges for outpatient setting,"$1,157.75 ","$2,041.85 ","$1,578.75 "
Outpatient Medical Services,RADIOLOGY,71260,CT scan of the thorax with dye,352,"$2,475.00 ","$2,277.00 ",92% of total billed charges for outpatient setting,"$1,361.25 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,"$2,128.50 ",86% of total billed charges for outpatient setting,"$1,980.00 ",80% of total billed charges for outpatient setting,"$1,361.25 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$2,351.25 ",95% of total billed charges for outpatient setting,"$2,351.25 ",95% of total billed charges for outpatient setting,"$1,856.25 ",75% of total billed charges for outpatient setting,"$2,103.75 ",85% of total billed charges for outpatient setting,"$2,400.75 ",97% of total billed charges for outpatient setting,"$1,361.25 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$2,227.50 ",90% of total billed charges for outpatient setting,"$2,400.75 ",97% of total billed charges for outpatient setting,"$2,400.75 ",97% of total billed charges for outpatient setting,"$2,400.75 ",97% of total billed charges for outpatient setting,"$2,103.75 ",85% of total billed charges for outpatient setting,"$2,227.50 ",90% of total billed charges for outpatient setting,"$2,103.75 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$2,351.25 ",90% of total billed charges for outpatient setting,"$1,361.25 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$2,301.75 ",93% of total billed charges for outpatient setting,"$1,361.25 ","$2,400.75 ","$1,856.25 "
Outpatient Medical Services,RADIOLOGY,71275,Diagnostic Radiology (Diagnostic Imaging) Procedures of the Chest,352,"$3,299.00 ","$3,035.08 ",92% of total billed charges for outpatient setting,"$1,814.45 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,"$2,837.14 ",86% of total billed charges for outpatient setting,"$2,639.20 ",80% of total billed charges for outpatient setting,"$1,814.45 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$3,134.05 ",95% of total billed charges for outpatient setting,"$3,134.05 ",95% of total billed charges for outpatient setting,"$2,474.25 ",75% of total billed charges for outpatient setting,"$2,804.15 ",85% of total billed charges for outpatient setting,"$3,200.03 ",97% of total billed charges for outpatient setting,"$1,814.45 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$2,969.10 ",90% of total billed charges for outpatient setting,"$3,200.03 ",97% of total billed charges for outpatient setting,"$3,200.03 ",97% of total billed charges for outpatient setting,"$3,200.03 ",97% of total billed charges for outpatient setting,"$2,804.15 ",85% of total billed charges for outpatient setting,"$2,969.10 ",90% of total billed charges for outpatient setting,"$2,804.15 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$3,134.05 ",90% of total billed charges for outpatient setting,"$1,814.45 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$3,068.07 ",93% of total billed charges for outpatient setting,"$1,814.45 ","$3,200.03 ","$2,474.25 "
Outpatient Medical Services,RADIOLOGY,72125,CT Spine Cervical w/o Contrast,352,"$2,176.00 ","$2,001.92 ",92% of total billed charges for outpatient setting,"$1,196.80 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,"$1,871.36 ",86% of total billed charges for outpatient setting,"$1,740.80 ",80% of total billed charges for outpatient setting,"$1,196.80 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$2,067.20 ",95% of total billed charges for outpatient setting,"$2,067.20 ",95% of total billed charges for outpatient setting,"$1,632.00 ",75% of total billed charges for outpatient setting,"$1,849.60 ",85% of total billed charges for outpatient setting,"$2,110.72 ",97% of total billed charges for outpatient setting,"$1,196.80 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$1,958.40 ",90% of total billed charges for outpatient setting,"$2,110.72 ",97% of total billed charges for outpatient setting,"$2,110.72 ",97% of total billed charges for outpatient setting,"$2,110.72 ",97% of total billed charges for outpatient setting,"$1,849.60 ",85% of total billed charges for outpatient setting,"$1,958.40 ",90% of total billed charges for outpatient setting,"$1,849.60 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$2,067.20 ",90% of total billed charges for outpatient setting,"$1,196.80 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$2,023.68 ",93% of total billed charges for outpatient setting,"$1,196.80 ","$2,110.72 ","$1,632.00 "
Outpatient Medical Services,RADIOLOGY,72192,CT of pelvis without dye,352,"$2,457.00 ","$2,260.44 ",92% of total billed charges for outpatient setting,"$1,351.35 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,"$2,113.02 ",86% of total billed charges for outpatient setting,"$1,965.60 ",80% of total billed charges for outpatient setting,"$1,351.35 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$2,334.15 ",95% of total billed charges for outpatient setting,"$2,334.15 ",95% of total billed charges for outpatient setting,"$1,842.75 ",75% of total billed charges for outpatient setting,"$2,088.45 ",85% of total billed charges for outpatient setting,"$2,383.29 ",97% of total billed charges for outpatient setting,"$1,351.35 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$2,211.30 ",90% of total billed charges for outpatient setting,"$2,383.29 ",97% of total billed charges for outpatient setting,"$2,383.29 ",97% of total billed charges for outpatient setting,"$2,383.29 ",97% of total billed charges for outpatient setting,"$2,088.45 ",85% of total billed charges for outpatient setting,"$2,211.30 ",90% of total billed charges for outpatient setting,"$2,088.45 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$2,334.15 ",90% of total billed charges for outpatient setting,"$1,351.35 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$2,285.01 ",93% of total billed charges for outpatient setting,"$1,351.35 ","$2,383.29 ","$1,842.75 "
Outpatient Medical Services,RADIOLOGY,73200,CT Upper Extremity w/o Contrast,352,"$2,105.00 ","$1,936.60 ",92% of total billed charges for outpatient setting,"$1,157.75 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,"$1,810.30 ",86% of total billed charges for outpatient setting,"$1,684.00 ",80% of total billed charges for outpatient setting,"$1,157.75 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$1,999.75 ",95% of total billed charges for outpatient setting,"$1,999.75 ",95% of total billed charges for outpatient setting,"$1,578.75 ",75% of total billed charges for outpatient setting,"$1,789.25 ",85% of total billed charges for outpatient setting,"$2,041.85 ",97% of total billed charges for outpatient setting,"$1,157.75 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$1,894.50 ",90% of total billed charges for outpatient setting,"$2,041.85 ",97% of total billed charges for outpatient setting,"$2,041.85 ",97% of total billed charges for outpatient setting,"$2,041.85 ",97% of total billed charges for outpatient setting,"$1,789.25 ",85% of total billed charges for outpatient setting,"$1,894.50 ",90% of total billed charges for outpatient setting,"$1,789.25 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$1,999.75 ",90% of total billed charges for outpatient setting,"$1,157.75 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$1,957.65 ",93% of total billed charges for outpatient setting,"$1,157.75 ","$2,041.85 ","$1,578.75 "
Outpatient Medical Services,RADIOLOGY,74176,CT of abdomen and pelvis without dye,352,"$3,792.00 ","$3,488.64 ",92% of total billed charges for outpatient setting,"$2,085.60 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,"$3,261.12 ",86% of total billed charges for outpatient setting,"$3,033.60 ",80% of total billed charges for outpatient setting,"$2,085.60 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$3,602.40 ",95% of total billed charges for outpatient setting,"$3,602.40 ",95% of total billed charges for outpatient setting,"$2,844.00 ",75% of total billed charges for outpatient setting,"$3,223.20 ",85% of total billed charges for outpatient setting,"$3,678.24 ",97% of total billed charges for outpatient setting,"$2,085.60 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$3,412.80 ",90% of total billed charges for outpatient setting,"$3,678.24 ",97% of total billed charges for outpatient setting,"$3,678.24 ",97% of total billed charges for outpatient setting,"$3,678.24 ",97% of total billed charges for outpatient setting,"$3,223.20 ",85% of total billed charges for outpatient setting,"$3,412.80 ",90% of total billed charges for outpatient setting,"$3,223.20 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$3,602.40 ",90% of total billed charges for outpatient setting,"$2,085.60 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$3,526.56 ",93% of total billed charges for outpatient setting,"$2,085.60 ","$3,678.24 ","$2,844.00 "
Outpatient Medical Services,RADIOLOGY,36430,Transfuse Red Blood Cells Leukoreduced,391,"$1,242.00 ","$1,142.64 ",92% of total billed charges for outpatient setting,$683.10 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,"$1,068.12 ",86% of total billed charges for outpatient setting,$993.60 ,80% of total billed charges for outpatient setting,$683.10 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$1,179.90 ",95% of total billed charges for outpatient setting,"$1,179.90 ",95% of total billed charges for outpatient setting,$931.50 ,75% of total billed charges for outpatient setting,"$1,055.70 ",85% of total billed charges for outpatient setting,"$1,204.74 ",97% of total billed charges for outpatient setting,$683.10 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$1,117.80 ",90% of total billed charges for outpatient setting,"$1,204.74 ",97% of total billed charges for outpatient setting,"$1,204.74 ",97% of total billed charges for outpatient setting,"$1,204.74 ",97% of total billed charges for outpatient setting,"$1,055.70 ",85% of total billed charges for outpatient setting,"$1,117.80 ",90% of total billed charges for outpatient setting,"$1,055.70 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$1,179.90 ",90% of total billed charges for outpatient setting,$683.10 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$1,155.06 ",93% of total billed charges for outpatient setting,$683.10 ,"$1,204.74 ",$931.50 
Outpatient Medical Services,RADIOLOGY,76642,Limited ultrasound of the breast,402,$724.00 ,$666.08 ,92% of total billed charges for outpatient setting,$398.20 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$622.64 ,86% of total billed charges for outpatient setting,$579.20 ,80% of total billed charges for outpatient setting,$398.20 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$687.80 ,95% of total billed charges for outpatient setting,$687.80 ,95% of total billed charges for outpatient setting,$543.00 ,75% of total billed charges for outpatient setting,$615.40 ,85% of total billed charges for outpatient setting,$702.28 ,97% of total billed charges for outpatient setting,$398.20 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$651.60 ,90% of total billed charges for outpatient setting,$702.28 ,97% of total billed charges for outpatient setting,$702.28 ,97% of total billed charges for outpatient setting,$702.28 ,97% of total billed charges for outpatient setting,$615.40 ,85% of total billed charges for outpatient setting,$651.60 ,90% of total billed charges for outpatient setting,$615.40 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$687.80 ,90% of total billed charges for outpatient setting,$398.20 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$673.32 ,93% of total billed charges for outpatient setting,$398.20 ,$702.28 ,$543.00 
Outpatient Medical Services,RADIOLOGY,76705,A diagnostic procedure that allows a provider to see the organs and other structures in the abdomen,402,$901.00 ,$828.92 ,92% of total billed charges for outpatient setting,$495.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$774.86 ,86% of total billed charges for outpatient setting,$720.80 ,80% of total billed charges for outpatient setting,$495.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$855.95 ,95% of total billed charges for outpatient setting,$855.95 ,95% of total billed charges for outpatient setting,$675.75 ,75% of total billed charges for outpatient setting,$765.85 ,85% of total billed charges for outpatient setting,$873.97 ,97% of total billed charges for outpatient setting,$495.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$810.90 ,90% of total billed charges for outpatient setting,$873.97 ,97% of total billed charges for outpatient setting,$873.97 ,97% of total billed charges for outpatient setting,$873.97 ,97% of total billed charges for outpatient setting,$765.85 ,85% of total billed charges for outpatient setting,$810.90 ,90% of total billed charges for outpatient setting,$765.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$855.95 ,90% of total billed charges for outpatient setting,$495.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$837.93 ,93% of total billed charges for outpatient setting,$495.55 ,$873.97 ,$675.75 
Outpatient Medical Services,RADIOLOGY,76801,Abdominal ultrasound of pregnant uterus (less than 14 weeks) single or first fetus,402,$812.00 ,$747.04 ,92% of total billed charges for outpatient setting,$446.60 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$698.32 ,86% of total billed charges for outpatient setting,$649.60 ,80% of total billed charges for outpatient setting,$446.60 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$771.40 ,95% of total billed charges for outpatient setting,$771.40 ,95% of total billed charges for outpatient setting,$609.00 ,75% of total billed charges for outpatient setting,$690.20 ,85% of total billed charges for outpatient setting,$787.64 ,97% of total billed charges for outpatient setting,$446.60 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$730.80 ,90% of total billed charges for outpatient setting,$787.64 ,97% of total billed charges for outpatient setting,$787.64 ,97% of total billed charges for outpatient setting,$787.64 ,97% of total billed charges for outpatient setting,$690.20 ,85% of total billed charges for outpatient setting,$730.80 ,90% of total billed charges for outpatient setting,$690.20 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$771.40 ,90% of total billed charges for outpatient setting,$446.60 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$755.16 ,93% of total billed charges for outpatient setting,$446.60 ,$787.64 ,$609.00 
Outpatient Medical Services,RADIOLOGY,76856,Complete ultrasound of the pelvis,402,"$1,061.00 ",$976.12 ,92% of total billed charges for outpatient setting,$583.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$912.46 ,86% of total billed charges for outpatient setting,$848.80 ,80% of total billed charges for outpatient setting,$583.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$1,007.95 ",95% of total billed charges for outpatient setting,"$1,007.95 ",95% of total billed charges for outpatient setting,$795.75 ,75% of total billed charges for outpatient setting,$901.85 ,85% of total billed charges for outpatient setting,"$1,029.17 ",97% of total billed charges for outpatient setting,$583.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$954.90 ,90% of total billed charges for outpatient setting,"$1,029.17 ",97% of total billed charges for outpatient setting,"$1,029.17 ",97% of total billed charges for outpatient setting,"$1,029.17 ",97% of total billed charges for outpatient setting,$901.85 ,85% of total billed charges for outpatient setting,$954.90 ,90% of total billed charges for outpatient setting,$901.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$1,007.95 ",90% of total billed charges for outpatient setting,$583.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$986.73 ,93% of total billed charges for outpatient setting,$583.55 ,"$1,029.17 ",$795.75 
Outpatient Medical Services,RADIOLOGY,77063,77063 MG Mammo Screen Bilateral,403,$187.00 ,$172.04 ,92% of total billed charges for outpatient setting,$102.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$160.82 ,86% of total billed charges for outpatient setting,$149.60 ,80% of total billed charges for outpatient setting,$102.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$177.65 ,95% of total billed charges for outpatient setting,$177.65 ,95% of total billed charges for outpatient setting,$140.25 ,75% of total billed charges for outpatient setting,$158.95 ,85% of total billed charges for outpatient setting,$181.39 ,97% of total billed charges for outpatient setting,$102.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$168.30 ,90% of total billed charges for outpatient setting,$181.39 ,97% of total billed charges for outpatient setting,$181.39 ,97% of total billed charges for outpatient setting,$181.39 ,97% of total billed charges for outpatient setting,$158.95 ,85% of total billed charges for outpatient setting,$168.30 ,90% of total billed charges for outpatient setting,$158.95 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$177.65 ,90% of total billed charges for outpatient setting,$102.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$173.91 ,93% of total billed charges for outpatient setting,$102.85 ,$181.39 ,$140.25 
Outpatient Medical Services,RADIOLOGY,77063,77063 Tomo,403,$187.00 ,$172.04 ,92% of total billed charges for outpatient setting,$102.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$160.82 ,86% of total billed charges for outpatient setting,$149.60 ,80% of total billed charges for outpatient setting,$102.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$177.65 ,95% of total billed charges for outpatient setting,$177.65 ,95% of total billed charges for outpatient setting,$140.25 ,75% of total billed charges for outpatient setting,$158.95 ,85% of total billed charges for outpatient setting,$181.39 ,97% of total billed charges for outpatient setting,$102.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$168.30 ,90% of total billed charges for outpatient setting,$181.39 ,97% of total billed charges for outpatient setting,$181.39 ,97% of total billed charges for outpatient setting,$181.39 ,97% of total billed charges for outpatient setting,$158.95 ,85% of total billed charges for outpatient setting,$168.30 ,90% of total billed charges for outpatient setting,$158.95 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$177.65 ,90% of total billed charges for outpatient setting,$102.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$173.91 ,93% of total billed charges for outpatient setting,$102.85 ,$181.39 ,$140.25 
Outpatient Medical Services,RADIOLOGY,70450,CT scan head or brain without dye,352,"$1,930.00 ","$1,775.60 ",92% of total billed charges for outpatient setting,"$1,061.50 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,"$1,659.80 ",86% of total billed charges for outpatient setting,"$1,544.00 ",80% of total billed charges for outpatient setting,"$1,061.50 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$1,833.50 ",95% of total billed charges for outpatient setting,"$1,833.50 ",95% of total billed charges for outpatient setting,"$1,447.50 ",75% of total billed charges for outpatient setting,"$1,640.50 ",85% of total billed charges for outpatient setting,"$1,872.10 ",97% of total billed charges for outpatient setting,"$1,061.50 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$1,737.00 ",90% of total billed charges for outpatient setting,"$1,872.10 ",97% of total billed charges for outpatient setting,"$1,872.10 ",97% of total billed charges for outpatient setting,"$1,872.10 ",97% of total billed charges for outpatient setting,"$1,640.50 ",85% of total billed charges for outpatient setting,"$1,737.00 ",90% of total billed charges for outpatient setting,"$1,640.50 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$1,833.50 ",90% of total billed charges for outpatient setting,"$1,061.50 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$1,794.90 ",93% of total billed charges for outpatient setting,"$1,061.50 ","$1,872.10 ","$1,447.50 "
Outpatient Medical Services,RADIOLOGY,70553,MRI scan of brain before and after contrast,611,"$6,668.00 ","$6,134.56 ",92% of total billed charges for outpatient setting,"$3,667.40 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,"$5,734.48 ",86% of total billed charges for outpatient setting,"$5,334.40 ",80% of total billed charges for outpatient setting,"$3,667.40 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$6,334.60 ",95% of total billed charges for outpatient setting,"$6,334.60 ",95% of total billed charges for outpatient setting,"$5,001.00 ",75% of total billed charges for outpatient setting,"$5,667.80 ",85% of total billed charges for outpatient setting,"$6,467.96 ",97% of total billed charges for outpatient setting,"$3,667.40 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$6,001.20 ",90% of total billed charges for outpatient setting,"$6,467.96 ",97% of total billed charges for outpatient setting,"$6,467.96 ",97% of total billed charges for outpatient setting,"$6,467.96 ",97% of total billed charges for outpatient setting,"$5,667.80 ",85% of total billed charges for outpatient setting,"$6,001.20 ",90% of total billed charges for outpatient setting,"$5,667.80 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$6,334.60 ",90% of total billed charges for outpatient setting,"$3,667.40 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$6,201.24 ",93% of total billed charges for outpatient setting,"$3,667.40 ","$6,467.96 ","$5,001.00 "
Outpatient Medical Services,RADIOLOGY,72110,"X-ray of lower and sacral spine, minimum of 4 views",320,$838.00 ,$770.96 ,92% of total billed charges for outpatient setting,$460.90 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$720.68 ,86% of total billed charges for outpatient setting,$670.40 ,80% of total billed charges for outpatient setting,$460.90 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$796.10 ,95% of total billed charges for outpatient setting,$796.10 ,95% of total billed charges for outpatient setting,$628.50 ,75% of total billed charges for outpatient setting,$712.30 ,85% of total billed charges for outpatient setting,$812.86 ,97% of total billed charges for outpatient setting,$460.90 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$754.20 ,90% of total billed charges for outpatient setting,$812.86 ,97% of total billed charges for outpatient setting,$812.86 ,97% of total billed charges for outpatient setting,$812.86 ,97% of total billed charges for outpatient setting,$712.30 ,85% of total billed charges for outpatient setting,$754.20 ,90% of total billed charges for outpatient setting,$712.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$796.10 ,90% of total billed charges for outpatient setting,$460.90 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$779.34 ,93% of total billed charges for outpatient setting,$460.90 ,$812.86 ,$628.50 
Outpatient Medical Services,RADIOLOGY,72148,MRI scan of lower spinal canal,611,"$3,081.00 ","$2,834.52 ",92% of total billed charges for outpatient setting,"$1,694.55 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,"$2,649.66 ",86% of total billed charges for outpatient setting,"$2,464.80 ",80% of total billed charges for outpatient setting,"$1,694.55 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$2,926.95 ",95% of total billed charges for outpatient setting,"$2,926.95 ",95% of total billed charges for outpatient setting,"$2,310.75 ",75% of total billed charges for outpatient setting,"$2,618.85 ",85% of total billed charges for outpatient setting,"$2,988.57 ",97% of total billed charges for outpatient setting,"$1,694.55 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$2,772.90 ",90% of total billed charges for outpatient setting,"$2,988.57 ",97% of total billed charges for outpatient setting,"$2,988.57 ",97% of total billed charges for outpatient setting,"$2,988.57 ",97% of total billed charges for outpatient setting,"$2,618.85 ",85% of total billed charges for outpatient setting,"$2,772.90 ",90% of total billed charges for outpatient setting,"$2,618.85 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$2,926.95 ",90% of total billed charges for outpatient setting,"$1,694.55 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$2,865.33 ",93% of total billed charges for outpatient setting,"$1,694.55 ","$2,988.57 ","$2,310.75 "
Outpatient Medical Services,RADIOLOGY,72193,"CT scan, pelvis, with contrast",352,"$2,343.00 ","$2,155.56 ",92% of total billed charges for outpatient setting,"$1,288.65 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,"$2,014.98 ",86% of total billed charges for outpatient setting,"$1,874.40 ",80% of total billed charges for outpatient setting,"$1,288.65 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$2,225.85 ",95% of total billed charges for outpatient setting,"$2,225.85 ",95% of total billed charges for outpatient setting,"$1,757.25 ",75% of total billed charges for outpatient setting,"$1,991.55 ",85% of total billed charges for outpatient setting,"$2,272.71 ",97% of total billed charges for outpatient setting,"$1,288.65 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$2,108.70 ",90% of total billed charges for outpatient setting,"$2,272.71 ",97% of total billed charges for outpatient setting,"$2,272.71 ",97% of total billed charges for outpatient setting,"$2,272.71 ",97% of total billed charges for outpatient setting,"$1,991.55 ",85% of total billed charges for outpatient setting,"$2,108.70 ",90% of total billed charges for outpatient setting,"$1,991.55 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$2,225.85 ",90% of total billed charges for outpatient setting,"$1,288.65 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$2,178.99 ",93% of total billed charges for outpatient setting,"$1,288.65 ","$2,272.71 ","$1,757.25 "
Outpatient Medical Services,RADIOLOGY,73721,MRI of lower extremity joint (knee/ankle) without dye,611,"$3,349.00 ","$3,081.08 ",92% of total billed charges for outpatient setting,"$1,841.95 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,"$2,880.14 ",86% of total billed charges for outpatient setting,"$2,679.20 ",80% of total billed charges for outpatient setting,"$1,841.95 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$3,181.55 ",95% of total billed charges for outpatient setting,"$3,181.55 ",95% of total billed charges for outpatient setting,"$2,511.75 ",75% of total billed charges for outpatient setting,"$2,846.65 ",85% of total billed charges for outpatient setting,"$3,248.53 ",97% of total billed charges for outpatient setting,"$1,841.95 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$3,014.10 ",90% of total billed charges for outpatient setting,"$3,248.53 ",97% of total billed charges for outpatient setting,"$3,248.53 ",97% of total billed charges for outpatient setting,"$3,248.53 ",97% of total billed charges for outpatient setting,"$2,846.65 ",85% of total billed charges for outpatient setting,"$3,014.10 ",90% of total billed charges for outpatient setting,"$2,846.65 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$3,181.55 ",90% of total billed charges for outpatient setting,"$1,841.95 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$3,114.57 ",93% of total billed charges for outpatient setting,"$1,841.95 ","$3,248.53 ","$2,511.75 "
Outpatient Medical Services,RADIOLOGY,74177,CT scan of abdomen and pelvis with contrast,352,"$3,868.00 ","$3,558.56 ",92% of total billed charges for outpatient setting,"$2,127.40 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,"$3,326.48 ",86% of total billed charges for outpatient setting,"$3,094.40 ",80% of total billed charges for outpatient setting,"$2,127.40 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$3,674.60 ",95% of total billed charges for outpatient setting,"$3,674.60 ",95% of total billed charges for outpatient setting,"$2,901.00 ",75% of total billed charges for outpatient setting,"$3,287.80 ",85% of total billed charges for outpatient setting,"$3,751.96 ",97% of total billed charges for outpatient setting,"$2,127.40 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$3,481.20 ",90% of total billed charges for outpatient setting,"$3,751.96 ",97% of total billed charges for outpatient setting,"$3,751.96 ",97% of total billed charges for outpatient setting,"$3,751.96 ",97% of total billed charges for outpatient setting,"$3,287.80 ",85% of total billed charges for outpatient setting,"$3,481.20 ",90% of total billed charges for outpatient setting,"$3,287.80 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$3,674.60 ",90% of total billed charges for outpatient setting,"$2,127.40 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$3,597.24 ",93% of total billed charges for outpatient setting,"$2,127.40 ","$3,751.96 ","$2,901.00 "
Outpatient Medical Services,RADIOLOGY,76700,Ultrasound of abdomen with all areas scanned,402,"$1,013.00 ",$931.96 ,92% of total billed charges for outpatient setting,$557.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$871.18 ,86% of total billed charges for outpatient setting,$810.40 ,80% of total billed charges for outpatient setting,$557.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$962.35 ,95% of total billed charges for outpatient setting,$962.35 ,95% of total billed charges for outpatient setting,$759.75 ,75% of total billed charges for outpatient setting,$861.05 ,85% of total billed charges for outpatient setting,$982.61 ,97% of total billed charges for outpatient setting,$557.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$911.70 ,90% of total billed charges for outpatient setting,$982.61 ,97% of total billed charges for outpatient setting,$982.61 ,97% of total billed charges for outpatient setting,$982.61 ,97% of total billed charges for outpatient setting,$861.05 ,85% of total billed charges for outpatient setting,$911.70 ,90% of total billed charges for outpatient setting,$861.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$962.35 ,90% of total billed charges for outpatient setting,$557.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$942.09 ,93% of total billed charges for outpatient setting,$557.15 ,$982.61 ,$759.75 
Outpatient Medical Services,RADIOLOGY,76805,Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus,402,"$1,254.00 ","$1,153.68 ",92% of total billed charges for outpatient setting,$689.70 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,"$1,078.44 ",86% of total billed charges for outpatient setting,"$1,003.20 ",80% of total billed charges for outpatient setting,$689.70 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$1,191.30 ",95% of total billed charges for outpatient setting,"$1,191.30 ",95% of total billed charges for outpatient setting,$940.50 ,75% of total billed charges for outpatient setting,"$1,065.90 ",85% of total billed charges for outpatient setting,"$1,216.38 ",97% of total billed charges for outpatient setting,$689.70 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$1,128.60 ",90% of total billed charges for outpatient setting,"$1,216.38 ",97% of total billed charges for outpatient setting,"$1,216.38 ",97% of total billed charges for outpatient setting,"$1,216.38 ",97% of total billed charges for outpatient setting,"$1,065.90 ",85% of total billed charges for outpatient setting,"$1,128.60 ",90% of total billed charges for outpatient setting,"$1,065.90 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$1,191.30 ",90% of total billed charges for outpatient setting,$689.70 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$1,166.22 ",93% of total billed charges for outpatient setting,$689.70 ,"$1,216.38 ",$940.50 
Outpatient Medical Services,RADIOLOGY,76830,Ultrasound of the pelvis through vagina,402,"$1,127.00 ","$1,036.84 ",92% of total billed charges for outpatient setting,$619.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$969.22 ,86% of total billed charges for outpatient setting,$901.60 ,80% of total billed charges for outpatient setting,$619.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$1,070.65 ",95% of total billed charges for outpatient setting,"$1,070.65 ",95% of total billed charges for outpatient setting,$845.25 ,75% of total billed charges for outpatient setting,$957.95 ,85% of total billed charges for outpatient setting,"$1,093.19 ",97% of total billed charges for outpatient setting,$619.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$1,014.30 ",90% of total billed charges for outpatient setting,"$1,093.19 ",97% of total billed charges for outpatient setting,"$1,093.19 ",97% of total billed charges for outpatient setting,"$1,093.19 ",97% of total billed charges for outpatient setting,$957.95 ,85% of total billed charges for outpatient setting,"$1,014.30 ",90% of total billed charges for outpatient setting,$957.95 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$1,070.65 ",90% of total billed charges for outpatient setting,$619.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$1,048.11 ",93% of total billed charges for outpatient setting,$619.85 ,"$1,093.19 ",$845.25 
Outpatient Medical Services,RADIOLOGY,77065,"Diagnostic mammography, including computer-aided detection (cad) when performed; unilateral",402,$213.00 ,$195.96 ,92% of total billed charges for outpatient setting,$117.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$183.18 ,86% of total billed charges for outpatient setting,$170.40 ,80% of total billed charges for outpatient setting,$117.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$202.35 ,95% of total billed charges for outpatient setting,$202.35 ,95% of total billed charges for outpatient setting,$159.75 ,75% of total billed charges for outpatient setting,$181.05 ,85% of total billed charges for outpatient setting,$206.61 ,97% of total billed charges for outpatient setting,$117.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$191.70 ,90% of total billed charges for outpatient setting,$206.61 ,97% of total billed charges for outpatient setting,$206.61 ,97% of total billed charges for outpatient setting,$206.61 ,97% of total billed charges for outpatient setting,$181.05 ,85% of total billed charges for outpatient setting,$191.70 ,90% of total billed charges for outpatient setting,$181.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$202.35 ,90% of total billed charges for outpatient setting,$117.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$198.09 ,93% of total billed charges for outpatient setting,$117.15 ,$206.61 ,$159.75 
Outpatient Medical Services,RADIOLOGY,77061,Mammography of One Breast/ Tomo,402,$298.00 ,$274.16 ,92% of total billed charges for outpatient setting,$163.90 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$256.28 ,86% of total billed charges for outpatient setting,$238.40 ,80% of total billed charges for outpatient setting,$163.90 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$283.10 ,95% of total billed charges for outpatient setting,$283.10 ,95% of total billed charges for outpatient setting,$223.50 ,75% of total billed charges for outpatient setting,$253.30 ,85% of total billed charges for outpatient setting,$289.06 ,97% of total billed charges for outpatient setting,$163.90 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$268.20 ,90% of total billed charges for outpatient setting,$289.06 ,97% of total billed charges for outpatient setting,$289.06 ,97% of total billed charges for outpatient setting,$289.06 ,97% of total billed charges for outpatient setting,$253.30 ,85% of total billed charges for outpatient setting,$268.20 ,90% of total billed charges for outpatient setting,$253.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$283.10 ,90% of total billed charges for outpatient setting,$163.90 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$277.14 ,93% of total billed charges for outpatient setting,$163.90 ,$289.06 ,$223.50 
Outpatient Medical Services,RADIOLOGY,77066,"Diagnostic mammography, including computer-aided detection (cad) when performed; bilateral",402,$271.00 ,$249.32 ,92% of total billed charges for outpatient setting,$149.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$233.06 ,86% of total billed charges for outpatient setting,$216.80 ,80% of total billed charges for outpatient setting,$149.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$257.45 ,95% of total billed charges for outpatient setting,$257.45 ,95% of total billed charges for outpatient setting,$203.25 ,75% of total billed charges for outpatient setting,$230.35 ,85% of total billed charges for outpatient setting,$262.87 ,97% of total billed charges for outpatient setting,$149.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$243.90 ,90% of total billed charges for outpatient setting,$262.87 ,97% of total billed charges for outpatient setting,$262.87 ,97% of total billed charges for outpatient setting,$262.87 ,97% of total billed charges for outpatient setting,$230.35 ,85% of total billed charges for outpatient setting,$243.90 ,90% of total billed charges for outpatient setting,$230.35 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$257.45 ,90% of total billed charges for outpatient setting,$149.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$252.03 ,93% of total billed charges for outpatient setting,$149.05 ,$262.87 ,$203.25 
Outpatient Medical Services,RADIOLOGY,77062,Mammography of Both Breasts W Tomo,402,$414.00 ,$380.88 ,92% of total billed charges for outpatient setting,$227.70 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$356.04 ,86% of total billed charges for outpatient setting,$331.20 ,80% of total billed charges for outpatient setting,$227.70 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$393.30 ,95% of total billed charges for outpatient setting,$393.30 ,95% of total billed charges for outpatient setting,$310.50 ,75% of total billed charges for outpatient setting,$351.90 ,85% of total billed charges for outpatient setting,$401.58 ,97% of total billed charges for outpatient setting,$227.70 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$372.60 ,90% of total billed charges for outpatient setting,$401.58 ,97% of total billed charges for outpatient setting,$401.58 ,97% of total billed charges for outpatient setting,$401.58 ,97% of total billed charges for outpatient setting,$351.90 ,85% of total billed charges for outpatient setting,$372.60 ,90% of total billed charges for outpatient setting,$351.90 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$393.30 ,90% of total billed charges for outpatient setting,$227.70 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$385.02 ,93% of total billed charges for outpatient setting,$227.70 ,$401.58 ,$310.50 
Outpatient Medical Services,RADIOLOGY,77067,Mammography of both breasts-2 or more views,403,$226.00 ,$207.92 ,92% of total billed charges for outpatient setting,$124.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$194.36 ,86% of total billed charges for outpatient setting,$180.80 ,80% of total billed charges for outpatient setting,$124.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$214.70 ,95% of total billed charges for outpatient setting,$214.70 ,95% of total billed charges for outpatient setting,$169.50 ,75% of total billed charges for outpatient setting,$192.10 ,85% of total billed charges for outpatient setting,$219.22 ,97% of total billed charges for outpatient setting,$124.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$203.40 ,90% of total billed charges for outpatient setting,$219.22 ,97% of total billed charges for outpatient setting,$219.22 ,97% of total billed charges for outpatient setting,$219.22 ,97% of total billed charges for outpatient setting,$192.10 ,85% of total billed charges for outpatient setting,$203.40 ,90% of total billed charges for outpatient setting,$192.10 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$214.70 ,90% of total billed charges for outpatient setting,$124.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$210.18 ,93% of total billed charges for outpatient setting,$124.30 ,$219.22 ,$169.50 
Outpatient Medical Services,RADIOLOGY,77063,"Mammography, Screening, Bilateral W/Tomo",403,$187.00 ,$172.04 ,92% of total billed charges for outpatient setting,$102.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$160.82 ,86% of total billed charges for outpatient setting,$149.60 ,80% of total billed charges for outpatient setting,$102.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$177.65 ,95% of total billed charges for outpatient setting,$177.65 ,95% of total billed charges for outpatient setting,$140.25 ,75% of total billed charges for outpatient setting,$158.95 ,85% of total billed charges for outpatient setting,$181.39 ,97% of total billed charges for outpatient setting,$102.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$168.30 ,90% of total billed charges for outpatient setting,$181.39 ,97% of total billed charges for outpatient setting,$181.39 ,97% of total billed charges for outpatient setting,$181.39 ,97% of total billed charges for outpatient setting,$158.95 ,85% of total billed charges for outpatient setting,$168.30 ,90% of total billed charges for outpatient setting,$158.95 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$177.65 ,90% of total billed charges for outpatient setting,$102.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$173.91 ,93% of total billed charges for outpatient setting,$102.85 ,$181.39 ,$140.25 
Outpatient Medical Services,RADIOLOGY,93306,"Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function",483,"$3,774.00 ","$3,472.08 ",92% of total billed charges for outpatient setting,"$2,075.70 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,"$3,245.64 ",86% of total billed charges for outpatient setting,"$3,019.20 ",80% of total billed charges for outpatient setting,"$2,075.70 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$3,585.30 ",95% of total billed charges for outpatient setting,"$3,585.30 ",95% of total billed charges for outpatient setting,"$2,830.50 ",75% of total billed charges for outpatient setting,"$3,207.90 ",85% of total billed charges for outpatient setting,"$3,660.78 ",97% of total billed charges for outpatient setting,"$2,075.70 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$3,396.60 ",90% of total billed charges for outpatient setting,"$3,660.78 ",97% of total billed charges for outpatient setting,"$3,660.78 ",97% of total billed charges for outpatient setting,"$3,660.78 ",97% of total billed charges for outpatient setting,"$3,207.90 ",85% of total billed charges for outpatient setting,"$3,396.60 ",90% of total billed charges for outpatient setting,"$3,207.90 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$3,585.30 ",90% of total billed charges for outpatient setting,"$2,075.70 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$3,509.82 ",93% of total billed charges for outpatient setting,"$2,075.70 ","$3,660.78 ","$2,830.50 "
Outpatient Medical Services,RADIOLOGY,93971,One sided or limited bilateral study,483,"$1,025.00 ",$943.00 ,92% of total billed charges for outpatient setting,$563.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$881.50 ,86% of total billed charges for outpatient setting,$820.00 ,80% of total billed charges for outpatient setting,$563.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$973.75 ,95% of total billed charges for outpatient setting,$973.75 ,95% of total billed charges for outpatient setting,$768.75 ,75% of total billed charges for outpatient setting,$871.25 ,85% of total billed charges for outpatient setting,$994.25 ,97% of total billed charges for outpatient setting,$563.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$922.50 ,90% of total billed charges for outpatient setting,$994.25 ,97% of total billed charges for outpatient setting,$994.25 ,97% of total billed charges for outpatient setting,$994.25 ,97% of total billed charges for outpatient setting,$871.25 ,85% of total billed charges for outpatient setting,$922.50 ,90% of total billed charges for outpatient setting,$871.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$973.75 ,90% of total billed charges for outpatient setting,$563.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$953.25 ,93% of total billed charges for outpatient setting,$563.75 ,$994.25 ,$768.75 
Outpatient Medical Services,RADIOLOGY,70551,MRI of brain stem without dye,611,"$3,449.00 ","$3,173.08 ",92% of total billed charges for outpatient setting,"$1,896.95 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,"$2,966.14 ",86% of total billed charges for outpatient setting,"$2,759.20 ",80% of total billed charges for outpatient setting,"$1,896.95 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$3,276.55 ",95% of total billed charges for outpatient setting,"$3,276.55 ",95% of total billed charges for outpatient setting,"$2,586.75 ",75% of total billed charges for outpatient setting,"$2,931.65 ",85% of total billed charges for outpatient setting,"$3,345.53 ",97% of total billed charges for outpatient setting,"$1,896.95 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$3,104.10 ",90% of total billed charges for outpatient setting,"$3,345.53 ",97% of total billed charges for outpatient setting,"$3,345.53 ",97% of total billed charges for outpatient setting,"$3,345.53 ",97% of total billed charges for outpatient setting,"$2,931.65 ",85% of total billed charges for outpatient setting,"$3,104.10 ",90% of total billed charges for outpatient setting,"$2,931.65 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$3,276.55 ",90% of total billed charges for outpatient setting,"$1,896.95 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$3,207.57 ",93% of total billed charges for outpatient setting,"$1,896.95 ","$3,345.53 ","$2,586.75 "
Outpatient Medical Services,RADIOLOGY,72141,MRI of the neck or spine without dye,612,"$3,298.00 ","$3,034.16 ",92% of total billed charges for outpatient setting,"$1,813.90 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,"$2,836.28 ",86% of total billed charges for outpatient setting,"$2,638.40 ",80% of total billed charges for outpatient setting,"$1,813.90 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$3,133.10 ",95% of total billed charges for outpatient setting,"$3,133.10 ",95% of total billed charges for outpatient setting,"$2,473.50 ",75% of total billed charges for outpatient setting,"$2,803.30 ",85% of total billed charges for outpatient setting,"$3,199.06 ",97% of total billed charges for outpatient setting,"$1,813.90 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$2,968.20 ",90% of total billed charges for outpatient setting,"$3,199.06 ",97% of total billed charges for outpatient setting,"$3,199.06 ",97% of total billed charges for outpatient setting,"$3,199.06 ",97% of total billed charges for outpatient setting,"$2,803.30 ",85% of total billed charges for outpatient setting,"$2,968.20 ",90% of total billed charges for outpatient setting,"$2,803.30 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$3,133.10 ",90% of total billed charges for outpatient setting,"$1,813.90 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$3,067.14 ",93% of total billed charges for outpatient setting,"$1,813.90 ","$3,199.06 ","$2,473.50 "
Outpatient Medical Services,RADIOLOGY,72156,MRI of neck/spine with and without dye,612,"$3,794.00 ","$3,490.48 ",92% of total billed charges for outpatient setting,"$2,086.70 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,"$3,262.84 ",86% of total billed charges for outpatient setting,"$3,035.20 ",80% of total billed charges for outpatient setting,"$2,086.70 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$3,604.30 ",95% of total billed charges for outpatient setting,"$3,604.30 ",95% of total billed charges for outpatient setting,"$2,845.50 ",75% of total billed charges for outpatient setting,"$3,224.90 ",85% of total billed charges for outpatient setting,"$3,680.18 ",97% of total billed charges for outpatient setting,"$2,086.70 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$3,414.60 ",90% of total billed charges for outpatient setting,"$3,680.18 ",97% of total billed charges for outpatient setting,"$3,680.18 ",97% of total billed charges for outpatient setting,"$3,680.18 ",97% of total billed charges for outpatient setting,"$3,224.90 ",85% of total billed charges for outpatient setting,"$3,414.60 ",90% of total billed charges for outpatient setting,"$3,224.90 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$3,604.30 ",90% of total billed charges for outpatient setting,"$2,086.70 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$3,528.42 ",93% of total billed charges for outpatient setting,"$2,086.70 ","$3,680.18 ","$2,845.50 "
Outpatient Medical Services,RADIOLOGY,72158,MRI of lower back with and without dye,612,"$3,794.00 ","$3,490.48 ",92% of total billed charges for outpatient setting,"$2,086.70 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,"$3,262.84 ",86% of total billed charges for outpatient setting,"$3,035.20 ",80% of total billed charges for outpatient setting,"$2,086.70 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$3,604.30 ",95% of total billed charges for outpatient setting,"$3,604.30 ",95% of total billed charges for outpatient setting,"$2,845.50 ",75% of total billed charges for outpatient setting,"$3,224.90 ",85% of total billed charges for outpatient setting,"$3,680.18 ",97% of total billed charges for outpatient setting,"$2,086.70 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$3,414.60 ",90% of total billed charges for outpatient setting,"$3,680.18 ",97% of total billed charges for outpatient setting,"$3,680.18 ",97% of total billed charges for outpatient setting,"$3,680.18 ",97% of total billed charges for outpatient setting,"$3,224.90 ",85% of total billed charges for outpatient setting,"$3,414.60 ",90% of total billed charges for outpatient setting,"$3,224.90 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$3,604.30 ",90% of total billed charges for outpatient setting,"$2,086.70 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$3,528.42 ",93% of total billed charges for outpatient setting,"$2,086.70 ","$3,680.18 ","$2,845.50 "
Outpatient Medical Services,RADIOLOGY,73218,MRI Upper Extremity w/o Contrast,614,"$3,136.00 ","$2,885.12 ",92% of total billed charges for outpatient setting,"$1,724.80 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,"$2,696.96 ",86% of total billed charges for outpatient setting,"$2,508.80 ",80% of total billed charges for outpatient setting,"$1,724.80 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$2,979.20 ",95% of total billed charges for outpatient setting,"$2,979.20 ",95% of total billed charges for outpatient setting,"$2,352.00 ",75% of total billed charges for outpatient setting,"$2,665.60 ",85% of total billed charges for outpatient setting,"$3,041.92 ",97% of total billed charges for outpatient setting,"$1,724.80 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$2,822.40 ",90% of total billed charges for outpatient setting,"$3,041.92 ",97% of total billed charges for outpatient setting,"$3,041.92 ",97% of total billed charges for outpatient setting,"$3,041.92 ",97% of total billed charges for outpatient setting,"$2,665.60 ",85% of total billed charges for outpatient setting,"$2,822.40 ",90% of total billed charges for outpatient setting,"$2,665.60 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$2,979.20 ",90% of total billed charges for outpatient setting,"$1,724.80 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$2,916.48 ",93% of total billed charges for outpatient setting,"$1,724.80 ","$3,041.92 ","$2,352.00 "
Outpatient Medical Services,RADIOLOGY,73221,MRI of upper extremity without dye,614,"$3,349.00 ","$3,081.08 ",92% of total billed charges for outpatient setting,"$1,841.95 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,"$2,880.14 ",86% of total billed charges for outpatient setting,"$2,679.20 ",80% of total billed charges for outpatient setting,"$1,841.95 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$3,181.55 ",95% of total billed charges for outpatient setting,"$3,181.55 ",95% of total billed charges for outpatient setting,"$2,511.75 ",75% of total billed charges for outpatient setting,"$2,846.65 ",85% of total billed charges for outpatient setting,"$3,248.53 ",97% of total billed charges for outpatient setting,"$1,841.95 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$3,014.10 ",90% of total billed charges for outpatient setting,"$3,248.53 ",97% of total billed charges for outpatient setting,"$3,248.53 ",97% of total billed charges for outpatient setting,"$3,248.53 ",97% of total billed charges for outpatient setting,"$2,846.65 ",85% of total billed charges for outpatient setting,"$3,014.10 ",90% of total billed charges for outpatient setting,"$2,846.65 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$3,181.55 ",90% of total billed charges for outpatient setting,"$1,841.95 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$3,114.57 ",93% of total billed charges for outpatient setting,"$1,841.95 ","$3,248.53 ","$2,511.75 "
Outpatient Medical Services,RADIOLOGY,76775,Ultrasound of back wall of the abdomen with limited areas viewed,402,$901.00 ,$828.92 ,92% of total billed charges for outpatient setting,$495.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$774.86 ,86% of total billed charges for outpatient setting,$720.80 ,80% of total billed charges for outpatient setting,$495.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$855.95 ,95% of total billed charges for outpatient setting,$855.95 ,95% of total billed charges for outpatient setting,$675.75 ,75% of total billed charges for outpatient setting,$765.85 ,85% of total billed charges for outpatient setting,$873.97 ,97% of total billed charges for outpatient setting,$495.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$810.90 ,90% of total billed charges for outpatient setting,$873.97 ,97% of total billed charges for outpatient setting,$873.97 ,97% of total billed charges for outpatient setting,$873.97 ,97% of total billed charges for outpatient setting,$765.85 ,85% of total billed charges for outpatient setting,$810.90 ,90% of total billed charges for outpatient setting,$765.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$855.95 ,90% of total billed charges for outpatient setting,$495.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$837.93 ,93% of total billed charges for outpatient setting,$495.55 ,$873.97 ,$675.75 
Outpatient Medical Services,RADIOLOGY,76942,US Breast Biopsy,402,$745.00 ,$685.40 ,92% of total billed charges for outpatient setting,$409.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$640.70 ,86% of total billed charges for outpatient setting,$596.00 ,80% of total billed charges for outpatient setting,$409.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$707.75 ,95% of total billed charges for outpatient setting,$707.75 ,95% of total billed charges for outpatient setting,$558.75 ,75% of total billed charges for outpatient setting,$633.25 ,85% of total billed charges for outpatient setting,$722.65 ,97% of total billed charges for outpatient setting,$409.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$670.50 ,90% of total billed charges for outpatient setting,$722.65 ,97% of total billed charges for outpatient setting,$722.65 ,97% of total billed charges for outpatient setting,$722.65 ,97% of total billed charges for outpatient setting,$633.25 ,85% of total billed charges for outpatient setting,$670.50 ,90% of total billed charges for outpatient setting,$633.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$707.75 ,90% of total billed charges for outpatient setting,$409.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$692.85 ,93% of total billed charges for outpatient setting,$409.75 ,$722.65 ,$558.75 
Outpatient Medical Services,RADIOLOGY,62323,Injection of substance into spinal canal of lower back or sacrum using imaging guidance,761,"$2,071.00 ","$1,905.32 ",92% of total billed charges for outpatient setting,"$1,139.05 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,"$1,781.06 ",86% of total billed charges for outpatient setting,"$1,656.80 ",80% of total billed charges for outpatient setting,"$1,139.05 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$1,967.45 ",95% of total billed charges for outpatient setting,"$1,967.45 ",95% of total billed charges for outpatient setting,"$1,553.25 ",75% of total billed charges for outpatient setting,"$1,760.35 ",85% of total billed charges for outpatient setting,"$2,008.87 ",97% of total billed charges for outpatient setting,"$1,139.05 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$1,863.90 ",90% of total billed charges for outpatient setting,"$2,008.87 ",97% of total billed charges for outpatient setting,"$2,008.87 ",97% of total billed charges for outpatient setting,"$2,008.87 ",97% of total billed charges for outpatient setting,"$1,760.35 ",85% of total billed charges for outpatient setting,"$1,863.90 ",90% of total billed charges for outpatient setting,"$1,760.35 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$1,967.45 ",90% of total billed charges for outpatient setting,"$1,139.05 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$1,926.03 ",93% of total billed charges for outpatient setting,"$1,139.05 ","$2,008.87 ","$1,553.25 "
Outpatient Medical Services,EMERGENCY SERVICES,51702,INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE,450,$211.00 ,$194.12 ,92% of total billed charges for outpatient setting,$116.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$181.46 ,86% of total billed charges for outpatient setting,$168.80 ,80% of total billed charges for outpatient setting,$116.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$200.45 ,95% of total billed charges for outpatient setting,$200.45 ,95% of total billed charges for outpatient setting,$158.25 ,75% of total billed charges for outpatient setting,$179.35 ,85% of total billed charges for outpatient setting,$204.67 ,97% of total billed charges for outpatient setting,$116.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$189.90 ,90% of total billed charges for outpatient setting,$204.67 ,97% of total billed charges for outpatient setting,$204.67 ,97% of total billed charges for outpatient setting,$204.67 ,97% of total billed charges for outpatient setting,$179.35 ,85% of total billed charges for outpatient setting,$189.90 ,90% of total billed charges for outpatient setting,$179.35 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$200.45 ,90% of total billed charges for outpatient setting,$116.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$196.23 ,93% of total billed charges for outpatient setting,$116.05 ,$204.67 ,$158.25 
Outpatient Medical Services,EMERGENCY SERVICES,99281,Emergency Department Level 1,450,$450.00 ,$414.00 ,92% of total billed charges for outpatient setting,$247.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$387.00 ,86% of total billed charges for ER visit,$360.00 ,80% of total billed charges for outpatient setting,$247.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$427.50 ,95% of total billed charges for outpatient setting,$427.50 ,95% of total billed charges for outpatient setting,$337.50 ,75% of total billed charges for outpatient setting,$382.50 ,85% of total billed charges for outpatient setting,$436.50 ,97% of total billed charges for outpatient setting,$247.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$405.00 ,90% of total billed charges for outpatient setting,$436.50 ,97% of total billed charges for outpatient setting,$436.50 ,97% of total billed charges for outpatient setting,$436.50 ,97% of total billed charges for outpatient setting,$382.50 ,85% of total billed charges for outpatient setting,$405.00 ,90% of total billed charges for outpatient setting,$382.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$427.50 ,90% of total billed charges for outpatient setting,$247.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$418.50 ,93% of total billed charges for outpatient setting,$247.50 ,$436.50 ,$337.50 
Outpatient Medical Services,EMERGENCY SERVICES,99282,Emergency Department Level 2,450,$450.00 ,$414.00 ,92% of total billed charges for outpatient setting,$247.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$387.00 ,86% of total billed charges for ER visit,$360.00 ,80% of total billed charges for outpatient setting,$247.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$427.50 ,95% of total billed charges for outpatient setting,$427.50 ,95% of total billed charges for outpatient setting,$337.50 ,75% of total billed charges for outpatient setting,$382.50 ,85% of total billed charges for outpatient setting,$436.50 ,97% of total billed charges for outpatient setting,$247.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$405.00 ,90% of total billed charges for outpatient setting,$436.50 ,97% of total billed charges for outpatient setting,$436.50 ,97% of total billed charges for outpatient setting,$436.50 ,97% of total billed charges for outpatient setting,$382.50 ,85% of total billed charges for outpatient setting,$405.00 ,90% of total billed charges for outpatient setting,$382.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$427.50 ,90% of total billed charges for outpatient setting,$247.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$418.50 ,93% of total billed charges for outpatient setting,$247.50 ,$436.50 ,$337.50 
Outpatient Medical Services,EMERGENCY SERVICES,99283,"Emergency department visit, moderately severe problem",450,$450.00 ,$414.00 ,92% of total billed charges for outpatient setting,$247.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$387.00 ,86% of total billed charges for ER visit,$360.00 ,80% of total billed charges for outpatient setting,$247.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$427.50 ,95% of total billed charges for outpatient setting,$427.50 ,95% of total billed charges for outpatient setting,$337.50 ,75% of total billed charges for outpatient setting,$382.50 ,85% of total billed charges for outpatient setting,$436.50 ,97% of total billed charges for outpatient setting,$247.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$405.00 ,90% of total billed charges for outpatient setting,$436.50 ,97% of total billed charges for outpatient setting,$436.50 ,97% of total billed charges for outpatient setting,$436.50 ,97% of total billed charges for outpatient setting,$382.50 ,85% of total billed charges for outpatient setting,$405.00 ,90% of total billed charges for outpatient setting,$382.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$427.50 ,90% of total billed charges for outpatient setting,$247.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$418.50 ,93% of total billed charges for outpatient setting,$247.50 ,$436.50 ,$337.50 
Outpatient Medical Services,EMERGENCY SERVICES,99284,"Emergency department visit, problem of high severity",450,$450.00 ,$414.00 ,92% of total billed charges for outpatient setting,$247.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$387.00 ,86% of total billed charges for ER visit,$360.00 ,80% of total billed charges for outpatient setting,$247.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$427.50 ,95% of total billed charges for outpatient setting,$427.50 ,95% of total billed charges for outpatient setting,$337.50 ,75% of total billed charges for outpatient setting,$382.50 ,85% of total billed charges for outpatient setting,$436.50 ,97% of total billed charges for outpatient setting,$247.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$405.00 ,90% of total billed charges for outpatient setting,$436.50 ,97% of total billed charges for outpatient setting,$436.50 ,97% of total billed charges for outpatient setting,$436.50 ,97% of total billed charges for outpatient setting,$382.50 ,85% of total billed charges for outpatient setting,$405.00 ,90% of total billed charges for outpatient setting,$382.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$427.50 ,90% of total billed charges for outpatient setting,$247.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$418.50 ,93% of total billed charges for outpatient setting,$247.50 ,$436.50 ,$337.50 
Outpatient Medical Services,EMERGENCY SERVICES,99285,"Emergency department visit, problem with significant threat to life or function",450,$450.00 ,$414.00 ,92% of total billed charges for outpatient setting,$247.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$387.00 ,86% of total billed charges for ER visit,$360.00 ,80% of total billed charges for outpatient setting,$247.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$427.50 ,95% of total billed charges for outpatient setting,$427.50 ,95% of total billed charges for outpatient setting,$337.50 ,75% of total billed charges for outpatient setting,$382.50 ,85% of total billed charges for outpatient setting,$436.50 ,97% of total billed charges for outpatient setting,$247.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$405.00 ,90% of total billed charges for outpatient setting,$436.50 ,97% of total billed charges for outpatient setting,$436.50 ,97% of total billed charges for outpatient setting,$436.50 ,97% of total billed charges for outpatient setting,$382.50 ,85% of total billed charges for outpatient setting,$405.00 ,90% of total billed charges for outpatient setting,$382.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$427.50 ,90% of total billed charges for outpatient setting,$247.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$418.50 ,93% of total billed charges for outpatient setting,$247.50 ,$436.50 ,$337.50 
Outpatient Medical Services,DAY SURGERY,62321,62321 INJ CERVICAL/THORACIC EPIDURAL W IMAGE,761,"$2,071.00 ","$1,905.32 ",92% of total billed charges for outpatient setting,"$1,139.05 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,"$1,781.06 ",86% of total billed charges for outpatient setting,"$1,656.80 ",80% of total billed charges for outpatient setting,"$1,139.05 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$1,967.45 ",95% of total billed charges for outpatient setting,"$1,967.45 ",95% of total billed charges for outpatient setting,"$1,553.25 ",75% of total billed charges for outpatient setting,"$1,760.35 ",85% of total billed charges for outpatient setting,"$2,008.87 ",97% of total billed charges for outpatient setting,"$1,139.05 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$1,863.90 ",90% of total billed charges for outpatient setting,"$2,008.87 ",97% of total billed charges for outpatient setting,"$2,008.87 ",97% of total billed charges for outpatient setting,"$2,008.87 ",97% of total billed charges for outpatient setting,"$1,760.35 ",85% of total billed charges for outpatient setting,"$1,863.90 ",90% of total billed charges for outpatient setting,"$1,760.35 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$1,967.45 ",90% of total billed charges for outpatient setting,"$1,139.05 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$1,926.03 ",93% of total billed charges for outpatient setting,"$1,139.05 ","$2,008.87 ","$1,553.25 "
Outpatient Medical Services,DAY SURGERY,27570,Fixation of Knee Joint,975,$507.00 ,$197.17 ,135% of 2011 CMS physician fee schedule,$158.61 ,100% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$188.12 ,100% of the Blue Cross physician fee schedule,$303.80 ,100% of Work Comp physician fee schedule. Multiple discount rules may apply,$158.61 ,100% CMS Medicare physician fee schedule ,$229.98 ,145% CMS Medicare physician fee schedule ,$481.65 ,95% of total billed charges for physician setting,,Not separately reimbursible. Not contracted for physician rates,$197.49 ,100% CMS Medicare physician fee schedule ,$221.27 ,100% Humana physician fee schedule,$158.61 ,100% CMS Medicare physician fee schedule ,$507.00 ,Not separately reimbursible. Not contracted for physician rates,,Not separately reimbursable per contract terms,$304.20 ,60% of total billed charges for physician settings,$304.20 ,60% of total billed charges for physician settings,$222.05 ,140% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$158.61 ,100% CMS Medicare physician fee schedule ,$481.65 ,95% of total billed charges,$158.61 ,100% CMS Medicare physician fee schedule ,$197.87 ,124.753% CMS Medicare physician fee schedule ,$158.61 ,$507.00 ,$380.25 
Outpatient Medical Services,DAY SURGERY,27570,Fixation of Knee Joint,360,$507.00 ,$466.44 ,92% of total billed charges for outpatient setting,$278.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$436.02 ,86% of total billed charges for outpatient setting,$405.60 ,80% of total billed charges for outpatient setting,$278.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$481.65 ,95% of total billed charges for outpatient setting,$481.65 ,95% of total billed charges for outpatient setting,$380.25 ,75% of total billed charges for outpatient setting,$430.95 ,85% of total billed charges for outpatient setting,$491.79 ,97% of total billed charges for outpatient setting,$278.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$456.30 ,90% of total billed charges for outpatient setting,$491.79 ,97% of total billed charges for outpatient setting,$491.79 ,97% of total billed charges for outpatient setting,$491.79 ,97% of total billed charges for outpatient setting,$430.95 ,85% of total billed charges for outpatient setting,$456.30 ,90% of total billed charges for outpatient setting,$430.95 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$481.65 ,90% of total billed charges for outpatient setting,$278.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$471.51 ,93% of total billed charges for outpatient setting,$278.85 ,$491.79 ,$380.25 
Outpatient Medical Services,DAY SURGERY,29870,Knee Arthroscopy Dx,975,$975.00 ,$543.06 ,135% of 2011 CMS physician fee schedule,$422.95 ,100% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$715.98 ,100% of the Blue Cross physician fee schedule,$826.70 ,100% of Work Comp physician fee schedule. Multiple discount rules may apply,$422.95 ,100% CMS Medicare physician fee schedule ,$613.28 ,145% CMS Medicare physician fee schedule ,$926.25 ,95% of total billed charges for physician setting,,Not separately reimbursible. Not contracted for physician rates,$526.38 ,100% CMS Medicare physician fee schedule ,$601.47 ,100% Humana physician fee schedule,$422.95 ,100% CMS Medicare physician fee schedule ,$975.00 ,Not separately reimbursible. Not contracted for physician rates,,Not separately reimbursable per contract terms,$585.00 ,60% of total billed charges for physician settings,$585.00 ,60% of total billed charges for physician settings,$592.13 ,140% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$422.95 ,100% CMS Medicare physician fee schedule ,$926.25 ,95% of total billed charges,$422.95 ,100% CMS Medicare physician fee schedule ,$527.64 ,124.753% CMS Medicare physician fee schedule ,$422.95 ,$975.00 ,$731.25 
Outpatient Medical Services,DAY SURGERY,29870,Knee Arthroscopy Dx,360,$975.00 ,$897.00 ,92% of total billed charges for outpatient setting,$536.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$838.50 ,86% of total billed charges for outpatient setting,$780.00 ,80% of total billed charges for outpatient setting,$536.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$926.25 ,95% of total billed charges for outpatient setting,$926.25 ,95% of total billed charges for outpatient setting,$731.25 ,75% of total billed charges for outpatient setting,$828.75 ,85% of total billed charges for outpatient setting,$945.75 ,97% of total billed charges for outpatient setting,$536.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$877.50 ,90% of total billed charges for outpatient setting,$945.75 ,97% of total billed charges for outpatient setting,$945.75 ,97% of total billed charges for outpatient setting,$945.75 ,97% of total billed charges for outpatient setting,$828.75 ,85% of total billed charges for outpatient setting,$877.50 ,90% of total billed charges for outpatient setting,$828.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$926.25 ,90% of total billed charges for outpatient setting,$536.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$906.75 ,93% of total billed charges for outpatient setting,$536.25 ,$945.75 ,$731.25 
Outpatient Medical Services,DAY SURGERY,29880,Surgery to remove of all or part of a torn meniscus in both medial and lateral compartments,975,"$1,995.00 ",$913.17 ,135% of 2011 CMS physician fee schedule,$583.07 ,100% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$700.09 ,100% of the Blue Cross physician fee schedule,"$1,133.30 ",100% of Work Comp physician fee schedule. Multiple discount rules may apply,$583.07 ,100% CMS Medicare physician fee schedule ,$845.45 ,145% CMS Medicare physician fee schedule ,"$1,895.25 ",95% of total billed charges for physician setting,,Not separately reimbursible. Not contracted for physician rates,$724.76 ,100% CMS Medicare physician fee schedule ,$823.49 ,100% Humana physician fee schedule,$583.07 ,100% CMS Medicare physician fee schedule ,"$1,995.00 ",Not separately reimbursible. Not contracted for physician rates,"$1,120.13 ",100% Midlands Choice physician fee schedule,"$1,197.00 ",60% of total billed charges for physician settings,"$1,197.00 ",60% of total billed charges for physician settings,$816.30 ,140% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$583.07 ,100% CMS Medicare physician fee schedule ,"$1,895.25 ",95% of total billed charges,$583.07 ,100% CMS Medicare physician fee schedule ,$727.40 ,124.753% CMS Medicare physician fee schedule ,$583.07 ,"$1,995.00 ","$1,496.25 "
Outpatient Medical Services,DAY SURGERY,29880,Surgery to remove of all or part of a torn meniscus in both medial and lateral compartments,360,"$9,700.00 ","$8,924.00 ",92% of total billed charges for outpatient setting,"$5,335.00 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,"$8,342.00 ",86% of total billed charges for outpatient setting,"$7,760.00 ",80% of total billed charges for outpatient setting,"$5,335.00 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$9,215.00 ",95% of total billed charges for outpatient setting,"$9,215.00 ",95% of total billed charges for outpatient setting,"$7,275.00 ",75% of total billed charges for outpatient setting,"$8,245.00 ",85% of total billed charges for outpatient setting,"$9,409.00 ",97% of total billed charges for outpatient setting,"$5,335.00 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$8,730.00 ",90% of total billed charges for outpatient setting,"$9,409.00 ",97% of total billed charges for outpatient setting,"$9,409.00 ",97% of total billed charges for outpatient setting,"$9,409.00 ",97% of total billed charges for outpatient setting,"$8,245.00 ",85% of total billed charges for outpatient setting,"$8,730.00 ",90% of total billed charges for outpatient setting,"$8,245.00 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$9,215.00 ",90% of total billed charges for outpatient setting,"$5,335.00 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$9,021.00 ",93% of total billed charges for outpatient setting,"$5,335.00 ","$9,409.00 ","$7,275.00 "
Outpatient Medical Services,DAY SURGERY,29888,ACL reconstruction,975,"$4,054.00 ","$1,307.92 ",135% of 2011 CMS physician fee schedule,"$1,007.60 ",100% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,"$1,221.07 ",100% of the Blue Cross physician fee schedule,"$1,982.40 ",100% of Work Comp physician fee schedule. Multiple discount rules may apply,"$1,007.60 ",100% CMS Medicare physician fee schedule ,"$1,461.02 ",145% CMS Medicare physician fee schedule ,"$3,851.30 ",95% of total billed charges for physician setting,,Not separately reimbursible. Not contracted for physician rates,"$1,249.99 ",100% CMS Medicare physician fee schedule ,"$1,436.67 ",100% Humana physician fee schedule,"$1,007.60 ",100% CMS Medicare physician fee schedule ,"$4,054.00 ",Not separately reimbursible. Not contracted for physician rates,"$1,961.18 ",100% Midlands Choice physician fee schedule,"$1,126.22 ",100% Multiplan physician fee schedule,"$1,126.22 ",100% Multiplan physician fee schedule,"$1,410.64 ",140% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,"$1,007.60 ",100% CMS Medicare physician fee schedule ,"$3,851.30 ",95% of total billed charges,"$1,007.60 ",100% CMS Medicare physician fee schedule ,"$1,257.01 ",124.753% CMS Medicare physician fee schedule ,"$1,007.60 ","$4,054.00 ","$3,040.50 "
Outpatient Medical Services,DAY SURGERY,29888,ACL reconstruction,360,"$4,054.00 ","$3,729.68 ",92% of total billed charges for outpatient setting,"$2,229.70 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,"$3,486.44 ",86% of total billed charges for outpatient setting,"$3,243.20 ",80% of total billed charges for outpatient setting,"$2,229.70 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$3,851.30 ",95% of total billed charges for outpatient setting,"$3,851.30 ",95% of total billed charges for outpatient setting,"$3,040.50 ",75% of total billed charges for outpatient setting,"$3,445.90 ",85% of total billed charges for outpatient setting,"$3,932.38 ",97% of total billed charges for outpatient setting,"$2,229.70 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$3,648.60 ",90% of total billed charges for outpatient setting,"$3,932.38 ",97% of total billed charges for outpatient setting,"$3,932.38 ",97% of total billed charges for outpatient setting,"$3,932.38 ",97% of total billed charges for outpatient setting,"$3,445.90 ",85% of total billed charges for outpatient setting,"$3,648.60 ",90% of total billed charges for outpatient setting,"$3,445.90 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$3,851.30 ",90% of total billed charges for outpatient setting,"$2,229.70 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$3,770.22 ",93% of total billed charges for outpatient setting,"$2,229.70 ","$3,932.38 ","$3,040.50 "
Outpatient Medical Services,DAY SURGERY,46200,"FISSURECTOMY, INCLUDING SPHINCTEROTOMY, WHEN PERFORMED",975,$975.00 ,$421.66 ,135% of 2011 CMS physician fee schedule,$352.78 ,100% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$579.40 ,100% of the Blue Cross physician fee schedule,$667.80 ,100% of Work Comp physician fee schedule. Multiple discount rules may apply,$352.78 ,100% CMS Medicare physician fee schedule ,$511.53 ,145% CMS Medicare physician fee schedule ,$926.25 ,95% of total billed charges for physician setting,,Not separately reimbursible. Not contracted for physician rates,$440.81 ,100% CMS Medicare physician fee schedule ,$487.93 ,100% Humana physician fee schedule,$352.78 ,100% CMS Medicare physician fee schedule ,$975.00 ,Not separately reimbursible. Not contracted for physician rates,,Not separately reimbursable per contract terms,$585.00 ,60% of total billed charges for physician settings,$585.00 ,60% of total billed charges for physician settings,$493.89 ,140% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$352.78 ,100% CMS Medicare physician fee schedule ,$926.25 ,95% of total billed charges,$352.78 ,100% CMS Medicare physician fee schedule ,$440.10 ,124.753% CMS Medicare physician fee schedule ,$352.78 ,$975.00 ,$731.25 
Outpatient Medical Services,DAY SURGERY,46200,"FISSURECTOMY, INCLUDING SPHINCTEROTOMY, WHEN PERFORMED",360,$975.00 ,$897.00 ,92% of total billed charges for outpatient setting,$536.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$838.50 ,86% of total billed charges for outpatient setting,$780.00 ,80% of total billed charges for outpatient setting,$536.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$926.25 ,95% of total billed charges for outpatient setting,$926.25 ,95% of total billed charges for outpatient setting,$731.25 ,75% of total billed charges for outpatient setting,$828.75 ,85% of total billed charges for outpatient setting,$945.75 ,97% of total billed charges for outpatient setting,$536.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$877.50 ,90% of total billed charges for outpatient setting,$945.75 ,97% of total billed charges for outpatient setting,$945.75 ,97% of total billed charges for outpatient setting,$945.75 ,97% of total billed charges for outpatient setting,$828.75 ,85% of total billed charges for outpatient setting,$877.50 ,90% of total billed charges for outpatient setting,$828.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$926.25 ,90% of total billed charges for outpatient setting,$536.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$906.75 ,93% of total billed charges for outpatient setting,$536.25 ,$945.75 ,$731.25 
Outpatient Medical Services,DAY SURGERY,46221,HEMORRHOIDECTOMY BY SIMPLE LIGATURE,975,$705.00 ,$249.59 ,135% of 2011 CMS physician fee schedule,$202.42 ,100% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$342.74 ,100% of the Blue Cross physician fee schedule,$386.40 ,100% of Work Comp physician fee schedule. Multiple discount rules may apply,$202.42 ,100% CMS Medicare physician fee schedule ,$293.51 ,145% CMS Medicare physician fee schedule ,$669.75 ,95% of total billed charges for physician setting,,Not separately reimbursible. Not contracted for physician rates,$252.86 ,100% CMS Medicare physician fee schedule ,$282.10 ,100% Humana physician fee schedule,$202.42 ,100% CMS Medicare physician fee schedule ,$705.00 ,Not separately reimbursible. Not contracted for physician rates,$386.49 ,100% Midlands Choice physician fee schedule,$423.00 ,60% of total billed charges for physician settings,$423.00 ,60% of total billed charges for physician settings,$283.39 ,140% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$202.42 ,100% CMS Medicare physician fee schedule ,$669.75 ,95% of total billed charges,$202.42 ,100% CMS Medicare physician fee schedule ,$252.53 ,124.753% CMS Medicare physician fee schedule ,$202.42 ,$705.00 ,$528.75 
Outpatient Medical Services,DAY SURGERY,46221,HEMORRHOIDECTOMY BY SIMPLE LIGATURE,360,"$7,335.00 ","$6,748.20 ",92% of total billed charges for outpatient setting,"$4,034.25 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,"$6,308.10 ",86% of total billed charges for outpatient setting,"$5,868.00 ",80% of total billed charges for outpatient setting,"$4,034.25 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$6,968.25 ",95% of total billed charges for outpatient setting,"$6,968.25 ",95% of total billed charges for outpatient setting,"$5,501.25 ",75% of total billed charges for outpatient setting,"$6,234.75 ",85% of total billed charges for outpatient setting,"$7,114.95 ",97% of total billed charges for outpatient setting,"$4,034.25 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$6,601.50 ",90% of total billed charges for outpatient setting,"$7,114.95 ",97% of total billed charges for outpatient setting,"$7,114.95 ",97% of total billed charges for outpatient setting,"$7,114.95 ",97% of total billed charges for outpatient setting,"$6,234.75 ",85% of total billed charges for outpatient setting,"$6,601.50 ",90% of total billed charges for outpatient setting,"$6,234.75 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$6,968.25 ",90% of total billed charges for outpatient setting,"$4,034.25 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$6,821.55 ",93% of total billed charges for outpatient setting,"$4,034.25 ","$7,114.95 ","$5,501.25 "
Outpatient Medical Services,DAY SURGERY,49560,Repair initial incisional or ventral hernia; reducible,975,"$2,544.00 ",$963.66 ,135% of 2011 CMS physician fee schedule,$761.78 ,100% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$921.71 ,100% of the Blue Cross physician fee schedule,"$1,505.00 ",100% of Work Comp physician fee schedule. Multiple discount rules may apply,$761.78 ,100% CMS Medicare physician fee schedule ,"$1,104.58 ",145% CMS Medicare physician fee schedule ,"$2,416.80 ",95% of total billed charges for physician setting,,Not separately reimbursible. Not contracted for physician rates,$939.30 ,100% CMS Medicare physician fee schedule ,"$1,084.16 ",100% Humana physician fee schedule,$761.78 ,100% CMS Medicare physician fee schedule ,"$2,544.00 ",Not separately reimbursible. Not contracted for physician rates,"$1,455.70 ",100% Midlands Choice physician fee schedule,"$1,526.40 ",60% of total billed charges for physician settings,"$1,526.40 ",60% of total billed charges for physician settings,"$1,066.49 ",140% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$761.78 ,100% CMS Medicare physician fee schedule ,"$2,416.80 ",95% of total billed charges,$761.78 ,100% CMS Medicare physician fee schedule ,$950.34 ,124.753% CMS Medicare physician fee schedule ,$761.78 ,"$2,544.00 ","$1,908.00 "
Outpatient Medical Services,DAY SURGERY,49560,Repair initial incisional or ventral hernia; reducible,360,"$2,544.00 ","$2,340.48 ",92% of total billed charges for outpatient setting,"$1,399.20 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,"$2,187.84 ",86% of total billed charges for outpatient setting,"$2,035.20 ",80% of total billed charges for outpatient setting,"$1,399.20 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$2,416.80 ",95% of total billed charges for outpatient setting,"$2,416.80 ",95% of total billed charges for outpatient setting,"$1,908.00 ",75% of total billed charges for outpatient setting,"$2,162.40 ",85% of total billed charges for outpatient setting,"$2,467.68 ",97% of total billed charges for outpatient setting,"$1,399.20 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$2,289.60 ",90% of total billed charges for outpatient setting,"$2,467.68 ",97% of total billed charges for outpatient setting,"$2,467.68 ",97% of total billed charges for outpatient setting,"$2,467.68 ",97% of total billed charges for outpatient setting,"$2,162.40 ",85% of total billed charges for outpatient setting,"$2,289.60 ",90% of total billed charges for outpatient setting,"$2,162.40 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$2,416.80 ",90% of total billed charges for outpatient setting,"$1,399.20 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$2,365.92 ",93% of total billed charges for outpatient setting,"$1,399.20 ","$2,467.68 ","$1,908.00 "
Outpatient Medical Services,DAY SURGERY,64447,"Injection(s), anesthetic agent(s) and/or steroid; femoral ne",964,$229.00 ,$88.48 ,135% of 2011 CMS physician fee schedule,$53.39 ,100% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$110.38 ,100% of the Blue Cross physician fee schedule,$107.10 ,100% of Work Comp physician fee schedule. Multiple discount rules may apply,$53.39 ,100% CMS Medicare physician fee schedule ,$77.42 ,145% CMS Medicare physician fee schedule ,$217.55 ,95% of total billed charges for physician setting,,Not separately reimbursible. Not contracted for physician rates,$66.41 ,100% CMS Medicare physician fee schedule ,$77.43 ,100% Humana physician fee schedule,$53.39 ,100% CMS Medicare physician fee schedule ,$229.00 ,Not separately reimbursible. Not contracted for physician rates,,Not separately reimbursable per contract terms,$137.40 ,60% of total billed charges for physician settings,$137.40 ,60% of total billed charges for physician settings,$74.75 ,140% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$53.39 ,100% CMS Medicare physician fee schedule ,$217.55 ,95% of total billed charges,$53.39 ,100% CMS Medicare physician fee schedule ,$66.61 ,124.753% CMS Medicare physician fee schedule ,$53.39 ,$229.00 ,$171.75 
Outpatient Medical Services,DAY SURGERY,64721,Release of the transverse carpal ligament,360,"$8,900.00 ","$8,188.00 ",92% of total billed charges for outpatient setting,"$4,895.00 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,"$7,654.00 ",86% of total billed charges for outpatient setting,"$7,120.00 ",80% of total billed charges for outpatient setting,"$4,895.00 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$8,455.00 ",95% of total billed charges for outpatient setting,"$8,455.00 ",95% of total billed charges for outpatient setting,"$6,675.00 ",75% of total billed charges for outpatient setting,"$7,565.00 ",85% of total billed charges for outpatient setting,"$8,633.00 ",97% of total billed charges for outpatient setting,"$4,895.00 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$8,010.00 ",90% of total billed charges for outpatient setting,"$8,633.00 ",97% of total billed charges for outpatient setting,"$8,633.00 ",97% of total billed charges for outpatient setting,"$8,633.00 ",97% of total billed charges for outpatient setting,"$7,565.00 ",85% of total billed charges for outpatient setting,"$8,010.00 ",90% of total billed charges for outpatient setting,"$7,565.00 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$8,455.00 ",90% of total billed charges for outpatient setting,"$4,895.00 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$8,277.00 ",93% of total billed charges for outpatient setting,"$4,895.00 ","$8,633.00 ","$6,675.00 "
Outpatient Medical Services,DAY SURGERY,62323,Injection of substance into spinal canal of lower back or sacrum using imaging guidance,761,"$2,071.00 ","$1,905.32 ",92% of total billed charges for outpatient setting,"$1,139.05 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,"$1,781.06 ",86% of total billed charges for outpatient setting,"$1,656.80 ",80% of total billed charges for outpatient setting,"$1,139.05 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$1,967.45 ",95% of total billed charges for outpatient setting,"$1,967.45 ",95% of total billed charges for outpatient setting,"$1,553.25 ",75% of total billed charges for outpatient setting,"$1,760.35 ",85% of total billed charges for outpatient setting,"$2,008.87 ",97% of total billed charges for outpatient setting,"$1,139.05 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$1,863.90 ",90% of total billed charges for outpatient setting,"$2,008.87 ",97% of total billed charges for outpatient setting,"$2,008.87 ",97% of total billed charges for outpatient setting,"$2,008.87 ",97% of total billed charges for outpatient setting,"$1,760.35 ",85% of total billed charges for outpatient setting,"$1,863.90 ",90% of total billed charges for outpatient setting,"$1,760.35 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$1,967.45 ",90% of total billed charges for outpatient setting,"$1,139.05 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$1,926.03 ",93% of total billed charges for outpatient setting,"$1,139.05 ","$2,008.87 ","$1,553.25 "
Outpatient Medical Services,OUTPATIENT SERVICES,96360,"IV INF,HYDRATION,1ST HR. CHARGE",260,$305.00 ,$280.60 ,92% of total billed charges for outpatient setting,$167.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$262.30 ,86% of total billed charges for outpatient setting,$244.00 ,80% of total billed charges for outpatient setting,$167.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$289.75 ,95% of total billed charges for outpatient setting,$289.75 ,95% of total billed charges for outpatient setting,$228.75 ,75% of total billed charges for outpatient setting,$259.25 ,85% of total billed charges for outpatient setting,$295.85 ,97% of total billed charges for outpatient setting,$167.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$274.50 ,90% of total billed charges for outpatient setting,$295.85 ,97% of total billed charges for outpatient setting,$295.85 ,97% of total billed charges for outpatient setting,$295.85 ,97% of total billed charges for outpatient setting,$259.25 ,85% of total billed charges for outpatient setting,$274.50 ,90% of total billed charges for outpatient setting,$259.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$289.75 ,90% of total billed charges for outpatient setting,$167.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$283.65 ,93% of total billed charges for outpatient setting,$167.75 ,$295.85 ,$228.75 
Outpatient Medical Services,OUTPATIENT SERVICES,96361,IV INFUSION HYDRATION EACH ADDITIONAL HOUR,260,$126.00 ,$115.92 ,92% of total billed charges for outpatient setting,$69.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$108.36 ,86% of total billed charges for outpatient setting,$100.80 ,80% of total billed charges for outpatient setting,$69.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$119.70 ,95% of total billed charges for outpatient setting,$119.70 ,95% of total billed charges for outpatient setting,$94.50 ,75% of total billed charges for outpatient setting,$107.10 ,85% of total billed charges for outpatient setting,$122.22 ,97% of total billed charges for outpatient setting,$69.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$113.40 ,90% of total billed charges for outpatient setting,$122.22 ,97% of total billed charges for outpatient setting,$122.22 ,97% of total billed charges for outpatient setting,$122.22 ,97% of total billed charges for outpatient setting,$107.10 ,85% of total billed charges for outpatient setting,$113.40 ,90% of total billed charges for outpatient setting,$107.10 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$119.70 ,90% of total billed charges for outpatient setting,$69.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$117.18 ,93% of total billed charges for outpatient setting,$69.30 ,$122.22 ,$94.50 
Outpatient Medical Services,OUTPATIENT SERVICES,96365,"Intravenous infusion, for therapy, prophylaxis, or diagnosis-initial infusion",260,$652.00 ,$599.84 ,92% of total billed charges for outpatient setting,$358.60 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$560.72 ,86% of total billed charges for outpatient setting,$521.60 ,80% of total billed charges for outpatient setting,$358.60 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$619.40 ,95% of total billed charges for outpatient setting,$619.40 ,95% of total billed charges for outpatient setting,$489.00 ,75% of total billed charges for outpatient setting,$554.20 ,85% of total billed charges for outpatient setting,$632.44 ,97% of total billed charges for outpatient setting,$358.60 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$586.80 ,90% of total billed charges for outpatient setting,$632.44 ,97% of total billed charges for outpatient setting,$632.44 ,97% of total billed charges for outpatient setting,$632.44 ,97% of total billed charges for outpatient setting,$554.20 ,85% of total billed charges for outpatient setting,$586.80 ,90% of total billed charges for outpatient setting,$554.20 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$619.40 ,90% of total billed charges for outpatient setting,$358.60 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$606.36 ,93% of total billed charges for outpatient setting,$358.60 ,$632.44 ,$489.00 
Outpatient Medical Services,OUTPATIENT SERVICES,96366,"Intravenous infusion, for therapy, prophylaxis, or diagnosis-additional infusions",260,$126.00 ,$115.92 ,92% of total billed charges for outpatient setting,$69.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$108.36 ,86% of total billed charges for outpatient setting,$100.80 ,80% of total billed charges for outpatient setting,$69.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$119.70 ,95% of total billed charges for outpatient setting,$119.70 ,95% of total billed charges for outpatient setting,$94.50 ,75% of total billed charges for outpatient setting,$107.10 ,85% of total billed charges for outpatient setting,$122.22 ,97% of total billed charges for outpatient setting,$69.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$113.40 ,90% of total billed charges for outpatient setting,$122.22 ,97% of total billed charges for outpatient setting,$122.22 ,97% of total billed charges for outpatient setting,$122.22 ,97% of total billed charges for outpatient setting,$107.10 ,85% of total billed charges for outpatient setting,$113.40 ,90% of total billed charges for outpatient setting,$107.10 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$119.70 ,90% of total billed charges for outpatient setting,$69.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$117.18 ,93% of total billed charges for outpatient setting,$69.30 ,$122.22 ,$94.50 
Outpatient Medical Services,OUTPATIENT SERVICES,96367,ADD SEQUENTIAL INFUSION UP TO 1HR CHARGE,260,$198.00 ,$182.16 ,92% of total billed charges for outpatient setting,$108.90 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$170.28 ,86% of total billed charges for outpatient setting,$158.40 ,80% of total billed charges for outpatient setting,$108.90 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$188.10 ,95% of total billed charges for outpatient setting,$188.10 ,95% of total billed charges for outpatient setting,$148.50 ,75% of total billed charges for outpatient setting,$168.30 ,85% of total billed charges for outpatient setting,$192.06 ,97% of total billed charges for outpatient setting,$108.90 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$178.20 ,90% of total billed charges for outpatient setting,$192.06 ,97% of total billed charges for outpatient setting,$192.06 ,97% of total billed charges for outpatient setting,$192.06 ,97% of total billed charges for outpatient setting,$168.30 ,85% of total billed charges for outpatient setting,$178.20 ,90% of total billed charges for outpatient setting,$168.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$188.10 ,90% of total billed charges for outpatient setting,$108.90 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$184.14 ,93% of total billed charges for outpatient setting,$108.90 ,$192.06 ,$148.50 
Outpatient Medical Services,OUTPATIENT SERVICES,96372,INJECTION SUBCUTANEOUS  OR INTRAMUSCULAR CHARGE,260,$189.00 ,$173.88 ,92% of total billed charges for outpatient setting,$103.95 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$162.54 ,86% of total billed charges for outpatient setting,$151.20 ,80% of total billed charges for outpatient setting,$103.95 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$25.00 ,100% of Cigna Behavioral Health fee schedule,$179.55 ,95% of total billed charges for outpatient setting,$141.75 ,75% of total billed charges for outpatient setting,$160.65 ,85% of total billed charges for outpatient setting,$183.33 ,97% of total billed charges for outpatient setting,$103.95 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$170.10 ,90% of total billed charges for outpatient setting,$183.33 ,97% of total billed charges for outpatient setting,$183.33 ,97% of total billed charges for outpatient setting,$183.33 ,97% of total billed charges for outpatient setting,$160.65 ,85% of total billed charges for outpatient setting,$170.10 ,90% of total billed charges for outpatient setting,$160.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$179.55 ,90% of total billed charges for outpatient setting,$103.95 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$175.77 ,93% of total billed charges for outpatient setting,$25.00 ,$183.33 ,$141.75 
Outpatient Medical Services,OUTPATIENT SERVICES,96374,"Intravenous infusion, for therapy, prophylaxis, or diagnosis-IV push",260,$290.00 ,$266.80 ,92% of total billed charges for outpatient setting,$159.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$249.40 ,86% of total billed charges for outpatient setting,$232.00 ,80% of total billed charges for outpatient setting,$159.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$275.50 ,95% of total billed charges for outpatient setting,$275.50 ,95% of total billed charges for outpatient setting,$217.50 ,75% of total billed charges for outpatient setting,$246.50 ,85% of total billed charges for outpatient setting,$281.30 ,97% of total billed charges for outpatient setting,$159.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$261.00 ,90% of total billed charges for outpatient setting,$281.30 ,97% of total billed charges for outpatient setting,$281.30 ,97% of total billed charges for outpatient setting,$281.30 ,97% of total billed charges for outpatient setting,$246.50 ,85% of total billed charges for outpatient setting,$261.00 ,90% of total billed charges for outpatient setting,$246.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$275.50 ,90% of total billed charges for outpatient setting,$159.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$269.70 ,93% of total billed charges for outpatient setting,$159.50 ,$281.30 ,$217.50 
Outpatient Medical Services,OUTPATIENT SERVICES,96375,"Intravenous infusion, for treatment, prophylaxis, or diagnosis-new drug add on",260,$126.00 ,$115.92 ,92% of total billed charges for outpatient setting,$69.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$108.36 ,86% of total billed charges for outpatient setting,$100.80 ,80% of total billed charges for outpatient setting,$69.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$119.70 ,95% of total billed charges for outpatient setting,$119.70 ,95% of total billed charges for outpatient setting,$94.50 ,75% of total billed charges for outpatient setting,$107.10 ,85% of total billed charges for outpatient setting,$122.22 ,97% of total billed charges for outpatient setting,$69.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$113.40 ,90% of total billed charges for outpatient setting,$122.22 ,97% of total billed charges for outpatient setting,$122.22 ,97% of total billed charges for outpatient setting,$122.22 ,97% of total billed charges for outpatient setting,$107.10 ,85% of total billed charges for outpatient setting,$113.40 ,90% of total billed charges for outpatient setting,$107.10 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$119.70 ,90% of total billed charges for outpatient setting,$69.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$117.18 ,93% of total billed charges for outpatient setting,$69.30 ,$122.22 ,$94.50 
Outpatient Medical Services,OUTPATIENT SERVICES,96376,"Intravenous infusion, for treatment, prophylaxis, or diagnosis-same drug add on",260,$54.00 ,$49.68 ,92% of total billed charges for outpatient setting,$29.70 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$46.44 ,86% of total billed charges for outpatient setting,$43.20 ,80% of total billed charges for outpatient setting,$29.70 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$51.30 ,95% of total billed charges for outpatient setting,$51.30 ,95% of total billed charges for outpatient setting,$40.50 ,75% of total billed charges for outpatient setting,$45.90 ,85% of total billed charges for outpatient setting,$52.38 ,97% of total billed charges for outpatient setting,$29.70 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$48.60 ,90% of total billed charges for outpatient setting,$52.38 ,97% of total billed charges for outpatient setting,$52.38 ,97% of total billed charges for outpatient setting,$52.38 ,97% of total billed charges for outpatient setting,$45.90 ,85% of total billed charges for outpatient setting,$48.60 ,90% of total billed charges for outpatient setting,$45.90 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$51.30 ,90% of total billed charges for outpatient setting,$29.70 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$50.22 ,93% of total billed charges for outpatient setting,$29.70 ,$52.38 ,$40.50 
Outpatient Medical Services,OUTPATIENT SERVICES,96523,PORT MAINTENANCE CHARGE,260,$190.00 ,$174.80 ,92% of total billed charges for outpatient setting,$104.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$163.40 ,86% of total billed charges for outpatient setting,$152.00 ,80% of total billed charges for outpatient setting,$104.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$180.50 ,95% of total billed charges for outpatient setting,$180.50 ,95% of total billed charges for outpatient setting,$142.50 ,75% of total billed charges for outpatient setting,$161.50 ,85% of total billed charges for outpatient setting,$184.30 ,97% of total billed charges for outpatient setting,$104.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$171.00 ,90% of total billed charges for outpatient setting,$184.30 ,97% of total billed charges for outpatient setting,$184.30 ,97% of total billed charges for outpatient setting,$184.30 ,97% of total billed charges for outpatient setting,$161.50 ,85% of total billed charges for outpatient setting,$171.00 ,90% of total billed charges for outpatient setting,$161.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$180.50 ,90% of total billed charges for outpatient setting,$104.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$176.70 ,93% of total billed charges for outpatient setting,$104.50 ,$184.30 ,$142.50 
Outpatient Medical Services,OUTPATIENT SERVICES,94640,UPDRAFT TREATMENT,410,$63.00 ,$57.96 ,92% of total billed charges for outpatient setting,$34.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$54.18 ,86% of total billed charges for outpatient setting,$50.40 ,80% of total billed charges for outpatient setting,$34.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$59.85 ,95% of total billed charges for outpatient setting,$59.85 ,95% of total billed charges for outpatient setting,$47.25 ,75% of total billed charges for outpatient setting,$53.55 ,85% of total billed charges for outpatient setting,$61.11 ,97% of total billed charges for outpatient setting,$34.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$56.70 ,90% of total billed charges for outpatient setting,$61.11 ,97% of total billed charges for outpatient setting,$61.11 ,97% of total billed charges for outpatient setting,$61.11 ,97% of total billed charges for outpatient setting,$53.55 ,85% of total billed charges for outpatient setting,$56.70 ,90% of total billed charges for outpatient setting,$53.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$59.85 ,90% of total billed charges for outpatient setting,$34.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$58.59 ,93% of total billed charges for outpatient setting,$34.65 ,$61.11 ,$47.25 
Outpatient Medical Services,OUTPATIENT SERVICES,94762,Pulse Oximetry Continuous,460,$419.00 ,$385.48 ,92% of total billed charges for outpatient setting,$230.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$360.34 ,86% of total billed charges for outpatient setting,$335.20 ,80% of total billed charges for outpatient setting,$230.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$398.05 ,95% of total billed charges for outpatient setting,$398.05 ,95% of total billed charges for outpatient setting,$314.25 ,75% of total billed charges for outpatient setting,$356.15 ,85% of total billed charges for outpatient setting,$406.43 ,97% of total billed charges for outpatient setting,$230.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$377.10 ,90% of total billed charges for outpatient setting,$406.43 ,97% of total billed charges for outpatient setting,$406.43 ,97% of total billed charges for outpatient setting,$406.43 ,97% of total billed charges for outpatient setting,$356.15 ,85% of total billed charges for outpatient setting,$377.10 ,90% of total billed charges for outpatient setting,$356.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$398.05 ,90% of total billed charges for outpatient setting,$230.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$389.67 ,93% of total billed charges for outpatient setting,$230.45 ,$406.43 ,$314.25 
Outpatient Medical Services,OUTPATIENT SERVICES,93017,Stress Test,482,"$1,150.00 ","$1,058.00 ",92% of total billed charges for outpatient setting,$632.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$989.00 ,86% of total billed charges for outpatient setting,$920.00 ,80% of total billed charges for outpatient setting,$632.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$1,092.50 ",95% of total billed charges for outpatient setting,"$1,092.50 ",95% of total billed charges for outpatient setting,$862.50 ,75% of total billed charges for outpatient setting,$977.50 ,85% of total billed charges for outpatient setting,"$1,115.50 ",97% of total billed charges for outpatient setting,$632.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$1,035.00 ",90% of total billed charges for outpatient setting,"$1,115.50 ",97% of total billed charges for outpatient setting,"$1,115.50 ",97% of total billed charges for outpatient setting,"$1,115.50 ",97% of total billed charges for outpatient setting,$977.50 ,85% of total billed charges for outpatient setting,"$1,035.00 ",90% of total billed charges for outpatient setting,$977.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$1,092.50 ",90% of total billed charges for outpatient setting,$632.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$1,069.50 ",93% of total billed charges for outpatient setting,$632.50 ,"$1,115.50 ",$862.50 
Outpatient Medical Services,OUTPATIENT SERVICES,36591,Blood Draw from Port Charge,761,$88.00 ,$80.96 ,92% of total billed charges for outpatient setting,$48.40 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$75.68 ,86% of total billed charges for outpatient setting,$70.40 ,80% of total billed charges for outpatient setting,$48.40 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$83.60 ,95% of total billed charges for outpatient setting,$83.60 ,95% of total billed charges for outpatient setting,$66.00 ,75% of total billed charges for outpatient setting,$74.80 ,85% of total billed charges for outpatient setting,$85.36 ,97% of total billed charges for outpatient setting,$48.40 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$79.20 ,90% of total billed charges for outpatient setting,$85.36 ,97% of total billed charges for outpatient setting,$85.36 ,97% of total billed charges for outpatient setting,$85.36 ,97% of total billed charges for outpatient setting,$74.80 ,85% of total billed charges for outpatient setting,$79.20 ,90% of total billed charges for outpatient setting,$74.80 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$83.60 ,90% of total billed charges for outpatient setting,$48.40 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$81.84 ,93% of total billed charges for outpatient setting,$48.40 ,$85.36 ,$66.00 
Outpatient Medical Services,OUTPATIENT SERVICES,62323,Injection of substance into spinal canal of lower back or sacrum using imaging guidance,761,"$2,071.00 ","$1,905.32 ",92% of total billed charges for outpatient setting,"$1,139.05 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,"$1,781.06 ",86% of total billed charges for outpatient setting,"$1,656.80 ",80% of total billed charges for outpatient setting,"$1,139.05 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$1,967.45 ",95% of total billed charges for outpatient setting,"$1,967.45 ",95% of total billed charges for outpatient setting,"$1,553.25 ",75% of total billed charges for outpatient setting,"$1,760.35 ",85% of total billed charges for outpatient setting,"$2,008.87 ",97% of total billed charges for outpatient setting,"$1,139.05 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$1,863.90 ",90% of total billed charges for outpatient setting,"$2,008.87 ",97% of total billed charges for outpatient setting,"$2,008.87 ",97% of total billed charges for outpatient setting,"$2,008.87 ",97% of total billed charges for outpatient setting,"$1,760.35 ",85% of total billed charges for outpatient setting,"$1,863.90 ",90% of total billed charges for outpatient setting,"$1,760.35 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$1,967.45 ",90% of total billed charges for outpatient setting,"$1,139.05 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$1,926.03 ",93% of total billed charges for outpatient setting,"$1,139.05 ","$2,008.87 ","$1,553.25 "
Outpatient Medical Services,OUTPATIENT SERVICES,93798,Use of EKG to monitor cardiac rehabilitation,943,$398.00 ,$366.16 ,92% of total billed charges for outpatient setting,$218.90 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$342.28 ,86% of total billed charges for outpatient setting,$318.40 ,80% of total billed charges for outpatient setting,$218.90 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$378.10 ,95% of total billed charges for outpatient setting,$378.10 ,95% of total billed charges for outpatient setting,$298.50 ,75% of total billed charges for outpatient setting,$338.30 ,85% of total billed charges for outpatient setting,$386.06 ,97% of total billed charges for outpatient setting,$218.90 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$358.20 ,90% of total billed charges for outpatient setting,$386.06 ,97% of total billed charges for outpatient setting,$386.06 ,97% of total billed charges for outpatient setting,$386.06 ,97% of total billed charges for outpatient setting,$338.30 ,85% of total billed charges for outpatient setting,$358.20 ,90% of total billed charges for outpatient setting,$338.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$378.10 ,90% of total billed charges for outpatient setting,$218.90 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$370.14 ,93% of total billed charges for outpatient setting,$218.90 ,$386.06 ,$298.50 
Outpatient Medical Services,OUTPATIENT SERVICES,90791,"A diagnostic tool employed by a psychiatrist to diagnose problems with memory, thought processes, and behaviors",961,$373.00 ,,Not separately reimbursable per contract terms,$154.16 ,100% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$83.00 ,100% of the Blue Cross physician fee schedule,$373.00 ,100% of Work Comp physician fee schedule. Multiple discount rules may apply,$154.16 ,100% CMS Medicare physician fee schedule ,$223.53 ,145% CMS Medicare physician fee schedule ,$354.35 ,95% of total billed charges for physician setting,,Not separately reimbursible. Not contracted for physician rates,$192.28 ,100% CMS Medicare physician fee schedule ,$179.05 ,100% Humana physician fee schedule,$154.16 ,100% CMS Medicare physician fee schedule ,$373.00 ,Not separately reimbursible. Not contracted for physician rates,$220.28 ,100% Midlands Choice physician fee schedule,$223.80 ,60% of total billed charges for physician settings,$223.80 ,60% of total billed charges for physician settings,$215.82 ,140% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$154.16 ,100% CMS Medicare physician fee schedule ,$354.35 ,95% of total billed charges,$154.16 ,100% CMS Medicare physician fee schedule ,$192.32 ,124.753% CMS Medicare physician fee schedule ,$83.00 ,$373.00 ,$279.75 
Outpatient Medical Services,OUTPATIENT SERVICES,20610,Draining or injecting medication into a major joint/bursa without ultrasound,981,$510.00 ,$66.26 ,135% of 2011 CMS physician fee schedule,$46.11 ,100% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$76.88 ,100% of the Blue Cross physician fee schedule,$92.40 ,100% of Work Comp physician fee schedule. Multiple discount rules may apply,$46.11 ,100% CMS Medicare physician fee schedule ,$66.86 ,145% CMS Medicare physician fee schedule ,$484.50 ,95% of total billed charges for physician setting,,Not separately reimbursible. Not contracted for physician rates,$57.18 ,100% CMS Medicare physician fee schedule ,$66.81 ,100% Humana physician fee schedule,$46.11 ,100% CMS Medicare physician fee schedule ,$510.00 ,Not separately reimbursible. Not contracted for physician rates,$92.59 ,100% Midlands Choice physician fee schedule,$52.34 ,100% Multiplan physician fee schedule,$52.34 ,100% Multiplan physician fee schedule,$64.55 ,140% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$46.11 ,100% CMS Medicare physician fee schedule ,$484.50 ,95% of total billed charges,$46.11 ,100% CMS Medicare physician fee schedule ,$57.52 ,124.753% CMS Medicare physician fee schedule ,$46.11 ,$510.00 ,$382.50 
Outpatient Medical Services,OUTPATIENT SERVICES,99217,OBSERVATION CARE DISCHARGE MANAGEMENT ProFee,982,$240.00 ,$94.41 ,135% of 2011 CMS physician fee schedule,$72.13 ,100% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$88.48 ,100% of the Blue Cross physician fee schedule,$114.80 ,100% of Work Comp physician fee schedule. Multiple discount rules may apply,$72.13 ,100% CMS Medicare physician fee schedule ,$104.59 ,145% CMS Medicare physician fee schedule ,$228.00 ,95% of total billed charges for physician setting,,Not separately reimbursible. Not contracted for physician rates,$90.05 ,100% CMS Medicare physician fee schedule ,$104.27 ,100% Humana physician fee schedule,$72.13 ,100% CMS Medicare physician fee schedule ,$240.00 ,Not separately reimbursible. Not contracted for physician rates,$122.24 ,100% Midlands Choice physician fee schedule,$144.00 ,60% of total billed charges for physician settings,$144.00 ,60% of total billed charges for physician settings,$100.98 ,140% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$72.13 ,100% CMS Medicare physician fee schedule ,$228.00 ,95% of total billed charges,$72.13 ,100% CMS Medicare physician fee schedule ,$89.98 ,124.753% CMS Medicare physician fee schedule ,$72.13 ,$240.00 ,$180.00 
Outpatient Medical Services,OUTPATIENT SERVICES,99219,LEVEL 2 Initial Observation Care,982,$437.00 ,$147.04 ,135% of 2011 CMS physician fee schedule,$133.06 ,100% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$165.36 ,100% of the Blue Cross physician fee schedule,$214.48 ,100% of Work Comp physician fee schedule. Multiple discount rules may apply,$133.06 ,100% CMS Medicare physician fee schedule ,$192.94 ,145% CMS Medicare physician fee schedule ,$415.15 ,95% of total billed charges for physician setting,,Not separately reimbursible. Not contracted for physician rates,$165.75 ,100% CMS Medicare physician fee schedule ,$194.40 ,100% Humana physician fee schedule,$133.06 ,100% CMS Medicare physician fee schedule ,$437.00 ,Not separately reimbursible. Not contracted for physician rates,$227.68 ,100% Midlands Choice physician fee schedule,$262.20 ,60% of total billed charges for physician settings,$262.20 ,60% of total billed charges for physician settings,$186.28 ,140% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$133.06 ,100% CMS Medicare physician fee schedule ,$415.15 ,95% of total billed charges,$133.06 ,100% CMS Medicare physician fee schedule ,$166.00 ,124.753% CMS Medicare physician fee schedule ,$133.06 ,$437.00 ,$327.75 
Outpatient Medical Services,OUTPATIENT SERVICES,59025,A common prenatal test used to check on a baby's health.,920,$548.00 ,$504.16 ,92% of total billed charges for outpatient setting,$301.40 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$471.28 ,86% of total billed charges for outpatient setting,$438.40 ,80% of total billed charges for outpatient setting,$301.40 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$520.60 ,95% of total billed charges for outpatient setting,$520.60 ,95% of total billed charges for outpatient setting,$411.00 ,75% of total billed charges for outpatient setting,$465.80 ,85% of total billed charges for outpatient setting,$531.56 ,97% of total billed charges for outpatient setting,$301.40 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$493.20 ,90% of total billed charges for outpatient setting,$531.56 ,97% of total billed charges for outpatient setting,$531.56 ,97% of total billed charges for outpatient setting,$531.56 ,97% of total billed charges for outpatient setting,$465.80 ,85% of total billed charges for outpatient setting,$493.20 ,90% of total billed charges for outpatient setting,$465.80 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$520.60 ,90% of total billed charges for outpatient setting,$301.40 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$509.64 ,93% of total billed charges for outpatient setting,$301.40 ,$531.56 ,$411.00 
Outpatient Medical Services,OUTPATIENT SERVICES,93005,Electrocardiogram (EKG) Routine Tracing Only,730,$270.00 ,$248.40 ,92% of total billed charges for outpatient setting,$148.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$232.20 ,86% of total billed charges for outpatient setting,$216.00 ,80% of total billed charges for outpatient setting,$148.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$256.50 ,95% of total billed charges for outpatient setting,$256.50 ,95% of total billed charges for outpatient setting,$202.50 ,75% of total billed charges for outpatient setting,$229.50 ,85% of total billed charges for outpatient setting,$261.90 ,97% of total billed charges for outpatient setting,$148.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$243.00 ,90% of total billed charges for outpatient setting,$261.90 ,97% of total billed charges for outpatient setting,$261.90 ,97% of total billed charges for outpatient setting,$261.90 ,97% of total billed charges for outpatient setting,$229.50 ,85% of total billed charges for outpatient setting,$243.00 ,90% of total billed charges for outpatient setting,$229.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$256.50 ,90% of total billed charges for outpatient setting,$148.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$251.10 ,93% of total billed charges for outpatient setting,$148.50 ,$261.90 ,$202.50 
Outpatient Medical Services,OUTPATIENT SERVICES,64483,Injections of anesthetic and/or steroid drug into lower or sacral spine nerve root using imaging guidance,761,"$2,690.00 ","$2,474.80 ",92% of total billed charges for outpatient setting,"$1,479.50 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,"$2,313.40 ",86% of total billed charges for outpatient setting,"$2,152.00 ",80% of total billed charges for outpatient setting,"$1,479.50 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$2,555.50 ",95% of total billed charges for outpatient setting,"$2,555.50 ",95% of total billed charges for outpatient setting,"$2,017.50 ",75% of total billed charges for outpatient setting,"$2,286.50 ",85% of total billed charges for outpatient setting,"$2,609.30 ",97% of total billed charges for outpatient setting,"$1,479.50 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$2,421.00 ",90% of total billed charges for outpatient setting,"$2,609.30 ",97% of total billed charges for outpatient setting,"$2,609.30 ",97% of total billed charges for outpatient setting,"$2,609.30 ",97% of total billed charges for outpatient setting,"$2,286.50 ",85% of total billed charges for outpatient setting,"$2,421.00 ",90% of total billed charges for outpatient setting,"$2,286.50 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$2,555.50 ",90% of total billed charges for outpatient setting,"$1,479.50 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$2,501.70 ",93% of total billed charges for outpatient setting,"$1,479.50 ","$2,609.30 ","$2,017.50 "
Outpatient Medical Services,OUTPATIENT SERVICES,94060,Test to determine if wheezing is present,460,$537.00 ,$494.04 ,92% of total billed charges for outpatient setting,$295.35 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$461.82 ,86% of total billed charges for outpatient setting,$429.60 ,80% of total billed charges for outpatient setting,$295.35 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$510.15 ,95% of total billed charges for outpatient setting,$510.15 ,95% of total billed charges for outpatient setting,$402.75 ,75% of total billed charges for outpatient setting,$456.45 ,85% of total billed charges for outpatient setting,$520.89 ,97% of total billed charges for outpatient setting,$295.35 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$483.30 ,90% of total billed charges for outpatient setting,$520.89 ,97% of total billed charges for outpatient setting,$520.89 ,97% of total billed charges for outpatient setting,$520.89 ,97% of total billed charges for outpatient setting,$456.45 ,85% of total billed charges for outpatient setting,$483.30 ,90% of total billed charges for outpatient setting,$456.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$510.15 ,90% of total billed charges for outpatient setting,$295.35 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$499.41 ,93% of total billed charges for outpatient setting,$295.35 ,$520.89 ,$402.75 
Outpatient Medical Services,OUTPATIENT SERVICES,94010,Test to determine how well oxygen moves from the lungs to the blood stream,460,$221.00 ,$203.32 ,92% of total billed charges for outpatient setting,$121.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$190.06 ,86% of total billed charges for outpatient setting,$176.80 ,80% of total billed charges for outpatient setting,$121.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$209.95 ,95% of total billed charges for outpatient setting,$209.95 ,95% of total billed charges for outpatient setting,$165.75 ,75% of total billed charges for outpatient setting,$187.85 ,85% of total billed charges for outpatient setting,$214.37 ,97% of total billed charges for outpatient setting,$121.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$198.90 ,90% of total billed charges for outpatient setting,$214.37 ,97% of total billed charges for outpatient setting,$214.37 ,97% of total billed charges for outpatient setting,$214.37 ,97% of total billed charges for outpatient setting,$187.85 ,85% of total billed charges for outpatient setting,$198.90 ,90% of total billed charges for outpatient setting,$187.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$209.95 ,90% of total billed charges for outpatient setting,$121.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$205.53 ,93% of total billed charges for outpatient setting,$121.55 ,$214.37 ,$165.75 
Outpatient Medical Services,OUTPATIENT SERVICES,93225,Holter Monitor,731,$348.00 ,$320.16 ,92% of total billed charges for outpatient setting,$191.40 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$299.28 ,86% of total billed charges for outpatient setting,$278.40 ,80% of total billed charges for outpatient setting,$191.40 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$330.60 ,95% of total billed charges for outpatient setting,$330.60 ,95% of total billed charges for outpatient setting,$261.00 ,75% of total billed charges for outpatient setting,$295.80 ,85% of total billed charges for outpatient setting,$337.56 ,97% of total billed charges for outpatient setting,$191.40 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$313.20 ,90% of total billed charges for outpatient setting,$337.56 ,97% of total billed charges for outpatient setting,$337.56 ,97% of total billed charges for outpatient setting,$337.56 ,97% of total billed charges for outpatient setting,$295.80 ,85% of total billed charges for outpatient setting,$313.20 ,90% of total billed charges for outpatient setting,$295.80 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$330.60 ,90% of total billed charges for outpatient setting,$191.40 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$323.64 ,93% of total billed charges for outpatient setting,$191.40 ,$337.56 ,$261.00 
Outpatient Medical Services,OUTPATIENT SERVICES,93270,Event Monitor,731,$348.00 ,$320.16 ,92% of total billed charges for outpatient setting,$191.40 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$299.28 ,86% of total billed charges for outpatient setting,$278.40 ,80% of total billed charges for outpatient setting,$191.40 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$330.60 ,95% of total billed charges for outpatient setting,$330.60 ,95% of total billed charges for outpatient setting,$261.00 ,75% of total billed charges for outpatient setting,$295.80 ,85% of total billed charges for outpatient setting,$337.56 ,97% of total billed charges for outpatient setting,$191.40 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$313.20 ,90% of total billed charges for outpatient setting,$337.56 ,97% of total billed charges for outpatient setting,$337.56 ,97% of total billed charges for outpatient setting,$337.56 ,97% of total billed charges for outpatient setting,$295.80 ,85% of total billed charges for outpatient setting,$313.20 ,90% of total billed charges for outpatient setting,$295.80 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$330.60 ,90% of total billed charges for outpatient setting,$191.40 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$323.64 ,93% of total billed charges for outpatient setting,$191.40 ,$337.56 ,$261.00 
Outpatient Medical Services,OUTPATIENT SERVICES,97802,MEDICAL NUTRITION THERAPY INITIAL 15 MIN CHARGE,942,$72.00 ,$66.24 ,92% of total billed charges for outpatient setting,$39.60 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$61.92 ,86% of total billed charges for outpatient setting,$57.60 ,80% of total billed charges for outpatient setting,$39.60 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$68.40 ,95% of total billed charges for outpatient setting,$68.40 ,95% of total billed charges for outpatient setting,$54.00 ,75% of total billed charges for outpatient setting,$61.20 ,85% of total billed charges for outpatient setting,$69.84 ,97% of total billed charges for outpatient setting,$39.60 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$64.80 ,90% of total billed charges for outpatient setting,$69.84 ,97% of total billed charges for outpatient setting,$69.84 ,97% of total billed charges for outpatient setting,$69.84 ,97% of total billed charges for outpatient setting,$61.20 ,85% of total billed charges for outpatient setting,$64.80 ,90% of total billed charges for outpatient setting,$61.20 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$68.40 ,90% of total billed charges for outpatient setting,$39.60 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$66.96 ,93% of total billed charges for outpatient setting,$39.60 ,$69.84 ,$54.00 
Outpatient Medical Services,OUTPATIENT SERVICES,97803,MEDICAL NUTRITION THERAPY REASSESSMENT 15 MIN CHARGE,942,$45.00 ,$41.40 ,92% of total billed charges for outpatient setting,$24.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$38.70 ,86% of total billed charges for outpatient setting,$36.00 ,80% of total billed charges for outpatient setting,$24.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$42.75 ,95% of total billed charges for outpatient setting,$42.75 ,95% of total billed charges for outpatient setting,$33.75 ,75% of total billed charges for outpatient setting,$38.25 ,85% of total billed charges for outpatient setting,$43.65 ,97% of total billed charges for outpatient setting,$24.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$40.50 ,90% of total billed charges for outpatient setting,$43.65 ,97% of total billed charges for outpatient setting,$43.65 ,97% of total billed charges for outpatient setting,$43.65 ,97% of total billed charges for outpatient setting,$38.25 ,85% of total billed charges for outpatient setting,$40.50 ,90% of total billed charges for outpatient setting,$38.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$42.75 ,90% of total billed charges for outpatient setting,$24.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$41.85 ,93% of total billed charges for outpatient setting,$24.75 ,$43.65 ,$33.75 
Outpatient Medical Services,LABORATORY,36415,Collection of venous blood by venipuncture,300,$33.00 ,$30.36 ,92% of total billed charges for outpatient setting,$18.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$1.32 ,44% of CMS Medicare lab fee schedule,$26.40 ,80% of total billed charges for outpatient setting,$18.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$31.35 ,95% of total billed charges for outpatient setting,$31.35 ,95% of total billed charges for outpatient setting,$24.75 ,75% of total billed charges for outpatient setting,$28.05 ,85% of total billed charges for outpatient setting,$32.01 ,97% of total billed charges for outpatient setting,$18.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$29.70 ,90% of total billed charges for outpatient setting,$32.01 ,97% of total billed charges for outpatient setting,$32.01 ,97% of total billed charges for outpatient setting,$32.01 ,97% of total billed charges for outpatient setting,$28.05 ,85% of total billed charges for outpatient setting,$29.70 ,90% of total billed charges for outpatient setting,$28.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$31.35 ,90% of total billed charges for outpatient setting,$18.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$30.69 ,93% of total billed charges for outpatient setting,$1.32 ,$32.01 ,$24.75 
Outpatient Medical Services,LABORATORY,36416,Collection: Capillary,300,$21.00 ,$19.32 ,92% of total billed charges for outpatient setting,$11.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$18.06 ,86% of total billed charges for outpatient setting,$16.80 ,80% of total billed charges for outpatient setting,$11.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$19.95 ,95% of total billed charges for outpatient setting,$19.95 ,95% of total billed charges for outpatient setting,$15.75 ,75% of total billed charges for outpatient setting,$17.85 ,85% of total billed charges for outpatient setting,$20.37 ,97% of total billed charges for outpatient setting,$11.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$18.90 ,90% of total billed charges for outpatient setting,$20.37 ,97% of total billed charges for outpatient setting,$20.37 ,97% of total billed charges for outpatient setting,$20.37 ,97% of total billed charges for outpatient setting,$17.85 ,85% of total billed charges for outpatient setting,$18.90 ,90% of total billed charges for outpatient setting,$17.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$19.95 ,90% of total billed charges for outpatient setting,$11.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$19.53 ,93% of total billed charges for outpatient setting,$11.55 ,$20.37 ,$15.75 
Outpatient Medical Services,LABORATORY,80306,Drug Screen Panel,300,$70.00 ,$64.40 ,92% of total billed charges for outpatient setting,$38.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$7.54 ,44% of CMS Medicare lab fee schedule,$56.00 ,80% of total billed charges for outpatient setting,$38.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$66.50 ,95% of total billed charges for outpatient setting,$66.50 ,95% of total billed charges for outpatient setting,$52.50 ,75% of total billed charges for outpatient setting,$59.50 ,85% of total billed charges for outpatient setting,$67.90 ,97% of total billed charges for outpatient setting,$38.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$63.00 ,90% of total billed charges for outpatient setting,$67.90 ,97% of total billed charges for outpatient setting,$67.90 ,97% of total billed charges for outpatient setting,$67.90 ,97% of total billed charges for outpatient setting,$59.50 ,85% of total billed charges for outpatient setting,$63.00 ,90% of total billed charges for outpatient setting,$59.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$66.50 ,90% of total billed charges for outpatient setting,$38.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$65.10 ,93% of total billed charges for outpatient setting,$7.54 ,$67.90 ,$52.50 
Outpatient Medical Services,LABORATORY,80143,Acetaminophen Level,300,$256.00 ,$235.52 ,92% of total billed charges for outpatient setting,$140.80 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$8.20 ,44% of CMS Medicare lab fee schedule,$204.80 ,80% of total billed charges for outpatient setting,$140.80 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$243.20 ,95% of total billed charges for outpatient setting,$243.20 ,95% of total billed charges for outpatient setting,$192.00 ,75% of total billed charges for outpatient setting,$217.60 ,85% of total billed charges for outpatient setting,$248.32 ,97% of total billed charges for outpatient setting,$140.80 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$230.40 ,90% of total billed charges for outpatient setting,$248.32 ,97% of total billed charges for outpatient setting,$248.32 ,97% of total billed charges for outpatient setting,$248.32 ,97% of total billed charges for outpatient setting,$217.60 ,85% of total billed charges for outpatient setting,$230.40 ,90% of total billed charges for outpatient setting,$217.60 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$243.20 ,90% of total billed charges for outpatient setting,$140.80 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$238.08 ,93% of total billed charges for outpatient setting,$8.20 ,$248.32 ,$192.00 
Outpatient Medical Services,LABORATORY,80320,Alcohol Level,300,$179.00 ,$164.68 ,92% of total billed charges for outpatient setting,$98.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$153.94 ,86% of total billed charges for outpatient setting,$143.20 ,80% of total billed charges for outpatient setting,$98.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$170.05 ,95% of total billed charges for outpatient setting,$170.05 ,95% of total billed charges for outpatient setting,$134.25 ,75% of total billed charges for outpatient setting,$152.15 ,85% of total billed charges for outpatient setting,$173.63 ,97% of total billed charges for outpatient setting,$98.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$161.10 ,90% of total billed charges for outpatient setting,$173.63 ,97% of total billed charges for outpatient setting,$173.63 ,97% of total billed charges for outpatient setting,$173.63 ,97% of total billed charges for outpatient setting,$152.15 ,85% of total billed charges for outpatient setting,$161.10 ,90% of total billed charges for outpatient setting,$152.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$170.05 ,90% of total billed charges for outpatient setting,$98.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$166.47 ,93% of total billed charges for outpatient setting,$98.45 ,$173.63 ,$134.25 
Outpatient Medical Services,LABORATORY,81015,Urinalysis Microscopic,300,$31.00 ,$28.52 ,92% of total billed charges for outpatient setting,$17.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$1.34 ,44% of CMS Medicare lab fee schedule,$24.80 ,80% of total billed charges for outpatient setting,$17.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$29.45 ,95% of total billed charges for outpatient setting,$29.45 ,95% of total billed charges for outpatient setting,$23.25 ,75% of total billed charges for outpatient setting,$26.35 ,85% of total billed charges for outpatient setting,$30.07 ,97% of total billed charges for outpatient setting,$17.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$27.90 ,90% of total billed charges for outpatient setting,$30.07 ,97% of total billed charges for outpatient setting,$30.07 ,97% of total billed charges for outpatient setting,$30.07 ,97% of total billed charges for outpatient setting,$26.35 ,85% of total billed charges for outpatient setting,$27.90 ,90% of total billed charges for outpatient setting,$26.35 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$29.45 ,90% of total billed charges for outpatient setting,$17.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$28.83 ,93% of total billed charges for outpatient setting,$1.34 ,$30.07 ,$23.25 
Outpatient Medical Services,LABORATORY,81025,Urine pregnancy test,300,$46.00 ,$42.32 ,92% of total billed charges for outpatient setting,$25.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$3.79 ,44% of CMS Medicare lab fee schedule,$36.80 ,80% of total billed charges for outpatient setting,$25.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$43.70 ,95% of total billed charges for outpatient setting,$43.70 ,95% of total billed charges for outpatient setting,$34.50 ,75% of total billed charges for outpatient setting,$39.10 ,85% of total billed charges for outpatient setting,$44.62 ,97% of total billed charges for outpatient setting,$25.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$41.40 ,90% of total billed charges for outpatient setting,$44.62 ,97% of total billed charges for outpatient setting,$44.62 ,97% of total billed charges for outpatient setting,$44.62 ,97% of total billed charges for outpatient setting,$39.10 ,85% of total billed charges for outpatient setting,$41.40 ,90% of total billed charges for outpatient setting,$39.10 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$43.70 ,90% of total billed charges for outpatient setting,$25.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$42.78 ,93% of total billed charges for outpatient setting,$3.79 ,$44.62 ,$34.50 
Outpatient Medical Services,LABORATORY,82043,Urine test to measure albumin,300,$130.00 ,$119.60 ,92% of total billed charges for outpatient setting,$71.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$2.54 ,44% of CMS Medicare lab fee schedule,$104.00 ,80% of total billed charges for outpatient setting,$71.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$123.50 ,95% of total billed charges for outpatient setting,$123.50 ,95% of total billed charges for outpatient setting,$97.50 ,75% of total billed charges for outpatient setting,$110.50 ,85% of total billed charges for outpatient setting,$126.10 ,97% of total billed charges for outpatient setting,$71.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$117.00 ,90% of total billed charges for outpatient setting,$126.10 ,97% of total billed charges for outpatient setting,$126.10 ,97% of total billed charges for outpatient setting,$126.10 ,97% of total billed charges for outpatient setting,$110.50 ,85% of total billed charges for outpatient setting,$117.00 ,90% of total billed charges for outpatient setting,$110.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$123.50 ,90% of total billed charges for outpatient setting,$71.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$120.90 ,93% of total billed charges for outpatient setting,$2.54 ,$126.10 ,$97.50 
Outpatient Medical Services,LABORATORY,82150,Amylase Level,300,$77.00 ,$70.84 ,92% of total billed charges for outpatient setting,$42.35 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$2.85 ,44% of CMS Medicare lab fee schedule,$61.60 ,80% of total billed charges for outpatient setting,$42.35 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$73.15 ,95% of total billed charges for outpatient setting,$73.15 ,95% of total billed charges for outpatient setting,$57.75 ,75% of total billed charges for outpatient setting,$65.45 ,85% of total billed charges for outpatient setting,$74.69 ,97% of total billed charges for outpatient setting,$42.35 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$69.30 ,90% of total billed charges for outpatient setting,$74.69 ,97% of total billed charges for outpatient setting,$74.69 ,97% of total billed charges for outpatient setting,$74.69 ,97% of total billed charges for outpatient setting,$65.45 ,85% of total billed charges for outpatient setting,$69.30 ,90% of total billed charges for outpatient setting,$65.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$73.15 ,90% of total billed charges for outpatient setting,$42.35 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$71.61 ,93% of total billed charges for outpatient setting,$2.85 ,$74.69 ,$57.75 
Outpatient Medical Services,LABORATORY,82306,Blood test to monitor vitamin D levels,300,$131.00 ,$120.52 ,92% of total billed charges for outpatient setting,$72.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$13.02 ,44% of CMS Medicare lab fee schedule,$104.80 ,80% of total billed charges for outpatient setting,$72.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$124.45 ,95% of total billed charges for outpatient setting,$124.45 ,95% of total billed charges for outpatient setting,$98.25 ,75% of total billed charges for outpatient setting,$111.35 ,85% of total billed charges for outpatient setting,$127.07 ,97% of total billed charges for outpatient setting,$72.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$117.90 ,90% of total billed charges for outpatient setting,$127.07 ,97% of total billed charges for outpatient setting,$127.07 ,97% of total billed charges for outpatient setting,$127.07 ,97% of total billed charges for outpatient setting,$111.35 ,85% of total billed charges for outpatient setting,$117.90 ,90% of total billed charges for outpatient setting,$111.35 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$124.45 ,90% of total billed charges for outpatient setting,$72.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$121.83 ,93% of total billed charges for outpatient setting,$13.02 ,$127.07 ,$98.25 
Outpatient Medical Services,LABORATORY,82378,Carcinoembryonic Antigen (CEA),300,$184.00 ,$169.28 ,92% of total billed charges for outpatient setting,$101.20 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$8.34 ,44% of CMS Medicare lab fee schedule,$147.20 ,80% of total billed charges for outpatient setting,$101.20 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$174.80 ,95% of total billed charges for outpatient setting,$174.80 ,95% of total billed charges for outpatient setting,$138.00 ,75% of total billed charges for outpatient setting,$156.40 ,85% of total billed charges for outpatient setting,$178.48 ,97% of total billed charges for outpatient setting,$101.20 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$165.60 ,90% of total billed charges for outpatient setting,$178.48 ,97% of total billed charges for outpatient setting,$178.48 ,97% of total billed charges for outpatient setting,$178.48 ,97% of total billed charges for outpatient setting,$156.40 ,85% of total billed charges for outpatient setting,$165.60 ,90% of total billed charges for outpatient setting,$156.40 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$174.80 ,90% of total billed charges for outpatient setting,$101.20 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$171.12 ,93% of total billed charges for outpatient setting,$8.34 ,$178.48 ,$138.00 
Outpatient Medical Services,LABORATORY,82550,Creatine Kinase,300,$147.00 ,$135.24 ,92% of total billed charges for outpatient setting,$80.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$2.86 ,44% of CMS Medicare lab fee schedule,$117.60 ,80% of total billed charges for outpatient setting,$80.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$139.65 ,95% of total billed charges for outpatient setting,$139.65 ,95% of total billed charges for outpatient setting,$110.25 ,75% of total billed charges for outpatient setting,$124.95 ,85% of total billed charges for outpatient setting,$142.59 ,97% of total billed charges for outpatient setting,$80.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$132.30 ,90% of total billed charges for outpatient setting,$142.59 ,97% of total billed charges for outpatient setting,$142.59 ,97% of total billed charges for outpatient setting,$142.59 ,97% of total billed charges for outpatient setting,$124.95 ,85% of total billed charges for outpatient setting,$132.30 ,90% of total billed charges for outpatient setting,$124.95 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$139.65 ,90% of total billed charges for outpatient setting,$80.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$136.71 ,93% of total billed charges for outpatient setting,$2.86 ,$142.59 ,$110.25 
Outpatient Medical Services,LABORATORY,82565,Creatinine,300,$136.00 ,$125.12 ,92% of total billed charges for outpatient setting,$74.80 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$2.25 ,44% of CMS Medicare lab fee schedule,$108.80 ,80% of total billed charges for outpatient setting,$74.80 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$129.20 ,95% of total billed charges for outpatient setting,$129.20 ,95% of total billed charges for outpatient setting,$102.00 ,75% of total billed charges for outpatient setting,$115.60 ,85% of total billed charges for outpatient setting,$131.92 ,97% of total billed charges for outpatient setting,$74.80 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$122.40 ,90% of total billed charges for outpatient setting,$131.92 ,97% of total billed charges for outpatient setting,$131.92 ,97% of total billed charges for outpatient setting,$131.92 ,97% of total billed charges for outpatient setting,$115.60 ,85% of total billed charges for outpatient setting,$122.40 ,90% of total billed charges for outpatient setting,$115.60 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$129.20 ,90% of total billed charges for outpatient setting,$74.80 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$126.48 ,93% of total billed charges for outpatient setting,$2.25 ,$131.92 ,$102.00 
Outpatient Medical Services,LABORATORY,82570,Test to measure creatinine in the urine,300,$106.00 ,$97.52 ,92% of total billed charges for outpatient setting,$58.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$2.28 ,44% of CMS Medicare lab fee schedule,$84.80 ,80% of total billed charges for outpatient setting,$58.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$100.70 ,95% of total billed charges for outpatient setting,$100.70 ,95% of total billed charges for outpatient setting,$79.50 ,75% of total billed charges for outpatient setting,$90.10 ,85% of total billed charges for outpatient setting,$102.82 ,97% of total billed charges for outpatient setting,$58.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$95.40 ,90% of total billed charges for outpatient setting,$102.82 ,97% of total billed charges for outpatient setting,$102.82 ,97% of total billed charges for outpatient setting,$102.82 ,97% of total billed charges for outpatient setting,$90.10 ,85% of total billed charges for outpatient setting,$95.40 ,90% of total billed charges for outpatient setting,$90.10 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$100.70 ,90% of total billed charges for outpatient setting,$58.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$98.58 ,93% of total billed charges for outpatient setting,$2.28 ,$102.82 ,$79.50 
Outpatient Medical Services,LABORATORY,82607,Blood test to measure B-12,300,$168.00 ,$154.56 ,92% of total billed charges for outpatient setting,$92.40 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$6.64 ,44% of CMS Medicare lab fee schedule,$134.40 ,80% of total billed charges for outpatient setting,$92.40 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$159.60 ,95% of total billed charges for outpatient setting,$159.60 ,95% of total billed charges for outpatient setting,$126.00 ,75% of total billed charges for outpatient setting,$142.80 ,85% of total billed charges for outpatient setting,$162.96 ,97% of total billed charges for outpatient setting,$92.40 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$151.20 ,90% of total billed charges for outpatient setting,$162.96 ,97% of total billed charges for outpatient setting,$162.96 ,97% of total billed charges for outpatient setting,$162.96 ,97% of total billed charges for outpatient setting,$142.80 ,85% of total billed charges for outpatient setting,$151.20 ,90% of total billed charges for outpatient setting,$142.80 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$159.60 ,90% of total billed charges for outpatient setting,$92.40 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$156.24 ,93% of total billed charges for outpatient setting,$6.64 ,$162.96 ,$126.00 
Outpatient Medical Services,LABORATORY,82728,Test to determine level of iron in the blood,300,$180.00 ,$165.60 ,92% of total billed charges for outpatient setting,$99.00 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$6.00 ,44% of CMS Medicare lab fee schedule,$144.00 ,80% of total billed charges for outpatient setting,$99.00 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$171.00 ,95% of total billed charges for outpatient setting,$171.00 ,95% of total billed charges for outpatient setting,$135.00 ,75% of total billed charges for outpatient setting,$153.00 ,85% of total billed charges for outpatient setting,$174.60 ,97% of total billed charges for outpatient setting,$99.00 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$162.00 ,90% of total billed charges for outpatient setting,$174.60 ,97% of total billed charges for outpatient setting,$174.60 ,97% of total billed charges for outpatient setting,$174.60 ,97% of total billed charges for outpatient setting,$153.00 ,85% of total billed charges for outpatient setting,$162.00 ,90% of total billed charges for outpatient setting,$153.00 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$171.00 ,90% of total billed charges for outpatient setting,$99.00 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$167.40 ,93% of total billed charges for outpatient setting,$6.00 ,$174.60 ,$135.00 
Outpatient Medical Services,LABORATORY,82962,Glucose POCT,300,$28.00 ,$25.76 ,92% of total billed charges for outpatient setting,$15.40 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$1.44 ,44% of CMS Medicare lab fee schedule,$22.40 ,80% of total billed charges for outpatient setting,$15.40 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$26.60 ,95% of total billed charges for outpatient setting,$26.60 ,95% of total billed charges for outpatient setting,$21.00 ,75% of total billed charges for outpatient setting,$23.80 ,85% of total billed charges for outpatient setting,$27.16 ,97% of total billed charges for outpatient setting,$15.40 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$25.20 ,90% of total billed charges for outpatient setting,$27.16 ,97% of total billed charges for outpatient setting,$27.16 ,97% of total billed charges for outpatient setting,$27.16 ,97% of total billed charges for outpatient setting,$23.80 ,85% of total billed charges for outpatient setting,$25.20 ,90% of total billed charges for outpatient setting,$23.80 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$26.60 ,90% of total billed charges for outpatient setting,$15.40 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$26.04 ,93% of total billed charges for outpatient setting,$1.44 ,$27.16 ,$21.00 
Outpatient Medical Services,LABORATORY,83036,Blood test to measure average blood glucose levels for past 2-3 months,300,$179.00 ,$164.68 ,92% of total billed charges for outpatient setting,$98.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$4.27 ,44% of CMS Medicare lab fee schedule,$143.20 ,80% of total billed charges for outpatient setting,$98.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$170.05 ,95% of total billed charges for outpatient setting,$170.05 ,95% of total billed charges for outpatient setting,$134.25 ,75% of total billed charges for outpatient setting,$152.15 ,85% of total billed charges for outpatient setting,$173.63 ,97% of total billed charges for outpatient setting,$98.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$161.10 ,90% of total billed charges for outpatient setting,$173.63 ,97% of total billed charges for outpatient setting,$173.63 ,97% of total billed charges for outpatient setting,$173.63 ,97% of total billed charges for outpatient setting,$152.15 ,85% of total billed charges for outpatient setting,$161.10 ,90% of total billed charges for outpatient setting,$152.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$170.05 ,90% of total billed charges for outpatient setting,$98.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$166.47 ,93% of total billed charges for outpatient setting,$4.27 ,$173.63 ,$134.25 
Outpatient Medical Services,LABORATORY,83540,Blood test to measure the amount of iron that is in transit in the body,300,$144.00 ,$132.48 ,92% of total billed charges for outpatient setting,$79.20 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$2.85 ,44% of CMS Medicare lab fee schedule,$115.20 ,80% of total billed charges for outpatient setting,$79.20 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$136.80 ,95% of total billed charges for outpatient setting,$136.80 ,95% of total billed charges for outpatient setting,$108.00 ,75% of total billed charges for outpatient setting,$122.40 ,85% of total billed charges for outpatient setting,$139.68 ,97% of total billed charges for outpatient setting,$79.20 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$129.60 ,90% of total billed charges for outpatient setting,$139.68 ,97% of total billed charges for outpatient setting,$139.68 ,97% of total billed charges for outpatient setting,$139.68 ,97% of total billed charges for outpatient setting,$122.40 ,85% of total billed charges for outpatient setting,$129.60 ,90% of total billed charges for outpatient setting,$122.40 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$136.80 ,90% of total billed charges for outpatient setting,$79.20 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$133.92 ,93% of total billed charges for outpatient setting,$2.85 ,$139.68 ,$108.00 
Outpatient Medical Services,LABORATORY,83550,Blood test that measures the amount of iron carried in the blood,300,$121.00 ,$111.32 ,92% of total billed charges for outpatient setting,$66.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$3.85 ,44% of CMS Medicare lab fee schedule,$96.80 ,80% of total billed charges for outpatient setting,$66.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$114.95 ,95% of total billed charges for outpatient setting,$114.95 ,95% of total billed charges for outpatient setting,$90.75 ,75% of total billed charges for outpatient setting,$102.85 ,85% of total billed charges for outpatient setting,$117.37 ,97% of total billed charges for outpatient setting,$66.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$108.90 ,90% of total billed charges for outpatient setting,$117.37 ,97% of total billed charges for outpatient setting,$117.37 ,97% of total billed charges for outpatient setting,$117.37 ,97% of total billed charges for outpatient setting,$102.85 ,85% of total billed charges for outpatient setting,$108.90 ,90% of total billed charges for outpatient setting,$102.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$114.95 ,90% of total billed charges for outpatient setting,$66.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$112.53 ,93% of total billed charges for outpatient setting,$3.85 ,$117.37 ,$90.75 
Outpatient Medical Services,LABORATORY,83605,Lactic Acid POCT,300,$167.00 ,$153.64 ,92% of total billed charges for outpatient setting,$91.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$5.09 ,44% of CMS Medicare lab fee schedule,$133.60 ,80% of total billed charges for outpatient setting,$91.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$158.65 ,95% of total billed charges for outpatient setting,$158.65 ,95% of total billed charges for outpatient setting,$125.25 ,75% of total billed charges for outpatient setting,$141.95 ,85% of total billed charges for outpatient setting,$161.99 ,97% of total billed charges for outpatient setting,$91.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$150.30 ,90% of total billed charges for outpatient setting,$161.99 ,97% of total billed charges for outpatient setting,$161.99 ,97% of total billed charges for outpatient setting,$161.99 ,97% of total billed charges for outpatient setting,$141.95 ,85% of total billed charges for outpatient setting,$150.30 ,90% of total billed charges for outpatient setting,$141.95 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$158.65 ,90% of total billed charges for outpatient setting,$91.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$155.31 ,93% of total billed charges for outpatient setting,$5.09 ,$161.99 ,$125.25 
Outpatient Medical Services,LABORATORY,83690,Lipase Level,300,$157.00 ,$144.44 ,92% of total billed charges for outpatient setting,$86.35 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$3.03 ,44% of CMS Medicare lab fee schedule,$125.60 ,80% of total billed charges for outpatient setting,$86.35 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$149.15 ,95% of total billed charges for outpatient setting,$149.15 ,95% of total billed charges for outpatient setting,$117.75 ,75% of total billed charges for outpatient setting,$133.45 ,85% of total billed charges for outpatient setting,$152.29 ,97% of total billed charges for outpatient setting,$86.35 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$141.30 ,90% of total billed charges for outpatient setting,$152.29 ,97% of total billed charges for outpatient setting,$152.29 ,97% of total billed charges for outpatient setting,$152.29 ,97% of total billed charges for outpatient setting,$133.45 ,85% of total billed charges for outpatient setting,$141.30 ,90% of total billed charges for outpatient setting,$133.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$149.15 ,90% of total billed charges for outpatient setting,$86.35 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$146.01 ,93% of total billed charges for outpatient setting,$3.03 ,$152.29 ,$117.75 
Outpatient Medical Services,LABORATORY,83735,Magnesium Level,300,$138.00 ,$126.96 ,92% of total billed charges for outpatient setting,$75.90 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$2.95 ,44% of CMS Medicare lab fee schedule,$110.40 ,80% of total billed charges for outpatient setting,$75.90 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$131.10 ,95% of total billed charges for outpatient setting,$131.10 ,95% of total billed charges for outpatient setting,$103.50 ,75% of total billed charges for outpatient setting,$117.30 ,85% of total billed charges for outpatient setting,$133.86 ,97% of total billed charges for outpatient setting,$75.90 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$124.20 ,90% of total billed charges for outpatient setting,$133.86 ,97% of total billed charges for outpatient setting,$133.86 ,97% of total billed charges for outpatient setting,$133.86 ,97% of total billed charges for outpatient setting,$117.30 ,85% of total billed charges for outpatient setting,$124.20 ,90% of total billed charges for outpatient setting,$117.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$131.10 ,90% of total billed charges for outpatient setting,$75.90 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$128.34 ,93% of total billed charges for outpatient setting,$2.95 ,$133.86 ,$103.50 
Outpatient Medical Services,LABORATORY,83803,Hepatitis C Antibody,300,$183.00 ,$168.36 ,92% of total billed charges for outpatient setting,$100.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$157.38 ,86% of total billed charges for outpatient setting,$146.40 ,80% of total billed charges for outpatient setting,$100.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$173.85 ,95% of total billed charges for outpatient setting,$173.85 ,95% of total billed charges for outpatient setting,$137.25 ,75% of total billed charges for outpatient setting,$155.55 ,85% of total billed charges for outpatient setting,$177.51 ,97% of total billed charges for outpatient setting,$100.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$164.70 ,90% of total billed charges for outpatient setting,$177.51 ,97% of total billed charges for outpatient setting,$177.51 ,97% of total billed charges for outpatient setting,$177.51 ,97% of total billed charges for outpatient setting,$155.55 ,85% of total billed charges for outpatient setting,$164.70 ,90% of total billed charges for outpatient setting,$155.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$173.85 ,90% of total billed charges for outpatient setting,$100.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$170.19 ,93% of total billed charges for outpatient setting,$100.65 ,$177.51 ,$137.25 
Outpatient Medical Services,LABORATORY,83880,Blood test used to diagnose heart failure,300,$247.00 ,$227.24 ,92% of total billed charges for outpatient setting,$135.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$17.27 ,44% of CMS Medicare lab fee schedule,$197.60 ,80% of total billed charges for outpatient setting,$135.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$234.65 ,95% of total billed charges for outpatient setting,$234.65 ,95% of total billed charges for outpatient setting,$185.25 ,75% of total billed charges for outpatient setting,$209.95 ,85% of total billed charges for outpatient setting,$239.59 ,97% of total billed charges for outpatient setting,$135.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$222.30 ,90% of total billed charges for outpatient setting,$239.59 ,97% of total billed charges for outpatient setting,$239.59 ,97% of total billed charges for outpatient setting,$239.59 ,97% of total billed charges for outpatient setting,$209.95 ,85% of total billed charges for outpatient setting,$222.30 ,90% of total billed charges for outpatient setting,$209.95 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$234.65 ,90% of total billed charges for outpatient setting,$135.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$229.71 ,93% of total billed charges for outpatient setting,$17.27 ,$239.59 ,$185.25 
Outpatient Medical Services,LABORATORY,83970,"Parathyroid Hormone,Intact",300,$184.00 ,$169.28 ,92% of total billed charges for outpatient setting,$101.20 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$18.16 ,44% of CMS Medicare lab fee schedule,$147.20 ,80% of total billed charges for outpatient setting,$101.20 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$174.80 ,95% of total billed charges for outpatient setting,$174.80 ,95% of total billed charges for outpatient setting,$138.00 ,75% of total billed charges for outpatient setting,$156.40 ,85% of total billed charges for outpatient setting,$178.48 ,97% of total billed charges for outpatient setting,$101.20 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$165.60 ,90% of total billed charges for outpatient setting,$178.48 ,97% of total billed charges for outpatient setting,$178.48 ,97% of total billed charges for outpatient setting,$178.48 ,97% of total billed charges for outpatient setting,$156.40 ,85% of total billed charges for outpatient setting,$165.60 ,90% of total billed charges for outpatient setting,$156.40 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$174.80 ,90% of total billed charges for outpatient setting,$101.20 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$171.12 ,93% of total billed charges for outpatient setting,$18.16 ,$178.48 ,$138.00 
Outpatient Medical Services,LABORATORY,84100,Phosphorus Level,300,$106.00 ,$97.52 ,92% of total billed charges for outpatient setting,$58.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$2.09 ,44% of CMS Medicare lab fee schedule,$84.80 ,80% of total billed charges for outpatient setting,$58.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$100.70 ,95% of total billed charges for outpatient setting,$100.70 ,95% of total billed charges for outpatient setting,$79.50 ,75% of total billed charges for outpatient setting,$90.10 ,85% of total billed charges for outpatient setting,$102.82 ,97% of total billed charges for outpatient setting,$58.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$95.40 ,90% of total billed charges for outpatient setting,$102.82 ,97% of total billed charges for outpatient setting,$102.82 ,97% of total billed charges for outpatient setting,$102.82 ,97% of total billed charges for outpatient setting,$90.10 ,85% of total billed charges for outpatient setting,$95.40 ,90% of total billed charges for outpatient setting,$90.10 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$100.70 ,90% of total billed charges for outpatient setting,$58.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$98.58 ,93% of total billed charges for outpatient setting,$2.09 ,$102.82 ,$79.50 
Outpatient Medical Services,LABORATORY,84439,Blood test to evaluate thyroid function,300,$96.00 ,$88.32 ,92% of total billed charges for outpatient setting,$52.80 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$3.97 ,44% of CMS Medicare lab fee schedule,$76.80 ,80% of total billed charges for outpatient setting,$52.80 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$91.20 ,95% of total billed charges for outpatient setting,$91.20 ,95% of total billed charges for outpatient setting,$72.00 ,75% of total billed charges for outpatient setting,$81.60 ,85% of total billed charges for outpatient setting,$93.12 ,97% of total billed charges for outpatient setting,$52.80 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$86.40 ,90% of total billed charges for outpatient setting,$93.12 ,97% of total billed charges for outpatient setting,$93.12 ,97% of total billed charges for outpatient setting,$93.12 ,97% of total billed charges for outpatient setting,$81.60 ,85% of total billed charges for outpatient setting,$86.40 ,90% of total billed charges for outpatient setting,$81.60 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$91.20 ,90% of total billed charges for outpatient setting,$52.80 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$89.28 ,93% of total billed charges for outpatient setting,$3.97 ,$93.12 ,$72.00 
Outpatient Medical Services,LABORATORY,84450,Aspartate Aminotransferase,300,$118.00 ,$108.56 ,92% of total billed charges for outpatient setting,$64.90 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$2.28 ,44% of CMS Medicare lab fee schedule,$94.40 ,80% of total billed charges for outpatient setting,$64.90 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$112.10 ,95% of total billed charges for outpatient setting,$112.10 ,95% of total billed charges for outpatient setting,$88.50 ,75% of total billed charges for outpatient setting,$100.30 ,85% of total billed charges for outpatient setting,$114.46 ,97% of total billed charges for outpatient setting,$64.90 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$106.20 ,90% of total billed charges for outpatient setting,$114.46 ,97% of total billed charges for outpatient setting,$114.46 ,97% of total billed charges for outpatient setting,$114.46 ,97% of total billed charges for outpatient setting,$100.30 ,85% of total billed charges for outpatient setting,$106.20 ,90% of total billed charges for outpatient setting,$100.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$112.10 ,90% of total billed charges for outpatient setting,$64.90 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$109.74 ,93% of total billed charges for outpatient setting,$2.28 ,$114.46 ,$88.50 
Outpatient Medical Services,LABORATORY,84460,Blood test to evaluate liver function,300,$121.00 ,$111.32 ,92% of total billed charges for outpatient setting,$66.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$2.33 ,44% of CMS Medicare lab fee schedule,$96.80 ,80% of total billed charges for outpatient setting,$66.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$114.95 ,95% of total billed charges for outpatient setting,$114.95 ,95% of total billed charges for outpatient setting,$90.75 ,75% of total billed charges for outpatient setting,$102.85 ,85% of total billed charges for outpatient setting,$117.37 ,97% of total billed charges for outpatient setting,$66.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$108.90 ,90% of total billed charges for outpatient setting,$117.37 ,97% of total billed charges for outpatient setting,$117.37 ,97% of total billed charges for outpatient setting,$117.37 ,97% of total billed charges for outpatient setting,$102.85 ,85% of total billed charges for outpatient setting,$108.90 ,90% of total billed charges for outpatient setting,$102.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$114.95 ,90% of total billed charges for outpatient setting,$66.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$112.53 ,93% of total billed charges for outpatient setting,$2.33 ,$117.37 ,$90.75 
Outpatient Medical Services,LABORATORY,84481,T3 Free,300,$227.00 ,$208.84 ,92% of total billed charges for outpatient setting,$124.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$7.45 ,44% of CMS Medicare lab fee schedule,$181.60 ,80% of total billed charges for outpatient setting,$124.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$215.65 ,95% of total billed charges for outpatient setting,$215.65 ,95% of total billed charges for outpatient setting,$170.25 ,75% of total billed charges for outpatient setting,$192.95 ,85% of total billed charges for outpatient setting,$220.19 ,97% of total billed charges for outpatient setting,$124.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$204.30 ,90% of total billed charges for outpatient setting,$220.19 ,97% of total billed charges for outpatient setting,$220.19 ,97% of total billed charges for outpatient setting,$220.19 ,97% of total billed charges for outpatient setting,$192.95 ,85% of total billed charges for outpatient setting,$204.30 ,90% of total billed charges for outpatient setting,$192.95 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$215.65 ,90% of total billed charges for outpatient setting,$124.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$211.11 ,93% of total billed charges for outpatient setting,$7.45 ,$220.19 ,$170.25 
Outpatient Medical Services,LABORATORY,84484,Blood test to measure a certain protein in the blood to determine heart muscle damage,300,$175.00 ,$161.00 ,92% of total billed charges for outpatient setting,$96.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$5.49 ,44% of CMS Medicare lab fee schedule,$140.00 ,80% of total billed charges for outpatient setting,$96.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$166.25 ,95% of total billed charges for outpatient setting,$166.25 ,95% of total billed charges for outpatient setting,$131.25 ,75% of total billed charges for outpatient setting,$148.75 ,85% of total billed charges for outpatient setting,$169.75 ,97% of total billed charges for outpatient setting,$96.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$157.50 ,90% of total billed charges for outpatient setting,$169.75 ,97% of total billed charges for outpatient setting,$169.75 ,97% of total billed charges for outpatient setting,$169.75 ,97% of total billed charges for outpatient setting,$148.75 ,85% of total billed charges for outpatient setting,$157.50 ,90% of total billed charges for outpatient setting,$148.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$166.25 ,90% of total billed charges for outpatient setting,$96.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$162.75 ,93% of total billed charges for outpatient setting,$5.49 ,$169.75 ,$131.25 
Outpatient Medical Services,LABORATORY,84550,Uric Acid,300,$102.00 ,$93.84 ,92% of total billed charges for outpatient setting,$56.10 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$1.99 ,44% of CMS Medicare lab fee schedule,$81.60 ,80% of total billed charges for outpatient setting,$56.10 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$96.90 ,95% of total billed charges for outpatient setting,$96.90 ,95% of total billed charges for outpatient setting,$76.50 ,75% of total billed charges for outpatient setting,$86.70 ,85% of total billed charges for outpatient setting,$98.94 ,97% of total billed charges for outpatient setting,$56.10 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$91.80 ,90% of total billed charges for outpatient setting,$98.94 ,97% of total billed charges for outpatient setting,$98.94 ,97% of total billed charges for outpatient setting,$98.94 ,97% of total billed charges for outpatient setting,$86.70 ,85% of total billed charges for outpatient setting,$91.80 ,90% of total billed charges for outpatient setting,$86.70 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$96.90 ,90% of total billed charges for outpatient setting,$56.10 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$94.86 ,93% of total billed charges for outpatient setting,$1.99 ,$98.94 ,$76.50 
Outpatient Medical Services,LABORATORY,84703,Blood test to assess for pregnancy,300,$48.00 ,$44.16 ,92% of total billed charges for outpatient setting,$26.40 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$3.31 ,44% of CMS Medicare lab fee schedule,$38.40 ,80% of total billed charges for outpatient setting,$26.40 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$45.60 ,95% of total billed charges for outpatient setting,$45.60 ,95% of total billed charges for outpatient setting,$36.00 ,75% of total billed charges for outpatient setting,$40.80 ,85% of total billed charges for outpatient setting,$46.56 ,97% of total billed charges for outpatient setting,$26.40 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$43.20 ,90% of total billed charges for outpatient setting,$46.56 ,97% of total billed charges for outpatient setting,$46.56 ,97% of total billed charges for outpatient setting,$46.56 ,97% of total billed charges for outpatient setting,$40.80 ,85% of total billed charges for outpatient setting,$43.20 ,90% of total billed charges for outpatient setting,$40.80 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$45.60 ,90% of total billed charges for outpatient setting,$26.40 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$44.64 ,93% of total billed charges for outpatient setting,$3.31 ,$46.56 ,$36.00 
Outpatient Medical Services,LABORATORY,85018,Blood test to measure levels of hemoglobin,300,$50.00 ,$46.00 ,92% of total billed charges for outpatient setting,$27.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$1.04 ,44% of CMS Medicare lab fee schedule,$40.00 ,80% of total billed charges for outpatient setting,$27.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$47.50 ,95% of total billed charges for outpatient setting,$47.50 ,95% of total billed charges for outpatient setting,$37.50 ,75% of total billed charges for outpatient setting,$42.50 ,85% of total billed charges for outpatient setting,$48.50 ,97% of total billed charges for outpatient setting,$27.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$45.00 ,90% of total billed charges for outpatient setting,$48.50 ,97% of total billed charges for outpatient setting,$48.50 ,97% of total billed charges for outpatient setting,$48.50 ,97% of total billed charges for outpatient setting,$42.50 ,85% of total billed charges for outpatient setting,$45.00 ,90% of total billed charges for outpatient setting,$42.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$47.50 ,90% of total billed charges for outpatient setting,$27.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$46.50 ,93% of total billed charges for outpatient setting,$1.04 ,$48.50 ,$37.50 
Outpatient Medical Services,LABORATORY,85379,D-Dimer,300,$151.00 ,$138.92 ,92% of total billed charges for outpatient setting,$83.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$4.48 ,44% of CMS Medicare lab fee schedule,$120.80 ,80% of total billed charges for outpatient setting,$83.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$143.45 ,95% of total billed charges for outpatient setting,$143.45 ,95% of total billed charges for outpatient setting,$113.25 ,75% of total billed charges for outpatient setting,$128.35 ,85% of total billed charges for outpatient setting,$146.47 ,97% of total billed charges for outpatient setting,$83.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$135.90 ,90% of total billed charges for outpatient setting,$146.47 ,97% of total billed charges for outpatient setting,$146.47 ,97% of total billed charges for outpatient setting,$146.47 ,97% of total billed charges for outpatient setting,$128.35 ,85% of total billed charges for outpatient setting,$135.90 ,90% of total billed charges for outpatient setting,$128.35 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$143.45 ,90% of total billed charges for outpatient setting,$83.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$140.43 ,93% of total billed charges for outpatient setting,$4.48 ,$146.47 ,$113.25 
Outpatient Medical Services,LABORATORY,85652,Automated Erythrocyte Sedimentation rate,300,$30.00 ,$27.60 ,92% of total billed charges for outpatient setting,$16.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$1.19 ,44% of CMS Medicare lab fee schedule,$24.00 ,80% of total billed charges for outpatient setting,$16.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$28.50 ,95% of total billed charges for outpatient setting,$28.50 ,95% of total billed charges for outpatient setting,$22.50 ,75% of total billed charges for outpatient setting,$25.50 ,85% of total billed charges for outpatient setting,$29.10 ,97% of total billed charges for outpatient setting,$16.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$27.00 ,90% of total billed charges for outpatient setting,$29.10 ,97% of total billed charges for outpatient setting,$29.10 ,97% of total billed charges for outpatient setting,$29.10 ,97% of total billed charges for outpatient setting,$25.50 ,85% of total billed charges for outpatient setting,$27.00 ,90% of total billed charges for outpatient setting,$25.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$28.50 ,90% of total billed charges for outpatient setting,$16.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$27.90 ,93% of total billed charges for outpatient setting,$1.19 ,$29.10 ,$22.50 
Outpatient Medical Services,LABORATORY,86038,Antinuclear Antibodies (ANA),300,$123.00 ,$113.16 ,92% of total billed charges for outpatient setting,$67.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$5.32 ,44% of CMS Medicare lab fee schedule,$98.40 ,80% of total billed charges for outpatient setting,$67.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$116.85 ,95% of total billed charges for outpatient setting,$116.85 ,95% of total billed charges for outpatient setting,$92.25 ,75% of total billed charges for outpatient setting,$104.55 ,85% of total billed charges for outpatient setting,$119.31 ,97% of total billed charges for outpatient setting,$67.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$110.70 ,90% of total billed charges for outpatient setting,$119.31 ,97% of total billed charges for outpatient setting,$119.31 ,97% of total billed charges for outpatient setting,$119.31 ,97% of total billed charges for outpatient setting,$104.55 ,85% of total billed charges for outpatient setting,$110.70 ,90% of total billed charges for outpatient setting,$104.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$116.85 ,90% of total billed charges for outpatient setting,$67.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$114.39 ,93% of total billed charges for outpatient setting,$5.32 ,$119.31 ,$92.25 
Outpatient Medical Services,LABORATORY,86140,C-Reactive Protein,300,$90.00 ,$82.80 ,92% of total billed charges for outpatient setting,$49.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$2.28 ,44% of CMS Medicare lab fee schedule,$72.00 ,80% of total billed charges for outpatient setting,$49.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$85.50 ,95% of total billed charges for outpatient setting,$85.50 ,95% of total billed charges for outpatient setting,$67.50 ,75% of total billed charges for outpatient setting,$76.50 ,85% of total billed charges for outpatient setting,$87.30 ,97% of total billed charges for outpatient setting,$49.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$81.00 ,90% of total billed charges for outpatient setting,$87.30 ,97% of total billed charges for outpatient setting,$87.30 ,97% of total billed charges for outpatient setting,$87.30 ,97% of total billed charges for outpatient setting,$76.50 ,85% of total billed charges for outpatient setting,$81.00 ,90% of total billed charges for outpatient setting,$76.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$85.50 ,90% of total billed charges for outpatient setting,$49.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$83.70 ,93% of total billed charges for outpatient setting,$2.28 ,$87.30 ,$67.50 
Outpatient Medical Services,LABORATORY,86200,Blood test to diagnose rheumatoid arthritis,300,$236.00 ,$217.12 ,92% of total billed charges for outpatient setting,$129.80 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$5.70 ,44% of CMS Medicare lab fee schedule,$188.80 ,80% of total billed charges for outpatient setting,$129.80 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$224.20 ,95% of total billed charges for outpatient setting,$224.20 ,95% of total billed charges for outpatient setting,$177.00 ,75% of total billed charges for outpatient setting,$200.60 ,85% of total billed charges for outpatient setting,$228.92 ,97% of total billed charges for outpatient setting,$129.80 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$212.40 ,90% of total billed charges for outpatient setting,$228.92 ,97% of total billed charges for outpatient setting,$228.92 ,97% of total billed charges for outpatient setting,$228.92 ,97% of total billed charges for outpatient setting,$200.60 ,85% of total billed charges for outpatient setting,$212.40 ,90% of total billed charges for outpatient setting,$200.60 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$224.20 ,90% of total billed charges for outpatient setting,$129.80 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$219.48 ,93% of total billed charges for outpatient setting,$5.70 ,$228.92 ,$177.00 
Outpatient Medical Services,LABORATORY,86431,Rheumatoid Factor; Quantitative,300,$124.00 ,$114.08 ,92% of total billed charges for outpatient setting,$68.20 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$2.49 ,44% of CMS Medicare lab fee schedule,$99.20 ,80% of total billed charges for outpatient setting,$68.20 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$117.80 ,95% of total billed charges for outpatient setting,$117.80 ,95% of total billed charges for outpatient setting,$93.00 ,75% of total billed charges for outpatient setting,$105.40 ,85% of total billed charges for outpatient setting,$120.28 ,97% of total billed charges for outpatient setting,$68.20 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$111.60 ,90% of total billed charges for outpatient setting,$120.28 ,97% of total billed charges for outpatient setting,$120.28 ,97% of total billed charges for outpatient setting,$120.28 ,97% of total billed charges for outpatient setting,$105.40 ,85% of total billed charges for outpatient setting,$111.60 ,90% of total billed charges for outpatient setting,$105.40 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$117.80 ,90% of total billed charges for outpatient setting,$68.20 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$115.32 ,93% of total billed charges for outpatient setting,$2.49 ,$120.28 ,$93.00 
Outpatient Medical Services,LABORATORY,86592,Blood test to screen for syphilis,300,$94.00 ,$86.48 ,92% of total billed charges for outpatient setting,$51.70 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$1.88 ,44% of CMS Medicare lab fee schedule,$75.20 ,80% of total billed charges for outpatient setting,$51.70 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$89.30 ,95% of total billed charges for outpatient setting,$89.30 ,95% of total billed charges for outpatient setting,$70.50 ,75% of total billed charges for outpatient setting,$79.90 ,85% of total billed charges for outpatient setting,$91.18 ,97% of total billed charges for outpatient setting,$51.70 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$84.60 ,90% of total billed charges for outpatient setting,$91.18 ,97% of total billed charges for outpatient setting,$91.18 ,97% of total billed charges for outpatient setting,$91.18 ,97% of total billed charges for outpatient setting,$79.90 ,85% of total billed charges for outpatient setting,$84.60 ,90% of total billed charges for outpatient setting,$79.90 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$89.30 ,90% of total billed charges for outpatient setting,$51.70 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$87.42 ,93% of total billed charges for outpatient setting,$1.88 ,$91.18 ,$70.50 
Outpatient Medical Services,LABORATORY,86769,"SARS-CoV-2 RNA (COVID-19), Qualitative NAAT QST",300,$213.00 ,$195.96 ,92% of total billed charges for outpatient setting,$117.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$18.54 ,44% of CMS Medicare lab fee schedule,$170.40 ,80% of total billed charges for outpatient setting,$117.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$202.35 ,95% of total billed charges for outpatient setting,$202.35 ,95% of total billed charges for outpatient setting,$159.75 ,75% of total billed charges for outpatient setting,$181.05 ,85% of total billed charges for outpatient setting,$206.61 ,97% of total billed charges for outpatient setting,$117.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$191.70 ,90% of total billed charges for outpatient setting,$206.61 ,97% of total billed charges for outpatient setting,$206.61 ,97% of total billed charges for outpatient setting,$206.61 ,97% of total billed charges for outpatient setting,$181.05 ,85% of total billed charges for outpatient setting,$191.70 ,90% of total billed charges for outpatient setting,$181.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$202.35 ,90% of total billed charges for outpatient setting,$117.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$198.09 ,93% of total billed charges for outpatient setting,$18.54 ,$206.61 ,$159.75 
Outpatient Medical Services,LABORATORY,86900,Autologous Blood Collection Processing and Storage,300,$105.00 ,$96.60 ,92% of total billed charges for outpatient setting,$57.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$1.32 ,44% of CMS Medicare lab fee schedule,$84.00 ,80% of total billed charges for outpatient setting,$57.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$99.75 ,95% of total billed charges for outpatient setting,$99.75 ,95% of total billed charges for outpatient setting,$78.75 ,75% of total billed charges for outpatient setting,$89.25 ,85% of total billed charges for outpatient setting,$101.85 ,97% of total billed charges for outpatient setting,$57.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$94.50 ,90% of total billed charges for outpatient setting,$101.85 ,97% of total billed charges for outpatient setting,$101.85 ,97% of total billed charges for outpatient setting,$101.85 ,97% of total billed charges for outpatient setting,$89.25 ,85% of total billed charges for outpatient setting,$94.50 ,90% of total billed charges for outpatient setting,$89.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$99.75 ,90% of total billed charges for outpatient setting,$57.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$97.65 ,93% of total billed charges for outpatient setting,$1.32 ,$101.85 ,$78.75 
Outpatient Medical Services,LABORATORY,87040,Blood test to screen for bacteria in the blood,300,$168.00 ,$154.56 ,92% of total billed charges for outpatient setting,$92.40 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$4.54 ,44% of CMS Medicare lab fee schedule,$134.40 ,80% of total billed charges for outpatient setting,$92.40 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$159.60 ,95% of total billed charges for outpatient setting,$159.60 ,95% of total billed charges for outpatient setting,$126.00 ,75% of total billed charges for outpatient setting,$142.80 ,85% of total billed charges for outpatient setting,$162.96 ,97% of total billed charges for outpatient setting,$92.40 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$151.20 ,90% of total billed charges for outpatient setting,$162.96 ,97% of total billed charges for outpatient setting,$162.96 ,97% of total billed charges for outpatient setting,$162.96 ,97% of total billed charges for outpatient setting,$142.80 ,85% of total billed charges for outpatient setting,$151.20 ,90% of total billed charges for outpatient setting,$142.80 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$159.60 ,90% of total billed charges for outpatient setting,$92.40 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$156.24 ,93% of total billed charges for outpatient setting,$4.54 ,$162.96 ,$126.00 
Outpatient Medical Services,LABORATORY,87070,Test of body fluid other than blood to assess for bacteria,300,$210.00 ,$193.20 ,92% of total billed charges for outpatient setting,$115.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$3.79 ,44% of CMS Medicare lab fee schedule,$168.00 ,80% of total billed charges for outpatient setting,$115.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$199.50 ,95% of total billed charges for outpatient setting,$199.50 ,95% of total billed charges for outpatient setting,$157.50 ,75% of total billed charges for outpatient setting,$178.50 ,85% of total billed charges for outpatient setting,$203.70 ,97% of total billed charges for outpatient setting,$115.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$189.00 ,90% of total billed charges for outpatient setting,$203.70 ,97% of total billed charges for outpatient setting,$203.70 ,97% of total billed charges for outpatient setting,$203.70 ,97% of total billed charges for outpatient setting,$178.50 ,85% of total billed charges for outpatient setting,$189.00 ,90% of total billed charges for outpatient setting,$178.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$199.50 ,90% of total billed charges for outpatient setting,$115.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$195.30 ,93% of total billed charges for outpatient setting,$3.79 ,$203.70 ,$157.50 
Outpatient Medical Services,LABORATORY,87088,Culture of the urine to determine bacterial infection,300,$99.00 ,$91.08 ,92% of total billed charges for outpatient setting,$54.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$3.56 ,44% of CMS Medicare lab fee schedule,$79.20 ,80% of total billed charges for outpatient setting,$54.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$94.05 ,95% of total billed charges for outpatient setting,$94.05 ,95% of total billed charges for outpatient setting,$74.25 ,75% of total billed charges for outpatient setting,$84.15 ,85% of total billed charges for outpatient setting,$96.03 ,97% of total billed charges for outpatient setting,$54.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$89.10 ,90% of total billed charges for outpatient setting,$96.03 ,97% of total billed charges for outpatient setting,$96.03 ,97% of total billed charges for outpatient setting,$96.03 ,97% of total billed charges for outpatient setting,$84.15 ,85% of total billed charges for outpatient setting,$89.10 ,90% of total billed charges for outpatient setting,$84.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$94.05 ,90% of total billed charges for outpatient setting,$54.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$92.07 ,93% of total billed charges for outpatient setting,$3.56 ,$96.03 ,$74.25 
Outpatient Medical Services,LABORATORY,87389,Test for HIV,300,$66.00 ,$60.72 ,92% of total billed charges for outpatient setting,$36.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$10.60 ,44% of CMS Medicare lab fee schedule,$52.80 ,80% of total billed charges for outpatient setting,$36.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$62.70 ,95% of total billed charges for outpatient setting,$62.70 ,95% of total billed charges for outpatient setting,$49.50 ,75% of total billed charges for outpatient setting,$56.10 ,85% of total billed charges for outpatient setting,$64.02 ,97% of total billed charges for outpatient setting,$36.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$59.40 ,90% of total billed charges for outpatient setting,$64.02 ,97% of total billed charges for outpatient setting,$64.02 ,97% of total billed charges for outpatient setting,$64.02 ,97% of total billed charges for outpatient setting,$56.10 ,85% of total billed charges for outpatient setting,$59.40 ,90% of total billed charges for outpatient setting,$56.10 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$62.70 ,90% of total billed charges for outpatient setting,$36.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$61.38 ,93% of total billed charges for outpatient setting,$10.60 ,$64.02 ,$49.50 
Outpatient Medical Services,LABORATORY,87502,Influenza A & B,300,$224.00 ,$206.08 ,92% of total billed charges for outpatient setting,$123.20 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$42.15 ,44% of CMS Medicare lab fee schedule,$179.20 ,80% of total billed charges for outpatient setting,$123.20 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$212.80 ,95% of total billed charges for outpatient setting,$212.80 ,95% of total billed charges for outpatient setting,$168.00 ,75% of total billed charges for outpatient setting,$190.40 ,85% of total billed charges for outpatient setting,$217.28 ,97% of total billed charges for outpatient setting,$123.20 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$201.60 ,90% of total billed charges for outpatient setting,$217.28 ,97% of total billed charges for outpatient setting,$217.28 ,97% of total billed charges for outpatient setting,$217.28 ,97% of total billed charges for outpatient setting,$190.40 ,85% of total billed charges for outpatient setting,$201.60 ,90% of total billed charges for outpatient setting,$190.40 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$212.80 ,90% of total billed charges for outpatient setting,$123.20 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$208.32 ,93% of total billed charges for outpatient setting,$42.15 ,$217.28 ,$168.00 
Outpatient Medical Services,LABORATORY,87507,Gastrointestinal Panel,300,"$1,298.00 ","$1,194.16 ",92% of total billed charges for outpatient setting,$713.90 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$183.38 ,44% of CMS Medicare lab fee schedule,"$1,038.40 ",80% of total billed charges for outpatient setting,$713.90 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$1,233.10 ",95% of total billed charges for outpatient setting,"$1,233.10 ",95% of total billed charges for outpatient setting,$973.50 ,75% of total billed charges for outpatient setting,"$1,103.30 ",85% of total billed charges for outpatient setting,"$1,259.06 ",97% of total billed charges for outpatient setting,$713.90 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$1,168.20 ",90% of total billed charges for outpatient setting,"$1,259.06 ",97% of total billed charges for outpatient setting,"$1,259.06 ",97% of total billed charges for outpatient setting,"$1,259.06 ",97% of total billed charges for outpatient setting,"$1,103.30 ",85% of total billed charges for outpatient setting,"$1,168.20 ",90% of total billed charges for outpatient setting,"$1,103.30 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$1,233.10 ",90% of total billed charges for outpatient setting,$713.90 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$1,207.14 ",93% of total billed charges for outpatient setting,$183.38 ,"$1,259.06 ",$973.50 
Outpatient Medical Services,LABORATORY,87591,Blood test for an STD,300,$79.00 ,$72.68 ,92% of total billed charges for outpatient setting,$43.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$15.44 ,44% of CMS Medicare lab fee schedule,$63.20 ,80% of total billed charges for outpatient setting,$43.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$75.05 ,95% of total billed charges for outpatient setting,$75.05 ,95% of total billed charges for outpatient setting,$59.25 ,75% of total billed charges for outpatient setting,$67.15 ,85% of total billed charges for outpatient setting,$76.63 ,97% of total billed charges for outpatient setting,$43.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$71.10 ,90% of total billed charges for outpatient setting,$76.63 ,97% of total billed charges for outpatient setting,$76.63 ,97% of total billed charges for outpatient setting,$76.63 ,97% of total billed charges for outpatient setting,$67.15 ,85% of total billed charges for outpatient setting,$71.10 ,90% of total billed charges for outpatient setting,$67.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$75.05 ,90% of total billed charges for outpatient setting,$43.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$73.47 ,93% of total billed charges for outpatient setting,$15.44 ,$76.63 ,$59.25 
Outpatient Medical Services,LABORATORY,87635,SARS-CoV-2 (COVID-19) RNA (ID Now) POCT,300,$132.00 ,$121.44 ,92% of total billed charges for outpatient setting,$72.60 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$22.58 ,44% of CMS Medicare lab fee schedule,$105.60 ,80% of total billed charges for outpatient setting,$72.60 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$125.40 ,95% of total billed charges for outpatient setting,$125.40 ,95% of total billed charges for outpatient setting,$99.00 ,75% of total billed charges for outpatient setting,$112.20 ,85% of total billed charges for outpatient setting,$128.04 ,97% of total billed charges for outpatient setting,$72.60 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$118.80 ,90% of total billed charges for outpatient setting,$128.04 ,97% of total billed charges for outpatient setting,$128.04 ,97% of total billed charges for outpatient setting,$128.04 ,97% of total billed charges for outpatient setting,$112.20 ,85% of total billed charges for outpatient setting,$118.80 ,90% of total billed charges for outpatient setting,$112.20 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$125.40 ,90% of total billed charges for outpatient setting,$72.60 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$122.76 ,93% of total billed charges for outpatient setting,$22.58 ,$128.04 ,$99.00 
Outpatient Medical Services,LABORATORY,87880,Test for strep A,300,$79.00 ,$72.68 ,92% of total billed charges for outpatient setting,$43.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$7.27 ,44% of CMS Medicare lab fee schedule,$63.20 ,80% of total billed charges for outpatient setting,$43.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$75.05 ,95% of total billed charges for outpatient setting,$75.05 ,95% of total billed charges for outpatient setting,$59.25 ,75% of total billed charges for outpatient setting,$67.15 ,85% of total billed charges for outpatient setting,$76.63 ,97% of total billed charges for outpatient setting,$43.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$71.10 ,90% of total billed charges for outpatient setting,$76.63 ,97% of total billed charges for outpatient setting,$76.63 ,97% of total billed charges for outpatient setting,$76.63 ,97% of total billed charges for outpatient setting,$67.15 ,85% of total billed charges for outpatient setting,$71.10 ,90% of total billed charges for outpatient setting,$67.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$75.05 ,90% of total billed charges for outpatient setting,$43.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$73.47 ,93% of total billed charges for outpatient setting,$7.27 ,$76.63 ,$59.25 
Outpatient Medical Services,LABORATORY,88305,Test of tissues for diagnosis of abnormalities,300,$202.00 ,$185.84 ,92% of total billed charges for outpatient setting,$111.10 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$173.72 ,86% of total billed charges for outpatient setting,$161.60 ,80% of total billed charges for outpatient setting,$111.10 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$191.90 ,95% of total billed charges for outpatient setting,$191.90 ,95% of total billed charges for outpatient setting,$151.50 ,75% of total billed charges for outpatient setting,$171.70 ,85% of total billed charges for outpatient setting,$195.94 ,97% of total billed charges for outpatient setting,$111.10 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$181.80 ,90% of total billed charges for outpatient setting,$195.94 ,97% of total billed charges for outpatient setting,$195.94 ,97% of total billed charges for outpatient setting,$195.94 ,97% of total billed charges for outpatient setting,$171.70 ,85% of total billed charges for outpatient setting,$181.80 ,90% of total billed charges for outpatient setting,$171.70 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$191.90 ,90% of total billed charges for outpatient setting,$111.10 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$187.86 ,93% of total billed charges for outpatient setting,$111.10 ,$195.94 ,$151.50 
Outpatient Medical Services,LABORATORY,80048,Basic metabolic panel,300,$187.00 ,$172.04 ,92% of total billed charges for outpatient setting,$102.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$3.72 ,44% of CMS Medicare lab fee schedule,$149.60 ,80% of total billed charges for outpatient setting,$102.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$177.65 ,95% of total billed charges for outpatient setting,$177.65 ,95% of total billed charges for outpatient setting,$140.25 ,75% of total billed charges for outpatient setting,$158.95 ,85% of total billed charges for outpatient setting,$181.39 ,97% of total billed charges for outpatient setting,$102.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$168.30 ,90% of total billed charges for outpatient setting,$181.39 ,97% of total billed charges for outpatient setting,$181.39 ,97% of total billed charges for outpatient setting,$181.39 ,97% of total billed charges for outpatient setting,$158.95 ,85% of total billed charges for outpatient setting,$168.30 ,90% of total billed charges for outpatient setting,$158.95 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$177.65 ,90% of total billed charges for outpatient setting,$102.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$173.91 ,93% of total billed charges for outpatient setting,$3.72 ,$181.39 ,$140.25 
Outpatient Medical Services,LABORATORY,80053,"Blood test, comprehensive group of blood chemicals",300,$233.00 ,$214.36 ,92% of total billed charges for outpatient setting,$128.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$4.65 ,44% of CMS Medicare lab fee schedule,$186.40 ,80% of total billed charges for outpatient setting,$128.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$221.35 ,95% of total billed charges for outpatient setting,$221.35 ,95% of total billed charges for outpatient setting,$174.75 ,75% of total billed charges for outpatient setting,$198.05 ,85% of total billed charges for outpatient setting,$226.01 ,97% of total billed charges for outpatient setting,$128.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$209.70 ,90% of total billed charges for outpatient setting,$226.01 ,97% of total billed charges for outpatient setting,$226.01 ,97% of total billed charges for outpatient setting,$226.01 ,97% of total billed charges for outpatient setting,$198.05 ,85% of total billed charges for outpatient setting,$209.70 ,90% of total billed charges for outpatient setting,$198.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$221.35 ,90% of total billed charges for outpatient setting,$128.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$216.69 ,93% of total billed charges for outpatient setting,$4.65 ,$226.01 ,$174.75 
Outpatient Medical Services,LABORATORY,80061,"Blood test, lipids (cholesterol and triglycerides)",300,$175.00 ,$161.00 ,92% of total billed charges for outpatient setting,$96.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$5.89 ,44% of CMS Medicare lab fee schedule,$140.00 ,80% of total billed charges for outpatient setting,$96.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$166.25 ,95% of total billed charges for outpatient setting,$166.25 ,95% of total billed charges for outpatient setting,$131.25 ,75% of total billed charges for outpatient setting,$148.75 ,85% of total billed charges for outpatient setting,$169.75 ,97% of total billed charges for outpatient setting,$96.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$157.50 ,90% of total billed charges for outpatient setting,$169.75 ,97% of total billed charges for outpatient setting,$169.75 ,97% of total billed charges for outpatient setting,$169.75 ,97% of total billed charges for outpatient setting,$148.75 ,85% of total billed charges for outpatient setting,$157.50 ,90% of total billed charges for outpatient setting,$148.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$166.25 ,90% of total billed charges for outpatient setting,$96.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$162.75 ,93% of total billed charges for outpatient setting,$5.89 ,$169.75 ,$131.25 
Outpatient Medical Services,LABORATORY,80069,Kidney function panel test,300,$196.00 ,$180.32 ,92% of total billed charges for outpatient setting,$107.80 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$3.82 ,44% of CMS Medicare lab fee schedule,$156.80 ,80% of total billed charges for outpatient setting,$107.80 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$186.20 ,95% of total billed charges for outpatient setting,$186.20 ,95% of total billed charges for outpatient setting,$147.00 ,75% of total billed charges for outpatient setting,$166.60 ,85% of total billed charges for outpatient setting,$190.12 ,97% of total billed charges for outpatient setting,$107.80 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$176.40 ,90% of total billed charges for outpatient setting,$190.12 ,97% of total billed charges for outpatient setting,$190.12 ,97% of total billed charges for outpatient setting,$190.12 ,97% of total billed charges for outpatient setting,$166.60 ,85% of total billed charges for outpatient setting,$176.40 ,90% of total billed charges for outpatient setting,$166.60 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$186.20 ,90% of total billed charges for outpatient setting,$107.80 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$182.28 ,93% of total billed charges for outpatient setting,$3.82 ,$190.12 ,$147.00 
Outpatient Medical Services,LABORATORY,80076,Liver function blood test panel,300,$185.00 ,$170.20 ,92% of total billed charges for outpatient setting,$101.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$3.59 ,44% of CMS Medicare lab fee schedule,$148.00 ,80% of total billed charges for outpatient setting,$101.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$175.75 ,95% of total billed charges for outpatient setting,$175.75 ,95% of total billed charges for outpatient setting,$138.75 ,75% of total billed charges for outpatient setting,$157.25 ,85% of total billed charges for outpatient setting,$179.45 ,97% of total billed charges for outpatient setting,$101.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$166.50 ,90% of total billed charges for outpatient setting,$179.45 ,97% of total billed charges for outpatient setting,$179.45 ,97% of total billed charges for outpatient setting,$179.45 ,97% of total billed charges for outpatient setting,$157.25 ,85% of total billed charges for outpatient setting,$166.50 ,90% of total billed charges for outpatient setting,$157.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$175.75 ,90% of total billed charges for outpatient setting,$101.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$172.05 ,93% of total billed charges for outpatient setting,$3.59 ,$179.45 ,$138.75 
Outpatient Medical Services,LABORATORY,81001,Manual urinalysis test with examination with or without using microscope,300,$72.00 ,$66.24 ,92% of total billed charges for outpatient setting,$39.60 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$1.39 ,44% of CMS Medicare lab fee schedule,$57.60 ,80% of total billed charges for outpatient setting,$39.60 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$68.40 ,95% of total billed charges for outpatient setting,$68.40 ,95% of total billed charges for outpatient setting,$54.00 ,75% of total billed charges for outpatient setting,$61.20 ,85% of total billed charges for outpatient setting,$69.84 ,97% of total billed charges for outpatient setting,$39.60 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$64.80 ,90% of total billed charges for outpatient setting,$69.84 ,97% of total billed charges for outpatient setting,$69.84 ,97% of total billed charges for outpatient setting,$69.84 ,97% of total billed charges for outpatient setting,$61.20 ,85% of total billed charges for outpatient setting,$64.80 ,90% of total billed charges for outpatient setting,$61.20 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$68.40 ,90% of total billed charges for outpatient setting,$39.60 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$66.96 ,93% of total billed charges for outpatient setting,$1.39 ,$69.84 ,$54.00 
Outpatient Medical Services,LABORATORY,81002,Manual urinalysis test with examination without using microscope,300,$23.00 ,$21.16 ,92% of total billed charges for outpatient setting,$12.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$1.53 ,44% of CMS Medicare lab fee schedule,$18.40 ,80% of total billed charges for outpatient setting,$12.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$21.85 ,95% of total billed charges for outpatient setting,$21.85 ,95% of total billed charges for outpatient setting,$17.25 ,75% of total billed charges for outpatient setting,$19.55 ,85% of total billed charges for outpatient setting,$22.31 ,97% of total billed charges for outpatient setting,$12.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$20.70 ,90% of total billed charges for outpatient setting,$22.31 ,97% of total billed charges for outpatient setting,$22.31 ,97% of total billed charges for outpatient setting,$22.31 ,97% of total billed charges for outpatient setting,$19.55 ,85% of total billed charges for outpatient setting,$20.70 ,90% of total billed charges for outpatient setting,$19.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$21.85 ,90% of total billed charges for outpatient setting,$12.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$21.39 ,93% of total billed charges for outpatient setting,$1.53 ,$22.31 ,$17.25 
Outpatient Medical Services,LABORATORY,84153,PSA (prostate specific antigen),300,$185.00 ,$170.20 ,92% of total billed charges for outpatient setting,$101.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$8.09 ,44% of CMS Medicare lab fee schedule,$148.00 ,80% of total billed charges for outpatient setting,$101.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$175.75 ,95% of total billed charges for outpatient setting,$175.75 ,95% of total billed charges for outpatient setting,$138.75 ,75% of total billed charges for outpatient setting,$157.25 ,85% of total billed charges for outpatient setting,$179.45 ,97% of total billed charges for outpatient setting,$101.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$166.50 ,90% of total billed charges for outpatient setting,$179.45 ,97% of total billed charges for outpatient setting,$179.45 ,97% of total billed charges for outpatient setting,$179.45 ,97% of total billed charges for outpatient setting,$157.25 ,85% of total billed charges for outpatient setting,$166.50 ,90% of total billed charges for outpatient setting,$157.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$175.75 ,90% of total billed charges for outpatient setting,$101.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$172.05 ,93% of total billed charges for outpatient setting,$8.09 ,$179.45 ,$138.75 
Outpatient Medical Services,LABORATORY,84153,PSA (prostate specific antigen),300,$185.00 ,$170.20 ,92% of total billed charges for outpatient setting,$101.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$8.09 ,44% of CMS Medicare lab fee schedule,$148.00 ,80% of total billed charges for outpatient setting,$101.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$175.75 ,95% of total billed charges for outpatient setting,$175.75 ,95% of total billed charges for outpatient setting,$138.75 ,75% of total billed charges for outpatient setting,$157.25 ,85% of total billed charges for outpatient setting,$179.45 ,97% of total billed charges for outpatient setting,$101.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$166.50 ,90% of total billed charges for outpatient setting,$179.45 ,97% of total billed charges for outpatient setting,$179.45 ,97% of total billed charges for outpatient setting,$179.45 ,97% of total billed charges for outpatient setting,$157.25 ,85% of total billed charges for outpatient setting,$166.50 ,90% of total billed charges for outpatient setting,$157.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$175.75 ,90% of total billed charges for outpatient setting,$101.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$172.05 ,93% of total billed charges for outpatient setting,$8.09 ,$179.45 ,$138.75 
Outpatient Medical Services,LABORATORY,84154,PSA (prostate specific antigen) measurement,300,$317.00 ,$291.64 ,92% of total billed charges for outpatient setting,$174.35 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$8.09 ,44% of CMS Medicare lab fee schedule,$253.60 ,80% of total billed charges for outpatient setting,$174.35 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$301.15 ,95% of total billed charges for outpatient setting,$301.15 ,95% of total billed charges for outpatient setting,$237.75 ,75% of total billed charges for outpatient setting,$269.45 ,85% of total billed charges for outpatient setting,$307.49 ,97% of total billed charges for outpatient setting,$174.35 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$285.30 ,90% of total billed charges for outpatient setting,$307.49 ,97% of total billed charges for outpatient setting,$307.49 ,97% of total billed charges for outpatient setting,$307.49 ,97% of total billed charges for outpatient setting,$269.45 ,85% of total billed charges for outpatient setting,$285.30 ,90% of total billed charges for outpatient setting,$269.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$301.15 ,90% of total billed charges for outpatient setting,$174.35 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$294.81 ,93% of total billed charges for outpatient setting,$8.09 ,$307.49 ,$237.75 
Outpatient Medical Services,LABORATORY,84443,"Blood test, thyroid stimulating hormone (TSH)",300,$154.00 ,$141.68 ,92% of total billed charges for outpatient setting,$84.70 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$7.39 ,44% of CMS Medicare lab fee schedule,$123.20 ,80% of total billed charges for outpatient setting,$84.70 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$146.30 ,95% of total billed charges for outpatient setting,$146.30 ,95% of total billed charges for outpatient setting,$115.50 ,75% of total billed charges for outpatient setting,$130.90 ,85% of total billed charges for outpatient setting,$149.38 ,97% of total billed charges for outpatient setting,$84.70 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$138.60 ,90% of total billed charges for outpatient setting,$149.38 ,97% of total billed charges for outpatient setting,$149.38 ,97% of total billed charges for outpatient setting,$149.38 ,97% of total billed charges for outpatient setting,$130.90 ,85% of total billed charges for outpatient setting,$138.60 ,90% of total billed charges for outpatient setting,$130.90 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$146.30 ,90% of total billed charges for outpatient setting,$84.70 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$143.22 ,93% of total billed charges for outpatient setting,$7.39 ,$149.38 ,$115.50 
Outpatient Medical Services,LABORATORY,85025,"Complete blood cell count, with differential white blood cells, automated",300,$94.00 ,$86.48 ,92% of total billed charges for outpatient setting,$51.70 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$3.42 ,44% of CMS Medicare lab fee schedule,$75.20 ,80% of total billed charges for outpatient setting,$51.70 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$89.30 ,95% of total billed charges for outpatient setting,$89.30 ,95% of total billed charges for outpatient setting,$70.50 ,75% of total billed charges for outpatient setting,$79.90 ,85% of total billed charges for outpatient setting,$91.18 ,97% of total billed charges for outpatient setting,$51.70 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$84.60 ,90% of total billed charges for outpatient setting,$91.18 ,97% of total billed charges for outpatient setting,$91.18 ,97% of total billed charges for outpatient setting,$91.18 ,97% of total billed charges for outpatient setting,$79.90 ,85% of total billed charges for outpatient setting,$84.60 ,90% of total billed charges for outpatient setting,$79.90 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$89.30 ,90% of total billed charges for outpatient setting,$51.70 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$87.42 ,93% of total billed charges for outpatient setting,$3.42 ,$91.18 ,$70.50 
Outpatient Medical Services,LABORATORY,85027,"Complete blood count, automated",300,$72.00 ,$66.24 ,92% of total billed charges for outpatient setting,$39.60 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$2.85 ,44% of CMS Medicare lab fee schedule,$57.60 ,80% of total billed charges for outpatient setting,$39.60 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$68.40 ,95% of total billed charges for outpatient setting,$68.40 ,95% of total billed charges for outpatient setting,$54.00 ,75% of total billed charges for outpatient setting,$61.20 ,85% of total billed charges for outpatient setting,$69.84 ,97% of total billed charges for outpatient setting,$39.60 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$64.80 ,90% of total billed charges for outpatient setting,$69.84 ,97% of total billed charges for outpatient setting,$69.84 ,97% of total billed charges for outpatient setting,$69.84 ,97% of total billed charges for outpatient setting,$61.20 ,85% of total billed charges for outpatient setting,$64.80 ,90% of total billed charges for outpatient setting,$61.20 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$68.40 ,90% of total billed charges for outpatient setting,$39.60 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$66.96 ,93% of total billed charges for outpatient setting,$2.85 ,$69.84 ,$54.00 
Outpatient Medical Services,LABORATORY,85610,"Blood test, clotting time",300,$56.00 ,$51.52 ,92% of total billed charges for outpatient setting,$30.80 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$1.89 ,44% of CMS Medicare lab fee schedule,$44.80 ,80% of total billed charges for outpatient setting,$30.80 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$53.20 ,95% of total billed charges for outpatient setting,$53.20 ,95% of total billed charges for outpatient setting,$42.00 ,75% of total billed charges for outpatient setting,$47.60 ,85% of total billed charges for outpatient setting,$54.32 ,97% of total billed charges for outpatient setting,$30.80 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$50.40 ,90% of total billed charges for outpatient setting,$54.32 ,97% of total billed charges for outpatient setting,$54.32 ,97% of total billed charges for outpatient setting,$54.32 ,97% of total billed charges for outpatient setting,$47.60 ,85% of total billed charges for outpatient setting,$50.40 ,90% of total billed charges for outpatient setting,$47.60 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$53.20 ,90% of total billed charges for outpatient setting,$30.80 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$52.08 ,93% of total billed charges for outpatient setting,$1.89 ,$54.32 ,$42.00 
Outpatient Medical Services,LABORATORY,85730,Coagulation assessment blood test,300,$86.00 ,$79.12 ,92% of total billed charges for outpatient setting,$47.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$2.64 ,44% of CMS Medicare lab fee schedule,$68.80 ,80% of total billed charges for outpatient setting,$47.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$81.70 ,95% of total billed charges for outpatient setting,$81.70 ,95% of total billed charges for outpatient setting,$64.50 ,75% of total billed charges for outpatient setting,$73.10 ,85% of total billed charges for outpatient setting,$83.42 ,97% of total billed charges for outpatient setting,$47.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$77.40 ,90% of total billed charges for outpatient setting,$83.42 ,97% of total billed charges for outpatient setting,$83.42 ,97% of total billed charges for outpatient setting,$83.42 ,97% of total billed charges for outpatient setting,$73.10 ,85% of total billed charges for outpatient setting,$77.40 ,90% of total billed charges for outpatient setting,$73.10 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$81.70 ,90% of total billed charges for outpatient setting,$47.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$79.98 ,93% of total billed charges for outpatient setting,$2.64 ,$83.42 ,$64.50 
Outpatient Medical Services,LABORATORY,87340,Hepatitis B Surface Antigen,300,$179.00 ,$164.68 ,92% of total billed charges for outpatient setting,$98.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$4.55 ,44% of CMS Medicare lab fee schedule,$143.20 ,80% of total billed charges for outpatient setting,$98.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$170.05 ,95% of total billed charges for outpatient setting,$170.05 ,95% of total billed charges for outpatient setting,$134.25 ,75% of total billed charges for outpatient setting,$152.15 ,85% of total billed charges for outpatient setting,$173.63 ,97% of total billed charges for outpatient setting,$98.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$161.10 ,90% of total billed charges for outpatient setting,$173.63 ,97% of total billed charges for outpatient setting,$173.63 ,97% of total billed charges for outpatient setting,$173.63 ,97% of total billed charges for outpatient setting,$152.15 ,85% of total billed charges for outpatient setting,$161.10 ,90% of total billed charges for outpatient setting,$152.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$170.05 ,90% of total billed charges for outpatient setting,$98.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$166.47 ,93% of total billed charges for outpatient setting,$4.55 ,$173.63 ,$134.25 
Outpatient Medical Services,LABORATORY,87801,Blood test to determine genetic material of certain infectious agents,300,$224.00 ,$206.08 ,92% of total billed charges for outpatient setting,$123.20 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$30.89 ,44% of CMS Medicare lab fee schedule,$179.20 ,80% of total billed charges for outpatient setting,$123.20 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$212.80 ,95% of total billed charges for outpatient setting,$212.80 ,95% of total billed charges for outpatient setting,$168.00 ,75% of total billed charges for outpatient setting,$190.40 ,85% of total billed charges for outpatient setting,$217.28 ,97% of total billed charges for outpatient setting,$123.20 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$201.60 ,90% of total billed charges for outpatient setting,$217.28 ,97% of total billed charges for outpatient setting,$217.28 ,97% of total billed charges for outpatient setting,$217.28 ,97% of total billed charges for outpatient setting,$190.40 ,85% of total billed charges for outpatient setting,$201.60 ,90% of total billed charges for outpatient setting,$190.40 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$212.80 ,90% of total billed charges for outpatient setting,$123.20 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$208.32 ,93% of total billed charges for outpatient setting,$30.89 ,$217.28 ,$168.00 
Inpatient Medical Services,INPATIENT,DRG 470,Major Joint Replacement or Reattachment of Lower Extremity w/o Major Comorbid Conditions or Complicatins,110,"$62,023.00 ",$110.40 ,92% of billed charges for inpatient setting,"$4,831.00 ",100% CMS per diem per day rate,N/A,Not separately reimbursable per contract terms for inpatient setting,$103.20 ,86% of total billed charges for inpatient setting,$96.00 ,80% of total billed charges for inpatient setting,"$4,831.00 ",100% CMS per diem per day rate,$114.00 ,95% of total billed charges for inpatient setting,$114.00 ,95% of total billed charges for inpatient setting,$90.00 ,75% of total billed charges for inpatient setting,$102.00 ,85% of total billed charges for inpatient setting,$116.40 ,97% of total billed charges for inpatient setting,"$4,831.00 ",100% CMS per diem per day rate,$108.00 ,90% of total billed charges for inpatient setting,$116.40 ,97% of total billed charges for inpatient setting,$116.40 ,97% of total billed charges for inpatient setting,$116.40 ,97% of total billed charges for inpatient setting,$102.00 ,85% of total billed charges for inpatient setting,$108.00 ,90% of total billed charges for inpatient setting,"$4,831.00 ",100% CMS per diem per day rate,$114.00 ,95% of total billed charges for inpatient setting,"$4,831.00 ",100% CMS per diem per day rate,$111.60 ,93% of total billed charges for inpatient setting,$90.00 ,"$4,831.00 ","$46,517.25 "
Outpatient Medical Services,YUMA SPECIALITY CLINIC,99211,Outpatient visit of established patient not requiring a physician,510,$293.00 ,$269.56 ,92% of total billed charges for outpatient setting,$161.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,,Not seperately reimbursible per contract terms,$234.40 ,80% of total billed charges for outpatient setting,$161.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$21.73 ,100% of Cigna Behavioral Health fee schedule,$278.35 ,95% of total billed charges for outpatient setting,$219.75 ,75% of total billed charges for outpatient setting,$249.05 ,85% of total billed charges for outpatient setting,$284.21 ,97% of total billed charges for outpatient setting,$161.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$263.70 ,90% of total billed charges for outpatient setting,$284.21 ,97% of total billed charges for outpatient setting,$284.21 ,97% of total billed charges for outpatient setting,$284.21 ,97% of total billed charges for outpatient setting,$35.00 ,100% case rate for treatment room,$263.70 ,90% of total billed charges for outpatient setting,$249.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$278.35 ,90% of total billed charges for outpatient setting,$161.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$272.49 ,93% of total billed charges for outpatient setting,$21.73 ,$284.21 ,$219.75 
Outpatient Medical Services,YUMA SPECIALITY CLINIC,99211,Outpatient visit of established patient not requiring a physician,510,$293.00 ,$269.56 ,92% of total billed charges for outpatient setting,$161.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,,Not seperately reimbursible per contract terms,$234.40 ,80% of total billed charges for outpatient setting,$161.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$21.73 ,100% of Cigna Behavioral Health fee schedule,$278.35 ,95% of total billed charges for outpatient setting,$219.75 ,75% of total billed charges for outpatient setting,$249.05 ,85% of total billed charges for outpatient setting,$284.21 ,97% of total billed charges for outpatient setting,$161.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$263.70 ,90% of total billed charges for outpatient setting,$284.21 ,97% of total billed charges for outpatient setting,$284.21 ,97% of total billed charges for outpatient setting,$284.21 ,97% of total billed charges for outpatient setting,$35.00 ,100% case rate for treatment room,$263.70 ,90% of total billed charges for outpatient setting,$249.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$278.35 ,90% of total billed charges for outpatient setting,$161.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$272.49 ,93% of total billed charges for outpatient setting,$21.73 ,$284.21 ,$219.75 
Outpatient Medical Services,YUMA SPECIALITY CLINIC,20610,Draining or injecting medication into a major joint/bursa without ultrasound,761,$510.00 ,$469.20 ,92% of total billed charges for outpatient setting,$280.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$438.60 ,86% of total billed charges for outpatient setting,$408.00 ,80% of total billed charges for outpatient setting,$280.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$484.50 ,95% of total billed charges for outpatient setting,$484.50 ,95% of total billed charges for outpatient setting,$382.50 ,75% of total billed charges for outpatient setting,$433.50 ,85% of total billed charges for outpatient setting,$494.70 ,97% of total billed charges for outpatient setting,$280.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$459.00 ,90% of total billed charges for outpatient setting,$494.70 ,97% of total billed charges for outpatient setting,$494.70 ,97% of total billed charges for outpatient setting,$494.70 ,97% of total billed charges for outpatient setting,$433.50 ,85% of total billed charges for outpatient setting,$459.00 ,90% of total billed charges for outpatient setting,$433.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$484.50 ,90% of total billed charges for outpatient setting,$280.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$474.30 ,93% of total billed charges for outpatient setting,$280.50 ,$494.70 ,$382.50 
Outpatient Medical Services,AKRON CLINIC,11104,Punch Biopsy Of Skin  Single Lesion,521,$411.00 ,$378.12 ,92% of total billed charges for outpatient setting,$226.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$353.46 ,86% of total billed charges for outpatient setting,$328.80 ,80% of total billed charges for outpatient setting,$226.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$390.45 ,95% of total billed charges for outpatient setting,$390.45 ,95% of total billed charges for outpatient setting,$308.25 ,75% of total billed charges for outpatient setting,$349.35 ,85% of total billed charges for outpatient setting,$398.67 ,97% of total billed charges for outpatient setting,$226.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$369.90 ,90% of total billed charges for outpatient setting,$398.67 ,97% of total billed charges for outpatient setting,$398.67 ,97% of total billed charges for outpatient setting,$398.67 ,97% of total billed charges for outpatient setting,$349.35 ,85% of total billed charges for outpatient setting,$369.90 ,90% of total billed charges for outpatient setting,$349.35 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$390.45 ,90% of total billed charges for outpatient setting,$226.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$226.05 ,$398.67 ,$308.25 
Outpatient Medical Services,AKRON CLINIC,11200,"Removal of skin tags, multiple fibrocutaneous tags, any area",521,$282.00 ,$259.44 ,92% of total billed charges for outpatient setting,$155.10 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$242.52 ,86% of total billed charges for outpatient setting,$225.60 ,80% of total billed charges for outpatient setting,$155.10 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$267.90 ,95% of total billed charges for outpatient setting,$267.90 ,95% of total billed charges for outpatient setting,$211.50 ,75% of total billed charges for outpatient setting,$239.70 ,85% of total billed charges for outpatient setting,$273.54 ,97% of total billed charges for outpatient setting,$155.10 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$253.80 ,90% of total billed charges for outpatient setting,$273.54 ,97% of total billed charges for outpatient setting,$273.54 ,97% of total billed charges for outpatient setting,$273.54 ,97% of total billed charges for outpatient setting,$239.70 ,85% of total billed charges for outpatient setting,$253.80 ,90% of total billed charges for outpatient setting,$239.70 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$267.90 ,90% of total billed charges for outpatient setting,$155.10 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$155.10 ,$273.54 ,$211.50 
Outpatient Medical Services,AKRON CLINIC,11750,EXCISION NAIL AND NAIL MATRIX;PERMANENT,521,$624.00 ,$574.08 ,92% of total billed charges for outpatient setting,$343.20 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$536.64 ,86% of total billed charges for outpatient setting,$499.20 ,80% of total billed charges for outpatient setting,$343.20 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$592.80 ,95% of total billed charges for outpatient setting,$592.80 ,95% of total billed charges for outpatient setting,$468.00 ,75% of total billed charges for outpatient setting,$530.40 ,85% of total billed charges for outpatient setting,$605.28 ,97% of total billed charges for outpatient setting,$343.20 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$561.60 ,90% of total billed charges for outpatient setting,$605.28 ,97% of total billed charges for outpatient setting,$605.28 ,97% of total billed charges for outpatient setting,$605.28 ,97% of total billed charges for outpatient setting,$530.40 ,85% of total billed charges for outpatient setting,$561.60 ,90% of total billed charges for outpatient setting,$530.40 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$592.80 ,90% of total billed charges for outpatient setting,$343.20 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$343.20 ,$605.28 ,$468.00 
Outpatient Medical Services,AKRON CLINIC,17000,Destruction of pre-cancerous lesion,521,$179.00 ,$164.68 ,92% of total billed charges for outpatient setting,$98.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$153.94 ,86% of total billed charges for outpatient setting,$143.20 ,80% of total billed charges for outpatient setting,$98.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$170.05 ,95% of total billed charges for outpatient setting,$170.05 ,95% of total billed charges for outpatient setting,$134.25 ,75% of total billed charges for outpatient setting,$152.15 ,85% of total billed charges for outpatient setting,$173.63 ,97% of total billed charges for outpatient setting,$98.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$161.10 ,90% of total billed charges for outpatient setting,$173.63 ,97% of total billed charges for outpatient setting,$173.63 ,97% of total billed charges for outpatient setting,$173.63 ,97% of total billed charges for outpatient setting,$152.15 ,85% of total billed charges for outpatient setting,$161.10 ,90% of total billed charges for outpatient setting,$152.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$170.05 ,90% of total billed charges for outpatient setting,$98.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$98.45 ,$173.63 ,$134.25 
Outpatient Medical Services,AKRON CLINIC,17003,Destruction of 2-14 pre-cancerous lesions,521,$41.00 ,$37.72 ,92% of total billed charges for outpatient setting,$22.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$35.26 ,86% of total billed charges for outpatient setting,$32.80 ,80% of total billed charges for outpatient setting,$22.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$38.95 ,95% of total billed charges for outpatient setting,$38.95 ,95% of total billed charges for outpatient setting,$30.75 ,75% of total billed charges for outpatient setting,$34.85 ,85% of total billed charges for outpatient setting,$39.77 ,97% of total billed charges for outpatient setting,$22.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$36.90 ,90% of total billed charges for outpatient setting,$39.77 ,97% of total billed charges for outpatient setting,$39.77 ,97% of total billed charges for outpatient setting,$39.77 ,97% of total billed charges for outpatient setting,$34.85 ,85% of total billed charges for outpatient setting,$36.90 ,90% of total billed charges for outpatient setting,$34.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$38.95 ,90% of total billed charges for outpatient setting,$22.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$22.55 ,$39.77 ,$30.75 
Outpatient Medical Services,AKRON CLINIC,17110,Destruction of 1-14 common or plantar warts,521,$234.00 ,$215.28 ,92% of total billed charges for outpatient setting,$128.70 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$201.24 ,86% of total billed charges for outpatient setting,$187.20 ,80% of total billed charges for outpatient setting,$128.70 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$222.30 ,95% of total billed charges for outpatient setting,$222.30 ,95% of total billed charges for outpatient setting,$175.50 ,75% of total billed charges for outpatient setting,$198.90 ,85% of total billed charges for outpatient setting,$226.98 ,97% of total billed charges for outpatient setting,$128.70 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$210.60 ,90% of total billed charges for outpatient setting,$226.98 ,97% of total billed charges for outpatient setting,$226.98 ,97% of total billed charges for outpatient setting,$226.98 ,97% of total billed charges for outpatient setting,$198.90 ,85% of total billed charges for outpatient setting,$210.60 ,90% of total billed charges for outpatient setting,$198.90 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$222.30 ,90% of total billed charges for outpatient setting,$128.70 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$128.70 ,$226.98 ,$175.50 
Outpatient Medical Services,AKRON CLINIC,20552,INJECTION SINGLE OR MULT TRIGGER PTS;1 OR 2,521,$165.00 ,$151.80 ,92% of total billed charges for outpatient setting,$90.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$141.90 ,86% of total billed charges for outpatient setting,$132.00 ,80% of total billed charges for outpatient setting,$90.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$156.75 ,95% of total billed charges for outpatient setting,$156.75 ,95% of total billed charges for outpatient setting,$123.75 ,75% of total billed charges for outpatient setting,$140.25 ,85% of total billed charges for outpatient setting,$160.05 ,97% of total billed charges for outpatient setting,$90.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$148.50 ,90% of total billed charges for outpatient setting,$160.05 ,97% of total billed charges for outpatient setting,$160.05 ,97% of total billed charges for outpatient setting,$160.05 ,97% of total billed charges for outpatient setting,$140.25 ,85% of total billed charges for outpatient setting,$148.50 ,90% of total billed charges for outpatient setting,$140.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$156.75 ,90% of total billed charges for outpatient setting,$90.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$90.75 ,$160.05 ,$123.75 
Outpatient Medical Services,AKRON CLINIC,20600,Draining or injecting medication into a small joint/bursa without ultrasound,521,$981.00 ,$902.52 ,92% of total billed charges for outpatient setting,$539.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$843.66 ,86% of total billed charges for outpatient setting,$784.80 ,80% of total billed charges for outpatient setting,$539.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$931.95 ,95% of total billed charges for outpatient setting,$931.95 ,95% of total billed charges for outpatient setting,$735.75 ,75% of total billed charges for outpatient setting,$833.85 ,85% of total billed charges for outpatient setting,$951.57 ,97% of total billed charges for outpatient setting,$539.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$882.90 ,90% of total billed charges for outpatient setting,$951.57 ,97% of total billed charges for outpatient setting,$951.57 ,97% of total billed charges for outpatient setting,$951.57 ,97% of total billed charges for outpatient setting,$833.85 ,85% of total billed charges for outpatient setting,$882.90 ,90% of total billed charges for outpatient setting,$833.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$931.95 ,90% of total billed charges for outpatient setting,$539.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$539.55 ,$951.57 ,$735.75 
Outpatient Medical Services,AKRON CLINIC,20610,Draining or injecting medication into a major joint/bursa without ultrasound,521,$510.00 ,$469.20 ,92% of total billed charges for outpatient setting,$280.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$438.60 ,86% of total billed charges for outpatient setting,$408.00 ,80% of total billed charges for outpatient setting,$280.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$484.50 ,95% of total billed charges for outpatient setting,$484.50 ,95% of total billed charges for outpatient setting,$382.50 ,75% of total billed charges for outpatient setting,$433.50 ,85% of total billed charges for outpatient setting,$494.70 ,97% of total billed charges for outpatient setting,$280.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$459.00 ,90% of total billed charges for outpatient setting,$494.70 ,97% of total billed charges for outpatient setting,$494.70 ,97% of total billed charges for outpatient setting,$494.70 ,97% of total billed charges for outpatient setting,$433.50 ,85% of total billed charges for outpatient setting,$459.00 ,90% of total billed charges for outpatient setting,$433.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$484.50 ,90% of total billed charges for outpatient setting,$280.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$280.50 ,$494.70 ,$382.50 
Outpatient Medical Services,AKRON CLINIC,69209,REMOVE IMPACTED EAR WAX UNILATERAL,521,$64.00 ,$58.88 ,92% of total billed charges for outpatient setting,$35.20 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$55.04 ,86% of total billed charges for outpatient setting,$51.20 ,80% of total billed charges for outpatient setting,$35.20 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$60.80 ,95% of total billed charges for outpatient setting,$60.80 ,95% of total billed charges for outpatient setting,$48.00 ,75% of total billed charges for outpatient setting,$54.40 ,85% of total billed charges for outpatient setting,$62.08 ,97% of total billed charges for outpatient setting,$35.20 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$57.60 ,90% of total billed charges for outpatient setting,$62.08 ,97% of total billed charges for outpatient setting,$62.08 ,97% of total billed charges for outpatient setting,$62.08 ,97% of total billed charges for outpatient setting,$54.40 ,85% of total billed charges for outpatient setting,$57.60 ,90% of total billed charges for outpatient setting,$54.40 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$60.80 ,90% of total billed charges for outpatient setting,$35.20 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$35.20 ,$62.08 ,$48.00 
Outpatient Medical Services,AKRON CLINIC,90471,Immunization administration by a medical assistant or nurse,521,$49.00 ,$45.08 ,92% of total billed charges for outpatient setting,$26.95 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$42.14 ,86% of total billed charges for outpatient setting,$39.20 ,80% of total billed charges for outpatient setting,$26.95 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$46.55 ,95% of total billed charges for outpatient setting,$46.55 ,95% of total billed charges for outpatient setting,$36.75 ,75% of total billed charges for outpatient setting,$41.65 ,85% of total billed charges for outpatient setting,$47.53 ,97% of total billed charges for outpatient setting,$26.95 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$44.10 ,90% of total billed charges for outpatient setting,$47.53 ,97% of total billed charges for outpatient setting,$47.53 ,97% of total billed charges for outpatient setting,$47.53 ,97% of total billed charges for outpatient setting,$41.65 ,85% of total billed charges for outpatient setting,$44.10 ,90% of total billed charges for outpatient setting,$41.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$46.55 ,90% of total billed charges for outpatient setting,$26.95 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$26.95 ,$47.53 ,$36.75 
Outpatient Medical Services,AKRON CLINIC,90472,Immunization administration; each additional vaccine,521,$26.00 ,$23.92 ,92% of total billed charges for outpatient setting,$14.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$22.36 ,86% of total billed charges for outpatient setting,$20.80 ,80% of total billed charges for outpatient setting,$14.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$24.70 ,95% of total billed charges for outpatient setting,$24.70 ,95% of total billed charges for outpatient setting,$19.50 ,75% of total billed charges for outpatient setting,$22.10 ,85% of total billed charges for outpatient setting,$25.22 ,97% of total billed charges for outpatient setting,$14.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$23.40 ,90% of total billed charges for outpatient setting,$25.22 ,97% of total billed charges for outpatient setting,$25.22 ,97% of total billed charges for outpatient setting,$25.22 ,97% of total billed charges for outpatient setting,$22.10 ,85% of total billed charges for outpatient setting,$23.40 ,90% of total billed charges for outpatient setting,$22.10 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$24.70 ,90% of total billed charges for outpatient setting,$14.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$14.30 ,$25.22 ,$19.50 
Outpatient Medical Services,AKRON CLINIC,90633,Hepatitis A vaccination for adolescents and children,521,$86.00 ,$79.12 ,92% of total billed charges for outpatient setting,$47.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$73.96 ,86% of total billed charges for outpatient setting,$68.80 ,80% of total billed charges for outpatient setting,$47.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$81.70 ,95% of total billed charges for outpatient setting,$81.70 ,95% of total billed charges for outpatient setting,$64.50 ,75% of total billed charges for outpatient setting,$73.10 ,85% of total billed charges for outpatient setting,$83.42 ,97% of total billed charges for outpatient setting,$47.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$77.40 ,90% of total billed charges for outpatient setting,$83.42 ,97% of total billed charges for outpatient setting,$83.42 ,97% of total billed charges for outpatient setting,$83.42 ,97% of total billed charges for outpatient setting,$73.10 ,85% of total billed charges for outpatient setting,$77.40 ,90% of total billed charges for outpatient setting,$73.10 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$81.70 ,90% of total billed charges for outpatient setting,$47.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$47.30 ,$83.42 ,$64.50 
Outpatient Medical Services,AKRON CLINIC,90634,"Hepatitis A vaccine (HepA), pediatric/adolescent",521,$109.00 ,$100.28 ,92% of total billed charges for outpatient setting,$59.95 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$93.74 ,86% of total billed charges for outpatient setting,$87.20 ,80% of total billed charges for outpatient setting,$59.95 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$103.55 ,95% of total billed charges for outpatient setting,$103.55 ,95% of total billed charges for outpatient setting,$81.75 ,75% of total billed charges for outpatient setting,$92.65 ,85% of total billed charges for outpatient setting,$105.73 ,97% of total billed charges for outpatient setting,$59.95 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$98.10 ,90% of total billed charges for outpatient setting,$105.73 ,97% of total billed charges for outpatient setting,$105.73 ,97% of total billed charges for outpatient setting,$105.73 ,97% of total billed charges for outpatient setting,$92.65 ,85% of total billed charges for outpatient setting,$98.10 ,90% of total billed charges for outpatient setting,$92.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$103.55 ,90% of total billed charges for outpatient setting,$59.95 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$59.95 ,$105.73 ,$81.75 
Outpatient Medical Services,AKRON CLINIC,90651,Vaccine- Gardasil 9,521,$21.68 ,$19.95 ,92% of total billed charges for outpatient setting,$11.92 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$18.64 ,86% of total billed charges for outpatient setting,$17.34 ,80% of total billed charges for outpatient setting,$11.92 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$20.60 ,95% of total billed charges for outpatient setting,$20.60 ,95% of total billed charges for outpatient setting,$16.26 ,75% of total billed charges for outpatient setting,$18.43 ,85% of total billed charges for outpatient setting,$21.03 ,97% of total billed charges for outpatient setting,$11.92 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$19.51 ,90% of total billed charges for outpatient setting,$21.03 ,97% of total billed charges for outpatient setting,$21.03 ,97% of total billed charges for outpatient setting,$21.03 ,97% of total billed charges for outpatient setting,$18.43 ,85% of total billed charges for outpatient setting,$19.51 ,90% of total billed charges for outpatient setting,$18.43 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$20.60 ,90% of total billed charges for outpatient setting,$11.92 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$11.92 ,$21.03 ,$16.26 
Outpatient Medical Services,AKRON CLINIC,90670,Pneumococcal 13-valent conjugate vaccine,521,$374.00 ,$344.08 ,92% of total billed charges for outpatient setting,$205.70 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$321.64 ,86% of total billed charges for outpatient setting,$299.20 ,80% of total billed charges for outpatient setting,$205.70 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$355.30 ,95% of total billed charges for outpatient setting,$355.30 ,95% of total billed charges for outpatient setting,$280.50 ,75% of total billed charges for outpatient setting,$317.90 ,85% of total billed charges for outpatient setting,$362.78 ,97% of total billed charges for outpatient setting,$205.70 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$336.60 ,90% of total billed charges for outpatient setting,$362.78 ,97% of total billed charges for outpatient setting,$362.78 ,97% of total billed charges for outpatient setting,$362.78 ,97% of total billed charges for outpatient setting,$317.90 ,85% of total billed charges for outpatient setting,$336.60 ,90% of total billed charges for outpatient setting,$317.90 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$355.30 ,90% of total billed charges for outpatient setting,$205.70 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$205.70 ,$362.78 ,$280.50 
Outpatient Medical Services,AKRON CLINIC,90680,"90680 Rotavirus vaccine, pentavalent, live",521,$247.00 ,$227.24 ,92% of total billed charges for outpatient setting,$135.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$212.42 ,86% of total billed charges for outpatient setting,$197.60 ,80% of total billed charges for outpatient setting,$135.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$234.65 ,95% of total billed charges for outpatient setting,$234.65 ,95% of total billed charges for outpatient setting,$185.25 ,75% of total billed charges for outpatient setting,$209.95 ,85% of total billed charges for outpatient setting,$239.59 ,97% of total billed charges for outpatient setting,$135.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$222.30 ,90% of total billed charges for outpatient setting,$239.59 ,97% of total billed charges for outpatient setting,$239.59 ,97% of total billed charges for outpatient setting,$239.59 ,97% of total billed charges for outpatient setting,$209.95 ,85% of total billed charges for outpatient setting,$222.30 ,90% of total billed charges for outpatient setting,$209.95 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$234.65 ,90% of total billed charges for outpatient setting,$135.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$135.85 ,$239.59 ,$185.25 
Outpatient Medical Services,AKRON CLINIC,90696,"DTaP-IPV, when administered to children 4 -6 yrs",521,$132.00 ,$121.44 ,92% of total billed charges for outpatient setting,$72.60 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$113.52 ,86% of total billed charges for outpatient setting,$105.60 ,80% of total billed charges for outpatient setting,$72.60 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$125.40 ,95% of total billed charges for outpatient setting,$125.40 ,95% of total billed charges for outpatient setting,$99.00 ,75% of total billed charges for outpatient setting,$112.20 ,85% of total billed charges for outpatient setting,$128.04 ,97% of total billed charges for outpatient setting,$72.60 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$118.80 ,90% of total billed charges for outpatient setting,$128.04 ,97% of total billed charges for outpatient setting,$128.04 ,97% of total billed charges for outpatient setting,$128.04 ,97% of total billed charges for outpatient setting,$112.20 ,85% of total billed charges for outpatient setting,$118.80 ,90% of total billed charges for outpatient setting,$112.20 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$125.40 ,90% of total billed charges for outpatient setting,$72.60 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$72.60 ,$128.04 ,$99.00 
Outpatient Medical Services,AKRON CLINIC,90700,"DAPTACEL DTaP, under 7 years",521,$65.00 ,$59.80 ,92% of total billed charges for outpatient setting,$35.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$55.90 ,86% of total billed charges for outpatient setting,$52.00 ,80% of total billed charges for outpatient setting,$35.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$61.75 ,95% of total billed charges for outpatient setting,$61.75 ,95% of total billed charges for outpatient setting,$48.75 ,75% of total billed charges for outpatient setting,$55.25 ,85% of total billed charges for outpatient setting,$63.05 ,97% of total billed charges for outpatient setting,$35.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$58.50 ,90% of total billed charges for outpatient setting,$63.05 ,97% of total billed charges for outpatient setting,$63.05 ,97% of total billed charges for outpatient setting,$63.05 ,97% of total billed charges for outpatient setting,$55.25 ,85% of total billed charges for outpatient setting,$58.50 ,90% of total billed charges for outpatient setting,$55.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$61.75 ,90% of total billed charges for outpatient setting,$35.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$35.75 ,$63.05 ,$48.75 
Outpatient Medical Services,AKRON CLINIC,90710,"measlesMeasles, mumps, rubella and varicella vaccine",521,$408.00 ,$375.36 ,92% of total billed charges for outpatient setting,$224.40 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$350.88 ,86% of total billed charges for outpatient setting,$326.40 ,80% of total billed charges for outpatient setting,$224.40 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$387.60 ,95% of total billed charges for outpatient setting,$387.60 ,95% of total billed charges for outpatient setting,$306.00 ,75% of total billed charges for outpatient setting,$346.80 ,85% of total billed charges for outpatient setting,$395.76 ,97% of total billed charges for outpatient setting,$224.40 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$367.20 ,90% of total billed charges for outpatient setting,$395.76 ,97% of total billed charges for outpatient setting,$395.76 ,97% of total billed charges for outpatient setting,$395.76 ,97% of total billed charges for outpatient setting,$346.80 ,85% of total billed charges for outpatient setting,$367.20 ,90% of total billed charges for outpatient setting,$346.80 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$387.60 ,90% of total billed charges for outpatient setting,$224.40 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$224.40 ,$395.76 ,$306.00 
Outpatient Medical Services,AKRON CLINIC,90715,"Diphtheria, tetanus acellular, and pertussis vaccine for adults",521,$133.00 ,$122.36 ,92% of total billed charges for outpatient setting,$73.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$114.38 ,86% of total billed charges for outpatient setting,$106.40 ,80% of total billed charges for outpatient setting,$73.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$126.35 ,95% of total billed charges for outpatient setting,$126.35 ,95% of total billed charges for outpatient setting,$99.75 ,75% of total billed charges for outpatient setting,$113.05 ,85% of total billed charges for outpatient setting,$129.01 ,97% of total billed charges for outpatient setting,$73.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$119.70 ,90% of total billed charges for outpatient setting,$129.01 ,97% of total billed charges for outpatient setting,$129.01 ,97% of total billed charges for outpatient setting,$129.01 ,97% of total billed charges for outpatient setting,$113.05 ,85% of total billed charges for outpatient setting,$119.70 ,90% of total billed charges for outpatient setting,$113.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$126.35 ,90% of total billed charges for outpatient setting,$73.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$73.15 ,$129.01 ,$99.75 
Outpatient Medical Services,AKRON CLINIC,90732,pneumococcal Pneumococcal vaccine,521,$186.00 ,$171.12 ,92% of total billed charges for outpatient setting,$102.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$159.96 ,86% of total billed charges for outpatient setting,$148.80 ,80% of total billed charges for outpatient setting,$102.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$176.70 ,95% of total billed charges for outpatient setting,$176.70 ,95% of total billed charges for outpatient setting,$139.50 ,75% of total billed charges for outpatient setting,$158.10 ,85% of total billed charges for outpatient setting,$180.42 ,97% of total billed charges for outpatient setting,$102.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$167.40 ,90% of total billed charges for outpatient setting,$180.42 ,97% of total billed charges for outpatient setting,$180.42 ,97% of total billed charges for outpatient setting,$180.42 ,97% of total billed charges for outpatient setting,$158.10 ,85% of total billed charges for outpatient setting,$167.40 ,90% of total billed charges for outpatient setting,$158.10 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$176.70 ,90% of total billed charges for outpatient setting,$102.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$102.30 ,$180.42 ,$139.50 
Outpatient Medical Services,AKRON CLINIC,90734,meningococcal Meningococcal conjugate vaccine,521,$261.00 ,$240.12 ,92% of total billed charges for outpatient setting,$143.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$224.46 ,86% of total billed charges for outpatient setting,$208.80 ,80% of total billed charges for outpatient setting,$143.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$247.95 ,95% of total billed charges for outpatient setting,$247.95 ,95% of total billed charges for outpatient setting,$195.75 ,75% of total billed charges for outpatient setting,$221.85 ,85% of total billed charges for outpatient setting,$253.17 ,97% of total billed charges for outpatient setting,$143.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$234.90 ,90% of total billed charges for outpatient setting,$253.17 ,97% of total billed charges for outpatient setting,$253.17 ,97% of total billed charges for outpatient setting,$253.17 ,97% of total billed charges for outpatient setting,$221.85 ,85% of total billed charges for outpatient setting,$234.90 ,90% of total billed charges for outpatient setting,$221.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$247.95 ,90% of total billed charges for outpatient setting,$143.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$143.55 ,$253.17 ,$195.75 
Outpatient Medical Services,AKRON CLINIC,95115,Allergy shot-1 shot,521,$28.00 ,$25.76 ,92% of total billed charges for outpatient setting,$15.40 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$24.08 ,86% of total billed charges for outpatient setting,$22.40 ,80% of total billed charges for outpatient setting,$15.40 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$26.60 ,95% of total billed charges for outpatient setting,$26.60 ,95% of total billed charges for outpatient setting,$21.00 ,75% of total billed charges for outpatient setting,$23.80 ,85% of total billed charges for outpatient setting,$27.16 ,97% of total billed charges for outpatient setting,$15.40 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$25.20 ,90% of total billed charges for outpatient setting,$27.16 ,97% of total billed charges for outpatient setting,$27.16 ,97% of total billed charges for outpatient setting,$27.16 ,97% of total billed charges for outpatient setting,$23.80 ,85% of total billed charges for outpatient setting,$25.20 ,90% of total billed charges for outpatient setting,$23.80 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$26.60 ,90% of total billed charges for outpatient setting,$15.40 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$15.40 ,$27.16 ,$21.00 
Outpatient Medical Services,AKRON CLINIC,95117,Multiple allergy shots,521,$34.00 ,$31.28 ,92% of total billed charges for outpatient setting,$18.70 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$29.24 ,86% of total billed charges for outpatient setting,$27.20 ,80% of total billed charges for outpatient setting,$18.70 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$32.30 ,95% of total billed charges for outpatient setting,$32.30 ,95% of total billed charges for outpatient setting,$25.50 ,75% of total billed charges for outpatient setting,$28.90 ,85% of total billed charges for outpatient setting,$32.98 ,97% of total billed charges for outpatient setting,$18.70 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$30.60 ,90% of total billed charges for outpatient setting,$32.98 ,97% of total billed charges for outpatient setting,$32.98 ,97% of total billed charges for outpatient setting,$32.98 ,97% of total billed charges for outpatient setting,$28.90 ,85% of total billed charges for outpatient setting,$30.60 ,90% of total billed charges for outpatient setting,$28.90 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$32.30 ,90% of total billed charges for outpatient setting,$18.70 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$18.70 ,$32.98 ,$25.50 
Outpatient Medical Services,AKRON CLINIC,96110,Childhood test to screen for developmental disabilities,521,$32.00 ,$29.44 ,92% of total billed charges for outpatient setting,$17.60 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$27.52 ,86% of total billed charges for outpatient setting,$25.60 ,80% of total billed charges for outpatient setting,$17.60 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$30.40 ,95% of total billed charges for outpatient setting,$30.40 ,95% of total billed charges for outpatient setting,$24.00 ,75% of total billed charges for outpatient setting,$27.20 ,85% of total billed charges for outpatient setting,$31.04 ,97% of total billed charges for outpatient setting,$17.60 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$28.80 ,90% of total billed charges for outpatient setting,$31.04 ,97% of total billed charges for outpatient setting,$31.04 ,97% of total billed charges for outpatient setting,$31.04 ,97% of total billed charges for outpatient setting,$27.20 ,85% of total billed charges for outpatient setting,$28.80 ,90% of total billed charges for outpatient setting,$27.20 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$30.40 ,90% of total billed charges for outpatient setting,$17.60 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$17.60 ,$31.04 ,$24.00 
Outpatient Medical Services,AKRON CLINIC,98926,Osteopathic manipulative treatment (OMT); 3-4 body regions,521,$131.00 ,$120.52 ,92% of total billed charges for outpatient setting,$72.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$112.66 ,86% of total billed charges for outpatient setting,$104.80 ,80% of total billed charges for outpatient setting,$72.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$124.45 ,95% of total billed charges for outpatient setting,$124.45 ,95% of total billed charges for outpatient setting,$98.25 ,75% of total billed charges for outpatient setting,$111.35 ,85% of total billed charges for outpatient setting,$127.07 ,97% of total billed charges for outpatient setting,$72.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$117.90 ,90% of total billed charges for outpatient setting,$127.07 ,97% of total billed charges for outpatient setting,$127.07 ,97% of total billed charges for outpatient setting,$127.07 ,97% of total billed charges for outpatient setting,$111.35 ,85% of total billed charges for outpatient setting,$117.90 ,90% of total billed charges for outpatient setting,$111.35 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$124.45 ,90% of total billed charges for outpatient setting,$72.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$72.05 ,$127.07 ,$98.25 
Outpatient Medical Services,AKRON CLINIC,98927,Osteopathic manipulative treatment (OMT); 5-6 body regions,521,$190.00 ,$174.80 ,92% of total billed charges for outpatient setting,$104.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$163.40 ,86% of total billed charges for outpatient setting,$152.00 ,80% of total billed charges for outpatient setting,$104.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$180.50 ,95% of total billed charges for outpatient setting,$180.50 ,95% of total billed charges for outpatient setting,$142.50 ,75% of total billed charges for outpatient setting,$161.50 ,85% of total billed charges for outpatient setting,$184.30 ,97% of total billed charges for outpatient setting,$104.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$171.00 ,90% of total billed charges for outpatient setting,$184.30 ,97% of total billed charges for outpatient setting,$184.30 ,97% of total billed charges for outpatient setting,$184.30 ,97% of total billed charges for outpatient setting,$161.50 ,85% of total billed charges for outpatient setting,$171.00 ,90% of total billed charges for outpatient setting,$161.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$180.50 ,90% of total billed charges for outpatient setting,$104.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$104.50 ,$184.30 ,$142.50 
Outpatient Medical Services,AKRON CLINIC,99202,"New patient office or other outpatient visit, typically 10 minutes",521,$983.00 ,$904.36 ,92% of total billed charges for outpatient setting,$540.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$845.38 ,86% of total billed charges for outpatient setting,$786.40 ,80% of total billed charges for outpatient setting,$540.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$65.23 ,100% of Cigna Behavioral Health fee schedule,$933.85 ,95% of total billed charges for outpatient setting,$737.25 ,75% of total billed charges for outpatient setting,$835.55 ,85% of total billed charges for outpatient setting,$953.51 ,97% of total billed charges for outpatient setting,$540.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$884.70 ,90% of total billed charges for outpatient setting,$953.51 ,97% of total billed charges for outpatient setting,$953.51 ,97% of total billed charges for outpatient setting,$953.51 ,97% of total billed charges for outpatient setting,$835.55 ,85% of total billed charges for outpatient setting,$884.70 ,90% of total billed charges for outpatient setting,$835.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$933.85 ,90% of total billed charges for outpatient setting,$540.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$65.23 ,$953.51 ,$737.25 
Outpatient Medical Services,AKRON CLINIC,99211,Outpatient visit of established patient not requiring a physician,521,$293.00 ,$269.56 ,92% of total billed charges for outpatient setting,$161.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$251.98 ,86% of total billed charges for outpatient setting,$234.40 ,80% of total billed charges for outpatient setting,$161.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$21.73 ,100% of Cigna Behavioral Health fee schedule,$278.35 ,95% of total billed charges for outpatient setting,$219.75 ,75% of total billed charges for outpatient setting,$249.05 ,85% of total billed charges for outpatient setting,$284.21 ,97% of total billed charges for outpatient setting,$161.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$263.70 ,90% of total billed charges for outpatient setting,$284.21 ,97% of total billed charges for outpatient setting,$284.21 ,97% of total billed charges for outpatient setting,$284.21 ,97% of total billed charges for outpatient setting,$249.05 ,85% of total billed charges for outpatient setting,$263.70 ,90% of total billed charges for outpatient setting,$249.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$278.35 ,90% of total billed charges for outpatient setting,$161.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$21.73 ,$284.21 ,$219.75 
Outpatient Medical Services,AKRON CLINIC,99212,Outpatient visit of established patient requiring a physician,521,$139.00 ,$127.88 ,92% of total billed charges for outpatient setting,$76.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$119.54 ,86% of total billed charges for outpatient setting,$111.20 ,80% of total billed charges for outpatient setting,$76.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$38.72 ,100% of Cigna Behavioral Health fee schedule,$132.05 ,95% of total billed charges for outpatient setting,$104.25 ,75% of total billed charges for outpatient setting,$118.15 ,85% of total billed charges for outpatient setting,$134.83 ,97% of total billed charges for outpatient setting,$76.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$125.10 ,90% of total billed charges for outpatient setting,$134.83 ,97% of total billed charges for outpatient setting,$134.83 ,97% of total billed charges for outpatient setting,$134.83 ,97% of total billed charges for outpatient setting,$118.15 ,85% of total billed charges for outpatient setting,$125.10 ,90% of total billed charges for outpatient setting,$118.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$132.05 ,90% of total billed charges for outpatient setting,$76.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$38.72 ,$134.83 ,$104.25 
Outpatient Medical Services,AKRON CLINIC,99213,"Established patient office or other outpatient visit, typically 15 minutes",521,$123.00 ,$113.16 ,92% of total billed charges for outpatient setting,$67.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$105.78 ,86% of total billed charges for outpatient setting,$98.40 ,80% of total billed charges for outpatient setting,$67.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$52.82 ,100% of Cigna Behavioral Health fee schedule,$116.85 ,95% of total billed charges for outpatient setting,$92.25 ,75% of total billed charges for outpatient setting,$104.55 ,85% of total billed charges for outpatient setting,$119.31 ,97% of total billed charges for outpatient setting,$67.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$110.70 ,90% of total billed charges for outpatient setting,$119.31 ,97% of total billed charges for outpatient setting,$119.31 ,97% of total billed charges for outpatient setting,$119.31 ,97% of total billed charges for outpatient setting,$104.55 ,85% of total billed charges for outpatient setting,$110.70 ,90% of total billed charges for outpatient setting,$104.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$116.85 ,90% of total billed charges for outpatient setting,$67.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$52.82 ,$119.31 ,$92.25 
Outpatient Medical Services,AKRON CLINIC,99214,"Established patient office or other outpatient visit, typically 25 minutes",521,$206.00 ,$189.52 ,92% of total billed charges for outpatient setting,$113.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$177.16 ,86% of total billed charges for outpatient setting,$164.80 ,80% of total billed charges for outpatient setting,$113.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$82.79 ,100% of Cigna Behavioral Health fee schedule,$195.70 ,95% of total billed charges for outpatient setting,$154.50 ,75% of total billed charges for outpatient setting,$175.10 ,85% of total billed charges for outpatient setting,$199.82 ,97% of total billed charges for outpatient setting,$113.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$185.40 ,90% of total billed charges for outpatient setting,$199.82 ,97% of total billed charges for outpatient setting,$199.82 ,97% of total billed charges for outpatient setting,$199.82 ,97% of total billed charges for outpatient setting,$175.10 ,85% of total billed charges for outpatient setting,$185.40 ,90% of total billed charges for outpatient setting,$175.10 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$195.70 ,90% of total billed charges for outpatient setting,$113.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$82.79 ,$199.82 ,$154.50 
Outpatient Medical Services,AKRON CLINIC,99215,"Established patient office or other outpatient, visit typically 40 minutes",521,$301.00 ,$276.92 ,92% of total billed charges for outpatient setting,$165.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$258.86 ,86% of total billed charges for outpatient setting,$240.80 ,80% of total billed charges for outpatient setting,$165.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$120.24 ,100% of Cigna Behavioral Health fee schedule,$285.95 ,95% of total billed charges for outpatient setting,$225.75 ,75% of total billed charges for outpatient setting,$255.85 ,85% of total billed charges for outpatient setting,$291.97 ,97% of total billed charges for outpatient setting,$165.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$270.90 ,90% of total billed charges for outpatient setting,$291.97 ,97% of total billed charges for outpatient setting,$291.97 ,97% of total billed charges for outpatient setting,$291.97 ,97% of total billed charges for outpatient setting,$255.85 ,85% of total billed charges for outpatient setting,$270.90 ,90% of total billed charges for outpatient setting,$255.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$285.95 ,90% of total billed charges for outpatient setting,$165.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$120.24 ,$291.97 ,$225.75 
Outpatient Medical Services,AKRON CLINIC,99307,"Subsequent Nursing Facility Care, Straightforward",521,$156.00 ,$143.52 ,92% of total billed charges for outpatient setting,$85.80 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$134.16 ,86% of total billed charges for outpatient setting,$124.80 ,80% of total billed charges for outpatient setting,$85.80 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$29.40 ,100% of Cigna Behavioral Health fee schedule,$148.20 ,95% of total billed charges for outpatient setting,$117.00 ,75% of total billed charges for outpatient setting,$132.60 ,85% of total billed charges for outpatient setting,$151.32 ,97% of total billed charges for outpatient setting,$85.80 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$140.40 ,90% of total billed charges for outpatient setting,$151.32 ,97% of total billed charges for outpatient setting,$151.32 ,97% of total billed charges for outpatient setting,$151.32 ,97% of total billed charges for outpatient setting,$132.60 ,85% of total billed charges for outpatient setting,$140.40 ,90% of total billed charges for outpatient setting,$132.60 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$148.20 ,90% of total billed charges for outpatient setting,$85.80 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$29.40 ,$151.32 ,$117.00 
Outpatient Medical Services,AKRON CLINIC,99308,"Subsequent Nursing Facility Care, Low",521,$233.00 ,$214.36 ,92% of total billed charges for outpatient setting,$128.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$200.38 ,86% of total billed charges for outpatient setting,$186.40 ,80% of total billed charges for outpatient setting,$128.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$44.96 ,100% of Cigna Behavioral Health fee schedule,$221.35 ,95% of total billed charges for outpatient setting,$174.75 ,75% of total billed charges for outpatient setting,$198.05 ,85% of total billed charges for outpatient setting,$226.01 ,97% of total billed charges for outpatient setting,$128.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$209.70 ,90% of total billed charges for outpatient setting,$226.01 ,97% of total billed charges for outpatient setting,$226.01 ,97% of total billed charges for outpatient setting,$226.01 ,97% of total billed charges for outpatient setting,$198.05 ,85% of total billed charges for outpatient setting,$209.70 ,90% of total billed charges for outpatient setting,$198.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$221.35 ,90% of total billed charges for outpatient setting,$128.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$44.96 ,$226.01 ,$174.75 
Outpatient Medical Services,AKRON CLINIC,99309,"Subsequent Nursing Facility Care, Moderate",521,$309.00 ,$284.28 ,92% of total billed charges for outpatient setting,$169.95 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$265.74 ,86% of total billed charges for outpatient setting,$247.20 ,80% of total billed charges for outpatient setting,$169.95 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$59.60 ,100% of Cigna Behavioral Health fee schedule,$293.55 ,95% of total billed charges for outpatient setting,$231.75 ,75% of total billed charges for outpatient setting,$262.65 ,85% of total billed charges for outpatient setting,$299.73 ,97% of total billed charges for outpatient setting,$169.95 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$278.10 ,90% of total billed charges for outpatient setting,$299.73 ,97% of total billed charges for outpatient setting,$299.73 ,97% of total billed charges for outpatient setting,$299.73 ,97% of total billed charges for outpatient setting,$262.65 ,85% of total billed charges for outpatient setting,$278.10 ,90% of total billed charges for outpatient setting,$262.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$293.55 ,90% of total billed charges for outpatient setting,$169.95 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$59.60 ,$299.73 ,$231.75 
Outpatient Medical Services,AKRON CLINIC,99391,Periodic primary re-evaluation for an established infant patient,521,$217.00 ,$199.64 ,92% of total billed charges for outpatient setting,$119.35 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$186.62 ,86% of total billed charges for outpatient setting,$173.60 ,80% of total billed charges for outpatient setting,$119.35 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$206.15 ,95% of total billed charges for outpatient setting,$206.15 ,95% of total billed charges for outpatient setting,$162.75 ,75% of total billed charges for outpatient setting,$184.45 ,85% of total billed charges for outpatient setting,$210.49 ,97% of total billed charges for outpatient setting,$119.35 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$195.30 ,90% of total billed charges for outpatient setting,$210.49 ,97% of total billed charges for outpatient setting,$210.49 ,97% of total billed charges for outpatient setting,$210.49 ,97% of total billed charges for outpatient setting,$184.45 ,85% of total billed charges for outpatient setting,$195.30 ,90% of total billed charges for outpatient setting,$184.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$206.15 ,90% of total billed charges for outpatient setting,$119.35 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$119.35 ,$210.49 ,$162.75 
Outpatient Medical Services,AKRON CLINIC,99392,Initial visit for new patients 1-4 years old,521,$237.00 ,$218.04 ,92% of total billed charges for outpatient setting,$130.35 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$203.82 ,86% of total billed charges for outpatient setting,$189.60 ,80% of total billed charges for outpatient setting,$130.35 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$225.15 ,95% of total billed charges for outpatient setting,$225.15 ,95% of total billed charges for outpatient setting,$177.75 ,75% of total billed charges for outpatient setting,$201.45 ,85% of total billed charges for outpatient setting,$229.89 ,97% of total billed charges for outpatient setting,$130.35 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$213.30 ,90% of total billed charges for outpatient setting,$229.89 ,97% of total billed charges for outpatient setting,$229.89 ,97% of total billed charges for outpatient setting,$229.89 ,97% of total billed charges for outpatient setting,$201.45 ,85% of total billed charges for outpatient setting,$213.30 ,90% of total billed charges for outpatient setting,$201.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$225.15 ,90% of total billed charges for outpatient setting,$130.35 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$130.35 ,$229.89 ,$177.75 
Outpatient Medical Services,AKRON CLINIC,99393,New preventative visit in new patients 5-11 years old,521,$237.00 ,$218.04 ,92% of total billed charges for outpatient setting,$130.35 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$203.82 ,86% of total billed charges for outpatient setting,$189.60 ,80% of total billed charges for outpatient setting,$130.35 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$225.15 ,95% of total billed charges for outpatient setting,$225.15 ,95% of total billed charges for outpatient setting,$177.75 ,75% of total billed charges for outpatient setting,$201.45 ,85% of total billed charges for outpatient setting,$229.89 ,97% of total billed charges for outpatient setting,$130.35 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$213.30 ,90% of total billed charges for outpatient setting,$229.89 ,97% of total billed charges for outpatient setting,$229.89 ,97% of total billed charges for outpatient setting,$229.89 ,97% of total billed charges for outpatient setting,$201.45 ,85% of total billed charges for outpatient setting,$213.30 ,90% of total billed charges for outpatient setting,$201.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$225.15 ,90% of total billed charges for outpatient setting,$130.35 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$130.35 ,$229.89 ,$177.75 
Outpatient Medical Services,AKRON CLINIC,99394,New preventative visit in new patients 12-17 years old,521,$269.00 ,$247.48 ,92% of total billed charges for outpatient setting,$147.95 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$231.34 ,86% of total billed charges for outpatient setting,$215.20 ,80% of total billed charges for outpatient setting,$147.95 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$255.55 ,95% of total billed charges for outpatient setting,$255.55 ,95% of total billed charges for outpatient setting,$201.75 ,75% of total billed charges for outpatient setting,$228.65 ,85% of total billed charges for outpatient setting,$260.93 ,97% of total billed charges for outpatient setting,$147.95 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$242.10 ,90% of total billed charges for outpatient setting,$260.93 ,97% of total billed charges for outpatient setting,$260.93 ,97% of total billed charges for outpatient setting,$260.93 ,97% of total billed charges for outpatient setting,$228.65 ,85% of total billed charges for outpatient setting,$242.10 ,90% of total billed charges for outpatient setting,$228.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$255.55 ,90% of total billed charges for outpatient setting,$147.95 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$147.95 ,$260.93 ,$201.75 
Outpatient Medical Services,AKRON CLINIC,99395,Established patient periodic preventive medicine examination age 18-39 years,521,$278.00 ,$255.76 ,92% of total billed charges for outpatient setting,$152.90 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$239.08 ,86% of total billed charges for outpatient setting,$222.40 ,80% of total billed charges for outpatient setting,$152.90 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$264.10 ,95% of total billed charges for outpatient setting,$264.10 ,95% of total billed charges for outpatient setting,$208.50 ,75% of total billed charges for outpatient setting,$236.30 ,85% of total billed charges for outpatient setting,$269.66 ,97% of total billed charges for outpatient setting,$152.90 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$250.20 ,90% of total billed charges for outpatient setting,$269.66 ,97% of total billed charges for outpatient setting,$269.66 ,97% of total billed charges for outpatient setting,$269.66 ,97% of total billed charges for outpatient setting,$236.30 ,85% of total billed charges for outpatient setting,$250.20 ,90% of total billed charges for outpatient setting,$236.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$264.10 ,90% of total billed charges for outpatient setting,$152.90 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$152.90 ,$269.66 ,$208.50 
Outpatient Medical Services,AKRON CLINIC,99396,Established patient periodic preventive medicine examination age 40-64 years,521,$318.00 ,$292.56 ,92% of total billed charges for outpatient setting,$174.90 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$273.48 ,86% of total billed charges for outpatient setting,$254.40 ,80% of total billed charges for outpatient setting,$174.90 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$302.10 ,95% of total billed charges for outpatient setting,$302.10 ,95% of total billed charges for outpatient setting,$238.50 ,75% of total billed charges for outpatient setting,$270.30 ,85% of total billed charges for outpatient setting,$308.46 ,97% of total billed charges for outpatient setting,$174.90 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$286.20 ,90% of total billed charges for outpatient setting,$308.46 ,97% of total billed charges for outpatient setting,$308.46 ,97% of total billed charges for outpatient setting,$308.46 ,97% of total billed charges for outpatient setting,$270.30 ,85% of total billed charges for outpatient setting,$286.20 ,90% of total billed charges for outpatient setting,$270.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$302.10 ,90% of total billed charges for outpatient setting,$174.90 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$174.90 ,$308.46 ,$238.50 
Outpatient Medical Services,AKRON CLINIC,58300,Insert intrauterine device (IUD) plus IUD,983,$310.00 ,$68.49 ,135% of 2011 CMS physician fee schedule,$51.71 ,100% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$113.39 ,100% of the Blue Cross physician fee schedule,$104.30 ,100% of Work Comp physician fee schedule. Multiple discount rules may apply,$51.71 ,100% CMS Medicare physician fee schedule ,$74.98 ,145% CMS Medicare physician fee schedule ,$294.50 ,95% of total billed charges for physician setting,,Not separately reimbursible. Not contracted for physician rates,$64.34 ,100% CMS Medicare physician fee schedule ,$75.50 ,100% Humana physician fee schedule,$51.71 ,100% CMS Medicare physician fee schedule ,$310.00 ,Not separately reimbursible. Not contracted for physician rates,$108.64 ,100% Midlands Choice physician fee schedule,$186.00 ,60% of total billed charges for physician settings,$186.00 ,60% of total billed charges for physician settings,$72.39 ,140% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$51.71 ,100% CMS Medicare physician fee schedule ,$294.50 ,95% of total billed charges,$51.71 ,100% CMS Medicare physician fee schedule ,$64.51 ,124.753% CMS Medicare physician fee schedule ,$51.71 ,$310.00 ,$232.50 
Outpatient Medical Services,AKRON CLINIC,58301,Remove intrauterine device (IUD),983,$328.00 ,$91.67 ,135% of 2011 CMS physician fee schedule,$67.73 ,100% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$126.27 ,100% of the Blue Cross physician fee schedule,$136.50 ,100% of Work Comp physician fee schedule. Multiple discount rules may apply,$67.73 ,100% CMS Medicare physician fee schedule ,$98.21 ,145% CMS Medicare physician fee schedule ,$311.60 ,95% of total billed charges for physician setting,,Not separately reimbursible. Not contracted for physician rates,$83.76 ,100% CMS Medicare physician fee schedule ,$98.43 ,100% Humana physician fee schedule,$67.73 ,100% CMS Medicare physician fee schedule ,$328.00 ,Not separately reimbursible. Not contracted for physician rates,$135.97 ,100% Midlands Choice physician fee schedule,$196.80 ,60% of total billed charges for physician settings,$196.80 ,60% of total billed charges for physician settings,$94.82 ,140% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$67.73 ,100% CMS Medicare physician fee schedule ,$311.60 ,95% of total billed charges,$67.73 ,100% CMS Medicare physician fee schedule ,$84.50 ,124.753% CMS Medicare physician fee schedule ,$67.73 ,$328.00 ,$246.00 
Outpatient Medical Services,AKRON CLINIC,99203,"New patient office or other outpatient visit, typically 30 min",521,$983.00 ,$904.36 ,92% of total billed charges for outpatient setting,$540.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$845.38 ,86% of total billed charges for outpatient setting,$786.40 ,80% of total billed charges for outpatient setting,$540.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$96.95 ,100% of Cigna Behavioral Health fee schedule,$933.85 ,95% of total billed charges for outpatient setting,$737.25 ,75% of total billed charges for outpatient setting,$835.55 ,85% of total billed charges for outpatient setting,$953.51 ,97% of total billed charges for outpatient setting,$540.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$884.70 ,90% of total billed charges for outpatient setting,$953.51 ,97% of total billed charges for outpatient setting,$953.51 ,97% of total billed charges for outpatient setting,$953.51 ,97% of total billed charges for outpatient setting,$835.55 ,85% of total billed charges for outpatient setting,$884.70 ,90% of total billed charges for outpatient setting,$835.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$933.85 ,90% of total billed charges for outpatient setting,$540.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$96.95 ,$953.51 ,$737.25 
Outpatient Medical Services,AKRON CLINIC,99204,"New patient office of other outpatient visit, typically 45 min",521,$983.00 ,$904.36 ,92% of total billed charges for outpatient setting,$540.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$845.38 ,86% of total billed charges for outpatient setting,$786.40 ,80% of total billed charges for outpatient setting,$540.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$137.09 ,100% of Cigna Behavioral Health fee schedule,$933.85 ,95% of total billed charges for outpatient setting,$737.25 ,75% of total billed charges for outpatient setting,$835.55 ,85% of total billed charges for outpatient setting,$953.51 ,97% of total billed charges for outpatient setting,$540.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$884.70 ,90% of total billed charges for outpatient setting,$953.51 ,97% of total billed charges for outpatient setting,$953.51 ,97% of total billed charges for outpatient setting,$953.51 ,97% of total billed charges for outpatient setting,$835.55 ,85% of total billed charges for outpatient setting,$884.70 ,90% of total billed charges for outpatient setting,$835.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$933.85 ,90% of total billed charges for outpatient setting,$540.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$137.09 ,$953.51 ,$737.25 
Outpatient Medical Services,AKRON CLINIC,99205,"New patient office of other outpatient visit, typically 60 min",521,$983.00 ,$904.36 ,92% of total billed charges for outpatient setting,$540.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$845.38 ,86% of total billed charges for outpatient setting,$786.40 ,80% of total billed charges for outpatient setting,$540.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$174.15 ,100% of Cigna Behavioral Health fee schedule,$933.85 ,95% of total billed charges for outpatient setting,$737.25 ,75% of total billed charges for outpatient setting,$835.55 ,85% of total billed charges for outpatient setting,$953.51 ,97% of total billed charges for outpatient setting,$540.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$884.70 ,90% of total billed charges for outpatient setting,$953.51 ,97% of total billed charges for outpatient setting,$953.51 ,97% of total billed charges for outpatient setting,$953.51 ,97% of total billed charges for outpatient setting,$835.55 ,85% of total billed charges for outpatient setting,$884.70 ,90% of total billed charges for outpatient setting,$835.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$933.85 ,90% of total billed charges for outpatient setting,$540.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$174.15 ,$953.51 ,$737.25 
Outpatient Medical Services,AKRON CLINIC,99385,Initial new patient preventive medicine evaluation (18–39 years),521,$305.00 ,$280.60 ,92% of total billed charges for outpatient setting,$167.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$262.30 ,86% of total billed charges for outpatient setting,$244.00 ,80% of total billed charges for outpatient setting,$167.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$289.75 ,95% of total billed charges for outpatient setting,$289.75 ,95% of total billed charges for outpatient setting,$228.75 ,75% of total billed charges for outpatient setting,$259.25 ,85% of total billed charges for outpatient setting,$295.85 ,97% of total billed charges for outpatient setting,$167.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$274.50 ,90% of total billed charges for outpatient setting,$295.85 ,97% of total billed charges for outpatient setting,$295.85 ,97% of total billed charges for outpatient setting,$295.85 ,97% of total billed charges for outpatient setting,$259.25 ,85% of total billed charges for outpatient setting,$274.50 ,90% of total billed charges for outpatient setting,$259.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$289.75 ,90% of total billed charges for outpatient setting,$167.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$167.75 ,$295.85 ,$228.75 
Outpatient Medical Services,AKRON CLINIC,99386,Initial new patient preventive medicine evaluation (40–64 years),521,$369.00 ,$339.48 ,92% of total billed charges for outpatient setting,$202.95 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$317.34 ,86% of total billed charges for outpatient setting,$295.20 ,80% of total billed charges for outpatient setting,$202.95 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$350.55 ,95% of total billed charges for outpatient setting,$350.55 ,95% of total billed charges for outpatient setting,$276.75 ,75% of total billed charges for outpatient setting,$313.65 ,85% of total billed charges for outpatient setting,$357.93 ,97% of total billed charges for outpatient setting,$202.95 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$332.10 ,90% of total billed charges for outpatient setting,$357.93 ,97% of total billed charges for outpatient setting,$357.93 ,97% of total billed charges for outpatient setting,$357.93 ,97% of total billed charges for outpatient setting,$313.65 ,85% of total billed charges for outpatient setting,$332.10 ,90% of total billed charges for outpatient setting,$313.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$350.55 ,90% of total billed charges for outpatient setting,$202.95 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$202.95 ,$357.93 ,$276.75 
Outpatient Medical Services,AKRON CLINIC,10060,Incision and drainage of abscess; simple or single and complex or multiple,521,$426.00 ,$391.92 ,92% of total billed charges for outpatient setting,$234.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$366.36 ,86% of total billed charges for outpatient setting,$340.80 ,80% of total billed charges for outpatient setting,$234.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$404.70 ,95% of total billed charges for outpatient setting,$404.70 ,95% of total billed charges for outpatient setting,$319.50 ,75% of total billed charges for outpatient setting,$362.10 ,85% of total billed charges for outpatient setting,$413.22 ,97% of total billed charges for outpatient setting,$234.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$383.40 ,90% of total billed charges for outpatient setting,$413.22 ,97% of total billed charges for outpatient setting,$413.22 ,97% of total billed charges for outpatient setting,$413.22 ,97% of total billed charges for outpatient setting,$362.10 ,85% of total billed charges for outpatient setting,$383.40 ,90% of total billed charges for outpatient setting,$362.10 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$404.70 ,90% of total billed charges for outpatient setting,$234.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$234.30 ,$413.22 ,$319.50 
Outpatient Medical Services,AKRON CLINIC,90736,Shingles vaccine,521,$251.00 ,$230.92 ,92% of total billed charges for outpatient setting,$138.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$215.86 ,86% of total billed charges for outpatient setting,$200.80 ,80% of total billed charges for outpatient setting,$138.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$238.45 ,95% of total billed charges for outpatient setting,$238.45 ,95% of total billed charges for outpatient setting,$188.25 ,75% of total billed charges for outpatient setting,$213.35 ,85% of total billed charges for outpatient setting,$243.47 ,97% of total billed charges for outpatient setting,$138.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$225.90 ,90% of total billed charges for outpatient setting,$243.47 ,97% of total billed charges for outpatient setting,$243.47 ,97% of total billed charges for outpatient setting,$243.47 ,97% of total billed charges for outpatient setting,$213.35 ,85% of total billed charges for outpatient setting,$225.90 ,90% of total billed charges for outpatient setting,$213.35 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$238.45 ,90% of total billed charges for outpatient setting,$138.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$138.05 ,$243.47 ,$188.25 
Outpatient Medical Services,AKRON CLINIC,99825,Osteopathic manipulative treatment (OMT); 1-2 body regions,521,$95.00 ,$87.40 ,92% of total billed charges for outpatient setting,$52.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$81.70 ,86% of total billed charges for outpatient setting,$76.00 ,80% of total billed charges for outpatient setting,$52.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$90.25 ,95% of total billed charges for outpatient setting,$90.25 ,95% of total billed charges for outpatient setting,$71.25 ,75% of total billed charges for outpatient setting,$80.75 ,85% of total billed charges for outpatient setting,$92.15 ,97% of total billed charges for outpatient setting,$52.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$85.50 ,90% of total billed charges for outpatient setting,$92.15 ,97% of total billed charges for outpatient setting,$92.15 ,97% of total billed charges for outpatient setting,$92.15 ,97% of total billed charges for outpatient setting,$80.75 ,85% of total billed charges for outpatient setting,$85.50 ,90% of total billed charges for outpatient setting,$80.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$90.25 ,90% of total billed charges for outpatient setting,$52.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$52.25 ,$92.15 ,$71.25 
Outpatient Medical Services,YUMA CLINIC,11104,Punch Biopsy Of Skin  Single Lesion,521,$411.00 ,$378.12 ,92% of total billed charges for outpatient setting,$226.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$353.46 ,86% of total billed charges for outpatient setting,$328.80 ,80% of total billed charges for outpatient setting,$226.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$390.45 ,95% of total billed charges for outpatient setting,$390.45 ,95% of total billed charges for outpatient setting,$308.25 ,75% of total billed charges for outpatient setting,$349.35 ,85% of total billed charges for outpatient setting,$398.67 ,97% of total billed charges for outpatient setting,$226.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$369.90 ,90% of total billed charges for outpatient setting,$398.67 ,97% of total billed charges for outpatient setting,$398.67 ,97% of total billed charges for outpatient setting,$398.67 ,97% of total billed charges for outpatient setting,$349.35 ,85% of total billed charges for outpatient setting,$369.90 ,90% of total billed charges for outpatient setting,$349.35 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$390.45 ,90% of total billed charges for outpatient setting,$226.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$226.05 ,$398.67 ,$308.25 
Outpatient Medical Services,YUMA CLINIC,11200,"Removal of skin tags, multiple fibrocutaneous tags, any area",521,$282.00 ,$259.44 ,92% of total billed charges for outpatient setting,$155.10 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$242.52 ,86% of total billed charges for outpatient setting,$225.60 ,80% of total billed charges for outpatient setting,$155.10 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$267.90 ,95% of total billed charges for outpatient setting,$267.90 ,95% of total billed charges for outpatient setting,$211.50 ,75% of total billed charges for outpatient setting,$239.70 ,85% of total billed charges for outpatient setting,$273.54 ,97% of total billed charges for outpatient setting,$155.10 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$253.80 ,90% of total billed charges for outpatient setting,$273.54 ,97% of total billed charges for outpatient setting,$273.54 ,97% of total billed charges for outpatient setting,$273.54 ,97% of total billed charges for outpatient setting,$239.70 ,85% of total billed charges for outpatient setting,$253.80 ,90% of total billed charges for outpatient setting,$239.70 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$267.90 ,90% of total billed charges for outpatient setting,$155.10 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$155.10 ,$273.54 ,$211.50 
Outpatient Medical Services,YUMA CLINIC,11750,EXCISION NAIL AND NAIL MATRIX;PERMANENT,521,$624.00 ,$574.08 ,92% of total billed charges for outpatient setting,$343.20 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$536.64 ,86% of total billed charges for outpatient setting,$499.20 ,80% of total billed charges for outpatient setting,$343.20 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$592.80 ,95% of total billed charges for outpatient setting,$592.80 ,95% of total billed charges for outpatient setting,$468.00 ,75% of total billed charges for outpatient setting,$530.40 ,85% of total billed charges for outpatient setting,$605.28 ,97% of total billed charges for outpatient setting,$343.20 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$561.60 ,90% of total billed charges for outpatient setting,$605.28 ,97% of total billed charges for outpatient setting,$605.28 ,97% of total billed charges for outpatient setting,$605.28 ,97% of total billed charges for outpatient setting,$530.40 ,85% of total billed charges for outpatient setting,$561.60 ,90% of total billed charges for outpatient setting,$530.40 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$592.80 ,90% of total billed charges for outpatient setting,$343.20 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$343.20 ,$605.28 ,$468.00 
Outpatient Medical Services,YUMA CLINIC,17000,Destruction of pre-cancerous lesion,521,$179.00 ,$164.68 ,92% of total billed charges for outpatient setting,$98.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$153.94 ,86% of total billed charges for outpatient setting,$143.20 ,80% of total billed charges for outpatient setting,$98.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$170.05 ,95% of total billed charges for outpatient setting,$170.05 ,95% of total billed charges for outpatient setting,$134.25 ,75% of total billed charges for outpatient setting,$152.15 ,85% of total billed charges for outpatient setting,$173.63 ,97% of total billed charges for outpatient setting,$98.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$161.10 ,90% of total billed charges for outpatient setting,$173.63 ,97% of total billed charges for outpatient setting,$173.63 ,97% of total billed charges for outpatient setting,$173.63 ,97% of total billed charges for outpatient setting,$152.15 ,85% of total billed charges for outpatient setting,$161.10 ,90% of total billed charges for outpatient setting,$152.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$170.05 ,90% of total billed charges for outpatient setting,$98.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$98.45 ,$173.63 ,$134.25 
Outpatient Medical Services,YUMA CLINIC,17003,Destruction of 2-14 pre-cancerous lesions,521,$41.00 ,$37.72 ,92% of total billed charges for outpatient setting,$22.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$35.26 ,86% of total billed charges for outpatient setting,$32.80 ,80% of total billed charges for outpatient setting,$22.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$38.95 ,95% of total billed charges for outpatient setting,$38.95 ,95% of total billed charges for outpatient setting,$30.75 ,75% of total billed charges for outpatient setting,$34.85 ,85% of total billed charges for outpatient setting,$39.77 ,97% of total billed charges for outpatient setting,$22.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$36.90 ,90% of total billed charges for outpatient setting,$39.77 ,97% of total billed charges for outpatient setting,$39.77 ,97% of total billed charges for outpatient setting,$39.77 ,97% of total billed charges for outpatient setting,$34.85 ,85% of total billed charges for outpatient setting,$36.90 ,90% of total billed charges for outpatient setting,$34.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$38.95 ,90% of total billed charges for outpatient setting,$22.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$22.55 ,$39.77 ,$30.75 
Outpatient Medical Services,YUMA CLINIC,17110,Destruction of 1-14 common or plantar warts,521,$234.00 ,$215.28 ,92% of total billed charges for outpatient setting,$128.70 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$201.24 ,86% of total billed charges for outpatient setting,$187.20 ,80% of total billed charges for outpatient setting,$128.70 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$222.30 ,95% of total billed charges for outpatient setting,$222.30 ,95% of total billed charges for outpatient setting,$175.50 ,75% of total billed charges for outpatient setting,$198.90 ,85% of total billed charges for outpatient setting,$226.98 ,97% of total billed charges for outpatient setting,$128.70 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$210.60 ,90% of total billed charges for outpatient setting,$226.98 ,97% of total billed charges for outpatient setting,$226.98 ,97% of total billed charges for outpatient setting,$226.98 ,97% of total billed charges for outpatient setting,$198.90 ,85% of total billed charges for outpatient setting,$210.60 ,90% of total billed charges for outpatient setting,$198.90 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$222.30 ,90% of total billed charges for outpatient setting,$128.70 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$128.70 ,$226.98 ,$175.50 
Outpatient Medical Services,YUMA CLINIC,20552,INJECTION SINGLE OR MULT TRIGGER PTS;1 OR 2,521,$165.00 ,$151.80 ,92% of total billed charges for outpatient setting,$90.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$141.90 ,86% of total billed charges for outpatient setting,$132.00 ,80% of total billed charges for outpatient setting,$90.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$156.75 ,95% of total billed charges for outpatient setting,$156.75 ,95% of total billed charges for outpatient setting,$123.75 ,75% of total billed charges for outpatient setting,$140.25 ,85% of total billed charges for outpatient setting,$160.05 ,97% of total billed charges for outpatient setting,$90.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$148.50 ,90% of total billed charges for outpatient setting,$160.05 ,97% of total billed charges for outpatient setting,$160.05 ,97% of total billed charges for outpatient setting,$160.05 ,97% of total billed charges for outpatient setting,$140.25 ,85% of total billed charges for outpatient setting,$148.50 ,90% of total billed charges for outpatient setting,$140.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$156.75 ,90% of total billed charges for outpatient setting,$90.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$90.75 ,$160.05 ,$123.75 
Outpatient Medical Services,YUMA CLINIC,20600,Draining or injecting medication into a small joint/bursa without ultrasound,521,$981.00 ,$902.52 ,92% of total billed charges for outpatient setting,$539.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$843.66 ,86% of total billed charges for outpatient setting,$784.80 ,80% of total billed charges for outpatient setting,$539.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$931.95 ,95% of total billed charges for outpatient setting,$931.95 ,95% of total billed charges for outpatient setting,$735.75 ,75% of total billed charges for outpatient setting,$833.85 ,85% of total billed charges for outpatient setting,$951.57 ,97% of total billed charges for outpatient setting,$539.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$882.90 ,90% of total billed charges for outpatient setting,$951.57 ,97% of total billed charges for outpatient setting,$951.57 ,97% of total billed charges for outpatient setting,$951.57 ,97% of total billed charges for outpatient setting,$833.85 ,85% of total billed charges for outpatient setting,$882.90 ,90% of total billed charges for outpatient setting,$833.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$931.95 ,90% of total billed charges for outpatient setting,$539.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$539.55 ,$951.57 ,$735.75 
Outpatient Medical Services,YUMA CLINIC,20610,Draining or injecting medication into a major joint/bursa without ultrasound,521,$510.00 ,$469.20 ,92% of total billed charges for outpatient setting,$280.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$438.60 ,86% of total billed charges for outpatient setting,$408.00 ,80% of total billed charges for outpatient setting,$280.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$484.50 ,95% of total billed charges for outpatient setting,$484.50 ,95% of total billed charges for outpatient setting,$382.50 ,75% of total billed charges for outpatient setting,$433.50 ,85% of total billed charges for outpatient setting,$494.70 ,97% of total billed charges for outpatient setting,$280.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$459.00 ,90% of total billed charges for outpatient setting,$494.70 ,97% of total billed charges for outpatient setting,$494.70 ,97% of total billed charges for outpatient setting,$494.70 ,97% of total billed charges for outpatient setting,$433.50 ,85% of total billed charges for outpatient setting,$459.00 ,90% of total billed charges for outpatient setting,$433.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$484.50 ,90% of total billed charges for outpatient setting,$280.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$280.50 ,$494.70 ,$382.50 
Outpatient Medical Services,YUMA CLINIC,69209,REMOVE IMPACTED EAR WAX UNILATERAL,521,$64.00 ,$58.88 ,92% of total billed charges for outpatient setting,$35.20 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$55.04 ,86% of total billed charges for outpatient setting,$51.20 ,80% of total billed charges for outpatient setting,$35.20 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$60.80 ,95% of total billed charges for outpatient setting,$60.80 ,95% of total billed charges for outpatient setting,$48.00 ,75% of total billed charges for outpatient setting,$54.40 ,85% of total billed charges for outpatient setting,$62.08 ,97% of total billed charges for outpatient setting,$35.20 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$57.60 ,90% of total billed charges for outpatient setting,$62.08 ,97% of total billed charges for outpatient setting,$62.08 ,97% of total billed charges for outpatient setting,$62.08 ,97% of total billed charges for outpatient setting,$54.40 ,85% of total billed charges for outpatient setting,$57.60 ,90% of total billed charges for outpatient setting,$54.40 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$60.80 ,90% of total billed charges for outpatient setting,$35.20 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$35.20 ,$62.08 ,$48.00 
Outpatient Medical Services,YUMA CLINIC,90471,Immunization administration by a medical assistant or nurse,521,$49.00 ,$45.08 ,92% of total billed charges for outpatient setting,$26.95 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$42.14 ,86% of total billed charges for outpatient setting,$39.20 ,80% of total billed charges for outpatient setting,$26.95 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$46.55 ,95% of total billed charges for outpatient setting,$46.55 ,95% of total billed charges for outpatient setting,$36.75 ,75% of total billed charges for outpatient setting,$41.65 ,85% of total billed charges for outpatient setting,$47.53 ,97% of total billed charges for outpatient setting,$26.95 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$44.10 ,90% of total billed charges for outpatient setting,$47.53 ,97% of total billed charges for outpatient setting,$47.53 ,97% of total billed charges for outpatient setting,$47.53 ,97% of total billed charges for outpatient setting,$41.65 ,85% of total billed charges for outpatient setting,$44.10 ,90% of total billed charges for outpatient setting,$41.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$46.55 ,90% of total billed charges for outpatient setting,$26.95 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$26.95 ,$47.53 ,$36.75 
Outpatient Medical Services,YUMA CLINIC,90472,Immunization administration; each additional vaccine,521,$26.00 ,$23.92 ,92% of total billed charges for outpatient setting,$14.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$22.36 ,86% of total billed charges for outpatient setting,$20.80 ,80% of total billed charges for outpatient setting,$14.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$24.70 ,95% of total billed charges for outpatient setting,$24.70 ,95% of total billed charges for outpatient setting,$19.50 ,75% of total billed charges for outpatient setting,$22.10 ,85% of total billed charges for outpatient setting,$25.22 ,97% of total billed charges for outpatient setting,$14.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$23.40 ,90% of total billed charges for outpatient setting,$25.22 ,97% of total billed charges for outpatient setting,$25.22 ,97% of total billed charges for outpatient setting,$25.22 ,97% of total billed charges for outpatient setting,$22.10 ,85% of total billed charges for outpatient setting,$23.40 ,90% of total billed charges for outpatient setting,$22.10 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$24.70 ,90% of total billed charges for outpatient setting,$14.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$14.30 ,$25.22 ,$19.50 
Outpatient Medical Services,YUMA CLINIC,90633,Hepatitis A vaccination for adolescents and children,521,$86.00 ,$79.12 ,92% of total billed charges for outpatient setting,$47.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$73.96 ,86% of total billed charges for outpatient setting,$68.80 ,80% of total billed charges for outpatient setting,$47.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$81.70 ,95% of total billed charges for outpatient setting,$81.70 ,95% of total billed charges for outpatient setting,$64.50 ,75% of total billed charges for outpatient setting,$73.10 ,85% of total billed charges for outpatient setting,$83.42 ,97% of total billed charges for outpatient setting,$47.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$77.40 ,90% of total billed charges for outpatient setting,$83.42 ,97% of total billed charges for outpatient setting,$83.42 ,97% of total billed charges for outpatient setting,$83.42 ,97% of total billed charges for outpatient setting,$73.10 ,85% of total billed charges for outpatient setting,$77.40 ,90% of total billed charges for outpatient setting,$73.10 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$81.70 ,90% of total billed charges for outpatient setting,$47.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$47.30 ,$83.42 ,$64.50 
Outpatient Medical Services,YUMA CLINIC,90634,"Hepatitis A vaccine (HepA), pediatric/adolescent",521,$109.00 ,$100.28 ,92% of total billed charges for outpatient setting,$59.95 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$93.74 ,86% of total billed charges for outpatient setting,$87.20 ,80% of total billed charges for outpatient setting,$59.95 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$103.55 ,95% of total billed charges for outpatient setting,$103.55 ,95% of total billed charges for outpatient setting,$81.75 ,75% of total billed charges for outpatient setting,$92.65 ,85% of total billed charges for outpatient setting,$105.73 ,97% of total billed charges for outpatient setting,$59.95 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$98.10 ,90% of total billed charges for outpatient setting,$105.73 ,97% of total billed charges for outpatient setting,$105.73 ,97% of total billed charges for outpatient setting,$105.73 ,97% of total billed charges for outpatient setting,$92.65 ,85% of total billed charges for outpatient setting,$98.10 ,90% of total billed charges for outpatient setting,$92.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$103.55 ,90% of total billed charges for outpatient setting,$59.95 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$59.95 ,$105.73 ,$81.75 
Outpatient Medical Services,YUMA CLINIC,90651,Vaccine- Gardasil 9,521,$21.68 ,$19.95 ,92% of total billed charges for outpatient setting,$11.92 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$18.64 ,86% of total billed charges for outpatient setting,$17.34 ,80% of total billed charges for outpatient setting,$11.92 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$20.60 ,95% of total billed charges for outpatient setting,$20.60 ,95% of total billed charges for outpatient setting,$16.26 ,75% of total billed charges for outpatient setting,$18.43 ,85% of total billed charges for outpatient setting,$21.03 ,97% of total billed charges for outpatient setting,$11.92 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$19.51 ,90% of total billed charges for outpatient setting,$21.03 ,97% of total billed charges for outpatient setting,$21.03 ,97% of total billed charges for outpatient setting,$21.03 ,97% of total billed charges for outpatient setting,$18.43 ,85% of total billed charges for outpatient setting,$19.51 ,90% of total billed charges for outpatient setting,$18.43 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$20.60 ,90% of total billed charges for outpatient setting,$11.92 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$11.92 ,$21.03 ,$16.26 
Outpatient Medical Services,YUMA CLINIC,90670,Pneumococcal 13-valent conjugate vaccine,521,$374.00 ,$344.08 ,92% of total billed charges for outpatient setting,$205.70 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$321.64 ,86% of total billed charges for outpatient setting,$299.20 ,80% of total billed charges for outpatient setting,$205.70 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$355.30 ,95% of total billed charges for outpatient setting,$355.30 ,95% of total billed charges for outpatient setting,$280.50 ,75% of total billed charges for outpatient setting,$317.90 ,85% of total billed charges for outpatient setting,$362.78 ,97% of total billed charges for outpatient setting,$205.70 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$336.60 ,90% of total billed charges for outpatient setting,$362.78 ,97% of total billed charges for outpatient setting,$362.78 ,97% of total billed charges for outpatient setting,$362.78 ,97% of total billed charges for outpatient setting,$317.90 ,85% of total billed charges for outpatient setting,$336.60 ,90% of total billed charges for outpatient setting,$317.90 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$355.30 ,90% of total billed charges for outpatient setting,$205.70 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$205.70 ,$362.78 ,$280.50 
Outpatient Medical Services,YUMA CLINIC,90680,"90680 Rotavirus vaccine, pentavalent, live",521,$247.00 ,$227.24 ,92% of total billed charges for outpatient setting,$135.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$212.42 ,86% of total billed charges for outpatient setting,$197.60 ,80% of total billed charges for outpatient setting,$135.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$234.65 ,95% of total billed charges for outpatient setting,$234.65 ,95% of total billed charges for outpatient setting,$185.25 ,75% of total billed charges for outpatient setting,$209.95 ,85% of total billed charges for outpatient setting,$239.59 ,97% of total billed charges for outpatient setting,$135.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$222.30 ,90% of total billed charges for outpatient setting,$239.59 ,97% of total billed charges for outpatient setting,$239.59 ,97% of total billed charges for outpatient setting,$239.59 ,97% of total billed charges for outpatient setting,$209.95 ,85% of total billed charges for outpatient setting,$222.30 ,90% of total billed charges for outpatient setting,$209.95 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$234.65 ,90% of total billed charges for outpatient setting,$135.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$135.85 ,$239.59 ,$185.25 
Outpatient Medical Services,YUMA CLINIC,90696,"DTaP-IPV, when administered to children 4 -6 yrs",521,$132.00 ,$121.44 ,92% of total billed charges for outpatient setting,$72.60 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$113.52 ,86% of total billed charges for outpatient setting,$105.60 ,80% of total billed charges for outpatient setting,$72.60 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$125.40 ,95% of total billed charges for outpatient setting,$125.40 ,95% of total billed charges for outpatient setting,$99.00 ,75% of total billed charges for outpatient setting,$112.20 ,85% of total billed charges for outpatient setting,$128.04 ,97% of total billed charges for outpatient setting,$72.60 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$118.80 ,90% of total billed charges for outpatient setting,$128.04 ,97% of total billed charges for outpatient setting,$128.04 ,97% of total billed charges for outpatient setting,$128.04 ,97% of total billed charges for outpatient setting,$112.20 ,85% of total billed charges for outpatient setting,$118.80 ,90% of total billed charges for outpatient setting,$112.20 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$125.40 ,90% of total billed charges for outpatient setting,$72.60 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$72.60 ,$128.04 ,$99.00 
Outpatient Medical Services,YUMA CLINIC,90700,"DAPTACEL DTaP, under 7 years",521,$65.00 ,$59.80 ,92% of total billed charges for outpatient setting,$35.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$55.90 ,86% of total billed charges for outpatient setting,$52.00 ,80% of total billed charges for outpatient setting,$35.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$61.75 ,95% of total billed charges for outpatient setting,$61.75 ,95% of total billed charges for outpatient setting,$48.75 ,75% of total billed charges for outpatient setting,$55.25 ,85% of total billed charges for outpatient setting,$63.05 ,97% of total billed charges for outpatient setting,$35.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$58.50 ,90% of total billed charges for outpatient setting,$63.05 ,97% of total billed charges for outpatient setting,$63.05 ,97% of total billed charges for outpatient setting,$63.05 ,97% of total billed charges for outpatient setting,$55.25 ,85% of total billed charges for outpatient setting,$58.50 ,90% of total billed charges for outpatient setting,$55.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$61.75 ,90% of total billed charges for outpatient setting,$35.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$35.75 ,$63.05 ,$48.75 
Outpatient Medical Services,YUMA CLINIC,90710,"measlesMeasles, mumps, rubella and varicella vaccine",521,$408.00 ,$375.36 ,92% of total billed charges for outpatient setting,$224.40 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$350.88 ,86% of total billed charges for outpatient setting,$326.40 ,80% of total billed charges for outpatient setting,$224.40 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$387.60 ,95% of total billed charges for outpatient setting,$387.60 ,95% of total billed charges for outpatient setting,$306.00 ,75% of total billed charges for outpatient setting,$346.80 ,85% of total billed charges for outpatient setting,$395.76 ,97% of total billed charges for outpatient setting,$224.40 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$367.20 ,90% of total billed charges for outpatient setting,$395.76 ,97% of total billed charges for outpatient setting,$395.76 ,97% of total billed charges for outpatient setting,$395.76 ,97% of total billed charges for outpatient setting,$346.80 ,85% of total billed charges for outpatient setting,$367.20 ,90% of total billed charges for outpatient setting,$346.80 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$387.60 ,90% of total billed charges for outpatient setting,$224.40 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$224.40 ,$395.76 ,$306.00 
Outpatient Medical Services,YUMA CLINIC,90715,"Diphtheria, tetanus acellular, and pertussis vaccine for adults",521,$133.00 ,$122.36 ,92% of total billed charges for outpatient setting,$73.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$114.38 ,86% of total billed charges for outpatient setting,$106.40 ,80% of total billed charges for outpatient setting,$73.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$126.35 ,95% of total billed charges for outpatient setting,$126.35 ,95% of total billed charges for outpatient setting,$99.75 ,75% of total billed charges for outpatient setting,$113.05 ,85% of total billed charges for outpatient setting,$129.01 ,97% of total billed charges for outpatient setting,$73.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$119.70 ,90% of total billed charges for outpatient setting,$129.01 ,97% of total billed charges for outpatient setting,$129.01 ,97% of total billed charges for outpatient setting,$129.01 ,97% of total billed charges for outpatient setting,$113.05 ,85% of total billed charges for outpatient setting,$119.70 ,90% of total billed charges for outpatient setting,$113.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$126.35 ,90% of total billed charges for outpatient setting,$73.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$73.15 ,$129.01 ,$99.75 
Outpatient Medical Services,YUMA CLINIC,90732,pneumococcal Pneumococcal vaccine,521,$186.00 ,$171.12 ,92% of total billed charges for outpatient setting,$102.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$159.96 ,86% of total billed charges for outpatient setting,$148.80 ,80% of total billed charges for outpatient setting,$102.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$176.70 ,95% of total billed charges for outpatient setting,$176.70 ,95% of total billed charges for outpatient setting,$139.50 ,75% of total billed charges for outpatient setting,$158.10 ,85% of total billed charges for outpatient setting,$180.42 ,97% of total billed charges for outpatient setting,$102.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$167.40 ,90% of total billed charges for outpatient setting,$180.42 ,97% of total billed charges for outpatient setting,$180.42 ,97% of total billed charges for outpatient setting,$180.42 ,97% of total billed charges for outpatient setting,$158.10 ,85% of total billed charges for outpatient setting,$167.40 ,90% of total billed charges for outpatient setting,$158.10 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$176.70 ,90% of total billed charges for outpatient setting,$102.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$102.30 ,$180.42 ,$139.50 
Outpatient Medical Services,YUMA CLINIC,90734,meningococcal Meningococcal conjugate vaccine,521,$261.00 ,$240.12 ,92% of total billed charges for outpatient setting,$143.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$224.46 ,86% of total billed charges for outpatient setting,$208.80 ,80% of total billed charges for outpatient setting,$143.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$247.95 ,95% of total billed charges for outpatient setting,$247.95 ,95% of total billed charges for outpatient setting,$195.75 ,75% of total billed charges for outpatient setting,$221.85 ,85% of total billed charges for outpatient setting,$253.17 ,97% of total billed charges for outpatient setting,$143.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$234.90 ,90% of total billed charges for outpatient setting,$253.17 ,97% of total billed charges for outpatient setting,$253.17 ,97% of total billed charges for outpatient setting,$253.17 ,97% of total billed charges for outpatient setting,$221.85 ,85% of total billed charges for outpatient setting,$234.90 ,90% of total billed charges for outpatient setting,$221.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$247.95 ,90% of total billed charges for outpatient setting,$143.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$143.55 ,$253.17 ,$195.75 
Outpatient Medical Services,YUMA CLINIC,95115,Allergy shot-1 shot,521,$28.00 ,$25.76 ,92% of total billed charges for outpatient setting,$15.40 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$24.08 ,86% of total billed charges for outpatient setting,$22.40 ,80% of total billed charges for outpatient setting,$15.40 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$26.60 ,95% of total billed charges for outpatient setting,$26.60 ,95% of total billed charges for outpatient setting,$21.00 ,75% of total billed charges for outpatient setting,$23.80 ,85% of total billed charges for outpatient setting,$27.16 ,97% of total billed charges for outpatient setting,$15.40 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$25.20 ,90% of total billed charges for outpatient setting,$27.16 ,97% of total billed charges for outpatient setting,$27.16 ,97% of total billed charges for outpatient setting,$27.16 ,97% of total billed charges for outpatient setting,$23.80 ,85% of total billed charges for outpatient setting,$25.20 ,90% of total billed charges for outpatient setting,$23.80 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$26.60 ,90% of total billed charges for outpatient setting,$15.40 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$15.40 ,$27.16 ,$21.00 
Outpatient Medical Services,YUMA CLINIC,95117,Multiple allergy shots,521,$34.00 ,$31.28 ,92% of total billed charges for outpatient setting,$18.70 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$29.24 ,86% of total billed charges for outpatient setting,$27.20 ,80% of total billed charges for outpatient setting,$18.70 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$32.30 ,95% of total billed charges for outpatient setting,$32.30 ,95% of total billed charges for outpatient setting,$25.50 ,75% of total billed charges for outpatient setting,$28.90 ,85% of total billed charges for outpatient setting,$32.98 ,97% of total billed charges for outpatient setting,$18.70 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$30.60 ,90% of total billed charges for outpatient setting,$32.98 ,97% of total billed charges for outpatient setting,$32.98 ,97% of total billed charges for outpatient setting,$32.98 ,97% of total billed charges for outpatient setting,$28.90 ,85% of total billed charges for outpatient setting,$30.60 ,90% of total billed charges for outpatient setting,$28.90 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$32.30 ,90% of total billed charges for outpatient setting,$18.70 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$18.70 ,$32.98 ,$25.50 
Outpatient Medical Services,YUMA CLINIC,96110,Childhood test to screen for developmental disabilities,521,$32.00 ,$29.44 ,92% of total billed charges for outpatient setting,$17.60 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$27.52 ,86% of total billed charges for outpatient setting,$25.60 ,80% of total billed charges for outpatient setting,$17.60 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$30.40 ,95% of total billed charges for outpatient setting,$30.40 ,95% of total billed charges for outpatient setting,$24.00 ,75% of total billed charges for outpatient setting,$27.20 ,85% of total billed charges for outpatient setting,$31.04 ,97% of total billed charges for outpatient setting,$17.60 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$28.80 ,90% of total billed charges for outpatient setting,$31.04 ,97% of total billed charges for outpatient setting,$31.04 ,97% of total billed charges for outpatient setting,$31.04 ,97% of total billed charges for outpatient setting,$27.20 ,85% of total billed charges for outpatient setting,$28.80 ,90% of total billed charges for outpatient setting,$27.20 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$30.40 ,90% of total billed charges for outpatient setting,$17.60 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$17.60 ,$31.04 ,$24.00 
Outpatient Medical Services,YUMA CLINIC,98926,Osteopathic manipulative treatment (OMT); 3-4 body regions,521,$131.00 ,$120.52 ,92% of total billed charges for outpatient setting,$72.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$112.66 ,86% of total billed charges for outpatient setting,$104.80 ,80% of total billed charges for outpatient setting,$72.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$124.45 ,95% of total billed charges for outpatient setting,$124.45 ,95% of total billed charges for outpatient setting,$98.25 ,75% of total billed charges for outpatient setting,$111.35 ,85% of total billed charges for outpatient setting,$127.07 ,97% of total billed charges for outpatient setting,$72.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$117.90 ,90% of total billed charges for outpatient setting,$127.07 ,97% of total billed charges for outpatient setting,$127.07 ,97% of total billed charges for outpatient setting,$127.07 ,97% of total billed charges for outpatient setting,$111.35 ,85% of total billed charges for outpatient setting,$117.90 ,90% of total billed charges for outpatient setting,$111.35 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$124.45 ,90% of total billed charges for outpatient setting,$72.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$72.05 ,$127.07 ,$98.25 
Outpatient Medical Services,YUMA CLINIC,98927,Osteopathic manipulative treatment (OMT); 5-6 body regions,521,$190.00 ,$174.80 ,92% of total billed charges for outpatient setting,$104.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$163.40 ,86% of total billed charges for outpatient setting,$152.00 ,80% of total billed charges for outpatient setting,$104.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$180.50 ,95% of total billed charges for outpatient setting,$180.50 ,95% of total billed charges for outpatient setting,$142.50 ,75% of total billed charges for outpatient setting,$161.50 ,85% of total billed charges for outpatient setting,$184.30 ,97% of total billed charges for outpatient setting,$104.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$171.00 ,90% of total billed charges for outpatient setting,$184.30 ,97% of total billed charges for outpatient setting,$184.30 ,97% of total billed charges for outpatient setting,$184.30 ,97% of total billed charges for outpatient setting,$161.50 ,85% of total billed charges for outpatient setting,$171.00 ,90% of total billed charges for outpatient setting,$161.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$180.50 ,90% of total billed charges for outpatient setting,$104.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$104.50 ,$184.30 ,$142.50 
Outpatient Medical Services,YUMA CLINIC,99202,"New patient office or other outpatient visit, typically 10 minutes",521,$983.00 ,$904.36 ,92% of total billed charges for outpatient setting,$540.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$845.38 ,86% of total billed charges for outpatient setting,$786.40 ,80% of total billed charges for outpatient setting,$540.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$65.23 ,100% of Cigna Behavioral Health fee schedule,$933.85 ,95% of total billed charges for outpatient setting,$737.25 ,75% of total billed charges for outpatient setting,$835.55 ,85% of total billed charges for outpatient setting,$953.51 ,97% of total billed charges for outpatient setting,$540.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$884.70 ,90% of total billed charges for outpatient setting,$953.51 ,97% of total billed charges for outpatient setting,$953.51 ,97% of total billed charges for outpatient setting,$953.51 ,97% of total billed charges for outpatient setting,$835.55 ,85% of total billed charges for outpatient setting,$884.70 ,90% of total billed charges for outpatient setting,$835.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$933.85 ,90% of total billed charges for outpatient setting,$540.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$65.23 ,$953.51 ,$737.25 
Outpatient Medical Services,YUMA CLINIC,99211,Outpatient visit of established patient not requiring a physician,521,$293.00 ,$269.56 ,92% of total billed charges for outpatient setting,$161.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$251.98 ,86% of total billed charges for outpatient setting,$234.40 ,80% of total billed charges for outpatient setting,$161.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$21.73 ,100% of Cigna Behavioral Health fee schedule,$278.35 ,95% of total billed charges for outpatient setting,$219.75 ,75% of total billed charges for outpatient setting,$249.05 ,85% of total billed charges for outpatient setting,$284.21 ,97% of total billed charges for outpatient setting,$161.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$263.70 ,90% of total billed charges for outpatient setting,$284.21 ,97% of total billed charges for outpatient setting,$284.21 ,97% of total billed charges for outpatient setting,$284.21 ,97% of total billed charges for outpatient setting,$249.05 ,85% of total billed charges for outpatient setting,$263.70 ,90% of total billed charges for outpatient setting,$249.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$278.35 ,90% of total billed charges for outpatient setting,$161.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$21.73 ,$284.21 ,$219.75 
Outpatient Medical Services,YUMA CLINIC,99212,Outpatient visit of established patient requiring a physician,521,$139.00 ,$127.88 ,92% of total billed charges for outpatient setting,$76.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$119.54 ,86% of total billed charges for outpatient setting,$111.20 ,80% of total billed charges for outpatient setting,$76.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$38.72 ,100% of Cigna Behavioral Health fee schedule,$132.05 ,95% of total billed charges for outpatient setting,$104.25 ,75% of total billed charges for outpatient setting,$118.15 ,85% of total billed charges for outpatient setting,$134.83 ,97% of total billed charges for outpatient setting,$76.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$125.10 ,90% of total billed charges for outpatient setting,$134.83 ,97% of total billed charges for outpatient setting,$134.83 ,97% of total billed charges for outpatient setting,$134.83 ,97% of total billed charges for outpatient setting,$118.15 ,85% of total billed charges for outpatient setting,$125.10 ,90% of total billed charges for outpatient setting,$118.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$132.05 ,90% of total billed charges for outpatient setting,$76.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$38.72 ,$134.83 ,$104.25 
Outpatient Medical Services,YUMA CLINIC,99213,"Established patient office or other outpatient visit, typically 15 minutes",521,$123.00 ,$113.16 ,92% of total billed charges for outpatient setting,$67.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$105.78 ,86% of total billed charges for outpatient setting,$98.40 ,80% of total billed charges for outpatient setting,$67.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$52.82 ,100% of Cigna Behavioral Health fee schedule,$116.85 ,95% of total billed charges for outpatient setting,$92.25 ,75% of total billed charges for outpatient setting,$104.55 ,85% of total billed charges for outpatient setting,$119.31 ,97% of total billed charges for outpatient setting,$67.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$110.70 ,90% of total billed charges for outpatient setting,$119.31 ,97% of total billed charges for outpatient setting,$119.31 ,97% of total billed charges for outpatient setting,$119.31 ,97% of total billed charges for outpatient setting,$104.55 ,85% of total billed charges for outpatient setting,$110.70 ,90% of total billed charges for outpatient setting,$104.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$116.85 ,90% of total billed charges for outpatient setting,$67.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$52.82 ,$119.31 ,$92.25 
Outpatient Medical Services,YUMA CLINIC,99214,"Established patient office or other outpatient visit, typically 25 minutes",521,$206.00 ,$189.52 ,92% of total billed charges for outpatient setting,$113.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$177.16 ,86% of total billed charges for outpatient setting,$164.80 ,80% of total billed charges for outpatient setting,$113.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$82.79 ,100% of Cigna Behavioral Health fee schedule,$195.70 ,95% of total billed charges for outpatient setting,$154.50 ,75% of total billed charges for outpatient setting,$175.10 ,85% of total billed charges for outpatient setting,$199.82 ,97% of total billed charges for outpatient setting,$113.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$185.40 ,90% of total billed charges for outpatient setting,$199.82 ,97% of total billed charges for outpatient setting,$199.82 ,97% of total billed charges for outpatient setting,$199.82 ,97% of total billed charges for outpatient setting,$175.10 ,85% of total billed charges for outpatient setting,$185.40 ,90% of total billed charges for outpatient setting,$175.10 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$195.70 ,90% of total billed charges for outpatient setting,$113.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$82.79 ,$199.82 ,$154.50 
Outpatient Medical Services,YUMA CLINIC,99215,"Established patient office or other outpatient, visit typically 40 minutes",521,$301.00 ,$276.92 ,92% of total billed charges for outpatient setting,$165.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$258.86 ,86% of total billed charges for outpatient setting,$240.80 ,80% of total billed charges for outpatient setting,$165.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$120.24 ,100% of Cigna Behavioral Health fee schedule,$285.95 ,95% of total billed charges for outpatient setting,$225.75 ,75% of total billed charges for outpatient setting,$255.85 ,85% of total billed charges for outpatient setting,$291.97 ,97% of total billed charges for outpatient setting,$165.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$270.90 ,90% of total billed charges for outpatient setting,$291.97 ,97% of total billed charges for outpatient setting,$291.97 ,97% of total billed charges for outpatient setting,$291.97 ,97% of total billed charges for outpatient setting,$255.85 ,85% of total billed charges for outpatient setting,$270.90 ,90% of total billed charges for outpatient setting,$255.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$285.95 ,90% of total billed charges for outpatient setting,$165.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$120.24 ,$291.97 ,$225.75 
Outpatient Medical Services,YUMA CLINIC,99307,"Subsequent Nursing Facility Care, Straightforward",521,$156.00 ,$143.52 ,92% of total billed charges for outpatient setting,$85.80 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$134.16 ,86% of total billed charges for outpatient setting,$124.80 ,80% of total billed charges for outpatient setting,$85.80 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$29.40 ,100% of Cigna Behavioral Health fee schedule,$148.20 ,95% of total billed charges for outpatient setting,$117.00 ,75% of total billed charges for outpatient setting,$132.60 ,85% of total billed charges for outpatient setting,$151.32 ,97% of total billed charges for outpatient setting,$85.80 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$140.40 ,90% of total billed charges for outpatient setting,$151.32 ,97% of total billed charges for outpatient setting,$151.32 ,97% of total billed charges for outpatient setting,$151.32 ,97% of total billed charges for outpatient setting,$132.60 ,85% of total billed charges for outpatient setting,$140.40 ,90% of total billed charges for outpatient setting,$132.60 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$148.20 ,90% of total billed charges for outpatient setting,$85.80 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$29.40 ,$151.32 ,$117.00 
Outpatient Medical Services,YUMA CLINIC,99308,"Subsequent Nursing Facility Care, Low",521,$233.00 ,$214.36 ,92% of total billed charges for outpatient setting,$128.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$200.38 ,86% of total billed charges for outpatient setting,$186.40 ,80% of total billed charges for outpatient setting,$128.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$44.96 ,100% of Cigna Behavioral Health fee schedule,$221.35 ,95% of total billed charges for outpatient setting,$174.75 ,75% of total billed charges for outpatient setting,$198.05 ,85% of total billed charges for outpatient setting,$226.01 ,97% of total billed charges for outpatient setting,$128.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$209.70 ,90% of total billed charges for outpatient setting,$226.01 ,97% of total billed charges for outpatient setting,$226.01 ,97% of total billed charges for outpatient setting,$226.01 ,97% of total billed charges for outpatient setting,$198.05 ,85% of total billed charges for outpatient setting,$209.70 ,90% of total billed charges for outpatient setting,$198.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$221.35 ,90% of total billed charges for outpatient setting,$128.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$44.96 ,$226.01 ,$174.75 
Outpatient Medical Services,YUMA CLINIC,99309,"Subsequent Nursing Facility Care, Moderate",521,$309.00 ,$284.28 ,92% of total billed charges for outpatient setting,$169.95 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$265.74 ,86% of total billed charges for outpatient setting,$247.20 ,80% of total billed charges for outpatient setting,$169.95 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$59.60 ,100% of Cigna Behavioral Health fee schedule,$293.55 ,95% of total billed charges for outpatient setting,$231.75 ,75% of total billed charges for outpatient setting,$262.65 ,85% of total billed charges for outpatient setting,$299.73 ,97% of total billed charges for outpatient setting,$169.95 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$278.10 ,90% of total billed charges for outpatient setting,$299.73 ,97% of total billed charges for outpatient setting,$299.73 ,97% of total billed charges for outpatient setting,$299.73 ,97% of total billed charges for outpatient setting,$262.65 ,85% of total billed charges for outpatient setting,$278.10 ,90% of total billed charges for outpatient setting,$262.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$293.55 ,90% of total billed charges for outpatient setting,$169.95 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$59.60 ,$299.73 ,$231.75 
Outpatient Medical Services,YUMA CLINIC,99391,Periodic primary re-evaluation for an established infant patient,521,$217.00 ,$199.64 ,92% of total billed charges for outpatient setting,$119.35 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$186.62 ,86% of total billed charges for outpatient setting,$173.60 ,80% of total billed charges for outpatient setting,$119.35 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$206.15 ,95% of total billed charges for outpatient setting,$206.15 ,95% of total billed charges for outpatient setting,$162.75 ,75% of total billed charges for outpatient setting,$184.45 ,85% of total billed charges for outpatient setting,$210.49 ,97% of total billed charges for outpatient setting,$119.35 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$195.30 ,90% of total billed charges for outpatient setting,$210.49 ,97% of total billed charges for outpatient setting,$210.49 ,97% of total billed charges for outpatient setting,$210.49 ,97% of total billed charges for outpatient setting,$184.45 ,85% of total billed charges for outpatient setting,$195.30 ,90% of total billed charges for outpatient setting,$184.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$206.15 ,90% of total billed charges for outpatient setting,$119.35 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$119.35 ,$210.49 ,$162.75 
Outpatient Medical Services,YUMA CLINIC,99392,Initial visit for new patients 1-4 years old,521,$237.00 ,$218.04 ,92% of total billed charges for outpatient setting,$130.35 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$203.82 ,86% of total billed charges for outpatient setting,$189.60 ,80% of total billed charges for outpatient setting,$130.35 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$225.15 ,95% of total billed charges for outpatient setting,$225.15 ,95% of total billed charges for outpatient setting,$177.75 ,75% of total billed charges for outpatient setting,$201.45 ,85% of total billed charges for outpatient setting,$229.89 ,97% of total billed charges for outpatient setting,$130.35 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$213.30 ,90% of total billed charges for outpatient setting,$229.89 ,97% of total billed charges for outpatient setting,$229.89 ,97% of total billed charges for outpatient setting,$229.89 ,97% of total billed charges for outpatient setting,$201.45 ,85% of total billed charges for outpatient setting,$213.30 ,90% of total billed charges for outpatient setting,$201.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$225.15 ,90% of total billed charges for outpatient setting,$130.35 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$130.35 ,$229.89 ,$177.75 
Outpatient Medical Services,YUMA CLINIC,99393,New preventative visit in new patients 5-11 years old,521,$237.00 ,$218.04 ,92% of total billed charges for outpatient setting,$130.35 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$203.82 ,86% of total billed charges for outpatient setting,$189.60 ,80% of total billed charges for outpatient setting,$130.35 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$225.15 ,95% of total billed charges for outpatient setting,$225.15 ,95% of total billed charges for outpatient setting,$177.75 ,75% of total billed charges for outpatient setting,$201.45 ,85% of total billed charges for outpatient setting,$229.89 ,97% of total billed charges for outpatient setting,$130.35 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$213.30 ,90% of total billed charges for outpatient setting,$229.89 ,97% of total billed charges for outpatient setting,$229.89 ,97% of total billed charges for outpatient setting,$229.89 ,97% of total billed charges for outpatient setting,$201.45 ,85% of total billed charges for outpatient setting,$213.30 ,90% of total billed charges for outpatient setting,$201.45 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$225.15 ,90% of total billed charges for outpatient setting,$130.35 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$130.35 ,$229.89 ,$177.75 
Outpatient Medical Services,YUMA CLINIC,99394,New preventative visit in new patients 12-17 years old,521,$269.00 ,$247.48 ,92% of total billed charges for outpatient setting,$147.95 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$231.34 ,86% of total billed charges for outpatient setting,$215.20 ,80% of total billed charges for outpatient setting,$147.95 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$255.55 ,95% of total billed charges for outpatient setting,$255.55 ,95% of total billed charges for outpatient setting,$201.75 ,75% of total billed charges for outpatient setting,$228.65 ,85% of total billed charges for outpatient setting,$260.93 ,97% of total billed charges for outpatient setting,$147.95 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$242.10 ,90% of total billed charges for outpatient setting,$260.93 ,97% of total billed charges for outpatient setting,$260.93 ,97% of total billed charges for outpatient setting,$260.93 ,97% of total billed charges for outpatient setting,$228.65 ,85% of total billed charges for outpatient setting,$242.10 ,90% of total billed charges for outpatient setting,$228.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$255.55 ,90% of total billed charges for outpatient setting,$147.95 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$147.95 ,$260.93 ,$201.75 
Outpatient Medical Services,YUMA CLINIC,99395,Established patient periodic preventive medicine examination age 18-39 years,521,$278.00 ,$255.76 ,92% of total billed charges for outpatient setting,$152.90 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$239.08 ,86% of total billed charges for outpatient setting,$222.40 ,80% of total billed charges for outpatient setting,$152.90 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$264.10 ,95% of total billed charges for outpatient setting,$264.10 ,95% of total billed charges for outpatient setting,$208.50 ,75% of total billed charges for outpatient setting,$236.30 ,85% of total billed charges for outpatient setting,$269.66 ,97% of total billed charges for outpatient setting,$152.90 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$250.20 ,90% of total billed charges for outpatient setting,$269.66 ,97% of total billed charges for outpatient setting,$269.66 ,97% of total billed charges for outpatient setting,$269.66 ,97% of total billed charges for outpatient setting,$236.30 ,85% of total billed charges for outpatient setting,$250.20 ,90% of total billed charges for outpatient setting,$236.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$264.10 ,90% of total billed charges for outpatient setting,$152.90 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$152.90 ,$269.66 ,$208.50 
Outpatient Medical Services,YUMA CLINIC,99396,Established patient periodic preventive medicine examination age 40-64 years,521,$318.00 ,$292.56 ,92% of total billed charges for outpatient setting,$174.90 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$273.48 ,86% of total billed charges for outpatient setting,$254.40 ,80% of total billed charges for outpatient setting,$174.90 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$302.10 ,95% of total billed charges for outpatient setting,$302.10 ,95% of total billed charges for outpatient setting,$238.50 ,75% of total billed charges for outpatient setting,$270.30 ,85% of total billed charges for outpatient setting,$308.46 ,97% of total billed charges for outpatient setting,$174.90 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$286.20 ,90% of total billed charges for outpatient setting,$308.46 ,97% of total billed charges for outpatient setting,$308.46 ,97% of total billed charges for outpatient setting,$308.46 ,97% of total billed charges for outpatient setting,$270.30 ,85% of total billed charges for outpatient setting,$286.20 ,90% of total billed charges for outpatient setting,$270.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$302.10 ,90% of total billed charges for outpatient setting,$174.90 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$174.90 ,$308.46 ,$238.50 
Outpatient Medical Services,YUMA CLINIC,58300,Insert intrauterine device (IUD) plus IUD,983,$310.00 ,$68.49 ,135% of 2011 CMS physician fee schedule,$51.71 ,100% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$113.39 ,100% of the Blue Cross physician fee schedule,$104.30 ,100% of Work Comp physician fee schedule. Multiple discount rules may apply,$51.71 ,100% CMS Medicare physician fee schedule ,$74.98 ,145% CMS Medicare physician fee schedule ,$294.50 ,95% of total billed charges for physician setting,,Not separately reimbursible. Not contracted for physician rates,$64.34 ,100% CMS Medicare physician fee schedule ,$75.50 ,100% Humana physician fee schedule,$51.71 ,100% CMS Medicare physician fee schedule ,$310.00 ,Not separately reimbursible. Not contracted for physician rates,$108.64 ,100% Midlands Choice physician fee schedule,$186.00 ,60% of total billed charges for physician settings,$186.00 ,60% of total billed charges for physician settings,$72.39 ,140% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$51.71 ,100% CMS Medicare physician fee schedule ,$294.50 ,95% of total billed charges,$51.71 ,100% CMS Medicare physician fee schedule ,$64.51 ,124.753% CMS Medicare physician fee schedule ,$51.71 ,$310.00 ,$232.50 
Outpatient Medical Services,YUMA CLINIC,58301,Remove intrauterine device (IUD),983,$328.00 ,$91.67 ,135% of 2011 CMS physician fee schedule,$67.73 ,100% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$126.27 ,100% of the Blue Cross physician fee schedule,$136.50 ,100% of Work Comp physician fee schedule. Multiple discount rules may apply,$67.73 ,100% CMS Medicare physician fee schedule ,$98.21 ,145% CMS Medicare physician fee schedule ,$311.60 ,95% of total billed charges for physician setting,,Not separately reimbursible. Not contracted for physician rates,$83.76 ,100% CMS Medicare physician fee schedule ,$98.43 ,100% Humana physician fee schedule,$67.73 ,100% CMS Medicare physician fee schedule ,$328.00 ,Not separately reimbursible. Not contracted for physician rates,$135.97 ,100% Midlands Choice physician fee schedule,$196.80 ,60% of total billed charges for physician settings,$196.80 ,60% of total billed charges for physician settings,$94.82 ,140% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$67.73 ,100% CMS Medicare physician fee schedule ,$311.60 ,95% of total billed charges,$67.73 ,100% CMS Medicare physician fee schedule ,$84.50 ,124.753% CMS Medicare physician fee schedule ,$67.73 ,$328.00 ,$246.00 
Outpatient Medical Services,YUMA CLINIC,99203,"New patient office or other outpatient visit, typically 30 min",521,$983.00 ,$904.36 ,92% of total billed charges for outpatient setting,$540.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$845.38 ,86% of total billed charges for outpatient setting,$786.40 ,80% of total billed charges for outpatient setting,$540.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$96.95 ,100% of Cigna Behavioral Health fee schedule,$933.85 ,95% of total billed charges for outpatient setting,$737.25 ,75% of total billed charges for outpatient setting,$835.55 ,85% of total billed charges for outpatient setting,$953.51 ,97% of total billed charges for outpatient setting,$540.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$884.70 ,90% of total billed charges for outpatient setting,$953.51 ,97% of total billed charges for outpatient setting,$953.51 ,97% of total billed charges for outpatient setting,$953.51 ,97% of total billed charges for outpatient setting,$835.55 ,85% of total billed charges for outpatient setting,$884.70 ,90% of total billed charges for outpatient setting,$835.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$933.85 ,90% of total billed charges for outpatient setting,$540.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$96.95 ,$953.51 ,$737.25 
Outpatient Medical Services,YUMA CLINIC,99204,"New patient office of other outpatient visit, typically 45 min",521,$983.00 ,$904.36 ,92% of total billed charges for outpatient setting,$540.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$845.38 ,86% of total billed charges for outpatient setting,$786.40 ,80% of total billed charges for outpatient setting,$540.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$137.09 ,100% of Cigna Behavioral Health fee schedule,$933.85 ,95% of total billed charges for outpatient setting,$737.25 ,75% of total billed charges for outpatient setting,$835.55 ,85% of total billed charges for outpatient setting,$953.51 ,97% of total billed charges for outpatient setting,$540.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$884.70 ,90% of total billed charges for outpatient setting,$953.51 ,97% of total billed charges for outpatient setting,$953.51 ,97% of total billed charges for outpatient setting,$953.51 ,97% of total billed charges for outpatient setting,$835.55 ,85% of total billed charges for outpatient setting,$884.70 ,90% of total billed charges for outpatient setting,$835.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$933.85 ,90% of total billed charges for outpatient setting,$540.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$137.09 ,$953.51 ,$737.25 
Outpatient Medical Services,YUMA CLINIC,99205,"New patient office of other outpatient visit, typically 60 min",521,$983.00 ,$904.36 ,92% of total billed charges for outpatient setting,$540.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$845.38 ,86% of total billed charges for outpatient setting,$786.40 ,80% of total billed charges for outpatient setting,$540.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$174.15 ,100% of Cigna Behavioral Health fee schedule,$933.85 ,95% of total billed charges for outpatient setting,$737.25 ,75% of total billed charges for outpatient setting,$835.55 ,85% of total billed charges for outpatient setting,$953.51 ,97% of total billed charges for outpatient setting,$540.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$884.70 ,90% of total billed charges for outpatient setting,$953.51 ,97% of total billed charges for outpatient setting,$953.51 ,97% of total billed charges for outpatient setting,$953.51 ,97% of total billed charges for outpatient setting,$835.55 ,85% of total billed charges for outpatient setting,$884.70 ,90% of total billed charges for outpatient setting,$835.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$933.85 ,90% of total billed charges for outpatient setting,$540.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$174.15 ,$953.51 ,$737.25 
Outpatient Medical Services,YUMA CLINIC,99385,Initial new patient preventive medicine evaluation (18–39 years),521,$305.00 ,$280.60 ,92% of total billed charges for outpatient setting,$167.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$262.30 ,86% of total billed charges for outpatient setting,$244.00 ,80% of total billed charges for outpatient setting,$167.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$289.75 ,95% of total billed charges for outpatient setting,$289.75 ,95% of total billed charges for outpatient setting,$228.75 ,75% of total billed charges for outpatient setting,$259.25 ,85% of total billed charges for outpatient setting,$295.85 ,97% of total billed charges for outpatient setting,$167.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$274.50 ,90% of total billed charges for outpatient setting,$295.85 ,97% of total billed charges for outpatient setting,$295.85 ,97% of total billed charges for outpatient setting,$295.85 ,97% of total billed charges for outpatient setting,$259.25 ,85% of total billed charges for outpatient setting,$274.50 ,90% of total billed charges for outpatient setting,$259.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$289.75 ,90% of total billed charges for outpatient setting,$167.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$167.75 ,$295.85 ,$228.75 
Outpatient Medical Services,YUMA CLINIC,99386,Initial new patient preventive medicine evaluation (40–64 years),521,$369.00 ,$339.48 ,92% of total billed charges for outpatient setting,$202.95 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$317.34 ,86% of total billed charges for outpatient setting,$295.20 ,80% of total billed charges for outpatient setting,$202.95 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$350.55 ,95% of total billed charges for outpatient setting,$350.55 ,95% of total billed charges for outpatient setting,$276.75 ,75% of total billed charges for outpatient setting,$313.65 ,85% of total billed charges for outpatient setting,$357.93 ,97% of total billed charges for outpatient setting,$202.95 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$332.10 ,90% of total billed charges for outpatient setting,$357.93 ,97% of total billed charges for outpatient setting,$357.93 ,97% of total billed charges for outpatient setting,$357.93 ,97% of total billed charges for outpatient setting,$313.65 ,85% of total billed charges for outpatient setting,$332.10 ,90% of total billed charges for outpatient setting,$313.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$350.55 ,90% of total billed charges for outpatient setting,$202.95 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$202.95 ,$357.93 ,$276.75 
Outpatient Medical Services,YUMA CLINIC,10060,Incision and drainage of abscess; simple or single and complex or multiple,521,$426.00 ,$391.92 ,92% of total billed charges for outpatient setting,$234.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$366.36 ,86% of total billed charges for outpatient setting,$340.80 ,80% of total billed charges for outpatient setting,$234.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$404.70 ,95% of total billed charges for outpatient setting,$404.70 ,95% of total billed charges for outpatient setting,$319.50 ,75% of total billed charges for outpatient setting,$362.10 ,85% of total billed charges for outpatient setting,$413.22 ,97% of total billed charges for outpatient setting,$234.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$383.40 ,90% of total billed charges for outpatient setting,$413.22 ,97% of total billed charges for outpatient setting,$413.22 ,97% of total billed charges for outpatient setting,$413.22 ,97% of total billed charges for outpatient setting,$362.10 ,85% of total billed charges for outpatient setting,$383.40 ,90% of total billed charges for outpatient setting,$362.10 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$404.70 ,90% of total billed charges for outpatient setting,$234.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$234.30 ,$413.22 ,$319.50 
Outpatient Medical Services,YUMA CLINIC,90736,Shingles vaccine,521,$251.00 ,$230.92 ,92% of total billed charges for outpatient setting,$138.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$215.86 ,86% of total billed charges for outpatient setting,$200.80 ,80% of total billed charges for outpatient setting,$138.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$238.45 ,95% of total billed charges for outpatient setting,$238.45 ,95% of total billed charges for outpatient setting,$188.25 ,75% of total billed charges for outpatient setting,$213.35 ,85% of total billed charges for outpatient setting,$243.47 ,97% of total billed charges for outpatient setting,$138.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$225.90 ,90% of total billed charges for outpatient setting,$243.47 ,97% of total billed charges for outpatient setting,$243.47 ,97% of total billed charges for outpatient setting,$243.47 ,97% of total billed charges for outpatient setting,$213.35 ,85% of total billed charges for outpatient setting,$225.90 ,90% of total billed charges for outpatient setting,$213.35 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$238.45 ,90% of total billed charges for outpatient setting,$138.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$138.05 ,$243.47 ,$188.25 
Outpatient Medical Services,YUMA CLINIC,99825,Osteopathic manipulative treatment (OMT); 1-2 body regions,521,$95.00 ,$87.40 ,92% of total billed charges for outpatient setting,$52.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$81.70 ,86% of total billed charges for outpatient setting,$76.00 ,80% of total billed charges for outpatient setting,$52.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$90.25 ,95% of total billed charges for outpatient setting,$90.25 ,95% of total billed charges for outpatient setting,$71.25 ,75% of total billed charges for outpatient setting,$80.75 ,85% of total billed charges for outpatient setting,$92.15 ,97% of total billed charges for outpatient setting,$52.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$85.50 ,90% of total billed charges for outpatient setting,$92.15 ,97% of total billed charges for outpatient setting,$92.15 ,97% of total billed charges for outpatient setting,$92.15 ,97% of total billed charges for outpatient setting,$80.75 ,85% of total billed charges for outpatient setting,$85.50 ,90% of total billed charges for outpatient setting,$80.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$90.25 ,90% of total billed charges for outpatient setting,$52.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$52.25 ,$92.15 ,$71.25 
Outpatient Medical Services,ENDOSCOPY,43239,"Biopsy of the esophagus, stomach, and/or upper small bowel using an endoscope",975,"$1,130.00 ",$229.42 ,135% of 2011 CMS physician fee schedule,$140.49 ,100% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$466.87 ,100% of the Blue Cross physician fee schedule,$279.30 ,100% of Work Comp physician fee schedule. Multiple discount rules may apply,$140.49 ,100% CMS Medicare physician fee schedule ,$203.71 ,145% CMS Medicare physician fee schedule ,"$1,073.50 ",95% of total billed charges for physician setting,,Not separately reimbursible. Not contracted for physician rates,$174.84 ,100% CMS Medicare physician fee schedule ,$202.45 ,100% Humana physician fee schedule,$140.49 ,100% CMS Medicare physician fee schedule ,"$1,130.00 ",Not separately reimbursible. Not contracted for physician rates,$286.10 ,100% Midlands Choice physician fee schedule,$160.57 ,100% Multiplan physician fee schedule,$160.57 ,100% Multiplan physician fee schedule,$196.69 ,140% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$140.49 ,100% CMS Medicare physician fee schedule ,"$1,073.50 ",95% of total billed charges,$140.49 ,100% CMS Medicare physician fee schedule ,$175.27 ,124.753% CMS Medicare physician fee schedule ,$140.49 ,"$1,130.00 ",$847.50 
Outpatient Medical Services,ENDOSCOPY,43239,"Biopsy of the esophagus, stomach, and/or upper small bowel using an endoscope",360,"$7,335.00 ","$6,748.20 ",92% of total billed charges for outpatient setting,"$4,034.25 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,"$6,308.10 ",86% of total billed charges for outpatient setting,"$5,868.00 ",80% of total billed charges for outpatient setting,"$4,034.25 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$6,968.25 ",95% of total billed charges for outpatient setting,"$6,968.25 ",95% of total billed charges for outpatient setting,"$5,501.25 ",75% of total billed charges for outpatient setting,"$6,234.75 ",85% of total billed charges for outpatient setting,"$7,114.95 ",97% of total billed charges for outpatient setting,"$4,034.25 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$6,601.50 ",90% of total billed charges for outpatient setting,"$7,114.95 ",97% of total billed charges for outpatient setting,"$7,114.95 ",97% of total billed charges for outpatient setting,"$7,114.95 ",97% of total billed charges for outpatient setting,"$6,234.75 ",85% of total billed charges for outpatient setting,"$6,601.50 ",90% of total billed charges for outpatient setting,"$6,234.75 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$6,968.25 ",90% of total billed charges for outpatient setting,"$4,034.25 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$6,821.55 ",93% of total billed charges for outpatient setting,"$4,034.25 ","$7,114.95 ","$5,501.25 "
Outpatient Medical Services,ENDOSCOPY,45331,Sigmoidoscopy/biopsy,975,$573.00 ,$100.98 ,135% of 2011 CMS physician fee schedule,$72.88 ,100% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$344.89 ,100% of the Blue Cross physician fee schedule,$144.19 ,100% of Work Comp physician fee schedule. Multiple discount rules may apply,$72.88 ,100% CMS Medicare physician fee schedule ,$105.68 ,145% CMS Medicare physician fee schedule ,$544.35 ,95% of total billed charges for physician setting,,Not separately reimbursible. Not contracted for physician rates,$90.88 ,100% CMS Medicare physician fee schedule ,$104.78 ,100% Humana physician fee schedule,$72.88 ,100% CMS Medicare physician fee schedule ,$573.00 ,Not separately reimbursible. Not contracted for physician rates,,Not separately reimbursable per contract terms,$343.80 ,60% of total billed charges for physician settings,$343.80 ,60% of total billed charges for physician settings,$102.03 ,140% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$72.88 ,100% CMS Medicare physician fee schedule ,$544.35 ,95% of total billed charges,$72.88 ,100% CMS Medicare physician fee schedule ,$90.92 ,124.753% CMS Medicare physician fee schedule ,$72.88 ,$573.00 ,$429.75 
Outpatient Medical Services,ENDOSCOPY,45331,Sigmoidoscopy/biopsy,360,"$5,960.00 ","$5,483.20 ",92% of total billed charges for outpatient setting,"$3,278.00 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,"$5,125.60 ",86% of total billed charges for outpatient setting,"$4,768.00 ",80% of total billed charges for outpatient setting,"$3,278.00 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$5,662.00 ",95% of total billed charges for outpatient setting,"$5,662.00 ",95% of total billed charges for outpatient setting,"$4,470.00 ",75% of total billed charges for outpatient setting,"$5,066.00 ",85% of total billed charges for outpatient setting,"$5,781.20 ",97% of total billed charges for outpatient setting,"$3,278.00 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$5,364.00 ",90% of total billed charges for outpatient setting,"$5,781.20 ",97% of total billed charges for outpatient setting,"$5,781.20 ",97% of total billed charges for outpatient setting,"$5,781.20 ",97% of total billed charges for outpatient setting,"$5,066.00 ",85% of total billed charges for outpatient setting,"$5,364.00 ",90% of total billed charges for outpatient setting,"$5,066.00 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$5,662.00 ",90% of total billed charges for outpatient setting,"$3,278.00 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$5,542.80 ",93% of total billed charges for outpatient setting,"$3,278.00 ","$5,781.20 ","$4,470.00 "
Outpatient Medical Services,ENDOSCOPY,45378,Diagnostic examination of large bowel using an endoscope,975,"$1,336.00 ",$289.85 ,135% of 2011 CMS physician fee schedule,$187.54 ,100% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$411.03 ,100% of the Blue Cross physician fee schedule,$374.50 ,100% of Work Comp physician fee schedule. Multiple discount rules may apply,$187.54 ,100% CMS Medicare physician fee schedule ,$271.93 ,145% CMS Medicare physician fee schedule ,"$1,269.20 ",95% of total billed charges for physician setting,,Not separately reimbursible. Not contracted for physician rates,$233.09 ,100% CMS Medicare physician fee schedule ,$271.14 ,100% Humana physician fee schedule,$187.54 ,100% CMS Medicare physician fee schedule ,"$1,336.00 ",Not separately reimbursible. Not contracted for physician rates,$190.24 ,100% Midlands Choice physician fee schedule,$214.47 ,100% Multiplan physician fee schedule,$214.47 ,100% Multiplan physician fee schedule,$262.56 ,140% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$187.54 ,100% CMS Medicare physician fee schedule ,"$1,269.20 ",95% of total billed charges,$187.54 ,100% CMS Medicare physician fee schedule ,$233.96 ,124.753% CMS Medicare physician fee schedule ,$187.54 ,"$1,336.00 ","$1,002.00 "
Outpatient Medical Services,ENDOSCOPY,45378,Diagnostic examination of large bowel using an endoscope,360,"$6,200.00 ","$5,704.00 ",92% of total billed charges for outpatient setting,"$3,410.00 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,"$5,332.00 ",86% of total billed charges for outpatient setting,"$4,960.00 ",80% of total billed charges for outpatient setting,"$3,410.00 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$5,890.00 ",95% of total billed charges for outpatient setting,"$5,890.00 ",95% of total billed charges for outpatient setting,"$4,650.00 ",75% of total billed charges for outpatient setting,"$5,270.00 ",85% of total billed charges for outpatient setting,"$6,014.00 ",97% of total billed charges for outpatient setting,"$3,410.00 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$5,580.00 ",90% of total billed charges for outpatient setting,"$6,014.00 ",97% of total billed charges for outpatient setting,"$6,014.00 ",97% of total billed charges for outpatient setting,"$6,014.00 ",97% of total billed charges for outpatient setting,"$5,270.00 ",85% of total billed charges for outpatient setting,"$5,580.00 ",90% of total billed charges for outpatient setting,"$5,270.00 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$5,890.00 ",90% of total billed charges for outpatient setting,"$3,410.00 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$5,766.00 ",93% of total billed charges for outpatient setting,"$3,410.00 ","$6,014.00 ","$4,650.00 "
Outpatient Medical Services,ENDOSCOPY,45384,Removal of polyps or growths in large bowel using an endoscope,975,"$1,435.00 ",$362.66 ,135% of 2011 CMS physician fee schedule,$232.20 ,100% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$591.42 ,100% of the Blue Cross physician fee schedule,$462.00 ,100% of Work Comp physician fee schedule. Multiple discount rules may apply,$232.20 ,100% CMS Medicare physician fee schedule ,$336.69 ,145% CMS Medicare physician fee schedule ,"$1,363.25 ",95% of total billed charges for physician setting,,Not separately reimbursible. Not contracted for physician rates,$287.90 ,100% CMS Medicare physician fee schedule ,$334.07 ,100% Humana physician fee schedule,$232.20 ,100% CMS Medicare physician fee schedule ,"$1,435.00 ",Not separately reimbursible. Not contracted for physician rates,$468.56 ,100% Midlands Choice physician fee schedule,$861.00 ,60% of total billed charges for physician settings,$861.00 ,60% of total billed charges for physician settings,$325.08 ,140% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$232.20 ,100% CMS Medicare physician fee schedule ,"$1,363.25 ",95% of total billed charges,$232.20 ,100% CMS Medicare physician fee schedule ,$289.68 ,124.753% CMS Medicare physician fee schedule ,$232.20 ,"$1,435.00 ","$1,076.25 "
Outpatient Medical Services,ENDOSCOPY,45384,Removal of polyps or growths in large bowel using an endoscope,360,"$5,950.00 ","$5,474.00 ",92% of total billed charges for outpatient setting,"$3,272.50 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,"$5,117.00 ",86% of total billed charges for outpatient setting,"$4,760.00 ",80% of total billed charges for outpatient setting,"$3,272.50 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$5,652.50 ",95% of total billed charges for outpatient setting,"$5,652.50 ",95% of total billed charges for outpatient setting,"$4,462.50 ",75% of total billed charges for outpatient setting,"$5,057.50 ",85% of total billed charges for outpatient setting,"$5,771.50 ",97% of total billed charges for outpatient setting,"$3,272.50 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$5,355.00 ",90% of total billed charges for outpatient setting,"$5,771.50 ",97% of total billed charges for outpatient setting,"$5,771.50 ",97% of total billed charges for outpatient setting,"$5,771.50 ",97% of total billed charges for outpatient setting,"$5,057.50 ",85% of total billed charges for outpatient setting,"$5,355.00 ",90% of total billed charges for outpatient setting,"$5,057.50 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$5,652.50 ",90% of total billed charges for outpatient setting,"$3,272.50 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$5,533.50 ",93% of total billed charges for outpatient setting,"$3,272.50 ","$5,771.50 ","$4,462.50 "
Outpatient Medical Services,ENDOSCOPY,43239,"Biopsy of the esophagus, stomach, and/or upper small bowel using an endoscope",975,"$1,130.00 ",$229.42 ,135% of 2011 CMS physician fee schedule,$140.49 ,100% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$466.87 ,100% of the Blue Cross physician fee schedule,$279.30 ,100% of Work Comp physician fee schedule. Multiple discount rules may apply,$140.49 ,100% CMS Medicare physician fee schedule ,$203.71 ,145% CMS Medicare physician fee schedule ,"$1,073.50 ",95% of total billed charges for physician setting,,Not separately reimbursible. Not contracted for physician rates,$174.84 ,100% CMS Medicare physician fee schedule ,$202.45 ,100% Humana physician fee schedule,$140.49 ,100% CMS Medicare physician fee schedule ,"$1,130.00 ",Not separately reimbursible. Not contracted for physician rates,$286.10 ,100% Midlands Choice physician fee schedule,$160.57 ,100% Multiplan physician fee schedule,$160.57 ,100% Multiplan physician fee schedule,$196.69 ,140% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$140.49 ,100% CMS Medicare physician fee schedule ,"$1,073.50 ",95% of total billed charges,$140.49 ,100% CMS Medicare physician fee schedule ,$175.27 ,124.753% CMS Medicare physician fee schedule ,$140.49 ,"$1,130.00 ",$847.50 
Outpatient Medical Services,ENDOSCOPY,43239,"Biopsy of the esophagus, stomach, and/or upper small bowel using an endoscope",360,"$7,600.00 ","$6,992.00 ",92% of total billed charges for outpatient setting,"$4,180.00 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,"$6,536.00 ",86% of total billed charges for outpatient setting,"$6,080.00 ",80% of total billed charges for outpatient setting,"$4,180.00 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$7,220.00 ",95% of total billed charges for outpatient setting,"$7,220.00 ",95% of total billed charges for outpatient setting,"$5,700.00 ",75% of total billed charges for outpatient setting,"$6,460.00 ",85% of total billed charges for outpatient setting,"$7,372.00 ",97% of total billed charges for outpatient setting,"$4,180.00 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$6,840.00 ",90% of total billed charges for outpatient setting,"$7,372.00 ",97% of total billed charges for outpatient setting,"$7,372.00 ",97% of total billed charges for outpatient setting,"$7,372.00 ",97% of total billed charges for outpatient setting,"$6,460.00 ",85% of total billed charges for outpatient setting,"$6,840.00 ",90% of total billed charges for outpatient setting,"$6,460.00 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$7,220.00 ",90% of total billed charges for outpatient setting,"$4,180.00 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$7,068.00 ",93% of total billed charges for outpatient setting,"$4,180.00 ","$7,372.00 ","$5,700.00 "
Outpatient Medical Services,ENDOSCOPY,45380,Biopsy of large bowel using an endoscope,975,"$1,795.00 ",$347.15 ,135% of 2011 CMS physician fee schedule,$203.60 ,100% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$530.86 ,100% of the Blue Cross physician fee schedule,$405.30 ,100% of Work Comp physician fee schedule. Multiple discount rules may apply,$203.60 ,100% CMS Medicare physician fee schedule ,$295.22 ,145% CMS Medicare physician fee schedule ,"$1,705.25 ",95% of total billed charges for physician setting,,Not separately reimbursible. Not contracted for physician rates,$253.20 ,100% CMS Medicare physician fee schedule ,$293.61 ,100% Humana physician fee schedule,$203.60 ,100% CMS Medicare physician fee schedule ,"$1,795.00 ",Not separately reimbursible. Not contracted for physician rates,$415.05 ,100% Midlands Choice physician fee schedule,$232.66 ,100% Multiplan physician fee schedule,$232.66 ,100% Multiplan physician fee schedule,$285.04 ,140% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$203.60 ,100% CMS Medicare physician fee schedule ,"$1,705.25 ",95% of total billed charges,$203.60 ,100% CMS Medicare physician fee schedule ,$254.00 ,124.753% CMS Medicare physician fee schedule ,$203.60 ,"$1,795.00 ","$1,346.25 "
Outpatient Medical Services,ENDOSCOPY,45380,Biopsy of large bowel using an endoscope,360,"$6,000.00 ","$5,520.00 ",92% of total billed charges for outpatient setting,"$3,300.00 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,"$5,160.00 ",86% of total billed charges for outpatient setting,"$4,800.00 ",80% of total billed charges for outpatient setting,"$3,300.00 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$5,700.00 ",95% of total billed charges for outpatient setting,"$5,700.00 ",95% of total billed charges for outpatient setting,"$4,500.00 ",75% of total billed charges for outpatient setting,"$5,100.00 ",85% of total billed charges for outpatient setting,"$5,820.00 ",97% of total billed charges for outpatient setting,"$3,300.00 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$5,400.00 ",90% of total billed charges for outpatient setting,"$5,820.00 ",97% of total billed charges for outpatient setting,"$5,820.00 ",97% of total billed charges for outpatient setting,"$5,820.00 ",97% of total billed charges for outpatient setting,"$5,100.00 ",85% of total billed charges for outpatient setting,"$5,400.00 ",90% of total billed charges for outpatient setting,"$5,100.00 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$5,700.00 ",90% of total billed charges for outpatient setting,"$3,300.00 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$5,580.00 ",93% of total billed charges for outpatient setting,"$3,300.00 ","$5,820.00 ","$4,500.00 "
Outpatient Medical Services,ENDOSCOPY,45385,Removal of polyps or growths of large bowel using an endoscope,975,"$1,910.00 ",$411.90 ,135% of 2011 CMS physician fee schedule,$258.71 ,100% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$552.77 ,100% of the Blue Cross physician fee schedule,$514.50 ,100% of Work Comp physician fee schedule. Multiple discount rules may apply,$258.71 ,100% CMS Medicare physician fee schedule ,$375.13 ,145% CMS Medicare physician fee schedule ,"$1,814.50 ",95% of total billed charges for physician setting,,Not separately reimbursible. Not contracted for physician rates,$321.58 ,100% CMS Medicare physician fee schedule ,$372.64 ,100% Humana physician fee schedule,$258.71 ,100% CMS Medicare physician fee schedule ,"$1,910.00 ",Not separately reimbursible. Not contracted for physician rates,$526.52 ,100% Midlands Choice physician fee schedule,$295.27 ,100% Multiplan physician fee schedule,$295.27 ,100% Multiplan physician fee schedule,$362.19 ,140% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$258.71 ,100% CMS Medicare physician fee schedule ,"$1,814.50 ",95% of total billed charges,$258.71 ,100% CMS Medicare physician fee schedule ,$322.75 ,124.753% CMS Medicare physician fee schedule ,$258.71 ,"$1,910.00 ","$1,432.50 "
Outpatient Medical Services,ENDOSCOPY,45385,Removal of polyps or growths of large bowel using an endoscope,360,"$4,700.00 ","$4,324.00 ",92% of total billed charges for outpatient setting,"$2,585.00 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,"$4,042.00 ",86% of total billed charges for outpatient setting,"$3,760.00 ",80% of total billed charges for outpatient setting,"$2,585.00 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$4,465.00 ",95% of total billed charges for outpatient setting,"$4,465.00 ",95% of total billed charges for outpatient setting,"$3,525.00 ",75% of total billed charges for outpatient setting,"$3,995.00 ",85% of total billed charges for outpatient setting,"$4,559.00 ",97% of total billed charges for outpatient setting,"$2,585.00 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$4,230.00 ",90% of total billed charges for outpatient setting,"$4,559.00 ",97% of total billed charges for outpatient setting,"$4,559.00 ",97% of total billed charges for outpatient setting,"$4,559.00 ",97% of total billed charges for outpatient setting,"$3,995.00 ",85% of total billed charges for outpatient setting,"$4,230.00 ",90% of total billed charges for outpatient setting,"$3,995.00 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$4,465.00 ",90% of total billed charges for outpatient setting,"$2,585.00 ","55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate","$4,371.00 ",93% of total billed charges for outpatient setting,"$2,585.00 ","$4,559.00 ","$3,525.00 "
Outpatient Medical Services,PSYCHIATRIC,90832,"Psychotherapy, 30 min",981,$139.00 ,,Not separately reimbursable per contract terms,$68.88 ,100% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$36.00 ,100% of the Blue Cross physician fee schedule,$123.90 ,100% of Work Comp physician fee schedule. Multiple discount rules may apply,$68.88 ,100% CMS Medicare physician fee schedule ,$99.88 ,145% CMS Medicare physician fee schedule ,$132.05 ,95% of total billed charges for physician setting,,Not separately reimbursible. Not contracted for physician rates,$85.81 ,100% CMS Medicare physician fee schedule ,$89.49 ,100% Humana physician fee schedule,$68.88 ,100% CMS Medicare physician fee schedule ,$139.00 ,Not separately reimbursible. Not contracted for physician rates,,Not separately reimbursable per contract terms,$83.40 ,60% of total billed charges for physician settings,$83.40 ,60% of total billed charges for physician settings,$96.43 ,140% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$68.88 ,100% CMS Medicare physician fee schedule ,$132.05 ,95% of total billed charges,$68.88 ,100% CMS Medicare physician fee schedule ,$85.93 ,124.753% CMS Medicare physician fee schedule ,$36.00 ,$139.00 ,$104.25 
Outpatient Medical Services,PSYCHIATRIC,90834,"Psychotherapy, 45 min",981,$230.00 ,,Not separately reimbursable per contract terms,$90.70 ,100% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$66.00 ,100% of the Blue Cross physician fee schedule,$165.20 ,100% of Work Comp physician fee schedule. Multiple discount rules may apply,$90.70 ,100% CMS Medicare physician fee schedule ,$131.52 ,145% CMS Medicare physician fee schedule ,$218.50 ,95% of total billed charges for physician setting,,Not separately reimbursible. Not contracted for physician rates,$113.01 ,100% CMS Medicare physician fee schedule ,$119.32 ,100% Humana physician fee schedule,$90.70 ,100% CMS Medicare physician fee schedule ,$230.00 ,Not separately reimbursible. Not contracted for physician rates,$146.40 ,100% Midlands Choice physician fee schedule,$138.00 ,60% of total billed charges for physician settings,$138.00 ,60% of total billed charges for physician settings,$126.98 ,140% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$90.70 ,100% CMS Medicare physician fee schedule ,$218.50 ,95% of total billed charges,$90.70 ,100% CMS Medicare physician fee schedule ,$113.15 ,124.753% CMS Medicare physician fee schedule ,$66.00 ,$230.00 ,$172.50 
Outpatient Medical Services,PSYCHIATRIC,90837,"Psychotherapy, 60 min",981,$330.00 ,,Not separately reimbursable per contract terms,$133.00 ,100% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$77.00 ,100% of the Blue Cross physician fee schedule,$247.10 ,100% of Work Comp physician fee schedule. Multiple discount rules may apply,$133.00 ,100% CMS Medicare physician fee schedule ,$192.85 ,145% CMS Medicare physician fee schedule ,$313.50 ,95% of total billed charges for physician setting,,Not separately reimbursible. Not contracted for physician rates,$165.85 ,100% CMS Medicare physician fee schedule ,$178.53 ,100% Humana physician fee schedule,$133.00 ,100% CMS Medicare physician fee schedule ,$330.00 ,Not separately reimbursible. Not contracted for physician rates,$219.70 ,100% Midlands Choice physician fee schedule,$198.00 ,60% of total billed charges for physician settings,$198.00 ,60% of total billed charges for physician settings,$186.20 ,140% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$133.00 ,100% CMS Medicare physician fee schedule ,$313.50 ,95% of total billed charges,$133.00 ,100% CMS Medicare physician fee schedule ,$165.92 ,124.753% CMS Medicare physician fee schedule ,$77.00 ,$330.00 ,$247.50 
Outpatient Medical Services,PSYCHIATRIC,90846,"Family psychotherapy, not including patient, 50 min",981,$280.00 ,$104.26 ,135% of 2011 CMS physician fee schedule,$97.67 ,100% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$66.00 ,100% of the Blue Cross physician fee schedule,$199.50 ,100% of Work Comp physician fee schedule. Multiple discount rules may apply,$97.67 ,100% CMS Medicare physician fee schedule ,$141.62 ,145% CMS Medicare physician fee schedule ,$266.00 ,95% of total billed charges for physician setting,,Not separately reimbursible. Not contracted for physician rates,$121.75 ,100% CMS Medicare physician fee schedule ,$144.17 ,100% Humana physician fee schedule,$97.67 ,100% CMS Medicare physician fee schedule ,$280.00 ,Not separately reimbursible. Not contracted for physician rates,,Not separately reimbursable per contract terms,$168.00 ,60% of total billed charges for physician settings,$168.00 ,60% of total billed charges for physician settings,$136.74 ,140% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$97.67 ,100% CMS Medicare physician fee schedule ,$266.00 ,95% of total billed charges,$97.67 ,100% CMS Medicare physician fee schedule ,$121.85 ,124.753% CMS Medicare physician fee schedule ,$66.00 ,$280.00 ,$210.00 
Outpatient Medical Services,PSYCHIATRIC,90847,"Family psychotherapy, including patient, 50 min",981,$279.00 ,$123.36 ,135% of 2011 CMS physician fee schedule,$101.48 ,100% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$66.00 ,100% of the Blue Cross physician fee schedule,$207.20 ,100% of Work Comp physician fee schedule. Multiple discount rules may apply,$101.48 ,100% CMS Medicare physician fee schedule ,$147.15 ,145% CMS Medicare physician fee schedule ,$265.05 ,95% of total billed charges for physician setting,,Not separately reimbursible. Not contracted for physician rates,$126.53 ,100% CMS Medicare physician fee schedule ,$149.74 ,100% Humana physician fee schedule,$101.48 ,100% CMS Medicare physician fee schedule ,$279.00 ,Not separately reimbursible. Not contracted for physician rates,,Not separately reimbursable per contract terms,$105.98 ,100% Multiplan physician fee schedule,$105.98 ,100% Multiplan physician fee schedule,$142.07 ,140% CMS Medicare physician fee schedule ,,Not separately reimbursible. Not contracted for physician rates,$101.48 ,100% CMS Medicare physician fee schedule ,$265.05 ,95% of total billed charges,$101.48 ,100% CMS Medicare physician fee schedule ,$126.60 ,124.753% CMS Medicare physician fee schedule ,$66.00 ,$279.00 ,$209.25 
Outpatient Medical Services,THERAPY,97014,One time use unattended,420,$52.00 ,$47.84 ,92% of total billed charges for outpatient setting,$28.60 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$36.40 ,70% of total billed charges for therapy rate with NTE of $70,$44.72 ,86% of total billed charges for outpatient setting,$41.60 ,80% of total billed charges for outpatient setting,$28.60 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$49.40 ,95% of total billed charges for outpatient setting,$49.40 ,95% of total billed charges for outpatient setting,$39.00 ,75% of total billed charges for outpatient setting,$44.20 ,85% of total billed charges for outpatient setting,$50.44 ,97% of total billed charges for outpatient setting,$28.60 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$65.00 ,100% case rate for initial eval or therapy,$50.44 ,97% of total billed charges for outpatient setting,$50.44 ,97% of total billed charges for outpatient setting,$50.44 ,97% of total billed charges for outpatient setting,$44.20 ,85% of total billed charges for outpatient setting,$46.80 ,90% of total billed charges for outpatient setting,$44.20 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$49.40 ,90% of total billed charges for outpatient setting,$28.60 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$48.36 ,93% of total billed charges for outpatient setting,$28.60 ,$65.00 ,$39.00 
Outpatient Medical Services,THERAPY,97018,Paraffin Bath Charge,420,$146.00 ,$134.32 ,92% of total billed charges for outpatient setting,$80.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$70.00 ,70% of total billed charges for therapy rate with NTE of $70,$125.56 ,86% of total billed charges for outpatient setting,$116.80 ,80% of total billed charges for outpatient setting,$80.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$138.70 ,95% of total billed charges for outpatient setting,$138.70 ,95% of total billed charges for outpatient setting,$109.50 ,75% of total billed charges for outpatient setting,$124.10 ,85% of total billed charges for outpatient setting,$141.62 ,97% of total billed charges for outpatient setting,$80.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$65.00 ,100% case rate for initial eval or therapy,$141.62 ,97% of total billed charges for outpatient setting,$141.62 ,97% of total billed charges for outpatient setting,$141.62 ,97% of total billed charges for outpatient setting,$124.10 ,85% of total billed charges for outpatient setting,$131.40 ,90% of total billed charges for outpatient setting,$124.10 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$138.70 ,90% of total billed charges for outpatient setting,$80.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$135.78 ,93% of total billed charges for outpatient setting,$65.00 ,$141.62 ,$109.50 
Outpatient Medical Services,THERAPY,97032,Repeated application to one or more parts of the body,420,$52.00 ,$47.84 ,92% of total billed charges for outpatient setting,$28.60 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$36.40 ,70% of total billed charges for therapy rate with NTE of $70,$44.72 ,86% of total billed charges for outpatient setting,$41.60 ,80% of total billed charges for outpatient setting,$28.60 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$49.40 ,95% of total billed charges for outpatient setting,$49.40 ,95% of total billed charges for outpatient setting,$39.00 ,75% of total billed charges for outpatient setting,$44.20 ,85% of total billed charges for outpatient setting,$50.44 ,97% of total billed charges for outpatient setting,$28.60 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$65.00 ,100% case rate for initial eval or therapy,$50.44 ,97% of total billed charges for outpatient setting,$50.44 ,97% of total billed charges for outpatient setting,$50.44 ,97% of total billed charges for outpatient setting,$44.20 ,85% of total billed charges for outpatient setting,$46.80 ,90% of total billed charges for outpatient setting,$44.20 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$49.40 ,90% of total billed charges for outpatient setting,$28.60 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$48.36 ,93% of total billed charges for outpatient setting,$28.60 ,$65.00 ,$39.00 
Outpatient Medical Services,THERAPY,97035,"Use of sound waves to treat medical problems, especially musculoskeletal problems like inflammation from injuries",420,$46.00 ,$42.32 ,92% of total billed charges for outpatient setting,$25.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$32.20 ,70% of total billed charges for therapy rate with NTE of $70,$39.56 ,86% of total billed charges for outpatient setting,$36.80 ,80% of total billed charges for outpatient setting,$25.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$43.70 ,95% of total billed charges for outpatient setting,$43.70 ,95% of total billed charges for outpatient setting,$34.50 ,75% of total billed charges for outpatient setting,$39.10 ,85% of total billed charges for outpatient setting,$44.62 ,97% of total billed charges for outpatient setting,$25.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$65.00 ,100% case rate for initial eval or therapy,$44.62 ,97% of total billed charges for outpatient setting,$44.62 ,97% of total billed charges for outpatient setting,$44.62 ,97% of total billed charges for outpatient setting,$39.10 ,85% of total billed charges for outpatient setting,$41.40 ,90% of total billed charges for outpatient setting,$39.10 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$43.70 ,90% of total billed charges for outpatient setting,$25.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$42.78 ,93% of total billed charges for outpatient setting,$25.30 ,$65.00 ,$34.50 
Outpatient Medical Services,THERAPY,97112,A technique used by physical therapists to restore normal body movement patterns,420,$203.00 ,$186.76 ,92% of total billed charges for outpatient setting,$111.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$70.00 ,70% of total billed charges for therapy rate with NTE of $70,$174.58 ,86% of total billed charges for outpatient setting,$162.40 ,80% of total billed charges for outpatient setting,$111.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$192.85 ,95% of total billed charges for outpatient setting,$192.85 ,95% of total billed charges for outpatient setting,$152.25 ,75% of total billed charges for outpatient setting,$172.55 ,85% of total billed charges for outpatient setting,$196.91 ,97% of total billed charges for outpatient setting,$111.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$65.00 ,100% case rate for initial eval or therapy,$196.91 ,97% of total billed charges for outpatient setting,$196.91 ,97% of total billed charges for outpatient setting,$196.91 ,97% of total billed charges for outpatient setting,$172.55 ,85% of total billed charges for outpatient setting,$182.70 ,90% of total billed charges for outpatient setting,$172.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$192.85 ,90% of total billed charges for outpatient setting,$111.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$188.79 ,93% of total billed charges for outpatient setting,$65.00 ,$196.91 ,$152.25 
Outpatient Medical Services,THERAPY,97113,Use of water for therapy/exercises,420,$165.00 ,$151.80 ,92% of total billed charges for outpatient setting,$90.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$70.00 ,70% of total billed charges for therapy rate with NTE of $70,$141.90 ,86% of total billed charges for outpatient setting,$132.00 ,80% of total billed charges for outpatient setting,$90.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$156.75 ,95% of total billed charges for outpatient setting,$156.75 ,95% of total billed charges for outpatient setting,$123.75 ,75% of total billed charges for outpatient setting,$140.25 ,85% of total billed charges for outpatient setting,$160.05 ,97% of total billed charges for outpatient setting,$90.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$65.00 ,100% case rate for initial eval or therapy,$160.05 ,97% of total billed charges for outpatient setting,$160.05 ,97% of total billed charges for outpatient setting,$160.05 ,97% of total billed charges for outpatient setting,$140.25 ,85% of total billed charges for outpatient setting,$148.50 ,90% of total billed charges for outpatient setting,$140.25 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$156.75 ,90% of total billed charges for outpatient setting,$90.75 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$153.45 ,93% of total billed charges for outpatient setting,$65.00 ,$160.05 ,$123.75 
Outpatient Medical Services,THERAPY,97116,A type of physical therapy,420,$127.00 ,$116.84 ,92% of total billed charges for outpatient setting,$69.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$70.00 ,70% of total billed charges for therapy rate with NTE of $70,$109.22 ,86% of total billed charges for outpatient setting,$101.60 ,80% of total billed charges for outpatient setting,$69.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$120.65 ,95% of total billed charges for outpatient setting,$120.65 ,95% of total billed charges for outpatient setting,$95.25 ,75% of total billed charges for outpatient setting,$107.95 ,85% of total billed charges for outpatient setting,$123.19 ,97% of total billed charges for outpatient setting,$69.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$65.00 ,100% case rate for initial eval or therapy,$123.19 ,97% of total billed charges for outpatient setting,$123.19 ,97% of total billed charges for outpatient setting,$123.19 ,97% of total billed charges for outpatient setting,$107.95 ,85% of total billed charges for outpatient setting,$114.30 ,90% of total billed charges for outpatient setting,$107.95 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$120.65 ,90% of total billed charges for outpatient setting,$69.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$118.11 ,93% of total billed charges for outpatient setting,$65.00 ,$123.19 ,$95.25 
Outpatient Medical Services,THERAPY,97139,PT Dry Needling Units,420,$22.00 ,$20.24 ,92% of total billed charges for outpatient setting,$12.10 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$15.40 ,70% of total billed charges for therapy rate with NTE of $70,$18.92 ,86% of total billed charges for outpatient setting,$17.60 ,80% of total billed charges for outpatient setting,$12.10 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$20.90 ,95% of total billed charges for outpatient setting,$20.90 ,95% of total billed charges for outpatient setting,$16.50 ,75% of total billed charges for outpatient setting,$18.70 ,85% of total billed charges for outpatient setting,$21.34 ,97% of total billed charges for outpatient setting,$12.10 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$65.00 ,100% case rate for initial eval or therapy,$21.34 ,97% of total billed charges for outpatient setting,$21.34 ,97% of total billed charges for outpatient setting,$21.34 ,97% of total billed charges for outpatient setting,$18.70 ,85% of total billed charges for outpatient setting,$19.80 ,90% of total billed charges for outpatient setting,$18.70 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$20.90 ,90% of total billed charges for outpatient setting,$12.10 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$20.46 ,93% of total billed charges for outpatient setting,$12.10 ,$65.00 ,$16.50 
Outpatient Medical Services,THERAPY,97140,Manipulation of 1 or more regions of the body,420,$183.00 ,$168.36 ,92% of total billed charges for outpatient setting,$100.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$70.00 ,70% of total billed charges for therapy rate with NTE of $70,$157.38 ,86% of total billed charges for outpatient setting,$146.40 ,80% of total billed charges for outpatient setting,$100.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$173.85 ,95% of total billed charges for outpatient setting,$173.85 ,95% of total billed charges for outpatient setting,$137.25 ,75% of total billed charges for outpatient setting,$155.55 ,85% of total billed charges for outpatient setting,$177.51 ,97% of total billed charges for outpatient setting,$100.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$65.00 ,100% case rate for initial eval or therapy,$177.51 ,97% of total billed charges for outpatient setting,$177.51 ,97% of total billed charges for outpatient setting,$177.51 ,97% of total billed charges for outpatient setting,$155.55 ,85% of total billed charges for outpatient setting,$164.70 ,90% of total billed charges for outpatient setting,$155.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$173.85 ,90% of total billed charges for outpatient setting,$100.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$170.19 ,93% of total billed charges for outpatient setting,$65.00 ,$177.51 ,$137.25 
Outpatient Medical Services,THERAPY,97161,Physical Therapy- Low Complex Evaluation,420,$150.00 ,$138.00 ,92% of total billed charges for outpatient setting,$82.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$70.00 ,70% of total billed charges for therapy rate with NTE of $70,$129.00 ,86% of total billed charges for outpatient setting,$120.00 ,80% of total billed charges for outpatient setting,$82.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$142.50 ,95% of total billed charges for outpatient setting,$142.50 ,95% of total billed charges for outpatient setting,$105.00 ,100% case rate for initial eval,$127.50 ,85% of total billed charges for outpatient setting,$145.50 ,97% of total billed charges for outpatient setting,$82.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$65.00 ,100% case rate for initial eval or therapy,$145.50 ,97% of total billed charges for outpatient setting,$145.50 ,97% of total billed charges for outpatient setting,$145.50 ,97% of total billed charges for outpatient setting,$127.50 ,85% of total billed charges for outpatient setting,$135.00 ,90% of total billed charges for outpatient setting,$127.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$142.50 ,90% of total billed charges for outpatient setting,$82.50 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$139.50 ,93% of total billed charges for outpatient setting,$65.00 ,$145.50 ,$112.50 
Outpatient Medical Services,THERAPY,97530,"Incorporates the use of multiple parameters, such as balance, strength, and range of motion, for a functional activity",420,$123.00 ,$113.16 ,92% of total billed charges for outpatient setting,$67.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$70.00 ,70% of total billed charges for therapy rate with NTE of $70,$105.78 ,86% of total billed charges for outpatient setting,$98.40 ,80% of total billed charges for outpatient setting,$67.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$116.85 ,95% of total billed charges for outpatient setting,$116.85 ,95% of total billed charges for outpatient setting,$92.25 ,75% of total billed charges for outpatient setting,$104.55 ,85% of total billed charges for outpatient setting,$119.31 ,97% of total billed charges for outpatient setting,$67.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$65.00 ,100% case rate for initial eval or therapy,$119.31 ,97% of total billed charges for outpatient setting,$119.31 ,97% of total billed charges for outpatient setting,$119.31 ,97% of total billed charges for outpatient setting,$104.55 ,85% of total billed charges for outpatient setting,$110.70 ,90% of total billed charges for outpatient setting,$104.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$116.85 ,90% of total billed charges for outpatient setting,$67.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$114.39 ,93% of total billed charges for outpatient setting,$65.00 ,$119.31 ,$92.25 
Outpatient Medical Services,THERAPY,97165,Occupational Therapy Low Complex Evaluation,430,$147.00 ,$135.24 ,92% of total billed charges for outpatient setting,$80.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$126.42 ,86% of total billed charges for outpatient setting,$117.60 ,80% of total billed charges for outpatient setting,$80.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$139.65 ,95% of total billed charges for outpatient setting,$139.65 ,95% of total billed charges for outpatient setting,$110.25 ,75% of total billed charges for outpatient setting,$124.95 ,85% of total billed charges for outpatient setting,$142.59 ,97% of total billed charges for outpatient setting,$80.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$65.00 ,100% case rate for initial eval or therapy,$142.59 ,97% of total billed charges for outpatient setting,$142.59 ,97% of total billed charges for outpatient setting,$142.59 ,97% of total billed charges for outpatient setting,$124.95 ,85% of total billed charges for outpatient setting,$132.30 ,90% of total billed charges for outpatient setting,$124.95 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$139.65 ,90% of total billed charges for outpatient setting,$80.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$136.71 ,93% of total billed charges for outpatient setting,$65.00 ,$142.59 ,$110.25 
Outpatient Medical Services,THERAPY,97535,Occupational therapy,430,$123.00 ,$113.16 ,92% of total billed charges for outpatient setting,$67.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$105.78 ,86% of total billed charges for outpatient setting,$98.40 ,80% of total billed charges for outpatient setting,$67.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$116.85 ,95% of total billed charges for outpatient setting,$116.85 ,95% of total billed charges for outpatient setting,$92.25 ,75% of total billed charges for outpatient setting,$104.55 ,85% of total billed charges for outpatient setting,$119.31 ,97% of total billed charges for outpatient setting,$67.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$65.00 ,100% case rate for initial eval or therapy,$119.31 ,97% of total billed charges for outpatient setting,$119.31 ,97% of total billed charges for outpatient setting,$119.31 ,97% of total billed charges for outpatient setting,$104.55 ,85% of total billed charges for outpatient setting,$110.70 ,90% of total billed charges for outpatient setting,$104.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$116.85 ,90% of total billed charges for outpatient setting,$67.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$114.39 ,93% of total billed charges for outpatient setting,$65.00 ,$119.31 ,$92.25 
Outpatient Medical Services,THERAPY,97110,"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",430,$89.00 ,$81.88 ,92% of total billed charges for outpatient setting,$48.95 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$76.54 ,86% of total billed charges for outpatient setting,$71.20 ,80% of total billed charges for outpatient setting,$48.95 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$84.55 ,95% of total billed charges for outpatient setting,$84.55 ,95% of total billed charges for outpatient setting,$66.75 ,75% of total billed charges for outpatient setting,$75.65 ,85% of total billed charges for outpatient setting,$86.33 ,97% of total billed charges for outpatient setting,$48.95 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$65.00 ,100% case rate for initial eval or therapy,$86.33 ,97% of total billed charges for outpatient setting,$86.33 ,97% of total billed charges for outpatient setting,$86.33 ,97% of total billed charges for outpatient setting,$75.65 ,85% of total billed charges for outpatient setting,$80.10 ,90% of total billed charges for outpatient setting,$75.65 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$84.55 ,90% of total billed charges for outpatient setting,$48.95 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$82.77 ,93% of total billed charges for outpatient setting,$48.95 ,$86.33 ,$66.75 
Outpatient Medical Services,THERAPY,93798,Use of EKG to monitor cardiac rehabilitation,943,$398.00 ,$366.16 ,92% of total billed charges for outpatient setting,$218.90 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$342.28 ,86% of total billed charges for outpatient setting,$318.40 ,80% of total billed charges for outpatient setting,$218.90 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$378.10 ,95% of total billed charges for outpatient setting,$378.10 ,95% of total billed charges for outpatient setting,$298.50 ,75% of total billed charges for outpatient setting,$338.30 ,85% of total billed charges for outpatient setting,$386.06 ,97% of total billed charges for outpatient setting,$218.90 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$358.20 ,90% of total billed charges for outpatient setting,$386.06 ,97% of total billed charges for outpatient setting,$386.06 ,97% of total billed charges for outpatient setting,$386.06 ,97% of total billed charges for outpatient setting,$338.30 ,85% of total billed charges for outpatient setting,$358.20 ,90% of total billed charges for outpatient setting,$338.30 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$378.10 ,90% of total billed charges for outpatient setting,$218.90 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$370.14 ,93% of total billed charges for outpatient setting,$218.90 ,$386.06 ,$298.50 
Outpatient Medical Services,THERAPY,97124,Use of massage,420,$61.00 ,$56.12 ,92% of total billed charges for outpatient setting,$33.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$42.70 ,70% of total billed charges for therapy rate with NTE of $70,$52.46 ,86% of total billed charges for outpatient setting,$48.80 ,80% of total billed charges for outpatient setting,$33.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$57.95 ,95% of total billed charges for outpatient setting,$57.95 ,95% of total billed charges for outpatient setting,$45.75 ,75% of total billed charges for outpatient setting,$51.85 ,85% of total billed charges for outpatient setting,$59.17 ,97% of total billed charges for outpatient setting,$33.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$65.00 ,100% case rate for initial eval or therapy,$59.17 ,97% of total billed charges for outpatient setting,$59.17 ,97% of total billed charges for outpatient setting,$59.17 ,97% of total billed charges for outpatient setting,$51.85 ,85% of total billed charges for outpatient setting,$54.90 ,90% of total billed charges for outpatient setting,$51.85 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$57.95 ,90% of total billed charges for outpatient setting,$33.55 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$56.73 ,93% of total billed charges for outpatient setting,$33.55 ,$65.00 ,$45.75 
Outpatient Medical Services,HOME HEALTH,G0156,CNA Visit,550,$273.00 ,$251.16 ,92% of total billed charges for outpatient setting,$150.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$234.78 ,86% of total billed charges for outpatient setting,$218.40 ,80% of total billed charges for outpatient setting,$150.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$259.35 ,95% of total billed charges for outpatient setting,$259.35 ,95% of total billed charges for outpatient setting,$204.75 ,75% of total billed charges for outpatient setting,$232.05 ,85% of total billed charges for outpatient setting,$264.81 ,97% of total billed charges for outpatient setting,$150.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$245.70 ,90% of total billed charges for outpatient setting,$264.81 ,97% of total billed charges for outpatient setting,$264.81 ,97% of total billed charges for outpatient setting,$264.81 ,97% of total billed charges for outpatient setting,$232.05 ,85% of total billed charges for outpatient setting,$245.70 ,90% of total billed charges for outpatient setting,$232.05 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$259.35 ,90% of total billed charges for outpatient setting,$150.15 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$150.15 ,$264.81 ,$204.75 
Outpatient Medical Services,HOME HEALTH,G0299,RN Visit,550,$460.00 ,$423.20 ,92% of total billed charges for outpatient setting,$253.00 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not seperately reimbursible per contract terms,$395.60 ,86% of total billed charges for outpatient setting,$368.00 ,80% of total billed charges for outpatient setting,$253.00 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$437.00 ,95% of total billed charges for outpatient setting,$437.00 ,95% of total billed charges for outpatient setting,$345.00 ,75% of total billed charges for outpatient setting,$391.00 ,85% of total billed charges for outpatient setting,$446.20 ,97% of total billed charges for outpatient setting,$253.00 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$414.00 ,90% of total billed charges for outpatient setting,$446.20 ,97% of total billed charges for outpatient setting,$446.20 ,97% of total billed charges for outpatient setting,$446.20 ,97% of total billed charges for outpatient setting,$391.00 ,85% of total billed charges for outpatient setting,$414.00 ,90% of total billed charges for outpatient setting,$391.00 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",$437.00 ,90% of total billed charges for outpatient setting,$253.00 ,"55% of total billed charges, which is 100 percent of CMS Medicare OP CCR rate",,Not separately reimbursable per table 3 referenced in contract,$253.00 ,$446.20 ,$345.00 
Outpatient Medical Services,BEHAVIORAL,90853,Group psychotherapy,900,SERVICE NOT OFFERED,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,,
Outpatient Medical Services,OFFICE VISIT,99243,"Patient office consultation, typically 40 min",761,SERVICE NOT OFFERED,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,,
Outpatient Medical Services,OFFICE VISIT,99244,"Patient office consultation, typically 60 min",761,SERVICE NOT OFFERED,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,,
Outpatient Medical Services,LABORATORY,80055,Obstetric blood test panel,300,SERVICE NOT OFFERED,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,,
Outpatient Medical Services,LABORATORY,81000,Manual urinalysis test with examination using microscope,300,SERVICE NOT OFFERED,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,,
Outpatient Medical Services,LABORATORY,81003,Prostate specific antigen,300,SERVICE NOT OFFERED,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,,
Outpatient Medical Services,RADIOLOGY,19120,"Removal of 1 or more breast growth, open procedure",360,SERVICE NOT OFFERED,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,,
Outpatient Medical Services,OUTPATIENT SERVICES,29826,Shaving of shoulder bone using an endoscope,360,SERVICE NOT OFFERED,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,,
Outpatient Medical Services,OUTPATIENT SERVICES,29881,Removal of one knee cartilage using an endoscope,360,SERVICE NOT OFFERED,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,,
Outpatient Medical Services,OUTPATIENT SERVICES,42820,Removal of tonsils and adenoid glands patient younger than age 12,360,SERVICE NOT OFFERED,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. 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,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,,
Outpatient Medical Services,OUTPATIENT SERVICES,45391,Ultrasound examination of lower large bowel using an endoscope,360,SERVICE NOT OFFERED,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,,
Outpatient Medical Services,OUTPATIENT SERVICES,47562,Removal of gallbladder using an endoscope,360,SERVICE NOT OFFERED,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,,
Outpatient Medical Services,OUTPATIENT SERVICES,49505,Repair of groin hernia patient age 5 or older,360,SERVICE NOT OFFERED,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,,
Outpatient Medical Services,OUTPATIENT SERVICES,55700,Biopsy of prostate gland,360,SERVICE NOT OFFERED,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,,
Outpatient Medical Services,OUTPATIENT SERVICES,55866,Surgical removal of prostate and surrounding lymph nodes using an endoscope,360,SERVICE NOT OFFERED,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. 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,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. 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,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. 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,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. 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,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,,
Outpatient Medical Services,OUTPATIENT SERVICES,66821,Removal of recurring cataract in lens capsule using laser,360,SERVICE NOT OFFERED,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,,
Outpatient Medical Services,OUTPATIENT SERVICES,66984,Removal of cataract with insertion of lens,360,SERVICE NOT OFFERED,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,,
Outpatient Medical Services,ECCG,93000,"Electrocardiogram, routine, with interpretation and report",730,SERVICE NOT OFFERED,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,,
Outpatient Medical Services,CARDIOLOGY,93452,Insertion of catheter into left heart for diagnosis,480,SERVICE NOT OFFERED,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,,
Inpatient Medical Services,INPATIENT,216,Cardiac valve and other major cardiothoracic procedures with cardiac catheterization with major complications or comorbidities,100,SERVICE NOT OFFERED,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,,
Inpatient Medical Services,INPATIENT,460,Spinal fusion except cervical without major comorbid conditions or complications,100,SERVICE NOT OFFERED,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,,
Inpatient Medical Services,INPATIENT,473,Cervical spinal fusion without comorbid conditions or major comorbid conditions or complications,100,SERVICE NOT OFFERED,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,,
Inpatient Medical Services,INPATIENT,743,Uterine and adnexa procedures for non-malignancy without comorbid conditions or major comorbid conditions or complications,100,SERVICE NOT OFFERED,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,,