hospital_name,last_updated_on,version,hospital_location,hospital_address,license_number|LA,"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.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Monroe Surgical Hospital LLC,2024-07-01,2.0.0,Monroe Surgical Hospital LLC,"2408 Broadmoor Blvd Monroe, LA 71201",721479756,TRUE,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SERVICE DESCRIPTION,CATEGORY,BILLING MSDRG | CPT | HCPCS,ITEM/SERVICE DESCRIPTION,BILLING REVENUE CODE,GROSS CHARGES,AETNA COMMERCIAL PLAN,AETNA COMMERCIAL REIMBURSEMENT METHOD,AETNA MEDICARE ADVANTAGE PLAN,AETNA MEDICARE ADVANTAGE REIMBURSEMENT METHOD,AETNA WORK COMP PLAN,AETNA WORK COMP REIMBURSEMENT METHOD,BEECH ST PLAN,BEECH ST REIMBURSEMENT METHOD,BLUE CROSS BLUE SHIELD PLAN,BLUE CROSS BLUE SHIELD REIMBURSEMENT METHOD,BLUE CROSS BLUE SHIELD MEDICARE ADVANTAGE PLAN,BLUE CROSS BLUE SHIELD MEDICARE ADVANTAGE REIMBURSEMENT METHOD,CIGNA PLAN,CIGNA REIMBURSEMENT METHOD,FIRST HEALTH PLAN,FIRST HEALTH REIMBURSEMENT METHOD,FORD BACON AND DAVIS PLAN,FORD BACON AND DAVIS REIMBURSEMENT METHOD,GILSBAR PLAN,GILSBAR REIMBURSEMENT METHOD,HEALTHY BLUE PLAN,HEALTHY BLUE REIMBURSEMENT METHOD,HUMANA COMMERCIAL PLAN,HUMANA COMMERCIAL REIMBURSEMENT METHOD,HUMANA MEDICARE ADVANTAGE PLAN,HUMANA MEDICARE ADVANTAGE REIMBURSEMENT METHOD,IMA PLAN,IMA REIMBURSEMENT METHOD,INSURANCE SYSTEMS PLAN,INSURANCE SYSTEMS REIMBURSEMENT METHOD,INSURANCE SYSTEMS SMSO EMPLOYEE PLAN,INSURANCE SYSTEMS SMSO EMPLOYEE REIMBURSEMENT METHOD,MEDICAID PLAN,MEDICAID REIMBURSEMENT METHOD,MEDICAID AMERIHEALTH PLAN,MEDICAID AMERIHEALTH REIMBURSEMENT METHOD,MEDICARE PLAN,MEDICARE REIMBURSEMENT METHOD,UHC PLAN,UHC REIMBURSEMENT METHOD,UHC MEDICARE ADVANTAGE PLAN,UHC MEDICARE ADVANTAGE REIMBURSEMENT METHOD,VACCN OPTUM PLAN,VACCN OPTUM REIMBURSEMENT METHOD,VANTAGE PLAN,VANTAGE REIMBURSEMENT METHOD,VANTAGE MEDICARE ADVANTAGE PLAN,VANTAGE MEDICARE ADVANTAGE REIMBURSEMENT METHOD,VERITY PLAN,VERITY REIMBURSEMENT METHOD,WORKERS COMP PLAN,WORKERS COMP REIMBURSEMENT METHOD,De-Identified Minimum Negotiated Rate,De-Identified Maximum Negotiated Rate,DISCOUNTED CASH PRICE
Outpatient Medical Services,ENDOSCOPY,43235,"Diagnostic examination of esophagus, stomach, and/or upper small bowel using an endoscope",360,"$6,059.88 ","$1,158.90 ",100% of APC Rate,$724.32 ,100% of Medicare OPPS,"$4,241.92 ",70% of total billed charges,"$5,143.63 ",84.88% of total billed charges,"$1,034.05 ",139.08% of ASC,$724.32 ,100% of Medicare OPPS,"$4,544.91 ",75% of total billed charges,"$2,000.00 ",70% of total billed charges,"$1,231.33 ",170% of Medicare OPPS,"$1,557.28 ",215% of Medicare OPPS,$778.09 ,12.84% of total billed charges,"$1,267.55 ",175% of Medicare OPPS,$724.32 ,100% of Medicare OPPS,"$4,847.90 ",80% of total billed charges,"$1,014.04 ",140% of Medicare OPPS,$905.39 ,125% of Medicare OPPS,$778.09 ,12.84% of LA Medicaid fee schedule,$778.09 ,12.84% of LA Medicaid fee schedule,$724.32 ,100% of Medicare OPPS,"$1,129.00 ",100% of ASC Grouper,$724.32 ,100% of Medicare OPPS,$724.32 ,100% of Medicare OPPS,"$1,267.55 ",100% of Medicare OPPS,$724.32 ,100% of Medicare OPPS,$797.58 ,100% of custom fee schedule,"$5,453.89 ",90% of total billed charges,$724.32 ,"$5,453.89 ","$6,059.88 "
Outpatient Medical Services,ENDOSCOPY,43239,"Biopsy of the esophagus, stomach, and/or upper small bowel using an endoscope",360,"$1,792.90 ","$1,158.90 ",100% of APC Rate,$724.32 ,100% of Medicare OPPS,"$1,255.03 ",70% of total billed charges,"$1,521.81 ",84.88% of total billed charges,"$1,034.05 ",139.08% of ASC,$724.32 ,100% of Medicare OPPS,"$1,344.68 ",75% of total billed charges,"$1,255.03 ",70% of total billed charges,"$1,231.33 ",170% of Medicare OPPS,"$1,557.28 ",215% of Medicare OPPS,$230.21 ,12.84% of total billed charges,"$1,267.55 ",175% of Medicare OPPS,$724.32 ,100% of Medicare OPPS,"$1,434.32 ",80% of total billed charges,"$1,014.04 ",140% of Medicare OPPS,$905.39 ,125% of Medicare OPPS,$230.21 ,12.84% of LA Medicaid fee schedule,$230.21 ,12.84% of LA Medicaid fee schedule,$724.32 ,100% of Medicare OPPS,"$1,129.00 ",100% of ASC Grouper,$724.32 ,100% of Medicare OPPS,$724.32 ,100% of Medicare OPPS,"$1,267.55 ",100% of Medicare OPPS,$724.32 ,100% of Medicare OPPS,$797.58 ,100% of custom fee schedule,"$1,613.61 ",90% of total billed charges,$230.21 ,"$1,613.61 ","$1,792.90 "
Outpatient Medical Services,ENDOSCOPY,43450,dilation of esophagus by bougie,360,"$3,598.70 ","$1,158.90 ",100% of APC Rate,$724.32 ,100% of Medicare OPPS,"$2,519.09 ",70% of total billed charges,"$3,054.58 ",84.88% of total billed charges,"$1,034.05 ",139.08% of ASC,$724.32 ,100% of Medicare OPPS,"$2,699.03 ",75% of total billed charges,"$2,000.00 ",70% of total billed charges,"$1,231.33 ",170% of Medicare OPPS,"$1,557.28 ",215% of Medicare OPPS,$462.07 ,12.84% of total billed charges,"$1,267.55 ",175% of Medicare OPPS,$724.32 ,100% of Medicare OPPS,"$2,878.96 ",80% of total billed charges,"$1,014.04 ",140% of Medicare OPPS,$905.39 ,125% of Medicare OPPS,$462.07 ,12.84% of LA Medicaid fee schedule,$462.07 ,12.84% of LA Medicaid fee schedule,$724.32 ,100% of Medicare OPPS,"$1,129.00 ",100% of ASC Grouper,$724.32 ,100% of Medicare OPPS,$724.32 ,100% of Medicare OPPS,"$1,267.55 ",100% of Medicare OPPS,$724.32 ,100% of Medicare OPPS,$797.58 ,100% of custom fee schedule,"$3,238.83 ",90% of total billed charges,$462.07 ,"$3,238.83 ","$3,598.70 "
Outpatient Medical Services,ENDOSCOPY,45378,Diagnostic examination of large bowel using an endoscope,360,"$1,757.58 ","$1,166.67 ",100% of APC Rate,$729.17 ,100% of Medicare OPPS,"$1,230.31 ",70% of total billed charges,"$1,491.83 ",84.88% of total billed charges,$987.44 ,139.08% of ASC,$729.17 ,100% of Medicare OPPS,"$1,318.19 ",75% of total billed charges,"$1,230.31 ",70% of total billed charges,"$1,239.58 ",170% of Medicare OPPS,"$1,567.71 ",215% of Medicare OPPS,$225.67 ,12.84% of total billed charges,"$1,276.04 ",175% of Medicare OPPS,$729.17 ,100% of Medicare OPPS,"$1,406.06 ",80% of total billed charges,"$1,020.83 ",140% of Medicare OPPS,$911.46 ,125% of Medicare OPPS,$225.67 ,12.84% of LA Medicaid fee schedule,$225.67 ,12.84% of LA Medicaid fee schedule,$729.17 ,100% of Medicare OPPS,"$1,129.00 ",100% of ASC Grouper,$729.17 ,100% of Medicare OPPS,$729.17 ,100% of Medicare OPPS,"$1,276.04 ",100% of Medicare OPPS,$729.17 ,100% of Medicare OPPS,$876.53 ,100% of custom fee schedule,"$1,581.82 ",90% of total billed charges,$225.67 ,"$1,581.82 ","$1,757.58 "
Outpatient Medical Services,ENDOSCOPY,45380,Biopsy of large bowel using an endoscope,360,"$2,296.40 ","$1,520.26 ",100% of APC Rate,$950.16 ,100% of Medicare OPPS,"$1,607.48 ",70% of total billed charges,"$1,949.18 ",84.88% of total billed charges,"$1,302.33 ",139.08% of ASC,$950.16 ,100% of Medicare OPPS,"$1,722.30 ",75% of total billed charges,"$1,607.48 ",70% of total billed charges,"$1,615.27 ",170% of Medicare OPPS,"$2,042.85 ",215% of Medicare OPPS,$294.86 ,12.84% of total billed charges,"$1,662.79 ",175% of Medicare OPPS,$950.16 ,100% of Medicare OPPS,"$1,837.12 ",80% of total billed charges,"$1,330.23 ",140% of Medicare OPPS,"$1,187.70 ",125% of Medicare OPPS,$294.86 ,12.84% of LA Medicaid fee schedule,$294.86 ,12.84% of LA Medicaid fee schedule,$950.16 ,100% of Medicare OPPS,"$1,129.00 ",100% of ASC Grouper,$950.16 ,100% of Medicare OPPS,$950.16 ,100% of Medicare OPPS,"$1,662.79 ",100% of Medicare OPPS,$950.16 ,100% of Medicare OPPS,$876.53 ,100% of custom fee schedule,"$2,066.76 ",90% of total billed charges,$294.86 ,"$2,066.76 ","$2,296.40 "
Outpatient Medical Services,ENDOSCOPY,45385,Removal of polyps or growths of large bowel using an endoscope,360,"$2,296.40 ","$1,520.26 ",100% of APC Rate,$950.16 ,100% of Medicare OPPS,"$1,607.48 ",70% of total billed charges,"$1,949.18 ",84.88% of total billed charges,"$1,302.33 ",139.08% of ASC,$950.16 ,100% of Medicare OPPS,"$1,722.30 ",75% of total billed charges,"$1,607.48 ",70% of total billed charges,"$1,615.27 ",170% of Medicare OPPS,"$2,042.85 ",215% of Medicare OPPS,$294.86 ,12.84% of total billed charges,"$1,662.79 ",175% of Medicare OPPS,$950.16 ,100% of Medicare OPPS,"$1,837.12 ",80% of total billed charges,"$1,330.23 ",140% of Medicare OPPS,"$1,187.70 ",125% of Medicare OPPS,$294.86 ,12.84% of LA Medicaid fee schedule,$294.86 ,12.84% of LA Medicaid fee schedule,$950.16 ,100% of Medicare OPPS,"$1,129.00 ",100% of ASC Grouper,$950.16 ,100% of Medicare OPPS,$950.16 ,100% of Medicare OPPS,"$1,662.79 ",100% of Medicare OPPS,$950.16 ,100% of Medicare OPPS,$876.53 ,100% of custom fee schedule,"$2,066.76 ",90% of total billed charges,$294.86 ,"$2,066.76 ","$2,296.40 "
Outpatient Medical Services,ENDOSCOPY,50590,Surgical procedures on the kidney to break up and remove kidney stones,360,"$15,066.52 ","$4,499.57 ",100% of APC Rate,"$2,812.23 ",100% of Medicare OPPS,"$10,546.56 ",70% of total billed charges,"$12,788.46 ",84.88% of total billed charges,"$4,845.09 ",139.08% of ASC,"$2,812.23 ",100% of Medicare OPPS,"$11,299.89 ",75% of total billed charges,"$2,000.00 ",70% of total billed charges,"$4,780.79 ",170% of Medicare OPPS,"$6,046.30 ",215% of Medicare OPPS,"$1,934.54 ",12.84% of total billed charges,"$4,921.41 ",175% of Medicare OPPS,"$2,812.23 ",100% of Medicare OPPS,"$12,053.22 ",80% of total billed charges,"$3,937.12 ",140% of Medicare OPPS,"$3,515.29 ",125% of Medicare OPPS,"$1,934.54 ",12.84% of LA Medicaid fee schedule,"$1,934.54 ",12.84% of LA Medicaid fee schedule,"$2,812.23 ",100% of Medicare OPPS,"$5,617.00 ",100% of ASC Grouper,"$2,812.23 ",100% of Medicare OPPS,"$2,812.23 ",100% of Medicare OPPS,"$4,921.41 ",100% of Medicare OPPS,"$2,812.23 ",100% of Medicare OPPS,"$3,558.21 ",100% of custom fee schedule,"$13,559.87 ",90% of total billed charges,"$1,934.54 ","$13,559.87 ","$15,066.52 "
Outpatient Medical Services,ENDOSCOPY,G0105,Colorectal cancer screening; colonoscopy on individual at high risk,360,"$1,757.58 ","$1,166.67 ",100% of APC Rate,$729.17 ,100% of Medicare OPPS,"$1,230.31 ",70% of total billed charges,"$1,491.83 ",84.88% of total billed charges,$987.44 ,139.08% of ASC,$729.17 ,100% of Medicare OPPS,"$1,318.19 ",75% of total billed charges,"$1,230.31 ",70% of total billed charges,"$1,239.58 ",170% of Medicare OPPS,"$1,567.71 ",215% of Medicare OPPS,$225.67 ,12.84% of total billed charges,"$1,276.04 ",175% of Medicare OPPS,$729.17 ,100% of Medicare OPPS,"$1,406.06 ",80% of total billed charges,"$1,020.83 ",140% of Medicare OPPS,$911.46 ,125% of Medicare OPPS,$225.67 ,12.84% of LA Medicaid fee schedule,$225.67 ,12.84% of LA Medicaid fee schedule,$729.17 ,100% of Medicare OPPS,$673.00 ,100% of ASC Grouper,$729.17 ,100% of Medicare OPPS,$729.17 ,100% of Medicare OPPS,"$1,276.04 ",100% of Medicare OPPS,$729.17 ,100% of Medicare OPPS,$769.34 ,100% of custom fee schedule,"$1,581.82 ",90% of total billed charges,$225.67 ,"$1,581.82 ","$1,757.58 "
Outpatient Medical Services,OUTPATIENT PROCEDURES,30117,removal of intranasal lesion,360,"$6,059.88 ","$3,994.05 ",100% of APC Rate,"$2,496.28 ",100% of Medicare OPPS,"$4,241.92 ",70% of total billed charges,"$5,143.63 ",84.88% of total billed charges,"$1,376.31 ",139.08% of ASC,"$2,496.28 ",100% of Medicare OPPS,"$4,544.91 ",75% of total billed charges,"$2,000.00 ",70% of total billed charges,"$4,243.68 ",170% of Medicare OPPS,"$5,367.01 ",215% of Medicare OPPS,$778.09 ,12.84% of total billed charges,"$4,368.49 ",175% of Medicare OPPS,"$2,496.28 ",100% of Medicare OPPS,"$4,847.90 ",80% of total billed charges,"$3,494.79 ",140% of Medicare OPPS,"$3,120.35 ",125% of Medicare OPPS,$778.09 ,12.84% of LA Medicaid fee schedule,$778.09 ,12.84% of LA Medicaid fee schedule,"$2,496.28 ",100% of Medicare OPPS,"$1,129.00 ",100% of ASC Grouper,"$2,496.28 ",100% of Medicare OPPS,"$2,496.28 ",100% of Medicare OPPS,"$4,368.49 ",100% of Medicare OPPS,"$2,496.28 ",100% of Medicare OPPS,"$1,448.71 ",100% of custom fee schedule,"$5,453.89 ",90% of total billed charges,$778.09 ,"$5,453.89 ","$6,059.88 "
Outpatient Medical Services,OUTPATIENT PROCEDURES,49652,laparoscopic ventral/abdominal hernia repair,360,"$11,206.60 ",N/A,Not covered by Contract,N/A,100% of Medicare OPPS,"$7,844.62 ",70% of total billed charges,"$9,512.16 ",84.88% of total billed charges,"$5,868.29 ",139.08% of ASC,N/A,100% of Medicare OPPS,"$8,404.95 ",75% of total billed charges,"$2,000.00 ",70% of total billed charges,"$1,306.16 ",170% of Medicare OPPS,N/A,215% of Medicare OPPS,"$1,438.93 ",12.84% of total billed charges,N/A,175% of Medicare OPPS,N/A,100% of Medicare OPPS,"$8,965.28 ",80% of total billed charges,N/A,140% of Medicare OPPS,N/A,125% of Medicare OPPS,"$1,438.93 ",12.84% of LA Medicaid fee schedule,"$1,438.93 ",12.84% of LA Medicaid fee schedule,N/A,100% of Medicare OPPS,"$5,617.00 ",100% of ASC Grouper,N/A,100% of Medicare OPPS,N/A,100% of Medicare OPPS,N/A,100% of Medicare OPPS,N/A,100% of Medicare OPPS,"$6,382.61 ",100% of custom fee schedule,"$10,085.94 ",90% of total billed charges,"$1,306.16 ","$10,085.94 ","$11,206.60 "
Outpatient Medical Services,OUTPATIENT PROCEDURES,52235,cystourethroscopy with fulguration and/or resection of medium bladder tumor,360,"$6,812.70 ","$4,499.57 ",100% of APC Rate,"$2,812.23 ",100% of Medicare OPPS,"$4,768.89 ",70% of total billed charges,"$5,782.62 ",84.88% of total billed charges,"$3,525.61 ",139.08% of ASC,"$2,812.23 ",100% of Medicare OPPS,"$5,109.53 ",75% of total billed charges,"$2,000.00 ",70% of total billed charges,"$4,780.79 ",170% of Medicare OPPS,"$6,046.30 ",215% of Medicare OPPS,$874.75 ,12.84% of total billed charges,"$4,921.41 ",175% of Medicare OPPS,"$2,812.23 ",100% of Medicare OPPS,"$5,450.16 ",80% of total billed charges,"$3,937.12 ",140% of Medicare OPPS,"$3,515.29 ",125% of Medicare OPPS,$874.75 ,12.84% of LA Medicaid fee schedule,$874.75 ,12.84% of LA Medicaid fee schedule,"$2,812.23 ",100% of Medicare OPPS,"$1,969.00 ",100% of ASC Grouper,"$2,812.23 ",100% of Medicare OPPS,"$2,812.23 ",100% of Medicare OPPS,"$4,921.41 ",100% of Medicare OPPS,"$2,812.23 ",100% of Medicare OPPS,"$2,387.87 ",100% of custom fee schedule,"$6,131.43 ",90% of total billed charges,$874.75 ,"$6,131.43 ","$6,812.70 "
Outpatient Medical Services,OUTPATIENT PROCEDURES,0191T,"insertion aqueous drainage device, initial",360,"$8,676.03 ",N/A,Not covered by Contract,N/A,100% of Medicare OPPS,"$6,073.22 ",70% of total billed charges,"$7,364.21 ",84.88% of total billed charges,"$4,338.02 ",50% of total billed charges,N/A,100% of Medicare OPPS,"$6,507.02 ",75% of total billed charges,"$2,000.00 ",70% of total billed charges,N/A,170% of Medicare OPPS,N/A,215% of Medicare OPPS,"$1,114.00 ",12.84% of total billed charges,N/A,175% of Medicare OPPS,N/A,100% of Medicare OPPS,"$6,940.82 ",80% of total billed charges,N/A,140% of Medicare OPPS,N/A,125% of Medicare OPPS,"$1,114.00 ",12.84% of LA Medicaid fee schedule,"$1,114.00 ",12.84% of LA Medicaid fee schedule,N/A,100% of Medicare OPPS,N/A,65% of total billed charges,N/A,100% of Medicare OPPS,N/A,100% of Medicare OPPS,N/A,100% of Medicare OPPS,N/A,100% of Medicare OPPS,"$3,613.20 ",100% of custom fee schedule,"$7,808.43 ",90% of total billed charges,"$1,114.00 ","$7,808.43 ","$8,676.03 "
Outpatient Medical Services,OUTPATIENT PROCEDURES,0376T,"insertion aqueous drainage device, each additional device",360,"$1,775.82 ",N/A,Not covered by Contract,N/A,100% of Medicare OPPS,"$1,243.07 ",70% of total billed charges,"$1,507.32 ",84.88% of total billed charges,$887.91 ,50% of total billed charges,N/A,100% of Medicare OPPS,"$1,331.87 ",75% of total billed charges,"$1,243.07 ",70% of total billed charges,N/A,170% of Medicare OPPS,N/A,215% of Medicare OPPS,$228.02 ,12.84% of total billed charges,N/A,175% of Medicare OPPS,N/A,100% of Medicare OPPS,"$1,420.66 ",80% of total billed charges,N/A,140% of Medicare OPPS,N/A,125% of Medicare OPPS,$228.02 ,12.84% of LA Medicaid fee schedule,$228.02 ,12.84% of LA Medicaid fee schedule,N/A,100% of Medicare OPPS,N/A,65% of total billed charges,N/A,100% of Medicare OPPS,N/A,100% of Medicare OPPS,N/A,100% of Medicare OPPS,N/A,100% of Medicare OPPS,N/A,100% of custom fee schedule,"$1,598.24 ",90% of total billed charges,$228.02 ,"$1,598.24 ","$1,775.82 "
Outpatient Medical Services,OUTPATIENT PROCEDURES,19120,REMOVAL OF BREAST LESION,360,"$6,992.98 ","$4,826.22 ",100% of APC Rate,"$3,016.39 ",100% of Medicare OPPS,"$4,895.09 ",70% of total billed charges,"$5,935.64 ",84.88% of total billed charges,"$3,718.00 ",139.08% of ASC,"$3,016.39 ",100% of Medicare OPPS,"$5,244.74 ",75% of total billed charges,"$2,000.00 ",70% of total billed charges,"$5,127.87 ",170% of Medicare OPPS,"$6,485.24 ",215% of Medicare OPPS,$897.90 ,12.84% of total billed charges,"$5,278.69 ",175% of Medicare OPPS,"$3,016.39 ",100% of Medicare OPPS,"$5,594.38 ",80% of total billed charges,"$4,222.95 ",140% of Medicare OPPS,"$3,770.49 ",125% of Medicare OPPS,$897.90 ,12.84% of LA Medicaid fee schedule,$897.90 ,12.84% of LA Medicaid fee schedule,"$3,016.39 ",100% of Medicare OPPS,"$1,969.00 ",100% of ASC Grouper,"$3,016.39 ",100% of Medicare OPPS,"$3,016.39 ",100% of Medicare OPPS,"$5,278.69 ",100% of Medicare OPPS,"$3,016.39 ",100% of Medicare OPPS,"$2,348.54 ",100% of custom fee schedule,"$6,293.68 ",90% of total billed charges,$897.90 ,"$6,485.24 ","$6,992.98 "
Outpatient Medical Services,OUTPATIENT PROCEDURES,19125,excision of breast lesion,360,"$6,992.98 ","$4,826.22 ",100% of APC Rate,"$3,016.39 ",100% of Medicare OPPS,"$4,895.09 ",70% of total billed charges,"$5,935.64 ",84.88% of total billed charges,"$3,224.79 ",139.08% of ASC,"$3,016.39 ",100% of Medicare OPPS,"$5,244.74 ",75% of total billed charges,"$2,000.00 ",70% of total billed charges,"$5,127.87 ",170% of Medicare OPPS,"$6,485.24 ",215% of Medicare OPPS,$897.90 ,12.84% of total billed charges,"$5,278.69 ",175% of Medicare OPPS,"$3,016.39 ",100% of Medicare OPPS,"$5,594.38 ",80% of total billed charges,"$4,222.95 ",140% of Medicare OPPS,"$3,770.49 ",125% of Medicare OPPS,$897.90 ,12.84% of LA Medicaid fee schedule,$897.90 ,12.84% of LA Medicaid fee schedule,"$3,016.39 ",100% of Medicare OPPS,"$1,969.00 ",100% of ASC Grouper,"$3,016.39 ",100% of Medicare OPPS,"$3,016.39 ",100% of Medicare OPPS,"$5,278.69 ",100% of Medicare OPPS,"$3,016.39 ",100% of Medicare OPPS,"$2,348.54 ",100% of custom fee schedule,"$6,293.68 ",90% of total billed charges,$897.90 ,"$6,485.24 ","$6,992.98 "
Outpatient Medical Services,OUTPATIENT PROCEDURES,20930,allograft for spine surgery,360,"$8,908.67 ",N/A,Not covered by Contract,N/A,100% of Medicare OPPS,"$6,236.07 ",70% of total billed charges,"$7,561.68 ",84.88% of total billed charges,N/A,139.08% of ASC,N/A,100% of Medicare OPPS,"$6,681.50 ",75% of total billed charges,"$2,000.00 ",70% of total billed charges,N/A,170% of Medicare OPPS,N/A,215% of Medicare OPPS,"$1,143.87 ",12.84% of total billed charges,N/A,175% of Medicare OPPS,N/A,100% of Medicare OPPS,"$7,126.94 ",80% of total billed charges,N/A,140% of Medicare OPPS,N/A,125% of Medicare OPPS,"$1,143.87 ",12.84% of LA Medicaid fee schedule,"$1,143.87 ",12.84% of LA Medicaid fee schedule,N/A,100% of Medicare OPPS,$490.00 ,100% of ASC Grouper,N/A,100% of Medicare OPPS,N/A,100% of Medicare OPPS,N/A,100% of Medicare OPPS,N/A,100% of Medicare OPPS,N/A,100% of custom fee schedule,"$8,017.80 ",90% of total billed charges,$490.00 ,"$8,017.80 ","$8,908.67 "
Outpatient Medical Services,OUTPATIENT PROCEDURES,22551,arthrodesis anterior interbody cervical below C2,360,"$27,271.65 ","$18,317.82 ",100% of APC Rate,"$11,448.64 ",100% of Medicare OPPS,"$19,090.16 ",70% of total billed charges,"$23,148.18 ",84.88% of total billed charges,"$13,797.38 ",139.08% of ASC,"$11,448.64 ",100% of Medicare OPPS,"$20,453.74 ",75% of total billed charges,"$2,000.00 ",70% of total billed charges,"$19,462.68 ",170% of Medicare OPPS,"$24,614.58 ",215% of Medicare OPPS,"$3,501.68 ",12.84% of total billed charges,"$20,035.13 ",175% of Medicare OPPS,"$11,448.64 ",100% of Medicare OPPS,"$21,817.32 ",80% of total billed charges,"$16,028.10 ",140% of Medicare OPPS,"$14,310.80 ",125% of Medicare OPPS,"$3,501.68 ",12.84% of LA Medicaid fee schedule,"$3,501.68 ",12.84% of LA Medicaid fee schedule,"$11,448.64 ",100% of Medicare OPPS,"$5,617.00 ",100% of ASC Grouper,"$11,448.64 ",100% of Medicare OPPS,"$11,448.64 ",100% of Medicare OPPS,"$20,035.13 ",100% of Medicare OPPS,"$11,448.64 ",100% of Medicare OPPS,"$4,762.27 ",100% of custom fee schedule,"$24,544.49 ",90% of total billed charges,"$2,000.00 ","$24,614.58 ","$27,271.65 "
Outpatient Medical Services,OUTPATIENT PROCEDURES,22853,insertion of device (spacer/cage) with anterior instrumentation intervertebral space,360,"$14,218.53 ",N/A,Not covered by Contract,N/A,100% of Medicare OPPS,"$9,952.97 ",70% of total billed charges,"$12,068.69 ",84.88% of total billed charges,N/A,139.08% of ASC,N/A,100% of Medicare OPPS,"$10,663.90 ",75% of total billed charges,"$2,000.00 ",70% of total billed charges,N/A,170% of Medicare OPPS,N/A,215% of Medicare OPPS,"$1,825.66 ",12.84% of total billed charges,N/A,175% of Medicare OPPS,N/A,100% of Medicare OPPS,"$11,374.82 ",80% of total billed charges,N/A,140% of Medicare OPPS,N/A,125% of Medicare OPPS,"$1,825.66 ",12.84% of LA Medicaid fee schedule,"$1,825.66 ",12.84% of LA Medicaid fee schedule,N/A,100% of Medicare OPPS,$490.00 ,100% of ASC Grouper,N/A,100% of Medicare OPPS,N/A,100% of Medicare OPPS,N/A,100% of Medicare OPPS,N/A,100% of Medicare OPPS,N/A,100% of custom fee schedule,"$12,796.68 ",90% of total billed charges,$490.00 ,"$12,796.68 ","$14,218.53 "
Outpatient Medical Services,OUTPATIENT PROCEDURES,26055,tendon sheath incision (trigger finger),360,"$3,083.43 ","$2,013.88 ",100% of APC Rate,"$1,258.67 ",100% of Medicare OPPS,"$2,158.40 ",70% of total billed charges,"$2,617.22 ",84.88% of total billed charges,"$1,595.87 ",139.08% of ASC,"$1,258.67 ",100% of Medicare OPPS,"$2,312.57 ",75% of total billed charges,"$2,000.00 ",70% of total billed charges,"$2,139.73 ",170% of Medicare OPPS,"$2,706.14 ",215% of Medicare OPPS,$395.91 ,12.84% of total billed charges,"$2,202.67 ",175% of Medicare OPPS,"$1,258.67 ",100% of Medicare OPPS,"$2,466.74 ",80% of total billed charges,"$1,762.14 ",140% of Medicare OPPS,"$1,573.34 ",125% of Medicare OPPS,$395.91 ,12.84% of LA Medicaid fee schedule,$395.91 ,12.84% of LA Medicaid fee schedule,"$1,258.67 ",100% of Medicare OPPS,"$1,129.00 ",100% of ASC Grouper,"$1,258.67 ",100% of Medicare OPPS,"$1,258.67 ",100% of Medicare OPPS,"$2,202.67 ",100% of Medicare OPPS,"$1,258.67 ",100% of Medicare OPPS,"$1,487.70 ",100% of custom fee schedule,"$2,775.09 ",90% of total billed charges,$395.91 ,"$2,775.09 ","$3,083.43 "
Outpatient Medical Services,OUTPATIENT PROCEDURES,27447,arthroplasty knee total,360,"$27,271.65 ","$18,317.82 ",100% of APC Rate,"$11,448.64 ",100% of Medicare OPPS,"$19,090.16 ",70% of total billed charges,"$23,148.18 ",84.88% of total billed charges,"$14,078.96 ",139.08% of ASC,"$11,448.64 ",100% of Medicare OPPS,"$20,453.74 ",75% of total billed charges,"$2,000.00 ",70% of total billed charges,"$19,462.68 ",170% of Medicare OPPS,"$24,614.58 ",215% of Medicare OPPS,"$3,501.68 ",12.84% of total billed charges,"$20,035.13 ",175% of Medicare OPPS,"$11,448.64 ",100% of Medicare OPPS,"$21,817.32 ",80% of total billed charges,"$16,028.10 ",140% of Medicare OPPS,"$14,310.80 ",125% of Medicare OPPS,"$3,501.68 ",12.84% of LA Medicaid fee schedule,"$3,501.68 ",12.84% of LA Medicaid fee schedule,"$11,448.64 ",100% of Medicare OPPS,"$6,662.00 ",100% of ASC Grouper,"$11,448.64 ",100% of Medicare OPPS,"$11,448.64 ",100% of Medicare OPPS,"$20,035.13 ",100% of Medicare OPPS,"$11,448.64 ",100% of Medicare OPPS,"$12,956.44 ",100% of custom fee schedule,"$24,544.49 ",90% of total billed charges,"$2,000.00 ","$24,614.58 ","$27,271.65 "
Outpatient Medical Services,OUTPATIENT PROCEDURES,29822,arthroscopy shoulder with debridement,360,"$6,268.05 ","$4,178.84 ",100% of APC Rate,"$2,611.78 ",100% of Medicare OPPS,"$4,387.64 ",70% of total billed charges,"$5,320.32 ",84.88% of total billed charges,"$3,127.14 ",139.08% of ASC,"$2,611.78 ",100% of Medicare OPPS,"$4,701.04 ",75% of total billed charges,"$2,000.00 ",70% of total billed charges,"$4,440.02 ",170% of Medicare OPPS,"$5,615.32 ",215% of Medicare OPPS,$804.82 ,12.84% of total billed charges,"$4,570.60 ",175% of Medicare OPPS,"$2,611.78 ",100% of Medicare OPPS,"$5,014.44 ",80% of total billed charges,"$3,656.49 ",140% of Medicare OPPS,"$3,264.72 ",125% of Medicare OPPS,$804.82 ,12.84% of LA Medicaid fee schedule,$804.82 ,12.84% of LA Medicaid fee schedule,"$2,611.78 ",100% of Medicare OPPS,"$2,939.00 ",100% of ASC Grouper,"$2,611.78 ",100% of Medicare OPPS,"$2,611.78 ",100% of Medicare OPPS,"$4,570.60 ",100% of Medicare OPPS,"$2,611.78 ",100% of Medicare OPPS,"$2,564.35 ",100% of custom fee schedule,"$5,641.25 ",90% of total billed charges,$804.82 ,"$5,641.25 ","$6,268.05 "
Outpatient Medical Services,OUTPATIENT PROCEDURES,29824,arthroscopy shoulder with distal claviculectomy (Mumford procedure),360,"$6,268.05 ","$4,178.84 ",100% of APC Rate,"$2,611.78 ",100% of Medicare OPPS,"$4,387.64 ",70% of total billed charges,"$5,320.32 ",84.88% of total billed charges,"$2,464.91 ",139.08% of ASC,"$2,611.78 ",100% of Medicare OPPS,"$4,701.04 ",75% of total billed charges,"$2,000.00 ",70% of total billed charges,"$4,440.02 ",170% of Medicare OPPS,"$5,615.32 ",215% of Medicare OPPS,$804.82 ,12.84% of total billed charges,"$4,570.60 ",175% of Medicare OPPS,"$2,611.78 ",100% of Medicare OPPS,"$5,014.44 ",80% of total billed charges,"$3,656.49 ",140% of Medicare OPPS,"$3,264.72 ",125% of Medicare OPPS,$804.82 ,12.84% of LA Medicaid fee schedule,$804.82 ,12.84% of LA Medicaid fee schedule,"$2,611.78 ",100% of Medicare OPPS,"$5,617.00 ",100% of ASC Grouper,"$2,611.78 ",100% of Medicare OPPS,"$2,611.78 ",100% of Medicare OPPS,"$4,570.60 ",100% of Medicare OPPS,"$2,611.78 ",100% of Medicare OPPS,"$5,066.44 ",100% of custom fee schedule,"$5,641.25 ",90% of total billed charges,$804.82 ,"$5,641.25 ","$6,268.05 "
Outpatient Medical Services,OUTPATIENT PROCEDURES,29826,Shaving of shoulder bone using an endoscope,360,"$18,079.70 ",N/A,Not covered by Contract,N/A,100% of Medicare OPPS,"$12,655.79 ",70% of total billed charges,"$15,346.05 ",84.88% of total billed charges,N/A,139.08% of ASC,N/A,100% of Medicare OPPS,"$13,559.78 ",75% of total billed charges,"$2,000.00 ",70% of total billed charges,N/A,170% of Medicare OPPS,N/A,215% of Medicare OPPS,"$2,321.43 ",12.84% of total billed charges,N/A,175% of Medicare OPPS,N/A,100% of Medicare OPPS,"$14,463.76 ",80% of total billed charges,N/A,140% of Medicare OPPS,N/A,125% of Medicare OPPS,"$2,321.43 ",12.84% of LA Medicaid fee schedule,"$2,321.43 ",12.84% of LA Medicaid fee schedule,N/A,100% of Medicare OPPS,$490.00 ,100% of ASC Grouper,N/A,100% of Medicare OPPS,N/A,100% of Medicare OPPS,N/A,100% of Medicare OPPS,N/A,100% of Medicare OPPS,N/A,100% of custom fee schedule,"$16,271.73 ",90% of total billed charges,$490.00 ,"$16,271.73 ","$18,079.70 "
Outpatient Medical Services,OUTPATIENT PROCEDURES,29880,Surgery to remove of all or part of a torn meniscus in both medial and lateral compartments,360,"$6,268.05 ","$4,178.84 ",100% of APC Rate,"$2,611.78 ",100% of Medicare OPPS,"$4,387.64 ",70% of total billed charges,"$5,320.32 ",84.88% of total billed charges,"$3,458.25 ",139.08% of ASC,"$2,611.78 ",100% of Medicare OPPS,"$4,701.04 ",75% of total billed charges,"$2,000.00 ",70% of total billed charges,"$4,440.02 ",170% of Medicare OPPS,"$5,615.32 ",215% of Medicare OPPS,$804.82 ,12.84% of total billed charges,"$4,570.60 ",175% of Medicare OPPS,"$2,611.78 ",100% of Medicare OPPS,"$5,014.44 ",80% of total billed charges,"$3,656.49 ",140% of Medicare OPPS,"$3,264.72 ",125% of Medicare OPPS,$804.82 ,12.84% of LA Medicaid fee schedule,$804.82 ,12.84% of LA Medicaid fee schedule,"$2,611.78 ",100% of Medicare OPPS,"$2,939.00 ",100% of ASC Grouper,"$2,611.78 ",100% of Medicare OPPS,"$2,611.78 ",100% of Medicare OPPS,"$4,570.60 ",100% of Medicare OPPS,"$2,611.78 ",100% of Medicare OPPS,"$2,564.35 ",100% of custom fee schedule,"$5,641.25 ",90% of total billed charges,$804.82 ,"$5,641.25 ","$6,268.05 "
Outpatient Medical Services,OUTPATIENT PROCEDURES,29881,Surgery to remove of all or part of a torn meniscus in one compartment,360,"$6,268.05 ","$4,178.84 ",100% of APC Rate,"$2,611.78 ",100% of Medicare OPPS,"$4,387.64 ",70% of total billed charges,"$5,320.32 ",84.88% of total billed charges,"$3,458.25 ",139.08% of ASC,"$2,611.78 ",100% of Medicare OPPS,"$4,701.04 ",75% of total billed charges,"$2,000.00 ",70% of total billed charges,"$4,440.02 ",170% of Medicare OPPS,"$5,615.32 ",215% of Medicare OPPS,$804.82 ,12.84% of total billed charges,"$4,570.60 ",175% of Medicare OPPS,"$2,611.78 ",100% of Medicare OPPS,"$5,014.44 ",80% of total billed charges,"$3,656.49 ",140% of Medicare OPPS,"$3,264.72 ",125% of Medicare OPPS,$804.82 ,12.84% of LA Medicaid fee schedule,$804.82 ,12.84% of LA Medicaid fee schedule,"$2,611.78 ",100% of Medicare OPPS,"$2,939.00 ",100% of ASC Grouper,"$2,611.78 ",100% of Medicare OPPS,"$2,611.78 ",100% of Medicare OPPS,"$4,570.60 ",100% of Medicare OPPS,"$2,611.78 ",100% of Medicare OPPS,"$2,564.35 ",100% of custom fee schedule,"$5,641.25 ",90% of total billed charges,$804.82 ,"$5,641.25 ","$6,268.05 "
Outpatient Medical Services,OUTPATIENT PROCEDURES,30140,sinus surgery with submucosal resection of inferior turbinate,360,"$6,059.88 ","$3,994.05 ",100% of APC Rate,"$2,496.28 ",100% of Medicare OPPS,"$4,241.92 ",70% of total billed charges,"$5,143.63 ",84.88% of total billed charges,"$1,376.31 ",139.08% of ASC,"$2,496.28 ",100% of Medicare OPPS,"$4,544.91 ",75% of total billed charges,"$2,000.00 ",70% of total billed charges,"$4,243.68 ",170% of Medicare OPPS,"$5,367.01 ",215% of Medicare OPPS,$778.09 ,12.84% of total billed charges,"$4,368.49 ",175% of Medicare OPPS,"$2,496.28 ",100% of Medicare OPPS,"$4,847.90 ",80% of total billed charges,"$3,494.79 ",140% of Medicare OPPS,"$3,120.35 ",125% of Medicare OPPS,$778.09 ,12.84% of LA Medicaid fee schedule,$778.09 ,12.84% of LA Medicaid fee schedule,"$2,496.28 ",100% of Medicare OPPS,"$1,969.00 ",100% of ASC Grouper,"$2,496.28 ",100% of Medicare OPPS,"$2,496.28 ",100% of Medicare OPPS,"$4,368.49 ",100% of Medicare OPPS,"$2,496.28 ",100% of Medicare OPPS,"$2,211.77 ",100% of custom fee schedule,"$5,453.89 ",90% of total billed charges,$778.09 ,"$5,453.89 ","$6,059.88 "
Outpatient Medical Services,OUTPATIENT PROCEDURES,30520,Repair procedures of the nose,360,"$6,059.88 ","$3,994.05 ",100% of APC Rate,"$2,496.28 ",100% of Medicare OPPS,"$4,241.92 ",70% of total billed charges,"$5,143.63 ",84.88% of total billed charges,"$1,376.31 ",139.08% of ASC,"$2,496.28 ",100% of Medicare OPPS,"$4,544.91 ",75% of total billed charges,"$2,000.00 ",70% of total billed charges,"$4,243.68 ",170% of Medicare OPPS,"$5,367.01 ",215% of Medicare OPPS,$778.09 ,12.84% of total billed charges,"$4,368.49 ",175% of Medicare OPPS,"$2,496.28 ",100% of Medicare OPPS,"$4,847.90 ",80% of total billed charges,"$3,494.79 ",140% of Medicare OPPS,"$3,120.35 ",125% of Medicare OPPS,$778.09 ,12.84% of LA Medicaid fee schedule,$778.09 ,12.84% of LA Medicaid fee schedule,"$2,496.28 ",100% of Medicare OPPS,"$1,969.00 ",100% of ASC Grouper,"$2,496.28 ",100% of Medicare OPPS,"$2,496.28 ",100% of Medicare OPPS,"$4,368.49 ",100% of Medicare OPPS,"$2,496.28 ",100% of Medicare OPPS,"$2,211.77 ",100% of custom fee schedule,"$5,453.89 ",90% of total billed charges,$778.09 ,"$5,453.89 ","$6,059.88 "
Outpatient Medical Services,OUTPATIENT PROCEDURES,30802,ablation inferior turbinates,360,"$2,995.83 ","$1,948.76 ",100% of APC Rate,"$1,217.98 ",100% of Medicare OPPS,"$2,097.08 ",70% of total billed charges,"$2,542.86 ",84.88% of total billed charges,"$1,582.98 ",139.08% of ASC,"$1,217.98 ",100% of Medicare OPPS,"$2,246.87 ",75% of total billed charges,"$2,000.00 ",70% of total billed charges,"$2,070.56 ",170% of Medicare OPPS,"$2,618.65 ",215% of Medicare OPPS,$384.66 ,12.84% of total billed charges,"$2,131.46 ",175% of Medicare OPPS,"$1,217.98 ",100% of Medicare OPPS,"$2,396.66 ",80% of total billed charges,"$1,705.17 ",140% of Medicare OPPS,"$1,522.47 ",125% of Medicare OPPS,$384.66 ,12.84% of LA Medicaid fee schedule,$384.66 ,12.84% of LA Medicaid fee schedule,"$1,217.98 ",100% of Medicare OPPS,"$1,129.00 ",100% of ASC Grouper,"$1,217.98 ",100% of Medicare OPPS,"$1,217.98 ",100% of Medicare OPPS,"$2,131.46 ",100% of Medicare OPPS,"$1,217.98 ",100% of Medicare OPPS,"$1,448.71 ",100% of custom fee schedule,"$2,696.25 ",90% of total billed charges,$384.66 ,"$2,696.25 ","$2,995.83 "
Outpatient Medical Services,OUTPATIENT PROCEDURES,31240,sinus surgery with resection concha bullosa,360,"$3,313.83 ","$2,244.16 ",100% of APC Rate,"$1,402.60 ",100% of Medicare OPPS,"$2,319.68 ",70% of total billed charges,"$2,812.78 ",84.88% of total billed charges,$828.46 ,139.08% of ASC,"$1,402.60 ",100% of Medicare OPPS,"$2,485.37 ",75% of total billed charges,"$2,000.00 ",70% of total billed charges,"$2,384.42 ",170% of Medicare OPPS,"$3,015.60 ",215% of Medicare OPPS,$425.50 ,12.84% of total billed charges,"$2,454.56 ",175% of Medicare OPPS,"$1,402.60 ",100% of Medicare OPPS,"$2,651.06 ",80% of total billed charges,"$1,963.65 ",140% of Medicare OPPS,"$1,753.26 ",125% of Medicare OPPS,$425.50 ,12.84% of LA Medicaid fee schedule,$425.50 ,12.84% of LA Medicaid fee schedule,"$1,402.60 ",100% of Medicare OPPS,"$1,969.00 ",100% of ASC Grouper,"$1,402.60 ",100% of Medicare OPPS,"$1,402.60 ",100% of Medicare OPPS,"$2,454.56 ",100% of Medicare OPPS,"$1,402.60 ",100% of Medicare OPPS,"$2,236.93 ",100% of custom fee schedule,"$2,982.45 ",90% of total billed charges,$425.50 ,"$3,015.60 ","$3,313.83 "
Outpatient Medical Services,OUTPATIENT PROCEDURES,31253,sinus surgery with ethmoidectomy total with removal of tissue when performed,360,"$12,894.80 ","$8,685.86 ",100% of APC Rate,"$5,428.66 ",100% of Medicare OPPS,"$9,026.36 ",70% of total billed charges,"$10,945.11 ",84.88% of total billed charges,"$6,765.09 ",139.08% of ASC,"$5,428.66 ",100% of Medicare OPPS,"$9,671.10 ",75% of total billed charges,"$2,000.00 ",70% of total billed charges,"$9,228.73 ",170% of Medicare OPPS,"$11,671.63 ",215% of Medicare OPPS,"$1,655.69 ",12.84% of total billed charges,"$9,500.16 ",175% of Medicare OPPS,"$5,428.66 ",100% of Medicare OPPS,"$10,315.84 ",80% of total billed charges,"$7,600.13 ",140% of Medicare OPPS,"$6,785.83 ",125% of Medicare OPPS,"$1,655.69 ",12.84% of LA Medicaid fee schedule,"$1,655.69 ",12.84% of LA Medicaid fee schedule,"$5,428.66 ",100% of Medicare OPPS,"$2,939.00 ",100% of ASC Grouper,"$5,428.66 ",100% of Medicare OPPS,"$5,428.66 ",100% of Medicare OPPS,"$9,500.16 ",100% of Medicare OPPS,"$5,428.66 ",100% of Medicare OPPS,"$6,225.70 ",100% of custom fee schedule,"$11,605.32 ",90% of total billed charges,"$1,655.69 ","$11,671.63 ","$12,894.80 "
Outpatient Medical Services,OUTPATIENT PROCEDURES,31255,sinus surgery with ethmoidectomy total,360,"$12,894.80 ","$8,685.86 ",100% of APC Rate,"$5,428.66 ",100% of Medicare OPPS,"$9,026.36 ",70% of total billed charges,"$10,945.11 ",84.88% of total billed charges,"$3,044.29 ",139.08% of ASC,"$5,428.66 ",100% of Medicare OPPS,"$9,671.10 ",75% of total billed charges,"$2,000.00 ",70% of total billed charges,"$9,228.73 ",170% of Medicare OPPS,"$11,671.63 ",215% of Medicare OPPS,"$1,655.69 ",12.84% of total billed charges,"$9,500.16 ",175% of Medicare OPPS,"$5,428.66 ",100% of Medicare OPPS,"$10,315.84 ",80% of total billed charges,"$7,600.13 ",140% of Medicare OPPS,"$6,785.83 ",125% of Medicare OPPS,"$1,655.69 ",12.84% of LA Medicaid fee schedule,"$1,655.69 ",12.84% of LA Medicaid fee schedule,"$5,428.66 ",100% of Medicare OPPS,"$2,939.00 ",100% of ASC Grouper,"$5,428.66 ",100% of Medicare OPPS,"$5,428.66 ",100% of Medicare OPPS,"$9,500.16 ",100% of Medicare OPPS,"$5,428.66 ",100% of Medicare OPPS,"$3,630.32 ",100% of custom fee schedule,"$11,605.32 ",90% of total billed charges,"$1,655.69 ","$11,671.63 ","$12,894.80 "
Outpatient Medical Services,OUTPATIENT PROCEDURES,31256,sinus w/maxillary antrostomy with removal of tissue,360,"$6,860.73 ","$4,680.01 ",100% of APC Rate,"$2,925.01 ",100% of Medicare OPPS,"$4,802.51 ",70% of total billed charges,"$5,823.39 ",84.88% of total billed charges,"$1,637.61 ",139.08% of ASC,"$2,925.01 ",100% of Medicare OPPS,"$5,145.55 ",75% of total billed charges,"$2,000.00 ",70% of total billed charges,"$4,972.51 ",170% of Medicare OPPS,"$6,288.76 ",215% of Medicare OPPS,$880.92 ,12.84% of total billed charges,"$5,118.76 ",175% of Medicare OPPS,"$2,925.01 ",100% of Medicare OPPS,"$5,488.58 ",80% of total billed charges,"$4,095.01 ",140% of Medicare OPPS,"$3,656.26 ",125% of Medicare OPPS,$880.92 ,12.84% of LA Medicaid fee schedule,$880.92 ,12.84% of LA Medicaid fee schedule,"$2,925.01 ",100% of Medicare OPPS,"$1,969.00 ",100% of ASC Grouper,"$2,925.01 ",100% of Medicare OPPS,"$2,925.01 ",100% of Medicare OPPS,"$5,118.76 ",100% of Medicare OPPS,"$2,925.01 ",100% of Medicare OPPS,"$2,236.93 ",100% of custom fee schedule,"$6,174.66 ",90% of total billed charges,$880.92 ,"$6,288.76 ","$6,860.73 "
Outpatient Medical Services,OUTPATIENT PROCEDURES,31267,sinus w/antrostomy maxillary sinus,360,"$12,894.80 ","$8,685.86 ",100% of APC Rate,"$5,428.66 ",100% of Medicare OPPS,"$9,026.36 ",70% of total billed charges,"$10,945.11 ",84.88% of total billed charges,"$3,044.29 ",139.08% of ASC,"$5,428.66 ",100% of Medicare OPPS,"$9,671.10 ",75% of total billed charges,"$2,000.00 ",70% of total billed charges,"$9,228.73 ",170% of Medicare OPPS,"$11,671.63 ",215% of Medicare OPPS,"$1,655.69 ",12.84% of total billed charges,"$9,500.16 ",175% of Medicare OPPS,"$5,428.66 ",100% of Medicare OPPS,"$10,315.84 ",80% of total billed charges,"$7,600.13 ",140% of Medicare OPPS,"$6,785.83 ",125% of Medicare OPPS,"$1,655.69 ",12.84% of LA Medicaid fee schedule,"$1,655.69 ",12.84% of LA Medicaid fee schedule,"$5,428.66 ",100% of Medicare OPPS,"$1,969.00 ",100% of ASC Grouper,"$5,428.66 ",100% of Medicare OPPS,"$5,428.66 ",100% of Medicare OPPS,"$9,500.16 ",100% of Medicare OPPS,"$5,428.66 ",100% of Medicare OPPS,"$2,236.93 ",100% of custom fee schedule,"$11,605.32 ",90% of total billed charges,"$1,655.69 ","$11,671.63 ","$12,894.80 "
Outpatient Medical Services,OUTPATIENT PROCEDURES,31276,sinus surgery with frontal sinus exploration and tissue removal when performed,360,"$12,894.80 ","$8,685.86 ",100% of APC Rate,"$5,428.66 ",100% of Medicare OPPS,"$9,026.36 ",70% of total billed charges,"$10,945.11 ",84.88% of total billed charges,"$3,044.29 ",139.08% of ASC,"$5,428.66 ",100% of Medicare OPPS,"$9,671.10 ",75% of total billed charges,"$2,000.00 ",70% of total billed charges,"$9,228.73 ",170% of Medicare OPPS,"$11,671.63 ",215% of Medicare OPPS,"$1,655.69 ",12.84% of total billed charges,"$9,500.16 ",175% of Medicare OPPS,"$5,428.66 ",100% of Medicare OPPS,"$10,315.84 ",80% of total billed charges,"$7,600.13 ",140% of Medicare OPPS,"$6,785.83 ",125% of Medicare OPPS,"$1,655.69 ",12.84% of LA Medicaid fee schedule,"$1,655.69 ",12.84% of LA Medicaid fee schedule,"$5,428.66 ",100% of Medicare OPPS,"$2,939.00 ",100% of ASC Grouper,"$5,428.66 ",100% of Medicare OPPS,"$5,428.66 ",100% of Medicare OPPS,"$9,500.16 ",100% of Medicare OPPS,"$5,428.66 ",100% of Medicare OPPS,"$3,630.32 ",100% of custom fee schedule,"$11,605.32 ",90% of total billed charges,"$1,655.69 ","$11,671.63 ","$12,894.80 "
Outpatient Medical Services,OUTPATIENT PROCEDURES,36561,insertion of infusaport,360,"$6,337.30 ","$4,182.09 ",100% of APC Rate,"$2,613.80 ",100% of Medicare OPPS,"$4,436.11 ",70% of total billed charges,"$5,379.10 ",84.88% of total billed charges,"$3,466.90 ",139.08% of ASC,"$2,613.80 ",100% of Medicare OPPS,"$4,752.98 ",75% of total billed charges,"$2,000.00 ",70% of total billed charges,"$4,443.46 ",170% of Medicare OPPS,"$5,619.68 ",215% of Medicare OPPS,$813.71 ,12.84% of total billed charges,"$4,574.14 ",175% of Medicare OPPS,"$2,613.80 ",100% of Medicare OPPS,"$5,069.84 ",80% of total billed charges,"$3,659.32 ",140% of Medicare OPPS,"$3,267.25 ",125% of Medicare OPPS,$813.71 ,12.84% of LA Medicaid fee schedule,$813.71 ,12.84% of LA Medicaid fee schedule,"$2,613.80 ",100% of Medicare OPPS,"$2,939.00 ",100% of ASC Grouper,"$2,613.80 ",100% of Medicare OPPS,"$2,613.80 ",100% of Medicare OPPS,"$4,574.14 ",100% of Medicare OPPS,"$2,613.80 ",100% of Medicare OPPS,"$2,791.28 ",100% of custom fee schedule,"$5,703.57 ",90% of total billed charges,$813.71 ,"$5,703.57 ","$6,337.30 "
Outpatient Medical Services,OUTPATIENT PROCEDURES,42820,Removal of tonsils and adenoid glands patient younger than age 12,360,"$11,263.30 ","$7,496.21 ",100% of APC Rate,"$4,685.13 ",100% of Medicare OPPS,"$7,884.31 ",70% of total billed charges,"$9,560.29 ",84.88% of total billed charges,"$5,913.70 ",139.08% of ASC,"$4,685.13 ",100% of Medicare OPPS,"$8,447.48 ",75% of total billed charges,"$2,000.00 ",70% of total billed charges,"$7,964.72 ",170% of Medicare OPPS,"$10,073.03 ",215% of Medicare OPPS,"$1,446.21 ",12.84% of total billed charges,"$8,198.98 ",175% of Medicare OPPS,"$4,685.13 ",100% of Medicare OPPS,"$9,010.64 ",80% of total billed charges,"$6,559.18 ",140% of Medicare OPPS,"$5,856.41 ",125% of Medicare OPPS,"$1,446.21 ",12.84% of LA Medicaid fee schedule,"$1,446.21 ",12.84% of LA Medicaid fee schedule,"$4,685.13 ",100% of Medicare OPPS,"$1,969.00 ",100% of ASC Grouper,"$4,685.13 ",100% of Medicare OPPS,"$4,685.13 ",100% of Medicare OPPS,"$8,198.98 ",100% of Medicare OPPS,"$4,685.13 ",100% of Medicare OPPS,"$2,211.77 ",100% of custom fee schedule,"$10,136.97 ",90% of total billed charges,"$1,446.21 ","$10,136.97 ","$11,263.30 "
Outpatient Medical Services,OUTPATIENT PROCEDURES,42821,T & A >12 years of age,360,"$6,059.88 ","$3,994.05 ",100% of APC Rate,"$2,496.28 ",100% of Medicare OPPS,"$4,241.92 ",70% of total billed charges,"$5,143.63 ",84.88% of total billed charges,"$2,997.29 ",139.08% of ASC,"$2,496.28 ",100% of Medicare OPPS,"$4,544.91 ",75% of total billed charges,"$2,000.00 ",70% of total billed charges,"$4,243.68 ",170% of Medicare OPPS,"$5,367.01 ",215% of Medicare OPPS,$778.09 ,12.84% of total billed charges,"$4,368.49 ",175% of Medicare OPPS,"$2,496.28 ",100% of Medicare OPPS,"$4,847.90 ",80% of total billed charges,"$3,494.79 ",140% of Medicare OPPS,"$3,120.35 ",125% of Medicare OPPS,$778.09 ,12.84% of LA Medicaid fee schedule,$778.09 ,12.84% of LA Medicaid fee schedule,"$2,496.28 ",100% of Medicare OPPS,"$1,969.00 ",100% of ASC Grouper,"$2,496.28 ",100% of Medicare OPPS,"$2,496.28 ",100% of Medicare OPPS,"$4,368.49 ",100% of Medicare OPPS,"$2,496.28 ",100% of Medicare OPPS,"$2,211.77 ",100% of custom fee schedule,"$5,453.89 ",90% of total billed charges,$778.09 ,"$5,453.89 ","$6,059.88 "
Outpatient Medical Services,OUTPATIENT PROCEDURES,42830,Primary removal of the adenoids,360,"$6,059.88 ","$3,994.05 ",100% of APC Rate,"$2,496.28 ",100% of Medicare OPPS,"$4,241.92 ",70% of total billed charges,"$5,143.63 ",84.88% of total billed charges,"$2,324.43 ",139.08% of ASC,"$2,496.28 ",100% of Medicare OPPS,"$4,544.91 ",75% of total billed charges,"$2,000.00 ",70% of total billed charges,"$4,243.68 ",170% of Medicare OPPS,"$5,367.01 ",215% of Medicare OPPS,$778.09 ,12.84% of total billed charges,"$4,368.49 ",175% of Medicare OPPS,"$2,496.28 ",100% of Medicare OPPS,"$4,847.90 ",80% of total billed charges,"$3,494.79 ",140% of Medicare OPPS,"$3,120.35 ",125% of Medicare OPPS,$778.09 ,12.84% of LA Medicaid fee schedule,$778.09 ,12.84% of LA Medicaid fee schedule,"$2,496.28 ",100% of Medicare OPPS,"$1,969.00 ",100% of ASC Grouper,"$2,496.28 ",100% of Medicare OPPS,"$2,496.28 ",100% of Medicare OPPS,"$4,368.49 ",100% of Medicare OPPS,"$2,496.28 ",100% of Medicare OPPS,"$4,240.49 ",100% of custom fee schedule,"$5,453.89 ",90% of total billed charges,$778.09 ,"$5,453.89 ","$6,059.88 "
Outpatient Medical Services,OUTPATIENT PROCEDURES,47562,Removal of gallbladder using an endoscope,360,"$11,206.60 ","$7,317.19 ",100% of APC Rate,"$4,573.22 ",100% of Medicare OPPS,"$7,844.62 ",70% of total billed charges,"$9,512.16 ",84.88% of total billed charges,"$6,118.00 ",139.08% of ASC,"$4,573.22 ",100% of Medicare OPPS,"$8,404.95 ",75% of total billed charges,"$2,000.00 ",70% of total billed charges,"$7,774.51 ",170% of Medicare OPPS,"$9,832.46 ",215% of Medicare OPPS,"$1,438.93 ",12.84% of total billed charges,"$8,003.17 ",175% of Medicare OPPS,"$4,573.22 ",100% of Medicare OPPS,"$8,965.28 ",80% of total billed charges,"$6,402.54 ",140% of Medicare OPPS,"$5,716.55 ",125% of Medicare OPPS,"$1,438.93 ",12.84% of LA Medicaid fee schedule,"$1,438.93 ",12.84% of LA Medicaid fee schedule,"$4,573.22 ",100% of Medicare OPPS,"$5,617.00 ",100% of ASC Grouper,"$4,573.22 ",100% of Medicare OPPS,"$4,573.22 ",100% of Medicare OPPS,"$8,003.17 ",100% of Medicare OPPS,"$4,573.22 ",100% of Medicare OPPS,"$4,340.18 ",100% of custom fee schedule,"$10,085.94 ",90% of total billed charges,"$1,438.93 ","$10,085.94 ","$11,206.60 "
Outpatient Medical Services,OUTPATIENT PROCEDURES,49505,Repair of groin hernia patient age 5 years or older,360,"$7,049.83 ","$4,972.41 ",100% of APC Rate,"$3,107.76 ",100% of Medicare OPPS,"$4,934.88 ",70% of total billed charges,"$5,983.90 ",84.88% of total billed charges,"$3,805.91 ",139.08% of ASC,"$3,107.76 ",100% of Medicare OPPS,"$5,287.37 ",75% of total billed charges,"$2,000.00 ",70% of total billed charges,"$5,283.19 ",170% of Medicare OPPS,"$6,681.67 ",215% of Medicare OPPS,$905.20 ,12.84% of total billed charges,"$5,438.57 ",175% of Medicare OPPS,"$3,107.76 ",100% of Medicare OPPS,"$5,639.86 ",80% of total billed charges,"$4,350.85 ",140% of Medicare OPPS,"$3,884.69 ",125% of Medicare OPPS,$905.20 ,12.84% of LA Medicaid fee schedule,$905.20 ,12.84% of LA Medicaid fee schedule,"$3,107.76 ",100% of Medicare OPPS,"$2,939.00 ",100% of ASC Grouper,"$3,107.76 ",100% of Medicare OPPS,"$3,107.76 ",100% of Medicare OPPS,"$5,438.57 ",100% of Medicare OPPS,"$3,107.76 ",100% of Medicare OPPS,"$3,092.48 ",100% of custom fee schedule,"$6,344.85 ",90% of total billed charges,$905.20 ,"$6,681.67 ","$7,049.83 "
Outpatient Medical Services,OUTPATIENT PROCEDURES,49650,Inguinal hernia repair done by laparoscope,360,"$11,206.60 ","$7,317.19 ",100% of APC Rate,"$4,573.22 ",100% of Medicare OPPS,"$7,844.62 ",70% of total billed charges,"$9,512.16 ",84.88% of total billed charges,"$5,868.29 ",139.08% of ASC,"$4,573.22 ",100% of Medicare OPPS,"$8,404.95 ",75% of total billed charges,"$2,000.00 ",70% of total billed charges,"$7,774.51 ",170% of Medicare OPPS,"$9,832.46 ",215% of Medicare OPPS,"$1,438.93 ",12.84% of total billed charges,"$8,003.17 ",175% of Medicare OPPS,"$4,573.22 ",100% of Medicare OPPS,"$8,965.28 ",80% of total billed charges,"$6,402.54 ",140% of Medicare OPPS,"$5,716.55 ",125% of Medicare OPPS,"$1,438.93 ",12.84% of LA Medicaid fee schedule,"$1,438.93 ",12.84% of LA Medicaid fee schedule,"$4,573.22 ",100% of Medicare OPPS,"$5,617.00 ",100% of ASC Grouper,"$4,573.22 ",100% of Medicare OPPS,"$4,573.22 ",100% of Medicare OPPS,"$8,003.17 ",100% of Medicare OPPS,"$4,573.22 ",100% of Medicare OPPS,"$4,340.18 ",100% of custom fee schedule,"$10,085.94 ",90% of total billed charges,"$1,438.93 ","$10,085.94 ","$11,206.60 "
Outpatient Medical Services,OUTPATIENT PROCEDURES,52310,Removing an indwelling ureteral stent by cystoscopy,360,"$3,970.68 ","$2,604.00 ",100% of APC Rate,"$1,627.51 ",100% of Medicare OPPS,"$2,779.48 ",70% of total billed charges,"$3,370.31 ",84.88% of total billed charges,"$2,311.19 ",139.08% of ASC,"$1,627.51 ",100% of Medicare OPPS,"$2,978.01 ",75% of total billed charges,"$2,000.00 ",70% of total billed charges,"$2,766.76 ",170% of Medicare OPPS,"$3,499.14 ",215% of Medicare OPPS,$509.84 ,12.84% of total billed charges,"$2,848.14 ",175% of Medicare OPPS,"$1,627.51 ",100% of Medicare OPPS,"$3,176.54 ",80% of total billed charges,"$2,278.51 ",140% of Medicare OPPS,"$2,034.38 ",125% of Medicare OPPS,$509.84 ,12.84% of LA Medicaid fee schedule,$509.84 ,12.84% of LA Medicaid fee schedule,"$1,627.51 ",100% of Medicare OPPS,"$1,129.00 ",100% of ASC Grouper,"$1,627.51 ",100% of Medicare OPPS,"$1,627.51 ",100% of Medicare OPPS,"$2,848.14 ",100% of Medicare OPPS,"$1,627.51 ",100% of Medicare OPPS,"$1,433.21 ",100% of custom fee schedule,"$3,573.61 ",90% of total billed charges,$509.84 ,"$3,573.61 ","$3,970.68 "
Outpatient Medical Services,OUTPATIENT PROCEDURES,52332,Ureteral stents inserted internally between the bladder and the kidney and will remain within the patient for a defined period of time,360,"$6,812.70 ","$4,499.57 ",100% of APC Rate,"$2,812.23 ",100% of Medicare OPPS,"$4,768.89 ",70% of total billed charges,"$5,782.62 ",84.88% of total billed charges,"$3,188.06 ",139.08% of ASC,"$2,812.23 ",100% of Medicare OPPS,"$5,109.53 ",75% of total billed charges,"$2,000.00 ",70% of total billed charges,"$4,780.79 ",170% of Medicare OPPS,"$6,046.30 ",215% of Medicare OPPS,$874.75 ,12.84% of total billed charges,"$4,921.41 ",175% of Medicare OPPS,"$2,812.23 ",100% of Medicare OPPS,"$5,450.16 ",80% of total billed charges,"$3,937.12 ",140% of Medicare OPPS,"$3,515.29 ",125% of Medicare OPPS,$874.75 ,12.84% of LA Medicaid fee schedule,$874.75 ,12.84% of LA Medicaid fee schedule,"$2,812.23 ",100% of Medicare OPPS,"$1,969.00 ",100% of ASC Grouper,"$2,812.23 ",100% of Medicare OPPS,"$2,812.23 ",100% of Medicare OPPS,"$4,921.41 ",100% of Medicare OPPS,"$2,812.23 ",100% of Medicare OPPS,"$2,387.87 ",100% of custom fee schedule,"$6,131.43 ",90% of total billed charges,$874.75 ,"$6,131.43 ","$6,812.70 "
Outpatient Medical Services,OUTPATIENT PROCEDURES,52601,TURP,360,"$9,774.80 ","$6,601.25 ",100% of APC Rate,"$4,125.78 ",100% of Medicare OPPS,"$6,842.36 ",70% of total billed charges,"$8,296.85 ",84.88% of total billed charges,"$5,051.26 ",139.08% of ASC,"$4,125.78 ",100% of Medicare OPPS,"$7,331.10 ",75% of total billed charges,"$2,000.00 ",70% of total billed charges,"$7,013.83 ",170% of Medicare OPPS,"$8,870.43 ",215% of Medicare OPPS,"$1,255.08 ",12.84% of total billed charges,"$7,220.12 ",175% of Medicare OPPS,"$4,125.78 ",100% of Medicare OPPS,"$7,819.84 ",80% of total billed charges,"$5,776.09 ",140% of Medicare OPPS,"$5,157.22 ",125% of Medicare OPPS,"$1,255.08 ",12.84% of LA Medicaid fee schedule,"$1,255.08 ",12.84% of LA Medicaid fee schedule,"$4,125.78 ",100% of Medicare OPPS,"$3,733.00 ",100% of ASC Grouper,"$4,125.78 ",100% of Medicare OPPS,"$4,125.78 ",100% of Medicare OPPS,"$7,220.12 ",100% of Medicare OPPS,"$4,125.78 ",100% of Medicare OPPS,"$3,455.75 ",100% of custom fee schedule,"$8,797.32 ",90% of total billed charges,"$1,255.08 ","$8,870.43 ","$9,774.80 "
Outpatient Medical Services,OUTPATIENT PROCEDURES,54161,circumcision > 28 days of age,360,"$3,970.68 ","$2,604.00 ",100% of APC Rate,"$1,627.51 ",100% of Medicare OPPS,"$2,779.48 ",70% of total billed charges,"$3,370.31 ",84.88% of total billed charges,"$2,216.85 ",139.08% of ASC,"$1,627.51 ",100% of Medicare OPPS,"$2,978.01 ",75% of total billed charges,"$2,000.00 ",70% of total billed charges,"$2,766.76 ",170% of Medicare OPPS,"$3,499.14 ",215% of Medicare OPPS,$509.84 ,12.84% of total billed charges,"$2,848.14 ",175% of Medicare OPPS,"$1,627.51 ",100% of Medicare OPPS,"$3,176.54 ",80% of total billed charges,"$2,278.51 ",140% of Medicare OPPS,"$2,034.38 ",125% of Medicare OPPS,$509.84 ,12.84% of LA Medicaid fee schedule,$509.84 ,12.84% of LA Medicaid fee schedule,"$1,627.51 ",100% of Medicare OPPS,"$1,969.00 ",100% of ASC Grouper,"$1,627.51 ",100% of Medicare OPPS,"$1,627.51 ",100% of Medicare OPPS,"$2,848.14 ",100% of Medicare OPPS,"$1,627.51 ",100% of Medicare OPPS,"$2,064.27 ",100% of custom fee schedule,"$3,573.61 ",90% of total billed charges,$509.84 ,"$3,573.61 ","$3,970.68 "
Outpatient Medical Services,OUTPATIENT PROCEDURES,55700,Biopsy of prostate gland,360,"$3,970.68 ","$2,604.00 ",100% of APC Rate,"$1,627.51 ",100% of Medicare OPPS,"$2,779.48 ",70% of total billed charges,"$3,370.31 ",84.88% of total billed charges,"$2,358.35 ",139.08% of ASC,"$1,627.51 ",100% of Medicare OPPS,"$2,978.01 ",75% of total billed charges,"$2,000.00 ",70% of total billed charges,"$2,766.76 ",170% of Medicare OPPS,"$3,499.14 ",215% of Medicare OPPS,$509.84 ,12.84% of total billed charges,"$2,848.14 ",175% of Medicare OPPS,"$1,627.51 ",100% of Medicare OPPS,"$3,176.54 ",80% of total billed charges,"$2,278.51 ",140% of Medicare OPPS,"$2,034.38 ",125% of Medicare OPPS,$509.84 ,12.84% of LA Medicaid fee schedule,$509.84 ,12.84% of LA Medicaid fee schedule,"$1,627.51 ",100% of Medicare OPPS,"$1,129.00 ",100% of ASC Grouper,"$1,627.51 ",100% of Medicare OPPS,"$1,627.51 ",100% of Medicare OPPS,"$2,848.14 ",100% of Medicare OPPS,"$1,627.51 ",100% of Medicare OPPS,"$1,263.32 ",100% of custom fee schedule,"$3,573.61 ",90% of total billed charges,$509.84 ,"$3,573.61 ","$3,970.68 "
Outpatient Medical Services,OUTPATIENT PROCEDURES,55866,Surgical removal of prostate and surrounding lymph nodes using an endoscope,360,"$19,726.45 ","$12,757.40 ",100% of APC Rate,"$7,973.37 ",100% of Medicare OPPS,"$13,808.52 ",70% of total billed charges,"$16,743.81 ",84.88% of total billed charges,"$10,563.71 ",139.08% of ASC,"$7,973.37 ",100% of Medicare OPPS,"$14,794.84 ",75% of total billed charges,"$2,000.00 ",70% of total billed charges,"$13,554.73 ",170% of Medicare OPPS,"$17,142.75 ",215% of Medicare OPPS,"$2,532.88 ",12.84% of total billed charges,"$13,953.40 ",175% of Medicare OPPS,"$7,973.37 ",100% of Medicare OPPS,"$15,781.16 ",80% of total billed charges,"$11,162.73 ",140% of Medicare OPPS,"$9,966.70 ",125% of Medicare OPPS,"$2,532.88 ",12.84% of LA Medicaid fee schedule,"$2,532.88 ",12.84% of LA Medicaid fee schedule,"$7,973.37 ",100% of Medicare OPPS,"$6,662.00 ",100% of ASC Grouper,"$7,973.37 ",100% of Medicare OPPS,"$7,973.37 ",100% of Medicare OPPS,"$13,953.40 ",100% of Medicare OPPS,"$7,973.37 ",100% of Medicare OPPS,"$9,721.46 ",100% of custom fee schedule,"$17,753.81 ",90% of total billed charges,"$2,000.00 ","$17,753.81 ","$19,726.45 "
Outpatient Medical Services,OUTPATIENT PROCEDURES,58571,Laparoscopic hysterectomy,360,"$19,726.45 ","$12,757.40 ",100% of APC Rate,"$7,973.37 ",100% of Medicare OPPS,"$13,808.52 ",70% of total billed charges,"$16,743.81 ",84.88% of total billed charges,"$9,929.88 ",139.08% of ASC,"$7,973.37 ",100% of Medicare OPPS,"$14,794.84 ",75% of total billed charges,"$2,000.00 ",70% of total billed charges,"$13,554.73 ",170% of Medicare OPPS,"$17,142.75 ",215% of Medicare OPPS,"$2,532.88 ",12.84% of total billed charges,"$13,953.40 ",175% of Medicare OPPS,"$7,973.37 ",100% of Medicare OPPS,"$15,781.16 ",80% of total billed charges,"$11,162.73 ",140% of Medicare OPPS,"$9,966.70 ",125% of Medicare OPPS,"$2,532.88 ",12.84% of LA Medicaid fee schedule,"$2,532.88 ",12.84% of LA Medicaid fee schedule,"$7,973.37 ",100% of Medicare OPPS,"$5,617.00 ",100% of ASC Grouper,"$7,973.37 ",100% of Medicare OPPS,"$7,973.37 ",100% of Medicare OPPS,"$13,953.40 ",100% of Medicare OPPS,"$7,973.37 ",100% of Medicare OPPS,"$4,340.18 ",100% of custom fee schedule,"$17,753.81 ",90% of total billed charges,"$2,000.00 ","$17,753.81 ","$19,726.45 "
Outpatient Medical Services,OUTPATIENT PROCEDURES,63030,Surgical procedure to decompress a herniated vertebra,360,"$13,874.05 ","$9,286.08 ",100% of APC Rate,"$5,803.81 ",100% of Medicare OPPS,"$9,711.84 ",70% of total billed charges,"$11,776.29 ",84.88% of total billed charges,"$7,641.46 ",139.08% of ASC,"$5,803.81 ",100% of Medicare OPPS,"$10,405.54 ",75% of total billed charges,"$2,000.00 ",70% of total billed charges,"$9,866.46 ",170% of Medicare OPPS,"$12,478.18 ",215% of Medicare OPPS,"$1,781.43 ",12.84% of total billed charges,"$10,156.66 ",175% of Medicare OPPS,"$5,803.81 ",100% of Medicare OPPS,"$11,099.24 ",80% of total billed charges,"$8,125.33 ",140% of Medicare OPPS,"$7,254.75 ",125% of Medicare OPPS,"$1,781.43 ",12.84% of LA Medicaid fee schedule,"$1,781.43 ",12.84% of LA Medicaid fee schedule,"$5,803.81 ",100% of Medicare OPPS,"$5,617.00 ",100% of ASC Grouper,"$5,803.81 ",100% of Medicare OPPS,"$5,803.81 ",100% of Medicare OPPS,"$10,156.66 ",100% of Medicare OPPS,"$5,803.81 ",100% of Medicare OPPS,"$4,762.27 ",100% of custom fee schedule,"$12,486.65 ",90% of total billed charges,"$1,781.43 ","$12,486.65 ","$13,874.05 "
Outpatient Medical Services,OUTPATIENT PROCEDURES,63047,Laminectomy w/decompression lumbar,360,"$13,874.05 ","$9,286.08 ",100% of APC Rate,"$5,803.81 ",100% of Medicare OPPS,"$9,711.84 ",70% of total billed charges,"$11,776.29 ",84.88% of total billed charges,"$7,641.46 ",139.08% of ASC,"$5,803.81 ",100% of Medicare OPPS,"$10,405.54 ",75% of total billed charges,"$2,000.00 ",70% of total billed charges,"$9,866.46 ",170% of Medicare OPPS,"$12,478.18 ",215% of Medicare OPPS,"$1,781.43 ",12.84% of total billed charges,"$10,156.66 ",175% of Medicare OPPS,"$5,803.81 ",100% of Medicare OPPS,"$11,099.24 ",80% of total billed charges,"$8,125.33 ",140% of Medicare OPPS,"$7,254.75 ",125% of Medicare OPPS,"$1,781.43 ",12.84% of LA Medicaid fee schedule,"$1,781.43 ",12.84% of LA Medicaid fee schedule,"$5,803.81 ",100% of Medicare OPPS,"$5,617.00 ",100% of ASC Grouper,"$5,803.81 ",100% of Medicare OPPS,"$5,803.81 ",100% of Medicare OPPS,"$10,156.66 ",100% of Medicare OPPS,"$5,803.81 ",100% of Medicare OPPS,"$4,762.27 ",100% of custom fee schedule,"$12,486.65 ",90% of total billed charges,"$1,781.43 ","$12,486.65 ","$13,874.05 "
Outpatient Medical Services,OUTPATIENT PROCEDURES,64721,Release of the transverse carpal ligament,360,"$3,885.18 ","$2,523.48 ",100% of APC Rate,"$1,577.18 ",100% of Medicare OPPS,"$2,719.63 ",70% of total billed charges,"$3,297.74 ",84.88% of total billed charges,"$2,105.49 ",139.08% of ASC,"$1,577.18 ",100% of Medicare OPPS,"$2,913.89 ",75% of total billed charges,"$2,000.00 ",70% of total billed charges,"$2,681.20 ",170% of Medicare OPPS,"$3,390.93 ",215% of Medicare OPPS,$498.86 ,12.84% of total billed charges,"$2,760.06 ",175% of Medicare OPPS,"$1,577.18 ",100% of Medicare OPPS,"$3,108.14 ",80% of total billed charges,"$2,208.04 ",140% of Medicare OPPS,"$1,971.47 ",125% of Medicare OPPS,$498.86 ,12.84% of LA Medicaid fee schedule,$498.86 ,12.84% of LA Medicaid fee schedule,"$1,577.18 ",100% of Medicare OPPS,"$1,969.00 ",100% of ASC Grouper,"$1,577.18 ",100% of Medicare OPPS,"$1,577.18 ",100% of Medicare OPPS,"$2,760.06 ",100% of Medicare OPPS,"$1,577.18 ",100% of Medicare OPPS,"$1,646.25 ",100% of custom fee schedule,"$3,496.66 ",90% of total billed charges,$498.86 ,"$3,496.66 ","$3,885.18 "
Outpatient Medical Services,OUTPATIENT PROCEDURES,66982,cataract complex,360,"$4,604.40 ","$3,031.57 ",100% of APC Rate,"$1,894.73 ",100% of Medicare OPPS,"$3,223.08 ",70% of total billed charges,"$3,908.21 ",84.88% of total billed charges,"$2,618.42 ",139.08% of ASC,"$1,894.73 ",100% of Medicare OPPS,"$3,453.30 ",75% of total billed charges,"$2,000.00 ",70% of total billed charges,"$3,221.04 ",170% of Medicare OPPS,"$4,073.67 ",215% of Medicare OPPS,$591.20 ,12.84% of total billed charges,"$3,315.78 ",175% of Medicare OPPS,"$1,894.73 ",100% of Medicare OPPS,"$3,683.52 ",80% of total billed charges,"$2,652.62 ",140% of Medicare OPPS,"$2,368.41 ",125% of Medicare OPPS,$591.20 ,12.84% of LA Medicaid fee schedule,$591.20 ,12.84% of LA Medicaid fee schedule,"$1,894.73 ",100% of Medicare OPPS,"$1,969.00 ",100% of ASC Grouper,"$1,894.73 ",100% of Medicare OPPS,"$1,894.73 ",100% of Medicare OPPS,"$3,315.78 ",100% of Medicare OPPS,"$1,894.73 ",100% of Medicare OPPS,"$2,100.81 ",100% of custom fee schedule,"$4,143.96 ",90% of total billed charges,$591.20 ,"$4,143.96 ","$4,604.40 "
Outpatient Medical Services,OUTPATIENT PROCEDURES,66984,Removal of cataract with insertion of lens,360,"$4,604.40 ","$3,031.57 ",100% of APC Rate,"$1,894.73 ",100% of Medicare OPPS,"$3,223.08 ",70% of total billed charges,"$3,908.21 ",84.88% of total billed charges,"$2,618.42 ",139.08% of ASC,"$1,894.73 ",100% of Medicare OPPS,"$3,453.30 ",75% of total billed charges,"$2,000.00 ",70% of total billed charges,"$3,221.04 ",170% of Medicare OPPS,"$4,073.67 ",215% of Medicare OPPS,$591.20 ,12.84% of total billed charges,"$3,315.78 ",175% of Medicare OPPS,"$1,894.73 ",100% of Medicare OPPS,"$3,683.52 ",80% of total billed charges,"$2,652.62 ",140% of Medicare OPPS,"$2,368.41 ",125% of Medicare OPPS,$591.20 ,12.84% of LA Medicaid fee schedule,$591.20 ,12.84% of LA Medicaid fee schedule,"$1,894.73 ",100% of Medicare OPPS,"$1,969.00 ",100% of ASC Grouper,"$1,894.73 ",100% of Medicare OPPS,"$1,894.73 ",100% of Medicare OPPS,"$3,315.78 ",100% of Medicare OPPS,"$1,894.73 ",100% of Medicare OPPS,"$2,100.81 ",100% of custom fee schedule,"$4,143.96 ",90% of total billed charges,$591.20 ,"$4,143.96 ","$4,604.40 "
Outpatient Medical Services,OUTPATIENT PROCEDURES,69436,Insertion of tubes into one or both ears,360,"$2,995.83 ","$1,948.76 ",100% of APC Rate,"$1,217.98 ",100% of Medicare OPPS,"$2,097.08 ",70% of total billed charges,"$2,542.86 ",84.88% of total billed charges,"$1,582.98 ",139.08% of ASC,"$1,217.98 ",100% of Medicare OPPS,"$2,246.87 ",75% of total billed charges,"$2,000.00 ",70% of total billed charges,"$2,070.56 ",170% of Medicare OPPS,"$2,618.65 ",215% of Medicare OPPS,$384.66 ,12.84% of total billed charges,"$2,131.46 ",175% of Medicare OPPS,"$1,217.98 ",100% of Medicare OPPS,"$2,396.66 ",80% of total billed charges,"$1,705.17 ",140% of Medicare OPPS,"$1,522.47 ",125% of Medicare OPPS,$384.66 ,12.84% of LA Medicaid fee schedule,$384.66 ,12.84% of LA Medicaid fee schedule,"$1,217.98 ",100% of Medicare OPPS,"$1,129.00 ",100% of ASC Grouper,"$1,217.98 ",100% of Medicare OPPS,"$1,217.98 ",100% of Medicare OPPS,"$2,131.46 ",100% of Medicare OPPS,"$1,217.98 ",100% of Medicare OPPS,"$1,448.71 ",100% of custom fee schedule,"$2,696.25 ",90% of total billed charges,$384.66 ,"$2,696.25 ","$2,995.83 "
Outpatient Medical Services,OUTPATIENT PROCEDURES,36600,arterial puncture,360,$230.37 ,$163.00 ,100% of APC Rate,$101.87 ,100% of Medicare OPPS,$161.26 ,70% of total billed charges,$195.54 ,84.88% of total billed charges,$146.09 ,139.08% of custom fee schedule,$101.87 ,100% of Medicare OPPS,$172.78 ,75% of total billed charges,$161.26 ,70% of total billed charges,$173.19 ,170% of Medicare OPPS,$219.03 ,215% of Medicare OPPS,$29.58 ,12.84% of total billed charges,$178.28 ,175% of Medicare OPPS,$101.87 ,100% of Medicare OPPS,$184.30 ,80% of total billed charges,$142.62 ,140% of Medicare OPPS,$127.34 ,125% of Medicare OPPS,$29.58 ,12.84% of LA Medicaid fee schedule,$29.58 ,12.84% of LA Medicaid fee schedule,$101.87 ,100% of Medicare OPPS,$490.00 ,100% of ASC Grouper,$101.87 ,100% of Medicare OPPS,$101.87 ,100% of Medicare OPPS,$178.28 ,100% of Medicare OPPS,$101.87 ,100% of Medicare OPPS,$116.88 ,100% of custom fee schedule,$207.33 ,90% of total billed charges,$29.58 ,$490.00 ,$230.37 
Outpatient Medical Services,OUTPATIENT PROCEDURES,51720,bladder instillation anticarcinogenic,360,$456.75 ,$877.89 ,100% of APC Rate,$548.67 ,100% of Medicare OPPS,$319.73 ,70% of total billed charges,$387.69 ,84.88% of total billed charges,$319.23 ,139.08% of ASC,$548.67 ,100% of Medicare OPPS,$342.56 ,75% of total billed charges,$319.73 ,70% of total billed charges,$932.75 ,170% of Medicare OPPS,"$1,179.67 ",215% of Medicare OPPS,$58.65 ,12.84% of total billed charges,$960.19 ,175% of Medicare OPPS,$548.67 ,100% of Medicare OPPS,$365.40 ,80% of total billed charges,$768.15 ,140% of Medicare OPPS,$685.85 ,125% of Medicare OPPS,$58.65 ,12.84% of LA Medicaid fee schedule,$58.65 ,12.84% of LA Medicaid fee schedule,$548.67 ,100% of Medicare OPPS,$490.00 ,100% of ASC Grouper,$548.67 ,100% of Medicare OPPS,$548.67 ,100% of Medicare OPPS,$960.19 ,100% of Medicare OPPS,$548.67 ,100% of Medicare OPPS,$251.12 ,100% of custom fee schedule,$411.08 ,90% of total billed charges,$58.65 ,"$1,179.67 ",$456.75 
Outpatient Medical Services,INFUSION,96365,"Intravenous infusion, for therapy, prophylaxis, or diagnosis-initial infusion",260,$489.98 ,$289.99 ,100% of APC Rate,$181.24 ,100% of Medicare OPPS,$342.99 ,70% of total billed charges,$415.90 ,84.88% of total billed charges,$265.77 ,139.08% of custom fee schedule,$181.24 ,100% of Medicare OPPS,$367.49 ,75% of total billed charges,$342.99 ,70% of total billed charges,$308.11 ,170% of Medicare OPPS,$389.68 ,215% of Medicare OPPS,$62.91 ,12.84% of total billed charges,$317.17 ,175% of Medicare OPPS,$181.24 ,100% of Medicare OPPS,$391.98 ,80% of total billed charges,$253.74 ,140% of Medicare OPPS,$226.55 ,125% of Medicare OPPS,$62.91 ,12.84% of LA Medicaid fee schedule,$62.91 ,12.84% of LA Medicaid fee schedule,$181.24 ,100% of Medicare OPPS,$128.00 ,100% of UHC Case Rate,$181.24 ,100% of Medicare OPPS,$181.24 ,100% of Medicare OPPS,$317.17 ,100% of Medicare OPPS,$181.24 ,100% of Medicare OPPS,$204.82 ,100% of custom fee schedule,$440.98 ,90% of total billed charges,$62.91 ,$440.98 ,$489.98 
Outpatient Medical Services,INFUSION,96366,"Intravenous infusion, for therapy, prophylaxis, or diagnosis-additional infusions",260,$49.81 ,$59.48 ,100% of APC Rate,$37.17 ,100% of Medicare OPPS,$34.87 ,70% of total billed charges,$42.28 ,84.88% of total billed charges,$51.50 ,139.08% of custom fee schedule,$37.17 ,100% of Medicare OPPS,$37.36 ,75% of total billed charges,$34.87 ,70% of total billed charges,$63.19 ,170% of Medicare OPPS,$79.92 ,215% of Medicare OPPS,$6.40 ,12.84% of total billed charges,$65.05 ,175% of Medicare OPPS,$37.17 ,100% of Medicare OPPS,$39.85 ,80% of total billed charges,$52.04 ,140% of Medicare OPPS,$46.46 ,125% of Medicare OPPS,$6.40 ,12.84% of LA Medicaid fee schedule,$6.40 ,12.84% of LA Medicaid fee schedule,$37.17 ,100% of Medicare OPPS,$128.00 ,100% of UHC Case Rate,$37.17 ,100% of Medicare OPPS,$37.17 ,100% of Medicare OPPS,$65.05 ,100% of Medicare OPPS,$37.17 ,100% of Medicare OPPS,$35.09 ,100% of custom fee schedule,$44.83 ,90% of total billed charges,$6.40 ,$128.00 ,$49.81 
Outpatient Medical Services,INFUSION,96375,"Intravenous infusion, for treatment, prophylaxis, or diagnosis-new drug add on",260,$298.96 ,$59.48 ,100% of APC Rate,$37.17 ,100% of Medicare OPPS,$209.27 ,70% of total billed charges,$253.76 ,84.88% of total billed charges,$51.50 ,139.08% of custom fee schedule,$37.17 ,100% of Medicare OPPS,$224.22 ,75% of total billed charges,$209.27 ,70% of total billed charges,$63.19 ,170% of Medicare OPPS,$79.92 ,215% of Medicare OPPS,$38.39 ,12.84% of total billed charges,$65.05 ,175% of Medicare OPPS,$37.17 ,100% of Medicare OPPS,$239.17 ,80% of total billed charges,$52.04 ,140% of Medicare OPPS,$46.46 ,125% of Medicare OPPS,$38.39 ,12.84% of LA Medicaid fee schedule,$38.39 ,12.84% of LA Medicaid fee schedule,$37.17 ,100% of Medicare OPPS,$128.00 ,100% of UHC Case Rate,$37.17 ,100% of Medicare OPPS,$37.17 ,100% of Medicare OPPS,$65.05 ,100% of Medicare OPPS,$37.17 ,100% of Medicare OPPS,$52.08 ,100% of custom fee schedule,$269.06 ,90% of total billed charges,$37.17 ,$269.06 ,$298.96 
Outpatient Medical Services,MRI,73218,MRI Upper Extremity without contrast,610,"$2,860.20 ",$327.83 ,100% of APC Rate,$204.89 ,100% of Medicare OPPS,"$2,002.14 ",70% of total billed charges,"$2,427.74 ",84.88% of total billed charges,$323.10 ,139.08% of custom fee schedule,$204.89 ,100% of Medicare OPPS,"$2,145.15 ",75% of total billed charges,"$2,000.00 ",70% of total billed charges,$348.31 ,170% of Medicare OPPS,$440.51 ,215% of Medicare OPPS,$367.25 ,12.84% of total billed charges,$358.56 ,175% of Medicare OPPS,$204.89 ,100% of Medicare OPPS,"$2,288.16 ",80% of total billed charges,$286.83 ,140% of Medicare OPPS,$256.11 ,125% of Medicare OPPS,$367.25 ,12.84% of LA Medicaid fee schedule,$367.25 ,12.84% of LA Medicaid fee schedule,$204.89 ,100% of Medicare OPPS,"$1,937.00 ",100% of UHC Case Rate,$204.89 ,100% of Medicare OPPS,$204.89 ,100% of Medicare OPPS,$358.56 ,100% of Medicare OPPS,$204.89 ,100% of Medicare OPPS,$350.66 ,100% of custom fee schedule,"$2,574.18 ",90% of total billed charges,$204.89 ,"$2,574.18 ","$2,145.15 "
Outpatient Medical Services,MRI,70544,MRI head w/o contrast,610,"$2,860.20 ",$327.83 ,100% of APC Rate,$204.89 ,100% of Medicare OPPS,"$2,002.14 ",70% of total billed charges,"$2,427.74 ",84.88% of total billed charges,$323.10 ,139.08% of custom fee schedule,$204.89 ,100% of Medicare OPPS,"$2,145.15 ",75% of total billed charges,"$2,000.00 ",70% of total billed charges,$348.31 ,170% of Medicare OPPS,$440.51 ,215% of Medicare OPPS,$367.25 ,12.84% of total billed charges,$358.56 ,175% of Medicare OPPS,$204.89 ,100% of Medicare OPPS,"$2,288.16 ",80% of total billed charges,$286.83 ,140% of Medicare OPPS,$256.11 ,125% of Medicare OPPS,$367.25 ,12.84% of LA Medicaid fee schedule,$367.25 ,12.84% of LA Medicaid fee schedule,$204.89 ,100% of Medicare OPPS,"$1,937.00 ",100% of UHC Case Rate,$204.89 ,100% of Medicare OPPS,$204.89 ,100% of Medicare OPPS,$358.56 ,100% of Medicare OPPS,$204.89 ,100% of Medicare OPPS,$350.66 ,100% of custom fee schedule,"$2,574.18 ",90% of total billed charges,$204.89 ,"$2,574.18 ","$2,145.15 "
Outpatient Medical Services,MRI,70551,MRI of brain stem without dye,610,"$2,860.20 ",$327.83 ,100% of APC Rate,$204.89 ,100% of Medicare OPPS,"$2,002.14 ",70% of total billed charges,"$2,427.74 ",84.88% of total billed charges,$323.10 ,139.08% of custom fee schedule,$204.89 ,100% of Medicare OPPS,"$2,145.15 ",75% of total billed charges,"$2,000.00 ",70% of total billed charges,$348.31 ,170% of Medicare OPPS,$440.51 ,215% of Medicare OPPS,$367.25 ,12.84% of total billed charges,$358.56 ,175% of Medicare OPPS,$204.89 ,100% of Medicare OPPS,"$2,288.16 ",80% of total billed charges,$286.83 ,140% of Medicare OPPS,$256.11 ,125% of Medicare OPPS,$367.25 ,12.84% of LA Medicaid fee schedule,$367.25 ,12.84% of LA Medicaid fee schedule,$204.89 ,100% of Medicare OPPS,"$1,937.00 ",100% of UHC Case Rate,$204.89 ,100% of Medicare OPPS,$204.89 ,100% of Medicare OPPS,$358.56 ,100% of Medicare OPPS,$204.89 ,100% of Medicare OPPS,$350.66 ,100% of custom fee schedule,"$2,574.18 ",90% of total billed charges,$204.89 ,"$2,574.18 ","$2,145.15 "
Outpatient Medical Services,MRI,70553,MRI scan of brain before and after contrast,610,"$2,860.20 ",$517.22 ,100% of APC Rate,$323.26 ,100% of Medicare OPPS,"$2,002.14 ",70% of total billed charges,"$2,427.74 ",84.88% of total billed charges,$634.72 ,139.08% of custom fee schedule,$323.26 ,100% of Medicare OPPS,"$2,145.15 ",75% of total billed charges,"$2,000.00 ",70% of total billed charges,$549.54 ,170% of Medicare OPPS,$695.02 ,215% of Medicare OPPS,$367.25 ,12.84% of total billed charges,$565.71 ,175% of Medicare OPPS,$323.26 ,100% of Medicare OPPS,"$2,288.16 ",80% of total billed charges,$452.57 ,140% of Medicare OPPS,$404.07 ,125% of Medicare OPPS,$367.25 ,12.84% of LA Medicaid fee schedule,$367.25 ,12.84% of LA Medicaid fee schedule,$323.26 ,100% of Medicare OPPS,"$1,937.00 ",100% of UHC Case Rate,$323.26 ,100% of Medicare OPPS,$323.26 ,100% of Medicare OPPS,$565.71 ,100% of Medicare OPPS,$323.26 ,100% of Medicare OPPS,$586.37 ,100% of custom fee schedule,"$2,574.18 ",90% of total billed charges,$323.26 ,"$2,574.18 ","$2,145.15 "
Outpatient Medical Services,MRI,73221,MRI of upper extremity without dye,610,"$2,860.20 ",$327.83 ,100% of APC Rate,$204.89 ,100% of Medicare OPPS,"$2,002.14 ",70% of total billed charges,"$2,427.74 ",84.88% of total billed charges,$323.10 ,139.08% of custom fee schedule,$204.89 ,100% of Medicare OPPS,"$2,145.15 ",75% of total billed charges,"$2,000.00 ",70% of total billed charges,$348.31 ,170% of Medicare OPPS,$440.51 ,215% of Medicare OPPS,$367.25 ,12.84% of total billed charges,$358.56 ,175% of Medicare OPPS,$204.89 ,100% of Medicare OPPS,"$2,288.16 ",80% of total billed charges,$286.83 ,140% of Medicare OPPS,$256.11 ,125% of Medicare OPPS,$367.25 ,12.84% of LA Medicaid fee schedule,$367.25 ,12.84% of LA Medicaid fee schedule,$204.89 ,100% of Medicare OPPS,"$1,937.00 ",100% of UHC Case Rate,$204.89 ,100% of Medicare OPPS,$204.89 ,100% of Medicare OPPS,$358.56 ,100% of Medicare OPPS,$204.89 ,100% of Medicare OPPS,$350.66 ,100% of custom fee schedule,"$2,574.18 ",90% of total billed charges,$204.89 ,"$2,574.18 ","$2,145.15 "
Outpatient Medical Services,MRI,73222,MRI any upper joint w/contrast,610,"$2,860.20 ","$1,039.91 ",100% of APC Rate,$649.94 ,100% of Medicare OPPS,"$2,002.14 ",70% of total billed charges,"$2,427.74 ",84.88% of total billed charges,$948.36 ,139.08% of custom fee schedule,$649.94 ,100% of Medicare OPPS,"$2,145.15 ",75% of total billed charges,"$2,000.00 ",70% of total billed charges,"$1,104.90 ",170% of Medicare OPPS,"$1,397.38 ",215% of Medicare OPPS,$367.25 ,12.84% of total billed charges,"$1,137.40 ",175% of Medicare OPPS,$649.94 ,100% of Medicare OPPS,"$2,288.16 ",80% of total billed charges,$909.92 ,140% of Medicare OPPS,$812.43 ,125% of Medicare OPPS,$367.25 ,12.84% of LA Medicaid fee schedule,$367.25 ,12.84% of LA Medicaid fee schedule,$649.94 ,100% of Medicare OPPS,"$1,937.00 ",100% of UHC Case Rate,$649.94 ,100% of Medicare OPPS,$649.94 ,100% of Medicare OPPS,"$1,137.40 ",100% of Medicare OPPS,$649.94 ,100% of Medicare OPPS,$507.34 ,100% of custom fee schedule,"$2,574.18 ",90% of total billed charges,$367.25 ,"$2,574.18 ","$2,145.15 "
Outpatient Medical Services,MRI,73718,MRI of leg without dye,610,"$2,860.20 ",$327.83 ,100% of APC Rate,$204.89 ,100% of Medicare OPPS,"$2,002.14 ",70% of total billed charges,"$2,427.74 ",84.88% of total billed charges,$323.10 ,139.08% of custom fee schedule,$204.89 ,100% of Medicare OPPS,"$2,145.15 ",75% of total billed charges,"$2,000.00 ",70% of total billed charges,$348.31 ,170% of Medicare OPPS,$440.51 ,215% of Medicare OPPS,$367.25 ,12.84% of total billed charges,$358.56 ,175% of Medicare OPPS,$204.89 ,100% of Medicare OPPS,"$2,288.16 ",80% of total billed charges,$286.83 ,140% of Medicare OPPS,$256.11 ,125% of Medicare OPPS,$367.25 ,12.84% of LA Medicaid fee schedule,$367.25 ,12.84% of LA Medicaid fee schedule,$204.89 ,100% of Medicare OPPS,"$1,937.00 ",100% of UHC Case Rate,$204.89 ,100% of Medicare OPPS,$204.89 ,100% of Medicare OPPS,$358.56 ,100% of Medicare OPPS,$204.89 ,100% of Medicare OPPS,$350.66 ,100% of custom fee schedule,"$2,574.18 ",90% of total billed charges,$204.89 ,"$2,574.18 ","$2,145.15 "
Outpatient Medical Services,MRI,73721,MRI of lower extremity joint (knee/ankle) without dye,610,"$2,860.20 ",$327.83 ,100% of APC Rate,$204.89 ,100% of Medicare OPPS,"$2,002.14 ",70% of total billed charges,"$2,427.74 ",84.88% of total billed charges,$323.10 ,139.08% of custom fee schedule,$204.89 ,100% of Medicare OPPS,"$2,145.15 ",75% of total billed charges,"$2,000.00 ",70% of total billed charges,$348.31 ,170% of Medicare OPPS,$440.51 ,215% of Medicare OPPS,$367.25 ,12.84% of total billed charges,$358.56 ,175% of Medicare OPPS,$204.89 ,100% of Medicare OPPS,"$2,288.16 ",80% of total billed charges,$286.83 ,140% of Medicare OPPS,$256.11 ,125% of Medicare OPPS,$367.25 ,12.84% of LA Medicaid fee schedule,$367.25 ,12.84% of LA Medicaid fee schedule,$204.89 ,100% of Medicare OPPS,"$1,937.00 ",100% of UHC Case Rate,$204.89 ,100% of Medicare OPPS,$204.89 ,100% of Medicare OPPS,$358.56 ,100% of Medicare OPPS,$204.89 ,100% of Medicare OPPS,$350.66 ,100% of custom fee schedule,"$2,574.18 ",90% of total billed charges,$204.89 ,"$2,574.18 ","$2,145.15 "
Outpatient Medical Services,MRI,74183,MRI of abdomen without and with dye,610,"$2,860.20 ",$517.22 ,100% of APC Rate,$323.26 ,100% of Medicare OPPS,"$2,002.14 ",70% of total billed charges,"$2,427.74 ",84.88% of total billed charges,$634.72 ,139.08% of custom fee schedule,$323.26 ,100% of Medicare OPPS,"$2,145.15 ",75% of total billed charges,"$2,000.00 ",70% of total billed charges,$549.54 ,170% of Medicare OPPS,$695.02 ,215% of Medicare OPPS,$367.25 ,12.84% of total billed charges,$565.71 ,175% of Medicare OPPS,$323.26 ,100% of Medicare OPPS,"$2,288.16 ",80% of total billed charges,$452.57 ,140% of Medicare OPPS,$404.07 ,125% of Medicare OPPS,$367.25 ,12.84% of LA Medicaid fee schedule,$367.25 ,12.84% of LA Medicaid fee schedule,$323.26 ,100% of Medicare OPPS,"$1,937.00 ",100% of UHC Case Rate,$323.26 ,100% of Medicare OPPS,$323.26 ,100% of Medicare OPPS,$565.71 ,100% of Medicare OPPS,$323.26 ,100% of Medicare OPPS,$586.37 ,100% of custom fee schedule,"$2,574.18 ",90% of total billed charges,$323.26 ,"$2,574.18 ","$2,145.15 "
Outpatient Medical Services,MRI,72141,MRI of the neck or spine without dye,612,"$2,860.20 ",$327.83 ,100% of APC Rate,$204.89 ,100% of Medicare OPPS,"$2,002.14 ",70% of total billed charges,"$2,427.74 ",84.88% of total billed charges,$323.10 ,139.08% of custom fee schedule,$204.89 ,100% of Medicare OPPS,"$2,145.15 ",75% of total billed charges,"$2,000.00 ",70% of total billed charges,$348.31 ,170% of Medicare OPPS,$440.51 ,215% of Medicare OPPS,$367.25 ,12.84% of total billed charges,$358.56 ,175% of Medicare OPPS,$204.89 ,100% of Medicare OPPS,"$2,288.16 ",80% of total billed charges,$286.83 ,140% of Medicare OPPS,$256.11 ,125% of Medicare OPPS,$367.25 ,12.84% of LA Medicaid fee schedule,$367.25 ,12.84% of LA Medicaid fee schedule,$204.89 ,100% of Medicare OPPS,"$1,937.00 ",100% of UHC Case Rate,$204.89 ,100% of Medicare OPPS,$204.89 ,100% of Medicare OPPS,$358.56 ,100% of Medicare OPPS,$204.89 ,100% of Medicare OPPS,$350.66 ,100% of custom fee schedule,"$2,574.18 ",90% of total billed charges,$204.89 ,"$2,574.18 ","$2,145.15 "
Outpatient Medical Services,MRI,72146,MRI of chest and spine without dye,612,"$2,860.20 ",$327.83 ,100% of APC Rate,$204.89 ,100% of Medicare OPPS,"$2,002.14 ",70% of total billed charges,"$2,427.74 ",84.88% of total billed charges,$323.10 ,139.08% of custom fee schedule,$204.89 ,100% of Medicare OPPS,"$2,145.15 ",75% of total billed charges,"$2,000.00 ",70% of total billed charges,$348.31 ,170% of Medicare OPPS,$440.51 ,215% of Medicare OPPS,$367.25 ,12.84% of total billed charges,$358.56 ,175% of Medicare OPPS,$204.89 ,100% of Medicare OPPS,"$2,288.16 ",80% of total billed charges,$286.83 ,140% of Medicare OPPS,$256.11 ,125% of Medicare OPPS,$367.25 ,12.84% of LA Medicaid fee schedule,$367.25 ,12.84% of LA Medicaid fee schedule,$204.89 ,100% of Medicare OPPS,"$1,937.00 ",100% of UHC Case Rate,$204.89 ,100% of Medicare OPPS,$204.89 ,100% of Medicare OPPS,$358.56 ,100% of Medicare OPPS,$204.89 ,100% of Medicare OPPS,$350.66 ,100% of custom fee schedule,"$2,574.18 ",90% of total billed charges,$204.89 ,"$2,574.18 ","$2,145.15 "
Outpatient Medical Services,MRI,72148,MRI scan of lower spinal canal,612,"$2,860.20 ",$327.83 ,100% of APC Rate,$204.89 ,100% of Medicare OPPS,"$2,002.14 ",70% of total billed charges,"$2,427.74 ",84.88% of total billed charges,$323.10 ,139.08% of custom fee schedule,$204.89 ,100% of Medicare OPPS,"$2,145.15 ",75% of total billed charges,"$2,000.00 ",70% of total billed charges,$348.31 ,170% of Medicare OPPS,$440.51 ,215% of Medicare OPPS,$367.25 ,12.84% of total billed charges,$358.56 ,175% of Medicare OPPS,$204.89 ,100% of Medicare OPPS,"$2,288.16 ",80% of total billed charges,$286.83 ,140% of Medicare OPPS,$256.11 ,125% of Medicare OPPS,$367.25 ,12.84% of LA Medicaid fee schedule,$367.25 ,12.84% of LA Medicaid fee schedule,$204.89 ,100% of Medicare OPPS,"$1,937.00 ",100% of UHC Case Rate,$204.89 ,100% of Medicare OPPS,$204.89 ,100% of Medicare OPPS,$358.56 ,100% of Medicare OPPS,$204.89 ,100% of Medicare OPPS,$350.66 ,100% of custom fee schedule,"$2,574.18 ",90% of total billed charges,$204.89 ,"$2,574.18 ","$2,145.15 "
Outpatient Medical Services,MRI,72156,MRI of neck/spine with and without dye,612,"$2,860.20 ",$517.22 ,100% of APC Rate,$323.26 ,100% of Medicare OPPS,"$2,002.14 ",70% of total billed charges,"$2,427.74 ",84.88% of total billed charges,$634.72 ,139.08% of custom fee schedule,$323.26 ,100% of Medicare OPPS,"$2,145.15 ",75% of total billed charges,"$2,000.00 ",70% of total billed charges,$549.54 ,170% of Medicare OPPS,$695.02 ,215% of Medicare OPPS,$367.25 ,12.84% of total billed charges,$565.71 ,175% of Medicare OPPS,$323.26 ,100% of Medicare OPPS,"$2,288.16 ",80% of total billed charges,$452.57 ,140% of Medicare OPPS,$404.07 ,125% of Medicare OPPS,$367.25 ,12.84% of LA Medicaid fee schedule,$367.25 ,12.84% of LA Medicaid fee schedule,$323.26 ,100% of Medicare OPPS,"$1,937.00 ",100% of UHC Case Rate,$323.26 ,100% of Medicare OPPS,$323.26 ,100% of Medicare OPPS,$565.71 ,100% of Medicare OPPS,$323.26 ,100% of Medicare OPPS,$586.37 ,100% of custom fee schedule,"$2,574.18 ",90% of total billed charges,$323.26 ,"$2,574.18 ","$2,145.15 "
Outpatient Medical Services,MRI,72158,MRI of lower back with and without dye,612,"$2,860.20 ",$517.22 ,100% of APC Rate,$323.26 ,100% of Medicare OPPS,"$2,002.14 ",70% of total billed charges,"$2,427.74 ",84.88% of total billed charges,$634.72 ,139.08% of custom fee schedule,$323.26 ,100% of Medicare OPPS,"$2,145.15 ",75% of total billed charges,"$2,000.00 ",70% of total billed charges,$549.54 ,170% of Medicare OPPS,$695.02 ,215% of Medicare OPPS,$367.25 ,12.84% of total billed charges,$565.71 ,175% of Medicare OPPS,$323.26 ,100% of Medicare OPPS,"$2,288.16 ",80% of total billed charges,$452.57 ,140% of Medicare OPPS,$404.07 ,125% of Medicare OPPS,$367.25 ,12.84% of LA Medicaid fee schedule,$367.25 ,12.84% of LA Medicaid fee schedule,$323.26 ,100% of Medicare OPPS,"$1,937.00 ",100% of UHC Case Rate,$323.26 ,100% of Medicare OPPS,$323.26 ,100% of Medicare OPPS,$565.71 ,100% of Medicare OPPS,$323.26 ,100% of Medicare OPPS,$586.37 ,100% of custom fee schedule,"$2,574.18 ",90% of total billed charges,$323.26 ,"$2,574.18 ","$2,145.15 "
Outpatient Medical Services,DUPLEX IMAGING,93985,duplex scan arterial bilat study,921,$411.85 ,$327.83 ,100% of APC Rate,$204.89 ,100% of Medicare OPPS,$288.30 ,70% of total billed charges,$349.58 ,84.88% of total billed charges,$324.11 ,139.08% of custom fee schedule,$204.89 ,100% of Medicare OPPS,$308.89 ,75% of total billed charges,$288.30 ,70% of total billed charges,$348.31 ,170% of Medicare OPPS,$440.51 ,215% of Medicare OPPS,$52.88 ,12.84% of total billed charges,$358.56 ,175% of Medicare OPPS,$204.89 ,100% of Medicare OPPS,$329.48 ,80% of total billed charges,$286.83 ,140% of Medicare OPPS,$256.11 ,125% of Medicare OPPS,$52.88 ,12.84% of LA Medicaid fee schedule,$52.88 ,12.84% of LA Medicaid fee schedule,$204.89 ,100% of Medicare OPPS,$193.00 ,100% of UHC Case Rate,$204.89 ,100% of Medicare OPPS,$204.89 ,100% of Medicare OPPS,$358.56 ,100% of Medicare OPPS,$204.89 ,100% of Medicare OPPS,$256.31 ,100% of custom fee schedule,$370.67 ,90% of total billed charges,$52.88 ,$440.51 ,$411.85 
Outpatient Medical Services,DUPLEX IMAGING,93880,Study of vessels on both sides of the head and neck,921,$421.72 ,$327.83 ,100% of APC Rate,$204.89 ,100% of Medicare OPPS,$295.20 ,70% of total billed charges,$357.96 ,84.88% of total billed charges,$323.10 ,139.08% of custom fee schedule,$204.89 ,100% of Medicare OPPS,$316.29 ,75% of total billed charges,$295.20 ,70% of total billed charges,$348.31 ,170% of Medicare OPPS,$440.51 ,215% of Medicare OPPS,$54.15 ,12.84% of total billed charges,$358.56 ,175% of Medicare OPPS,$204.89 ,100% of Medicare OPPS,$337.38 ,80% of total billed charges,$286.83 ,140% of Medicare OPPS,$256.11 ,125% of Medicare OPPS,$54.15 ,12.84% of LA Medicaid fee schedule,$54.15 ,12.84% of LA Medicaid fee schedule,$204.89 ,100% of Medicare OPPS,$193.00 ,100% of UHC Case Rate,$204.89 ,100% of Medicare OPPS,$204.89 ,100% of Medicare OPPS,$358.56 ,100% of Medicare OPPS,$204.89 ,100% of Medicare OPPS,$227.02 ,100% of custom fee schedule,$379.55 ,90% of total billed charges,$54.15 ,$440.51 ,$421.72 
Outpatient Medical Services,DUPLEX IMAGING,93922,Limited bilateral noninvasive physiologic studies of upper or lower extremity arteries,921,$191.12 ,$163.00 ,100% of APC Rate,$101.87 ,100% of Medicare OPPS,$133.78 ,70% of total billed charges,$162.22 ,84.88% of total billed charges,$146.09 ,139.08% of custom fee schedule,$101.87 ,100% of Medicare OPPS,$143.34 ,75% of total billed charges,$133.78 ,70% of total billed charges,$173.19 ,170% of Medicare OPPS,$219.03 ,215% of Medicare OPPS,$24.54 ,12.84% of total billed charges,$178.28 ,175% of Medicare OPPS,$101.87 ,100% of Medicare OPPS,$152.90 ,80% of total billed charges,$142.62 ,140% of Medicare OPPS,$127.34 ,125% of Medicare OPPS,$24.54 ,12.84% of LA Medicaid fee schedule,$24.54 ,12.84% of LA Medicaid fee schedule,$101.87 ,100% of Medicare OPPS,$193.00 ,100% of UHC Case Rate,$101.87 ,100% of Medicare OPPS,$101.87 ,100% of Medicare OPPS,$178.28 ,100% of Medicare OPPS,$101.87 ,100% of Medicare OPPS,$83.48 ,100% of custom fee schedule,$172.01 ,90% of total billed charges,$24.54 ,$219.03 ,$191.12 
Outpatient Medical Services,DUPLEX IMAGING,93925,duplex scan lower extremity arteries bilat,921,$411.57 ,$327.83 ,100% of APC Rate,$204.89 ,100% of Medicare OPPS,$288.10 ,70% of total billed charges,$349.34 ,84.88% of total billed charges,$323.10 ,139.08% of custom fee schedule,$204.89 ,100% of Medicare OPPS,$308.68 ,75% of total billed charges,$288.10 ,70% of total billed charges,$348.31 ,170% of Medicare OPPS,$440.51 ,215% of Medicare OPPS,$52.85 ,12.84% of total billed charges,$358.56 ,175% of Medicare OPPS,$204.89 ,100% of Medicare OPPS,$329.26 ,80% of total billed charges,$286.83 ,140% of Medicare OPPS,$256.11 ,125% of Medicare OPPS,$52.85 ,12.84% of LA Medicaid fee schedule,$52.85 ,12.84% of LA Medicaid fee schedule,$204.89 ,100% of Medicare OPPS,$193.00 ,100% of UHC Case Rate,$204.89 ,100% of Medicare OPPS,$204.89 ,100% of Medicare OPPS,$358.56 ,100% of Medicare OPPS,$204.89 ,100% of Medicare OPPS,$227.02 ,100% of custom fee schedule,$370.41 ,90% of total billed charges,$52.85 ,$440.51 ,$411.57 
Outpatient Medical Services,DUPLEX IMAGING,93926,duplex scan lower extremity arteries unilateral,921,$199.02 ,$150.03 ,100% of APC Rate,$93.78 ,100% of Medicare OPPS,$139.31 ,70% of total billed charges,$168.93 ,84.88% of total billed charges,$159.19 ,139.08% of custom fee schedule,$93.78 ,100% of Medicare OPPS,$149.27 ,75% of total billed charges,$139.31 ,70% of total billed charges,$159.41 ,170% of Medicare OPPS,$201.62 ,215% of Medicare OPPS,$25.55 ,12.84% of total billed charges,$164.11 ,175% of Medicare OPPS,$93.78 ,100% of Medicare OPPS,$159.22 ,80% of total billed charges,$131.28 ,140% of Medicare OPPS,$117.22 ,125% of Medicare OPPS,$25.55 ,12.84% of LA Medicaid fee schedule,$25.55 ,12.84% of LA Medicaid fee schedule,$93.78 ,100% of Medicare OPPS,$193.00 ,100% of UHC Case Rate,$93.78 ,100% of Medicare OPPS,$93.78 ,100% of Medicare OPPS,$164.11 ,100% of Medicare OPPS,$93.78 ,100% of Medicare OPPS,$160.08 ,100% of custom fee schedule,$179.12 ,90% of total billed charges,$25.55 ,$201.62 ,$199.02 
Outpatient Medical Services,DUPLEX IMAGING,93970,Complete bilateral study of the extremities,921,$451.48 ,$327.83 ,100% of APC Rate,$204.89 ,100% of Medicare OPPS,$316.04 ,70% of total billed charges,$383.22 ,84.88% of total billed charges,$323.10 ,139.08% of custom fee schedule,$204.89 ,100% of Medicare OPPS,$338.61 ,75% of total billed charges,$316.04 ,70% of total billed charges,$348.31 ,170% of Medicare OPPS,$440.51 ,215% of Medicare OPPS,$57.97 ,12.84% of total billed charges,$358.56 ,175% of Medicare OPPS,$204.89 ,100% of Medicare OPPS,$361.18 ,80% of total billed charges,$286.83 ,140% of Medicare OPPS,$256.11 ,125% of Medicare OPPS,$57.97 ,12.84% of LA Medicaid fee schedule,$57.97 ,12.84% of LA Medicaid fee schedule,$204.89 ,100% of Medicare OPPS,$193.00 ,100% of UHC Case Rate,$204.89 ,100% of Medicare OPPS,$204.89 ,100% of Medicare OPPS,$358.56 ,100% of Medicare OPPS,$204.89 ,100% of Medicare OPPS,$227.02 ,100% of custom fee schedule,$406.33 ,90% of total billed charges,$57.97 ,$440.51 ,$451.48 
Outpatient Medical Services,DUPLEX IMAGING,93971,One sided or limited bilateral study,921,$254.66 ,$150.03 ,100% of APC Rate,$93.78 ,100% of Medicare OPPS,$178.26 ,70% of total billed charges,$216.16 ,84.88% of total billed charges,$159.19 ,139.08% of custom fee schedule,$93.78 ,100% of Medicare OPPS,$191.00 ,75% of total billed charges,$178.26 ,70% of total billed charges,$159.41 ,170% of Medicare OPPS,$201.62 ,215% of Medicare OPPS,$32.70 ,12.84% of total billed charges,$164.11 ,175% of Medicare OPPS,$93.78 ,100% of Medicare OPPS,$203.73 ,80% of total billed charges,$131.28 ,140% of Medicare OPPS,$117.22 ,125% of Medicare OPPS,$32.70 ,12.84% of LA Medicaid fee schedule,$32.70 ,12.84% of LA Medicaid fee schedule,$93.78 ,100% of Medicare OPPS,$193.00 ,100% of UHC Case Rate,$93.78 ,100% of Medicare OPPS,$93.78 ,100% of Medicare OPPS,$164.11 ,100% of Medicare OPPS,$93.78 ,100% of Medicare OPPS,$160.08 ,100% of custom fee schedule,$229.19 ,90% of total billed charges,$32.70 ,$229.19 ,$254.66 
Outpatient Medical Services,CT SCAN,72131,CT scan of lower spine without dye,352,"$2,290.05 ",$150.03 ,100% of APC Rate,$93.78 ,100% of Medicare OPPS,"$1,603.04 ",70% of total billed charges,"$1,943.79 ",84.88% of total billed charges,$159.19 ,139.08% of custom fee schedule,$93.78 ,100% of Medicare OPPS,"$1,717.54 ",75% of total billed charges,"$1,603.04 ",70% of total billed charges,$159.41 ,170% of Medicare OPPS,$201.62 ,215% of Medicare OPPS,$294.04 ,12.84% of total billed charges,$164.11 ,175% of Medicare OPPS,$93.78 ,100% of Medicare OPPS,"$1,832.04 ",80% of total billed charges,$131.28 ,140% of Medicare OPPS,$117.22 ,125% of Medicare OPPS,$294.04 ,12.84% of LA Medicaid fee schedule,$294.04 ,12.84% of LA Medicaid fee schedule,$93.78 ,100% of Medicare OPPS,"$1,550.00 ",100% of UHC Case Rate,$93.78 ,100% of Medicare OPPS,$93.78 ,100% of Medicare OPPS,$164.11 ,100% of Medicare OPPS,$93.78 ,100% of Medicare OPPS,$150.45 ,100% of custom fee schedule,"$2,061.05 ",90% of total billed charges,$93.78 ,"$2,061.05 ","$1,717.54 "
Outpatient Medical Services,CT SCAN,72193,"CT scan, pelvis, with contrast",352,"$2,290.05 ",$253.17 ,100% of APC Rate,$158.22 ,100% of Medicare OPPS,"$1,603.04 ",70% of total billed charges,"$1,943.79 ",84.88% of total billed charges,$351.51 ,139.08% of custom fee schedule,$158.22 ,100% of Medicare OPPS,"$1,717.54 ",75% of total billed charges,"$1,603.04 ",70% of total billed charges,$268.99 ,170% of Medicare OPPS,$340.20 ,215% of Medicare OPPS,$294.04 ,12.84% of total billed charges,$276.89 ,175% of Medicare OPPS,$158.22 ,100% of Medicare OPPS,"$1,832.04 ",80% of total billed charges,$221.52 ,140% of Medicare OPPS,$197.78 ,125% of Medicare OPPS,$294.04 ,12.84% of LA Medicaid fee schedule,$294.04 ,12.84% of LA Medicaid fee schedule,$158.22 ,100% of Medicare OPPS,"$1,550.00 ",100% of UHC Case Rate,$158.22 ,100% of Medicare OPPS,$158.22 ,100% of Medicare OPPS,$276.89 ,100% of Medicare OPPS,$158.22 ,100% of Medicare OPPS,$296.21 ,100% of custom fee schedule,"$2,061.05 ",90% of total billed charges,$158.22 ,"$2,061.05 ","$1,717.54 "
Outpatient Medical Services,CT SCAN,74150,CT of abdomen without dye,352,"$2,290.05 ",$150.03 ,100% of APC Rate,$93.78 ,100% of Medicare OPPS,"$1,603.04 ",70% of total billed charges,"$1,943.79 ",84.88% of total billed charges,$159.19 ,139.08% of custom fee schedule,$93.78 ,100% of Medicare OPPS,"$1,717.54 ",75% of total billed charges,"$1,603.04 ",70% of total billed charges,$159.41 ,170% of Medicare OPPS,$201.62 ,215% of Medicare OPPS,$294.04 ,12.84% of total billed charges,$164.11 ,175% of Medicare OPPS,$93.78 ,100% of Medicare OPPS,"$1,832.04 ",80% of total billed charges,$131.28 ,140% of Medicare OPPS,$117.22 ,125% of Medicare OPPS,$294.04 ,12.84% of LA Medicaid fee schedule,$294.04 ,12.84% of LA Medicaid fee schedule,$93.78 ,100% of Medicare OPPS,"$1,550.00 ",100% of UHC Case Rate,$93.78 ,100% of Medicare OPPS,$93.78 ,100% of Medicare OPPS,$164.11 ,100% of Medicare OPPS,$93.78 ,100% of Medicare OPPS,$150.45 ,100% of custom fee schedule,"$2,061.05 ",90% of total billed charges,$93.78 ,"$2,061.05 ","$1,717.54 "
Outpatient Medical Services,CT SCAN,74160,CT of abdomen with dye,352,"$2,290.05 ",$253.17 ,100% of APC Rate,$158.22 ,100% of Medicare OPPS,"$1,603.04 ",70% of total billed charges,"$1,943.79 ",84.88% of total billed charges,$351.51 ,139.08% of custom fee schedule,$158.22 ,100% of Medicare OPPS,"$1,717.54 ",75% of total billed charges,"$1,603.04 ",70% of total billed charges,$268.99 ,170% of Medicare OPPS,$340.20 ,215% of Medicare OPPS,$294.04 ,12.84% of total billed charges,$276.89 ,175% of Medicare OPPS,$158.22 ,100% of Medicare OPPS,"$1,832.04 ",80% of total billed charges,$221.52 ,140% of Medicare OPPS,$197.78 ,125% of Medicare OPPS,$294.04 ,12.84% of LA Medicaid fee schedule,$294.04 ,12.84% of LA Medicaid fee schedule,$158.22 ,100% of Medicare OPPS,"$1,550.00 ",100% of UHC Case Rate,$158.22 ,100% of Medicare OPPS,$158.22 ,100% of Medicare OPPS,$276.89 ,100% of Medicare OPPS,$158.22 ,100% of Medicare OPPS,$296.21 ,100% of custom fee schedule,"$2,061.05 ",90% of total billed charges,$158.22 ,"$2,061.05 ","$1,717.54 "
Outpatient Medical Services,CT SCAN,74170,CT of abdomen with and without dye,352,"$2,290.05 ",$253.17 ,100% of APC Rate,$158.22 ,100% of Medicare OPPS,"$1,603.04 ",70% of total billed charges,"$1,943.79 ",84.88% of total billed charges,$351.51 ,139.08% of custom fee schedule,$158.22 ,100% of Medicare OPPS,"$1,717.54 ",75% of total billed charges,"$1,603.04 ",70% of total billed charges,$268.99 ,170% of Medicare OPPS,$340.20 ,215% of Medicare OPPS,$294.04 ,12.84% of total billed charges,$276.89 ,175% of Medicare OPPS,$158.22 ,100% of Medicare OPPS,"$1,832.04 ",80% of total billed charges,$221.52 ,140% of Medicare OPPS,$197.78 ,125% of Medicare OPPS,$294.04 ,12.84% of LA Medicaid fee schedule,$294.04 ,12.84% of LA Medicaid fee schedule,$158.22 ,100% of Medicare OPPS,"$1,550.00 ",100% of UHC Case Rate,$158.22 ,100% of Medicare OPPS,$158.22 ,100% of Medicare OPPS,$276.89 ,100% of Medicare OPPS,$158.22 ,100% of Medicare OPPS,$333.56 ,100% of custom fee schedule,"$2,061.05 ",90% of total billed charges,$158.22 ,"$2,061.05 ","$1,717.54 "
Outpatient Medical Services,CT SCAN,74176,CT of abdomen and pelvis without dye,352,"$2,290.05 ",$327.83 ,100% of APC Rate,$204.89 ,100% of Medicare OPPS,"$1,603.04 ",70% of total billed charges,"$1,943.79 ",84.88% of total billed charges,$323.10 ,139.08% of custom fee schedule,$204.89 ,100% of Medicare OPPS,"$1,717.54 ",75% of total billed charges,"$1,603.04 ",70% of total billed charges,$348.31 ,170% of Medicare OPPS,$440.51 ,215% of Medicare OPPS,$294.04 ,12.84% of total billed charges,$358.56 ,175% of Medicare OPPS,$204.89 ,100% of Medicare OPPS,"$1,832.04 ",80% of total billed charges,$286.83 ,140% of Medicare OPPS,$256.11 ,125% of Medicare OPPS,$294.04 ,12.84% of LA Medicaid fee schedule,$294.04 ,12.84% of LA Medicaid fee schedule,$204.89 ,100% of Medicare OPPS,"$1,550.00 ",100% of UHC Case Rate,$204.89 ,100% of Medicare OPPS,$204.89 ,100% of Medicare OPPS,$358.56 ,100% of Medicare OPPS,$204.89 ,100% of Medicare OPPS,$287.63 ,100% of custom fee schedule,"$2,061.05 ",90% of total billed charges,$204.89 ,"$2,061.05 ","$1,717.54 "
Outpatient Medical Services,CT SCAN,74177,CT scan of abdomen and pelvis with contrast,352,"$2,290.05 ",$517.22 ,100% of APC Rate,$323.26 ,100% of Medicare OPPS,"$1,603.04 ",70% of total billed charges,"$1,943.79 ",84.88% of total billed charges,$351.51 ,139.08% of custom fee schedule,$323.26 ,100% of Medicare OPPS,"$1,717.54 ",75% of total billed charges,"$1,603.04 ",70% of total billed charges,$549.54 ,170% of Medicare OPPS,$695.02 ,215% of Medicare OPPS,$294.04 ,12.84% of total billed charges,$565.71 ,175% of Medicare OPPS,$323.26 ,100% of Medicare OPPS,"$1,832.04 ",80% of total billed charges,$452.57 ,140% of Medicare OPPS,$404.07 ,125% of Medicare OPPS,$294.04 ,12.84% of LA Medicaid fee schedule,$294.04 ,12.84% of LA Medicaid fee schedule,$323.26 ,100% of Medicare OPPS,"$1,550.00 ",100% of UHC Case Rate,$323.26 ,100% of Medicare OPPS,$323.26 ,100% of Medicare OPPS,$565.71 ,100% of Medicare OPPS,$323.26 ,100% of Medicare OPPS,$464.09 ,100% of custom fee schedule,"$2,061.05 ",90% of total billed charges,$294.04 ,"$2,061.05 ","$1,717.54 "
Outpatient Medical Services,CT SCAN,74178,"Computed tomography, abdomen and pelvis; without contrast material in one or both body regions, followed by contrast material(s) and further sections ",352,"$2,290.05 ",$517.22 ,100% of APC Rate,$323.26 ,100% of Medicare OPPS,"$1,603.04 ",70% of total billed charges,"$1,943.79 ",84.88% of total billed charges,$351.51 ,139.08% of custom fee schedule,$323.26 ,100% of Medicare OPPS,"$1,717.54 ",75% of total billed charges,"$1,603.04 ",70% of total billed charges,$549.54 ,170% of Medicare OPPS,$695.02 ,215% of Medicare OPPS,$294.04 ,12.84% of total billed charges,$565.71 ,175% of Medicare OPPS,$323.26 ,100% of Medicare OPPS,"$1,832.04 ",80% of total billed charges,$452.57 ,140% of Medicare OPPS,$404.07 ,125% of Medicare OPPS,$294.04 ,12.84% of LA Medicaid fee schedule,$294.04 ,12.84% of LA Medicaid fee schedule,$323.26 ,100% of Medicare OPPS,"$1,550.00 ",100% of UHC Case Rate,$323.26 ,100% of Medicare OPPS,$323.26 ,100% of Medicare OPPS,$565.71 ,100% of Medicare OPPS,$323.26 ,100% of Medicare OPPS,$464.09 ,100% of custom fee schedule,"$2,061.05 ",90% of total billed charges,$294.04 ,"$2,061.05 ","$1,717.54 "
Outpatient Medical Services,CT SCAN,73700,CT scan of leg without dye,359,"$2,290.05 ",$150.03 ,100% of APC Rate,$93.78 ,100% of Medicare OPPS,"$1,603.04 ",70% of total billed charges,"$1,943.79 ",84.88% of total billed charges,$159.19 ,139.08% of custom fee schedule,$93.78 ,100% of Medicare OPPS,"$1,717.54 ",75% of total billed charges,"$1,603.04 ",70% of total billed charges,$159.41 ,170% of Medicare OPPS,$201.62 ,215% of Medicare OPPS,$294.04 ,12.84% of total billed charges,$164.11 ,175% of Medicare OPPS,$93.78 ,100% of Medicare OPPS,"$1,832.04 ",80% of total billed charges,$131.28 ,140% of Medicare OPPS,$117.22 ,125% of Medicare OPPS,$294.04 ,12.84% of LA Medicaid fee schedule,$294.04 ,12.84% of LA Medicaid fee schedule,$93.78 ,100% of Medicare OPPS,"$1,550.00 ",100% of UHC Case Rate,$93.78 ,100% of Medicare OPPS,$93.78 ,100% of Medicare OPPS,$164.11 ,100% of Medicare OPPS,$93.78 ,100% of Medicare OPPS,$150.45 ,100% of custom fee schedule,"$2,061.05 ",90% of total billed charges,$93.78 ,"$2,061.05 ","$1,717.54 "
Outpatient Medical Services,RADIOLOGY,74246,x-ray exam upper gastrointestinal tract,320,$323.00 ,$253.17 ,100% of APC Rate,$158.23 ,100% of Medicare OPPS,$226.10 ,70% of total billed charges,$274.16 ,84.88% of total billed charges,$351.51 ,139.08% of custom fee schedule,$158.23 ,100% of Medicare OPPS,$242.25 ,75% of total billed charges,$226.10 ,70% of total billed charges,$268.99 ,170% of Medicare OPPS,$340.20 ,215% of Medicare OPPS,$41.47 ,12.84% of total billed charges,$276.90 ,175% of Medicare OPPS,$158.23 ,100% of Medicare OPPS,$258.40 ,80% of total billed charges,$221.52 ,140% of Medicare OPPS,$197.79 ,125% of Medicare OPPS,$41.47 ,12.84% of LA Medicaid fee schedule,$41.47 ,12.84% of LA Medicaid fee schedule,$158.23 ,100% of Medicare OPPS,$128.00 ,100% of UHC Case Rate,$158.23 ,100% of Medicare OPPS,$158.23 ,100% of Medicare OPPS,$276.90 ,100% of Medicare OPPS,$158.23 ,100% of Medicare OPPS,$179.90 ,100% of custom fee schedule,$290.70 ,90% of total billed charges,$41.47 ,$351.51 ,$242.25 
Outpatient Medical Services,RADIOLOGY,70160,x-ray nasal bones,320,$143.24 ,$121.96 ,100% of APC Rate,$76.23 ,100% of Medicare OPPS,$100.27 ,70% of total billed charges,$121.58 ,84.88% of total billed charges,$86.40 ,139.08% of custom fee schedule,$76.23 ,100% of Medicare OPPS,$107.43 ,75% of total billed charges,$100.27 ,70% of total billed charges,$129.59 ,170% of Medicare OPPS,$163.89 ,215% of Medicare OPPS,$18.39 ,12.84% of total billed charges,$133.40 ,175% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$114.59 ,80% of total billed charges,$106.72 ,140% of Medicare OPPS,$95.28 ,125% of Medicare OPPS,$18.39 ,12.84% of LA Medicaid fee schedule,$18.39 ,12.84% of LA Medicaid fee schedule,$76.23 ,100% of Medicare OPPS,$128.00 ,100% of UHC Case Rate,$76.23 ,100% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$133.40 ,100% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$68.22 ,100% of custom fee schedule,$128.92 ,90% of total billed charges,$18.39 ,$163.89 ,$107.43 
Outpatient Medical Services,RADIOLOGY,70220,x-ray sinuses,320,$139.65 ,$121.96 ,100% of APC Rate,$76.23 ,100% of Medicare OPPS,$97.76 ,70% of total billed charges,$118.53 ,84.88% of total billed charges,$86.40 ,139.08% of custom fee schedule,$76.23 ,100% of Medicare OPPS,$104.74 ,75% of total billed charges,$97.76 ,70% of total billed charges,$129.59 ,170% of Medicare OPPS,$163.89 ,215% of Medicare OPPS,$17.93 ,12.84% of total billed charges,$133.40 ,175% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$111.72 ,80% of total billed charges,$106.72 ,140% of Medicare OPPS,$95.28 ,125% of Medicare OPPS,$17.93 ,12.84% of LA Medicaid fee schedule,$17.93 ,12.84% of LA Medicaid fee schedule,$76.23 ,100% of Medicare OPPS,$128.00 ,100% of UHC Case Rate,$76.23 ,100% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$133.40 ,100% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$68.22 ,100% of custom fee schedule,$125.69 ,90% of total billed charges,$17.93 ,$163.89 ,$104.74 
Outpatient Medical Services,RADIOLOGY,70360,x-ray neck soft tissue,320,$143.24 ,$121.96 ,100% of APC Rate,$76.23 ,100% of Medicare OPPS,$100.27 ,70% of total billed charges,$121.58 ,84.88% of total billed charges,$86.40 ,139.08% of custom fee schedule,$76.23 ,100% of Medicare OPPS,$107.43 ,75% of total billed charges,$100.27 ,70% of total billed charges,$129.59 ,170% of Medicare OPPS,$163.89 ,215% of Medicare OPPS,$18.39 ,12.84% of total billed charges,$133.40 ,175% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$114.59 ,80% of total billed charges,$106.72 ,140% of Medicare OPPS,$95.28 ,125% of Medicare OPPS,$18.39 ,12.84% of LA Medicaid fee schedule,$18.39 ,12.84% of LA Medicaid fee schedule,$76.23 ,100% of Medicare OPPS,$128.00 ,100% of UHC Case Rate,$76.23 ,100% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$133.40 ,100% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$68.22 ,100% of custom fee schedule,$128.92 ,90% of total billed charges,$18.39 ,$163.89 ,$107.43 
Outpatient Medical Services,RADIOLOGY,71110,x-ray ribs bilat,320,$197.35 ,$150.04 ,100% of APC Rate,$93.77 ,100% of Medicare OPPS,$138.15 ,70% of total billed charges,$167.51 ,84.88% of total billed charges,$159.19 ,139.08% of custom fee schedule,$93.77 ,100% of Medicare OPPS,$148.01 ,75% of total billed charges,$138.15 ,70% of total billed charges,$159.42 ,170% of Medicare OPPS,$201.62 ,215% of Medicare OPPS,$25.34 ,12.84% of total billed charges,$164.11 ,175% of Medicare OPPS,$93.77 ,100% of Medicare OPPS,$157.88 ,80% of total billed charges,$131.29 ,140% of Medicare OPPS,$117.22 ,125% of Medicare OPPS,$25.34 ,12.84% of LA Medicaid fee schedule,$25.34 ,12.84% of LA Medicaid fee schedule,$93.77 ,100% of Medicare OPPS,$128.00 ,100% of UHC Case Rate,$93.77 ,100% of Medicare OPPS,$93.77 ,100% of Medicare OPPS,$164.11 ,100% of Medicare OPPS,$93.77 ,100% of Medicare OPPS,$108.12 ,100% of custom fee schedule,$177.62 ,90% of total billed charges,$25.34 ,$201.62 ,$148.01 
Outpatient Medical Services,RADIOLOGY,72040,"Radiologic examination of the neck/spine, 2-3 views",320,$141.88 ,$121.96 ,100% of APC Rate,$76.23 ,100% of Medicare OPPS,$99.32 ,70% of total billed charges,$120.43 ,84.88% of total billed charges,$86.40 ,139.08% of custom fee schedule,$76.23 ,100% of Medicare OPPS,$106.41 ,75% of total billed charges,$99.32 ,70% of total billed charges,$129.59 ,170% of Medicare OPPS,$163.89 ,215% of Medicare OPPS,$18.22 ,12.84% of total billed charges,$133.40 ,175% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$113.50 ,80% of total billed charges,$106.72 ,140% of Medicare OPPS,$95.28 ,125% of Medicare OPPS,$18.22 ,12.84% of LA Medicaid fee schedule,$18.22 ,12.84% of LA Medicaid fee schedule,$76.23 ,100% of Medicare OPPS,$128.00 ,100% of UHC Case Rate,$76.23 ,100% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$133.40 ,100% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$68.22 ,100% of custom fee schedule,$127.69 ,90% of total billed charges,$18.22 ,$163.89 ,$106.41 
Outpatient Medical Services,RADIOLOGY,72050,"Radiologic examination of the neck/spine, 4-5 views",320,$197.35 ,$150.04 ,100% of APC Rate,$93.77 ,100% of Medicare OPPS,$138.15 ,70% of total billed charges,$167.51 ,84.88% of total billed charges,$159.19 ,139.08% of custom fee schedule,$93.77 ,100% of Medicare OPPS,$148.01 ,75% of total billed charges,$138.15 ,70% of total billed charges,$159.42 ,170% of Medicare OPPS,$201.62 ,215% of Medicare OPPS,$25.34 ,12.84% of total billed charges,$164.11 ,175% of Medicare OPPS,$93.77 ,100% of Medicare OPPS,$157.88 ,80% of total billed charges,$131.29 ,140% of Medicare OPPS,$117.22 ,125% of Medicare OPPS,$25.34 ,12.84% of LA Medicaid fee schedule,$25.34 ,12.84% of LA Medicaid fee schedule,$93.77 ,100% of Medicare OPPS,$128.00 ,100% of UHC Case Rate,$93.77 ,100% of Medicare OPPS,$93.77 ,100% of Medicare OPPS,$164.11 ,100% of Medicare OPPS,$93.77 ,100% of Medicare OPPS,$108.12 ,100% of custom fee schedule,$177.62 ,90% of total billed charges,$25.34 ,$201.62 ,$148.01 
Outpatient Medical Services,RADIOLOGY,72070,"Radiologic examination of the middle spine, 2 views",320,$197.35 ,$150.04 ,100% of APC Rate,$93.77 ,100% of Medicare OPPS,$138.15 ,70% of total billed charges,$167.51 ,84.88% of total billed charges,$159.19 ,139.08% of custom fee schedule,$93.77 ,100% of Medicare OPPS,$148.01 ,75% of total billed charges,$138.15 ,70% of total billed charges,$159.42 ,170% of Medicare OPPS,$201.62 ,215% of Medicare OPPS,$25.34 ,12.84% of total billed charges,$164.11 ,175% of Medicare OPPS,$93.77 ,100% of Medicare OPPS,$157.88 ,80% of total billed charges,$131.29 ,140% of Medicare OPPS,$117.22 ,125% of Medicare OPPS,$25.34 ,12.84% of LA Medicaid fee schedule,$25.34 ,12.84% of LA Medicaid fee schedule,$93.77 ,100% of Medicare OPPS,$128.00 ,100% of UHC Case Rate,$93.77 ,100% of Medicare OPPS,$93.77 ,100% of Medicare OPPS,$164.11 ,100% of Medicare OPPS,$93.77 ,100% of Medicare OPPS,$68.22 ,100% of custom fee schedule,$177.62 ,90% of total billed charges,$25.34 ,$201.62 ,$148.01 
Outpatient Medical Services,RADIOLOGY,72072,"Radiologic examination of the middle spine, 3 views",320,$197.35 ,$150.04 ,100% of APC Rate,$93.77 ,100% of Medicare OPPS,$138.15 ,70% of total billed charges,$167.51 ,84.88% of total billed charges,$159.19 ,139.08% of custom fee schedule,$93.77 ,100% of Medicare OPPS,$148.01 ,75% of total billed charges,$138.15 ,70% of total billed charges,$159.42 ,170% of Medicare OPPS,$201.62 ,215% of Medicare OPPS,$25.34 ,12.84% of total billed charges,$164.11 ,175% of Medicare OPPS,$93.77 ,100% of Medicare OPPS,$157.88 ,80% of total billed charges,$131.29 ,140% of Medicare OPPS,$117.22 ,125% of Medicare OPPS,$25.34 ,12.84% of LA Medicaid fee schedule,$25.34 ,12.84% of LA Medicaid fee schedule,$93.77 ,100% of Medicare OPPS,$128.00 ,100% of UHC Case Rate,$93.77 ,100% of Medicare OPPS,$93.77 ,100% of Medicare OPPS,$164.11 ,100% of Medicare OPPS,$93.77 ,100% of Medicare OPPS,$108.12 ,100% of custom fee schedule,$177.62 ,90% of total billed charges,$25.34 ,$201.62 ,$148.01 
Outpatient Medical Services,RADIOLOGY,72100,X-ray of the lower spine 2-3 views,320,$197.35 ,$150.04 ,100% of APC Rate,$93.77 ,100% of Medicare OPPS,$138.15 ,70% of total billed charges,$167.51 ,84.88% of total billed charges,$159.19 ,139.08% of custom fee schedule,$93.77 ,100% of Medicare OPPS,$148.01 ,75% of total billed charges,$138.15 ,70% of total billed charges,$159.42 ,170% of Medicare OPPS,$201.62 ,215% of Medicare OPPS,$25.34 ,12.84% of total billed charges,$164.11 ,175% of Medicare OPPS,$93.77 ,100% of Medicare OPPS,$157.88 ,80% of total billed charges,$131.29 ,140% of Medicare OPPS,$117.22 ,125% of Medicare OPPS,$25.34 ,12.84% of LA Medicaid fee schedule,$25.34 ,12.84% of LA Medicaid fee schedule,$93.77 ,100% of Medicare OPPS,$128.00 ,100% of UHC Case Rate,$93.77 ,100% of Medicare OPPS,$93.77 ,100% of Medicare OPPS,$164.11 ,100% of Medicare OPPS,$93.77 ,100% of Medicare OPPS,$68.22 ,100% of custom fee schedule,$177.62 ,90% of total billed charges,$25.34 ,$201.62 ,$148.01 
Outpatient Medical Services,RADIOLOGY,72114,x-ray spine lumbosacral,320,$197.35 ,$150.04 ,100% of APC Rate,$93.77 ,100% of Medicare OPPS,$138.15 ,70% of total billed charges,$167.51 ,84.88% of total billed charges,$159.19 ,139.08% of custom fee schedule,$93.77 ,100% of Medicare OPPS,$148.01 ,75% of total billed charges,$138.15 ,70% of total billed charges,$159.42 ,170% of Medicare OPPS,$201.62 ,215% of Medicare OPPS,$25.34 ,12.84% of total billed charges,$164.11 ,175% of Medicare OPPS,$93.77 ,100% of Medicare OPPS,$157.88 ,80% of total billed charges,$131.29 ,140% of Medicare OPPS,$117.22 ,125% of Medicare OPPS,$25.34 ,12.84% of LA Medicaid fee schedule,$25.34 ,12.84% of LA Medicaid fee schedule,$93.77 ,100% of Medicare OPPS,$128.00 ,100% of UHC Case Rate,$93.77 ,100% of Medicare OPPS,$93.77 ,100% of Medicare OPPS,$164.11 ,100% of Medicare OPPS,$93.77 ,100% of Medicare OPPS,$108.12 ,100% of custom fee schedule,$177.62 ,90% of total billed charges,$25.34 ,$201.62 ,$148.01 
Outpatient Medical Services,RADIOLOGY,72170,Radiologic examination of the pelvis,320,$197.35 ,$150.04 ,100% of APC Rate,$93.77 ,100% of Medicare OPPS,$138.15 ,70% of total billed charges,$167.51 ,84.88% of total billed charges,$159.19 ,139.08% of custom fee schedule,$93.77 ,100% of Medicare OPPS,$148.01 ,75% of total billed charges,$138.15 ,70% of total billed charges,$159.42 ,170% of Medicare OPPS,$201.62 ,215% of Medicare OPPS,$25.34 ,12.84% of total billed charges,$164.11 ,175% of Medicare OPPS,$93.77 ,100% of Medicare OPPS,$157.88 ,80% of total billed charges,$131.29 ,140% of Medicare OPPS,$117.22 ,125% of Medicare OPPS,$25.34 ,12.84% of LA Medicaid fee schedule,$25.34 ,12.84% of LA Medicaid fee schedule,$93.77 ,100% of Medicare OPPS,$128.00 ,100% of UHC Case Rate,$93.77 ,100% of Medicare OPPS,$93.77 ,100% of Medicare OPPS,$164.11 ,100% of Medicare OPPS,$93.77 ,100% of Medicare OPPS,$68.22 ,100% of custom fee schedule,$177.62 ,90% of total billed charges,$25.34 ,$201.62 ,$148.01 
Outpatient Medical Services,RADIOLOGY,72220,x-ray sacrum & coccyx,320,$143.24 ,$121.96 ,100% of APC Rate,$76.23 ,100% of Medicare OPPS,$100.27 ,70% of total billed charges,$121.58 ,84.88% of total billed charges,$86.40 ,139.08% of custom fee schedule,$76.23 ,100% of Medicare OPPS,$107.43 ,75% of total billed charges,$100.27 ,70% of total billed charges,$129.59 ,170% of Medicare OPPS,$163.89 ,215% of Medicare OPPS,$18.39 ,12.84% of total billed charges,$133.40 ,175% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$114.59 ,80% of total billed charges,$106.72 ,140% of Medicare OPPS,$95.28 ,125% of Medicare OPPS,$18.39 ,12.84% of LA Medicaid fee schedule,$18.39 ,12.84% of LA Medicaid fee schedule,$76.23 ,100% of Medicare OPPS,$128.00 ,100% of UHC Case Rate,$76.23 ,100% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$133.40 ,100% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$68.22 ,100% of custom fee schedule,$128.92 ,90% of total billed charges,$18.39 ,$163.89 ,$107.43 
Outpatient Medical Services,RADIOLOGY,73030,Radiologic examination of the shoulder,320,$151.73 ,$121.96 ,100% of APC Rate,$76.23 ,100% of Medicare OPPS,$106.21 ,70% of total billed charges,$128.79 ,84.88% of total billed charges,$86.40 ,139.08% of custom fee schedule,$76.23 ,100% of Medicare OPPS,$113.80 ,75% of total billed charges,$106.21 ,70% of total billed charges,$129.59 ,170% of Medicare OPPS,$163.89 ,215% of Medicare OPPS,$19.48 ,12.84% of total billed charges,$133.40 ,175% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$121.38 ,80% of total billed charges,$106.72 ,140% of Medicare OPPS,$95.28 ,125% of Medicare OPPS,$19.48 ,12.84% of LA Medicaid fee schedule,$19.48 ,12.84% of LA Medicaid fee schedule,$76.23 ,100% of Medicare OPPS,$128.00 ,100% of UHC Case Rate,$76.23 ,100% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$133.40 ,100% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$68.22 ,100% of custom fee schedule,$136.56 ,90% of total billed charges,$19.48 ,$163.89 ,$113.80 
Outpatient Medical Services,RADIOLOGY,73060,x-ray humerus 2 views,320,$143.24 ,$121.96 ,100% of APC Rate,$76.23 ,100% of Medicare OPPS,$100.27 ,70% of total billed charges,$121.58 ,84.88% of total billed charges,$86.40 ,139.08% of custom fee schedule,$76.23 ,100% of Medicare OPPS,$107.43 ,75% of total billed charges,$100.27 ,70% of total billed charges,$129.59 ,170% of Medicare OPPS,$163.89 ,215% of Medicare OPPS,$18.39 ,12.84% of total billed charges,$133.40 ,175% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$114.59 ,80% of total billed charges,$106.72 ,140% of Medicare OPPS,$95.28 ,125% of Medicare OPPS,$18.39 ,12.84% of LA Medicaid fee schedule,$18.39 ,12.84% of LA Medicaid fee schedule,$76.23 ,100% of Medicare OPPS,$128.00 ,100% of UHC Case Rate,$76.23 ,100% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$133.40 ,100% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$68.22 ,100% of custom fee schedule,$128.92 ,90% of total billed charges,$18.39 ,$163.89 ,$107.43 
Outpatient Medical Services,RADIOLOGY,73080,"Radiologic examination, elbow; 3 or more views",320,$143.24 ,$121.96 ,100% of APC Rate,$76.23 ,100% of Medicare OPPS,$100.27 ,70% of total billed charges,$121.58 ,84.88% of total billed charges,$86.40 ,139.08% of custom fee schedule,$76.23 ,100% of Medicare OPPS,$107.43 ,75% of total billed charges,$100.27 ,70% of total billed charges,$129.59 ,170% of Medicare OPPS,$163.89 ,215% of Medicare OPPS,$18.39 ,12.84% of total billed charges,$133.40 ,175% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$114.59 ,80% of total billed charges,$106.72 ,140% of Medicare OPPS,$95.28 ,125% of Medicare OPPS,$18.39 ,12.84% of LA Medicaid fee schedule,$18.39 ,12.84% of LA Medicaid fee schedule,$76.23 ,100% of Medicare OPPS,$128.00 ,100% of UHC Case Rate,$76.23 ,100% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$133.40 ,100% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$68.22 ,100% of custom fee schedule,$128.92 ,90% of total billed charges,$18.39 ,$163.89 ,$107.43 
Outpatient Medical Services,RADIOLOGY,73090,Radiologic examination of the forearm,320,$143.24 ,$121.96 ,100% of APC Rate,$76.23 ,100% of Medicare OPPS,$100.27 ,70% of total billed charges,$121.58 ,84.88% of total billed charges,$86.40 ,139.08% of custom fee schedule,$76.23 ,100% of Medicare OPPS,$107.43 ,75% of total billed charges,$100.27 ,70% of total billed charges,$129.59 ,170% of Medicare OPPS,$163.89 ,215% of Medicare OPPS,$18.39 ,12.84% of total billed charges,$133.40 ,175% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$114.59 ,80% of total billed charges,$106.72 ,140% of Medicare OPPS,$95.28 ,125% of Medicare OPPS,$18.39 ,12.84% of LA Medicaid fee schedule,$18.39 ,12.84% of LA Medicaid fee schedule,$76.23 ,100% of Medicare OPPS,$128.00 ,100% of UHC Case Rate,$76.23 ,100% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$133.40 ,100% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$68.22 ,100% of custom fee schedule,$128.92 ,90% of total billed charges,$18.39 ,$163.89 ,$107.43 
Outpatient Medical Services,RADIOLOGY,73110,Up to 3 views,320,$143.24 ,$121.96 ,100% of APC Rate,$76.23 ,100% of Medicare OPPS,$100.27 ,70% of total billed charges,$121.58 ,84.88% of total billed charges,$86.40 ,139.08% of custom fee schedule,$76.23 ,100% of Medicare OPPS,$107.43 ,75% of total billed charges,$100.27 ,70% of total billed charges,$129.59 ,170% of Medicare OPPS,$163.89 ,215% of Medicare OPPS,$18.39 ,12.84% of total billed charges,$133.40 ,175% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$114.59 ,80% of total billed charges,$106.72 ,140% of Medicare OPPS,$95.28 ,125% of Medicare OPPS,$18.39 ,12.84% of LA Medicaid fee schedule,$18.39 ,12.84% of LA Medicaid fee schedule,$76.23 ,100% of Medicare OPPS,$128.00 ,100% of UHC Case Rate,$76.23 ,100% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$133.40 ,100% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$68.22 ,100% of custom fee schedule,$128.92 ,90% of total billed charges,$18.39 ,$163.89 ,$107.43 
Outpatient Medical Services,RADIOLOGY,73130,X-ray of the hand with 3 or more views,320,$141.88 ,$121.96 ,100% of APC Rate,$76.23 ,100% of Medicare OPPS,$99.32 ,70% of total billed charges,$120.43 ,84.88% of total billed charges,$86.40 ,139.08% of custom fee schedule,$76.23 ,100% of Medicare OPPS,$106.41 ,75% of total billed charges,$99.32 ,70% of total billed charges,$129.59 ,170% of Medicare OPPS,$163.89 ,215% of Medicare OPPS,$18.22 ,12.84% of total billed charges,$133.40 ,175% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$113.50 ,80% of total billed charges,$106.72 ,140% of Medicare OPPS,$95.28 ,125% of Medicare OPPS,$18.22 ,12.84% of LA Medicaid fee schedule,$18.22 ,12.84% of LA Medicaid fee schedule,$76.23 ,100% of Medicare OPPS,$128.00 ,100% of UHC Case Rate,$76.23 ,100% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$133.40 ,100% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$68.22 ,100% of custom fee schedule,$127.69 ,90% of total billed charges,$18.22 ,$163.89 ,$106.41 
Outpatient Medical Services,RADIOLOGY,73140,Radiologic examination of the finger(s),320,$143.24 ,$121.96 ,100% of APC Rate,$76.23 ,100% of Medicare OPPS,$100.27 ,70% of total billed charges,$121.58 ,84.88% of total billed charges,$86.40 ,139.08% of custom fee schedule,$76.23 ,100% of Medicare OPPS,$107.43 ,75% of total billed charges,$100.27 ,70% of total billed charges,$129.59 ,170% of Medicare OPPS,$163.89 ,215% of Medicare OPPS,$18.39 ,12.84% of total billed charges,$133.40 ,175% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$114.59 ,80% of total billed charges,$106.72 ,140% of Medicare OPPS,$95.28 ,125% of Medicare OPPS,$18.39 ,12.84% of LA Medicaid fee schedule,$18.39 ,12.84% of LA Medicaid fee schedule,$76.23 ,100% of Medicare OPPS,$128.00 ,100% of UHC Case Rate,$76.23 ,100% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$133.40 ,100% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$68.22 ,100% of custom fee schedule,$128.92 ,90% of total billed charges,$18.39 ,$163.89 ,$107.43 
Outpatient Medical Services,RADIOLOGY,73502,x-ray hip unilateral,320,$143.24 ,$121.96 ,100% of APC Rate,$76.23 ,100% of Medicare OPPS,$100.27 ,70% of total billed charges,$121.58 ,84.88% of total billed charges,$86.40 ,139.08% of custom fee schedule,$76.23 ,100% of Medicare OPPS,$107.43 ,75% of total billed charges,$100.27 ,70% of total billed charges,$129.59 ,170% of Medicare OPPS,$163.89 ,215% of Medicare OPPS,$18.39 ,12.84% of total billed charges,$133.40 ,175% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$114.59 ,80% of total billed charges,$106.72 ,140% of Medicare OPPS,$95.28 ,125% of Medicare OPPS,$18.39 ,12.84% of LA Medicaid fee schedule,$18.39 ,12.84% of LA Medicaid fee schedule,$76.23 ,100% of Medicare OPPS,$128.00 ,100% of UHC Case Rate,$76.23 ,100% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$133.40 ,100% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$40.28 ,100% of custom fee schedule,$128.92 ,90% of total billed charges,$18.39 ,$163.89 ,$107.43 
Outpatient Medical Services,RADIOLOGY,73521,x-ray hips bilateral 2 views,320,$197.35 ,$150.04 ,100% of APC Rate,$93.77 ,100% of Medicare OPPS,$138.15 ,70% of total billed charges,$167.51 ,84.88% of total billed charges,$159.19 ,139.08% of custom fee schedule,$93.77 ,100% of Medicare OPPS,$148.01 ,75% of total billed charges,$138.15 ,70% of total billed charges,$159.42 ,170% of Medicare OPPS,$201.62 ,215% of Medicare OPPS,$25.34 ,12.84% of total billed charges,$164.11 ,175% of Medicare OPPS,$93.77 ,100% of Medicare OPPS,$157.88 ,80% of total billed charges,$131.29 ,140% of Medicare OPPS,$117.22 ,125% of Medicare OPPS,$25.34 ,12.84% of LA Medicaid fee schedule,$25.34 ,12.84% of LA Medicaid fee schedule,$93.77 ,100% of Medicare OPPS,$128.00 ,100% of UHC Case Rate,$93.77 ,100% of Medicare OPPS,$93.77 ,100% of Medicare OPPS,$164.11 ,100% of Medicare OPPS,$93.77 ,100% of Medicare OPPS,$38.61 ,100% of custom fee schedule,$177.62 ,90% of total billed charges,$25.34 ,$201.62 ,$148.01 
Outpatient Medical Services,RADIOLOGY,73552,x-ray femur,320,$143.24 ,$121.96 ,100% of APC Rate,$76.23 ,100% of Medicare OPPS,$100.27 ,70% of total billed charges,$121.58 ,84.88% of total billed charges,$86.40 ,139.08% of custom fee schedule,$76.23 ,100% of Medicare OPPS,$107.43 ,75% of total billed charges,$100.27 ,70% of total billed charges,$129.59 ,170% of Medicare OPPS,$163.89 ,215% of Medicare OPPS,$18.39 ,12.84% of total billed charges,$133.40 ,175% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$114.59 ,80% of total billed charges,$106.72 ,140% of Medicare OPPS,$95.28 ,125% of Medicare OPPS,$18.39 ,12.84% of LA Medicaid fee schedule,$18.39 ,12.84% of LA Medicaid fee schedule,$76.23 ,100% of Medicare OPPS,$128.00 ,100% of UHC Case Rate,$76.23 ,100% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$133.40 ,100% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$31.75 ,100% of custom fee schedule,$128.92 ,90% of total billed charges,$18.39 ,$163.89 ,$107.43 
Outpatient Medical Services,RADIOLOGY,73560,Radiologic examination of the knee with 1 or 2 views,320,$143.24 ,$121.96 ,100% of APC Rate,$76.23 ,100% of Medicare OPPS,$100.27 ,70% of total billed charges,$121.58 ,84.88% of total billed charges,$86.40 ,139.08% of custom fee schedule,$76.23 ,100% of Medicare OPPS,$107.43 ,75% of total billed charges,$100.27 ,70% of total billed charges,$129.59 ,170% of Medicare OPPS,$163.89 ,215% of Medicare OPPS,$18.39 ,12.84% of total billed charges,$133.40 ,175% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$114.59 ,80% of total billed charges,$106.72 ,140% of Medicare OPPS,$95.28 ,125% of Medicare OPPS,$18.39 ,12.84% of LA Medicaid fee schedule,$18.39 ,12.84% of LA Medicaid fee schedule,$76.23 ,100% of Medicare OPPS,$128.00 ,100% of UHC Case Rate,$76.23 ,100% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$133.40 ,100% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$68.22 ,100% of custom fee schedule,$128.92 ,90% of total billed charges,$18.39 ,$163.89 ,$107.43 
Outpatient Medical Services,RADIOLOGY,73562,Radiologic examination of the knee with 3 views,320,$143.24 ,$121.96 ,100% of APC Rate,$76.23 ,100% of Medicare OPPS,$100.27 ,70% of total billed charges,$121.58 ,84.88% of total billed charges,$86.40 ,139.08% of custom fee schedule,$76.23 ,100% of Medicare OPPS,$107.43 ,75% of total billed charges,$100.27 ,70% of total billed charges,$129.59 ,170% of Medicare OPPS,$163.89 ,215% of Medicare OPPS,$18.39 ,12.84% of total billed charges,$133.40 ,175% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$114.59 ,80% of total billed charges,$106.72 ,140% of Medicare OPPS,$95.28 ,125% of Medicare OPPS,$18.39 ,12.84% of LA Medicaid fee schedule,$18.39 ,12.84% of LA Medicaid fee schedule,$76.23 ,100% of Medicare OPPS,$128.00 ,100% of UHC Case Rate,$76.23 ,100% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$133.40 ,100% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$68.22 ,100% of custom fee schedule,$128.92 ,90% of total billed charges,$18.39 ,$163.89 ,$107.43 
Outpatient Medical Services,RADIOLOGY,73564,Radiologic examination of the knee with 4 or more views,320,$197.35 ,$150.04 ,100% of APC Rate,$93.77 ,100% of Medicare OPPS,$138.15 ,70% of total billed charges,$167.51 ,84.88% of total billed charges,$159.19 ,139.08% of custom fee schedule,$93.77 ,100% of Medicare OPPS,$148.01 ,75% of total billed charges,$138.15 ,70% of total billed charges,$159.42 ,170% of Medicare OPPS,$201.62 ,215% of Medicare OPPS,$25.34 ,12.84% of total billed charges,$164.11 ,175% of Medicare OPPS,$93.77 ,100% of Medicare OPPS,$157.88 ,80% of total billed charges,$131.29 ,140% of Medicare OPPS,$117.22 ,125% of Medicare OPPS,$25.34 ,12.84% of LA Medicaid fee schedule,$25.34 ,12.84% of LA Medicaid fee schedule,$93.77 ,100% of Medicare OPPS,$128.00 ,100% of UHC Case Rate,$93.77 ,100% of Medicare OPPS,$93.77 ,100% of Medicare OPPS,$164.11 ,100% of Medicare OPPS,$93.77 ,100% of Medicare OPPS,$68.22 ,100% of custom fee schedule,$177.62 ,90% of total billed charges,$25.34 ,$201.62 ,$148.01 
Outpatient Medical Services,RADIOLOGY,73590,Radiologic examination of the lower leg,320,$143.24 ,$121.96 ,100% of APC Rate,$76.23 ,100% of Medicare OPPS,$100.27 ,70% of total billed charges,$121.58 ,84.88% of total billed charges,$86.40 ,139.08% of custom fee schedule,$76.23 ,100% of Medicare OPPS,$107.43 ,75% of total billed charges,$100.27 ,70% of total billed charges,$129.59 ,170% of Medicare OPPS,$163.89 ,215% of Medicare OPPS,$18.39 ,12.84% of total billed charges,$133.40 ,175% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$114.59 ,80% of total billed charges,$106.72 ,140% of Medicare OPPS,$95.28 ,125% of Medicare OPPS,$18.39 ,12.84% of LA Medicaid fee schedule,$18.39 ,12.84% of LA Medicaid fee schedule,$76.23 ,100% of Medicare OPPS,$128.00 ,100% of UHC Case Rate,$76.23 ,100% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$133.40 ,100% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$68.22 ,100% of custom fee schedule,$128.92 ,90% of total billed charges,$18.39 ,$163.89 ,$107.43 
Outpatient Medical Services,RADIOLOGY,73610,Radiologic examination of the ankle with 3 views,320,$143.24 ,$121.96 ,100% of APC Rate,$76.23 ,100% of Medicare OPPS,$100.27 ,70% of total billed charges,$121.58 ,84.88% of total billed charges,$86.40 ,139.08% of custom fee schedule,$76.23 ,100% of Medicare OPPS,$107.43 ,75% of total billed charges,$100.27 ,70% of total billed charges,$129.59 ,170% of Medicare OPPS,$163.89 ,215% of Medicare OPPS,$18.39 ,12.84% of total billed charges,$133.40 ,175% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$114.59 ,80% of total billed charges,$106.72 ,140% of Medicare OPPS,$95.28 ,125% of Medicare OPPS,$18.39 ,12.84% of LA Medicaid fee schedule,$18.39 ,12.84% of LA Medicaid fee schedule,$76.23 ,100% of Medicare OPPS,$128.00 ,100% of UHC Case Rate,$76.23 ,100% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$133.40 ,100% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$68.22 ,100% of custom fee schedule,$128.92 ,90% of total billed charges,$18.39 ,$163.89 ,$107.43 
Outpatient Medical Services,RADIOLOGY,73630,Radiologic examination of the foot with 3 or more views,320,$143.24 ,$121.96 ,100% of APC Rate,$76.23 ,100% of Medicare OPPS,$100.27 ,70% of total billed charges,$121.58 ,84.88% of total billed charges,$86.40 ,139.08% of custom fee schedule,$76.23 ,100% of Medicare OPPS,$107.43 ,75% of total billed charges,$100.27 ,70% of total billed charges,$129.59 ,170% of Medicare OPPS,$163.89 ,215% of Medicare OPPS,$18.39 ,12.84% of total billed charges,$133.40 ,175% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$114.59 ,80% of total billed charges,$106.72 ,140% of Medicare OPPS,$95.28 ,125% of Medicare OPPS,$18.39 ,12.84% of LA Medicaid fee schedule,$18.39 ,12.84% of LA Medicaid fee schedule,$76.23 ,100% of Medicare OPPS,$128.00 ,100% of UHC Case Rate,$76.23 ,100% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$133.40 ,100% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$68.22 ,100% of custom fee schedule,$128.92 ,90% of total billed charges,$18.39 ,$163.89 ,$107.43 
Outpatient Medical Services,RADIOLOGY,73650,Radiologic examination of the heel,320,$143.24 ,$121.96 ,100% of APC Rate,$76.23 ,100% of Medicare OPPS,$100.27 ,70% of total billed charges,$121.58 ,84.88% of total billed charges,$86.40 ,139.08% of custom fee schedule,$76.23 ,100% of Medicare OPPS,$107.43 ,75% of total billed charges,$100.27 ,70% of total billed charges,$129.59 ,170% of Medicare OPPS,$163.89 ,215% of Medicare OPPS,$18.39 ,12.84% of total billed charges,$133.40 ,175% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$114.59 ,80% of total billed charges,$106.72 ,140% of Medicare OPPS,$95.28 ,125% of Medicare OPPS,$18.39 ,12.84% of LA Medicaid fee schedule,$18.39 ,12.84% of LA Medicaid fee schedule,$76.23 ,100% of Medicare OPPS,$128.00 ,100% of UHC Case Rate,$76.23 ,100% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$133.40 ,100% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$68.22 ,100% of custom fee schedule,$128.92 ,90% of total billed charges,$18.39 ,$163.89 ,$107.43 
Outpatient Medical Services,RADIOLOGY,73660,Radiologic examination of the toe(s),320,$143.24 ,$121.96 ,100% of APC Rate,$76.23 ,100% of Medicare OPPS,$100.27 ,70% of total billed charges,$121.58 ,84.88% of total billed charges,$86.40 ,139.08% of custom fee schedule,$76.23 ,100% of Medicare OPPS,$107.43 ,75% of total billed charges,$100.27 ,70% of total billed charges,$129.59 ,170% of Medicare OPPS,$163.89 ,215% of Medicare OPPS,$18.39 ,12.84% of total billed charges,$133.40 ,175% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$114.59 ,80% of total billed charges,$106.72 ,140% of Medicare OPPS,$95.28 ,125% of Medicare OPPS,$18.39 ,12.84% of LA Medicaid fee schedule,$18.39 ,12.84% of LA Medicaid fee schedule,$76.23 ,100% of Medicare OPPS,$128.00 ,100% of UHC Case Rate,$76.23 ,100% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$133.40 ,100% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$68.22 ,100% of custom fee schedule,$128.92 ,90% of total billed charges,$18.39 ,$163.89 ,$107.43 
Outpatient Medical Services,RADIOLOGY,74018,x-ray abdomen 1 view,320,$143.24 ,$121.96 ,100% of APC Rate,$76.23 ,100% of Medicare OPPS,$100.27 ,70% of total billed charges,$121.58 ,84.88% of total billed charges,$86.40 ,139.08% of custom fee schedule,$76.23 ,100% of Medicare OPPS,$107.43 ,75% of total billed charges,$100.27 ,70% of total billed charges,$129.59 ,170% of Medicare OPPS,$163.89 ,215% of Medicare OPPS,$18.39 ,12.84% of total billed charges,$133.40 ,175% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$114.59 ,80% of total billed charges,$106.72 ,140% of Medicare OPPS,$95.28 ,125% of Medicare OPPS,$18.39 ,12.84% of LA Medicaid fee schedule,$18.39 ,12.84% of LA Medicaid fee schedule,$76.23 ,100% of Medicare OPPS,$128.00 ,100% of UHC Case Rate,$76.23 ,100% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$133.40 ,100% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$26.67 ,100% of custom fee schedule,$128.92 ,90% of total billed charges,$18.39 ,$163.89 ,$107.43 
Outpatient Medical Services,RADIOLOGY,74019,x-ray abdomen 2 views,320,$182.47 ,$150.04 ,100% of APC Rate,$93.77 ,100% of Medicare OPPS,$127.73 ,70% of total billed charges,$154.88 ,84.88% of total billed charges,$159.19 ,139.08% of custom fee schedule,$93.77 ,100% of Medicare OPPS,$136.85 ,75% of total billed charges,$127.73 ,70% of total billed charges,$159.42 ,170% of Medicare OPPS,$201.62 ,215% of Medicare OPPS,$23.43 ,12.84% of total billed charges,$164.11 ,175% of Medicare OPPS,$93.77 ,100% of Medicare OPPS,$145.98 ,80% of total billed charges,$131.29 ,140% of Medicare OPPS,$117.22 ,125% of Medicare OPPS,$23.43 ,12.84% of LA Medicaid fee schedule,$23.43 ,12.84% of LA Medicaid fee schedule,$93.77 ,100% of Medicare OPPS,$128.00 ,100% of UHC Case Rate,$93.77 ,100% of Medicare OPPS,$93.77 ,100% of Medicare OPPS,$164.11 ,100% of Medicare OPPS,$93.77 ,100% of Medicare OPPS,$32.54 ,100% of custom fee schedule,$164.22 ,90% of total billed charges,$23.43 ,$201.62 ,$136.85 
Outpatient Medical Services,RADIOLOGY,74220,x-ray esophagus,320,$473.90 ,$253.17 ,100% of APC Rate,$158.23 ,100% of Medicare OPPS,$331.73 ,70% of total billed charges,$402.25 ,84.88% of total billed charges,$351.51 ,139.08% of custom fee schedule,$158.23 ,100% of Medicare OPPS,$355.43 ,75% of total billed charges,$331.73 ,70% of total billed charges,$268.99 ,170% of Medicare OPPS,$340.20 ,215% of Medicare OPPS,$60.85 ,12.84% of total billed charges,$276.90 ,175% of Medicare OPPS,$158.23 ,100% of Medicare OPPS,$379.12 ,80% of total billed charges,$221.52 ,140% of Medicare OPPS,$197.79 ,125% of Medicare OPPS,$60.85 ,12.84% of LA Medicaid fee schedule,$60.85 ,12.84% of LA Medicaid fee schedule,$158.23 ,100% of Medicare OPPS,$128.00 ,100% of UHC Case Rate,$158.23 ,100% of Medicare OPPS,$158.23 ,100% of Medicare OPPS,$276.90 ,100% of Medicare OPPS,$158.23 ,100% of Medicare OPPS,$121.15 ,100% of custom fee schedule,$426.51 ,90% of total billed charges,$60.85 ,$426.51 ,$355.43 
Outpatient Medical Services,RADIOLOGY,74230,x-ray swallow function study,320,$277.63 ,$253.17 ,100% of APC Rate,$158.23 ,100% of Medicare OPPS,$194.34 ,70% of total billed charges,$235.65 ,84.88% of total billed charges,$159.19 ,139.08% of custom fee schedule,$158.23 ,100% of Medicare OPPS,$208.22 ,75% of total billed charges,$194.34 ,70% of total billed charges,$268.99 ,170% of Medicare OPPS,$340.20 ,215% of Medicare OPPS,$35.65 ,12.84% of total billed charges,$276.90 ,175% of Medicare OPPS,$158.23 ,100% of Medicare OPPS,$222.10 ,80% of total billed charges,$221.52 ,140% of Medicare OPPS,$197.79 ,125% of Medicare OPPS,$35.65 ,12.84% of LA Medicaid fee schedule,$35.65 ,12.84% of LA Medicaid fee schedule,$158.23 ,100% of Medicare OPPS,$128.00 ,100% of UHC Case Rate,$158.23 ,100% of Medicare OPPS,$158.23 ,100% of Medicare OPPS,$276.90 ,100% of Medicare OPPS,$158.23 ,100% of Medicare OPPS,$121.15 ,100% of custom fee schedule,$249.87 ,90% of total billed charges,$35.65 ,$340.20 ,$208.22 
Outpatient Medical Services,RADIOLOGY,74450,urethrocystography retrograde,320,$374.47 ,$327.83 ,100% of APC Rate,$204.89 ,100% of Medicare OPPS,$262.13 ,70% of total billed charges,$317.85 ,84.88% of total billed charges,$323.10 ,139.08% of custom fee schedule,$204.89 ,100% of Medicare OPPS,$280.85 ,75% of total billed charges,$262.13 ,70% of total billed charges,$348.32 ,170% of Medicare OPPS,$440.52 ,215% of Medicare OPPS,$48.08 ,12.84% of total billed charges,$358.56 ,175% of Medicare OPPS,$204.89 ,100% of Medicare OPPS,$299.58 ,80% of total billed charges,$286.85 ,140% of Medicare OPPS,$256.11 ,125% of Medicare OPPS,$48.08 ,12.84% of LA Medicaid fee schedule,$48.08 ,12.84% of LA Medicaid fee schedule,$204.89 ,100% of Medicare OPPS,$128.00 ,100% of UHC Case Rate,$204.89 ,100% of Medicare OPPS,$204.89 ,100% of Medicare OPPS,$358.56 ,100% of Medicare OPPS,$204.89 ,100% of Medicare OPPS,$306.44 ,100% of custom fee schedule,$337.02 ,90% of total billed charges,$48.08 ,$440.52 ,$280.85 
Outpatient Medical Services,RADIOLOGY,76000,"Flouroscopy, or x-ray ""movie"" that takes less than an hour",320,$374.47 ,$327.83 ,100% of APC Rate,$204.89 ,100% of Medicare OPPS,$262.13 ,70% of total billed charges,$317.85 ,84.88% of total billed charges,$323.10 ,139.08% of custom fee schedule,$204.89 ,100% of Medicare OPPS,$280.85 ,75% of total billed charges,$262.13 ,70% of total billed charges,$348.31 ,170% of Medicare OPPS,$440.51 ,215% of Medicare OPPS,$48.08 ,12.84% of total billed charges,$358.56 ,175% of Medicare OPPS,$204.89 ,100% of Medicare OPPS,$299.58 ,80% of total billed charges,$286.83 ,140% of Medicare OPPS,$256.11 ,125% of Medicare OPPS,$48.08 ,12.84% of LA Medicaid fee schedule,$48.08 ,12.84% of LA Medicaid fee schedule,$204.89 ,100% of Medicare OPPS,$128.00 ,100% of UHC Case Rate,$204.89 ,100% of Medicare OPPS,$204.89 ,100% of Medicare OPPS,$358.56 ,100% of Medicare OPPS,$204.89 ,100% of Medicare OPPS,$186.37 ,100% of custom fee schedule,$337.02 ,90% of total billed charges,$48.08 ,$440.51 ,$280.85 
Outpatient Medical Services,RADIOLOGY,77001,fluoroscopic guidance for CV access device placement,320,$189.00 ,N/A,Not covered by Contract,N/A,100% of Medicare OPPS,$132.30 ,70% of total billed charges,$160.42 ,84.88% of total billed charges,N/A,139.08% of custom fee schedule,N/A,100% of Medicare OPPS,$141.75 ,75% of total billed charges,$132.30 ,70% of total billed charges,N/A,170% of Medicare OPPS,N/A,215% of Medicare OPPS,$24.27 ,12.84% of total billed charges,N/A,175% of Medicare OPPS,N/A,100% of Medicare OPPS,$151.20 ,80% of total billed charges,N/A,140% of Medicare OPPS,N/A,125% of Medicare OPPS,$24.27 ,12.84% of LA Medicaid fee schedule,$24.27 ,12.84% of LA Medicaid fee schedule,N/A,100% of Medicare OPPS,$128.00 ,100% of UHC Case Rate,N/A,100% of Medicare OPPS,N/A,100% of Medicare OPPS,N/A,100% of Medicare OPPS,N/A,100% of Medicare OPPS,N/A,100% of custom fee schedule,$170.10 ,90% of total billed charges,$24.27 ,$170.10 ,$141.75 
Outpatient Medical Services,RADIOLOGY,77080,Scan to measure bone mineral density (BMD) at the spine and hip,320,$197.35 ,$150.03 ,100% of APC Rate,$93.78 ,100% of Medicare OPPS,$138.15 ,70% of total billed charges,$167.51 ,84.88% of total billed charges,$159.19 ,139.08% of custom fee schedule,$93.78 ,100% of Medicare OPPS,$148.01 ,75% of total billed charges,$138.15 ,70% of total billed charges,$159.41 ,170% of Medicare OPPS,$201.62 ,215% of Medicare OPPS,$25.34 ,12.84% of total billed charges,$164.11 ,175% of Medicare OPPS,$93.78 ,100% of Medicare OPPS,$157.88 ,80% of total billed charges,$131.28 ,140% of Medicare OPPS,$117.22 ,125% of Medicare OPPS,$25.34 ,12.84% of LA Medicaid fee schedule,$25.34 ,12.84% of LA Medicaid fee schedule,$93.78 ,100% of Medicare OPPS,$128.00 ,100% of UHC Case Rate,$93.78 ,100% of Medicare OPPS,$93.78 ,100% of Medicare OPPS,$164.11 ,100% of Medicare OPPS,$93.78 ,100% of Medicare OPPS,$107.25 ,100% of custom fee schedule,$177.62 ,90% of total billed charges,$25.34 ,$201.62 ,$148.01 
Outpatient Medical Services,RADIOLOGY,73040,arthrography shoulder,322,$631.24 ,$517.22 ,100% of APC Rate,$323.26 ,100% of Medicare OPPS,$441.87 ,70% of total billed charges,$535.80 ,84.88% of total billed charges,$634.72 ,139.08% of custom fee schedule,$323.26 ,100% of Medicare OPPS,$473.43 ,75% of total billed charges,$441.87 ,70% of total billed charges,$549.55 ,170% of Medicare OPPS,$695.02 ,215% of Medicare OPPS,$81.05 ,12.84% of total billed charges,$565.71 ,175% of Medicare OPPS,$323.26 ,100% of Medicare OPPS,$504.99 ,80% of total billed charges,$452.57 ,140% of Medicare OPPS,$404.08 ,125% of Medicare OPPS,$81.05 ,12.84% of LA Medicaid fee schedule,$81.05 ,12.84% of LA Medicaid fee schedule,$323.26 ,100% of Medicare OPPS,$128.00 ,100% of UHC Case Rate,$323.26 ,100% of Medicare OPPS,$323.26 ,100% of Medicare OPPS,$565.71 ,100% of Medicare OPPS,$323.26 ,100% of Medicare OPPS,$403.66 ,100% of custom fee schedule,$568.12 ,90% of total billed charges,$81.05 ,$695.02 ,$473.43 
Outpatient Medical Services,RADIOLOGY,71045,Single view,324,$143.24 ,$121.96 ,100% of APC Rate,$76.23 ,100% of Medicare OPPS,$100.27 ,70% of total billed charges,$121.58 ,84.88% of total billed charges,$86.40 ,139.08% of custom fee schedule,$76.23 ,100% of Medicare OPPS,$107.43 ,75% of total billed charges,$100.27 ,70% of total billed charges,$129.58 ,170% of Medicare OPPS,$163.89 ,215% of Medicare OPPS,$18.39 ,12.84% of total billed charges,$133.40 ,175% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$114.59 ,80% of total billed charges,$106.72 ,140% of Medicare OPPS,$95.28 ,125% of Medicare OPPS,$18.39 ,12.84% of LA Medicaid fee schedule,$18.39 ,12.84% of LA Medicaid fee schedule,$76.23 ,100% of Medicare OPPS,$128.00 ,100% of UHC Case Rate,$76.23 ,100% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$133.40 ,100% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$19.62 ,100% of custom fee schedule,$128.92 ,90% of total billed charges,$18.39 ,$163.89 ,$107.43 
Outpatient Medical Services,RADIOLOGY,71046,"2 views, front and back",324,$143.24 ,$121.96 ,100% of APC Rate,$76.23 ,100% of Medicare OPPS,$100.27 ,70% of total billed charges,$121.58 ,84.88% of total billed charges,$86.40 ,139.08% of custom fee schedule,$76.23 ,100% of Medicare OPPS,$107.43 ,75% of total billed charges,$100.27 ,70% of total billed charges,$129.58 ,170% of Medicare OPPS,$163.89 ,215% of Medicare OPPS,$18.39 ,12.84% of total billed charges,$133.40 ,175% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$114.59 ,80% of total billed charges,$106.72 ,140% of Medicare OPPS,$95.28 ,125% of Medicare OPPS,$18.39 ,12.84% of LA Medicaid fee schedule,$18.39 ,12.84% of LA Medicaid fee schedule,$76.23 ,100% of Medicare OPPS,$128.00 ,100% of UHC Case Rate,$76.23 ,100% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$133.40 ,100% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$29.82 ,100% of custom fee schedule,$128.92 ,90% of total billed charges,$18.39 ,$163.89 ,$107.43 
Outpatient Medical Services,RADIOLOGY,73000,Radiologic examination of the collar bone,324,$143.24 ,$121.96 ,100% of APC Rate,$76.23 ,100% of Medicare OPPS,$100.27 ,70% of total billed charges,$121.58 ,84.88% of total billed charges,$86.40 ,139.08% of custom fee schedule,$76.23 ,100% of Medicare OPPS,$107.43 ,75% of total billed charges,$100.27 ,70% of total billed charges,$129.59 ,170% of Medicare OPPS,$163.89 ,215% of Medicare OPPS,$18.39 ,12.84% of total billed charges,$133.40 ,175% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$114.59 ,80% of total billed charges,$106.72 ,140% of Medicare OPPS,$95.28 ,125% of Medicare OPPS,$18.39 ,12.84% of LA Medicaid fee schedule,$18.39 ,12.84% of LA Medicaid fee schedule,$76.23 ,100% of Medicare OPPS,$128.00 ,100% of UHC Case Rate,$76.23 ,100% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$133.40 ,100% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$68.22 ,100% of custom fee schedule,$128.92 ,90% of total billed charges,$18.39 ,$163.89 ,$107.43 
Outpatient Medical Services,RADIOLOGY,78472,"cardiac blood pool imaging, wall motion study plus EF",341,$726.61 ,$545.65 ,100% of APC Rate,$341.03 ,100% of Medicare OPPS,$508.63 ,70% of total billed charges,$616.75 ,84.88% of total billed charges,$486.00 ,139.08% of custom fee schedule,$341.03 ,100% of Medicare OPPS,$544.96 ,75% of total billed charges,$508.63 ,70% of total billed charges,$579.75 ,170% of Medicare OPPS,$733.22 ,215% of Medicare OPPS,$93.30 ,12.84% of total billed charges,$596.80 ,175% of Medicare OPPS,$341.03 ,100% of Medicare OPPS,$581.29 ,80% of total billed charges,$477.44 ,140% of Medicare OPPS,$426.29 ,125% of Medicare OPPS,$93.30 ,12.84% of LA Medicaid fee schedule,$93.30 ,12.84% of LA Medicaid fee schedule,$341.03 ,100% of Medicare OPPS,$774.00 ,100% of UHC Case Rate,$341.03 ,100% of Medicare OPPS,$341.03 ,100% of Medicare OPPS,$596.80 ,100% of Medicare OPPS,$341.03 ,100% of Medicare OPPS,$455.73 ,100% of custom fee schedule,$653.95 ,90% of total billed charges,$93.30 ,$774.00 ,$544.96 
Outpatient Medical Services,RADIOLOGY,38792,injection radioactive tracer for sentinel node ID,341,"$1,143.45 ",$545.65 ,100% of APC Rate,$341.03 ,100% of Medicare OPPS,$800.42 ,70% of total billed charges,$970.56 ,84.88% of total billed charges,$486.00 ,139.08% of ASC,$341.03 ,100% of Medicare OPPS,$857.59 ,75% of total billed charges,$800.42 ,70% of total billed charges,$579.76 ,170% of Medicare OPPS,$733.22 ,215% of Medicare OPPS,$146.82 ,12.84% of total billed charges,$596.81 ,175% of Medicare OPPS,$341.03 ,100% of Medicare OPPS,$914.76 ,80% of total billed charges,$477.44 ,140% of Medicare OPPS,$426.29 ,125% of Medicare OPPS,$146.82 ,12.84% of LA Medicaid fee schedule,$146.82 ,12.84% of LA Medicaid fee schedule,$341.03 ,100% of Medicare OPPS,$774.00 ,100% of UHC Case Rate,$341.03 ,100% of Medicare OPPS,$341.03 ,100% of Medicare OPPS,$596.81 ,100% of Medicare OPPS,$341.03 ,100% of Medicare OPPS,$306.23 ,100% of custom fee schedule,"$1,029.11 ",90% of total billed charges,$146.82 ,"$1,029.11 ",$857.59 
Outpatient Medical Services,RADIOLOGY,78227,scan of hepatobiliary system/gallbladder,341,$921.47 ,$708.25 ,100% of APC Rate,$442.65 ,100% of Medicare OPPS,$645.03 ,70% of total billed charges,$782.14 ,84.88% of total billed charges,$630.14 ,139.08% of custom fee schedule,$442.65 ,100% of Medicare OPPS,$691.10 ,75% of total billed charges,$645.03 ,70% of total billed charges,$752.51 ,170% of Medicare OPPS,$951.71 ,215% of Medicare OPPS,$118.32 ,12.84% of total billed charges,$774.64 ,175% of Medicare OPPS,$442.65 ,100% of Medicare OPPS,$737.18 ,80% of total billed charges,$619.72 ,140% of Medicare OPPS,$553.30 ,125% of Medicare OPPS,$118.32 ,12.84% of LA Medicaid fee schedule,$118.32 ,12.84% of LA Medicaid fee schedule,$442.65 ,100% of Medicare OPPS,$774.00 ,100% of UHC Case Rate,$442.65 ,100% of Medicare OPPS,$442.65 ,100% of Medicare OPPS,$774.64 ,100% of Medicare OPPS,$442.65 ,100% of Medicare OPPS,$443.20 ,100% of custom fee schedule,$829.32 ,90% of total billed charges,$118.32 ,$951.71 ,$691.10 
Outpatient Medical Services,RADIOLOGY,78264,gastric emptying study,341,"$1,143.45 ",$545.65 ,100% of APC Rate,$341.03 ,100% of Medicare OPPS,$800.42 ,70% of total billed charges,$970.56 ,84.88% of total billed charges,$486.00 ,139.08% of custom fee schedule,$341.03 ,100% of Medicare OPPS,$857.59 ,75% of total billed charges,$800.42 ,70% of total billed charges,$579.75 ,170% of Medicare OPPS,$733.22 ,215% of Medicare OPPS,$146.82 ,12.84% of total billed charges,$596.80 ,175% of Medicare OPPS,$341.03 ,100% of Medicare OPPS,$914.76 ,80% of total billed charges,$477.44 ,140% of Medicare OPPS,$426.29 ,125% of Medicare OPPS,$146.82 ,12.84% of LA Medicaid fee schedule,$146.82 ,12.84% of LA Medicaid fee schedule,$341.03 ,100% of Medicare OPPS,$774.00 ,100% of UHC Case Rate,$341.03 ,100% of Medicare OPPS,$341.03 ,100% of Medicare OPPS,$596.80 ,100% of Medicare OPPS,$341.03 ,100% of Medicare OPPS,$385.16 ,100% of custom fee schedule,"$1,029.11 ",90% of total billed charges,$146.82 ,"$1,029.11 ",$857.59 
Outpatient Medical Services,RADIOLOGY,78306,"A procedure most commonly ordered to detect areas of abnormal bone growth due to fractures, tumors, infection, or other bone issues",341,$830.42 ,$545.65 ,100% of APC Rate,$341.03 ,100% of Medicare OPPS,$581.29 ,70% of total billed charges,$704.86 ,84.88% of total billed charges,$486.00 ,139.08% of custom fee schedule,$341.03 ,100% of Medicare OPPS,$622.82 ,75% of total billed charges,$581.29 ,70% of total billed charges,$579.75 ,170% of Medicare OPPS,$733.22 ,215% of Medicare OPPS,$106.63 ,12.84% of total billed charges,$596.80 ,175% of Medicare OPPS,$341.03 ,100% of Medicare OPPS,$664.34 ,80% of total billed charges,$477.44 ,140% of Medicare OPPS,$426.29 ,125% of Medicare OPPS,$106.63 ,12.84% of LA Medicaid fee schedule,$106.63 ,12.84% of LA Medicaid fee schedule,$341.03 ,100% of Medicare OPPS,$774.00 ,100% of UHC Case Rate,$341.03 ,100% of Medicare OPPS,$341.03 ,100% of Medicare OPPS,$596.80 ,100% of Medicare OPPS,$341.03 ,100% of Medicare OPPS,$385.35 ,100% of custom fee schedule,$747.38 ,90% of total billed charges,$106.63 ,$774.00 ,$622.82 
Outpatient Medical Services,RADIOLOGY,78452,Image of the heart to assess perfusion,341,"$2,130.53 ","$1,863.31 ",100% of APC Rate,"$1,164.57 ",100% of Medicare OPPS,"$1,491.37 ",70% of total billed charges,"$1,808.39 ",84.88% of total billed charges,"$1,672.69 ",139.08% of custom fee schedule,"$1,164.57 ",100% of Medicare OPPS,"$1,597.90 ",75% of total billed charges,"$1,491.37 ",70% of total billed charges,"$1,979.76 ",170% of Medicare OPPS,"$2,503.83 ",215% of Medicare OPPS,$273.56 ,12.84% of total billed charges,"$2,038.00 ",175% of Medicare OPPS,"$1,164.57 ",100% of Medicare OPPS,"$1,704.42 ",80% of total billed charges,"$1,630.39 ",140% of Medicare OPPS,"$1,455.71 ",125% of Medicare OPPS,$273.56 ,12.84% of LA Medicaid fee schedule,$273.56 ,12.84% of LA Medicaid fee schedule,"$1,164.57 ",100% of Medicare OPPS,$774.00 ,100% of UHC Case Rate,"$1,164.57 ",100% of Medicare OPPS,"$1,164.57 ",100% of Medicare OPPS,"$2,038.00 ",100% of Medicare OPPS,"$1,164.57 ",100% of Medicare OPPS,"$1,372.33 ",100% of custom fee schedule,"$1,917.48 ",90% of total billed charges,$273.56 ,"$2,503.83 ","$1,597.90 "
Outpatient Medical Services,RADIOLOGY,77065,"Diagnostic mammography, including computer-aided detection (cad) when performed; unilateral",401,$242.32 ,$124.58 ,160% of Fee Schedule,$77.86 ,100% of Medicare OPPS,$169.62 ,70% of total billed charges,$205.68 ,84.88% of total billed charges,$118.73 ,139.08% of custom fee schedule,$77.86 ,100% of Medicare OPPS,$181.74 ,75% of total billed charges,$169.62 ,70% of total billed charges,$267.02 ,170% of Medicare OPPS,$167.40 ,215% of Medicare OPPS,$31.11 ,12.84% of total billed charges,$136.26 ,175% of Medicare OPPS,$77.86 ,100% of Medicare OPPS,$193.86 ,80% of total billed charges,$109.00 ,140% of Medicare OPPS,$97.33 ,125% of Medicare OPPS,$31.11 ,12.84% of LA Medicaid fee schedule,$31.11 ,12.84% of LA Medicaid fee schedule,$77.86 ,100% of Medicare OPPS,$214.00 ,100% of UHC Case Rate,$77.86 ,100% of Medicare OPPS,$77.86 ,100% of Medicare OPPS,$136.26 ,100% of Medicare OPPS,$77.86 ,100% of Medicare OPPS,$130.54 ,100% of custom fee schedule,$218.09 ,90% of total billed charges,$31.11 ,$267.02 ,$181.74 
Outpatient Medical Services,RADIOLOGY,77066,"Diagnostic mammography, including computer-aided detection (cad) when performed; bilateral",401,$265.59 ,$158.77 ,160% of Fee Schedule,$99.23 ,100% of Medicare OPPS,$185.91 ,70% of total billed charges,$225.43 ,84.88% of total billed charges,$151.60 ,139.08% of custom fee schedule,$99.23 ,100% of Medicare OPPS,$199.19 ,75% of total billed charges,$185.91 ,70% of total billed charges,$340.29 ,170% of Medicare OPPS,$213.34 ,215% of Medicare OPPS,$34.10 ,12.84% of total billed charges,$173.65 ,175% of Medicare OPPS,$99.23 ,100% of Medicare OPPS,$212.47 ,80% of total billed charges,$138.92 ,140% of Medicare OPPS,$124.04 ,125% of Medicare OPPS,$34.10 ,12.84% of LA Medicaid fee schedule,$34.10 ,12.84% of LA Medicaid fee schedule,$99.23 ,100% of Medicare OPPS,$214.00 ,100% of UHC Case Rate,$99.23 ,100% of Medicare OPPS,$99.23 ,100% of Medicare OPPS,$173.65 ,100% of Medicare OPPS,$99.23 ,100% of Medicare OPPS,$165.17 ,100% of custom fee schedule,$239.03 ,90% of total billed charges,$34.10 ,$340.29 ,$199.19 
Outpatient Medical Services,RADIOLOGY,G0279,diagnostic digital tomosynthesis,401,$316.58 ,$34.19 ,160% of Fee Schedule,$21.37 ,100% of Medicare OPPS,$221.61 ,70% of total billed charges,$268.71 ,84.88% of total billed charges,$34.34 ,139.08% of custom fee schedule,$21.37 ,100% of Medicare OPPS,$237.44 ,75% of total billed charges,$221.61 ,70% of total billed charges,$72.23 ,170% of Medicare OPPS,$45.95 ,215% of Medicare OPPS,$40.65 ,12.84% of total billed charges,$37.40 ,175% of Medicare OPPS,$21.37 ,100% of Medicare OPPS,$253.26 ,80% of total billed charges,$29.92 ,140% of Medicare OPPS,$26.71 ,125% of Medicare OPPS,$40.65 ,12.84% of LA Medicaid fee schedule,$40.65 ,12.84% of LA Medicaid fee schedule,$21.37 ,100% of Medicare OPPS,$214.00 ,100% of UHC Case Rate,$21.37 ,100% of Medicare OPPS,$21.37 ,100% of Medicare OPPS,$37.40 ,100% of Medicare OPPS,$21.37 ,100% of Medicare OPPS,$55.39 ,100% of custom fee schedule,$284.92 ,90% of total billed charges,$21.37 ,$284.92 ,$237.44 
Outpatient Medical Services,RADIOLOGY,76536,Ultrasound of head and neck,402,$667.80 ,$150.04 ,100% of APC Rate,$93.77 ,100% of Medicare OPPS,$467.46 ,70% of total billed charges,$566.83 ,84.88% of total billed charges,$159.19 ,139.08% of custom fee schedule,$93.77 ,100% of Medicare OPPS,$500.85 ,75% of total billed charges,$467.46 ,70% of total billed charges,$159.42 ,170% of Medicare OPPS,$201.62 ,215% of Medicare OPPS,$85.75 ,12.84% of total billed charges,$164.11 ,175% of Medicare OPPS,$93.77 ,100% of Medicare OPPS,$534.24 ,80% of total billed charges,$131.29 ,140% of Medicare OPPS,$117.22 ,125% of Medicare OPPS,$85.75 ,12.84% of LA Medicaid fee schedule,$85.75 ,12.84% of LA Medicaid fee schedule,$93.77 ,100% of Medicare OPPS,$452.00 ,100% of UHC Case Rate,$93.77 ,100% of Medicare OPPS,$93.77 ,100% of Medicare OPPS,$164.11 ,100% of Medicare OPPS,$93.77 ,100% of Medicare OPPS,$160.08 ,100% of custom fee schedule,$601.02 ,90% of total billed charges,$85.75 ,$601.02 ,$500.85 
Outpatient Medical Services,RADIOLOGY,76642,Limited ultrasound of the breast,402,$667.80 ,$121.96 ,100% of APC Rate,$76.23 ,100% of Medicare OPPS,$467.46 ,70% of total billed charges,$566.83 ,84.88% of total billed charges,$86.40 ,139.08% of custom fee schedule,$76.23 ,100% of Medicare OPPS,$500.85 ,75% of total billed charges,$467.46 ,70% of total billed charges,$129.59 ,170% of Medicare OPPS,$163.89 ,215% of Medicare OPPS,$85.75 ,12.84% of total billed charges,$133.40 ,175% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$534.24 ,80% of total billed charges,$106.72 ,140% of Medicare OPPS,$95.28 ,125% of Medicare OPPS,$85.75 ,12.84% of LA Medicaid fee schedule,$85.75 ,12.84% of LA Medicaid fee schedule,$76.23 ,100% of Medicare OPPS,$452.00 ,100% of UHC Case Rate,$76.23 ,100% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$133.40 ,100% of Medicare OPPS,$76.23 ,100% of Medicare OPPS,$87.38 ,100% of custom fee schedule,$601.02 ,90% of total billed charges,$76.23 ,$601.02 ,$500.85 
Outpatient Medical Services,RADIOLOGY,76700,Ultrasound of abdomen with all areas scanned,402,$667.80 ,$150.03 ,100% of APC Rate,$93.78 ,100% of Medicare OPPS,$467.46 ,70% of total billed charges,$566.83 ,84.88% of total billed charges,$159.19 ,139.08% of custom fee schedule,$93.78 ,100% of Medicare OPPS,$500.85 ,75% of total billed charges,$467.46 ,70% of total billed charges,$159.41 ,170% of Medicare OPPS,$201.62 ,215% of Medicare OPPS,$85.75 ,12.84% of total billed charges,$164.11 ,175% of Medicare OPPS,$93.78 ,100% of Medicare OPPS,$534.24 ,80% of total billed charges,$131.28 ,140% of Medicare OPPS,$117.22 ,125% of Medicare OPPS,$85.75 ,12.84% of LA Medicaid fee schedule,$85.75 ,12.84% of LA Medicaid fee schedule,$93.78 ,100% of Medicare OPPS,$452.00 ,100% of UHC Case Rate,$93.78 ,100% of Medicare OPPS,$93.78 ,100% of Medicare OPPS,$164.11 ,100% of Medicare OPPS,$93.78 ,100% of Medicare OPPS,$160.08 ,100% of custom fee schedule,$601.02 ,90% of total billed charges,$85.75 ,$601.02 ,$500.85 
Outpatient Medical Services,RADIOLOGY,76705,A diagnostic procedure that allows a provider to see the organs and other structures in the abdomen,402,$667.80 ,$150.03 ,100% of APC Rate,$93.78 ,100% of Medicare OPPS,$467.46 ,70% of total billed charges,$566.83 ,84.88% of total billed charges,$159.19 ,139.08% of custom fee schedule,$93.78 ,100% of Medicare OPPS,$500.85 ,75% of total billed charges,$467.46 ,70% of total billed charges,$159.41 ,170% of Medicare OPPS,$201.62 ,215% of Medicare OPPS,$85.75 ,12.84% of total billed charges,$164.11 ,175% of Medicare OPPS,$93.78 ,100% of Medicare OPPS,$534.24 ,80% of total billed charges,$131.28 ,140% of Medicare OPPS,$117.22 ,125% of Medicare OPPS,$85.75 ,12.84% of LA Medicaid fee schedule,$85.75 ,12.84% of LA Medicaid fee schedule,$93.78 ,100% of Medicare OPPS,$452.00 ,100% of UHC Case Rate,$93.78 ,100% of Medicare OPPS,$93.78 ,100% of Medicare OPPS,$164.11 ,100% of Medicare OPPS,$93.78 ,100% of Medicare OPPS,$160.08 ,100% of custom fee schedule,$601.02 ,90% of total billed charges,$85.75 ,$601.02 ,$500.85 
Outpatient Medical Services,RADIOLOGY,76706,US abdominal aorta screening for AAA,402,$667.80 ,$150.03 ,100% of APC Rate,$93.78 ,100% of Medicare OPPS,$467.46 ,70% of total billed charges,$566.83 ,84.88% of total billed charges,$159.19 ,139.08% of custom fee schedule,$93.78 ,100% of Medicare OPPS,$500.85 ,75% of total billed charges,$467.46 ,70% of total billed charges,$159.41 ,170% of Medicare OPPS,$201.62 ,215% of Medicare OPPS,$85.75 ,12.84% of total billed charges,$164.11 ,175% of Medicare OPPS,$93.78 ,100% of Medicare OPPS,$534.24 ,80% of total billed charges,$131.28 ,140% of Medicare OPPS,$117.22 ,125% of Medicare OPPS,$85.75 ,12.84% of LA Medicaid fee schedule,$85.75 ,12.84% of LA Medicaid fee schedule,$93.78 ,100% of Medicare OPPS,$452.00 ,100% of UHC Case Rate,$93.78 ,100% of Medicare OPPS,$93.78 ,100% of Medicare OPPS,$164.11 ,100% of Medicare OPPS,$93.78 ,100% of Medicare OPPS,$91.73 ,100% of custom fee schedule,$601.02 ,90% of total billed charges,$85.75 ,$601.02 ,$500.85 
Outpatient Medical Services,RADIOLOGY,76770,Ultrasound of back wall of the abdomen with all areas viewed,402,$667.80 ,$150.03 ,100% of APC Rate,$93.78 ,100% of Medicare OPPS,$467.46 ,70% of total billed charges,$566.83 ,84.88% of total billed charges,$159.19 ,139.08% of custom fee schedule,$93.78 ,100% of Medicare OPPS,$500.85 ,75% of total billed charges,$467.46 ,70% of total billed charges,$159.41 ,170% of Medicare OPPS,$201.62 ,215% of Medicare OPPS,$85.75 ,12.84% of total billed charges,$164.11 ,175% of Medicare OPPS,$93.78 ,100% of Medicare OPPS,$534.24 ,80% of total billed charges,$131.28 ,140% of Medicare OPPS,$117.22 ,125% of Medicare OPPS,$85.75 ,12.84% of LA Medicaid fee schedule,$85.75 ,12.84% of LA Medicaid fee schedule,$93.78 ,100% of Medicare OPPS,$452.00 ,100% of UHC Case Rate,$93.78 ,100% of Medicare OPPS,$93.78 ,100% of Medicare OPPS,$164.11 ,100% of Medicare OPPS,$93.78 ,100% of Medicare OPPS,$160.08 ,100% of custom fee schedule,$601.02 ,90% of total billed charges,$85.75 ,$601.02 ,$500.85 
Outpatient Medical Services,RADIOLOGY,76830,Ultrasound of the pelvis through vagina,402,$667.80 ,$150.03 ,100% of APC Rate,$93.78 ,100% of Medicare OPPS,$467.46 ,70% of total billed charges,$566.83 ,84.88% of total billed charges,$159.19 ,139.08% of custom fee schedule,$93.78 ,100% of Medicare OPPS,$500.85 ,75% of total billed charges,$467.46 ,70% of total billed charges,$159.41 ,170% of Medicare OPPS,$201.62 ,215% of Medicare OPPS,$85.75 ,12.84% of total billed charges,$164.11 ,175% of Medicare OPPS,$93.78 ,100% of Medicare OPPS,$534.24 ,80% of total billed charges,$131.28 ,140% of Medicare OPPS,$117.22 ,125% of Medicare OPPS,$85.75 ,12.84% of LA Medicaid fee schedule,$85.75 ,12.84% of LA Medicaid fee schedule,$93.78 ,100% of Medicare OPPS,$452.00 ,100% of UHC Case Rate,$93.78 ,100% of Medicare OPPS,$93.78 ,100% of Medicare OPPS,$164.11 ,100% of Medicare OPPS,$93.78 ,100% of Medicare OPPS,$160.08 ,100% of custom fee schedule,$601.02 ,90% of total billed charges,$85.75 ,$601.02 ,$500.85 
Outpatient Medical Services,RADIOLOGY,76856,Complete ultrasound of the pelvis,402,$667.80 ,$150.03 ,100% of APC Rate,$93.78 ,100% of Medicare OPPS,$467.46 ,70% of total billed charges,$566.83 ,84.88% of total billed charges,$159.19 ,139.08% of custom fee schedule,$93.78 ,100% of Medicare OPPS,$500.85 ,75% of total billed charges,$467.46 ,70% of total billed charges,$159.41 ,170% of Medicare OPPS,$201.62 ,215% of Medicare OPPS,$85.75 ,12.84% of total billed charges,$164.11 ,175% of Medicare OPPS,$93.78 ,100% of Medicare OPPS,$534.24 ,80% of total billed charges,$131.28 ,140% of Medicare OPPS,$117.22 ,125% of Medicare OPPS,$85.75 ,12.84% of LA Medicaid fee schedule,$85.75 ,12.84% of LA Medicaid fee schedule,$93.78 ,100% of Medicare OPPS,$452.00 ,100% of UHC Case Rate,$93.78 ,100% of Medicare OPPS,$93.78 ,100% of Medicare OPPS,$164.11 ,100% of Medicare OPPS,$93.78 ,100% of Medicare OPPS,$160.08 ,100% of custom fee schedule,$601.02 ,90% of total billed charges,$85.75 ,$601.02 ,$500.85 
Outpatient Medical Services,RADIOLOGY,76870,Ultrasound of the scrotum,402,$667.80 ,$150.04 ,100% of APC Rate,$93.77 ,100% of Medicare OPPS,$467.46 ,70% of total billed charges,$566.83 ,84.88% of total billed charges,$159.19 ,139.08% of custom fee schedule,$93.77 ,100% of Medicare OPPS,$500.85 ,75% of total billed charges,$467.46 ,70% of total billed charges,$159.42 ,170% of Medicare OPPS,$201.62 ,215% of Medicare OPPS,$85.75 ,12.84% of total billed charges,$164.11 ,175% of Medicare OPPS,$93.77 ,100% of Medicare OPPS,$534.24 ,80% of total billed charges,$131.29 ,140% of Medicare OPPS,$117.22 ,125% of Medicare OPPS,$85.75 ,12.84% of LA Medicaid fee schedule,$85.75 ,12.84% of LA Medicaid fee schedule,$93.77 ,100% of Medicare OPPS,$452.00 ,100% of UHC Case Rate,$93.77 ,100% of Medicare OPPS,$93.77 ,100% of Medicare OPPS,$164.11 ,100% of Medicare OPPS,$93.77 ,100% of Medicare OPPS,$160.08 ,100% of custom fee schedule,$601.02 ,90% of total billed charges,$85.75 ,$601.02 ,$500.85 
Outpatient Medical Services,RADIOLOGY,76882,"Diagnostic ultrasound of an extremity excluding the bone, joints or vessels",402,$667.80 ,$150.04 ,100% of APC Rate,$93.77 ,100% of Medicare OPPS,$467.46 ,70% of total billed charges,$566.83 ,84.88% of total billed charges,$159.19 ,139.08% of custom fee schedule,$93.77 ,100% of Medicare OPPS,$500.85 ,75% of total billed charges,$467.46 ,70% of total billed charges,$159.42 ,170% of Medicare OPPS,$201.62 ,215% of Medicare OPPS,$85.75 ,12.84% of total billed charges,$164.11 ,175% of Medicare OPPS,$93.77 ,100% of Medicare OPPS,$534.24 ,80% of total billed charges,$131.29 ,140% of Medicare OPPS,$117.22 ,125% of Medicare OPPS,$85.75 ,12.84% of LA Medicaid fee schedule,$85.75 ,12.84% of LA Medicaid fee schedule,$93.77 ,100% of Medicare OPPS,$452.00 ,100% of UHC Case Rate,$93.77 ,100% of Medicare OPPS,$93.77 ,100% of Medicare OPPS,$164.11 ,100% of Medicare OPPS,$93.77 ,100% of Medicare OPPS,$107.12 ,100% of custom fee schedule,$601.02 ,90% of total billed charges,$85.75 ,$601.02 ,$500.85 
Outpatient Medical Services,RADIOLOGY,77063,screening mammography tomosynthesis bilateral,403,$316.58 ,$34.19 ,160% of Fee Schedule,$21.37 ,100% of Medicare OPPS,$221.61 ,70% of total billed charges,$268.71 ,84.88% of total billed charges,$34.34 ,139.08% of custom fee schedule,$21.37 ,100% of Medicare OPPS,$237.44 ,75% of total billed charges,$221.61 ,70% of total billed charges,$72.23 ,170% of Medicare OPPS,$45.95 ,215% of Medicare OPPS,$40.65 ,12.84% of total billed charges,$37.40 ,175% of Medicare OPPS,$21.37 ,100% of Medicare OPPS,$253.26 ,80% of total billed charges,$29.92 ,140% of Medicare OPPS,$26.71 ,125% of Medicare OPPS,$40.65 ,12.84% of LA Medicaid fee schedule,$40.65 ,12.84% of LA Medicaid fee schedule,$21.37 ,100% of Medicare OPPS,$214.00 ,100% of UHC Case Rate,$21.37 ,100% of Medicare OPPS,$21.37 ,100% of Medicare OPPS,$37.40 ,100% of Medicare OPPS,$21.37 ,100% of Medicare OPPS,$55.39 ,100% of custom fee schedule,$284.92 ,90% of total billed charges,$21.37 ,$284.92 ,$237.44 
Outpatient Medical Services,RADIOLOGY,77067,Mammography of both breasts-2 or more views,403,$247.04 ,$131.70 ,160% of Fee Schedule,$82.31 ,100% of Medicare OPPS,$172.93 ,70% of total billed charges,$209.69 ,84.88% of total billed charges,$125.39 ,139.08% of custom fee schedule,$82.31 ,100% of Medicare OPPS,$185.28 ,75% of total billed charges,$172.93 ,70% of total billed charges,$281.76 ,170% of Medicare OPPS,$176.97 ,215% of Medicare OPPS,$31.72 ,12.84% of total billed charges,$144.04 ,175% of Medicare OPPS,$82.31 ,100% of Medicare OPPS,$197.63 ,80% of total billed charges,$115.23 ,140% of Medicare OPPS,$102.89 ,125% of Medicare OPPS,$31.72 ,12.84% of LA Medicaid fee schedule,$31.72 ,12.84% of LA Medicaid fee schedule,$82.31 ,100% of Medicare OPPS,$214.00 ,100% of UHC Case Rate,$82.31 ,100% of Medicare OPPS,$82.31 ,100% of Medicare OPPS,$144.04 ,100% of Medicare OPPS,$82.31 ,100% of Medicare OPPS,$133.27 ,100% of custom fee schedule,$222.34 ,90% of total billed charges,$31.72 ,$281.76 ,$185.28 
Outpatient Medical Services,RADIOLOGY,51798,Ultrasound of bladder to measure urine capacity,402,$640.79 ,$80.69 ,100% of APC Rate,$50.43 ,100% of Medicare OPPS,$448.55 ,70% of total billed charges,$543.90 ,84.88% of total billed charges,$77.83 ,139.08% of custom fee schedule,$50.43 ,100% of Medicare OPPS,$480.59 ,75% of total billed charges,$448.55 ,70% of total billed charges,$85.73 ,170% of Medicare OPPS,$108.43 ,215% of Medicare OPPS,$82.28 ,12.84% of total billed charges,$88.25 ,175% of Medicare OPPS,$50.43 ,100% of Medicare OPPS,$512.63 ,80% of total billed charges,$70.60 ,140% of Medicare OPPS,$63.04 ,125% of Medicare OPPS,$82.28 ,12.84% of LA Medicaid fee schedule,$82.28 ,12.84% of LA Medicaid fee schedule,$50.43 ,100% of Medicare OPPS,$452.00 ,100% of UHC Case Rate,$50.43 ,100% of Medicare OPPS,$50.43 ,100% of Medicare OPPS,$88.25 ,100% of Medicare OPPS,$50.43 ,100% of Medicare OPPS,$63.57 ,100% of custom fee schedule,$576.71 ,90% of total billed charges,$50.43 ,$576.71 ,$480.59 
Outpatient Medical Services,BLOOD TRANSFUSION,36430,Blood transfusion,391,$908.97 ,$572.41 ,100% of APC Rate,$357.76 ,100% of Medicare OPPS,$636.28 ,70% of total billed charges,$771.53 ,84.88% of total billed charges,$521.65 ,139.08% of custom fee schedule,$357.76 ,100% of Medicare OPPS,$681.73 ,75% of total billed charges,$636.28 ,70% of total billed charges,$608.20 ,170% of Medicare OPPS,$769.20 ,215% of Medicare OPPS,$116.71 ,12.84% of total billed charges,$626.09 ,175% of Medicare OPPS,$357.76 ,100% of Medicare OPPS,$727.18 ,80% of total billed charges,$500.87 ,140% of Medicare OPPS,$447.20 ,125% of Medicare OPPS,$116.71 ,12.84% of LA Medicaid fee schedule,$116.71 ,12.84% of LA Medicaid fee schedule,$357.76 ,100% of Medicare OPPS,$590.83 ,65% of total billed charges,$357.76 ,100% of Medicare OPPS,$357.76 ,100% of Medicare OPPS,$626.09 ,100% of Medicare OPPS,$357.76 ,100% of Medicare OPPS,$339.23 ,100% of custom fee schedule,$818.07 ,90% of total billed charges,$116.71 ,$818.07 ,$908.97 
Outpatient Medical Services,PATHOLOGY CYTOPATHOLOGY,88304,Level III surgical path,310,$63.78 ,$70.39 ,100% of APC Rate,$43.99 ,100% of Medicare OPPS,$44.65 ,70% of total billed charges,$54.14 ,84.88% of total billed charges,$62.17 ,139.08% of custom fee schedule,$43.99 ,100% of Medicare OPPS,$47.84 ,75% of total billed charges,$44.65 ,70% of total billed charges,$74.78 ,170% of Medicare OPPS,$94.58 ,215% of Medicare OPPS,$35.09 ,12.84% of total billed charges,$76.98 ,175% of Medicare OPPS,$43.99 ,100% of Medicare OPPS,$51.02 ,80% of total billed charges,$61.59 ,140% of Medicare OPPS,$54.99 ,125% of Medicare OPPS,$35.09 ,12.84% of LA Medicaid fee schedule,$35.09 ,12.84% of LA Medicaid fee schedule,$43.99 ,100% of Medicare OPPS,N/A,65% of total billed charges,$43.99 ,100% of Medicare OPPS,$43.99 ,100% of Medicare OPPS,$76.98 ,100% of Medicare OPPS,$43.99 ,100% of Medicare OPPS,$43.46 ,100% of custom fee schedule,$57.40 ,90% of total billed charges,$35.09 ,$94.58 ,$57.40 
Outpatient Medical Services,PATHOLOGY CYTOPATHOLOGY,88307,Level V surgical path,310,$424.14 ,$455.00 ,100% of APC Rate,$284.38 ,100% of Medicare OPPS,$296.90 ,70% of total billed charges,$360.01 ,84.88% of total billed charges,$299.62 ,139.08% of custom fee schedule,$284.38 ,100% of Medicare OPPS,$318.11 ,75% of total billed charges,$296.90 ,70% of total billed charges,$483.44 ,170% of Medicare OPPS,$611.41 ,215% of Medicare OPPS,$70.70 ,12.84% of total billed charges,$497.66 ,175% of Medicare OPPS,$284.38 ,100% of Medicare OPPS,$339.31 ,80% of total billed charges,$398.13 ,140% of Medicare OPPS,$355.47 ,125% of Medicare OPPS,$70.70 ,12.84% of LA Medicaid fee schedule,$70.70 ,12.84% of LA Medicaid fee schedule,$284.38 ,100% of Medicare OPPS,N/A,65% of total billed charges,$284.38 ,100% of Medicare OPPS,$284.38 ,100% of Medicare OPPS,$497.66 ,100% of Medicare OPPS,$284.38 ,100% of Medicare OPPS,$73.12 ,100% of custom fee schedule,$381.73 ,90% of total billed charges,$70.70 ,$611.41 ,$381.73 
Outpatient Medical Services,PATHOLOGY CYTOPATHOLOGY,88311,decalcification for path,310,$30.27 ,N/A,Not covered by Contract,N/A,100% of Medicare OPPS,$21.19 ,70% of total billed charges,$25.69 ,84.88% of total billed charges,N/A,139.08% of custom fee schedule,N/A,100% of Medicare OPPS,$22.70 ,75% of total billed charges,$21.19 ,70% of total billed charges,N/A,170% of Medicare OPPS,N/A,215% of Medicare OPPS,$5.70 ,12.84% of total billed charges,N/A,175% of Medicare OPPS,N/A,100% of Medicare OPPS,$24.22 ,80% of total billed charges,N/A,140% of Medicare OPPS,N/A,125% of Medicare OPPS,$5.70 ,12.84% of LA Medicaid fee schedule,$5.70 ,12.84% of LA Medicaid fee schedule,N/A,100% of Medicare OPPS,N/A,65% of total billed charges,N/A,100% of Medicare OPPS,N/A,100% of Medicare OPPS,N/A,100% of Medicare OPPS,N/A,100% of Medicare OPPS,N/A,100% of custom fee schedule,$27.24 ,90% of total billed charges,$5.70 ,$27.24 ,$27.24 
Outpatient Medical Services,PATHOLOGY CYTOPATHOLOGY,88312,Blood test to assist with diagnosis,310,$105.86 ,$70.39 ,100% of APC Rate,$43.99 ,100% of Medicare OPPS,$74.10 ,70% of total billed charges,$89.85 ,84.88% of total billed charges,$62.17 ,139.08% of custom fee schedule,$43.99 ,100% of Medicare OPPS,$79.40 ,75% of total billed charges,$74.10 ,70% of total billed charges,$74.78 ,170% of Medicare OPPS,$94.58 ,215% of Medicare OPPS,$12.02 ,12.84% of total billed charges,$76.98 ,175% of Medicare OPPS,$43.99 ,100% of Medicare OPPS,$84.69 ,80% of total billed charges,$61.59 ,140% of Medicare OPPS,$54.99 ,125% of Medicare OPPS,$12.02 ,12.84% of LA Medicaid fee schedule,$12.02 ,12.84% of LA Medicaid fee schedule,$43.99 ,100% of Medicare OPPS,N/A,65% of total billed charges,$43.99 ,100% of Medicare OPPS,$43.99 ,100% of Medicare OPPS,$76.98 ,100% of Medicare OPPS,$43.99 ,100% of Medicare OPPS,$23.60 ,100% of custom fee schedule,$95.27 ,90% of total billed charges,$12.02 ,$95.27 ,$95.27 
Outpatient Medical Services,PATHOLOGY CYTOPATHOLOGY,88341,immunohistochemistry/immunocytochemistry each additional specimen,310,$77.62 ,N/A,Not covered by Contract,N/A,100% of Medicare OPPS,$54.33 ,70% of total billed charges,$65.88 ,84.88% of total billed charges,N/A,139.08% of custom fee schedule,N/A,100% of Medicare OPPS,$58.22 ,75% of total billed charges,$54.33 ,70% of total billed charges,N/A,170% of Medicare OPPS,N/A,215% of Medicare OPPS,$59.94 ,12.84% of total billed charges,N/A,175% of Medicare OPPS,N/A,100% of Medicare OPPS,$62.10 ,80% of total billed charges,N/A,140% of Medicare OPPS,N/A,125% of Medicare OPPS,$59.94 ,12.84% of LA Medicaid fee schedule,$59.94 ,12.84% of LA Medicaid fee schedule,N/A,100% of Medicare OPPS,N/A,65% of total billed charges,N/A,100% of Medicare OPPS,N/A,100% of Medicare OPPS,N/A,100% of Medicare OPPS,N/A,100% of Medicare OPPS,N/A,100% of custom fee schedule,$69.86 ,90% of total billed charges,$54.33 ,$69.86 ,$69.86 
Outpatient Medical Services,PATHOLOGY CYTOPATHOLOGY,88342,Pathology test,310,$319.59 ,$220.75 ,100% of APC Rate,$137.97 ,100% of Medicare OPPS,$223.71 ,70% of total billed charges,$271.27 ,84.88% of total billed charges,$299.62 ,139.08% of custom fee schedule,$137.97 ,100% of Medicare OPPS,$239.69 ,75% of total billed charges,$223.71 ,70% of total billed charges,$234.55 ,170% of Medicare OPPS,$296.64 ,215% of Medicare OPPS,$49.84 ,12.84% of total billed charges,$241.45 ,175% of Medicare OPPS,$137.97 ,100% of Medicare OPPS,$255.67 ,80% of total billed charges,$193.16 ,140% of Medicare OPPS,$172.46 ,125% of Medicare OPPS,$49.84 ,12.84% of LA Medicaid fee schedule,$49.84 ,12.84% of LA Medicaid fee schedule,$137.97 ,100% of Medicare OPPS,N/A,65% of total billed charges,$137.97 ,100% of Medicare OPPS,$137.97 ,100% of Medicare OPPS,$241.45 ,100% of Medicare OPPS,$137.97 ,100% of Medicare OPPS,$84.41 ,100% of custom fee schedule,$287.63 ,90% of total billed charges,$49.84 ,$299.62 ,$287.63 
Outpatient Medical Services,PATHOLOGY CYTOPATHOLOGY,88172,cytopathology fine needle aspirate immediate,311,$64.90 ,$220.75 ,100% of APC Rate,$137.97 ,100% of Medicare OPPS,$45.43 ,70% of total billed charges,$55.09 ,84.88% of total billed charges,$179.66 ,139.08% of custom fee schedule,$137.97 ,100% of Medicare OPPS,$48.68 ,75% of total billed charges,$45.43 ,70% of total billed charges,$234.55 ,170% of Medicare OPPS,$296.64 ,215% of Medicare OPPS,$18.51 ,12.84% of total billed charges,$241.45 ,175% of Medicare OPPS,$137.97 ,100% of Medicare OPPS,$51.92 ,80% of total billed charges,$193.16 ,140% of Medicare OPPS,$172.46 ,125% of Medicare OPPS,$18.51 ,12.84% of LA Medicaid fee schedule,$18.51 ,12.84% of LA Medicaid fee schedule,$137.97 ,100% of Medicare OPPS,N/A,65% of total billed charges,$137.97 ,100% of Medicare OPPS,$137.97 ,100% of Medicare OPPS,$241.45 ,100% of Medicare OPPS,$137.97 ,100% of Medicare OPPS,$23.60 ,100% of custom fee schedule,$58.41 ,90% of total billed charges,$18.51 ,$296.64 ,$58.41 
Outpatient Medical Services,PATHOLOGY CYTOPATHOLOGY,88173,cytopathology fine needle aspirate,311,$86.36 ,$70.39 ,100% of APC Rate,$43.99 ,100% of Medicare OPPS,$60.45 ,70% of total billed charges,$73.30 ,84.88% of total billed charges,$62.17 ,139.08% of custom fee schedule,$43.99 ,100% of Medicare OPPS,$64.77 ,75% of total billed charges,$60.45 ,70% of total billed charges,$74.78 ,170% of Medicare OPPS,$94.58 ,215% of Medicare OPPS,$37.04 ,12.84% of total billed charges,$76.98 ,175% of Medicare OPPS,$43.99 ,100% of Medicare OPPS,$69.09 ,80% of total billed charges,$61.59 ,140% of Medicare OPPS,$54.99 ,125% of Medicare OPPS,$37.04 ,12.84% of LA Medicaid fee schedule,$37.04 ,12.84% of LA Medicaid fee schedule,$43.99 ,100% of Medicare OPPS,N/A,65% of total billed charges,$43.99 ,100% of Medicare OPPS,$43.99 ,100% of Medicare OPPS,$76.98 ,100% of Medicare OPPS,$43.99 ,100% of Medicare OPPS,$43.46 ,100% of custom fee schedule,$77.72 ,90% of total billed charges,$37.04 ,$94.58 ,$77.72 
Outpatient Medical Services,PATHOLOGY CYTOPATHOLOGY,88305,Test of tissues for diagnosis of abnormalities,314,$106.94 ,$70.39 ,100% of APC Rate,$43.99 ,100% of Medicare OPPS,$74.86 ,70% of total billed charges,$90.77 ,84.88% of total billed charges,$62.17 ,139.08% of custom fee schedule,$43.99 ,100% of Medicare OPPS,$80.21 ,75% of total billed charges,$74.86 ,70% of total billed charges,$74.78 ,170% of Medicare OPPS,$94.58 ,215% of Medicare OPPS,$49.42 ,12.84% of total billed charges,$76.98 ,175% of Medicare OPPS,$43.99 ,100% of Medicare OPPS,$85.55 ,80% of total billed charges,$61.59 ,140% of Medicare OPPS,$54.99 ,125% of Medicare OPPS,$49.42 ,12.84% of LA Medicaid fee schedule,$49.42 ,12.84% of LA Medicaid fee schedule,$43.99 ,100% of Medicare OPPS,N/A,65% of total billed charges,$43.99 ,100% of Medicare OPPS,$43.99 ,100% of Medicare OPPS,$76.98 ,100% of Medicare OPPS,$43.99 ,100% of Medicare OPPS,$43.46 ,100% of custom fee schedule,$96.25 ,90% of total billed charges,$43.46 ,$96.25 ,$96.25 
Outpatient Medical Services,LABORATORY,36415,Collection of venous blood by venipuncture,300,$18.53 ,$13.71 ,160% of Fee Schedule,$8.57 ,100% of Medicare OPPS,$12.97 ,70% of total billed charges,$15.73 ,84.88% of total billed charges,N/A,Not reimbursable per contract,$8.57 ,100% of Medicare OPPS,$13.90 ,75% of total billed charges,$12.97 ,70% of total billed charges,$14.56 ,170% of Medicare OPPS,$18.42 ,215% of Medicare OPPS,$2.99 ,12.84% of total billed charges,$14.99 ,175% of Medicare OPPS,$8.57 ,100% of Medicare OPPS,$14.82 ,80% of total billed charges,$11.99 ,140% of Medicare OPPS,$10.71 ,125% of Medicare OPPS,$2.99 ,12.84% of LA Medicaid fee schedule,$2.99 ,12.84% of LA Medicaid fee schedule,$8.57 ,100% of Medicare OPPS,$3.00 ,100% of fee schedule,$8.57 ,100% of Medicare OPPS,$8.57 ,100% of Medicare OPPS,$14.99 ,100% of Medicare OPPS,$8.57 ,100% of Medicare OPPS,$4.17 ,100% of custom fee schedule,$16.68 ,90% of total billed charges,$2.99 ,$18.42 ,$16.68 
Outpatient Medical Services,LABORATORY,80048,Basic metabolic panel,300,$84.51 ,$13.53 ,160% of Fee Schedule,$8.46 ,100% of Medicare OPPS,$59.16 ,70% of total billed charges,$71.73 ,84.88% of total billed charges,$14.52 ,139.08% of custom fee schedule,$8.46 ,100% of Medicare OPPS,$63.38 ,75% of total billed charges,$59.16 ,70% of total billed charges,$14.38 ,170% of Medicare OPPS,$18.18 ,215% of Medicare OPPS,$8.46 ,12.84% of total billed charges,$14.80 ,175% of Medicare OPPS,$8.46 ,100% of Medicare OPPS,$67.61 ,80% of total billed charges,$11.84 ,140% of Medicare OPPS,$10.57 ,125% of Medicare OPPS,$8.46 ,12.84% of LA Medicaid fee schedule,$8.46 ,12.84% of LA Medicaid fee schedule,$8.46 ,100% of Medicare OPPS,$12.36 ,100% of fee schedule,$8.46 ,100% of Medicare OPPS,$8.46 ,100% of Medicare OPPS,$14.80 ,100% of Medicare OPPS,$8.46 ,100% of Medicare OPPS,$16.04 ,100% of custom fee schedule,$76.06 ,90% of total billed charges,$8.46 ,$76.06 ,$76.06 
Outpatient Medical Services,LABORATORY,80061,"Blood test, lipids (cholesterol and triglycerides)",300,$118.40 ,$21.42 ,160% of Fee Schedule,$13.39 ,100% of Medicare OPPS,$82.88 ,70% of total billed charges,$100.50 ,84.88% of total billed charges,$22.99 ,139.08% of custom fee schedule,$13.39 ,100% of Medicare OPPS,$88.80 ,75% of total billed charges,$82.88 ,70% of total billed charges,$22.76 ,170% of Medicare OPPS,$28.78 ,215% of Medicare OPPS,$13.39 ,12.84% of total billed charges,$23.43 ,175% of Medicare OPPS,$13.39 ,100% of Medicare OPPS,$94.72 ,80% of total billed charges,$18.74 ,140% of Medicare OPPS,$16.73 ,125% of Medicare OPPS,$13.39 ,12.84% of LA Medicaid fee schedule,$13.39 ,12.84% of LA Medicaid fee schedule,$13.39 ,100% of Medicare OPPS,$19.57 ,100% of fee schedule,$13.39 ,100% of Medicare OPPS,$13.39 ,100% of Medicare OPPS,$23.43 ,100% of Medicare OPPS,$13.39 ,100% of Medicare OPPS,$22.67 ,100% of custom fee schedule,$106.56 ,90% of total billed charges,$13.39 ,$106.56 ,$106.56 
Outpatient Medical Services,LABORATORY,80069,Kidney function panel test,300,$86.11 ,$13.88 ,160% of Fee Schedule,$8.68 ,100% of Medicare OPPS,$60.28 ,70% of total billed charges,$73.09 ,84.88% of total billed charges,$14.91 ,139.08% of custom fee schedule,$8.68 ,100% of Medicare OPPS,$64.58 ,75% of total billed charges,$60.28 ,70% of total billed charges,$14.75 ,170% of Medicare OPPS,$18.66 ,215% of Medicare OPPS,$8.68 ,12.84% of total billed charges,$15.19 ,175% of Medicare OPPS,$8.68 ,100% of Medicare OPPS,$68.89 ,80% of total billed charges,$12.15 ,140% of Medicare OPPS,$10.85 ,125% of Medicare OPPS,$8.68 ,12.84% of LA Medicaid fee schedule,$8.68 ,12.84% of LA Medicaid fee schedule,$8.68 ,100% of Medicare OPPS,$12.68 ,100% of fee schedule,$8.68 ,100% of Medicare OPPS,$8.68 ,100% of Medicare OPPS,$15.19 ,100% of Medicare OPPS,$8.68 ,100% of Medicare OPPS,$16.47 ,100% of custom fee schedule,$77.50 ,90% of total billed charges,$8.68 ,$77.50 ,$77.50 
Outpatient Medical Services,LABORATORY,80074,Acute hepatitis panel,300,$138.63 ,$76.20 ,160% of Fee Schedule,$47.63 ,100% of Medicare OPPS,$97.04 ,70% of total billed charges,$117.67 ,84.88% of total billed charges,$81.79 ,139.08% of custom fee schedule,$47.63 ,100% of Medicare OPPS,$103.97 ,75% of total billed charges,$97.04 ,70% of total billed charges,$80.97 ,170% of Medicare OPPS,$102.40 ,215% of Medicare OPPS,$47.63 ,12.84% of total billed charges,$83.35 ,175% of Medicare OPPS,$47.63 ,100% of Medicare OPPS,$110.90 ,80% of total billed charges,$66.68 ,140% of Medicare OPPS,$59.53 ,125% of Medicare OPPS,$47.63 ,12.84% of LA Medicaid fee schedule,$47.63 ,12.84% of LA Medicaid fee schedule,$47.63 ,100% of Medicare OPPS,$69.54 ,100% of fee schedule,$47.63 ,100% of Medicare OPPS,$47.63 ,100% of Medicare OPPS,$83.35 ,100% of Medicare OPPS,$47.63 ,100% of Medicare OPPS,$90.34 ,100% of custom fee schedule,$124.77 ,90% of total billed charges,$47.63 ,$124.77 ,$124.77 
Outpatient Medical Services,LABORATORY,80076,Liver function blood test panel,300,$26.59 ,$13.07 ,160% of Fee Schedule,$8.17 ,100% of Medicare OPPS,$18.61 ,70% of total billed charges,$22.57 ,84.88% of total billed charges,$14.03 ,139.08% of custom fee schedule,$8.17 ,100% of Medicare OPPS,$19.94 ,75% of total billed charges,$18.61 ,70% of total billed charges,$13.88 ,170% of Medicare OPPS,$17.56 ,215% of Medicare OPPS,$8.17 ,12.84% of total billed charges,$14.29 ,175% of Medicare OPPS,$8.17 ,100% of Medicare OPPS,$21.27 ,80% of total billed charges,$11.43 ,140% of Medicare OPPS,$10.21 ,125% of Medicare OPPS,$8.17 ,12.84% of LA Medicaid fee schedule,$8.17 ,12.84% of LA Medicaid fee schedule,$8.17 ,100% of Medicare OPPS,$11.93 ,100% of fee schedule,$8.17 ,100% of Medicare OPPS,$8.17 ,100% of Medicare OPPS,$14.29 ,100% of Medicare OPPS,$8.17 ,100% of Medicare OPPS,$15.48 ,100% of custom fee schedule,$23.93 ,90% of total billed charges,$8.17 ,$23.93 ,$23.93 
Outpatient Medical Services,LABORATORY,80170,gentamicin monitoring,300,$115.74 ,$26.20 ,160% of Fee Schedule,$16.38 ,100% of Medicare OPPS,$81.02 ,70% of total billed charges,$98.24 ,84.88% of total billed charges,$28.12 ,139.08% of custom fee schedule,$16.38 ,100% of Medicare OPPS,$86.81 ,75% of total billed charges,$81.02 ,70% of total billed charges,$27.84 ,170% of Medicare OPPS,$35.21 ,215% of Medicare OPPS,$14.18 ,12.84% of total billed charges,$28.66 ,175% of Medicare OPPS,$16.38 ,100% of Medicare OPPS,$92.59 ,80% of total billed charges,$22.93 ,140% of Medicare OPPS,$20.47 ,125% of Medicare OPPS,$14.18 ,12.84% of LA Medicaid fee schedule,$14.18 ,12.84% of LA Medicaid fee schedule,$16.38 ,100% of Medicare OPPS,$23.93 ,100% of fee schedule,$16.38 ,100% of Medicare OPPS,$16.38 ,100% of Medicare OPPS,$28.66 ,100% of Medicare OPPS,$16.38 ,100% of Medicare OPPS,$22.07 ,100% of custom fee schedule,$104.17 ,90% of total billed charges,$14.18 ,$104.17 ,$104.17 
Outpatient Medical Services,LABORATORY,82172,apolipoprotein,300,$72.70 ,$33.74 ,160% of Fee Schedule,$21.09 ,100% of Medicare OPPS,$50.89 ,70% of total billed charges,$61.71 ,84.88% of total billed charges,$29.33 ,139.08% of custom fee schedule,$21.09 ,100% of Medicare OPPS,$54.53 ,75% of total billed charges,$50.89 ,70% of total billed charges,$35.85 ,170% of Medicare OPPS,$45.34 ,215% of Medicare OPPS,$9.33 ,12.84% of total billed charges,$36.90 ,175% of Medicare OPPS,$21.09 ,100% of Medicare OPPS,$58.16 ,80% of total billed charges,$29.52 ,140% of Medicare OPPS,$26.36 ,125% of Medicare OPPS,$9.33 ,12.84% of LA Medicaid fee schedule,$9.33 ,12.84% of LA Medicaid fee schedule,$21.09 ,100% of Medicare OPPS,$22.62 ,100% of fee schedule,$21.09 ,100% of Medicare OPPS,$21.09 ,100% of Medicare OPPS,$36.90 ,100% of Medicare OPPS,$21.09 ,100% of Medicare OPPS,$29.38 ,100% of custom fee schedule,$65.43 ,90% of total billed charges,$9.33 ,$65.43 ,$65.43 
Outpatient Medical Services,LABORATORY,82247,bilirubin,300,$11.34 ,$8.03 ,160% of Fee Schedule,$5.01 ,100% of Medicare OPPS,$7.94 ,70% of total billed charges,$9.63 ,84.88% of total billed charges,$8.61 ,139.08% of custom fee schedule,$5.01 ,100% of Medicare OPPS,$8.51 ,75% of total billed charges,$7.94 ,70% of total billed charges,$8.53 ,170% of Medicare OPPS,$10.79 ,215% of Medicare OPPS,$4.84 ,12.84% of total billed charges,$8.78 ,175% of Medicare OPPS,$5.01 ,100% of Medicare OPPS,$9.07 ,80% of total billed charges,$7.02 ,140% of Medicare OPPS,$6.27 ,125% of Medicare OPPS,$4.84 ,12.84% of LA Medicaid fee schedule,$4.84 ,12.84% of LA Medicaid fee schedule,$5.01 ,100% of Medicare OPPS,$7.33 ,100% of fee schedule,$5.01 ,100% of Medicare OPPS,$5.01 ,100% of Medicare OPPS,$8.78 ,100% of Medicare OPPS,$5.01 ,100% of Medicare OPPS,$6.59 ,100% of custom fee schedule,$10.21 ,90% of total billed charges,$4.84 ,$10.79 ,$10.21 
Outpatient Medical Services,LABORATORY,82310,calcium,300,$50.91 ,$8.25 ,160% of Fee Schedule,$5.16 ,100% of Medicare OPPS,$35.64 ,70% of total billed charges,$43.21 ,84.88% of total billed charges,$8.86 ,139.08% of custom fee schedule,$5.16 ,100% of Medicare OPPS,$38.18 ,75% of total billed charges,$35.64 ,70% of total billed charges,$8.77 ,170% of Medicare OPPS,$11.09 ,215% of Medicare OPPS,$5.16 ,12.84% of total billed charges,$9.03 ,175% of Medicare OPPS,$5.16 ,100% of Medicare OPPS,$40.73 ,80% of total billed charges,$7.22 ,140% of Medicare OPPS,$6.45 ,125% of Medicare OPPS,$5.16 ,12.84% of LA Medicaid fee schedule,$5.16 ,12.84% of LA Medicaid fee schedule,$5.16 ,100% of Medicare OPPS,$7.53 ,100% of fee schedule,$5.16 ,100% of Medicare OPPS,$5.16 ,100% of Medicare OPPS,$9.03 ,100% of Medicare OPPS,$5.16 ,100% of Medicare OPPS,$9.79 ,100% of custom fee schedule,$45.82 ,90% of total billed charges,$5.16 ,$45.82 ,$45.82 
Outpatient Medical Services,LABORATORY,82378,CEA,300,$178.85 ,$30.33 ,160% of Fee Schedule,$18.96 ,100% of Medicare OPPS,$125.20 ,70% of total billed charges,$151.81 ,84.88% of total billed charges,$32.56 ,139.08% of custom fee schedule,$18.96 ,100% of Medicare OPPS,$134.14 ,75% of total billed charges,$125.20 ,70% of total billed charges,$32.23 ,170% of Medicare OPPS,$40.76 ,215% of Medicare OPPS,$18.96 ,12.84% of total billed charges,$33.18 ,175% of Medicare OPPS,$18.96 ,100% of Medicare OPPS,$143.08 ,80% of total billed charges,$26.54 ,140% of Medicare OPPS,$23.70 ,125% of Medicare OPPS,$18.96 ,12.84% of LA Medicaid fee schedule,$18.96 ,12.84% of LA Medicaid fee schedule,$18.96 ,100% of Medicare OPPS,$27.70 ,100% of fee schedule,$18.96 ,100% of Medicare OPPS,$18.96 ,100% of Medicare OPPS,$33.18 ,100% of Medicare OPPS,$18.96 ,100% of Medicare OPPS,$35.97 ,100% of custom fee schedule,$160.97 ,90% of total billed charges,$18.96 ,$160.97 ,$160.97 
Outpatient Medical Services,LABORATORY,82465,cholesterol,300,$43.97 ,$6.96 ,160% of Fee Schedule,$4.34 ,100% of Medicare OPPS,$30.78 ,70% of total billed charges,$37.32 ,84.88% of total billed charges,$7.47 ,139.08% of custom fee schedule,$4.34 ,100% of Medicare OPPS,$32.98 ,75% of total billed charges,$30.78 ,70% of total billed charges,$7.39 ,170% of Medicare OPPS,$9.35 ,215% of Medicare OPPS,$4.26 ,12.84% of total billed charges,$7.61 ,175% of Medicare OPPS,$4.34 ,100% of Medicare OPPS,$35.18 ,80% of total billed charges,$6.09 ,140% of Medicare OPPS,$5.43 ,125% of Medicare OPPS,$4.26 ,12.84% of LA Medicaid fee schedule,$4.26 ,12.84% of LA Medicaid fee schedule,$4.34 ,100% of Medicare OPPS,$6.36 ,100% of fee schedule,$4.34 ,100% of Medicare OPPS,$4.34 ,100% of Medicare OPPS,$7.61 ,100% of Medicare OPPS,$4.34 ,100% of Medicare OPPS,$8.24 ,100% of custom fee schedule,$39.57 ,90% of total billed charges,$4.26 ,$39.57 ,$39.57 
Outpatient Medical Services,LABORATORY,82565,creatinine,300,$16.66 ,$8.19 ,160% of Fee Schedule,$5.12 ,100% of Medicare OPPS,$11.66 ,70% of total billed charges,$14.14 ,84.88% of total billed charges,$8.80 ,139.08% of custom fee schedule,$5.12 ,100% of Medicare OPPS,$12.50 ,75% of total billed charges,$11.66 ,70% of total billed charges,$8.70 ,170% of Medicare OPPS,$11.00 ,215% of Medicare OPPS,$5.12 ,12.84% of total billed charges,$8.96 ,175% of Medicare OPPS,$5.12 ,100% of Medicare OPPS,$13.33 ,80% of total billed charges,$7.16 ,140% of Medicare OPPS,$6.40 ,125% of Medicare OPPS,$5.12 ,12.84% of LA Medicaid fee schedule,$5.12 ,12.84% of LA Medicaid fee schedule,$5.12 ,100% of Medicare OPPS,$7.48 ,100% of fee schedule,$5.12 ,100% of Medicare OPPS,$5.12 ,100% of Medicare OPPS,$8.96 ,100% of Medicare OPPS,$5.12 ,100% of Medicare OPPS,$9.72 ,100% of custom fee schedule,$14.99 ,90% of total billed charges,$5.12 ,$14.99 ,$14.99 
Outpatient Medical Services,LABORATORY,82728,Test to determine level of iron in the blood,300,$118.07 ,$21.80 ,160% of Fee Schedule,$13.63 ,100% of Medicare OPPS,$82.65 ,70% of total billed charges,$100.22 ,84.88% of total billed charges,$23.41 ,139.08% of custom fee schedule,$13.63 ,100% of Medicare OPPS,$88.55 ,75% of total billed charges,$82.65 ,70% of total billed charges,$23.17 ,170% of Medicare OPPS,$29.30 ,215% of Medicare OPPS,$13.63 ,12.84% of total billed charges,$23.85 ,175% of Medicare OPPS,$13.63 ,100% of Medicare OPPS,$94.46 ,80% of total billed charges,$19.08 ,140% of Medicare OPPS,$17.03 ,125% of Medicare OPPS,$13.63 ,12.84% of LA Medicaid fee schedule,$13.63 ,12.84% of LA Medicaid fee schedule,$13.63 ,100% of Medicare OPPS,$19.89 ,100% of fee schedule,$13.63 ,100% of Medicare OPPS,$13.63 ,100% of Medicare OPPS,$23.85 ,100% of Medicare OPPS,$13.63 ,100% of Medicare OPPS,$25.84 ,100% of custom fee schedule,$106.26 ,90% of total billed charges,$13.63 ,$106.26 ,$106.26 
Outpatient Medical Services,LABORATORY,82746,folic acid,300,$126.75 ,$23.52 ,160% of Fee Schedule,$14.70 ,100% of Medicare OPPS,$88.73 ,70% of total billed charges,$107.59 ,84.88% of total billed charges,$25.24 ,139.08% of custom fee schedule,$14.70 ,100% of Medicare OPPS,$95.06 ,75% of total billed charges,$88.73 ,70% of total billed charges,$24.99 ,170% of Medicare OPPS,$31.60 ,215% of Medicare OPPS,$14.70 ,12.84% of total billed charges,$25.72 ,175% of Medicare OPPS,$14.70 ,100% of Medicare OPPS,$101.40 ,80% of total billed charges,$20.58 ,140% of Medicare OPPS,$18.37 ,125% of Medicare OPPS,$14.70 ,12.84% of LA Medicaid fee schedule,$14.70 ,12.84% of LA Medicaid fee schedule,$14.70 ,100% of Medicare OPPS,$21.47 ,100% of fee schedule,$14.70 ,100% of Medicare OPPS,$14.70 ,100% of Medicare OPPS,$25.72 ,100% of Medicare OPPS,$14.70 ,100% of Medicare OPPS,$27.88 ,100% of custom fee schedule,$114.08 ,90% of total billed charges,$14.70 ,$114.08 ,$114.08 
Outpatient Medical Services,LABORATORY,82784,Test to determine levels of immunoglobulins in the blood,300,$80.47 ,$14.88 ,160% of Fee Schedule,$9.30 ,100% of Medicare OPPS,$56.33 ,70% of total billed charges,$68.30 ,84.88% of total billed charges,$15.97 ,139.08% of custom fee schedule,$9.30 ,100% of Medicare OPPS,$60.35 ,75% of total billed charges,$56.33 ,70% of total billed charges,$15.81 ,170% of Medicare OPPS,$19.99 ,215% of Medicare OPPS,$9.30 ,12.84% of total billed charges,$16.27 ,175% of Medicare OPPS,$9.30 ,100% of Medicare OPPS,$64.38 ,80% of total billed charges,$13.02 ,140% of Medicare OPPS,$11.62 ,125% of Medicare OPPS,$9.30 ,12.84% of LA Medicaid fee schedule,$9.30 ,12.84% of LA Medicaid fee schedule,$9.30 ,100% of Medicare OPPS,$13.58 ,100% of fee schedule,$9.30 ,100% of Medicare OPPS,$9.30 ,100% of Medicare OPPS,$16.27 ,100% of Medicare OPPS,$9.30 ,100% of Medicare OPPS,$17.63 ,100% of custom fee schedule,$72.42 ,90% of total billed charges,$9.30 ,$72.42 ,$72.42 
Outpatient Medical Services,LABORATORY,82785,gammaglobulin IgE,300,$53.58 ,$26.33 ,160% of Fee Schedule,$16.46 ,100% of Medicare OPPS,$37.51 ,70% of total billed charges,$45.48 ,84.88% of total billed charges,$28.26 ,139.08% of custom fee schedule,$16.46 ,100% of Medicare OPPS,$40.19 ,75% of total billed charges,$37.51 ,70% of total billed charges,$27.98 ,170% of Medicare OPPS,$35.38 ,215% of Medicare OPPS,$16.46 ,12.84% of total billed charges,$28.80 ,175% of Medicare OPPS,$16.46 ,100% of Medicare OPPS,$42.86 ,80% of total billed charges,$23.04 ,140% of Medicare OPPS,$20.57 ,125% of Medicare OPPS,$16.46 ,12.84% of LA Medicaid fee schedule,$16.46 ,12.84% of LA Medicaid fee schedule,$16.46 ,100% of Medicare OPPS,$24.05 ,100% of fee schedule,$16.46 ,100% of Medicare OPPS,$16.46 ,100% of Medicare OPPS,$28.80 ,100% of Medicare OPPS,$16.46 ,100% of Medicare OPPS,$31.23 ,100% of custom fee schedule,$48.22 ,90% of total billed charges,$16.46 ,$48.22 ,$48.22 
Outpatient Medical Services,LABORATORY,82948,bedside glucose,300,$30.09 ,$8.06 ,160% of Fee Schedule,$5.04 ,100% of Medicare OPPS,$21.06 ,70% of total billed charges,$25.54 ,84.88% of total billed charges,$7.01 ,139.08% of custom fee schedule,$5.04 ,100% of Medicare OPPS,$22.57 ,75% of total billed charges,$21.06 ,70% of total billed charges,$8.56 ,170% of Medicare OPPS,$10.83 ,215% of Medicare OPPS,$4.07 ,12.84% of total billed charges,$8.82 ,175% of Medicare OPPS,$5.04 ,100% of Medicare OPPS,$24.07 ,80% of total billed charges,$7.05 ,140% of Medicare OPPS,$6.30 ,125% of Medicare OPPS,$4.07 ,12.84% of LA Medicaid fee schedule,$4.07 ,12.84% of LA Medicaid fee schedule,$5.04 ,100% of Medicare OPPS,$4.63 ,100% of fee schedule,$5.04 ,100% of Medicare OPPS,$5.04 ,100% of Medicare OPPS,$8.82 ,100% of Medicare OPPS,$5.04 ,100% of Medicare OPPS,$6.00 ,100% of custom fee schedule,$27.08 ,90% of total billed charges,$4.07 ,$27.08 ,$27.08 
Outpatient Medical Services,LABORATORY,82977,GGT,300,$69.11 ,$11.52 ,160% of Fee Schedule,$7.20 ,100% of Medicare OPPS,$48.38 ,70% of total billed charges,$58.66 ,84.88% of total billed charges,$12.36 ,139.08% of custom fee schedule,$7.20 ,100% of Medicare OPPS,$51.83 ,75% of total billed charges,$48.38 ,70% of total billed charges,$12.24 ,170% of Medicare OPPS,$15.48 ,215% of Medicare OPPS,$7.20 ,12.84% of total billed charges,$12.60 ,175% of Medicare OPPS,$7.20 ,100% of Medicare OPPS,$55.29 ,80% of total billed charges,$10.08 ,140% of Medicare OPPS,$9.00 ,125% of Medicare OPPS,$7.20 ,12.84% of LA Medicaid fee schedule,$7.20 ,12.84% of LA Medicaid fee schedule,$7.20 ,100% of Medicare OPPS,$10.51 ,100% of fee schedule,$7.20 ,100% of Medicare OPPS,$7.20 ,100% of Medicare OPPS,$12.60 ,100% of Medicare OPPS,$7.20 ,100% of Medicare OPPS,$13.65 ,100% of custom fee schedule,$62.20 ,90% of total billed charges,$7.20 ,$62.20 ,$62.20 
Outpatient Medical Services,LABORATORY,83010,haptoglobin,300,$67.22 ,$20.12 ,160% of Fee Schedule,$12.58 ,100% of Medicare OPPS,$47.05 ,70% of total billed charges,$57.06 ,84.88% of total billed charges,$21.60 ,139.08% of custom fee schedule,$12.58 ,100% of Medicare OPPS,$50.42 ,75% of total billed charges,$47.05 ,70% of total billed charges,$21.38 ,170% of Medicare OPPS,$27.04 ,215% of Medicare OPPS,$12.58 ,12.84% of total billed charges,$22.01 ,175% of Medicare OPPS,$12.58 ,100% of Medicare OPPS,$53.78 ,80% of total billed charges,$17.61 ,140% of Medicare OPPS,$15.72 ,125% of Medicare OPPS,$12.58 ,12.84% of LA Medicaid fee schedule,$12.58 ,12.84% of LA Medicaid fee schedule,$12.58 ,100% of Medicare OPPS,$18.37 ,100% of fee schedule,$12.58 ,100% of Medicare OPPS,$12.58 ,100% of Medicare OPPS,$22.01 ,100% of Medicare OPPS,$12.58 ,100% of Medicare OPPS,$23.85 ,100% of custom fee schedule,$60.50 ,90% of total billed charges,$12.58 ,$60.50 ,$60.50 
Outpatient Medical Services,LABORATORY,83036,Blood test to measure average blood glucose levels for past 2-3 months,300,$106.48 ,$15.53 ,160% of Fee Schedule,$9.71 ,100% of Medicare OPPS,$74.54 ,70% of total billed charges,$90.38 ,84.88% of total billed charges,$16.68 ,139.08% of custom fee schedule,$9.71 ,100% of Medicare OPPS,$79.86 ,75% of total billed charges,$74.54 ,70% of total billed charges,$16.50 ,170% of Medicare OPPS,$20.87 ,215% of Medicare OPPS,$9.71 ,12.84% of total billed charges,$16.99 ,175% of Medicare OPPS,$9.71 ,100% of Medicare OPPS,$85.18 ,80% of total billed charges,$13.59 ,140% of Medicare OPPS,$12.13 ,125% of Medicare OPPS,$9.71 ,12.84% of LA Medicaid fee schedule,$9.71 ,12.84% of LA Medicaid fee schedule,$9.71 ,100% of Medicare OPPS,$14.17 ,100% of fee schedule,$9.71 ,100% of Medicare OPPS,$9.71 ,100% of Medicare OPPS,$16.99 ,100% of Medicare OPPS,$9.71 ,100% of Medicare OPPS,$18.40 ,100% of custom fee schedule,$95.83 ,90% of total billed charges,$9.71 ,$95.83 ,$95.83 
Outpatient Medical Services,LABORATORY,83540,Blood test to measure the amount of iron that is in transit in the body,300,$57.89 ,$10.35 ,160% of Fee Schedule,$6.47 ,100% of Medicare OPPS,$40.52 ,70% of total billed charges,$49.14 ,84.88% of total billed charges,$11.11 ,139.08% of custom fee schedule,$6.47 ,100% of Medicare OPPS,$43.42 ,75% of total billed charges,$40.52 ,70% of total billed charges,$10.99 ,170% of Medicare OPPS,$13.91 ,215% of Medicare OPPS,$6.34 ,12.84% of total billed charges,$11.32 ,175% of Medicare OPPS,$6.47 ,100% of Medicare OPPS,$46.31 ,80% of total billed charges,$9.05 ,140% of Medicare OPPS,$8.08 ,125% of Medicare OPPS,$6.34 ,12.84% of LA Medicaid fee schedule,$6.34 ,12.84% of LA Medicaid fee schedule,$6.47 ,100% of Medicare OPPS,$9.46 ,100% of fee schedule,$6.47 ,100% of Medicare OPPS,$6.47 ,100% of Medicare OPPS,$11.32 ,100% of Medicare OPPS,$6.47 ,100% of Medicare OPPS,$10.17 ,100% of custom fee schedule,$52.10 ,90% of total billed charges,$6.34 ,$52.10 ,$52.10 
Outpatient Medical Services,LABORATORY,83550,Blood test that measures the amount of iron carried in the blood,300,$86.84 ,$13.98 ,160% of Fee Schedule,$8.74 ,100% of Medicare OPPS,$60.79 ,70% of total billed charges,$73.71 ,84.88% of total billed charges,$15.01 ,139.08% of custom fee schedule,$8.74 ,100% of Medicare OPPS,$65.13 ,75% of total billed charges,$60.79 ,70% of total billed charges,$14.85 ,170% of Medicare OPPS,$18.79 ,215% of Medicare OPPS,$8.74 ,12.84% of total billed charges,$15.29 ,175% of Medicare OPPS,$8.74 ,100% of Medicare OPPS,$69.47 ,80% of total billed charges,$12.23 ,140% of Medicare OPPS,$10.92 ,125% of Medicare OPPS,$8.74 ,12.84% of LA Medicaid fee schedule,$8.74 ,12.84% of LA Medicaid fee schedule,$8.74 ,100% of Medicare OPPS,$12.77 ,100% of fee schedule,$8.74 ,100% of Medicare OPPS,$8.74 ,100% of Medicare OPPS,$15.29 ,100% of Medicare OPPS,$8.74 ,100% of Medicare OPPS,$16.58 ,100% of custom fee schedule,$78.16 ,90% of total billed charges,$8.74 ,$78.16 ,$78.16 
Outpatient Medical Services,LABORATORY,83690,lipase,300,$22.41 ,$11.02 ,160% of Fee Schedule,$6.89 ,100% of Medicare OPPS,$15.69 ,70% of total billed charges,$19.02 ,84.88% of total billed charges,$11.84 ,139.08% of custom fee schedule,$6.89 ,100% of Medicare OPPS,$16.81 ,75% of total billed charges,$15.69 ,70% of total billed charges,$11.71 ,170% of Medicare OPPS,$14.81 ,215% of Medicare OPPS,$6.89 ,12.84% of total billed charges,$12.05 ,175% of Medicare OPPS,$6.89 ,100% of Medicare OPPS,$17.93 ,80% of total billed charges,$9.64 ,140% of Medicare OPPS,$8.61 ,125% of Medicare OPPS,$6.89 ,12.84% of LA Medicaid fee schedule,$6.89 ,12.84% of LA Medicaid fee schedule,$6.89 ,100% of Medicare OPPS,$10.06 ,100% of fee schedule,$6.89 ,100% of Medicare OPPS,$6.89 ,100% of Medicare OPPS,$12.05 ,100% of Medicare OPPS,$6.89 ,100% of Medicare OPPS,$13.07 ,100% of custom fee schedule,$20.17 ,90% of total billed charges,$6.89 ,$20.17 ,$20.17 
Outpatient Medical Services,LABORATORY,84100,phosphate,300,$50.91 ,$7.58 ,160% of Fee Schedule,$4.74 ,100% of Medicare OPPS,$35.64 ,70% of total billed charges,$43.21 ,84.88% of total billed charges,$8.14 ,139.08% of custom fee schedule,$4.74 ,100% of Medicare OPPS,$38.18 ,75% of total billed charges,$35.64 ,70% of total billed charges,$8.05 ,170% of Medicare OPPS,$10.19 ,215% of Medicare OPPS,$4.74 ,12.84% of total billed charges,$8.29 ,175% of Medicare OPPS,$4.74 ,100% of Medicare OPPS,$40.73 ,80% of total billed charges,$6.63 ,140% of Medicare OPPS,$5.92 ,125% of Medicare OPPS,$4.74 ,12.84% of LA Medicaid fee schedule,$4.74 ,12.84% of LA Medicaid fee schedule,$4.74 ,100% of Medicare OPPS,$6.93 ,100% of fee schedule,$4.74 ,100% of Medicare OPPS,$4.74 ,100% of Medicare OPPS,$8.29 ,100% of Medicare OPPS,$4.74 ,100% of Medicare OPPS,$8.98 ,100% of custom fee schedule,$45.82 ,90% of total billed charges,$4.74 ,$45.82 ,$45.82 
Outpatient Medical Services,LABORATORY,84132,potassium,300,$45.87 ,$7.61 ,160% of Fee Schedule,$4.76 ,100% of Medicare OPPS,$32.11 ,70% of total billed charges,$38.93 ,84.88% of total billed charges,$7.90 ,139.08% of custom fee schedule,$4.76 ,100% of Medicare OPPS,$34.40 ,75% of total billed charges,$32.11 ,70% of total billed charges,$8.09 ,170% of Medicare OPPS,$10.23 ,215% of Medicare OPPS,$4.76 ,12.84% of total billed charges,$8.33 ,175% of Medicare OPPS,$4.76 ,100% of Medicare OPPS,$36.70 ,80% of total billed charges,$6.66 ,140% of Medicare OPPS,$5.95 ,125% of Medicare OPPS,$4.76 ,12.84% of LA Medicaid fee schedule,$4.76 ,12.84% of LA Medicaid fee schedule,$4.76 ,100% of Medicare OPPS,$6.70 ,100% of fee schedule,$4.76 ,100% of Medicare OPPS,$4.76 ,100% of Medicare OPPS,$8.33 ,100% of Medicare OPPS,$4.76 ,100% of Medicare OPPS,$8.72 ,100% of custom fee schedule,$41.28 ,90% of total billed charges,$4.76 ,$41.28 ,$41.28 
Outpatient Medical Services,LABORATORY,84153,PSA (prostate specific antigen),300,$59.82 ,$29.42 ,160% of Fee Schedule,$18.39 ,100% of Medicare OPPS,$41.87 ,70% of total billed charges,$50.78 ,84.88% of total billed charges,$31.59 ,139.08% of custom fee schedule,$18.39 ,100% of Medicare OPPS,$44.87 ,75% of total billed charges,$41.87 ,70% of total billed charges,$31.26 ,170% of Medicare OPPS,$39.53 ,215% of Medicare OPPS,$18.39 ,12.84% of total billed charges,$32.18 ,175% of Medicare OPPS,$18.39 ,100% of Medicare OPPS,$47.86 ,80% of total billed charges,$25.74 ,140% of Medicare OPPS,$22.98 ,125% of Medicare OPPS,$18.39 ,12.84% of LA Medicaid fee schedule,$18.39 ,12.84% of LA Medicaid fee schedule,$18.39 ,100% of Medicare OPPS,$26.85 ,100% of fee schedule,$18.39 ,100% of Medicare OPPS,$18.39 ,100% of Medicare OPPS,$32.18 ,100% of Medicare OPPS,$18.39 ,100% of Medicare OPPS,$34.88 ,100% of custom fee schedule,$53.84 ,90% of total billed charges,$18.39 ,$53.84 ,$53.84 
Outpatient Medical Services,LABORATORY,84403,testosterone,300,$247.70 ,$41.29 ,160% of Fee Schedule,$25.81 ,100% of Medicare OPPS,$173.39 ,70% of total billed charges,$210.25 ,84.88% of total billed charges,$44.32 ,139.08% of custom fee schedule,$25.81 ,100% of Medicare OPPS,$185.78 ,75% of total billed charges,$173.39 ,70% of total billed charges,$43.87 ,170% of Medicare OPPS,$55.49 ,215% of Medicare OPPS,$25.81 ,12.84% of total billed charges,$45.16 ,175% of Medicare OPPS,$25.81 ,100% of Medicare OPPS,$198.16 ,80% of total billed charges,$36.13 ,140% of Medicare OPPS,$32.26 ,125% of Medicare OPPS,$25.81 ,12.84% of LA Medicaid fee schedule,$25.81 ,12.84% of LA Medicaid fee schedule,$25.81 ,100% of Medicare OPPS,$37.70 ,100% of fee schedule,$25.81 ,100% of Medicare OPPS,$25.81 ,100% of Medicare OPPS,$45.16 ,100% of Medicare OPPS,$25.81 ,100% of Medicare OPPS,$48.96 ,100% of custom fee schedule,$222.93 ,90% of total billed charges,$25.81 ,$222.93 ,$222.93 
Outpatient Medical Services,LABORATORY,84436,Blood test to measure a type of thyroid hormone,300,$62.50 ,$10.99 ,160% of Fee Schedule,$6.87 ,100% of Medicare OPPS,$43.75 ,70% of total billed charges,$53.05 ,84.88% of total billed charges,$11.79 ,139.08% of custom fee schedule,$6.87 ,100% of Medicare OPPS,$46.88 ,75% of total billed charges,$43.75 ,70% of total billed charges,$11.67 ,170% of Medicare OPPS,$14.77 ,215% of Medicare OPPS,$5.86 ,12.84% of total billed charges,$12.02 ,175% of Medicare OPPS,$6.87 ,100% of Medicare OPPS,$50.00 ,80% of total billed charges,$9.61 ,140% of Medicare OPPS,$8.58 ,125% of Medicare OPPS,$5.86 ,12.84% of LA Medicaid fee schedule,$5.86 ,12.84% of LA Medicaid fee schedule,$6.87 ,100% of Medicare OPPS,$10.03 ,100% of fee schedule,$6.87 ,100% of Medicare OPPS,$6.87 ,100% of Medicare OPPS,$12.02 ,100% of Medicare OPPS,$6.87 ,100% of Medicare OPPS,$9.17 ,100% of custom fee schedule,$56.25 ,90% of total billed charges,$5.86 ,$56.25 ,$56.25 
Outpatient Medical Services,LABORATORY,84439,Blood test to evaluate thyroid function,300,$90.28 ,$14.43 ,160% of Fee Schedule,$9.02 ,100% of Medicare OPPS,$63.20 ,70% of total billed charges,$76.63 ,84.88% of total billed charges,$15.48 ,139.08% of custom fee schedule,$9.02 ,100% of Medicare OPPS,$67.71 ,75% of total billed charges,$63.20 ,70% of total billed charges,$15.33 ,170% of Medicare OPPS,$19.39 ,215% of Medicare OPPS,$9.02 ,12.84% of total billed charges,$15.78 ,175% of Medicare OPPS,$9.02 ,100% of Medicare OPPS,$72.22 ,80% of total billed charges,$12.62 ,140% of Medicare OPPS,$11.27 ,125% of Medicare OPPS,$9.02 ,12.84% of LA Medicaid fee schedule,$9.02 ,12.84% of LA Medicaid fee schedule,$9.02 ,100% of Medicare OPPS,$13.17 ,100% of fee schedule,$9.02 ,100% of Medicare OPPS,$9.02 ,100% of Medicare OPPS,$15.78 ,100% of Medicare OPPS,$9.02 ,100% of Medicare OPPS,$17.10 ,100% of custom fee schedule,$81.25 ,90% of total billed charges,$9.02 ,$81.25 ,$81.25 
Outpatient Medical Services,LABORATORY,84450,SGOT,300,$17.22 ,$8.28 ,160% of Fee Schedule,$5.18 ,100% of Medicare OPPS,$12.05 ,70% of total billed charges,$14.62 ,84.88% of total billed charges,$8.89 ,139.08% of custom fee schedule,$5.18 ,100% of Medicare OPPS,$12.92 ,75% of total billed charges,$12.05 ,70% of total billed charges,$8.80 ,170% of Medicare OPPS,$11.13 ,215% of Medicare OPPS,$5.18 ,12.84% of total billed charges,$9.06 ,175% of Medicare OPPS,$5.18 ,100% of Medicare OPPS,$13.78 ,80% of total billed charges,$7.25 ,140% of Medicare OPPS,$6.47 ,125% of Medicare OPPS,$5.18 ,12.84% of LA Medicaid fee schedule,$5.18 ,12.84% of LA Medicaid fee schedule,$5.18 ,100% of Medicare OPPS,$7.55 ,100% of fee schedule,$5.18 ,100% of Medicare OPPS,$5.18 ,100% of Medicare OPPS,$9.06 ,100% of Medicare OPPS,$5.18 ,100% of Medicare OPPS,$9.81 ,100% of custom fee schedule,$15.50 ,90% of total billed charges,$5.18 ,$15.50 ,$15.50 
Outpatient Medical Services,LABORATORY,84460,Blood test to evaluate liver function,300,$50.91 ,$8.48 ,160% of Fee Schedule,$5.30 ,100% of Medicare OPPS,$35.64 ,70% of total billed charges,$43.21 ,84.88% of total billed charges,$9.10 ,139.08% of custom fee schedule,$5.30 ,100% of Medicare OPPS,$38.18 ,75% of total billed charges,$35.64 ,70% of total billed charges,$9.01 ,170% of Medicare OPPS,$11.39 ,215% of Medicare OPPS,$5.30 ,12.84% of total billed charges,$9.27 ,175% of Medicare OPPS,$5.30 ,100% of Medicare OPPS,$40.73 ,80% of total billed charges,$7.42 ,140% of Medicare OPPS,$6.62 ,125% of Medicare OPPS,$5.30 ,12.84% of LA Medicaid fee schedule,$5.30 ,12.84% of LA Medicaid fee schedule,$5.30 ,100% of Medicare OPPS,$7.73 ,100% of fee schedule,$5.30 ,100% of Medicare OPPS,$5.30 ,100% of Medicare OPPS,$9.27 ,100% of Medicare OPPS,$5.30 ,100% of Medicare OPPS,$10.04 ,100% of custom fee schedule,$45.82 ,90% of total billed charges,$5.30 ,$45.82 ,$45.82 
Outpatient Medical Services,LABORATORY,84481,Free T3,300,$97.88 ,$27.10 ,160% of Fee Schedule,$16.94 ,100% of Medicare OPPS,$68.52 ,70% of total billed charges,$83.08 ,84.88% of total billed charges,$29.10 ,139.08% of custom fee schedule,$16.94 ,100% of Medicare OPPS,$73.41 ,75% of total billed charges,$68.52 ,70% of total billed charges,$28.79 ,170% of Medicare OPPS,$36.42 ,215% of Medicare OPPS,$12.02 ,12.84% of total billed charges,$29.64 ,175% of Medicare OPPS,$16.94 ,100% of Medicare OPPS,$78.30 ,80% of total billed charges,$23.71 ,140% of Medicare OPPS,$21.17 ,125% of Medicare OPPS,$12.02 ,12.84% of LA Medicaid fee schedule,$12.02 ,12.84% of LA Medicaid fee schedule,$16.94 ,100% of Medicare OPPS,$24.74 ,100% of fee schedule,$16.94 ,100% of Medicare OPPS,$16.94 ,100% of Medicare OPPS,$29.64 ,100% of Medicare OPPS,$16.94 ,100% of Medicare OPPS,$18.71 ,100% of custom fee schedule,$88.09 ,90% of total billed charges,$12.02 ,$88.09 ,$88.09 
Outpatient Medical Services,LABORATORY,84520,BUN,300,$20.65 ,$6.32 ,160% of Fee Schedule,$3.95 ,100% of Medicare OPPS,$14.46 ,70% of total billed charges,$17.53 ,84.88% of total billed charges,$6.79 ,139.08% of custom fee schedule,$3.95 ,100% of Medicare OPPS,$15.49 ,75% of total billed charges,$14.46 ,70% of total billed charges,$6.71 ,170% of Medicare OPPS,$8.49 ,215% of Medicare OPPS,$3.95 ,12.84% of total billed charges,$6.91 ,175% of Medicare OPPS,$3.95 ,100% of Medicare OPPS,$16.52 ,80% of total billed charges,$5.53 ,140% of Medicare OPPS,$4.93 ,125% of Medicare OPPS,$3.95 ,12.84% of LA Medicaid fee schedule,$3.95 ,12.84% of LA Medicaid fee schedule,$3.95 ,100% of Medicare OPPS,$5.76 ,100% of fee schedule,$3.95 ,100% of Medicare OPPS,$3.95 ,100% of Medicare OPPS,$6.91 ,100% of Medicare OPPS,$3.95 ,100% of Medicare OPPS,$7.49 ,100% of custom fee schedule,$18.59 ,90% of total billed charges,$3.95 ,$18.59 ,$18.59 
Outpatient Medical Services,LABORATORY,84550,uric acid,300,$46.28 ,$7.23 ,160% of Fee Schedule,$4.51 ,100% of Medicare OPPS,$32.40 ,70% of total billed charges,$39.28 ,84.88% of total billed charges,$7.76 ,139.08% of custom fee schedule,$4.51 ,100% of Medicare OPPS,$34.71 ,75% of total billed charges,$32.40 ,70% of total billed charges,$7.68 ,170% of Medicare OPPS,$9.71 ,215% of Medicare OPPS,$4.52 ,12.84% of total billed charges,$7.90 ,175% of Medicare OPPS,$4.51 ,100% of Medicare OPPS,$37.02 ,80% of total billed charges,$6.32 ,140% of Medicare OPPS,$5.65 ,125% of Medicare OPPS,$4.52 ,12.84% of LA Medicaid fee schedule,$4.52 ,12.84% of LA Medicaid fee schedule,$4.51 ,100% of Medicare OPPS,$6.59 ,100% of fee schedule,$4.51 ,100% of Medicare OPPS,$4.51 ,100% of Medicare OPPS,$7.90 ,100% of Medicare OPPS,$4.51 ,100% of Medicare OPPS,$8.56 ,100% of custom fee schedule,$41.65 ,90% of total billed charges,$4.51 ,$41.65 ,$41.65 
Outpatient Medical Services,LABORATORY,84703,Blood test to assess for pregnancy,300,$81.03 ,$12.03 ,160% of Fee Schedule,$7.52 ,100% of Medicare OPPS,$56.72 ,70% of total billed charges,$68.78 ,84.88% of total billed charges,$12.92 ,139.08% of custom fee schedule,$7.52 ,100% of Medicare OPPS,$60.77 ,75% of total billed charges,$56.72 ,70% of total billed charges,$12.78 ,170% of Medicare OPPS,$16.16 ,215% of Medicare OPPS,$7.52 ,12.84% of total billed charges,$13.16 ,175% of Medicare OPPS,$7.52 ,100% of Medicare OPPS,$64.82 ,80% of total billed charges,$10.52 ,140% of Medicare OPPS,$9.40 ,125% of Medicare OPPS,$7.52 ,12.84% of LA Medicaid fee schedule,$7.52 ,12.84% of LA Medicaid fee schedule,$7.52 ,100% of Medicare OPPS,$10.97 ,100% of fee schedule,$7.52 ,100% of Medicare OPPS,$7.52 ,100% of Medicare OPPS,$13.16 ,100% of Medicare OPPS,$7.52 ,100% of Medicare OPPS,$14.26 ,100% of custom fee schedule,$72.93 ,90% of total billed charges,$7.52 ,$72.93 ,$72.93 
Outpatient Medical Services,LABORATORY,85007,Blood test to assess for infection,300,$41.66 ,$6.08 ,160% of Fee Schedule,$3.80 ,100% of Medicare OPPS,$29.16 ,70% of total billed charges,$35.36 ,84.88% of total billed charges,$5.90 ,139.08% of custom fee schedule,$3.80 ,100% of Medicare OPPS,$31.25 ,75% of total billed charges,$29.16 ,70% of total billed charges,$6.46 ,170% of Medicare OPPS,$8.17 ,215% of Medicare OPPS,$3.05 ,12.84% of total billed charges,$6.65 ,175% of Medicare OPPS,$3.80 ,100% of Medicare OPPS,$33.33 ,80% of total billed charges,$5.32 ,140% of Medicare OPPS,$4.75 ,125% of Medicare OPPS,$3.05 ,12.84% of LA Medicaid fee schedule,$3.05 ,12.84% of LA Medicaid fee schedule,$3.80 ,100% of Medicare OPPS,$5.02 ,100% of fee schedule,$3.80 ,100% of Medicare OPPS,$3.80 ,100% of Medicare OPPS,$6.65 ,100% of Medicare OPPS,$3.80 ,100% of Medicare OPPS,$4.75 ,100% of custom fee schedule,$37.49 ,90% of total billed charges,$3.05 ,$37.49 ,$37.49 
Outpatient Medical Services,LABORATORY,85014,hematocrit,300,$24.08 ,$3.79 ,160% of Fee Schedule,$2.37 ,100% of Medicare OPPS,$16.86 ,70% of total billed charges,$20.44 ,84.88% of total billed charges,$4.08 ,139.08% of custom fee schedule,$2.37 ,100% of Medicare OPPS,$18.06 ,75% of total billed charges,$16.86 ,70% of total billed charges,$4.02 ,170% of Medicare OPPS,$5.09 ,215% of Medicare OPPS,$2.37 ,12.84% of total billed charges,$4.14 ,175% of Medicare OPPS,$2.37 ,100% of Medicare OPPS,$19.26 ,80% of total billed charges,$3.31 ,140% of Medicare OPPS,$2.96 ,125% of Medicare OPPS,$2.37 ,12.84% of LA Medicaid fee schedule,$2.37 ,12.84% of LA Medicaid fee schedule,$2.37 ,100% of Medicare OPPS,$3.46 ,100% of fee schedule,$2.37 ,100% of Medicare OPPS,$2.37 ,100% of Medicare OPPS,$4.14 ,100% of Medicare OPPS,$2.37 ,100% of Medicare OPPS,$4.49 ,100% of custom fee schedule,$21.67 ,90% of total billed charges,$2.37 ,$21.67 ,$21.67 
Outpatient Medical Services,LABORATORY,85018,Blood test to measure levels of hemoglobin,300,$24.08 ,$3.79 ,160% of Fee Schedule,$2.37 ,100% of Medicare OPPS,$16.86 ,70% of total billed charges,$20.44 ,84.88% of total billed charges,$4.08 ,139.08% of custom fee schedule,$2.37 ,100% of Medicare OPPS,$18.06 ,75% of total billed charges,$16.86 ,70% of total billed charges,$4.02 ,170% of Medicare OPPS,$5.09 ,215% of Medicare OPPS,$2.37 ,12.84% of total billed charges,$4.14 ,175% of Medicare OPPS,$2.37 ,100% of Medicare OPPS,$19.26 ,80% of total billed charges,$3.31 ,140% of Medicare OPPS,$2.96 ,125% of Medicare OPPS,$2.37 ,12.84% of LA Medicaid fee schedule,$2.37 ,12.84% of LA Medicaid fee schedule,$2.37 ,100% of Medicare OPPS,$3.46 ,100% of fee schedule,$2.37 ,100% of Medicare OPPS,$2.37 ,100% of Medicare OPPS,$4.14 ,100% of Medicare OPPS,$2.37 ,100% of Medicare OPPS,$4.49 ,100% of custom fee schedule,$21.67 ,90% of total billed charges,$2.37 ,$21.67 ,$21.67 
Outpatient Medical Services,LABORATORY,86140,c-reactive protein,300,$104.19 ,$8.28 ,160% of Fee Schedule,$5.18 ,100% of Medicare OPPS,$72.93 ,70% of total billed charges,$88.44 ,84.88% of total billed charges,$8.89 ,139.08% of custom fee schedule,$5.18 ,100% of Medicare OPPS,$78.14 ,75% of total billed charges,$72.93 ,70% of total billed charges,$8.80 ,170% of Medicare OPPS,$11.13 ,215% of Medicare OPPS,$5.18 ,12.84% of total billed charges,$9.06 ,175% of Medicare OPPS,$5.18 ,100% of Medicare OPPS,$83.35 ,80% of total billed charges,$7.25 ,140% of Medicare OPPS,$6.47 ,125% of Medicare OPPS,$5.18 ,12.84% of LA Medicaid fee schedule,$5.18 ,12.84% of LA Medicaid fee schedule,$5.18 ,100% of Medicare OPPS,$7.56 ,100% of fee schedule,$5.18 ,100% of Medicare OPPS,$5.18 ,100% of Medicare OPPS,$9.06 ,100% of Medicare OPPS,$5.18 ,100% of Medicare OPPS,$9.81 ,100% of custom fee schedule,$93.77 ,90% of total billed charges,$5.18 ,$93.77 ,$93.77 
Outpatient Medical Services,LABORATORY,86160,complement antigen,300,$56.85 ,$19.20 ,160% of Fee Schedule,$12.00 ,100% of Medicare OPPS,$39.80 ,70% of total billed charges,$48.25 ,84.88% of total billed charges,$20.60 ,139.08% of custom fee schedule,$12.00 ,100% of Medicare OPPS,$42.64 ,75% of total billed charges,$39.80 ,70% of total billed charges,$20.40 ,170% of Medicare OPPS,$25.80 ,215% of Medicare OPPS,$12.00 ,12.84% of total billed charges,$21.00 ,175% of Medicare OPPS,$12.00 ,100% of Medicare OPPS,$45.48 ,80% of total billed charges,$16.80 ,140% of Medicare OPPS,$15.00 ,125% of Medicare OPPS,$12.00 ,12.84% of LA Medicaid fee schedule,$12.00 ,12.84% of LA Medicaid fee schedule,$12.00 ,100% of Medicare OPPS,$17.53 ,100% of fee schedule,$12.00 ,100% of Medicare OPPS,$12.00 ,100% of Medicare OPPS,$21.00 ,100% of Medicare OPPS,$12.00 ,100% of Medicare OPPS,$22.77 ,100% of custom fee schedule,$51.17 ,90% of total billed charges,$12.00 ,$51.17 ,$51.17 
Outpatient Medical Services,LABORATORY,86430,Rheumatoid factor,300,$42.20 ,$9.82 ,160% of Fee Schedule,$6.14 ,100% of Medicare OPPS,$29.54 ,70% of total billed charges,$35.82 ,84.88% of total billed charges,$9.74 ,139.08% of custom fee schedule,$6.14 ,100% of Medicare OPPS,$31.65 ,75% of total billed charges,$29.54 ,70% of total billed charges,$10.43 ,170% of Medicare OPPS,$13.20 ,215% of Medicare OPPS,$6.14 ,12.84% of total billed charges,$10.74 ,175% of Medicare OPPS,$6.14 ,100% of Medicare OPPS,$33.76 ,80% of total billed charges,$8.59 ,140% of Medicare OPPS,$7.67 ,125% of Medicare OPPS,$6.14 ,12.84% of LA Medicaid fee schedule,$6.14 ,12.84% of LA Medicaid fee schedule,$6.14 ,100% of Medicare OPPS,$8.29 ,100% of fee schedule,$6.14 ,100% of Medicare OPPS,$6.14 ,100% of Medicare OPPS,$10.74 ,100% of Medicare OPPS,$6.14 ,100% of Medicare OPPS,$10.76 ,100% of custom fee schedule,$37.98 ,90% of total billed charges,$6.14 ,$37.98 ,$37.98 
Outpatient Medical Services,LABORATORY,86706,hepatitis B antibodies,300,$125.60 ,$17.18 ,160% of Fee Schedule,$10.74 ,100% of Medicare OPPS,$87.92 ,70% of total billed charges,$106.61 ,84.88% of total billed charges,$18.44 ,139.08% of custom fee schedule,$10.74 ,100% of Medicare OPPS,$94.20 ,75% of total billed charges,$87.92 ,70% of total billed charges,$18.25 ,170% of Medicare OPPS,$23.09 ,215% of Medicare OPPS,$10.74 ,12.84% of total billed charges,$18.79 ,175% of Medicare OPPS,$10.74 ,100% of Medicare OPPS,$100.48 ,80% of total billed charges,$15.03 ,140% of Medicare OPPS,$13.42 ,125% of Medicare OPPS,$10.74 ,12.84% of LA Medicaid fee schedule,$10.74 ,12.84% of LA Medicaid fee schedule,$10.74 ,100% of Medicare OPPS,$15.68 ,100% of fee schedule,$10.74 ,100% of Medicare OPPS,$10.74 ,100% of Medicare OPPS,$18.79 ,100% of Medicare OPPS,$10.74 ,100% of Medicare OPPS,$20.36 ,100% of custom fee schedule,$113.04 ,90% of total billed charges,$10.74 ,$113.04 ,$113.04 
Outpatient Medical Services,LABORATORY,86708,Blood test indicating infection with Hepatitis A,300,$138.33 ,$19.82 ,160% of Fee Schedule,$12.39 ,100% of Medicare OPPS,$96.83 ,70% of total billed charges,$117.41 ,84.88% of total billed charges,$21.27 ,139.08% of custom fee schedule,$12.39 ,100% of Medicare OPPS,$103.75 ,75% of total billed charges,$96.83 ,70% of total billed charges,$21.06 ,170% of Medicare OPPS,$26.63 ,215% of Medicare OPPS,$12.39 ,12.84% of total billed charges,$21.68 ,175% of Medicare OPPS,$12.39 ,100% of Medicare OPPS,$110.66 ,80% of total billed charges,$17.34 ,140% of Medicare OPPS,$15.48 ,125% of Medicare OPPS,$12.39 ,12.84% of LA Medicaid fee schedule,$12.39 ,12.84% of LA Medicaid fee schedule,$12.39 ,100% of Medicare OPPS,$18.09 ,100% of fee schedule,$12.39 ,100% of Medicare OPPS,$12.39 ,100% of Medicare OPPS,$21.68 ,100% of Medicare OPPS,$12.39 ,100% of Medicare OPPS,$22.07 ,100% of custom fee schedule,$124.50 ,90% of total billed charges,$12.39 ,$124.50 ,$124.50 
Outpatient Medical Services,LABORATORY,86803,Blood test to determine infection with Hepatitis C,300,$158.00 ,$22.83 ,160% of Fee Schedule,$14.27 ,100% of Medicare OPPS,$110.60 ,70% of total billed charges,$134.11 ,84.88% of total billed charges,$24.49 ,139.08% of custom fee schedule,$14.27 ,100% of Medicare OPPS,$118.50 ,75% of total billed charges,$110.60 ,70% of total billed charges,$24.25 ,170% of Medicare OPPS,$30.68 ,215% of Medicare OPPS,$14.27 ,12.84% of total billed charges,$24.97 ,175% of Medicare OPPS,$14.27 ,100% of Medicare OPPS,$126.40 ,80% of total billed charges,$19.97 ,140% of Medicare OPPS,$17.83 ,125% of Medicare OPPS,$14.27 ,12.84% of LA Medicaid fee schedule,$14.27 ,12.84% of LA Medicaid fee schedule,$14.27 ,100% of Medicare OPPS,$20.84 ,100% of fee schedule,$14.27 ,100% of Medicare OPPS,$14.27 ,100% of Medicare OPPS,$24.97 ,100% of Medicare OPPS,$14.27 ,100% of Medicare OPPS,$27.06 ,100% of custom fee schedule,$142.20 ,90% of total billed charges,$14.27 ,$142.20 ,$142.20 
Outpatient Medical Services,LABORATORY,87015,concentration any infectious agents,300,$22.82 ,$10.68 ,160% of Fee Schedule,$6.68 ,100% of Medicare OPPS,$15.97 ,70% of total billed charges,$19.37 ,84.88% of total billed charges,$11.46 ,139.08% of custom fee schedule,$6.68 ,100% of Medicare OPPS,$17.12 ,75% of total billed charges,$15.97 ,70% of total billed charges,$11.35 ,170% of Medicare OPPS,$14.36 ,215% of Medicare OPPS,$6.68 ,12.84% of total billed charges,$11.69 ,175% of Medicare OPPS,$6.68 ,100% of Medicare OPPS,$18.26 ,80% of total billed charges,$9.35 ,140% of Medicare OPPS,$8.35 ,125% of Medicare OPPS,$6.68 ,12.84% of LA Medicaid fee schedule,$6.68 ,12.84% of LA Medicaid fee schedule,$6.68 ,100% of Medicare OPPS,$9.75 ,100% of fee schedule,$6.68 ,100% of Medicare OPPS,$6.68 ,100% of Medicare OPPS,$11.69 ,100% of Medicare OPPS,$6.68 ,100% of Medicare OPPS,$12.66 ,100% of custom fee schedule,$20.54 ,90% of total billed charges,$6.68 ,$20.54 ,$20.54 
Outpatient Medical Services,LABORATORY,87040,Blood test to screen for bacteria in the blood,300,$49.49 ,$16.51 ,160% of Fee Schedule,$10.32 ,100% of Medicare OPPS,$34.64 ,70% of total billed charges,$42.01 ,84.88% of total billed charges,$17.72 ,139.08% of custom fee schedule,$10.32 ,100% of Medicare OPPS,$37.12 ,75% of total billed charges,$34.64 ,70% of total billed charges,$17.54 ,170% of Medicare OPPS,$22.18 ,215% of Medicare OPPS,$10.32 ,12.84% of total billed charges,$18.06 ,175% of Medicare OPPS,$10.32 ,100% of Medicare OPPS,$39.59 ,80% of total billed charges,$14.44 ,140% of Medicare OPPS,$12.90 ,125% of Medicare OPPS,$10.32 ,12.84% of LA Medicaid fee schedule,$10.32 ,12.84% of LA Medicaid fee schedule,$10.32 ,100% of Medicare OPPS,$15.07 ,100% of fee schedule,$10.32 ,100% of Medicare OPPS,$10.32 ,100% of Medicare OPPS,$18.06 ,100% of Medicare OPPS,$10.32 ,100% of Medicare OPPS,$19.59 ,100% of custom fee schedule,$44.54 ,90% of total billed charges,$10.32 ,$44.54 ,$44.54 
Outpatient Medical Services,LABORATORY,87075,anaerobic culture,300,$45.00 ,$15.15 ,160% of Fee Schedule,$9.47 ,100% of Medicare OPPS,$31.50 ,70% of total billed charges,$38.20 ,84.88% of total billed charges,$16.26 ,139.08% of custom fee schedule,$9.47 ,100% of Medicare OPPS,$33.75 ,75% of total billed charges,$31.50 ,70% of total billed charges,$16.09 ,170% of Medicare OPPS,$20.36 ,215% of Medicare OPPS,$9.47 ,12.84% of total billed charges,$16.57 ,175% of Medicare OPPS,$9.47 ,100% of Medicare OPPS,$36.00 ,80% of total billed charges,$13.25 ,140% of Medicare OPPS,$11.83 ,125% of Medicare OPPS,$9.47 ,12.84% of LA Medicaid fee schedule,$9.47 ,12.84% of LA Medicaid fee schedule,$9.47 ,100% of Medicare OPPS,$13.81 ,100% of fee schedule,$9.47 ,100% of Medicare OPPS,$9.47 ,100% of Medicare OPPS,$16.57 ,100% of Medicare OPPS,$9.47 ,100% of Medicare OPPS,$17.94 ,100% of custom fee schedule,$40.50 ,90% of total billed charges,$9.47 ,$40.50 ,$40.50 
Outpatient Medical Services,LABORATORY,87086,Culture of the urine to determine number of bacteria,300,$78.70 ,$12.91 ,160% of Fee Schedule,$8.07 ,100% of Medicare OPPS,$55.09 ,70% of total billed charges,$66.80 ,84.88% of total billed charges,$13.85 ,139.08% of custom fee schedule,$8.07 ,100% of Medicare OPPS,$59.03 ,75% of total billed charges,$55.09 ,70% of total billed charges,$13.71 ,170% of Medicare OPPS,$17.35 ,215% of Medicare OPPS,$8.07 ,12.84% of total billed charges,$14.12 ,175% of Medicare OPPS,$8.07 ,100% of Medicare OPPS,$62.96 ,80% of total billed charges,$11.29 ,140% of Medicare OPPS,$10.08 ,125% of Medicare OPPS,$8.07 ,12.84% of LA Medicaid fee schedule,$8.07 ,12.84% of LA Medicaid fee schedule,$8.07 ,100% of Medicare OPPS,$11.79 ,100% of fee schedule,$8.07 ,100% of Medicare OPPS,$8.07 ,100% of Medicare OPPS,$14.12 ,100% of Medicare OPPS,$8.07 ,100% of Medicare OPPS,$15.30 ,100% of custom fee schedule,$70.83 ,90% of total billed charges,$8.07 ,$70.83 ,$70.83 
Outpatient Medical Services,LABORATORY,87102,culture fungi,300,$85.00 ,$13.45 ,160% of Fee Schedule,$8.41 ,100% of Medicare OPPS,$59.50 ,70% of total billed charges,$72.15 ,84.88% of total billed charges,$14.44 ,139.08% of custom fee schedule,$8.41 ,100% of Medicare OPPS,$63.75 ,75% of total billed charges,$59.50 ,70% of total billed charges,$14.29 ,170% of Medicare OPPS,$18.08 ,215% of Medicare OPPS,$8.41 ,12.84% of total billed charges,$14.71 ,175% of Medicare OPPS,$8.41 ,100% of Medicare OPPS,$68.00 ,80% of total billed charges,$11.77 ,140% of Medicare OPPS,$10.51 ,125% of Medicare OPPS,$8.41 ,12.84% of LA Medicaid fee schedule,$8.41 ,12.84% of LA Medicaid fee schedule,$8.41 ,100% of Medicare OPPS,$12.26 ,100% of fee schedule,$8.41 ,100% of Medicare OPPS,$8.41 ,100% of Medicare OPPS,$14.71 ,100% of Medicare OPPS,$8.41 ,100% of Medicare OPPS,$15.93 ,100% of custom fee schedule,$76.50 ,90% of total billed charges,$8.41 ,$76.50 ,$76.50 
Outpatient Medical Services,LABORATORY,87149,culture nucleic probe,300,$94.91 ,$32.08 ,160% of Fee Schedule,$20.05 ,100% of Medicare OPPS,$66.44 ,70% of total billed charges,$80.56 ,84.88% of total billed charges,$34.44 ,139.08% of custom fee schedule,$20.05 ,100% of Medicare OPPS,$71.18 ,75% of total billed charges,$66.44 ,70% of total billed charges,$34.08 ,170% of Medicare OPPS,$43.10 ,215% of Medicare OPPS,$20.05 ,12.84% of total billed charges,$35.08 ,175% of Medicare OPPS,$20.05 ,100% of Medicare OPPS,$75.93 ,80% of total billed charges,$28.07 ,140% of Medicare OPPS,$25.06 ,125% of Medicare OPPS,$20.05 ,12.84% of LA Medicaid fee schedule,$20.05 ,12.84% of LA Medicaid fee schedule,$20.05 ,100% of Medicare OPPS,$29.27 ,100% of fee schedule,$20.05 ,100% of Medicare OPPS,$20.05 ,100% of Medicare OPPS,$35.08 ,100% of Medicare OPPS,$20.05 ,100% of Medicare OPPS,$38.03 ,100% of custom fee schedule,$85.42 ,90% of total billed charges,$20.05 ,$85.42 ,$85.42 
Outpatient Medical Services,LABORATORY,87340,infectious agent antigen detection,300,$94.91 ,$16.52 ,160% of Fee Schedule,$10.33 ,100% of Medicare OPPS,$66.44 ,70% of total billed charges,$80.56 ,84.88% of total billed charges,$17.73 ,139.08% of custom fee schedule,$10.33 ,100% of Medicare OPPS,$71.18 ,75% of total billed charges,$66.44 ,70% of total billed charges,$17.56 ,170% of Medicare OPPS,$22.20 ,215% of Medicare OPPS,$10.33 ,12.84% of total billed charges,$18.07 ,175% of Medicare OPPS,$10.33 ,100% of Medicare OPPS,$75.93 ,80% of total billed charges,$14.46 ,140% of Medicare OPPS,$12.91 ,125% of Medicare OPPS,$10.33 ,12.84% of LA Medicaid fee schedule,$10.33 ,12.84% of LA Medicaid fee schedule,$10.33 ,100% of Medicare OPPS,$15.08 ,100% of fee schedule,$10.33 ,100% of Medicare OPPS,$10.33 ,100% of Medicare OPPS,$18.07 ,100% of Medicare OPPS,$10.33 ,100% of Medicare OPPS,$19.60 ,100% of custom fee schedule,$85.42 ,90% of total billed charges,$10.33 ,$85.42 ,$85.42 
Outpatient Medical Services,LABORATORY,C9803,COVID collection,300,$63.00 ,$35.04 ,100% of APC Rate,$21.90 ,100% of Medicare OPPS,$44.10 ,70% of total billed charges,$53.47 ,84.88% of total billed charges,$37.85 ,100% of custom fee schedule,$21.90 ,100% of Medicare OPPS,$47.25 ,75% of total billed charges,$44.10 ,70% of total billed charges,$37.23 ,170% of Medicare OPPS,$47.08 ,215% of Medicare OPPS,$8.09 ,12.84% of total billed charges,$38.32 ,175% of Medicare OPPS,$21.90 ,100% of Medicare OPPS,$50.40 ,80% of total billed charges,$30.66 ,140% of Medicare OPPS,$27.37 ,125% of Medicare OPPS,$8.09 ,12.84% of LA Medicaid fee schedule,$8.09 ,12.84% of LA Medicaid fee schedule,$21.90 ,100% of Medicare OPPS,$31.50 ,100% of fee schedule,$21.90 ,100% of Medicare OPPS,$21.90 ,100% of Medicare OPPS,$38.32 ,100% of Medicare OPPS,$21.90 ,100% of Medicare OPPS,$22.05 ,100% of custom fee schedule,$56.70 ,90% of total billed charges,$8.09 ,$56.70 ,$56.70 
Outpatient Medical Services,LABORATORY,G0103,Prostate cancer screening; prostate specific antigen test (psa),300,$79.36 ,$30.89 ,160% of Fee Schedule,$19.30 ,100% of Medicare OPPS,$55.55 ,70% of total billed charges,$67.36 ,84.88% of total billed charges,$31.59 ,139.08% of custom fee schedule,$19.30 ,100% of Medicare OPPS,$59.52 ,75% of total billed charges,$55.55 ,70% of total billed charges,$32.82 ,170% of Medicare OPPS,$41.51 ,215% of Medicare OPPS,$10.19 ,12.84% of total billed charges,$33.79 ,175% of Medicare OPPS,$19.30 ,100% of Medicare OPPS,$63.49 ,80% of total billed charges,$27.03 ,140% of Medicare OPPS,$24.13 ,125% of Medicare OPPS,$10.19 ,12.84% of LA Medicaid fee schedule,$10.19 ,12.84% of LA Medicaid fee schedule,$19.30 ,100% of Medicare OPPS,$26.85 ,100% of fee schedule,$19.30 ,100% of Medicare OPPS,$19.30 ,100% of Medicare OPPS,$33.79 ,100% of Medicare OPPS,$19.30 ,100% of Medicare OPPS,$34.88 ,100% of custom fee schedule,$71.42 ,90% of total billed charges,$10.19 ,$71.42 ,$71.42 
Outpatient Medical Services,LABORATORY,82570,Test to measure creatinine in the urine,301,$64.84 ,$8.28 ,160% of Fee Schedule,$5.18 ,100% of Medicare OPPS,$45.39 ,70% of total billed charges,$55.04 ,84.88% of total billed charges,$8.89 ,139.08% of custom fee schedule,$5.18 ,100% of Medicare OPPS,$48.63 ,75% of total billed charges,$45.39 ,70% of total billed charges,$8.80 ,170% of Medicare OPPS,$11.13 ,215% of Medicare OPPS,$5.18 ,12.84% of total billed charges,$9.06 ,175% of Medicare OPPS,$5.18 ,100% of Medicare OPPS,$51.87 ,80% of total billed charges,$7.25 ,140% of Medicare OPPS,$6.47 ,125% of Medicare OPPS,$5.18 ,12.84% of LA Medicaid fee schedule,$5.18 ,12.84% of LA Medicaid fee schedule,$5.18 ,100% of Medicare OPPS,$7.56 ,100% of fee schedule,$5.18 ,100% of Medicare OPPS,$5.18 ,100% of Medicare OPPS,$9.06 ,100% of Medicare OPPS,$5.18 ,100% of Medicare OPPS,$9.81 ,100% of custom fee schedule,$58.36 ,90% of total billed charges,$5.18 ,$58.36 ,$58.36 
Outpatient Medical Services,LABORATORY,80053,"Blood test, comprehensive group of blood chemicals",301,$104.85 ,$16.89 ,160% of Fee Schedule,$10.56 ,100% of Medicare OPPS,$73.40 ,70% of total billed charges,$89.00 ,84.88% of total billed charges,$18.14 ,139.08% of custom fee schedule,$10.56 ,100% of Medicare OPPS,$78.64 ,75% of total billed charges,$73.40 ,70% of total billed charges,$17.95 ,170% of Medicare OPPS,$22.70 ,215% of Medicare OPPS,$10.56 ,12.84% of total billed charges,$18.48 ,175% of Medicare OPPS,$10.56 ,100% of Medicare OPPS,$83.88 ,80% of total billed charges,$14.78 ,140% of Medicare OPPS,$13.20 ,125% of Medicare OPPS,$10.56 ,12.84% of LA Medicaid fee schedule,$10.56 ,12.84% of LA Medicaid fee schedule,$10.56 ,100% of Medicare OPPS,$15.44 ,100% of fee schedule,$10.56 ,100% of Medicare OPPS,$10.56 ,100% of Medicare OPPS,$18.48 ,100% of Medicare OPPS,$10.56 ,100% of Medicare OPPS,$20.03 ,100% of custom fee schedule,$94.37 ,90% of total billed charges,$10.56 ,$94.37 ,$94.37 
Outpatient Medical Services,LABORATORY,82043,Urine test to measure albumin,301,$57.89 ,$9.24 ,160% of Fee Schedule,$5.78 ,100% of Medicare OPPS,$40.52 ,70% of total billed charges,$49.14 ,84.88% of total billed charges,$9.93 ,139.08% of custom fee schedule,$5.78 ,100% of Medicare OPPS,$43.42 ,75% of total billed charges,$40.52 ,70% of total billed charges,$9.82 ,170% of Medicare OPPS,$12.42 ,215% of Medicare OPPS,$5.78 ,12.84% of total billed charges,$10.11 ,175% of Medicare OPPS,$5.78 ,100% of Medicare OPPS,$46.31 ,80% of total billed charges,$8.09 ,140% of Medicare OPPS,$7.22 ,125% of Medicare OPPS,$5.78 ,12.84% of LA Medicaid fee schedule,$5.78 ,12.84% of LA Medicaid fee schedule,$5.78 ,100% of Medicare OPPS,$8.45 ,100% of fee schedule,$5.78 ,100% of Medicare OPPS,$5.78 ,100% of Medicare OPPS,$10.11 ,100% of Medicare OPPS,$5.78 ,100% of Medicare OPPS,$10.97 ,100% of custom fee schedule,$52.10 ,90% of total billed charges,$5.78 ,$52.10 ,$52.10 
Outpatient Medical Services,LABORATORY,82550,CPK,301,$128.49 ,$10.41 ,160% of Fee Schedule,$6.51 ,100% of Medicare OPPS,$89.94 ,70% of total billed charges,$109.06 ,84.88% of total billed charges,$11.18 ,139.08% of custom fee schedule,$6.51 ,100% of Medicare OPPS,$96.37 ,75% of total billed charges,$89.94 ,70% of total billed charges,$11.06 ,170% of Medicare OPPS,$13.99 ,215% of Medicare OPPS,$6.51 ,12.84% of total billed charges,$11.39 ,175% of Medicare OPPS,$6.51 ,100% of Medicare OPPS,$102.79 ,80% of total billed charges,$9.11 ,140% of Medicare OPPS,$8.13 ,125% of Medicare OPPS,$6.51 ,12.84% of LA Medicaid fee schedule,$6.51 ,12.84% of LA Medicaid fee schedule,$6.51 ,100% of Medicare OPPS,$9.51 ,100% of fee schedule,$6.51 ,100% of Medicare OPPS,$6.51 ,100% of Medicare OPPS,$11.39 ,100% of Medicare OPPS,$6.51 ,100% of Medicare OPPS,$12.34 ,100% of custom fee schedule,$115.64 ,90% of total billed charges,$6.51 ,$115.64 ,$115.64 
Outpatient Medical Services,LABORATORY,82607,Blood test to measure B-12,301,$163.77 ,$24.12 ,160% of Fee Schedule,$15.08 ,100% of Medicare OPPS,$114.64 ,70% of total billed charges,$139.01 ,84.88% of total billed charges,$25.88 ,139.08% of custom fee schedule,$15.08 ,100% of Medicare OPPS,$122.83 ,75% of total billed charges,$114.64 ,70% of total billed charges,$25.63 ,170% of Medicare OPPS,$32.42 ,215% of Medicare OPPS,$15.08 ,12.84% of total billed charges,$26.39 ,175% of Medicare OPPS,$15.08 ,100% of Medicare OPPS,$131.02 ,80% of total billed charges,$21.11 ,140% of Medicare OPPS,$18.85 ,125% of Medicare OPPS,$15.08 ,12.84% of LA Medicaid fee schedule,$15.08 ,12.84% of LA Medicaid fee schedule,$15.08 ,100% of Medicare OPPS,$22.01 ,100% of fee schedule,$15.08 ,100% of Medicare OPPS,$15.08 ,100% of Medicare OPPS,$26.39 ,100% of Medicare OPPS,$15.08 ,100% of Medicare OPPS,$28.58 ,100% of custom fee schedule,$147.39 ,90% of total billed charges,$15.08 ,$147.39 ,$147.39 
Outpatient Medical Services,LABORATORY,82670,Blood test to measure a type of estrogen in the blood,301,$232.17 ,$44.70 ,160% of Fee Schedule,$27.94 ,100% of Medicare OPPS,$162.52 ,70% of total billed charges,$197.07 ,84.88% of total billed charges,$47.97 ,139.08% of custom fee schedule,$27.94 ,100% of Medicare OPPS,$174.13 ,75% of total billed charges,$162.52 ,70% of total billed charges,$47.49 ,170% of Medicare OPPS,$60.07 ,215% of Medicare OPPS,$27.94 ,12.84% of total billed charges,$48.89 ,175% of Medicare OPPS,$27.94 ,100% of Medicare OPPS,$185.74 ,80% of total billed charges,$39.11 ,140% of Medicare OPPS,$34.92 ,125% of Medicare OPPS,$27.94 ,12.84% of LA Medicaid fee schedule,$27.94 ,12.84% of LA Medicaid fee schedule,$27.94 ,100% of Medicare OPPS,$40.80 ,100% of fee schedule,$27.94 ,100% of Medicare OPPS,$27.94 ,100% of Medicare OPPS,$48.89 ,100% of Medicare OPPS,$27.94 ,100% of Medicare OPPS,$52.99 ,100% of custom fee schedule,$208.95 ,90% of total billed charges,$27.94 ,$208.95 ,$208.95 
Outpatient Medical Services,LABORATORY,82803,Test to measure arterial blood gases,301,$407.07 ,$41.71 ,160% of Fee Schedule,$26.07 ,100% of Medicare OPPS,$284.95 ,70% of total billed charges,$345.52 ,84.88% of total billed charges,$36.26 ,139.08% of custom fee schedule,$26.07 ,100% of Medicare OPPS,$305.30 ,75% of total billed charges,$284.95 ,70% of total billed charges,$44.31 ,170% of Medicare OPPS,$56.05 ,215% of Medicare OPPS,$6.35 ,12.84% of total billed charges,$45.62 ,175% of Medicare OPPS,$26.07 ,100% of Medicare OPPS,$325.66 ,80% of total billed charges,$36.49 ,140% of Medicare OPPS,$32.58 ,125% of Medicare OPPS,$6.35 ,12.84% of LA Medicaid fee schedule,$6.35 ,12.84% of LA Medicaid fee schedule,$26.07 ,100% of Medicare OPPS,$28.25 ,100% of fee schedule,$26.07 ,100% of Medicare OPPS,$26.07 ,100% of Medicare OPPS,$45.62 ,100% of Medicare OPPS,$26.07 ,100% of Medicare OPPS,$9.90 ,100% of custom fee schedule,$366.36 ,90% of total billed charges,$6.35 ,$366.36 ,$366.36 
Outpatient Medical Services,LABORATORY,83880,Blood test used to diagnose heart failure,301,$329.39 ,$62.81 ,160% of Fee Schedule,$39.26 ,100% of Medicare OPPS,$230.57 ,70% of total billed charges,$279.59 ,84.88% of total billed charges,$58.27 ,139.08% of custom fee schedule,$39.26 ,100% of Medicare OPPS,$247.04 ,75% of total billed charges,$230.57 ,70% of total billed charges,$66.74 ,170% of Medicare OPPS,$84.40 ,215% of Medicare OPPS,$39.26 ,12.84% of total billed charges,$68.70 ,175% of Medicare OPPS,$39.26 ,100% of Medicare OPPS,$263.51 ,80% of total billed charges,$54.96 ,140% of Medicare OPPS,$49.07 ,125% of Medicare OPPS,$39.26 ,12.84% of LA Medicaid fee schedule,$39.26 ,12.84% of LA Medicaid fee schedule,$39.26 ,100% of Medicare OPPS,$49.56 ,100% of fee schedule,$39.26 ,100% of Medicare OPPS,$39.26 ,100% of Medicare OPPS,$68.70 ,100% of Medicare OPPS,$39.26 ,100% of Medicare OPPS,$64.37 ,100% of custom fee schedule,$296.45 ,90% of total billed charges,$39.26 ,$296.45 ,$296.45 
Outpatient Medical Services,LABORATORY,83883,nephelometry each analyte,301,$15.12 ,$21.76 ,160% of Fee Schedule,$13.60 ,100% of Medicare OPPS,$10.58 ,70% of total billed charges,$12.83 ,84.88% of total billed charges,$23.35 ,139.08% of custom fee schedule,$13.60 ,100% of Medicare OPPS,$11.34 ,75% of total billed charges,$10.58 ,70% of total billed charges,$23.12 ,170% of Medicare OPPS,$29.24 ,215% of Medicare OPPS,$5.68 ,12.84% of total billed charges,$23.80 ,175% of Medicare OPPS,$13.60 ,100% of Medicare OPPS,$12.10 ,80% of total billed charges,$19.04 ,140% of Medicare OPPS,$17.00 ,125% of Medicare OPPS,$5.68 ,12.84% of LA Medicaid fee schedule,$5.68 ,12.84% of LA Medicaid fee schedule,$13.60 ,100% of Medicare OPPS,$19.85 ,100% of fee schedule,$13.60 ,100% of Medicare OPPS,$13.60 ,100% of Medicare OPPS,$23.80 ,100% of Medicare OPPS,$13.60 ,100% of Medicare OPPS,$8.80 ,100% of custom fee schedule,$13.61 ,90% of total billed charges,$5.68 ,$29.24 ,$13.61 
Outpatient Medical Services,LABORATORY,84443,"Blood test, thyroid stimulating hormone (TSH)",301,$54.65 ,$26.88 ,160% of Fee Schedule,$16.80 ,100% of Medicare OPPS,$38.26 ,70% of total billed charges,$46.39 ,84.88% of total billed charges,$28.86 ,139.08% of custom fee schedule,$16.80 ,100% of Medicare OPPS,$40.99 ,75% of total billed charges,$38.26 ,70% of total billed charges,$28.56 ,170% of Medicare OPPS,$36.12 ,215% of Medicare OPPS,$16.80 ,12.84% of total billed charges,$29.40 ,175% of Medicare OPPS,$16.80 ,100% of Medicare OPPS,$43.72 ,80% of total billed charges,$23.52 ,140% of Medicare OPPS,$21.00 ,125% of Medicare OPPS,$16.80 ,12.84% of LA Medicaid fee schedule,$16.80 ,12.84% of LA Medicaid fee schedule,$16.80 ,100% of Medicare OPPS,$24.53 ,100% of fee schedule,$16.80 ,100% of Medicare OPPS,$16.80 ,100% of Medicare OPPS,$29.40 ,100% of Medicare OPPS,$16.80 ,100% of Medicare OPPS,$31.87 ,100% of custom fee schedule,$49.19 ,90% of total billed charges,$16.80 ,$49.19 ,$49.19 
Outpatient Medical Services,LABORATORY,84478,triglycerides,301,$55.22 ,$9.18 ,160% of Fee Schedule,$5.74 ,100% of Medicare OPPS,$38.65 ,70% of total billed charges,$46.87 ,84.88% of total billed charges,$9.86 ,139.08% of custom fee schedule,$5.74 ,100% of Medicare OPPS,$41.42 ,75% of total billed charges,$38.65 ,70% of total billed charges,$9.75 ,170% of Medicare OPPS,$12.34 ,215% of Medicare OPPS,$5.74 ,12.84% of total billed charges,$10.04 ,175% of Medicare OPPS,$5.74 ,100% of Medicare OPPS,$44.18 ,80% of total billed charges,$8.03 ,140% of Medicare OPPS,$7.17 ,125% of Medicare OPPS,$5.74 ,12.84% of LA Medicaid fee schedule,$5.74 ,12.84% of LA Medicaid fee schedule,$5.74 ,100% of Medicare OPPS,$8.40 ,100% of fee schedule,$5.74 ,100% of Medicare OPPS,$5.74 ,100% of Medicare OPPS,$10.04 ,100% of Medicare OPPS,$5.74 ,100% of Medicare OPPS,$10.90 ,100% of custom fee schedule,$49.70 ,90% of total billed charges,$5.74 ,$49.70 ,$49.70 
Outpatient Medical Services,LABORATORY,84479,T3/T4 uptake,301,$15.13 ,$10.35 ,160% of Fee Schedule,$6.47 ,100% of Medicare OPPS,$10.59 ,70% of total billed charges,$12.84 ,84.88% of total billed charges,$11.10 ,139.08% of custom fee schedule,$6.47 ,100% of Medicare OPPS,$11.35 ,75% of total billed charges,$10.59 ,70% of total billed charges,$10.99 ,170% of Medicare OPPS,$13.91 ,215% of Medicare OPPS,$5.69 ,12.84% of total billed charges,$11.32 ,175% of Medicare OPPS,$6.47 ,100% of Medicare OPPS,$12.10 ,80% of total billed charges,$9.05 ,140% of Medicare OPPS,$8.08 ,125% of Medicare OPPS,$5.69 ,12.84% of LA Medicaid fee schedule,$5.69 ,12.84% of LA Medicaid fee schedule,$6.47 ,100% of Medicare OPPS,$9.45 ,100% of fee schedule,$6.47 ,100% of Medicare OPPS,$6.47 ,100% of Medicare OPPS,$11.32 ,100% of Medicare OPPS,$6.47 ,100% of Medicare OPPS,$8.81 ,100% of custom fee schedule,$13.62 ,90% of total billed charges,$5.69 ,$13.91 ,$13.62 
Outpatient Medical Services,LABORATORY,86235,extractable nuclear antigen,301,$71.13 ,$28.68 ,160% of Fee Schedule,$17.93 ,100% of Medicare OPPS,$49.79 ,70% of total billed charges,$60.38 ,84.88% of total billed charges,$30.79 ,139.08% of custom fee schedule,$17.93 ,100% of Medicare OPPS,$53.35 ,75% of total billed charges,$49.79 ,70% of total billed charges,$30.48 ,170% of Medicare OPPS,$38.54 ,215% of Medicare OPPS,$14.15 ,12.84% of total billed charges,$31.37 ,175% of Medicare OPPS,$17.93 ,100% of Medicare OPPS,$56.90 ,80% of total billed charges,$25.10 ,140% of Medicare OPPS,$22.41 ,125% of Medicare OPPS,$14.15 ,12.84% of LA Medicaid fee schedule,$14.15 ,12.84% of LA Medicaid fee schedule,$17.93 ,100% of Medicare OPPS,$26.18 ,100% of fee schedule,$17.93 ,100% of Medicare OPPS,$17.93 ,100% of Medicare OPPS,$31.37 ,100% of Medicare OPPS,$17.93 ,100% of Medicare OPPS,$22.07 ,100% of custom fee schedule,$64.02 ,90% of total billed charges,$14.15 ,$64.02 ,$64.02 
Outpatient Medical Services,LABORATORY,85576,platelet aggregation,302,$171.11 ,$39.85 ,160% of Fee Schedule,$24.91 ,100% of Medicare OPPS,$119.78 ,70% of total billed charges,$145.24 ,84.88% of total billed charges,$36.88 ,139.08% of custom fee schedule,$24.91 ,100% of Medicare OPPS,$128.33 ,75% of total billed charges,$119.78 ,70% of total billed charges,$42.34 ,170% of Medicare OPPS,$53.55 ,215% of Medicare OPPS,$16.35 ,12.84% of total billed charges,$43.59 ,175% of Medicare OPPS,$24.91 ,100% of Medicare OPPS,$136.89 ,80% of total billed charges,$34.87 ,140% of Medicare OPPS,$31.13 ,125% of Medicare OPPS,$16.35 ,12.84% of LA Medicaid fee schedule,$16.35 ,12.84% of LA Medicaid fee schedule,$24.91 ,100% of Medicare OPPS,$31.37 ,100% of fee schedule,$24.91 ,100% of Medicare OPPS,$24.91 ,100% of Medicare OPPS,$43.59 ,100% of Medicare OPPS,$24.91 ,100% of Medicare OPPS,$40.74 ,100% of custom fee schedule,$154.00 ,90% of total billed charges,$16.35 ,$154.00 ,$154.00 
Outpatient Medical Services,LABORATORY,86038,ANA,302,$144.11 ,$19.34 ,160% of Fee Schedule,$12.09 ,100% of Medicare OPPS,$100.88 ,70% of total billed charges,$122.32 ,84.88% of total billed charges,$20.75 ,139.08% of custom fee schedule,$12.09 ,100% of Medicare OPPS,$108.08 ,75% of total billed charges,$100.88 ,70% of total billed charges,$20.55 ,170% of Medicare OPPS,$25.99 ,215% of Medicare OPPS,$12.09 ,12.84% of total billed charges,$21.15 ,175% of Medicare OPPS,$12.09 ,100% of Medicare OPPS,$115.29 ,80% of total billed charges,$16.92 ,140% of Medicare OPPS,$15.11 ,125% of Medicare OPPS,$12.09 ,12.84% of LA Medicaid fee schedule,$12.09 ,12.84% of LA Medicaid fee schedule,$12.09 ,100% of Medicare OPPS,$17.65 ,100% of fee schedule,$12.09 ,100% of Medicare OPPS,$12.09 ,100% of Medicare OPPS,$21.15 ,100% of Medicare OPPS,$12.09 ,100% of Medicare OPPS,$22.92 ,100% of custom fee schedule,$129.70 ,90% of total billed charges,$12.09 ,$129.70 ,$129.70 
Outpatient Medical Services,LABORATORY,86255,fluorescent noninfectious antibody screen,302,$36.91 ,$19.28 ,160% of Fee Schedule,$12.05 ,100% of Medicare OPPS,$25.84 ,70% of total billed charges,$31.33 ,84.88% of total billed charges,$20.70 ,139.08% of custom fee schedule,$12.05 ,100% of Medicare OPPS,$27.68 ,75% of total billed charges,$25.84 ,70% of total billed charges,$20.48 ,170% of Medicare OPPS,$25.90 ,215% of Medicare OPPS,$12.05 ,12.84% of total billed charges,$21.08 ,175% of Medicare OPPS,$12.05 ,100% of Medicare OPPS,$29.53 ,80% of total billed charges,$16.87 ,140% of Medicare OPPS,$15.06 ,125% of Medicare OPPS,$12.05 ,12.84% of LA Medicaid fee schedule,$12.05 ,12.84% of LA Medicaid fee schedule,$12.05 ,100% of Medicare OPPS,$17.60 ,100% of fee schedule,$12.05 ,100% of Medicare OPPS,$12.05 ,100% of Medicare OPPS,$21.08 ,100% of Medicare OPPS,$12.05 ,100% of Medicare OPPS,$21.53 ,100% of custom fee schedule,$33.22 ,90% of total billed charges,$12.05 ,$33.22 ,$33.22 
Outpatient Medical Services,LABORATORY,86376,microsomal antibodies,302,$54.15 ,$23.28 ,160% of Fee Schedule,$14.55 ,100% of Medicare OPPS,$37.91 ,70% of total billed charges,$45.96 ,84.88% of total billed charges,$24.98 ,139.08% of custom fee schedule,$14.55 ,100% of Medicare OPPS,$40.61 ,75% of total billed charges,$37.91 ,70% of total billed charges,$24.73 ,170% of Medicare OPPS,$31.28 ,215% of Medicare OPPS,$14.55 ,12.84% of total billed charges,$25.46 ,175% of Medicare OPPS,$14.55 ,100% of Medicare OPPS,$43.32 ,80% of total billed charges,$20.37 ,140% of Medicare OPPS,$18.18 ,125% of Medicare OPPS,$14.55 ,12.84% of LA Medicaid fee schedule,$14.55 ,12.84% of LA Medicaid fee schedule,$14.55 ,100% of Medicare OPPS,$21.25 ,100% of fee schedule,$14.55 ,100% of Medicare OPPS,$14.55 ,100% of Medicare OPPS,$25.46 ,100% of Medicare OPPS,$14.55 ,100% of Medicare OPPS,$27.59 ,100% of custom fee schedule,$48.74 ,90% of total billed charges,$14.55 ,$48.74 ,$48.74 
Outpatient Medical Services,LABORATORY,86480,cell mediated response gamma interferon,302,$293.38 ,$99.16 ,160% of Fee Schedule,$61.98 ,100% of Medicare OPPS,$205.37 ,70% of total billed charges,$249.02 ,84.88% of total billed charges,$106.42 ,139.08% of custom fee schedule,$61.98 ,100% of Medicare OPPS,$220.04 ,75% of total billed charges,$205.37 ,70% of total billed charges,$105.36 ,170% of Medicare OPPS,$133.25 ,215% of Medicare OPPS,$61.98 ,12.84% of total billed charges,$108.46 ,175% of Medicare OPPS,$61.98 ,100% of Medicare OPPS,$234.70 ,80% of total billed charges,$86.77 ,140% of Medicare OPPS,$77.47 ,125% of Medicare OPPS,$61.98 ,12.84% of LA Medicaid fee schedule,$61.98 ,12.84% of LA Medicaid fee schedule,$61.98 ,100% of Medicare OPPS,$90.49 ,100% of fee schedule,$61.98 ,100% of Medicare OPPS,$61.98 ,100% of Medicare OPPS,$108.46 ,100% of Medicare OPPS,$61.98 ,100% of Medicare OPPS,$117.54 ,100% of custom fee schedule,$264.04 ,90% of total billed charges,$61.98 ,$264.04 ,$264.04 
Outpatient Medical Services,LABORATORY,86800,thyroglobulin antibody,302,$152.62 ,$25.45 ,160% of Fee Schedule,$15.91 ,100% of Medicare OPPS,$106.83 ,70% of total billed charges,$129.54 ,84.88% of total billed charges,$27.32 ,139.08% of custom fee schedule,$15.91 ,100% of Medicare OPPS,$114.47 ,75% of total billed charges,$106.83 ,70% of total billed charges,$27.04 ,170% of Medicare OPPS,$34.20 ,215% of Medicare OPPS,$15.91 ,12.84% of total billed charges,$27.84 ,175% of Medicare OPPS,$15.91 ,100% of Medicare OPPS,$122.10 ,80% of total billed charges,$22.27 ,140% of Medicare OPPS,$19.88 ,125% of Medicare OPPS,$15.91 ,12.84% of LA Medicaid fee schedule,$15.91 ,12.84% of LA Medicaid fee schedule,$15.91 ,100% of Medicare OPPS,$23.22 ,100% of fee schedule,$15.91 ,100% of Medicare OPPS,$15.91 ,100% of Medicare OPPS,$27.84 ,100% of Medicare OPPS,$15.91 ,100% of Medicare OPPS,$30.16 ,100% of custom fee schedule,$137.36 ,90% of total billed charges,$15.91 ,$137.36 ,$137.36 
Outpatient Medical Services,LABORATORY,86850,Blood test to screen for antibodies that could harm red blood cells,302,$180.56 ,$70.39 ,100% of APC Rate,$43.99 ,100% of Medicare OPPS,$126.39 ,70% of total billed charges,$153.26 ,84.88% of total billed charges,$13.59 ,139.08% of custom fee schedule,$43.99 ,100% of Medicare OPPS,$135.42 ,75% of total billed charges,$126.39 ,70% of total billed charges,$74.78 ,170% of Medicare OPPS,$94.58 ,215% of Medicare OPPS,$6.74 ,12.84% of total billed charges,$76.98 ,175% of Medicare OPPS,$43.99 ,100% of Medicare OPPS,$144.45 ,80% of total billed charges,$61.59 ,140% of Medicare OPPS,$54.99 ,125% of Medicare OPPS,$6.74 ,12.84% of LA Medicaid fee schedule,$6.74 ,12.84% of LA Medicaid fee schedule,$43.99 ,100% of Medicare OPPS,N/A,65% of total billed charges,$43.99 ,100% of Medicare OPPS,$43.99 ,100% of Medicare OPPS,$76.98 ,100% of Medicare OPPS,$43.99 ,100% of Medicare OPPS,$14.42 ,100% of custom fee schedule,$162.50 ,90% of total billed charges,$6.74 ,$162.50 ,$162.50 
Outpatient Medical Services,LABORATORY,86900,blood type,302,$137.78 ,$163.00 ,100% of APC Rate,$101.87 ,100% of Medicare OPPS,$96.45 ,70% of total billed charges,$116.95 ,84.88% of total billed charges,$5.13 ,139.08% of custom fee schedule,$101.87 ,100% of Medicare OPPS,$103.34 ,75% of total billed charges,$96.45 ,70% of total billed charges,$173.19 ,170% of Medicare OPPS,$219.03 ,215% of Medicare OPPS,$2.99 ,12.84% of total billed charges,$178.28 ,175% of Medicare OPPS,$101.87 ,100% of Medicare OPPS,$110.22 ,80% of total billed charges,$142.62 ,140% of Medicare OPPS,$127.34 ,125% of Medicare OPPS,$2.99 ,12.84% of LA Medicaid fee schedule,$2.99 ,12.84% of LA Medicaid fee schedule,$101.87 ,100% of Medicare OPPS,$4.35 ,100% of fee schedule,$101.87 ,100% of Medicare OPPS,$101.87 ,100% of Medicare OPPS,$178.28 ,100% of Medicare OPPS,$101.87 ,100% of Medicare OPPS,$14.42 ,100% of custom fee schedule,$124.00 ,90% of total billed charges,$2.99 ,$219.03 ,$124.00 
Outpatient Medical Services,LABORATORY,86901,blood RH,302,$77.56 ,$47.67 ,100% of APC Rate,$29.79 ,100% of Medicare OPPS,$54.29 ,70% of total billed charges,$65.83 ,84.88% of total billed charges,$5.13 ,139.08% of custom fee schedule,$29.79 ,100% of Medicare OPPS,$58.17 ,75% of total billed charges,$54.29 ,70% of total billed charges,$50.65 ,170% of Medicare OPPS,$64.06 ,215% of Medicare OPPS,$2.99 ,12.84% of total billed charges,$52.14 ,175% of Medicare OPPS,$29.79 ,100% of Medicare OPPS,$62.05 ,80% of total billed charges,$41.71 ,140% of Medicare OPPS,$37.24 ,125% of Medicare OPPS,$2.99 ,12.84% of LA Medicaid fee schedule,$2.99 ,12.84% of LA Medicaid fee schedule,$29.79 ,100% of Medicare OPPS,$4.35 ,100% of fee schedule,$29.79 ,100% of Medicare OPPS,$29.79 ,100% of Medicare OPPS,$52.14 ,100% of Medicare OPPS,$29.79 ,100% of Medicare OPPS,$14.42 ,100% of custom fee schedule,$69.80 ,90% of total billed charges,$2.99 ,$69.80 ,$69.80 
Outpatient Medical Services,LABORATORY,86920,blood compatibility,302,$179.40 ,$220.75 ,100% of APC Rate,$137.97 ,100% of Medicare OPPS,$125.58 ,70% of total billed charges,$152.27 ,84.88% of total billed charges,$179.66 ,139.08% of custom fee schedule,$137.97 ,100% of Medicare OPPS,$134.55 ,75% of total billed charges,$125.58 ,70% of total billed charges,$234.55 ,170% of Medicare OPPS,$296.64 ,215% of Medicare OPPS,$51.38 ,12.84% of total billed charges,$241.45 ,175% of Medicare OPPS,$137.97 ,100% of Medicare OPPS,$143.52 ,80% of total billed charges,$193.16 ,140% of Medicare OPPS,$172.46 ,125% of Medicare OPPS,$51.38 ,12.84% of LA Medicaid fee schedule,$51.38 ,12.84% of LA Medicaid fee schedule,$137.97 ,100% of Medicare OPPS,N/A,65% of total billed charges,$137.97 ,100% of Medicare OPPS,$137.97 ,100% of Medicare OPPS,$241.45 ,100% of Medicare OPPS,$137.97 ,100% of Medicare OPPS,$37.56 ,100% of custom fee schedule,$161.46 ,90% of total billed charges,$37.56 ,$296.64 ,$161.46 
Outpatient Medical Services,LABORATORY,85025,"Complete blood cell count, with differential white blood cells, automated",305,$84.51 ,$12.43 ,160% of Fee Schedule,$7.77 ,100% of Medicare OPPS,$59.16 ,70% of total billed charges,$71.73 ,84.88% of total billed charges,$13.34 ,139.08% of custom fee schedule,$7.77 ,100% of Medicare OPPS,$63.38 ,75% of total billed charges,$59.16 ,70% of total billed charges,$13.20 ,170% of Medicare OPPS,$16.70 ,215% of Medicare OPPS,$7.77 ,12.84% of total billed charges,$13.59 ,175% of Medicare OPPS,$7.77 ,100% of Medicare OPPS,$67.61 ,80% of total billed charges,$10.87 ,140% of Medicare OPPS,$9.71 ,125% of Medicare OPPS,$7.77 ,12.84% of LA Medicaid fee schedule,$7.77 ,12.84% of LA Medicaid fee schedule,$7.77 ,100% of Medicare OPPS,$11.35 ,100% of fee schedule,$7.77 ,100% of Medicare OPPS,$7.77 ,100% of Medicare OPPS,$13.59 ,100% of Medicare OPPS,$7.77 ,100% of Medicare OPPS,$14.75 ,100% of custom fee schedule,$76.06 ,90% of total billed charges,$7.77 ,$76.06 ,$76.06 
Outpatient Medical Services,LABORATORY,85610,"Blood test, clotting time",305,$46.28 ,$6.86 ,160% of Fee Schedule,$4.29 ,100% of Medicare OPPS,$32.40 ,70% of total billed charges,$39.28 ,84.88% of total billed charges,$6.75 ,139.08% of custom fee schedule,$4.29 ,100% of Medicare OPPS,$34.71 ,75% of total billed charges,$32.40 ,70% of total billed charges,$7.29 ,170% of Medicare OPPS,$9.22 ,215% of Medicare OPPS,$4.29 ,12.84% of total billed charges,$7.50 ,175% of Medicare OPPS,$4.29 ,100% of Medicare OPPS,$37.02 ,80% of total billed charges,$6.00 ,140% of Medicare OPPS,$5.36 ,125% of Medicare OPPS,$4.29 ,12.84% of LA Medicaid fee schedule,$4.29 ,12.84% of LA Medicaid fee schedule,$4.29 ,100% of Medicare OPPS,$5.74 ,100% of fee schedule,$4.29 ,100% of Medicare OPPS,$4.29 ,100% of Medicare OPPS,$7.50 ,100% of Medicare OPPS,$4.29 ,100% of Medicare OPPS,$7.46 ,100% of custom fee schedule,$41.65 ,90% of total billed charges,$4.29 ,$41.65 ,$41.65 
Outpatient Medical Services,LABORATORY,85652,sed rate,305,$34.74 ,$4.32 ,160% of Fee Schedule,$2.70 ,100% of Medicare OPPS,$24.32 ,70% of total billed charges,$29.49 ,84.88% of total billed charges,$4.63 ,139.08% of custom fee schedule,$2.70 ,100% of Medicare OPPS,$26.06 ,75% of total billed charges,$24.32 ,70% of total billed charges,$4.59 ,170% of Medicare OPPS,$5.80 ,215% of Medicare OPPS,$2.70 ,12.84% of total billed charges,$4.72 ,175% of Medicare OPPS,$2.70 ,100% of Medicare OPPS,$27.79 ,80% of total billed charges,$3.78 ,140% of Medicare OPPS,$3.37 ,125% of Medicare OPPS,$2.70 ,12.84% of LA Medicaid fee schedule,$2.70 ,12.84% of LA Medicaid fee schedule,$2.70 ,100% of Medicare OPPS,$3.94 ,100% of fee schedule,$2.70 ,100% of Medicare OPPS,$2.70 ,100% of Medicare OPPS,$4.72 ,100% of Medicare OPPS,$2.70 ,100% of Medicare OPPS,$5.13 ,100% of custom fee schedule,$31.27 ,90% of total billed charges,$2.70 ,$31.27 ,$31.27 
Outpatient Medical Services,LABORATORY,85730,Coagulation assessment blood test,305,$60.20 ,$9.61 ,160% of Fee Schedule,$6.01 ,100% of Medicare OPPS,$42.14 ,70% of total billed charges,$51.10 ,84.88% of total billed charges,$10.32 ,139.08% of custom fee schedule,$6.01 ,100% of Medicare OPPS,$45.15 ,75% of total billed charges,$42.14 ,70% of total billed charges,$10.21 ,170% of Medicare OPPS,$12.92 ,215% of Medicare OPPS,$6.01 ,12.84% of total billed charges,$10.51 ,175% of Medicare OPPS,$6.01 ,100% of Medicare OPPS,$48.16 ,80% of total billed charges,$8.41 ,140% of Medicare OPPS,$7.51 ,125% of Medicare OPPS,$6.01 ,12.84% of LA Medicaid fee schedule,$6.01 ,12.84% of LA Medicaid fee schedule,$6.01 ,100% of Medicare OPPS,$8.76 ,100% of fee schedule,$6.01 ,100% of Medicare OPPS,$6.01 ,100% of Medicare OPPS,$10.51 ,100% of Medicare OPPS,$6.01 ,100% of Medicare OPPS,$11.38 ,100% of custom fee schedule,$54.18 ,90% of total billed charges,$6.01 ,$54.18 ,$54.18 
Outpatient Medical Services,LABORATORY,87070,Test of body fluid other than blood to assess for bacteria,306,$83.34 ,$13.79 ,160% of Fee Schedule,$8.61 ,100% of Medicare OPPS,$58.34 ,70% of total billed charges,$70.74 ,84.88% of total billed charges,$14.80 ,139.08% of custom fee schedule,$8.61 ,100% of Medicare OPPS,$62.51 ,75% of total billed charges,$58.34 ,70% of total billed charges,$14.65 ,170% of Medicare OPPS,$18.53 ,215% of Medicare OPPS,$8.62 ,12.84% of total billed charges,$15.08 ,175% of Medicare OPPS,$8.61 ,100% of Medicare OPPS,$66.67 ,80% of total billed charges,$12.06 ,140% of Medicare OPPS,$10.77 ,125% of Medicare OPPS,$8.62 ,12.84% of LA Medicaid fee schedule,$8.62 ,12.84% of LA Medicaid fee schedule,$8.61 ,100% of Medicare OPPS,$12.57 ,100% of fee schedule,$8.61 ,100% of Medicare OPPS,$8.61 ,100% of Medicare OPPS,$15.08 ,100% of Medicare OPPS,$8.61 ,100% of Medicare OPPS,$16.33 ,100% of custom fee schedule,$75.01 ,90% of total billed charges,$8.61 ,$75.01 ,$75.01 
Outpatient Medical Services,LABORATORY,81001,Manual urinalysis test with examination with or without using microscope,307,$34.74 ,$5.07 ,160% of Fee Schedule,$3.17 ,100% of Medicare OPPS,$24.32 ,70% of total billed charges,$29.49 ,84.88% of total billed charges,$5.45 ,139.08% of custom fee schedule,$3.17 ,100% of Medicare OPPS,$26.06 ,75% of total billed charges,$24.32 ,70% of total billed charges,$5.38 ,170% of Medicare OPPS,$6.81 ,215% of Medicare OPPS,$3.17 ,12.84% of total billed charges,$5.54 ,175% of Medicare OPPS,$3.17 ,100% of Medicare OPPS,$27.79 ,80% of total billed charges,$4.43 ,140% of Medicare OPPS,$3.96 ,125% of Medicare OPPS,$3.17 ,12.84% of LA Medicaid fee schedule,$3.17 ,12.84% of LA Medicaid fee schedule,$3.17 ,100% of Medicare OPPS,$4.63 ,100% of fee schedule,$3.17 ,100% of Medicare OPPS,$3.17 ,100% of Medicare OPPS,$5.54 ,100% of Medicare OPPS,$3.17 ,100% of Medicare OPPS,$6.00 ,100% of custom fee schedule,$31.27 ,90% of total billed charges,$3.17 ,$31.27 ,$31.27 
Outpatient Medical Services,LABORATORY,81003,Automated urinalysis test,307,$23.14 ,$3.60 ,160% of Fee Schedule,$2.25 ,100% of Medicare OPPS,$16.20 ,70% of total billed charges,$19.64 ,84.88% of total billed charges,$3.85 ,139.08% of custom fee schedule,$2.25 ,100% of Medicare OPPS,$17.36 ,75% of total billed charges,$16.20 ,70% of total billed charges,$3.82 ,170% of Medicare OPPS,$4.83 ,215% of Medicare OPPS,$2.25 ,12.84% of total billed charges,$3.93 ,175% of Medicare OPPS,$2.25 ,100% of Medicare OPPS,$18.51 ,80% of total billed charges,$3.15 ,140% of Medicare OPPS,$2.81 ,125% of Medicare OPPS,$2.25 ,12.84% of LA Medicaid fee schedule,$2.25 ,12.84% of LA Medicaid fee schedule,$2.25 ,100% of Medicare OPPS,$3.28 ,100% of fee schedule,$2.25 ,100% of Medicare OPPS,$2.25 ,100% of Medicare OPPS,$3.93 ,100% of Medicare OPPS,$2.25 ,100% of Medicare OPPS,$4.25 ,100% of custom fee schedule,$20.83 ,90% of total billed charges,$2.25 ,$20.83 ,$20.83 
Outpatient Medical Services,LABORATORY,81025,Urine pregnancy test,307,$20.58 ,$13.77 ,160% of Fee Schedule,$8.61 ,100% of Medicare OPPS,$14.41 ,70% of total billed charges,$17.47 ,84.88% of total billed charges,$11.97 ,139.08% of custom fee schedule,$8.61 ,100% of Medicare OPPS,$15.44 ,75% of total billed charges,$14.41 ,70% of total billed charges,$14.63 ,170% of Medicare OPPS,$18.51 ,215% of Medicare OPPS,$8.15 ,12.84% of total billed charges,$15.06 ,175% of Medicare OPPS,$8.61 ,100% of Medicare OPPS,$16.46 ,80% of total billed charges,$12.05 ,140% of Medicare OPPS,$10.76 ,125% of Medicare OPPS,$8.15 ,12.84% of LA Medicaid fee schedule,$8.15 ,12.84% of LA Medicaid fee schedule,$8.61 ,100% of Medicare OPPS,$9.24 ,100% of fee schedule,$8.61 ,100% of Medicare OPPS,$8.61 ,100% of Medicare OPPS,$15.06 ,100% of Medicare OPPS,$8.61 ,100% of Medicare OPPS,$12.00 ,100% of custom fee schedule,$18.52 ,90% of total billed charges,$8.15 ,$18.52 ,$18.52 
Outpatient Medical Services,LABORATORY,87635,COVID lab test,310,$110.25 ,$82.09 ,160% of Fee Schedule,$51.31 ,100% of Medicare OPPS,$77.18 ,70% of total billed charges,$93.58 ,84.88% of total billed charges,$77.00 ,100% of custom fee schedule,$51.31 ,100% of Medicare OPPS,$82.69 ,75% of total billed charges,$77.18 ,70% of total billed charges,$87.22 ,170% of Medicare OPPS,$110.31 ,215% of Medicare OPPS,$51.31 ,12.84% of total billed charges,$89.79 ,175% of Medicare OPPS,$51.31 ,100% of Medicare OPPS,$88.20 ,80% of total billed charges,$71.83 ,140% of Medicare OPPS,$64.13 ,125% of Medicare OPPS,$51.31 ,12.84% of LA Medicaid fee schedule,$51.31 ,12.84% of LA Medicaid fee schedule,$51.31 ,100% of Medicare OPPS,$51.33 ,100% of fee schedule,$51.31 ,100% of Medicare OPPS,$51.31 ,100% of Medicare OPPS,$89.79 ,100% of Medicare OPPS,$51.31 ,100% of Medicare OPPS,$51.33 ,100% of custom fee schedule,$99.23 ,90% of total billed charges,$51.31 ,$110.31 ,$99.23 
Outpatient Medical Services,LABORATORY,82306,Blood test to monitor vitamin D levels,300,$96.29 ,$47.36 ,160% of Fee Schedule,$29.60 ,100% of Medicare OPPS,$67.40 ,70% of total billed charges,$81.73 ,84.88% of total billed charges,$50.83 ,139.08% of custom fee schedule,$29.60 ,100% of Medicare OPPS,$72.22 ,75% of total billed charges,$67.40 ,70% of total billed charges,$50.32 ,170% of Medicare OPPS,$63.64 ,215% of Medicare OPPS,$29.60 ,12.84% of total billed charges,$51.80 ,175% of Medicare OPPS,$29.60 ,100% of Medicare OPPS,$77.03 ,80% of total billed charges,$41.44 ,140% of Medicare OPPS,$37.00 ,125% of Medicare OPPS,$29.60 ,12.84% of LA Medicaid fee schedule,$29.60 ,12.84% of LA Medicaid fee schedule,$29.60 ,100% of Medicare OPPS,$43.22 ,100% of fee schedule,$29.60 ,100% of Medicare OPPS,$29.60 ,100% of Medicare OPPS,$51.80 ,100% of Medicare OPPS,$29.60 ,100% of Medicare OPPS,$56.16 ,100% of custom fee schedule,$86.66 ,90% of total billed charges,$29.60 ,$86.66 ,$86.66 
Outpatient Medical Services,LABORATORY,82947,Quantitative measure of glucose build up in the blood over time,300,$40.44 ,$6.28 ,160% of Fee Schedule,$3.93 ,100% of Medicare OPPS,$28.31 ,70% of total billed charges,$34.33 ,84.88% of total billed charges,$6.75 ,139.08% of custom fee schedule,$3.93 ,100% of Medicare OPPS,$30.33 ,75% of total billed charges,$28.31 ,70% of total billed charges,$6.68 ,170% of Medicare OPPS,$8.44 ,215% of Medicare OPPS,$3.93 ,12.84% of total billed charges,$6.87 ,175% of Medicare OPPS,$3.93 ,100% of Medicare OPPS,$32.35 ,80% of total billed charges,$5.50 ,140% of Medicare OPPS,$4.91 ,125% of Medicare OPPS,$3.93 ,12.84% of LA Medicaid fee schedule,$3.93 ,12.84% of LA Medicaid fee schedule,$3.93 ,100% of Medicare OPPS,$5.73 ,100% of fee schedule,$3.93 ,100% of Medicare OPPS,$3.93 ,100% of Medicare OPPS,$6.87 ,100% of Medicare OPPS,$3.93 ,100% of Medicare OPPS,$7.45 ,100% of custom fee schedule,$36.40 ,90% of total billed charges,$3.93 ,$36.40 ,$36.40 
Outpatient Medical Services,LABORATORY,83735,Magnesium,300,$21.79 ,$10.72 ,160% of Fee Schedule,$6.70 ,100% of Medicare OPPS,$15.25 ,70% of total billed charges,$18.50 ,84.88% of total billed charges,$11.50 ,139.08% of custom fee schedule,$6.70 ,100% of Medicare OPPS,$16.34 ,75% of total billed charges,$15.25 ,70% of total billed charges,$11.39 ,170% of Medicare OPPS,$14.40 ,215% of Medicare OPPS,$6.70 ,12.84% of total billed charges,$11.72 ,175% of Medicare OPPS,$6.70 ,100% of Medicare OPPS,$17.43 ,80% of total billed charges,$9.38 ,140% of Medicare OPPS,$8.37 ,125% of Medicare OPPS,$6.70 ,12.84% of LA Medicaid fee schedule,$6.70 ,12.84% of LA Medicaid fee schedule,$6.70 ,100% of Medicare OPPS,$9.78 ,100% of fee schedule,$6.70 ,100% of Medicare OPPS,$6.70 ,100% of Medicare OPPS,$11.72 ,100% of Medicare OPPS,$6.70 ,100% of Medicare OPPS,$12.70 ,100% of custom fee schedule,$19.61 ,90% of total billed charges,$6.70 ,$19.61 ,$19.61 
Outpatient Medical Services,LABORATORY,83970,parathyroid hormone,300,$134.27 ,$66.04 ,160% of Fee Schedule,$41.28 ,100% of Medicare OPPS,$93.99 ,70% of total billed charges,$113.97 ,84.88% of total billed charges,$70.88 ,139.08% of custom fee schedule,$41.28 ,100% of Medicare OPPS,$100.70 ,75% of total billed charges,$93.99 ,70% of total billed charges,$70.17 ,170% of Medicare OPPS,$88.75 ,215% of Medicare OPPS,$41.28 ,12.84% of total billed charges,$72.24 ,175% of Medicare OPPS,$41.28 ,100% of Medicare OPPS,$107.42 ,80% of total billed charges,$57.79 ,140% of Medicare OPPS,$51.60 ,125% of Medicare OPPS,$41.28 ,12.84% of LA Medicaid fee schedule,$41.28 ,12.84% of LA Medicaid fee schedule,$41.28 ,100% of Medicare OPPS,$60.27 ,100% of fee schedule,$41.28 ,100% of Medicare OPPS,$41.28 ,100% of Medicare OPPS,$72.24 ,100% of Medicare OPPS,$41.28 ,100% of Medicare OPPS,$78.27 ,100% of custom fee schedule,$120.84 ,90% of total billed charges,$41.28 ,$120.84 ,$120.84 
Outpatient Medical Services,LABORATORY,84165,protein electrophoretic,300,$34.93 ,$17.18 ,160% of Fee Schedule,$10.74 ,100% of Medicare OPPS,$24.45 ,70% of total billed charges,$29.65 ,84.88% of total billed charges,$18.44 ,139.08% of custom fee schedule,$10.74 ,100% of Medicare OPPS,$26.20 ,75% of total billed charges,$24.45 ,70% of total billed charges,$18.25 ,170% of Medicare OPPS,$23.09 ,215% of Medicare OPPS,$10.74 ,12.84% of total billed charges,$18.79 ,175% of Medicare OPPS,$10.74 ,100% of Medicare OPPS,$27.94 ,80% of total billed charges,$15.03 ,140% of Medicare OPPS,$13.42 ,125% of Medicare OPPS,$10.74 ,12.84% of LA Medicaid fee schedule,$10.74 ,12.84% of LA Medicaid fee schedule,$10.74 ,100% of Medicare OPPS,$15.68 ,100% of fee schedule,$10.74 ,100% of Medicare OPPS,$10.74 ,100% of Medicare OPPS,$18.79 ,100% of Medicare OPPS,$10.74 ,100% of Medicare OPPS,$20.36 ,100% of custom fee schedule,$31.44 ,90% of total billed charges,$10.74 ,$31.44 ,$31.44 
Outpatient Medical Services,LABORATORY,85027,"Complete blood count, automated",300,$62.50 ,$10.35 ,160% of Fee Schedule,$6.47 ,100% of Medicare OPPS,$43.75 ,70% of total billed charges,$53.05 ,84.88% of total billed charges,$11.10 ,139.08% of custom fee schedule,$6.47 ,100% of Medicare OPPS,$46.88 ,75% of total billed charges,$43.75 ,70% of total billed charges,$10.99 ,170% of Medicare OPPS,$13.91 ,215% of Medicare OPPS,$6.47 ,12.84% of total billed charges,$11.32 ,175% of Medicare OPPS,$6.47 ,100% of Medicare OPPS,$50.00 ,80% of total billed charges,$9.05 ,140% of Medicare OPPS,$8.08 ,125% of Medicare OPPS,$6.47 ,12.84% of LA Medicaid fee schedule,$6.47 ,12.84% of LA Medicaid fee schedule,$6.47 ,100% of Medicare OPPS,$9.45 ,100% of fee schedule,$6.47 ,100% of Medicare OPPS,$6.47 ,100% of Medicare OPPS,$11.32 ,100% of Medicare OPPS,$6.47 ,100% of Medicare OPPS,$12.27 ,100% of custom fee schedule,$56.25 ,90% of total billed charges,$6.47 ,$56.25 ,$56.25 
Outpatient Medical Services,LABORATORY,83516,Chemical test of the blood to measure presence or concentration of a substance in the blood,300,$37.54 ,$18.44 ,160% of Fee Schedule,$11.53 ,100% of Medicare OPPS,$26.28 ,70% of total billed charges,$31.86 ,84.88% of total billed charges,$19.80 ,139.08% of custom fee schedule,$11.53 ,100% of Medicare OPPS,$28.16 ,75% of total billed charges,$26.28 ,70% of total billed charges,$19.60 ,170% of Medicare OPPS,$24.78 ,215% of Medicare OPPS,$11.53 ,12.84% of total billed charges,$20.17 ,175% of Medicare OPPS,$11.53 ,100% of Medicare OPPS,$30.03 ,80% of total billed charges,$16.14 ,140% of Medicare OPPS,$14.41 ,125% of Medicare OPPS,$11.53 ,12.84% of LA Medicaid fee schedule,$11.53 ,12.84% of LA Medicaid fee schedule,$11.53 ,100% of Medicare OPPS,$16.85 ,100% of fee schedule,$11.53 ,100% of Medicare OPPS,$11.53 ,100% of Medicare OPPS,$20.17 ,100% of Medicare OPPS,$11.53 ,100% of Medicare OPPS,$21.88 ,100% of custom fee schedule,$33.79 ,90% of total billed charges,$11.53 ,$33.79 ,$33.79 
Outpatient Medical Services,THERAPY,94664,nebulizer therapy,410,$242.94 ,$268.84 ,100% of APC Rate,$168.02 ,100% of Medicare OPPS,$170.06 ,70% of total billed charges,$206.21 ,84.88% of total billed charges,$259.22 ,139.08% of custom fee schedule,$168.02 ,100% of Medicare OPPS,$182.21 ,75% of total billed charges,$170.06 ,70% of total billed charges,$285.64 ,170% of Medicare OPPS,$361.25 ,215% of Medicare OPPS,$31.19 ,12.84% of total billed charges,$294.04 ,175% of Medicare OPPS,$168.02 ,100% of Medicare OPPS,$194.35 ,80% of total billed charges,$235.23 ,140% of Medicare OPPS,$210.03 ,125% of Medicare OPPS,$31.19 ,12.84% of LA Medicaid fee schedule,$31.19 ,12.84% of LA Medicaid fee schedule,$168.02 ,100% of Medicare OPPS,$181.00 ,100% of UHC Case Rate,$168.02 ,100% of Medicare OPPS,$168.02 ,100% of Medicare OPPS,$294.04 ,100% of Medicare OPPS,$168.02 ,100% of Medicare OPPS,$93.01 ,100% of custom fee schedule,$218.65 ,90% of total billed charges,$31.19 ,$361.25 ,$242.94 
Outpatient Medical Services,THERAPY,97110,"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",420,$178.46 ,$44.96 ,160% of Fee Schedule,$28.10 ,100% of Medicare OPPS,$124.92 ,70% of total billed charges,$151.48 ,84.88% of total billed charges,$43.16 ,139.08% of custom fee schedule,$28.10 ,100% of Medicare OPPS,$133.85 ,75% of total billed charges,$124.92 ,70% of total billed charges,$96.29 ,170% of Medicare OPPS,$60.42 ,215% of Medicare OPPS,$16.21 ,12.84% of total billed charges,$49.18 ,175% of Medicare OPPS,$28.10 ,100% of Medicare OPPS,$142.77 ,80% of total billed charges,$39.34 ,140% of Medicare OPPS,$35.13 ,125% of Medicare OPPS,$16.21 ,12.84% of LA Medicaid fee schedule,$16.21 ,12.84% of LA Medicaid fee schedule,$28.10 ,100% of Medicare OPPS,$156.00 ,100% of UHC Case Rate,$28.10 ,100% of Medicare OPPS,$28.10 ,100% of Medicare OPPS,$49.18 ,100% of Medicare OPPS,$28.10 ,100% of Medicare OPPS,$32.91 ,100% of custom fee schedule,$160.61 ,90% of total billed charges,$16.21 ,$160.61 ,$178.46 
Outpatient Medical Services,THERAPY,97116,A type of physical therapy,420,$157.03 ,$44.96 ,160% of Fee Schedule,$28.10 ,100% of Medicare OPPS,$109.92 ,70% of total billed charges,$133.29 ,84.88% of total billed charges,$42.67 ,139.08% of custom fee schedule,$28.10 ,100% of Medicare OPPS,$117.77 ,75% of total billed charges,$109.92 ,70% of total billed charges,$96.29 ,170% of Medicare OPPS,$60.42 ,215% of Medicare OPPS,$20.16 ,12.84% of total billed charges,$49.18 ,175% of Medicare OPPS,$28.10 ,100% of Medicare OPPS,$125.62 ,80% of total billed charges,$39.34 ,140% of Medicare OPPS,$35.13 ,125% of Medicare OPPS,$20.16 ,12.84% of LA Medicaid fee schedule,$20.16 ,12.84% of LA Medicaid fee schedule,$28.10 ,100% of Medicare OPPS,$156.00 ,100% of UHC Case Rate,$28.10 ,100% of Medicare OPPS,$28.10 ,100% of Medicare OPPS,$49.18 ,100% of Medicare OPPS,$28.10 ,100% of Medicare OPPS,$28.56 ,100% of custom fee schedule,$141.33 ,90% of total billed charges,$20.16 ,$156.00 ,$157.03 
Outpatient Medical Services,THERAPY,97161,PT eval low complexity,420,$373.03 ,$153.41 ,160% of Fee Schedule,$95.88 ,100% of Medicare OPPS,$261.12 ,70% of total billed charges,$316.63 ,84.88% of total billed charges,$117.93 ,139.08% of custom fee schedule,$95.88 ,100% of Medicare OPPS,$279.77 ,75% of total billed charges,$261.12 ,70% of total billed charges,$328.22 ,170% of Medicare OPPS,$206.14 ,215% of Medicare OPPS,$74.48 ,12.84% of total billed charges,$167.79 ,175% of Medicare OPPS,$95.88 ,100% of Medicare OPPS,$298.42 ,80% of total billed charges,$134.23 ,140% of Medicare OPPS,$119.85 ,125% of Medicare OPPS,$74.48 ,12.84% of LA Medicaid fee schedule,$74.48 ,12.84% of LA Medicaid fee schedule,$95.88 ,100% of Medicare OPPS,$156.00 ,100% of UHC Case Rate,$95.88 ,100% of Medicare OPPS,$95.88 ,100% of Medicare OPPS,$167.79 ,100% of Medicare OPPS,$95.88 ,100% of Medicare OPPS,$82.51 ,100% of custom fee schedule,$335.73 ,90% of total billed charges,$74.48 ,$335.73 ,$373.03 
Outpatient Medical Services,THERAPY,97162,PT evaluation mod complexity,420,$432.60 ,$153.41 ,160% of Fee Schedule,$95.88 ,100% of Medicare OPPS,$302.82 ,70% of total billed charges,$367.19 ,84.88% of total billed charges,$117.93 ,139.08% of custom fee schedule,$95.88 ,100% of Medicare OPPS,$324.45 ,75% of total billed charges,$302.82 ,70% of total billed charges,$328.22 ,170% of Medicare OPPS,$206.14 ,215% of Medicare OPPS,$74.48 ,12.84% of total billed charges,$167.79 ,175% of Medicare OPPS,$95.88 ,100% of Medicare OPPS,$346.08 ,80% of total billed charges,$134.23 ,140% of Medicare OPPS,$119.85 ,125% of Medicare OPPS,$74.48 ,12.84% of LA Medicaid fee schedule,$74.48 ,12.84% of LA Medicaid fee schedule,$95.88 ,100% of Medicare OPPS,$156.00 ,100% of UHC Case Rate,$95.88 ,100% of Medicare OPPS,$95.88 ,100% of Medicare OPPS,$167.79 ,100% of Medicare OPPS,$95.88 ,100% of Medicare OPPS,$82.51 ,100% of custom fee schedule,$389.34 ,90% of total billed charges,$74.48 ,$389.34 ,$432.60 
Outpatient Medical Services,THERAPY,92611,fluoroscopy for swallow study,440,$356.60 ,$139.82 ,160% of Fee Schedule,$87.39 ,100% of Medicare OPPS,$249.62 ,70% of total billed charges,$302.68 ,84.88% of total billed charges,$123.46 ,139.08% of custom fee schedule,$87.39 ,100% of Medicare OPPS,$267.45 ,75% of total billed charges,$249.62 ,70% of total billed charges,$299.97 ,170% of Medicare OPPS,$187.89 ,215% of Medicare OPPS,$40.36 ,12.84% of total billed charges,$152.93 ,175% of Medicare OPPS,$87.39 ,100% of Medicare OPPS,$285.28 ,80% of total billed charges,$122.35 ,140% of Medicare OPPS,$109.24 ,125% of Medicare OPPS,$40.36 ,12.84% of LA Medicaid fee schedule,$40.36 ,12.84% of LA Medicaid fee schedule,$87.39 ,100% of Medicare OPPS,$156.00 ,100% of UHC Case Rate,$87.39 ,100% of Medicare OPPS,$87.39 ,100% of Medicare OPPS,$152.93 ,100% of Medicare OPPS,$87.39 ,100% of Medicare OPPS,$88.88 ,100% of custom fee schedule,$320.94 ,90% of total billed charges,$40.36 ,$320.94 ,$356.60 
Outpatient Medical Services,MEDICAL SERVICES,93005,EKG,730,$130.22 ,$80.69 ,100% of APC Rate,$50.43 ,100% of Medicare OPPS,$91.15 ,70% of total billed charges,$110.53 ,84.88% of total billed charges,$77.83 ,139.08% of custom fee schedule,$50.43 ,100% of Medicare OPPS,$97.67 ,75% of total billed charges,$91.15 ,70% of total billed charges,$85.73 ,170% of Medicare OPPS,$108.43 ,215% of Medicare OPPS,$16.72 ,12.84% of total billed charges,$88.25 ,175% of Medicare OPPS,$50.43 ,100% of Medicare OPPS,$104.18 ,80% of total billed charges,$70.60 ,140% of Medicare OPPS,$63.04 ,125% of Medicare OPPS,$16.72 ,12.84% of LA Medicaid fee schedule,$16.72 ,12.84% of LA Medicaid fee schedule,$50.43 ,100% of Medicare OPPS,$239.00 ,100% of UHC Case Rate,$50.43 ,100% of Medicare OPPS,$50.43 ,100% of Medicare OPPS,$88.25 ,100% of Medicare OPPS,$50.43 ,100% of Medicare OPPS,$32.26 ,100% of custom fee schedule,$117.20 ,90% of total billed charges,$16.72 ,$239.00 ,$130.22 
Outpatient Medical Services,MEDICAL SERVICES,93242,48 hr - 21 day cardiac monitor,731,$379.58 ,$47.67 ,100% of APC Rate,$29.79 ,100% of Medicare OPPS,$265.71 ,70% of total billed charges,$322.19 ,84.88% of total billed charges,$47.06 ,139.08% of custom fee schedule,$29.79 ,100% of Medicare OPPS,$284.69 ,75% of total billed charges,$265.71 ,70% of total billed charges,$50.65 ,170% of Medicare OPPS,$64.06 ,215% of Medicare OPPS,$48.74 ,12.84% of total billed charges,$52.14 ,175% of Medicare OPPS,$29.79 ,100% of Medicare OPPS,$303.66 ,80% of total billed charges,$41.71 ,140% of Medicare OPPS,$37.24 ,125% of Medicare OPPS,$48.74 ,12.84% of LA Medicaid fee schedule,$48.74 ,12.84% of LA Medicaid fee schedule,$29.79 ,100% of Medicare OPPS,$256.00 ,100% of UHC Case Rate,$29.79 ,100% of Medicare OPPS,$29.79 ,100% of Medicare OPPS,$52.14 ,100% of Medicare OPPS,$29.79 ,100% of Medicare OPPS,$132.85 ,100% of custom fee schedule,$341.62 ,90% of total billed charges,$29.79 ,$341.62 ,$379.58 
Outpatient Medical Services,MEDICAL SERVICES,93225,48 hour monitor,731,$379.58 ,$163.00 ,100% of APC Rate,$101.87 ,100% of Medicare OPPS,$265.71 ,70% of total billed charges,$322.19 ,84.88% of total billed charges,$146.09 ,139.08% of custom fee schedule,$101.87 ,100% of Medicare OPPS,$284.69 ,75% of total billed charges,$265.71 ,70% of total billed charges,$173.19 ,170% of Medicare OPPS,$219.03 ,215% of Medicare OPPS,$48.74 ,12.84% of total billed charges,$178.28 ,175% of Medicare OPPS,$101.87 ,100% of Medicare OPPS,$303.66 ,80% of total billed charges,$142.62 ,140% of Medicare OPPS,$127.34 ,125% of Medicare OPPS,$48.74 ,12.84% of LA Medicaid fee schedule,$48.74 ,12.84% of LA Medicaid fee schedule,$101.87 ,100% of Medicare OPPS,$256.00 ,100% of UHC Case Rate,$101.87 ,100% of Medicare OPPS,$101.87 ,100% of Medicare OPPS,$178.28 ,100% of Medicare OPPS,$101.87 ,100% of Medicare OPPS,$83.48 ,100% of custom fee schedule,$341.62 ,90% of total billed charges,$48.74 ,$341.62 ,$379.58 
Outpatient Medical Services,MEDICAL SERVICES,93270,30 day monitor,731,$379.58 ,$49.13 ,100% of APC Rate,$30.70 ,100% of Medicare OPPS,$265.71 ,70% of total billed charges,$322.19 ,84.88% of total billed charges,$52.49 ,139.08% of custom fee schedule,$30.70 ,100% of Medicare OPPS,$284.69 ,75% of total billed charges,$265.71 ,70% of total billed charges,$52.20 ,170% of Medicare OPPS,$66.02 ,215% of Medicare OPPS,$48.74 ,12.84% of total billed charges,$53.74 ,175% of Medicare OPPS,$30.70 ,100% of Medicare OPPS,$303.66 ,80% of total billed charges,$42.99 ,140% of Medicare OPPS,$38.38 ,125% of Medicare OPPS,$48.74 ,12.84% of LA Medicaid fee schedule,$48.74 ,12.84% of LA Medicaid fee schedule,$30.70 ,100% of Medicare OPPS,$256.00 ,100% of UHC Case Rate,$30.70 ,100% of Medicare OPPS,$30.70 ,100% of Medicare OPPS,$53.74 ,100% of Medicare OPPS,$30.70 ,100% of Medicare OPPS,$43.00 ,100% of custom fee schedule,$341.62 ,90% of total billed charges,$30.70 ,$341.62 ,$379.58 
Outpatient Medical Services,MEDICAL SERVICES,95938,study upper lower extremities for intraop monitoring,740,$681.48 ,$678.66 ,100% of APC Rate,$424.17 ,100% of Medicare OPPS,$477.04 ,70% of total billed charges,$578.44 ,84.88% of total billed charges,$618.06 ,139.08% of custom fee schedule,$424.17 ,100% of Medicare OPPS,$511.11 ,75% of total billed charges,$477.04 ,70% of total billed charges,$721.09 ,170% of Medicare OPPS,$911.96 ,215% of Medicare OPPS,$87.50 ,12.84% of total billed charges,$742.29 ,175% of Medicare OPPS,$424.17 ,100% of Medicare OPPS,$545.18 ,80% of total billed charges,$593.83 ,140% of Medicare OPPS,$530.20 ,125% of Medicare OPPS,$87.50 ,12.84% of LA Medicaid fee schedule,$87.50 ,12.84% of LA Medicaid fee schedule,$424.17 ,100% of Medicare OPPS,$323.00 ,100% of UHC Case Rate,$424.17 ,100% of Medicare OPPS,$424.17 ,100% of Medicare OPPS,$742.29 ,100% of Medicare OPPS,$424.17 ,100% of Medicare OPPS,$257.89 ,100% of custom fee schedule,$613.33 ,90% of total billed charges,$87.50 ,$911.96 ,$681.48 
Outpatient Medical Services,MEDICAL SERVICES,95939,evoked potential study intraop monitoring,740,$940.86 ,"$1,311.74 ",100% of APC Rate,$819.84 ,100% of Medicare OPPS,$658.60 ,70% of total billed charges,$798.60 ,84.88% of total billed charges,"$1,255.86 ",139.08% of custom fee schedule,$819.84 ,100% of Medicare OPPS,$705.65 ,75% of total billed charges,$658.60 ,70% of total billed charges,"$1,393.72 ",170% of Medicare OPPS,"$1,762.65 ",215% of Medicare OPPS,$120.81 ,12.84% of total billed charges,"$1,434.72 ",175% of Medicare OPPS,$819.84 ,100% of Medicare OPPS,$752.69 ,80% of total billed charges,"$1,147.78 ",140% of Medicare OPPS,"$1,024.80 ",125% of Medicare OPPS,$120.81 ,12.84% of LA Medicaid fee schedule,$120.81 ,12.84% of LA Medicaid fee schedule,$819.84 ,100% of Medicare OPPS,$323.00 ,100% of UHC Case Rate,$819.84 ,100% of Medicare OPPS,$819.84 ,100% of Medicare OPPS,"$1,434.72 ",100% of Medicare OPPS,$819.84 ,100% of Medicare OPPS,$257.89 ,100% of custom fee schedule,$846.77 ,90% of total billed charges,$120.81 ,"$1,762.65 ",$940.86 
Outpatient Medical Services,MEDICAL SERVICES,95941,intraop monitoring,740,$392.11 ,N/A,Not covered by Contract,N/A,100% of Medicare OPPS,$274.48 ,70% of total billed charges,$332.82 ,84.88% of total billed charges,N/A,139.08% of custom fee schedule,N/A,100% of Medicare OPPS,$294.08 ,75% of total billed charges,$274.48 ,70% of total billed charges,N/A,170% of Medicare OPPS,N/A,215% of Medicare OPPS,$50.35 ,12.84% of total billed charges,N/A,175% of Medicare OPPS,N/A,100% of Medicare OPPS,$313.69 ,80% of total billed charges,N/A,140% of Medicare OPPS,N/A,125% of Medicare OPPS,$50.35 ,12.84% of LA Medicaid fee schedule,$50.35 ,12.84% of LA Medicaid fee schedule,N/A,100% of Medicare OPPS,$323.00 ,100% of UHC Case Rate,N/A,100% of Medicare OPPS,N/A,100% of Medicare OPPS,N/A,100% of Medicare OPPS,N/A,100% of Medicare OPPS,N/A,100% of custom fee schedule,$352.90 ,90% of total billed charges,$50.35 ,$352.90 ,$392.11 
Outpatient Medical Services,MEDICAL SERVICES,92015,refractive state (eyes ORA),920,$175.00 ,N/A,Not covered by Contract,N/A,100% of Medicare OPPS,$122.50 ,70% of total billed charges,$148.54 ,84.88% of total billed charges,N/A,139.08% of custom fee schedule,N/A,100% of Medicare OPPS,$131.25 ,75% of total billed charges,$122.50 ,70% of total billed charges,N/A,170% of Medicare OPPS,N/A,215% of Medicare OPPS,$22.47 ,12.84% of total billed charges,N/A,175% of Medicare OPPS,N/A,100% of Medicare OPPS,$140.00 ,80% of total billed charges,N/A,140% of Medicare OPPS,N/A,125% of Medicare OPPS,$22.47 ,12.84% of LA Medicaid fee schedule,$22.47 ,12.84% of LA Medicaid fee schedule,N/A,100% of Medicare OPPS,$226.00 ,100% of UHC Case Rate,N/A,100% of Medicare OPPS,N/A,100% of Medicare OPPS,N/A,100% of Medicare OPPS,N/A,100% of Medicare OPPS,$61.25 ,100% of custom fee schedule,$157.50 ,90% of total billed charges,$22.47 ,$226.00 ,$175.00 
Outpatient Medical Services,MEDICAL SERVICES,95861,Test to measure electrical activity of muscles or nerves in 2 limb,922,$425.32 ,$163.00 ,100% of APC Rate,$101.87 ,100% of Medicare OPPS,$297.72 ,70% of total billed charges,$361.01 ,84.88% of total billed charges,$146.09 ,139.08% of custom fee schedule,$101.87 ,100% of Medicare OPPS,$318.99 ,75% of total billed charges,$297.72 ,70% of total billed charges,$173.19 ,170% of Medicare OPPS,$219.03 ,215% of Medicare OPPS,$54.61 ,12.84% of total billed charges,$178.28 ,175% of Medicare OPPS,$101.87 ,100% of Medicare OPPS,$340.26 ,80% of total billed charges,$142.62 ,140% of Medicare OPPS,$127.34 ,125% of Medicare OPPS,$54.61 ,12.84% of LA Medicaid fee schedule,$54.61 ,12.84% of LA Medicaid fee schedule,$101.87 ,100% of Medicare OPPS,$323.00 ,100% of UHC Case Rate,$101.87 ,100% of Medicare OPPS,$101.87 ,100% of Medicare OPPS,$178.28 ,100% of Medicare OPPS,$101.87 ,100% of Medicare OPPS,$151.97 ,100% of custom fee schedule,$382.79 ,90% of total billed charges,$54.61 ,$382.79 ,$425.32 
Outpatient Medical Services,MEDICAL SERVICES,95870,Needle EMG for intraop monitoring,922,$182.35 ,$163.00 ,100% of APC Rate,$101.87 ,100% of Medicare OPPS,$127.65 ,70% of total billed charges,$154.78 ,84.88% of total billed charges,$77.83 ,139.08% of custom fee schedule,$101.87 ,100% of Medicare OPPS,$136.76 ,75% of total billed charges,$127.65 ,70% of total billed charges,$173.19 ,170% of Medicare OPPS,$219.03 ,215% of Medicare OPPS,$23.41 ,12.84% of total billed charges,$178.28 ,175% of Medicare OPPS,$101.87 ,100% of Medicare OPPS,$145.88 ,80% of total billed charges,$142.62 ,140% of Medicare OPPS,$127.34 ,125% of Medicare OPPS,$23.41 ,12.84% of LA Medicaid fee schedule,$23.41 ,12.84% of LA Medicaid fee schedule,$101.87 ,100% of Medicare OPPS,$323.00 ,100% of UHC Case Rate,$101.87 ,100% of Medicare OPPS,$101.87 ,100% of Medicare OPPS,$178.28 ,100% of Medicare OPPS,$101.87 ,100% of Medicare OPPS,$63.57 ,100% of custom fee schedule,$164.12 ,90% of total billed charges,$23.41 ,$323.00 ,$182.35 
Outpatient Medical Services,MEDICAL SERVICES,93320,Echo with doppler,480,$667.80 ,N/A,Not covered by Contract,N/A,100% of Medicare OPPS,$467.46 ,70% of total billed charges,$566.83 ,84.88% of total billed charges,N/A,139.08% of custom fee schedule,N/A,100% of Medicare OPPS,$500.85 ,75% of total billed charges,$467.46 ,70% of total billed charges,N/A,170% of Medicare OPPS,N/A,215% of Medicare OPPS,$85.75 ,12.84% of total billed charges,N/A,175% of Medicare OPPS,N/A,100% of Medicare OPPS,$534.24 ,80% of total billed charges,N/A,140% of Medicare OPPS,N/A,125% of Medicare OPPS,$85.75 ,12.84% of LA Medicaid fee schedule,$85.75 ,12.84% of LA Medicaid fee schedule,N/A,100% of Medicare OPPS,$452.00 ,100% of UHC Case Rate,N/A,100% of Medicare OPPS,N/A,100% of Medicare OPPS,N/A,100% of Medicare OPPS,N/A,100% of Medicare OPPS,N/A,100% of custom fee schedule,$601.02 ,90% of total billed charges,$85.75 ,$601.02 ,$667.80 
Outpatient Medical Services,MEDICAL SERVICES,93325,echocardiography doppler color flow,480,$667.80 ,N/A,Not covered by Contract,N/A,100% of Medicare OPPS,$467.46 ,70% of total billed charges,$566.83 ,84.88% of total billed charges,N/A,139.08% of custom fee schedule,N/A,100% of Medicare OPPS,$500.85 ,75% of total billed charges,$467.46 ,70% of total billed charges,N/A,170% of Medicare OPPS,N/A,215% of Medicare OPPS,$85.75 ,12.84% of total billed charges,N/A,175% of Medicare OPPS,N/A,100% of Medicare OPPS,$534.24 ,80% of total billed charges,N/A,140% of Medicare OPPS,N/A,125% of Medicare OPPS,$85.75 ,12.84% of LA Medicaid fee schedule,$85.75 ,12.84% of LA Medicaid fee schedule,N/A,100% of Medicare OPPS,$452.00 ,100% of UHC Case Rate,N/A,100% of Medicare OPPS,N/A,100% of Medicare OPPS,N/A,100% of Medicare OPPS,N/A,100% of Medicare OPPS,N/A,100% of custom fee schedule,$601.02 ,90% of total billed charges,$85.75 ,$601.02 ,$667.80 
Outpatient Medical Services,MEDICAL SERVICES,93017,stress test tracing,482,$467.51 ,$393.16 ,100% of APC Rate,$245.73 ,100% of Medicare OPPS,$327.26 ,70% of total billed charges,$396.82 ,84.88% of total billed charges,$346.07 ,139.08% of custom fee schedule,$245.73 ,100% of Medicare OPPS,$350.63 ,75% of total billed charges,$327.26 ,70% of total billed charges,$417.74 ,170% of Medicare OPPS,$528.32 ,215% of Medicare OPPS,$60.03 ,12.84% of total billed charges,$430.02 ,175% of Medicare OPPS,$245.73 ,100% of Medicare OPPS,$374.01 ,80% of total billed charges,$344.02 ,140% of Medicare OPPS,$307.16 ,125% of Medicare OPPS,$60.03 ,12.84% of LA Medicaid fee schedule,$60.03 ,12.84% of LA Medicaid fee schedule,$245.73 ,100% of Medicare OPPS,$354.00 ,100% of UHC Case Rate,$245.73 ,100% of Medicare OPPS,$245.73 ,100% of Medicare OPPS,$430.02 ,100% of Medicare OPPS,$245.73 ,100% of Medicare OPPS,$290.51 ,100% of custom fee schedule,$420.76 ,90% of total billed charges,$60.03 ,$528.32 ,$467.51 
Outpatient Medical Services,MEDICAL SERVICES,93350,Stress test with echocardiogram,482,"$1,110.22 ",$706.32 ,100% of APC Rate,$441.45 ,100% of Medicare OPPS,$777.15 ,70% of total billed charges,$942.35 ,84.88% of total billed charges,$676.89 ,139.08% of custom fee schedule,$441.45 ,100% of Medicare OPPS,$832.67 ,75% of total billed charges,$777.15 ,70% of total billed charges,$750.47 ,170% of Medicare OPPS,$949.12 ,215% of Medicare OPPS,$142.55 ,12.84% of total billed charges,$772.54 ,175% of Medicare OPPS,$441.45 ,100% of Medicare OPPS,$888.18 ,80% of total billed charges,$618.03 ,140% of Medicare OPPS,$551.80 ,125% of Medicare OPPS,$142.55 ,12.84% of LA Medicaid fee schedule,$142.55 ,12.84% of LA Medicaid fee schedule,$441.45 ,100% of Medicare OPPS,$354.00 ,100% of UHC Case Rate,$441.45 ,100% of Medicare OPPS,$441.45 ,100% of Medicare OPPS,$772.54 ,100% of Medicare OPPS,$441.45 ,100% of Medicare OPPS,$508.27 ,100% of custom fee schedule,$999.20 ,90% of total billed charges,$142.55 ,$999.20 ,"$1,110.22 "
Outpatient Medical Services,MEDICAL SERVICES,93306,"Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function",483,$906.69 ,$706.32 ,100% of APC Rate,$441.45 ,100% of Medicare OPPS,$634.68 ,70% of total billed charges,$769.60 ,84.88% of total billed charges,$676.89 ,139.08% of custom fee schedule,$441.45 ,100% of Medicare OPPS,$680.02 ,75% of total billed charges,$634.68 ,70% of total billed charges,$750.47 ,170% of Medicare OPPS,$949.12 ,215% of Medicare OPPS,$116.42 ,12.84% of total billed charges,$772.54 ,175% of Medicare OPPS,$441.45 ,100% of Medicare OPPS,$725.35 ,80% of total billed charges,$618.03 ,140% of Medicare OPPS,$551.80 ,125% of Medicare OPPS,$116.42 ,12.84% of LA Medicaid fee schedule,$116.42 ,12.84% of LA Medicaid fee schedule,$441.45 ,100% of Medicare OPPS,$388.00 ,100% of UHC Case Rate,$441.45 ,100% of Medicare OPPS,$441.45 ,100% of Medicare OPPS,$772.54 ,100% of Medicare OPPS,$441.45 ,100% of Medicare OPPS,$508.27 ,100% of custom fee schedule,$816.02 ,90% of total billed charges,$116.42 ,$949.12 ,$906.69 
Outpatient Medical Services,MEDICAL SERVICES,93308,TTE limited/follow up,483,$438.52 ,$327.83 ,100% of APC Rate,$204.89 ,100% of Medicare OPPS,$306.96 ,70% of total billed charges,$372.22 ,84.88% of total billed charges,$323.10 ,139.08% of custom fee schedule,$204.89 ,100% of Medicare OPPS,$328.89 ,75% of total billed charges,$306.96 ,70% of total billed charges,$348.31 ,170% of Medicare OPPS,$440.51 ,215% of Medicare OPPS,$56.31 ,12.84% of total billed charges,$358.56 ,175% of Medicare OPPS,$204.89 ,100% of Medicare OPPS,$350.82 ,80% of total billed charges,$286.83 ,140% of Medicare OPPS,$256.11 ,125% of Medicare OPPS,$56.31 ,12.84% of LA Medicaid fee schedule,$56.31 ,12.84% of LA Medicaid fee schedule,$204.89 ,100% of Medicare OPPS,$388.00 ,100% of UHC Case Rate,$204.89 ,100% of Medicare OPPS,$204.89 ,100% of Medicare OPPS,$358.56 ,100% of Medicare OPPS,$204.89 ,100% of Medicare OPPS,$298.19 ,100% of custom fee schedule,$394.67 ,90% of total billed charges,$56.31 ,$440.51 ,$438.52 
Outpatient Medical Services,MEDICAL SERVICES,C8924,TTE w/contrast or w/o followed by w/contrast follow-up or limited,483,$682.37 ,$517.22 ,100% of APC Rate,$323.26 ,100% of Medicare OPPS,$477.66 ,70% of total billed charges,$579.20 ,84.88% of total billed charges,$634.72 ,139.08% of custom fee schedule,$323.26 ,100% of Medicare OPPS,$511.78 ,75% of total billed charges,$477.66 ,70% of total billed charges,$549.54 ,170% of Medicare OPPS,$695.02 ,215% of Medicare OPPS,$87.62 ,12.84% of total billed charges,$565.71 ,175% of Medicare OPPS,$323.26 ,100% of Medicare OPPS,$545.90 ,80% of total billed charges,$452.57 ,140% of Medicare OPPS,$404.07 ,125% of Medicare OPPS,$87.62 ,12.84% of LA Medicaid fee schedule,$87.62 ,12.84% of LA Medicaid fee schedule,$323.26 ,100% of Medicare OPPS,$388.00 ,100% of UHC Case Rate,$323.26 ,100% of Medicare OPPS,$323.26 ,100% of Medicare OPPS,$565.71 ,100% of Medicare OPPS,$323.26 ,100% of Medicare OPPS,$595.47 ,100% of custom fee schedule,$614.13 ,90% of total billed charges,$87.62 ,$695.02 ,$682.37 
Outpatient Medical Services,MEDICAL SERVICES,C8929,TTE w/contrast or w/o followed by w/contrast complete,483,"$1,098.58 ","$1,039.91 ",100% of APC Rate,$649.94 ,100% of Medicare OPPS,$769.01 ,70% of total billed charges,$932.47 ,84.88% of total billed charges,$948.36 ,139.08% of custom fee schedule,$649.94 ,100% of Medicare OPPS,$823.94 ,75% of total billed charges,$769.01 ,70% of total billed charges,"$1,104.90 ",170% of Medicare OPPS,"$1,397.38 ",215% of Medicare OPPS,$141.06 ,12.84% of total billed charges,"$1,137.40 ",175% of Medicare OPPS,$649.94 ,100% of Medicare OPPS,$878.86 ,80% of total billed charges,$909.92 ,140% of Medicare OPPS,$812.43 ,125% of Medicare OPPS,$141.06 ,12.84% of LA Medicaid fee schedule,$141.06 ,12.84% of LA Medicaid fee schedule,$649.94 ,100% of Medicare OPPS,$388.00 ,100% of UHC Case Rate,$649.94 ,100% of Medicare OPPS,$649.94 ,100% of Medicare OPPS,"$1,137.40 ",100% of Medicare OPPS,$649.94 ,100% of Medicare OPPS,$778.28 ,100% of custom fee schedule,$988.72 ,90% of total billed charges,$141.06 ,"$1,397.38 ","$1,098.58 "
Outpatient Medical Services,MEDICAL SERVICES,C8930,TTE w/contrast or w/o followed by w/contrast with stress,483,"$1,098.58 ","$1,039.91 ",100% of APC Rate,$649.94 ,100% of Medicare OPPS,$769.01 ,70% of total billed charges,$932.47 ,84.88% of total billed charges,$948.36 ,139.08% of custom fee schedule,$649.94 ,100% of Medicare OPPS,$823.94 ,75% of total billed charges,$769.01 ,70% of total billed charges,"$1,104.90 ",170% of Medicare OPPS,"$1,397.38 ",215% of Medicare OPPS,$141.06 ,12.84% of total billed charges,"$1,137.40 ",175% of Medicare OPPS,$649.94 ,100% of Medicare OPPS,$878.86 ,80% of total billed charges,$909.92 ,140% of Medicare OPPS,$812.43 ,125% of Medicare OPPS,$141.06 ,12.84% of LA Medicaid fee schedule,$141.06 ,12.84% of LA Medicaid fee schedule,$649.94 ,100% of Medicare OPPS,$388.00 ,100% of UHC Case Rate,$649.94 ,100% of Medicare OPPS,$649.94 ,100% of Medicare OPPS,"$1,137.40 ",100% of Medicare OPPS,$649.94 ,100% of Medicare OPPS,$778.28 ,100% of custom fee schedule,$988.72 ,90% of total billed charges,$141.06 ,"$1,397.38 ","$1,098.58 "
Mangham Clinic,Surgery,10060,Incision and drainage of abscess; simple or single and complex or multiple,981,$225.00 ,$99.42 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$225.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$225.00 ,100% of CMS physician fee schedule,$146.08 ,100% of CMS physician fee schedule,$225.00 ,100% of CMS physician fee schedule,$99.42 ,100% of CMS physician fee schedule,$65.58 ,100% of CMS physician fee schedule,$99.42 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$99.42 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$65.58 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$225.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$101.07 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$65.58 ,$225.00 ,$225.00 
Mangham Clinic,Surgery,10061,"Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complica",981,$400.00 ,$175.39 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$400.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$400.00 ,100% of CMS physician fee schedule,$239.58 ,100% of CMS physician fee schedule,$400.00 ,100% of CMS physician fee schedule,$175.39 ,100% of CMS physician fee schedule,$113.80 ,100% of CMS physician fee schedule,$175.39 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$175.39 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$113.80 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$400.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$187.21 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$113.80 ,$400.00 ,$400.00 
Mangham Clinic,Surgery,10140,"Incision and drainage of hematoma, seroma or fluid collection",981,$312.00 ,$112.65 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$312.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$312.00 ,100% of CMS physician fee schedule,$164.99 ,100% of CMS physician fee schedule,$312.00 ,100% of CMS physician fee schedule,$112.65 ,100% of CMS physician fee schedule,$92.18 ,100% of CMS physician fee schedule,$112.65 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$112.65 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$92.18 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$312.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$123.24 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$92.18 ,$312.00 ,$312.00 
Mangham Clinic,Wound Care/Diabetic Footcare,11055,"Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); single lesion",981,$89.00 ,$15.78 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$89.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$89.00 ,100% of CMS physician fee schedule,$50.54 ,100% of CMS physician fee schedule,$89.00 ,100% of CMS physician fee schedule,$15.78 ,100% of CMS physician fee schedule,$28.85 ,100% of CMS physician fee schedule,$15.78 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$15.78 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$28.85 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$89.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$17.17 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$15.78 ,$89.00 ,$89.00 
Mangham Clinic,Wound Care/Diabetic Footcare,11056,Paring or cutting of benign hyperkeratotic lesion,981,$110.00 ,$21.75 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$110.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$110.00 ,100% of CMS physician fee schedule,$65.25 ,100% of CMS physician fee schedule,$110.00 ,100% of CMS physician fee schedule,$21.75 ,100% of CMS physician fee schedule,$35.57 ,100% of CMS physician fee schedule,$21.75 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$21.75 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$35.57 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$110.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$24.31 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$21.75 ,$110.00 ,$110.00 
Mangham Clinic,Wound Care/Diabetic Footcare,11057,"Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); more than four lesions",981,$124.00 ,$28.03 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$124.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$124.00 ,100% of CMS physician fee schedule,$80.34 ,100% of CMS physician fee schedule,$124.00 ,100% of CMS physician fee schedule,$28.03 ,100% of CMS physician fee schedule,$43.18 ,100% of CMS physician fee schedule,$28.03 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$28.03 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$43.18 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$124.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$31.78 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$28.03 ,$124.00 ,$124.00 
Mangham Clinic,Surgery,11200,"Removal of skin tags, multiple fibrocutaneous tags, any area",981,$169.00 ,$72.03 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$169.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$169.00 ,100% of CMS physician fee schedule,$110.11 ,100% of CMS physician fee schedule,$169.00 ,100% of CMS physician fee schedule,$72.03 ,100% of CMS physician fee schedule,$48.16 ,100% of CMS physician fee schedule,$72.03 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$72.03 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$48.16 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$169.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$75.18 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$48.16 ,$169.00 ,$169.00 
Mangham Clinic,Surgery,11305,"Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 0.5 cm or less",981,$187.00 ,$36.94 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$187.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$187.00 ,100% of CMS physician fee schedule,$79.02 ,100% of CMS physician fee schedule,$187.00 ,100% of CMS physician fee schedule,$36.94 ,100% of CMS physician fee schedule,$41.44 ,100% of CMS physician fee schedule,$36.94 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$36.94 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$41.44 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$187.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$41.84 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$36.94 ,$187.00 ,$187.00 
Mangham Clinic,Surgery,11306,"Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 0.6 to 1.0 cm",981,$232.00 ,$48.28 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$232.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$232.00 ,100% of CMS physician fee schedule,$109.76 ,100% of CMS physician fee schedule,$232.00 ,100% of CMS physician fee schedule,$48.28 ,100% of CMS physician fee schedule,$57.21 ,100% of CMS physician fee schedule,$48.28 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$48.28 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$57.21 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$232.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$55.41 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$48.28 ,$232.00 ,$232.00 
Mangham Clinic,Surgery,11308,"Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter over 2.0 cm",981,$288.00 ,$68.67 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$288.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$288.00 ,100% of CMS physician fee schedule,$149.82 ,100% of CMS physician fee schedule,$288.00 ,100% of CMS physician fee schedule,$68.67 ,100% of CMS physician fee schedule,$76.50 ,100% of CMS physician fee schedule,$68.67 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$68.67 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$76.50 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$288.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$79.84 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$68.67 ,$288.00 ,$288.00 
Mangham Clinic,Surgery,11401,Under Excision-Benign Lesions Procedures on the Skin 0.6-1 CM,981,$284.00 ,$101.11 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$284.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$284.00 ,100% of CMS physician fee schedule,$171.09 ,100% of CMS physician fee schedule,$284.00 ,100% of CMS physician fee schedule,$101.11 ,100% of CMS physician fee schedule,$83.48 ,100% of CMS physician fee schedule,$101.11 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$101.11 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$83.48 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$284.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$108.07 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$83.48 ,$284.00 ,$284.00 
Mangham Clinic,Surgery,11421,"Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 0.6 to 1.0",981,$299.00 ,$104.88 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$299.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$299.00 ,100% of CMS physician fee schedule,$183.05 ,100% of CMS physician fee schedule,$299.00 ,100% of CMS physician fee schedule,$104.88 ,100% of CMS physician fee schedule,$89.54 ,100% of CMS physician fee schedule,$104.88 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$104.88 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$89.54 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$299.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$114.38 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$89.54 ,$299.00 ,$299.00 
Mangham Clinic,Wound Care/Diabetic Footcare,11719,"Trimming of nondystrophic nails, any number",981,$27.00 ,$7.33 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$27.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$27.00 ,100% of CMS physician fee schedule,$21.64 ,100% of CMS physician fee schedule,$27.00 ,100% of CMS physician fee schedule,$7.33 ,100% of CMS physician fee schedule,$12.58 ,100% of CMS physician fee schedule,$7.33 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$7.33 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$12.58 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$27.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$11.76 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$7.33 ,$27.00 ,$27.00 
Mangham Clinic,Wound Care/Diabetic Footcare,11720,Debridement of nail(s) by any method(s); one to five,981,$61.00 ,$14.47 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$61.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$61.00 ,100% of CMS physician fee schedule,$34.63 ,100% of CMS physician fee schedule,$61.00 ,100% of CMS physician fee schedule,$14.47 ,100% of CMS physician fee schedule,$18.74 ,100% of CMS physician fee schedule,$14.47 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$14.47 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$18.74 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$61.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$22.43 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$14.47 ,$61.00 ,$61.00 
Mangham Clinic,Wound Care/Diabetic Footcare,11721,Removal of 6 or more nails,981,$86.00 ,$23.41 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$86.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$86.00 ,100% of CMS physician fee schedule,$52.58 ,100% of CMS physician fee schedule,$86.00 ,100% of CMS physician fee schedule,$23.41 ,100% of CMS physician fee schedule,$27.17 ,100% of CMS physician fee schedule,$23.41 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$23.41 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$27.17 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$86.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$38.02 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$23.41 ,$86.00 ,$86.00 
Mangham Clinic,Surgery,11730,Separation and removal of the entire nail plate or a portion of nail plate,981,$199.00 ,$52.51 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$199.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$199.00 ,100% of CMS physician fee schedule,$125.21 ,100% of CMS physician fee schedule,$199.00 ,100% of CMS physician fee schedule,$52.51 ,100% of CMS physician fee schedule,$59.63 ,100% of CMS physician fee schedule,$52.51 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$52.51 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$59.63 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$199.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$83.53 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$52.51 ,$199.00 ,$199.00 
Mangham Clinic,Surgery,11765,"Wedge excision of skin of nail fold (eg, for ingrown toenail)",981,$314.00 ,$87.37 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$314.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$314.00 ,100% of CMS physician fee schedule,$94.87 ,100% of CMS physician fee schedule,$314.00 ,100% of CMS physician fee schedule,$87.37 ,100% of CMS physician fee schedule,$74.27 ,100% of CMS physician fee schedule,$87.37 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$87.37 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$74.27 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$314.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$137.00 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$74.27 ,$314.00 ,$314.00 
Mangham Clinic,Surgery,11981,"Insertion, non-biodegradable drug delivery implant",981,$273.00 ,$61.82 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$273.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$273.00 ,100% of CMS physician fee schedule,$172.56 ,100% of CMS physician fee schedule,$273.00 ,100% of CMS physician fee schedule,$61.82 ,100% of CMS physician fee schedule,$83.08 ,100% of CMS physician fee schedule,$61.82 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$61.82 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$83.08 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$273.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$128.50 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$61.82 ,$273.00 ,$273.00 
Mangham Clinic,Surgery,12002,"Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.6 cm to 7.5 cm",981,$209.00 ,$58.73 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$209.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$209.00 ,100% of CMS physician fee schedule,$137.84 ,100% of CMS physician fee schedule,$209.00 ,100% of CMS physician fee schedule,$58.73 ,100% of CMS physician fee schedule,$94.12 ,100% of CMS physician fee schedule,$58.73 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$58.73 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$94.12 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$209.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$89.58 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$58.73 ,$209.00 ,$209.00 
Mangham Clinic,Surgery,17000,Destruction of pre-cancerous lesion,981,$127.00 ,$51.49 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$127.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$127.00 ,100% of CMS physician fee schedule,$93.42 ,100% of CMS physician fee schedule,$127.00 ,100% of CMS physician fee schedule,$51.49 ,100% of CMS physician fee schedule,$46.04 ,100% of CMS physician fee schedule,$51.49 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$51.49 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$46.04 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$127.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$54.91 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$46.04 ,$127.00 ,$127.00 
Mangham Clinic,Surgery,17003,Destruction of 2-14 pre-cancerous lesions,981,$11.00 ,$1.94 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$11.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$11.00 ,100% of CMS physician fee schedule,$12.22 ,100% of CMS physician fee schedule,$11.00 ,100% of CMS physician fee schedule,$1.94 ,100% of CMS physician fee schedule,$4.54 ,100% of CMS physician fee schedule,$1.94 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$1.94 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$4.54 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$11.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$2.64 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$1.94 ,$12.22 ,$11.00 
Mangham Clinic,Surgery,17110,Destruction of 1-14 common or plantar warts,981,$208.00 ,$62.94 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$208.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$208.00 ,100% of CMS physician fee schedule,$134.45 ,100% of CMS physician fee schedule,$208.00 ,100% of CMS physician fee schedule,$62.94 ,100% of CMS physician fee schedule,$63.45 ,100% of CMS physician fee schedule,$62.94 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$62.94 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$63.45 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$208.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$69.84 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$62.94 ,$208.00 ,$208.00 
Mangham Clinic,Surgery,17111,Destruction of >15 common or plantar warts,981,$248.00 ,$77.71 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$248.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$248.00 ,100% of CMS physician fee schedule,$132.31 ,100% of CMS physician fee schedule,$248.00 ,100% of CMS physician fee schedule,$77.71 ,100% of CMS physician fee schedule,$75.67 ,100% of CMS physician fee schedule,$77.71 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$77.71 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$75.67 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$248.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$86.58 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$75.67 ,$248.00 ,$248.00 
Mangham Clinic,Laboratory,36415,Collection of venous blood by venipuncture,981,$6.00 ,$8.57 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$6.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$6.00 ,100% of CMS physician fee schedule,$4.05 ,100% of CMS physician fee schedule,$6.00 ,100% of CMS physician fee schedule,$8.57 ,100% of CMS physician fee schedule,$2.15 ,100% of CMS physician fee schedule,$8.57 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$8.57 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$2.15 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$6.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$2.15 ,$8.57 ,$5.40 
Mangham Clinic,Surgery,51701,"Bladder catheter (eg, straight catheterization for residual urine), Insertion of non-indwelling",981,$137.00 ,$25.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$137.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$137.00 ,100% of CMS physician fee schedule,$68.34 ,100% of CMS physician fee schedule,$137.00 ,100% of CMS physician fee schedule,$25.00 ,100% of CMS physician fee schedule,$40.43 ,100% of CMS physician fee schedule,$25.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$25.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$40.43 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$137.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$51.87 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$25.00 ,$137.00 ,$137.00 
Mangham Clinic,Surgery,51702,"Insertion of temporary indwelling bladder catheter; simple (eg, Foley)",981,$179.00 ,$24.61 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$179.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$179.00 ,100% of CMS physician fee schedule,$140.12 ,100% of CMS physician fee schedule,$179.00 ,100% of CMS physician fee schedule,$24.61 ,100% of CMS physician fee schedule,$51.57 ,100% of CMS physician fee schedule,$24.61 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$24.61 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$51.57 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$179.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$51.87 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$24.61 ,$179.00 ,$179.00 
Mangham Clinic,Surgery,51720,Bladder instillation of anticarcinogenic agent (including retention time),981,$253.00 ,$42.94 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$253.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$253.00 ,100% of CMS physician fee schedule,$199.26 ,100% of CMS physician fee schedule,$253.00 ,100% of CMS physician fee schedule,$42.94 ,100% of CMS physician fee schedule,$80.19 ,100% of CMS physician fee schedule,$42.94 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$42.94 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$80.19 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$253.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$90.31 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$42.94 ,$253.00 ,$253.00 
Mangham Clinic,Surgery,69209,"Removal impacted cerumen using irrigation/lavage, unilateral",981,$23.00 ,$13.74 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$23.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$23.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,$23.00 ,100% of CMS physician fee schedule,$13.74 ,100% of CMS physician fee schedule,$8.66 ,100% of CMS physician fee schedule,$13.74 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$13.74 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$8.66 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$23.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$19.35 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$8.66 ,$23.00 ,$23.00 
Mangham Clinic,Surgery,69210,Removal of ear wax from one or both ears,981,$143.00 ,$32.08 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$143.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$143.00 ,100% of CMS physician fee schedule,$63.52 ,100% of CMS physician fee schedule,$143.00 ,100% of CMS physician fee schedule,$32.08 ,100% of CMS physician fee schedule,$30.33 ,100% of CMS physician fee schedule,$32.08 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$32.08 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$30.33 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$143.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$49.98 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$30.33 ,$143.00 ,$143.00 
Mangham Clinic,Laboratory,81003,Automated urinalysis test,981,$9.00 ,$2.25 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$9.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$9.00 ,100% of CMS physician fee schedule,$4.59 ,100% of CMS physician fee schedule,$9.00 ,100% of CMS physician fee schedule,$2.25 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,$2.25 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$2.25 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$9.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$2.25 ,$9.00 ,$8.10 
Mangham Clinic,Laboratory,81025,Urine pregnancy test,981,$20.00 ,$8.61 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$20.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$20.00 ,100% of CMS physician fee schedule,$12.95 ,100% of CMS physician fee schedule,$20.00 ,100% of CMS physician fee schedule,$8.61 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,$8.61 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$8.61 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$20.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$8.61 ,$20.00 ,$18.00 
Mangham Clinic,Laboratory,82272,"Blood, occult, qualitative, feces, single specimen",981,$10.00 ,$4.23 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$10.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$10.00 ,100% of CMS physician fee schedule,$6.66 ,100% of CMS physician fee schedule,$10.00 ,100% of CMS physician fee schedule,$4.23 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,$4.23 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$4.23 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$10.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$4.23 ,$10.00 ,$9.00 
Mangham Clinic,Laboratory,82962,"Glucose, blood by glucose monitoring device",981,$9.00 ,$3.28 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$9.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$9.00 ,100% of CMS physician fee schedule,$4.80 ,100% of CMS physician fee schedule,$9.00 ,100% of CMS physician fee schedule,$3.28 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,$3.28 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$3.28 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$9.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$3.28 ,$9.00 ,$8.10 
Mangham Clinic,Laboratory,83036,Blood test to measure average blood glucose levels for past 2-3 months,981,$26.00 ,$9.71 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$26.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$26.00 ,100% of CMS physician fee schedule,$19.86 ,100% of CMS physician fee schedule,$26.00 ,100% of CMS physician fee schedule,$9.71 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,$9.71 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$9.71 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$26.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$9.71 ,$26.00 ,$23.40 
Mangham Clinic,Laboratory,85025,"Complete blood cell count, with differential white blood cells, automated",981,$21.00 ,$7.77 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$21.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$21.00 ,100% of CMS physician fee schedule,$15.92 ,100% of CMS physician fee schedule,$21.00 ,100% of CMS physician fee schedule,$7.77 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,$7.77 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$7.77 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$21.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$7.77 ,$21.00 ,$18.90 
Mangham Clinic,Laboratory,85610,"Blood test, clotting time",981,$11.00 ,$4.29 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$11.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$11.00 ,100% of CMS physician fee schedule,$8.06 ,100% of CMS physician fee schedule,$11.00 ,100% of CMS physician fee schedule,$4.29 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,$4.29 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$4.29 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$11.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$4.29 ,$11.00 ,$9.90 
Mangham Clinic,Laboratory,86308,Mono - Heterophile antibodies; screening,981,$14.00 ,$5.18 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$14.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$14.00 ,100% of CMS physician fee schedule,$10.59 ,100% of CMS physician fee schedule,$14.00 ,100% of CMS physician fee schedule,$5.18 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,$5.18 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$5.18 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$14.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$5.18 ,$14.00 ,$12.60 
Mangham Clinic,Laboratory,86318,"Immunoassay for infectious agent antibody, qualitative or semiquantitative, single step method (eg, reagent strip)",981,$35.00 ,$18.09 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$35.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$35.00 ,100% of CMS physician fee schedule,$26.49 ,100% of CMS physician fee schedule,$35.00 ,100% of CMS physician fee schedule,$18.09 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,$18.09 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$18.09 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$35.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$18.09 ,$35.00 ,$31.50 
Mangham Clinic,Laboratory,87635,"COVID-19/SARS-CoV-2 RT-PCR, Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Cor",981,$103.00 ,$51.31 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$103.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$103.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,$103.00 ,100% of CMS physician fee schedule,$51.31 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,$51.31 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$51.31 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$103.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$51.31 ,$103.00 ,$92.70 
Mangham Clinic,Laboratory,87804,Flu test,981,$33.00 ,$16.55 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$33.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$33.00 ,100% of CMS physician fee schedule,$24.54 ,100% of CMS physician fee schedule,$33.00 ,100% of CMS physician fee schedule,$16.55 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,$16.55 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$16.55 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$33.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$16.55 ,$33.00 ,$29.70 
Mangham Clinic,Laboratory,87807,Test for RSV,981,$33.00 ,$13.10 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$33.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$33.00 ,100% of CMS physician fee schedule,$24.54 ,100% of CMS physician fee schedule,$33.00 ,100% of CMS physician fee schedule,$13.10 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,$13.10 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$13.10 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$33.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$13.10 ,$33.00 ,$29.70 
Mangham Clinic,Laboratory,87880,Test for strep A,981,$33.00 ,$16.53 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$33.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$33.00 ,100% of CMS physician fee schedule,$24.54 ,100% of CMS physician fee schedule,$33.00 ,100% of CMS physician fee schedule,$16.53 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,$16.53 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$16.53 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$33.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$16.53 ,$33.00 ,$29.70 
Mangham Clinic,Specialized Medicine,90471,Immunization administration by a medical assistant or nurse,981,$47.00 ,$18.61 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$47.00 ,100% of CMS physician fee schedule,$19.31 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$47.00 ,100% of CMS physician fee schedule,$30.87 ,100% of CMS physician fee schedule,$47.00 ,100% of CMS physician fee schedule,$18.61 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,$18.61 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$18.61 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$47.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$15.83 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$15.83 ,$47.00 ,$47.00 
Mangham Clinic,Specialized Medicine,90472,Administation of vaccine ( for each additional vaccine),981,$24.00 ,$13.48 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$24.00 ,100% of CMS physician fee schedule,$14.92 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$24.00 ,100% of CMS physician fee schedule,$15.84 ,100% of CMS physician fee schedule,$24.00 ,100% of CMS physician fee schedule,$13.48 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,$13.48 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$13.48 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$24.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$12.23 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$12.23 ,$24.00 ,$24.00 
Mangham Clinic,Specialized Medicine,90474,Immunization administered orally or nasally,981,$24.00 ,$11.11 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$24.00 ,100% of CMS physician fee schedule,$14.92 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$24.00 ,100% of CMS physician fee schedule,$15.84 ,100% of CMS physician fee schedule,$24.00 ,100% of CMS physician fee schedule,$11.11 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,$11.11 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$11.11 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$24.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$12.23 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$11.11 ,$24.00 ,$24.00 
Mangham Clinic,Vaccines,90620,"Meningococcal recombinant protein and outer membrane vesicle vaccine, serogroup B, 2 dose schedule, for intramuscular use",981,$198.00 ,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$198.00 ,100% of CMS physician fee schedule,$204.20 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$198.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,$198.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$198.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$198.00 ,$204.20 ,$198.00 
Mangham Clinic,Vaccines,90632,Hepatitis A vaccination for adults,981,$105.00 ,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$105.00 ,100% of CMS physician fee schedule,$65.91 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$105.00 ,100% of CMS physician fee schedule,$68.93 ,100% of CMS physician fee schedule,$105.00 ,100% of CMS physician fee schedule,$70.08 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,$70.08 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$70.08 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$105.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$65.91 ,$105.00 ,$105.00 
Mangham Clinic,Vaccines,90633,Hepatitis A vaccination for adolescents and children,981,$46.00 ,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$46.00 ,100% of CMS physician fee schedule,$37.81 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$46.00 ,100% of CMS physician fee schedule,$29.11 ,100% of CMS physician fee schedule,$46.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$46.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$29.11 ,$46.00 ,$46.00 
Mangham Clinic,Vaccines,90647,"Hemophilus influenza b vaccine (Hib), PRP-OMP conjugate (3 dose schedule), for intramuscular use",981,$38.00 ,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$38.00 ,100% of CMS physician fee schedule,$29.76 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$38.00 ,100% of CMS physician fee schedule,$29.03 ,100% of CMS physician fee schedule,$38.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$38.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$29.03 ,$38.00 ,$38.00 
Mangham Clinic,Vaccines,90651,"Human Papillomavirus vaccine types 6, 11, 16, 18, 31, 33, 45, 52, 58, nonavalent (HPV), 3 dose schedule, for intramuscular use",981,$280.00 ,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$280.00 ,100% of CMS physician fee schedule,$259.70 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$280.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,$280.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$280.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$259.70 ,$280.00 ,$280.00 
Mangham Clinic,Vaccines,90662,"influenza virus vaccine 65 and older, intradermal",981,$85.00 ,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$85.00 ,100% of CMS physician fee schedule,$60.98 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$85.00 ,100% of CMS physician fee schedule,$42.96 ,100% of CMS physician fee schedule,$85.00 ,100% of CMS physician fee schedule,$73.40 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,$73.40 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$73.40 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$85.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$42.96 ,$85.00 ,$85.00 
Mangham Clinic,Vaccines,90670,"Pneumococcal conjugate vaccine, 13 valent, for intramuscular use(Prevnar13-PFS)",981,$362.00 ,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$362.00 ,100% of CMS physician fee schedule,$253.15 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$362.00 ,100% of CMS physician fee schedule,$207.85 ,100% of CMS physician fee schedule,$362.00 ,100% of CMS physician fee schedule,$257.99 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,$257.99 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$257.99 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$362.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$207.85 ,$362.00 ,$362.00 
Mangham Clinic,Vaccines,90681,Rotavirus vaccination,981,$168.00 ,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$168.00 ,100% of CMS physician fee schedule,$141.85 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$168.00 ,100% of CMS physician fee schedule,$139.25 ,100% of CMS physician fee schedule,$168.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$168.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$139.25 ,$168.00 ,$168.00 
Mangham Clinic,Vaccines,90686,Flu shot-high dose for 2019-2020 flu season given by injection for people >65,981,$38.00 ,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$38.00 ,100% of CMS physician fee schedule,$19.58 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$38.00 ,100% of CMS physician fee schedule,$26.20 ,100% of CMS physician fee schedule,$38.00 ,100% of CMS physician fee schedule,$22.35 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,$22.35 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$22.35 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$38.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$19.58 ,$38.00 ,$38.00 
Mangham Clinic,Vaccines,90688,"Influenza virus vaccine, quadrivalent, split virus, when administered to individuals 3 years of age and older, for intramuscular use(multidose vial)",981,$36.00 ,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$36.00 ,100% of CMS physician fee schedule,$19.17 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$36.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,$36.00 ,100% of CMS physician fee schedule,$20.88 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,$20.88 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$20.88 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$36.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$19.17 ,$36.00 ,$36.00 
Mangham Clinic,Vaccines,90696,"DTaP-IPV - Diphtheria, tetanus toxoids, acellular pertussis vaccine and poliovirus vaccine, inactivated when administered to children 4 through 6 year",981,$106.00 ,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$106.00 ,100% of CMS physician fee schedule,$60.55 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$106.00 ,100% of CMS physician fee schedule,$66.84 ,100% of CMS physician fee schedule,$106.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$106.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$60.55 ,$106.00 ,$106.00 
Mangham Clinic,Vaccines,90700,"DTaP - Diphtheria, tetanus toxoids, and acellular pertussis vaccine, when administered to younger than 7 years, for intramuscular use",981,$50.00 ,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$50.00 ,100% of CMS physician fee schedule,$28.51 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$50.00 ,100% of CMS physician fee schedule,$21.89 ,100% of CMS physician fee schedule,$50.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$50.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$21.89 ,$50.00 ,$50.00 
Mangham Clinic,Vaccines,90707,"Measles, mumps and rubella vaccine",981,$87.00 ,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$87.00 ,100% of CMS physician fee schedule,$89.26 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$87.00 ,100% of CMS physician fee schedule,$65.01 ,100% of CMS physician fee schedule,$87.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$87.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$65.01 ,$89.26 ,$87.00 
Mangham Clinic,Vaccines,90710,"measlesMeasles, mumps, rubella and varicella vaccine",981,$290.00 ,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$290.00 ,100% of CMS physician fee schedule,$255.85 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$290.00 ,100% of CMS physician fee schedule,$181.58 ,100% of CMS physician fee schedule,$290.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$290.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$181.58 ,$290.00 ,$290.00 
Mangham Clinic,Vaccines,90714,"Tetanus and diphtheria toxoids (Td) adsorbed, preservative free, when administered to 7 years or older, for intramuscular use",981,$46.00 ,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$46.00 ,100% of CMS physician fee schedule,$26.63 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$46.00 ,100% of CMS physician fee schedule,$28.55 ,100% of CMS physician fee schedule,$46.00 ,100% of CMS physician fee schedule,$28.65 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,$28.65 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$28.65 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$46.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$26.63 ,$46.00 ,$46.00 
Mangham Clinic,Vaccines,90715,"Diphtheria, tetanus acellular, and pertussis vaccine for adults",981,$60.00 ,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$60.00 ,100% of CMS physician fee schedule,$36.41 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$60.00 ,100% of CMS physician fee schedule,$45.36 ,100% of CMS physician fee schedule,$60.00 ,100% of CMS physician fee schedule,$38.67 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,$38.67 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$38.67 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$60.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$36.41 ,$60.00 ,$60.00 
Mangham Clinic,Vaccines,90716,Varicella vaccine,981,$155.00 ,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$155.00 ,100% of CMS physician fee schedule,$154.58 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$155.00 ,100% of CMS physician fee schedule,$110.40 ,100% of CMS physician fee schedule,$155.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$155.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$110.40 ,$155.00 ,$155.00 
Mangham Clinic,Vaccines,90718,Vaccine - TD,981,$46.00 ,N/A,Not covered by Contract,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$46.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$46.00 ,100% of CMS physician fee schedule,$23.26 ,100% of CMS physician fee schedule,$46.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$46.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$23.26 ,$46.00 ,$46.00 
Mangham Clinic,Vaccines,90723,"DTP,IVP,HBV - Diphtheria, tetanus toxoids, acellular pertussis vaccine, Hepatitis B, and poliovirus",981,$100.00 ,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$100.00 ,100% of CMS physician fee schedule,$93.81 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$100.00 ,100% of CMS physician fee schedule,$91.83 ,100% of CMS physician fee schedule,$100.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$100.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$91.83 ,$100.00 ,$100.00 
Mangham Clinic,Vaccines,90734,meningococcal Meningococcal conjugate vaccine,981,$150.00 ,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$150.00 ,100% of CMS physician fee schedule,$146.21 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$150.00 ,100% of CMS physician fee schedule,$125.52 ,100% of CMS physician fee schedule,$150.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$150.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$125.52 ,$150.00 ,$150.00 
Mangham Clinic,Vaccines,90750,"Zoster (shingles) vaccine (HZV), recombinant, sub-unit, adjuvanted, for intramuscular injection",981,N/A,N/A,100% of Fee Schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$172.61 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,$162.09 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$162.09 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$162.09 ,$172.61 ,N/A
Mangham Clinic,Psychiatry,90791,"A diagnostic tool employed by a psychiatrist to diagnose problems with memory, thought processes, and behaviors",981,$261.00 ,$149.14 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$261.00 ,100% of CMS physician fee schedule,$145.30 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$261.00 ,100% of CMS physician fee schedule,$127.39 ,100% of CMS physician fee schedule,$261.00 ,100% of CMS physician fee schedule,$149.14 ,100% of CMS physician fee schedule,$102.85 ,100% of CMS physician fee schedule,$149.14 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$149.14 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$102.85 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$261.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$145.61 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$102.85 ,$261.00 ,$261.00 
Mangham Clinic,Psychiatry,90832,"Psychotherapy, 30 min",981,$127.00 ,$65.68 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$127.00 ,100% of CMS physician fee schedule,$63.22 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$127.00 ,100% of CMS physician fee schedule,$53.14 ,100% of CMS physician fee schedule,$127.00 ,100% of CMS physician fee schedule,$65.68 ,100% of CMS physician fee schedule,$94.54 ,100% of CMS physician fee schedule,$65.68 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$65.68 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$42.97 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$127.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$66.08 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$42.97 ,$127.00 ,$127.00 
Mangham Clinic,Psychiatry,90834,"Psychotherapy, 45 min",981,$169.00 ,$87.13 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$169.00 ,100% of CMS physician fee schedule,$96.90 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$169.00 ,100% of CMS physician fee schedule,$69.20 ,100% of CMS physician fee schedule,$169.00 ,100% of CMS physician fee schedule,$87.13 ,100% of CMS physician fee schedule,$123.56 ,100% of CMS physician fee schedule,$87.13 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$87.13 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$56.16 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$169.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$96.66 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$56.16 ,$169.00 ,$169.00 
Mangham Clinic,Psychiatry,90837,"Psychotherapy, 60 min",981,$254.00 ,$128.03 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$254.00 ,100% of CMS physician fee schedule,$146.58 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$254.00 ,100% of CMS physician fee schedule,$101.46 ,100% of CMS physician fee schedule,$254.00 ,100% of CMS physician fee schedule,$128.03 ,100% of CMS physician fee schedule,$181.27 ,100% of CMS physician fee schedule,$128.03 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$128.03 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$82.40 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$254.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$145.24 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$82.40 ,$254.00 ,$254.00 
Mangham Clinic,Vaccines,91300,SARSCOV2 30MCG 0.3ML IM Pfizer,981,N/A,N/A,100% of Fee Schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,N/A,N/A
Mangham Clinic,Vaccines,91301,"Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100",981,N/A,N/A,100% of Fee Schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,N/A,N/A
Mangham Clinic,Vaccines,91306,"Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100",981,N/A,N/A,100% of Fee Schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,N/A,N/A
Mangham Clinic,Specialized Medicine,92551,"Screening test, pure tone, air only",981,$36.00 ,$10.77 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$36.00 ,100% of CMS physician fee schedule,$15.32 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$36.00 ,100% of CMS physician fee schedule,$35.02 ,100% of CMS physician fee schedule,$36.00 ,100% of CMS physician fee schedule,$10.77 ,100% of CMS physician fee schedule,$14.50 ,100% of CMS physician fee schedule,$10.77 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$10.77 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$6.59 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$36.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$13.86 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$6.59 ,$36.00 ,$36.00 
Mangham Clinic,Specialized Medicine,93000,Routine EKG using at least 12 leads including interpretation and report,981,$49.00 ,$13.66 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$49.00 ,100% of CMS physician fee schedule,$29.16 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$49.00 ,100% of CMS physician fee schedule,$21.11 ,100% of CMS physician fee schedule,$49.00 ,100% of CMS physician fee schedule,$13.66 ,100% of CMS physician fee schedule,$30.18 ,100% of CMS physician fee schedule,$13.66 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$13.66 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$13.72 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$49.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$32.52 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$13.66 ,$49.00 ,$49.00 
Mangham Clinic,Specialized Medicine,93010,"Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only",981,$25.00 ,$7.92 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$25.00 ,100% of CMS physician fee schedule,$15.19 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$25.00 ,100% of CMS physician fee schedule,$11.25 ,100% of CMS physician fee schedule,$25.00 ,100% of CMS physician fee schedule,$7.92 ,100% of CMS physician fee schedule,$13.67 ,100% of CMS physician fee schedule,$7.92 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$7.92 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$6.22 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$25.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$16.95 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$6.22 ,$25.00 ,$25.00 
Mangham Clinic,Specialized Medicine,94640,Resp. - Treatment Pressurized or nonpressurized inhalation treatment,981,$33.00 ,$8.10 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$33.00 ,100% of CMS physician fee schedule,$23.34 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$33.00 ,100% of CMS physician fee schedule,$21.80 ,100% of CMS physician fee schedule,$33.00 ,100% of CMS physician fee schedule,$8.10 ,100% of CMS physician fee schedule,$18.52 ,100% of CMS physician fee schedule,$8.10 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$8.10 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$8.42 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$33.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$21.34 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$8.10 ,$33.00 ,$33.00 
Mangham Clinic,Specialized Medicine,95115,Allergy shot-1 shot,981,$16.00 ,$8.99 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$16.00 ,100% of CMS physician fee schedule,$8.47 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$16.00 ,100% of CMS physician fee schedule,$10.71 ,100% of CMS physician fee schedule,$16.00 ,100% of CMS physician fee schedule,$8.99 ,100% of CMS physician fee schedule,$14.50 ,100% of CMS physician fee schedule,$8.99 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$8.99 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$6.59 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$16.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$8.85 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$6.59 ,$16.00 ,$16.00 
Mangham Clinic,Therapy - DHS,96105,"Mini Mental Status Exam - Assessment of aphasia (includes assessment of expressive and receptive speech and language function, language comprehension,",981,$209.00 ,$94.34 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$209.00 ,100% of CMS physician fee schedule,$130.83 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$209.00 ,100% of CMS physician fee schedule,$94.11 ,100% of CMS physician fee schedule,$209.00 ,100% of CMS physician fee schedule,$94.34 ,100% of CMS physician fee schedule,$102.08 ,100% of CMS physician fee schedule,$94.34 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$94.34 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$46.40 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$209.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$133.59 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$46.40 ,$209.00 ,$209.00 
Mangham Clinic,Specialized Medicine,96110,Childhood test to screen for developmental disabilities,981,$25.00 ,$9.59 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$25.00 ,100% of CMS physician fee schedule,$10.89 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$25.00 ,100% of CMS physician fee schedule,$20.39 ,100% of CMS physician fee schedule,$25.00 ,100% of CMS physician fee schedule,$9.59 ,100% of CMS physician fee schedule,$10.00 ,100% of CMS physician fee schedule,$9.59 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$9.59 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$10.00 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$25.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$11.78 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$9.59 ,$25.00 ,$25.00 
Mangham Clinic,Specialized Medicine,96127,"Brief emotional/behavioral assessment (eg, depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentatio",981,$10.00 ,$4.24 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$10.00 ,100% of CMS physician fee schedule,$6.51 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$10.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,$10.00 ,100% of CMS physician fee schedule,$4.24 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,$4.24 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$4.24 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$10.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$6.38 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$4.24 ,$10.00 ,$10.00 
Mangham Clinic,Specialized Medicine,96360,"Intravenous infusion, hydration; initial, 31 minutes to 1 hour",981,$106.00 ,$29.59 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$106.00 ,100% of CMS physician fee schedule,$42.85 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$106.00 ,100% of CMS physician fee schedule,$68.93 ,100% of CMS physician fee schedule,$106.00 ,100% of CMS physician fee schedule,$29.59 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,$29.59 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$29.59 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$106.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$45.66 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$29.59 ,$106.00 ,$106.00 
Mangham Clinic,Specialized Medicine,96361,"Intravenous infusion, hydration; each additional hour (List separately in addition to code for primary procedure)",981,$28.00 ,$11.74 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$28.00 ,100% of CMS physician fee schedule,$15.41 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$28.00 ,100% of CMS physician fee schedule,$18.47 ,100% of CMS physician fee schedule,$28.00 ,100% of CMS physician fee schedule,$11.74 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,$11.74 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$11.74 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$28.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$16.42 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$11.74 ,$28.00 ,$28.00 
Mangham Clinic,Specialized Medicine,96372,Administration of injection,981,$47.00 ,$13.27 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$47.00 ,100% of CMS physician fee schedule,$19.31 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$47.00 ,100% of CMS physician fee schedule,$30.87 ,100% of CMS physician fee schedule,$47.00 ,100% of CMS physician fee schedule,$13.27 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,$13.27 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$13.27 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$47.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$13.27 ,$47.00 ,$47.00 
Mangham Clinic,Specialized Medicine,99050,"Services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed (eg, holidays, Saturd",981,$25.00 ,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$25.00 ,100% of CMS physician fee schedule,$17.90 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$25.00 ,100% of CMS physician fee schedule,$30.34 ,100% of CMS physician fee schedule,$25.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,$26.76 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$13.38 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$25.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$13.38 ,$30.34 ,$25.00 
Mangham Clinic,Supplies,99070,"Supplies and materials (except spectacles), provided by the physician over and above those usually included with the office visit or other services re",981,N/A,N/A,100% of Fee Schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$37.15 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$37.15 ,$37.15 ,N/A
Mangham Clinic,Office Visit,99201,Office - New Patient (level 1),981,$84.00 ,N/A,Not covered by Contract,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$84.00 ,100% of CMS physician fee schedule,$30.72 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$84.00 ,100% of CMS physician fee schedule,$48.87 ,100% of CMS physician fee schedule,$84.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$84.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$28.15 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$28.15 ,$84.00 ,$84.00 
Mangham Clinic,Office Visit,99202,"New patient office or other outpatient visit, typically 10 minutes",981,$144.00 ,$46.78 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$144.00 ,100% of CMS physician fee schedule,$57.73 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$144.00 ,100% of CMS physician fee schedule,$84.55 ,100% of CMS physician fee schedule,$144.00 ,100% of CMS physician fee schedule,$46.78 ,100% of CMS physician fee schedule,$42.77 ,100% of CMS physician fee schedule,$46.78 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$46.78 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$42.77 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$144.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$52.92 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$42.77 ,$144.00 ,$144.00 
Mangham Clinic,Office Visit,99203,"New patient office or other outpatient visit, typically 30 min",981,$209.00 ,$80.99 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$209.00 ,100% of CMS physician fee schedule,$88.01 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$209.00 ,100% of CMS physician fee schedule,$123.24 ,100% of CMS physician fee schedule,$209.00 ,100% of CMS physician fee schedule,$80.99 ,100% of CMS physician fee schedule,$62.18 ,100% of CMS physician fee schedule,$80.99 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$80.99 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$62.18 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$209.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$79.89 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$62.18 ,$209.00 ,$209.00 
Mangham Clinic,Office Visit,99204,"New patient office of other outpatient visit, typically 45 min",981,$319.00 ,$129.97 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$319.00 ,100% of CMS physician fee schedule,$148.55 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$319.00 ,100% of CMS physician fee schedule,$190.71 ,100% of CMS physician fee schedule,$319.00 ,100% of CMS physician fee schedule,$129.97 ,100% of CMS physician fee schedule,$96.56 ,100% of CMS physician fee schedule,$129.97 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$129.97 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$96.56 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$319.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$135.05 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$96.56 ,$319.00 ,$319.00 
Mangham Clinic,Office Visit,99205,"New patient office of other outpatient visit, typically 60 min",981,$403.00 ,$176.33 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$403.00 ,100% of CMS physician fee schedule,$193.55 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$403.00 ,100% of CMS physician fee schedule,$238.24 ,100% of CMS physician fee schedule,$403.00 ,100% of CMS physician fee schedule,$176.33 ,100% of CMS physician fee schedule,$122.19 ,100% of CMS physician fee schedule,$176.33 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$176.33 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$122.19 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$403.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$176.18 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$122.19 ,$403.00 ,$403.00 
Mangham Clinic,Office Visit,99211,Outpatient visit of established patient not requiring a physician,981,$38.00 ,$8.56 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$38.00 ,100% of CMS physician fee schedule,$10.49 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$38.00 ,100% of CMS physician fee schedule,$22.37 ,100% of CMS physician fee schedule,$38.00 ,100% of CMS physician fee schedule,$8.56 ,100% of CMS physician fee schedule,$12.36 ,100% of CMS physician fee schedule,$8.56 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$8.56 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$12.36 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$38.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$9.62 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$8.56 ,$38.00 ,$38.00 
Mangham Clinic,Office Visit,99212,Outpatient visit of established patient requiring a physician,981,$83.00 ,$34.65 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$83.00 ,100% of CMS physician fee schedule,$29.12 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$83.00 ,100% of CMS physician fee schedule,$49.26 ,100% of CMS physician fee schedule,$83.00 ,100% of CMS physician fee schedule,$34.65 ,100% of CMS physician fee schedule,$24.83 ,100% of CMS physician fee schedule,$34.65 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$34.65 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$24.83 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$83.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$26.69 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$24.83 ,$83.00 ,$83.00 
Mangham Clinic,Office Visit,99213,"Established patient office or other outpatient visit, typically 15 minutes",981,$141.00 ,$64.25 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$141.00 ,100% of CMS physician fee schedule,$58.16 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$141.00 ,100% of CMS physician fee schedule,$83.24 ,100% of CMS physician fee schedule,$141.00 ,100% of CMS physician fee schedule,$64.25 ,100% of CMS physician fee schedule,$41.53 ,100% of CMS physician fee schedule,$64.25 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$64.25 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$41.53 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$141.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$53.31 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$41.53 ,$141.00 ,$141.00 
Mangham Clinic,Office Visit,99214,"Established patient office or other outpatient visit, typically 25 minutes",981,$207.00 ,$94.83 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$207.00 ,100% of CMS physician fee schedule,$89.56 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$207.00 ,100% of CMS physician fee schedule,$123.15 ,100% of CMS physician fee schedule,$207.00 ,100% of CMS physician fee schedule,$94.83 ,100% of CMS physician fee schedule,$62.65 ,100% of CMS physician fee schedule,$94.83 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$94.83 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$62.65 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$207.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$82.11 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$62.65 ,$207.00 ,$207.00 
Mangham Clinic,Office Visit,99215,"Established patient office or other outpatient, visit typically 40 minutes",981,$282.00 ,$139.15 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$282.00 ,100% of CMS physician fee schedule,$126.74 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$282.00 ,100% of CMS physician fee schedule,$165.38 ,100% of CMS physician fee schedule,$282.00 ,100% of CMS physician fee schedule,$139.15 ,100% of CMS physician fee schedule,$84.93 ,100% of CMS physician fee schedule,$139.15 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$139.15 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$84.93 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$282.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$115.85 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$84.93 ,$282.00 ,$282.00 
Mangham Clinic,Office Visit,99381,Initial visit for an infant,981,$209.00 ,$71.92 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$209.00 ,100% of CMS physician fee schedule,$87.61 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$209.00 ,100% of CMS physician fee schedule,$138.50 ,100% of CMS physician fee schedule,$209.00 ,100% of CMS physician fee schedule,$71.92 ,100% of CMS physician fee schedule,$64.85 ,100% of CMS physician fee schedule,$71.92 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$71.92 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$64.85 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$209.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$76.49 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$64.85 ,$209.00 ,$209.00 
Mangham Clinic,Office Visit,99382,Initial visit for new patients 1-4 years old,981,$218.00 ,$76.50 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$218.00 ,100% of CMS physician fee schedule,$92.83 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$218.00 ,100% of CMS physician fee schedule,$157.10 ,100% of CMS physician fee schedule,$218.00 ,100% of CMS physician fee schedule,$76.50 ,100% of CMS physician fee schedule,$70.76 ,100% of CMS physician fee schedule,$76.50 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$76.50 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$70.76 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$218.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$81.80 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$70.76 ,$218.00 ,$218.00 
Mangham Clinic,Office Visit,99383,New preventative visit in new patients 5-11 years old,981,$228.00 ,$81.07 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$228.00 ,100% of CMS physician fee schedule,$98.92 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$228.00 ,100% of CMS physician fee schedule,$146.79 ,100% of CMS physician fee schedule,$228.00 ,100% of CMS physician fee schedule,$81.07 ,100% of CMS physician fee schedule,$70.28 ,100% of CMS physician fee schedule,$81.07 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$81.07 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$70.28 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$228.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$86.68 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$70.28 ,$228.00 ,$228.00 
Mangham Clinic,Office Visit,99384,New preventative visit in new patients 12-17 years old,981,$258.00 ,$95.28 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$258.00 ,100% of CMS physician fee schedule,$116.69 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$258.00 ,100% of CMS physician fee schedule,$159.90 ,100% of CMS physician fee schedule,$258.00 ,100% of CMS physician fee schedule,$95.28 ,100% of CMS physician fee schedule,$86.25 ,100% of CMS physician fee schedule,$95.28 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$95.28 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$86.25 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$258.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$101.56 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$86.25 ,$258.00 ,$258.00 
Mangham Clinic,Office Visit,99385,Initial new patient preventive medicine evaluation (18–39 years),981,$251.00 ,$91.68 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$251.00 ,100% of CMS physician fee schedule,$111.79 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$251.00 ,100% of CMS physician fee schedule,$167.89 ,100% of CMS physician fee schedule,$251.00 ,100% of CMS physician fee schedule,$91.68 ,100% of CMS physician fee schedule,$76.67 ,100% of CMS physician fee schedule,$91.68 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$91.68 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$76.67 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$251.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$97.28 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$76.67 ,$251.00 ,$251.00 
Mangham Clinic,Office Visit,99386,Initial new patient preventive medicine evaluation (40–64 years),981,$290.00 ,$111.10 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$290.00 ,100% of CMS physician fee schedule,$136.06 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$290.00 ,100% of CMS physician fee schedule,$197.91 ,100% of CMS physician fee schedule,$290.00 ,100% of CMS physician fee schedule,$111.10 ,100% of CMS physician fee schedule,$89.97 ,100% of CMS physician fee schedule,$111.10 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$111.10 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$89.97 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$290.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$118.47 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$89.97 ,$290.00 ,$290.00 
Mangham Clinic,Office Visit,99391,Periodic primary re-evaluation for an established infant patient,981,$188.00 ,$65.25 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$188.00 ,100% of CMS physician fee schedule,$79.91 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$188.00 ,100% of CMS physician fee schedule,$111.27 ,100% of CMS physician fee schedule,$188.00 ,100% of CMS physician fee schedule,$65.25 ,100% of CMS physician fee schedule,$54.11 ,100% of CMS physician fee schedule,$65.25 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$65.25 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$54.11 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$188.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$69.77 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$54.11 ,$188.00 ,$188.00 
Mangham Clinic,Office Visit,99392,Initial visit for new patients 1-4 years old,981,$202.00 ,$71.92 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$202.00 ,100% of CMS physician fee schedule,$87.61 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$202.00 ,100% of CMS physician fee schedule,$125.06 ,100% of CMS physician fee schedule,$202.00 ,100% of CMS physician fee schedule,$71.92 ,100% of CMS physician fee schedule,$60.50 ,100% of CMS physician fee schedule,$71.92 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$71.92 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$60.50 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$202.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$76.49 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$60.50 ,$202.00 ,$202.00 
Mangham Clinic,Office Visit,99393,New preventative visit in new patients 5-11 years old,981,$201.00 ,$71.92 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$201.00 ,100% of CMS physician fee schedule,$87.61 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$201.00 ,100% of CMS physician fee schedule,$123.57 ,100% of CMS physician fee schedule,$201.00 ,100% of CMS physician fee schedule,$71.92 ,100% of CMS physician fee schedule,$60.25 ,100% of CMS physician fee schedule,$71.92 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$71.92 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$60.25 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$201.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$76.49 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$60.25 ,$201.00 ,$201.00 
Mangham Clinic,Office Visit,99394,New preventative visit in new patients 12-17 years old,981,$220.00 ,$81.07 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$220.00 ,100% of CMS physician fee schedule,$98.92 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$220.00 ,100% of CMS physician fee schedule,$136.74 ,100% of CMS physician fee schedule,$220.00 ,100% of CMS physician fee schedule,$81.07 ,100% of CMS physician fee schedule,$66.40 ,100% of CMS physician fee schedule,$81.07 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$81.07 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$66.40 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$220.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$86.68 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$66.40 ,$220.00 ,$220.00 
Mangham Clinic,Office Visit,99395,Established patient periodic preventive medicine examination age 18-39 years,981,$225.00 ,$83.75 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$225.00 ,100% of CMS physician fee schedule,$101.72 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$225.00 ,100% of CMS physician fee schedule,$138.24 ,100% of CMS physician fee schedule,$225.00 ,100% of CMS physician fee schedule,$83.75 ,100% of CMS physician fee schedule,$66.65 ,100% of CMS physician fee schedule,$83.75 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$83.75 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$66.65 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$225.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$89.13 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$66.65 ,$225.00 ,$225.00 
Mangham Clinic,Office Visit,99396,Established patient periodic preventive medicine examination age 40-64 years,981,$241.00 ,$90.61 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$241.00 ,100% of CMS physician fee schedule,$110.60 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$241.00 ,100% of CMS physician fee schedule,$145.73 ,100% of CMS physician fee schedule,$241.00 ,100% of CMS physician fee schedule,$90.61 ,100% of CMS physician fee schedule,$73.03 ,100% of CMS physician fee schedule,$90.61 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$90.61 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$73.03 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$241.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$96.56 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$73.03 ,$241.00 ,$241.00 
Mangham Clinic,Office Visit,99397,Periodic primary re-evaluation for an established patient 65 and older,981,$258.00 ,$95.28 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$258.00 ,100% of CMS physician fee schedule,$116.69 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$258.00 ,100% of CMS physician fee schedule,$168.73 ,100% of CMS physician fee schedule,$258.00 ,100% of CMS physician fee schedule,$95.28 ,100% of CMS physician fee schedule,$81.88 ,100% of CMS physician fee schedule,$95.28 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$95.28 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$81.88 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$258.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$101.56 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$81.88 ,$258.00 ,$258.00 
Mangham Clinic,Pharmacology,99406,"Smoke cessation counseling, 3-10 minutes",981,$29.00 ,$11.57 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$29.00 ,100% of CMS physician fee schedule,$14.19 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$29.00 ,100% of CMS physician fee schedule,$16.18 ,100% of CMS physician fee schedule,$29.00 ,100% of CMS physician fee schedule,$11.57 ,100% of CMS physician fee schedule,$11.22 ,100% of CMS physician fee schedule,$11.57 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$11.57 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$11.22 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$29.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$13.01 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$11.22 ,$29.00 ,$29.00 
Mangham Clinic,Other E&M Code,99441,"Physician telephone patient service, 5-10 minutes of medical discussion",981,$27.00 ,$27.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$27.00 ,100% of CMS physician fee schedule,$14.48 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$27.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,$27.00 ,100% of CMS physician fee schedule,$27.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,$27.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$27.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$27.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$13.27 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$13.27 ,$27.00 ,$27.00 
Mangham Clinic,Other E&M Code,99495,"Transitional Care Management Services with the following required elements: Communication (direct contact, telephone, electronic) with the patient and",981,$314.00 ,$135.91 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$314.00 ,100% of CMS physician fee schedule,$125.75 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$314.00 ,100% of CMS physician fee schedule,$186.41 ,100% of CMS physician fee schedule,$314.00 ,100% of CMS physician fee schedule,$135.91 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,$135.91 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$135.91 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$314.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$114.95 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$114.95 ,$314.00 ,$314.00 
Mangham Clinic,Other E&M Code,99496,"Transitional Care Management Services with the following required elements: Communication (direct contact, telephone, electronic) with the patient and",981,$444.00 ,$185.32 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$444.00 ,100% of CMS physician fee schedule,$182.16 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$444.00 ,100% of CMS physician fee schedule,$263.72 ,100% of CMS physician fee schedule,$444.00 ,100% of CMS physician fee schedule,$185.32 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,$185.32 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$185.32 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$444.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$166.78 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$166.78 ,$444.00 ,$444.00 
Mangham Clinic,Other E&M Code,99499,CDL/DOT Physical/UA    Unlisted evaluation and management service,981,$85.00 ,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$85.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$85.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,$85.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$85.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$85.00 ,$85.00 ,$85.00 
Mangham Clinic,Office Visit,G0438,"Annual wellness visit; includes a personalized prevention plan of service (pps), initial visit",981,$331.00 ,$158.31 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$331.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$331.00 ,100% of CMS physician fee schedule,$218.58 ,100% of CMS physician fee schedule,$331.00 ,100% of CMS physician fee schedule,$158.31 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,$158.31 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$158.31 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$331.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$158.31 ,$331.00 ,$331.00 
Mangham Clinic,Office Visit,G0439,"Annual wellness visit, includes a personalized prevention plan of service (pps), subsequent visit",981,$223.00 ,$123.14 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$223.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$223.00 ,100% of CMS physician fee schedule,$144.98 ,100% of CMS physician fee schedule,$223.00 ,100% of CMS physician fee schedule,$123.14 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,$123.14 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$123.14 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$223.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$117.69 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$117.69 ,$223.00 ,$223.00 
Mangham Clinic,Injections/Rx Medication,J0696,"Ceftriaxone sodium, per 250 mg, Injection",981,$6.00 ,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$6.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$6.00 ,100% of CMS physician fee schedule,$0.97 ,100% of CMS physician fee schedule,$6.00 ,100% of CMS physician fee schedule,$0.47 ,100% of CMS physician fee schedule,$0.56 ,100% of CMS physician fee schedule,$0.47 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$0.47 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$0.56 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$6.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$0.47 ,$6.00 ,$6.00 
Mangham Clinic,Injections/Rx Medication,J0702,Injection to treat reaction to a drug,981,$12.00 ,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$12.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$12.00 ,100% of CMS physician fee schedule,$7.81 ,100% of CMS physician fee schedule,$12.00 ,100% of CMS physician fee schedule,$6.41 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,$6.41 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$6.41 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$12.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$6.41 ,$12.00 ,$12.00 
Mangham Clinic,Injections/Rx Medication,J1000,"Injection, depo-estradiol cypionate, up to 5 mg",981,$36.00 ,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$36.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$36.00 ,100% of CMS physician fee schedule,$1.77 ,100% of CMS physician fee schedule,$36.00 ,100% of CMS physician fee schedule,$32.67 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,$32.67 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$32.67 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$36.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$1.77 ,$36.00 ,$36.00 
Mangham Clinic,Injections/Rx Medication,J1000,"Injection, depo-estradiol cypionate, up to 5 mg",981,$36.00 ,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$36.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$36.00 ,100% of CMS physician fee schedule,$1.77 ,100% of CMS physician fee schedule,$36.00 ,100% of CMS physician fee schedule,$32.67 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,$32.67 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$32.67 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$36.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$1.77 ,$36.00 ,$36.00 
Mangham Clinic,Injections/Rx Medication,J1020,"Injection, methylprednisolone acetate, 20 mg",981,$10.00 ,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$10.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$10.00 ,100% of CMS physician fee schedule,$2.49 ,100% of CMS physician fee schedule,$10.00 ,100% of CMS physician fee schedule,$7.10 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,$7.10 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$7.10 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$10.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$2.49 ,$10.00 ,$10.00 
Mangham Clinic,Injections/Rx Medication,J1030,"Injection, methylprednisolone acetate, 40 mg",981,$11.00 ,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$11.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$11.00 ,100% of CMS physician fee schedule,$3.89 ,100% of CMS physician fee schedule,$11.00 ,100% of CMS physician fee schedule,$7.20 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,$7.20 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$7.20 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$11.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$3.89 ,$11.00 ,$11.00 
Mangham Clinic,Injections/Rx Medication,J1040,"Injection, methylprednisolone acetate, 80 mg",981,$21.00 ,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$21.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$21.00 ,100% of CMS physician fee schedule,$7.43 ,100% of CMS physician fee schedule,$21.00 ,100% of CMS physician fee schedule,$10.76 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,$10.76 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$10.76 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$21.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$7.43 ,$21.00 ,$21.00 
Mangham Clinic,Injections/Rx Medication,J1050,"Medroxyprogesterone acetate per 1 mg, Injection",981,$0.88 ,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$0.88 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$0.88 ,100% of CMS physician fee schedule,$0.33 ,100% of CMS physician fee schedule,$0.88 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,$0.57 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$0.57 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$0.88 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$0.33 ,$0.88 ,$0.88 
Mangham Clinic,Injections/Rx Medication,J1050,"Medroxyprogesterone acetate per 1 mg, Injection",981,$0.88 ,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$0.88 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$0.88 ,100% of CMS physician fee schedule,$0.33 ,100% of CMS physician fee schedule,$0.88 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,$0.57 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$0.57 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$0.88 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$0.33 ,$0.88 ,$0.88 
Mangham Clinic,Injections/Rx Medication,J1051,"Injection, medroxyprogesterone acetate, 50 mg",981,N/A,N/A,Not covered by Contract,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$4.68 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$4.68 ,$4.68 ,N/A
Mangham Clinic,Injections/Rx Medication,J1071,"Injection, testosterone cyopionate, 1 mg",981,$0.04 ,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$0.04 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$0.04 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,$0.04 ,100% of CMS physician fee schedule,$0.03 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,$0.03 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$0.03 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$0.04 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$0.03 ,$0.04 ,$0.04 
Mangham Clinic,Injections/Rx Medication,J1071,"Injection, testosterone cyopionate, 1 mg",981,$0.04 ,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$0.04 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$0.04 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,$0.04 ,100% of CMS physician fee schedule,$0.03 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,$0.03 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$0.03 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$0.04 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$0.03 ,$0.04 ,$0.04 
Mangham Clinic,Injections/Rx Medication,J1100,"Dexamethasone Na phosphate injection, 1 mg",981,$0.24 ,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$0.24 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$0.24 ,100% of CMS physician fee schedule,$0.16 ,100% of CMS physician fee schedule,$0.24 ,100% of CMS physician fee schedule,$0.13 ,100% of CMS physician fee schedule,$0.14 ,100% of CMS physician fee schedule,$0.13 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$0.13 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$0.14 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$0.24 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$0.13 ,$0.24 ,$0.24 
Mangham Clinic,Injections/Rx Medication,J1885,"Injection, ketorolac tromethamine, per 15 mg",981,$2.00 ,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$2.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$2.00 ,100% of CMS physician fee schedule,$0.50 ,100% of CMS physician fee schedule,$2.00 ,100% of CMS physician fee schedule,$0.61 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,$0.61 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$0.61 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$2.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$0.50 ,$2.00 ,$2.00 
Mangham Clinic,Injections/Rx Medication,J1940,"Injection, furosemide, up to 20 mg",981,$4.00 ,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$4.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$4.00 ,100% of CMS physician fee schedule,$0.92 ,100% of CMS physician fee schedule,$4.00 ,100% of CMS physician fee schedule,$0.58 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,$0.58 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$0.58 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$4.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$0.58 ,$4.00 ,$4.00 
Mangham Clinic,Injections/Rx Medication,J2010,"Injection, lincomycin HCl, up to 300 mg",981,$24.00 ,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$24.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$24.00 ,100% of CMS physician fee schedule,$11.29 ,100% of CMS physician fee schedule,$24.00 ,100% of CMS physician fee schedule,$11.04 ,100% of CMS physician fee schedule,$13.21 ,100% of CMS physician fee schedule,$11.04 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$11.04 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$13.21 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$24.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$11.04 ,$24.00 ,$24.00 
Mangham Clinic,Injections/Rx Medication,J2300,"Injection, nalbuphine HCl, per 10 mg",981,$5.00 ,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$5.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$5.00 ,100% of CMS physician fee schedule,$1.40 ,100% of CMS physician fee schedule,$5.00 ,100% of CMS physician fee schedule,$2.87 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,$2.87 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$2.87 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$5.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$1.40 ,$5.00 ,$5.00 
Mangham Clinic,Injections/Rx Medication,J2550,"Promethazine HCl injection, up to 50 mg",981,$4.00 ,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$4.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$4.00 ,100% of CMS physician fee schedule,$2.15 ,100% of CMS physician fee schedule,$4.00 ,100% of CMS physician fee schedule,$3.48 ,100% of CMS physician fee schedule,$2.32 ,100% of CMS physician fee schedule,$3.48 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$3.48 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$2.32 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$4.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$2.15 ,$4.00 ,$4.00 
Mangham Clinic,Injections/Rx Medication,J3301,"Injection, triamcinolone acetonide, per 10 mg",981,$4.00 ,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$4.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$4.00 ,100% of CMS physician fee schedule,$2.41 ,100% of CMS physician fee schedule,$4.00 ,100% of CMS physician fee schedule,$1.16 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,$1.16 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$1.16 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$4.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$1.16 ,$4.00 ,$4.00 
Mangham Clinic,Injections/Rx Medication,J3420,"Injection, vitamin B-12 cyanocobalamin, up to 1,000 mcg",981,$8.00 ,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$8.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$8.00 ,100% of CMS physician fee schedule,$3.44 ,100% of CMS physician fee schedule,$8.00 ,100% of CMS physician fee schedule,$1.33 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,$1.33 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$1.33 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$8.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$1.33 ,$8.00 ,$8.00 
Mangham Clinic,Injections/Rx Medication,J7030,"Infusion, normal saline solution, 1,000 cc",981,$4.00 ,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$4.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$4.00 ,100% of CMS physician fee schedule,$1.86 ,100% of CMS physician fee schedule,$4.00 ,100% of CMS physician fee schedule,$2.58 ,100% of CMS physician fee schedule,$2.73 ,100% of CMS physician fee schedule,$2.58 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$2.58 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$2.73 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$4.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$1.86 ,$4.00 ,$4.00 
Mangham Clinic,Injections/Rx Medication,J7040,"Infusion, normal saline solution, sterile (500 ml = 1 unit)",981,$2.00 ,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$2.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$2.00 ,100% of CMS physician fee schedule,$0.92 ,100% of CMS physician fee schedule,$2.00 ,100% of CMS physician fee schedule,$1.29 ,100% of CMS physician fee schedule,$1.37 ,100% of CMS physician fee schedule,$1.29 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$1.29 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$1.37 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$2.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$0.92 ,$2.00 ,$2.00 
Mangham Clinic,Injections/Rx Medication,J7120,"Ringer's lactate infusion, up to 1,000 cc",981,$5.00 ,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$5.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$5.00 ,100% of CMS physician fee schedule,$1.58 ,100% of CMS physician fee schedule,$5.00 ,100% of CMS physician fee schedule,$2.45 ,100% of CMS physician fee schedule,$2.49 ,100% of CMS physician fee schedule,$2.45 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$2.45 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$2.49 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$5.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$1.58 ,$5.00 ,$5.00 
Mangham Clinic,Specialized Medicine,J7307,"Etonogestrel (contraceptive) implant system, including implant and supplies",981,"$1,111.00 ",N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,"$1,111.00 ",100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,"$1,111.00 ",100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,"$1,111.00 ",100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,$981.56 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$981.56 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,"$1,111.00 ",100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$981.56 ,"$1,111.00 ","$1,111.00 "
Mangham Clinic,Injections/Rx Medication,J7613,"Albuterol, inhalation solution, FDA-approved final product, noncompounded, administered through DME, unit dose, 1 mg",981,$0.10 ,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$0.10 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$0.10 ,100% of CMS physician fee schedule,$0.07 ,100% of CMS physician fee schedule,$0.10 ,100% of CMS physician fee schedule,$0.04 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,$0.04 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$0.04 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$0.10 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$0.04 ,$0.10 ,$0.10 
Mangham Clinic,Injections/Rx Medication,J7614,"Levalbuterol, inhalation solution, FDA-approved final product, noncompounded, administered through DME, unit dose, 0.5 mg",981,$0.14 ,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$0.14 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$0.14 ,100% of CMS physician fee schedule,$0.12 ,100% of CMS physician fee schedule,$0.14 ,100% of CMS physician fee schedule,$0.05 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,$0.05 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$0.05 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$0.14 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$0.05 ,$0.14 ,$0.14 
Mangham Clinic,Injections/Rx Medication,J7620,"Albuterol, up to 2.5 mg and ipratropium bromide, up to 0.5 mg, FDA-approved final product, noncompounded, administered through DME",981,$0.34 ,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$0.34 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$0.34 ,100% of CMS physician fee schedule,$0.26 ,100% of CMS physician fee schedule,$0.34 ,100% of CMS physician fee schedule,$0.15 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,$0.15 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$0.15 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$0.34 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$0.15 ,$0.34 ,$0.34 
Mangham Clinic,Injections/Rx Medication,J7633,"Budesonide, inhalation solution, FDA-approved final product, noncompounded, administered through DME, concentrated form, per 0.25 milligram",981,$6.00 ,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$6.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$6.00 ,100% of CMS physician fee schedule,$0.05 ,100% of CMS physician fee schedule,$6.00 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,$4.75 ,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$4.75 ,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,$6.00 ,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of CMS physician fee schedule,N/A,Not reimbursable. No contract for Physician,$0.05 ,$6.00 ,$6.00 
Inpatient Medical Services,INPATIENT PROCEDURES,460,Spinal fusion except cervical,111,"$54,845.93 ","$26,362.00 ",Custom DRG with base of 7000,"$22,584.57 ",100% of Medicare ,"$1,406.00 ","Per day rate of 892.50 for Med DRGS, and 1406 for Surg DRGs",N/A,Not seperately reimbursable,"$26,633.15 ",100% of IP Carve Out,"$22,584.57 ",100% of Medicare ,"$1,200.00 ",Per day rate of 1200 for med/surg DRGs,"$1,093.00 ",Per day rate of 1093 for Inpatient rev codes,"$38,393.77 ",170% of Medicare CMS MS-DRG,"$1,370.00 ","per day rate of 1120 for Med DRGS, and 1370 for Surg DRGs","$1,173.72 ",per day rate of 1173.72 ,"$39,523.00 ",175% of Medicare CMS MS-DRG,"$39,523.00 ",100% of Medicare CMS MS-DRG,"$43,876.74 ",80% of total billed charges,"$28,230.71 ",140% of Medicare CMS MS-DRG,"$49,403.75 ",100% of IP Carve Out,"$1,173.72 ",per day rate of 1173.72 ,"$1,173.72 ",per day rate of 1173.72 ,"$39,523.00 ",100% of Medicare CMS MS-DRG,"$3,259.00 ",rate of 3259 for one day stays with rev code 100-214,"$22,584.57 ",100% of Medicare CMS MS-DRG,"$22,584.57 ",100% of Medicare CMS MS-DRG,"$22,584.57 ",100% of Medicare CMS MS-DRG,"$22,584.57 ",100% of Medicare CMS MS-DRG,N/A,40% of total billed charges,"$1,654.00 ","per day rate of 1050 for Med DRGs, and 1654 for Surg DRGs","$43,876.74 ","$43,876.74 ","$54,845.93 "
Inpatient Medical Services,INPATIENT PROCEDURES,470,Major joint replacement or reattachment of lower extremity,111,"$27,260.18 ","$13,383.30 ",Custom DRG with base of 7000,"$11,617.97 ",100% of Medicare ,"$1,406.00 ","Per day rate of 892.50 for Med DRGS, and 1406 for Surg DRGs",N/A,Not seperately reimbursable,"$13,520.96 ",100% of IP Carve Out,"$11,617.97 ",100% of Medicare ,"$1,200.00 ",Per day rate of 1200 for med/surg DRGs,"$1,093.00 ",Per day rate of 1093 for Inpatient rev codes,"$19,750.55 ",170% of Medicare CMS MS-DRG,"$1,370.00 ","per day rate of 1120 for Med DRGS, and 1370 for Surg DRGs","$1,173.72 ",per day rate of 1173.72 ,"$20,331.45 ",175% of Medicare CMS MS-DRG,"$20,331.45 ",100% of Medicare CMS MS-DRG,"$21,808.14 ",80% of total billed charges,"$14,522.46 ",140% of Medicare CMS MS-DRG,"$25,414.31 ",100% of IP Carve Out,"$1,173.72 ",per day rate of 1173.72 ,"$1,173.72 ",per day rate of 1173.72 ,"$20,331.45 ",100% of Medicare CMS MS-DRG,"$3,259.00 ",rate of 3259 for one day stays with rev code 100-214,"$11,617.97 ",100% of Medicare CMS MS-DRG,"$11,617.97 ",100% of Medicare CMS MS-DRG,"$11,617.97 ",100% of Medicare CMS MS-DRG,"$11,617.97 ",100% of Medicare CMS MS-DRG,N/A,40% of total billed charges,"$1,654.00 ","per day rate of 1050 for Med DRGs, and 1654 for Surg DRGs","$21,808.14 ","$21,808.14 ","$27,260.18 "
Inpatient Medical Services,INPATIENT PROCEDURES,473,Cervical spinal fusion,111,"$34,793.98 ","$17,745.70 ",Custom DRG with base of 7000,"$15,192.20 ",100% of Medicare ,"$1,406.00 ","Per day rate of 892.50 for Med DRGS, and 1406 for Surg DRGs",N/A,Not seperately reimbursable,"$17,928.23 ",100% of IP Carve Out,"$15,192.20 ",100% of Medicare ,"$1,200.00 ",Per day rate of 1200 for med/surg DRGs,"$1,093.00 ",Per day rate of 1093 for Inpatient rev codes,"$25,826.74 ",170% of Medicare CMS MS-DRG,"$1,370.00 ","per day rate of 1120 for Med DRGS, and 1370 for Surg DRGs","$1,173.72 ",per day rate of 1173.72 ,"$26,586.35 ",175% of Medicare CMS MS-DRG,"$26,586.35 ",100% of Medicare CMS MS-DRG,"$27,835.18 ",80% of total billed charges,"$18,990.25 ",140% of Medicare CMS MS-DRG,"$33,232.94 ",100% of IP Carve Out,"$1,173.72 ",per day rate of 1173.72 ,"$1,173.72 ",per day rate of 1173.72 ,"$26,586.35 ",100% of Medicare CMS MS-DRG,"$3,259.00 ",rate of 3259 for one day stays with rev code 100-214,"$15,192.20 ",100% of Medicare CMS MS-DRG,"$15,192.20 ",100% of Medicare CMS MS-DRG,"$15,192.20 ",100% of Medicare CMS MS-DRG,"$15,192.20 ",100% of Medicare CMS MS-DRG,N/A,40% of total billed charges,"$1,654.00 ","per day rate of 1050 for Med DRGs, and 1654 for Surg DRGs","$27,835.18 ","$27,835.18 ","$34,793.98 "
Inpatient Medical Services,INPATIENT PROCEDURES,743,Uterine and adnexa procedures for non-malignancy,111,"$15,905.45 ","$8,194.20 ",Custom DRG with base of 7000,"$7,174.41 ",100% of Medicare ,"$1,406.00 ","Per day rate of 892.50 for Med DRGS, and 1406 for Surg DRGs",N/A,Not seperately reimbursable,"$8,278.48 ",100% of IP Carve Out,"$7,174.41 ",100% of Medicare ,"$1,200.00 ",Per day rate of 1200 for med/surg DRGs,"$1,093.00 ",Per day rate of 1093 for Inpatient rev codes,"$12,196.50 ",170% of Medicare CMS MS-DRG,"$1,370.00 ","per day rate of 1120 for Med DRGS, and 1370 for Surg DRGs","$1,173.72 ",per day rate of 1173.72 ,"$12,555.22 ",175% of Medicare CMS MS-DRG,"$12,555.22 ",100% of Medicare CMS MS-DRG,"$12,724.36 ",80% of total billed charges,"$8,968.01 ",140% of Medicare CMS MS-DRG,"$15,694.03 ",100% of IP Carve Out,"$1,173.72 ",per day rate of 1173.72 ,"$1,173.72 ",per day rate of 1173.72 ,"$12,555.22 ",100% of Medicare CMS MS-DRG,"$3,259.00 ",rate of 3259 for one day stays with rev code 100-214,"$7,174.41 ",100% of Medicare CMS MS-DRG,"$7,174.41 ",100% of Medicare CMS MS-DRG,"$7,174.41 ",100% of Medicare CMS MS-DRG,"$7,174.41 ",100% of Medicare CMS MS-DRG,N/A,40% of total billed charges,"$1,654.00 ","per day rate of 1050 for Med DRGs, and 1654 for Surg DRGs","$12,724.36 ","$12,724.36 ","$15,905.45 "
Outpatient Medical Services,BEHAVIORAL,90846,"Family psychotherapy, not including patient, 50 min",900,N/A,$204.54 ,100% of APC Rate,$127.83 ,100% of Medicare OPPS,N/A,Not covered by Contract,N/A,Not reimbursable. No contract for Physician,$172.39 ,139.08% of custom fee schedule,$127.83 ,100% of Medicare OPPS,N/A,Not covered by Contract,N/A,Not covered by Contract,$217.32 ,170% of Medicare OPPS,$274.85 ,215% of Medicare OPPS,N/A,Not covered by Contract,$223.71 ,175% of Medicare OPPS,$127.83 ,100% of Medicare OPPS,N/A,Not covered by Contract,$178.97 ,140% of Medicare OPPS,$159.79 ,125% of Medicare OPPS,N/A,Not covered by Contract,N/A,Not covered by Contract,$127.83 ,100% of Medicare OPPS,$256.00 ,100% of UHC Case Rate,$127.83 ,100% of Medicare OPPS,$127.83 ,100% of Medicare OPPS,$223.71 ,100% of Medicare OPPS,$127.83 ,100% of Medicare OPPS,$153.74 ,100% of custom fee schedule,N/A,Not covered by Contract,$127.83 ,$274.85 ,N/A
Outpatient Medical Services,BEHAVIORAL,90847,"Family psychotherapy, including patient, 50 min",900,N/A,$204.54 ,100% of APC Rate,$127.83 ,100% of Medicare OPPS,N/A,Not covered by Contract,N/A,Not reimbursable. No contract for Physician,$172.39 ,139.08% of custom fee schedule,$127.83 ,100% of Medicare OPPS,N/A,Not covered by Contract,N/A,Not covered by Contract,$217.32 ,170% of Medicare OPPS,$274.85 ,215% of Medicare OPPS,N/A,Not covered by Contract,$223.71 ,175% of Medicare OPPS,$127.83 ,100% of Medicare OPPS,N/A,Not covered by Contract,$178.97 ,140% of Medicare OPPS,$159.79 ,125% of Medicare OPPS,N/A,Not covered by Contract,N/A,Not covered by Contract,$127.83 ,100% of Medicare OPPS,$256.00 ,100% of UHC Case Rate,$127.83 ,100% of Medicare OPPS,$127.83 ,100% of Medicare OPPS,$223.71 ,100% of Medicare OPPS,$127.83 ,100% of Medicare OPPS,$153.74 ,100% of custom fee schedule,N/A,Not covered by Contract,$127.83 ,$274.85 ,N/A
Outpatient Medical Services,BEHAVIORAL,90853,Group psychotherapy,900,N/A,$106.48 ,100% of APC Rate,$66.54 ,100% of Medicare OPPS,N/A,Not covered by Contract,N/A,Not reimbursable. No contract for Physician,$100.05 ,139.08% of custom fee schedule,$66.54 ,100% of Medicare OPPS,N/A,Not covered by Contract,N/A,Not covered by Contract,$113.13 ,170% of Medicare OPPS,$143.08 ,215% of Medicare OPPS,N/A,Not covered by Contract,$116.46 ,175% of Medicare OPPS,$66.54 ,100% of Medicare OPPS,N/A,Not covered by Contract,$93.17 ,140% of Medicare OPPS,$83.18 ,125% of Medicare OPPS,N/A,Not covered by Contract,N/A,Not covered by Contract,$66.54 ,100% of Medicare OPPS,$256.00 ,100% of UHC Case Rate,$66.54 ,100% of Medicare OPPS,$66.54 ,100% of Medicare OPPS,$116.46 ,100% of Medicare OPPS,$66.54 ,100% of Medicare OPPS,$82.49 ,100% of custom fee schedule,N/A,Not covered by Contract,$66.54 ,$256.00 ,N/A
Outpatient Medical Services,OFFICE VISIT,99243,"Patient office consultation, typically 40 min",761,N/A,N/A,Not covered by Contract,N/A,100% of Medicare OPPS,N/A,Not covered by Contract,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of Medicare OPPS,N/A,Not covered by Contract,N/A,Not covered by Contract,N/A,170% of Medicare OPPS,N/A,215% of Medicare OPPS,N/A,Not covered by Contract,N/A,175% of Medicare OPPS,N/A,100% of Medicare OPPS,N/A,Not covered by Contract,N/A,140% of Medicare OPPS,N/A,125% of Medicare OPPS,N/A,Not covered by Contract,N/A,Not covered by Contract,N/A,100% of Medicare OPPS,N/A,Not covered by Contract,N/A,100% of Medicare OPPS,N/A,100% of Medicare OPPS,N/A,100% of Medicare OPPS,N/A,100% of Medicare OPPS,N/A,Not covered by Contract,N/A,Not covered by Contract,N/A,N/A,N/A
Outpatient Medical Services,OFFICE VISIT,99244,"Patient office consultation, typically 60 min",761,N/A,N/A,Not covered by Contract,N/A,100% of Medicare OPPS,N/A,Not covered by Contract,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of Medicare OPPS,N/A,Not covered by Contract,N/A,Not covered by Contract,N/A,170% of Medicare OPPS,N/A,215% of Medicare OPPS,N/A,Not covered by Contract,N/A,175% of Medicare OPPS,N/A,100% of Medicare OPPS,N/A,Not covered by Contract,N/A,140% of Medicare OPPS,N/A,125% of Medicare OPPS,N/A,Not covered by Contract,N/A,Not covered by Contract,N/A,100% of Medicare OPPS,N/A,Not covered by Contract,N/A,100% of Medicare OPPS,N/A,100% of Medicare OPPS,N/A,100% of Medicare OPPS,N/A,100% of Medicare OPPS,N/A,Not covered by Contract,N/A,Not covered by Contract,N/A,N/A,N/A
Outpatient Medical Services,LABORATORY,80055,Obstetric blood test panel,300,N/A,$76.49 ,160% of Fee Schedule,$47.81 ,100% of Medicare OPPS,N/A,Not covered by Contract,N/A,Not reimbursable. No contract for Physician,$82.09 ,139.08% of custom fee schedule,$47.81 ,100% of Medicare OPPS,N/A,Not covered by Contract,N/A,Not covered by Contract,$81.27 ,170% of Medicare OPPS,$102.79 ,215% of Medicare OPPS,$24.01 ,12.84% of total billed charges,$83.66 ,175% of Medicare OPPS,$47.81 ,100% of Medicare OPPS,N/A,Not covered by Contract,$66.93 ,140% of Medicare OPPS,$59.76 ,125% of Medicare OPPS,$24.01 ,12.84% of LA Medicaid fee schedule,$24.01 ,12.84% of LA Medicaid fee schedule,$47.81 ,100% of Medicare OPPS,N/A,Not covered by Contract,$47.81 ,100% of Medicare OPPS,$47.81 ,100% of Medicare OPPS,$83.66 ,100% of Medicare OPPS,$47.81 ,100% of Medicare OPPS,$55.74 ,100% of custom fee schedule,N/A,Not covered by Contract,$24.01 ,$102.79 ,N/A
Outpatient Medical Services,LABORATORY,81000,Manual urinalysis test with examination using microscope,300,N/A,$6.43 ,160% of Fee Schedule,$4.01 ,100% of Medicare OPPS,N/A,Not covered by Contract,N/A,Not reimbursable. No contract for Physician,$5.59 ,139.08% of custom fee schedule,$4.01 ,100% of Medicare OPPS,N/A,Not covered by Contract,N/A,Not covered by Contract,$6.83 ,170% of Medicare OPPS,$8.64 ,215% of Medicare OPPS,$3.94 ,12.84% of total billed charges,$7.03 ,175% of Medicare OPPS,$4.01 ,100% of Medicare OPPS,N/A,Not covered by Contract,$5.62 ,140% of Medicare OPPS,$5.02 ,125% of Medicare OPPS,$3.94 ,12.84% of LA Medicaid fee schedule,$3.94 ,12.84% of LA Medicaid fee schedule,$4.01 ,100% of Medicare OPPS,$4.63 ,100% of fee schedule,$4.01 ,100% of Medicare OPPS,$4.01 ,100% of Medicare OPPS,$7.03 ,100% of Medicare OPPS,$4.01 ,100% of Medicare OPPS,$6.00 ,100% of custom fee schedule,N/A,Not covered by Contract,$3.94 ,$8.64 ,N/A
Outpatient Medical Services,LABORATORY,81002,Manual urinalysis test with examination without using microscope,300,N/A,$5.56 ,160% of Fee Schedule,$3.48 ,100% of Medicare OPPS,N/A,Not covered by Contract,N/A,Not reimbursable. No contract for Physician,$4.84 ,139.08% of custom fee schedule,$3.48 ,100% of Medicare OPPS,N/A,Not covered by Contract,N/A,Not covered by Contract,$5.91 ,170% of Medicare OPPS,$7.48 ,215% of Medicare OPPS,$3.28 ,12.84% of total billed charges,$6.09 ,175% of Medicare OPPS,$3.48 ,100% of Medicare OPPS,N/A,Not covered by Contract,$4.87 ,140% of Medicare OPPS,$4.35 ,125% of Medicare OPPS,$3.28 ,12.84% of LA Medicaid fee schedule,$3.28 ,12.84% of LA Medicaid fee schedule,$3.48 ,100% of Medicare OPPS,$3.74 ,100% of fee schedule,$3.48 ,100% of Medicare OPPS,$3.48 ,100% of Medicare OPPS,$6.09 ,100% of Medicare OPPS,$3.48 ,100% of Medicare OPPS,$4.85 ,100% of custom fee schedule,N/A,Not covered by Contract,$3.28 ,$7.48 ,N/A
Outpatient Medical Services,RADIOLOGY,70450,CT scan head or brain without dye,350,N/A,$150.03 ,100% of APC Rate,$93.78 ,100% of Medicare OPPS,N/A,Not covered by Contract,N/A,Not reimbursable. No contract for Physician,$159.19 ,139.08% of custom fee schedule,$93.78 ,100% of Medicare OPPS,N/A,Not covered by Contract,N/A,Not covered by Contract,$159.41 ,170% of Medicare OPPS,$201.62 ,215% of Medicare OPPS,N/A,Not covered by Contract,$164.11 ,175% of Medicare OPPS,$93.78 ,100% of Medicare OPPS,N/A,Not covered by Contract,$131.28 ,140% of Medicare OPPS,$117.22 ,125% of Medicare OPPS,N/A,Not covered by Contract,N/A,Not covered by Contract,$93.78 ,100% of Medicare OPPS,"$1,550.00 ",100% of UHC Case Rate,$93.78 ,100% of Medicare OPPS,$93.78 ,100% of Medicare OPPS,$164.11 ,100% of Medicare OPPS,$93.78 ,100% of Medicare OPPS,$150.45 ,100% of custom fee schedule,N/A,Not covered by Contract,$93.78 ,"$1,550.00 ",N/A
Outpatient Medical Services,RADIOLOGY,72110,"X-ray of lower and sacral spine, minimum of 4 views",320,N/A,$150.04 ,100% of APC Rate,$93.77 ,100% of Medicare OPPS,N/A,Not covered by Contract,N/A,Not reimbursable. No contract for Physician,$159.19 ,139.08% of custom fee schedule,$93.77 ,100% of Medicare OPPS,N/A,Not covered by Contract,N/A,Not covered by Contract,$159.42 ,170% of Medicare OPPS,$201.62 ,215% of Medicare OPPS,N/A,Not covered by Contract,$164.11 ,175% of Medicare OPPS,$93.77 ,100% of Medicare OPPS,N/A,Not covered by Contract,$131.29 ,140% of Medicare OPPS,$117.22 ,125% of Medicare OPPS,N/A,Not covered by Contract,N/A,Not covered by Contract,$93.77 ,100% of Medicare OPPS,$128.00 ,100% of UHC Case Rate,$93.77 ,100% of Medicare OPPS,$93.77 ,100% of Medicare OPPS,$164.11 ,100% of Medicare OPPS,$93.77 ,100% of Medicare OPPS,$108.12 ,100% of custom fee schedule,N/A,Not covered by Contract,$93.77 ,$201.62 ,N/A
Outpatient Medical Services,RADIOLOGY,76805,Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus,402,N/A,$150.03 ,100% of APC Rate,$93.78 ,100% of Medicare OPPS,N/A,Not covered by Contract,N/A,Not reimbursable. No contract for Physician,$159.19 ,139.08% of custom fee schedule,$93.78 ,100% of Medicare OPPS,N/A,Not covered by Contract,N/A,Not covered by Contract,$159.41 ,170% of Medicare OPPS,$201.62 ,215% of Medicare OPPS,N/A,Not covered by Contract,$164.11 ,175% of Medicare OPPS,$93.78 ,100% of Medicare OPPS,N/A,Not covered by Contract,$131.28 ,140% of Medicare OPPS,$117.22 ,125% of Medicare OPPS,N/A,Not covered by Contract,N/A,Not covered by Contract,$93.78 ,100% of Medicare OPPS,$452.00 ,100% of UHC Case Rate,$93.78 ,100% of Medicare OPPS,$93.78 ,100% of Medicare OPPS,$164.11 ,100% of Medicare OPPS,$93.78 ,100% of Medicare OPPS,$160.08 ,100% of custom fee schedule,N/A,Not covered by Contract,$93.78 ,$452.00 ,N/A
Outpatient Medical Services,OUTPATIENT PROCEDURES,45391,Ultrasound examination of lower large bowel using an endoscope,360,N/A,"$1,520.26 ",100% of APC Rate,$950.16 ,100% of Medicare OPPS,N/A,Not covered by Contract,N/A,Not reimbursable. No contract for Physician,"$1,302.33 ",139.08% of ASC,$950.16 ,100% of Medicare OPPS,N/A,Not covered by Contract,N/A,Not covered by Contract,"$1,615.27 ",170% of Medicare OPPS,"$2,042.85 ",215% of Medicare OPPS,N/A,Not covered by Contract,"$1,662.79 ",175% of Medicare OPPS,$950.16 ,100% of Medicare OPPS,N/A,Not covered by Contract,"$1,330.23 ",140% of Medicare OPPS,"$1,187.70 ",125% of Medicare OPPS,N/A,Not covered by Contract,N/A,Not covered by Contract,$950.16 ,100% of Medicare OPPS,"$1,129.00 ",100% of ASC Grouper,$950.16 ,100% of Medicare OPPS,$950.16 ,100% of Medicare OPPS,"$1,662.79 ",100% of Medicare OPPS,$950.16 ,100% of Medicare OPPS,$876.53 ,100% of custom fee schedule,N/A,Not covered by Contract,$876.53 ,"$2,042.85 ",N/A
Outpatient Medical Services,OUTPATIENT PROCEDURES,59400,Obstetrical pre- and postpartum care and vaginal delivery,720,N/A,N/A,Not covered by Contract,N/A,100% of Medicare OPPS,N/A,Not covered by Contract,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of Medicare OPPS,N/A,Not covered by Contract,N/A,Not covered by Contract,N/A,170% of Medicare OPPS,N/A,215% of Medicare OPPS,N/A,Not covered by Contract,N/A,175% of Medicare OPPS,N/A,100% of Medicare OPPS,N/A,Not covered by Contract,N/A,140% of Medicare OPPS,N/A,125% of Medicare OPPS,N/A,Not covered by Contract,N/A,Not covered by Contract,N/A,100% of Medicare OPPS,N/A,Not covered by Contract,N/A,100% of Medicare OPPS,N/A,100% of Medicare OPPS,N/A,100% of Medicare OPPS,N/A,100% of Medicare OPPS,"$1,230.08 ",100% of custom fee schedule,N/A,Not covered by Contract,"$1,230.08 ","$1,230.08 ",N/A
Outpatient Medical Services,OUTPATIENT PROCEDURES,59510,Cesarean delivery with pre- and post-delivery care,720,N/A,N/A,Not covered by Contract,N/A,100% of Medicare OPPS,N/A,Not covered by Contract,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of Medicare OPPS,N/A,Not covered by Contract,N/A,Not covered by Contract,N/A,170% of Medicare OPPS,N/A,215% of Medicare OPPS,N/A,Not covered by Contract,N/A,175% of Medicare OPPS,N/A,100% of Medicare OPPS,N/A,Not covered by Contract,N/A,140% of Medicare OPPS,N/A,125% of Medicare OPPS,N/A,Not covered by Contract,N/A,Not covered by Contract,N/A,100% of Medicare OPPS,N/A,Not covered by Contract,N/A,100% of Medicare OPPS,N/A,100% of Medicare OPPS,N/A,100% of Medicare OPPS,N/A,100% of Medicare OPPS,"$1,368.52 ",100% of custom fee schedule,N/A,Not covered by Contract,"$1,368.52 ","$1,368.52 ",N/A
Outpatient Medical Services,OUTPATIENT PROCEDURES,59610,Vaginal delivery after prior cesarean delivery,720,N/A,N/A,Not covered by Contract,N/A,100% of Medicare OPPS,N/A,Not covered by Contract,N/A,Not reimbursable. No contract for Physician,N/A,Not reimbursable. No contract for Physician,N/A,100% of Medicare OPPS,N/A,Not covered by Contract,N/A,Not covered by Contract,N/A,170% of Medicare OPPS,N/A,215% of Medicare OPPS,N/A,Not covered by Contract,N/A,175% of Medicare OPPS,N/A,100% of Medicare OPPS,N/A,Not covered by Contract,N/A,140% of Medicare OPPS,N/A,125% of Medicare OPPS,N/A,Not covered by Contract,N/A,Not covered by Contract,N/A,100% of Medicare OPPS,N/A,Not covered by Contract,N/A,100% of Medicare OPPS,N/A,100% of Medicare OPPS,N/A,100% of Medicare OPPS,N/A,100% of Medicare OPPS,"$1,298.69 ",100% of custom fee schedule,N/A,Not covered by Contract,"$1,298.69 ","$1,298.69 ",N/A
Outpatient Medical Services,OUTPATIENT PROCEDURES,62323,Injection of substance into spinal canal of lower back or sacrum using imaging guidance,360,N/A,$904.56 ,100% of APC Rate,$565.35 ,100% of Medicare OPPS,N/A,Not covered by Contract,N/A,Not reimbursable. No contract for Physician,$755.73 ,139.08% of ASC,$565.35 ,100% of Medicare OPPS,N/A,Not covered by Contract,N/A,Not covered by Contract,$961.09 ,170% of Medicare OPPS,"$1,215.51 ",215% of Medicare OPPS,N/A,Not covered by Contract,$989.37 ,175% of Medicare OPPS,$565.35 ,100% of Medicare OPPS,N/A,Not covered by Contract,$791.49 ,140% of Medicare OPPS,$706.69 ,125% of Medicare OPPS,N/A,Not covered by Contract,N/A,Not covered by Contract,$565.35 ,100% of Medicare OPPS,$673.00 ,100% of ASC Grouper,$565.35 ,100% of Medicare OPPS,$565.35 ,100% of Medicare OPPS,$989.37 ,100% of Medicare OPPS,$565.35 ,100% of Medicare OPPS,$695.48 ,100% of custom fee schedule,N/A,Not covered by Contract,$565.35 ,"$1,215.51 ",N/A
Outpatient Medical Services,OUTPATIENT PROCEDURES,62322,Injection of substance into spinal canal of lower back or sacrum using imaging guidance,360,N/A,"$1,196.33 ",100% of APC Rate,$747.72 ,100% of Medicare OPPS,N/A,Not covered by Contract,N/A,Not reimbursable. No contract for Physician,$755.73 ,139.08% of ASC,$747.72 ,100% of Medicare OPPS,N/A,Not covered by Contract,N/A,Not covered by Contract,"$1,271.10 ",170% of Medicare OPPS,"$1,607.59 ",215% of Medicare OPPS,N/A,Not covered by Contract,"$1,308.50 ",175% of Medicare OPPS,$747.72 ,100% of Medicare OPPS,N/A,Not covered by Contract,"$1,046.80 ",140% of Medicare OPPS,$934.64 ,125% of Medicare OPPS,N/A,Not covered by Contract,N/A,Not covered by Contract,$747.72 ,100% of Medicare OPPS,$673.00 ,100% of ASC Grouper,$747.72 ,100% of Medicare OPPS,$747.72 ,100% of Medicare OPPS,"$1,308.50 ",100% of Medicare OPPS,$747.72 ,100% of Medicare OPPS,$695.48 ,100% of custom fee schedule,N/A,Not covered by Contract,$673.00 ,"$1,607.59 ",N/A
Outpatient Medical Services,OUTPATIENT PROCEDURES,64483,Injections of anesthetic and/or steroid drug into lower or sacral spine nerve root using imaging guidance,360,N/A,"$1,196.33 ",100% of APC Rate,$747.72 ,100% of Medicare OPPS,N/A,Not covered by Contract,N/A,Not reimbursable. No contract for Physician,$934.87 ,139.08% of ASC,$747.72 ,100% of Medicare OPPS,N/A,Not covered by Contract,N/A,Not covered by Contract,"$1,271.10 ",170% of Medicare OPPS,"$1,607.59 ",215% of Medicare OPPS,N/A,Not covered by Contract,"$1,308.50 ",175% of Medicare OPPS,$747.72 ,100% of Medicare OPPS,N/A,Not covered by Contract,"$1,046.80 ",140% of Medicare OPPS,$934.64 ,125% of Medicare OPPS,N/A,Not covered by Contract,N/A,Not covered by Contract,$747.72 ,100% of Medicare OPPS,$673.00 ,100% of ASC Grouper,$747.72 ,100% of Medicare OPPS,$747.72 ,100% of Medicare OPPS,"$1,308.50 ",100% of Medicare OPPS,$747.72 ,100% of Medicare OPPS,$796.91 ,100% of custom fee schedule,N/A,Not covered by Contract,$673.00 ,"$1,607.59 ",N/A
Outpatient Medical Services,OUTPATIENT PROCEDURES,66821,Removal of recurring cataract in lens capsule using laser,360,N/A,$745.13 ,100% of APC Rate,$465.70 ,100% of Medicare OPPS,N/A,Not covered by Contract,N/A,Not reimbursable. No contract for Physician,$678.68 ,139.08% of ASC,$465.70 ,100% of Medicare OPPS,N/A,Not covered by Contract,N/A,Not covered by Contract,$791.69 ,170% of Medicare OPPS,"$1,001.26 ",215% of Medicare OPPS,N/A,Not covered by Contract,$814.98 ,175% of Medicare OPPS,$465.70 ,100% of Medicare OPPS,N/A,Not covered by Contract,$651.98 ,140% of Medicare OPPS,$582.13 ,125% of Medicare OPPS,N/A,Not covered by Contract,N/A,Not covered by Contract,$465.70 ,100% of Medicare OPPS,$673.00 ,100% of ASC Grouper,$465.70 ,100% of Medicare OPPS,$465.70 ,100% of Medicare OPPS,$814.98 ,100% of Medicare OPPS,$465.70 ,100% of Medicare OPPS,$509.43 ,100% of custom fee schedule,N/A,Not covered by Contract,$465.70 ,"$1,001.26 ",N/A
Outpatient Medical Services,CARDIOLOGY,93452,Insertion of catheter into left heart for diagnosis,480,N/A,"$4,153.29 ",100% of APC Rate,"$2,595.81 ",100% of Medicare OPPS,N/A,Not covered by Contract,N/A,Not reimbursable. No contract for Physician,"$3,913.15 ",139.08% of ASC,"$2,595.81 ",100% of Medicare OPPS,N/A,Not covered by Contract,N/A,Not covered by Contract,"$4,412.88 ",170% of Medicare OPPS,"$5,580.98 ",215% of Medicare OPPS,N/A,Not covered by Contract,"$4,542.66 ",175% of Medicare OPPS,"$2,595.81 ",100% of Medicare OPPS,N/A,Not covered by Contract,"$3,634.13 ",140% of Medicare OPPS,"$3,244.76 ",125% of Medicare OPPS,N/A,Not covered by Contract,N/A,Not covered by Contract,"$2,595.81 ",100% of Medicare OPPS,$452.00 ,100% of UHC Case Rate,"$2,595.81 ",100% of Medicare OPPS,"$2,595.81 ",100% of Medicare OPPS,"$4,542.66 ",100% of Medicare OPPS,"$2,595.81 ",100% of Medicare OPPS,"$3,077.42 ",100% of custom fee schedule,N/A,Not covered by Contract,$452.00 ,"$5,580.98 ",N/A
Outpatient Medical Services,SLEEP STUDY,95810,Sleep monitoring of patient (6 years or older) in sleep lab,920,N/A,"$1,311.74 ",100% of APC Rate,$819.84 ,100% of Medicare OPPS,N/A,Not covered by Contract,N/A,Not reimbursable. No contract for Physician,"$1,255.86 ",139.08% of custom fee schedule,$819.84 ,100% of Medicare OPPS,N/A,Not covered by Contract,N/A,Not covered by Contract,"$1,393.72 ",170% of Medicare OPPS,"$1,762.65 ",215% of Medicare OPPS,N/A,Not covered by Contract,"$1,434.72 ",175% of Medicare OPPS,$819.84 ,100% of Medicare OPPS,N/A,Not covered by Contract,"$1,147.78 ",140% of Medicare OPPS,"$1,024.80 ",125% of Medicare OPPS,N/A,Not covered by Contract,N/A,Not covered by Contract,$819.84 ,100% of Medicare OPPS,$581.00 ,100% of UHC Case Rate,$819.84 ,100% of Medicare OPPS,$819.84 ,100% of Medicare OPPS,"$1,434.72 ",100% of Medicare OPPS,$819.84 ,100% of Medicare OPPS,"$1,026.03 ",100% of custom fee schedule,N/A,Not covered by Contract,$581.00 ,"$1,762.65 ",N/A
Inpatient Medical Services,INPATIENT PROCEDURES,216,Cardiac valve and other major cardiothoracic procedures with cardiac catheterization with major complications or comorbidities,100,N/A,"$68,193.30 ",Custom DRG with base of 7000,"$59,922.35 ",100% of Medicare ,"$1,406.00 ","Per day rate of 892.50 for Med DRGS, and 1406 for Surg DRGs",N/A,Not seperately reimbursable,"$68,894.72 ",139.08% of custom fee schedule,N/A,100% of Medicare ,"$1,200.00 ",Per day rate of 1200 for med/surg DRGs,"$1,093.00 ",Per day rate of 1093 for Inpatient rev codes,"$101,868.00 ",170% of Medicare CMS MS-DRG,"$1,370.00 ","per day rate of 1120 for Med DRGS, and 1370 for Surg DRGs","$1,173.72 ",per day rate of 1173.72 ,"$104,864.11 ",175% of Medicare CMS MS-DRG,"$104,864.11 ",100% of Medicare CMS MS-DRG,N/A,Not covered by Contract,"$74,902.94 ",140% of Medicare CMS MS-DRG,"$131,080.14 ",125% of Medicare CMS New Technology,"$1,173.72 ",per day rate of 1173.72 ,"$1,173.72 ",per day rate of 1173.72 ,"$104,864.11 ",100% of Medicare CMS MS-DRG,"$3,259.00 ",rate of 3259 for one day stays with rev code 100-214,"$59,922.35 ",100% of Medicare CMS MS-DRG,"$59,922.35 ",100% of Medicare CMS MS-DRG,"$59,922.35 ",100% of Medicare CMS MS-DRG,"$59,922.35 ",100% of Medicare CMS MS-DRG,N/A,40% of total billed charges,"$1,654.00 ","per day rate of 1050 for Med DRGs, and 1654 for Surg DRGs","$1,093.00 ","$68,894.72 ",N/A