hospital_name,last_updated_on,version,hospital_location,hospital_address,license_number|CA,"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.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Lompoc Valley Medical Center,2024-07-01,2.0.0,Lompoc Valley Medical Center,1515 E Ocean Ave Lompoc CA 93436 ,956001880,TRUE,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SERVICE DESCRIPTION,CATEGORY,BILLING MSDRG | CPT | HCPCS,ITEM/SERVICE DESCRIPTION,BILLING REVENUE CODE,GROSS CHARGES,AETNA NAP PLAN,AETNA NAP REIMBURSEMENT METHOD,AETNA MEDICARE PLAN,AETNA MEDICARE REIMBURSEMENT METHOD,ANTHEM BCBS PLAN,ANTHEM BCBS REIMBURSEMENT METHOD,ANTHEM BCBS MEDICARE PLAN,ANTHEM BCBS MEDICARE REIMBURSEMENT METHOD,BLUE SHIELD NATIONAL PLAN,BLUE SHIELD NATIONAL REIMBURSEMENT METHOD,BLUE SHIELD MEDICARE PLAN,BLUE SHIELD MEDICARE REIMBURSEMENT METHOD,CIGNA HMO PLAN,CIGNA HMO REIMBURSEMENT METHOD,CIGNA PPO PLAN,CIGNA PPO REIMBURSEMENT METHOD,COVENTRY PLAN,COVENTRY REIMBURSEMENT METHOD,COVENTRY MEDICARE PLAN,COVENTRY MEDICARE REIMBURSEMENT METHOD,HEALTH NET MEDICARE PLAN,HEALTH NET MEDICARE REIMBURSEMENT METHOD,HUMANA MEDICARE PLAN,HUMANA MEDICARE REIMBURSEMENT METHOD,MAGELLAN PLAN,MAGELLAN REIMBURSEMENT METHOD,MEDI CAL PLAN,MEDI CAL REIMBURSEMENT METHOD,MEDI CAL MANAGED CARE PLAN,MEDI CAL MANAGED CARE REIMBURSEMENT METHOD,MEDICARE PLAN,MEDICARE REIMBURSEMENT METHOD,MEDICARE ADV PLAN,MEDICARE ADV REIMBURSEMENT METHOD,SANSUM PLAN,SANSUM REIMBURSEMENT METHOD,TRICARE PLAN,TRICARE REIMBURSEMENT METHOD,UHC PLAN,UHC REIMBURSEMENT METHOD,UHC MEDICARE PLAN,UHC MEDICARE REIMBURSEMENT METHOD,WORK COMP PLAN,WORK COMP REIMBURSEMENT METHOD,AETNA PPO PLAN,AETNA PPO REIMBURSEMENT METHOD,AETNA SELECT PLAN,AETNA SELECT REIMBURSEMENT METHOD,AETNA US HEALTHCARE PLAN,AETNA US HEALTHCARE REIMBURSEMENT METHOD,AETNA CORESOURCE PLAN,AETNA CORESOURCE REIMBURSEMENT METHOD,AETNA MAIL HANDLERS PLAN,AETNA MAIL HANDLERS REIMBURSEMENT METHOD,AETNA SANSUM PLAN,AETNA SANSUM REIMBURSEMENT METHOD,BLUE CROSS HMO PLAN,BLUE CROSS HMO REIMBURSEMENT METHOD,BLUE CROSS HMO SANSUM PLAN,BLUE CROSS HMO SANSUM REIMBURSEMENT METHOD,BLUE CROSS LOMPOC HEALTH PLAN,BLUE CROSS LOMPOC HEALTH REIMBURSEMENT METHOD,BLUE CROSS PLUS PLAN,BLUE CROSS PLUS REIMBURSEMENT METHOD,BLUE CROSS PPO PLAN,BLUE CROSS PPO REIMBURSEMENT METHOD,BLUE CROSS PRUDENT BUYER PLAN,BLUE CROSS PRUDENT BUYER REIMBURSEMENT METHOD,BLUE CROSS SISC PLAN,BLUE CROSS SISC REIMBURSEMENT METHOD,BLUE CROSS SISC PPO PLAN,BLUE CROSS SISC PPO REIMBURSEMENT METHOD,BLUE_CROSS FEP PLAN,BLUE_CROSS FEP REIMBURSEMENT METHOD,BLUE SHIELD PPO PLAN,BLUE SHIELD PPO REIMBURSEMENT METHOD,BLUE SHIELD HMO PLAN,BLUE SHIELD HMO REIMBURSEMENT METHOD,BLUE SHIELD HMO SANSUM PLAN,BLUE SHIELD HMO SANSUM REIMBURSEMENT METHOD,BLUE SHIELD LOMPOC HEALTH PLAN PLAN,BLUE SHIELD LOMPOC HEALTH PLAN REIMBURSEMENT METHOD,BLUE SHIELD COVERED CA PLAN,BLUE SHIELD COVERED CA REIMBURSEMENT METHOD,CIGNA COSTA HEALTH PLAN PLAN,CIGNA COSTA HEALTH PLAN REIMBURSEMENT METHOD,CIGNA HMO SBMFC PLAN,CIGNA HMO SBMFC REIMBURSEMENT METHOD,CIGNA GREAT WEST PLAN,CIGNA GREAT WEST REIMBURSEMENT METHOD,UHC GEHA PLAN,UHC GEHA REIMBURSEMENT METHOD,UHC MEDICARE HMO PLAN,UHC MEDICARE HMO REIMBURSEMENT METHOD,UHC MEDICARE PPO PLAN,UHC MEDICARE PPO REIMBURSEMENT METHOD,UHC MEDICARE SANSUM PLAN,UHC MEDICARE SANSUM REIMBURSEMENT METHOD,UHC MEDICARE LOMPOC PLAN,UHC MEDICARE LOMPOC REIMBURSEMENT METHOD,BC SMART VALUE MEDICARE PLAN,BC SMART VALUE MEDICARE REIMBURSEMENT METHOD,BC FREEDOM BLUE PPO MEDICARE PLAN,BC FREEDOM BLUE PPO MEDICARE REIMBURSEMENT METHOD,BLUE SHIELD 65 PLUS MEDICARE PLAN,BLUE SHIELD 65 PLUS MEDICARE REIMBURSEMENT METHOD,VETERANS ADMINISTRATION COMMERCIAL PLAN,VETERANS ADMINISTRATION COMMERCIAL REIMBURSEMENT METHOD,VETERANS CHOICE COMMERCIAL PLAN,VETERANS CHOICE COMMERCIAL REIMBURSEMENT METHOD,WELLCARE MEDICARE PLAN,WELLCARE MEDICARE REIMBURSEMENT METHOD,WPS VA PCC MEDICARE PLAN,WPS VA PCC MEDICARE REIMBURSEMENT METHOD,HEALTH NET PEARL MEDICARE PLAN,HEALTH NET PEARL MEDICARE REIMBURSEMENT METHOD,HEALTH NET SR PLUS MEDICARE PLAN,HEALTH NET SR PLUS MEDICARE REIMBURSEMENT METHOD,HEALTHMARKETS CARE MEDICARE PLAN,HEALTHMARKETS CARE MEDICARE REIMBURSEMENT METHOD,IMPERIAL HEALTH MEDICARE PLAN,IMPERIAL HEALTH MEDICARE REIMBURSEMENT METHOD,SECURE HORIZONS MEDICARE PLAN,SECURE HORIZONS MEDICARE REIMBURSEMENT METHOD,ALAMEDA ALLIANCE MEDI CAL PLAN,ALAMEDA ALLIANCE MEDI CAL REIMBURSEMENT METHOD,BLUE CROSS MEDI CAL PLAN,BLUE CROSS MEDI CAL REIMBURSEMENT METHOD,BLUE SHIELD MEDI CAL PLAN,BLUE SHIELD MEDI CAL REIMBURSEMENT METHOD,CALIFORNIA HEALTH MEDI CAL PLAN,CALIFORNIA HEALTH MEDI CAL REIMBURSEMENT METHOD,CA OPTIMA MEDI CAL PLAN,CA OPTIMA MEDI CAL REIMBURSEMENT METHOD,CALVIVA MEDI CAL PLAN,CALVIVA MEDI CAL REIMBURSEMENT METHOD,CARE FIRST MEDI CAL PLAN,CARE FIRST MEDI CAL REIMBURSEMENT METHOD,CENCAL MEDI CAL PLAN,CENCAL MEDI CAL REIMBURSEMENT METHOD,CECAL HEALTHY FAMILY MEDI CAL PLAN,CECAL HEALTHY FAMILY MEDI CAL REIMBURSEMENT METHOD,CECAL HEALTHY KIDS MEDI CAL PLAN,CECAL HEALTHY KIDS MEDI CAL REIMBURSEMENT METHOD,CENTRAL CA ALLIANCE MEDI CAL PLAN,CENTRAL CA ALLIANCE MEDI CAL REIMBURSEMENT METHOD,CONRA COSA MEDI CAL PLAN,CONRA COSA MEDI CAL REIMBURSEMENT METHOD,GOLD COAST MEDI CAL PLAN,GOLD COAST MEDI CAL REIMBURSEMENT METHOD,HEALTHNET MEDI CAL PLAN,HEALTHNET MEDI CAL REIMBURSEMENT METHOD,INLAND EMPIRE MEDI CAL PLAN,INLAND EMPIRE MEDI CAL REIMBURSEMENT METHOD,KERN FAMILY HEALTH MEDI CAL PLAN,KERN FAMILY HEALTH MEDI CAL REIMBURSEMENT METHOD,LA CARE MEDI CAL PLAN,LA CARE MEDI CAL REIMBURSEMENT METHOD,MOLINA MEDI CAL PLAN,MOLINA MEDI CAL REIMBURSEMENT METHOD,PARTNERSHIP MEDI CAL PLAN,PARTNERSHIP MEDI CAL REIMBURSEMENT METHOD,SANTA CARA FAMILY HEALTH MEDI CAL PLAN,SANTA CARA FAMILY HEALTH MEDI CAL REIMBURSEMENT METHOD,De-Identified Minimum Negotiated Rate,De-Identified Maximum Negotiated Rate,DISCOUNTED CASH PRICE
Outpatient Medical Services,CT SCAN,77014,CT GUIDANCE FOR PLACEMENT RADIATION,350,917.75,660.78,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,509.36,442% of BCBS Fee Schedule,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,917.75,Case rate,917.75,Case rate,660.78,72% of total billed charges,N/A,Not Separately reimbursable,596.54,65% of total billed charges,N/A,Not Separately reimbursable,550.65,60% of total billed charges,150.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,150.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,90.58,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,642.43,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,660.78,Pays at 72% of billed charges with lesser of charges applied,660.78,Pays at 72% of billed charges with lesser of charges applied,660.78,Pays at 72% of billed charges with lesser of charges applied,660.78,Pays at 72% of billed charges with lesser of charges applied,660.78,Pays at 72% of billed charges with lesser of charges applied,660.78,Pays at 72% of billed charges with lesser of charges applied,509.36,442% of BCBS Fee Schedule,509.36,442% of BCBS Fee Schedule,509.36,442% of BCBS Fee Schedule,509.36,442% of BCBS Fee Schedule,509.36,442% of BCBS Fee Schedule,509.36,442% of BCBS Fee Schedule,509.36,442% of BCBS Fee Schedule,509.36,442% of BCBS Fee Schedule,509.36,442% of BCBS Fee Schedule,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,917.75,Case rate,917.75,Case rate,917.75,Case rate,642.43,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,150.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,150.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,150.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,150.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,150.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,150.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,150.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,150.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,150.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,150.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,150.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,150.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,150.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,150.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,150.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,150.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,150.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,150.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,150.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,150.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,90.58,917.75,688.31
Outpatient Medical Services,CT SCAN,77012,CT GUIDED NEEDLE BIOPSY,350,2066,1487.52,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,1542.18,442% of BCBS Fee Schedule,N/A,Not Separately reimbursable,452.96,100% of BCBS Fee Schedule,N/A,Not Separately reimbursable,2066,Case rate,2066,Case rate,1487.52,72% of total billed charges,N/A,Not Separately reimbursable,1342.9,65% of total billed charges,N/A,Not Separately reimbursable,1239.6,60% of total billed charges,159.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,159.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,85.8,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,1446.2,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,1487.52,Pays at 72% of billed charges with lesser of charges applied,1487.52,Pays at 72% of billed charges with lesser of charges applied,1487.52,Pays at 72% of billed charges with lesser of charges applied,1487.52,Pays at 72% of billed charges with lesser of charges applied,1487.52,Pays at 72% of billed charges with lesser of charges applied,1487.52,Pays at 72% of billed charges with lesser of charges applied,1542.18,442% of BCBS Fee Schedule,1542.18,442% of BCBS Fee Schedule,1542.18,442% of BCBS Fee Schedule,1542.18,442% of BCBS Fee Schedule,1542.18,442% of BCBS Fee Schedule,1542.18,442% of BCBS Fee Schedule,1542.18,442% of BCBS Fee Schedule,1542.18,442% of BCBS Fee Schedule,1542.18,442% of BCBS Fee Schedule,452.96,100% of BCBS Fee Schedule,452.96,100% of BCBS Fee Schedule,452.96,100% of BCBS Fee Schedule,452.96,100% of BCBS Fee Schedule,452.96,100% of BCBS Fee Schedule,2066,Case rate,2066,Case rate,2066,Case rate,1446.2,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,159.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,159.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,159.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,159.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,159.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,159.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,159.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,159.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,159.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,159.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,159.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,159.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,159.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,159.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,159.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,159.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,159.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,159.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,159.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,159.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,85.80,2066.00,1549.5
Outpatient Medical Services,CT SCAN,76380,CT LIMITED OR LOCALIZED,350,1376.75,991.26,Pays at 72% of billed charges with lesser of charges applied,110.43,100% OF CMS OPPS Rate,598.82,442% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,780.95,100% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,1376.75,Case rate,1376.75,Case rate,991.26,72% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% of CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,826.05,60% of total billed charges,182.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,182.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,108.49,100% OF CMS OPPS RATE,110.43,100% OF CMS OPPS Rate,963.73,70% of total billed charges,110.43,100% OF CMS OPPS Rate,132.51,120% of CMS OPPS RATE,991.26,Pays at 72% of billed charges with lesser of charges applied,991.26,Pays at 72% of billed charges with lesser of charges applied,991.26,Pays at 72% of billed charges with lesser of charges applied,991.26,Pays at 72% of billed charges with lesser of charges applied,991.26,Pays at 72% of billed charges with lesser of charges applied,991.26,Pays at 72% of billed charges with lesser of charges applied,598.82,442% of BCBS Fee Schedule,598.82,442% of BCBS Fee Schedule,598.82,442% of BCBS Fee Schedule,598.82,442% of BCBS Fee Schedule,598.82,442% of BCBS Fee Schedule,598.82,442% of BCBS Fee Schedule,598.82,442% of BCBS Fee Schedule,598.82,442% of BCBS Fee Schedule,598.82,442% of BCBS Fee Schedule,780.95,100% of BCBS Fee Schedule,780.95,100% of BCBS Fee Schedule,780.95,100% of BCBS Fee Schedule,780.95,100% of BCBS Fee Schedule,780.95,100% of BCBS Fee Schedule,1376.75,Case rate,1376.75,Case rate,1376.75,Case rate,963.73,70% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,182.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,182.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,182.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,182.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,182.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,182.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,182.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,182.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,182.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,182.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,182.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,182.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,182.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,182.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,182.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,182.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,182.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,182.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,182.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,182.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,108.49,1376.75,1032.56
Outpatient Medical Services,CT SCAN,70486,CT Scan of the face and jaw without dye,350,1951.75,1405.26,Pays at 72% of billed charges with lesser of charges applied,135.84,100% OF CMS OPPS Rate,882.67,442% of BCBS Fee Schedule,135.84,100% OF CMS OPPS Rate,1055.68,100% of BCBS Fee Schedule,135.84,100% OF CMS OPPS Rate,1951.75,Case rate,1951.75,Case rate,1405.26,72% of total billed charges,135.84,100% OF CMS OPPS Rate,135.84,100% of CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,1171.05,60% of total billed charges,176.93,100% of CA Medicaid Fee Schedule with lesser of charges applied,176.93,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,110.09,100% OF CMS OPPS RATE,135.84,100% OF CMS OPPS Rate,1366.23,70% of total billed charges,135.84,100% OF CMS OPPS Rate,163.01,120% of CMS OPPS RATE,1405.26,Pays at 72% of billed charges with lesser of charges applied,1405.26,Pays at 72% of billed charges with lesser of charges applied,1405.26,Pays at 72% of billed charges with lesser of charges applied,1405.26,Pays at 72% of billed charges with lesser of charges applied,1405.26,Pays at 72% of billed charges with lesser of charges applied,1405.26,Pays at 72% of billed charges with lesser of charges applied,882.67,442% of BCBS Fee Schedule,882.67,442% of BCBS Fee Schedule,882.67,442% of BCBS Fee Schedule,882.67,442% of BCBS Fee Schedule,882.67,442% of BCBS Fee Schedule,882.67,442% of BCBS Fee Schedule,882.67,442% of BCBS Fee Schedule,882.67,442% of BCBS Fee Schedule,882.67,442% of BCBS Fee Schedule,1055.68,100% of BCBS Fee Schedule,1055.68,100% of BCBS Fee Schedule,1055.68,100% of BCBS Fee Schedule,1055.68,100% of BCBS Fee Schedule,1055.68,100% of BCBS Fee Schedule,1951.75,Case rate,1951.75,Case rate,1951.75,Case rate,1366.23,70% of total billed charges,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,176.93,100% of CA Medicaid Fee Schedule with lesser of charges applied,176.93,100% of CA Medicaid Fee Schedule with lesser of charges applied,176.93,100% of CA Medicaid Fee Schedule with lesser of charges applied,176.93,100% of CA Medicaid Fee Schedule with lesser of charges applied,176.93,100% of CA Medicaid Fee Schedule with lesser of charges applied,176.93,100% of CA Medicaid Fee Schedule with lesser of charges applied,176.93,100% of CA Medicaid Fee Schedule with lesser of charges applied,176.93,100% of CA Medicaid Fee Schedule with lesser of charges applied,176.93,100% of CA Medicaid Fee Schedule with lesser of charges applied,176.93,100% of CA Medicaid Fee Schedule with lesser of charges applied,176.93,100% of CA Medicaid Fee Schedule with lesser of charges applied,176.93,100% of CA Medicaid Fee Schedule with lesser of charges applied,176.93,100% of CA Medicaid Fee Schedule with lesser of charges applied,176.93,100% of CA Medicaid Fee Schedule with lesser of charges applied,176.93,100% of CA Medicaid Fee Schedule with lesser of charges applied,176.93,100% of CA Medicaid Fee Schedule with lesser of charges applied,176.93,100% of CA Medicaid Fee Schedule with lesser of charges applied,176.93,100% of CA Medicaid Fee Schedule with lesser of charges applied,176.93,100% of CA Medicaid Fee Schedule with lesser of charges applied,176.93,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.09,1951.75,1463.81
Outpatient Medical Services,CT SCAN,77078,CT BONE DENSITY,350,403.5,290.52,Pays at 72% of billed charges with lesser of charges applied,110.42,100% OF CMS OPPS Rate,403.5,BCBS Fee Schedule,110.42,100% OF CMS OPPS Rate,122.96,100% of BCBS Fee Schedule,110.42,100% OF CMS OPPS Rate,403.5,Case rate,403.5,Case rate,290.52,72% of total billed charges,110.42,100% OF CMS OPPS Rate,110.42,100% of CMS OPPS Rate,110.42,100% OF CMS OPPS Rate,242.1,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,110.42,100% OF CMS OPPS Rate,110.42,100% OF CMS OPPS Rate,111.28,100% OF CMS OPPS RATE,110.42,100% OF CMS OPPS Rate,282.45,70% of total billed charges,110.42,100% OF CMS OPPS Rate,132.51,120% of CMS OPPS RATE,290.52,Pays at 72% of billed charges with lesser of charges applied,290.52,Pays at 72% of billed charges with lesser of charges applied,290.52,Pays at 72% of billed charges with lesser of charges applied,290.52,Pays at 72% of billed charges with lesser of charges applied,290.52,Pays at 72% of billed charges with lesser of charges applied,290.52,Pays at 72% of billed charges with lesser of charges applied,403.5,BCBS Fee Schedule,403.5,BCBS Fee Schedule,403.5,BCBS Fee Schedule,403.5,BCBS Fee Schedule,403.5,BCBS Fee Schedule,403.5,BCBS Fee Schedule,403.5,BCBS Fee Schedule,403.5,BCBS Fee Schedule,403.5,BCBS Fee Schedule,122.96,100% of BCBS Fee Schedule,122.96,100% of BCBS Fee Schedule,122.96,100% of BCBS Fee Schedule,122.96,100% of BCBS Fee Schedule,122.96,100% of BCBS Fee Schedule,403.5,Case rate,403.5,Case rate,403.5,Case rate,282.45,70% of total billed charges,110.42,100% OF CMS OPPS Rate,110.42,100% OF CMS OPPS Rate,110.42,100% OF CMS OPPS Rate,110.42,100% OF CMS OPPS Rate,110.42,100% OF CMS OPPS Rate,110.42,100% OF CMS OPPS Rate,110.42,100% OF CMS OPPS Rate,110.42,100% OF CMS OPPS Rate,110.42,100% OF CMS OPPS Rate,110.42,100% OF CMS OPPS Rate,110.42,100% OF CMS OPPS Rate,110.42,100% OF CMS OPPS Rate,110.42,100% OF CMS OPPS Rate,110.42,100% OF CMS OPPS Rate,110.42,100% OF CMS OPPS Rate,110.42,100% OF CMS OPPS Rate,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,110.42,403.50,302.63
Outpatient Medical Services,CT SCAN,70482,"CT ORBIT, SELLA, EAR W & W/O CONTRAST",351,2524.25,1817.46,Pays at 72% of billed charges with lesser of charges applied,229.22,100% OF CMS OPPS Rate,1319.24,442% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,1580.6,100% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,2430,Case rate,2430,Case rate,1817.46,72% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% of CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,1514.55,60% of total billed charges,295.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,295.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,189.52,100% OF CMS OPPS RATE,229.22,100% OF CMS OPPS Rate,1766.98,70% of total billed charges,229.22,100% OF CMS OPPS Rate,275.06,120% of CMS OPPS RATE,1817.46,Pays at 72% of billed charges with lesser of charges applied,1817.46,Pays at 72% of billed charges with lesser of charges applied,1817.46,Pays at 72% of billed charges with lesser of charges applied,1817.46,Pays at 72% of billed charges with lesser of charges applied,1817.46,Pays at 72% of billed charges with lesser of charges applied,1817.46,Pays at 72% of billed charges with lesser of charges applied,1319.24,442% of BCBS Fee Schedule,1319.24,442% of BCBS Fee Schedule,1319.24,442% of BCBS Fee Schedule,1319.24,442% of BCBS Fee Schedule,1319.24,442% of BCBS Fee Schedule,1319.24,442% of BCBS Fee Schedule,1319.24,442% of BCBS Fee Schedule,1319.24,442% of BCBS Fee Schedule,1319.24,442% of BCBS Fee Schedule,1580.6,100% of BCBS Fee Schedule,1580.6,100% of BCBS Fee Schedule,1580.6,100% of BCBS Fee Schedule,1580.6,100% of BCBS Fee Schedule,1580.6,100% of BCBS Fee Schedule,2430,Case rate,2430,Case rate,2430,Case rate,1766.98,70% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,295.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,295.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,295.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,295.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,295.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,295.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,295.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,295.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,295.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,295.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,295.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,295.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,295.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,295.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,295.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,295.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,295.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,295.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,295.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,295.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,189.52,2430.00,1893.19
Outpatient Medical Services,CT SCAN,70492,CT SOFT TISSUE NECK W & W/O CONTRAST,351,3099,2231.28,Pays at 72% of billed charges with lesser of charges applied,229.22,100% OF CMS OPPS Rate,1319.24,442% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,1580.6,100% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,2430,Case rate,2430,Case rate,2231.28,72% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% of CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,1859.4,60% of total billed charges,308.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,308.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,183.55,100% OF CMS OPPS RATE,229.22,100% OF CMS OPPS Rate,2169.3,70% of total billed charges,229.22,100% OF CMS OPPS Rate,275.06,120% of CMS OPPS RATE,2231.28,Pays at 72% of billed charges with lesser of charges applied,2231.28,Pays at 72% of billed charges with lesser of charges applied,2231.28,Pays at 72% of billed charges with lesser of charges applied,2231.28,Pays at 72% of billed charges with lesser of charges applied,2231.28,Pays at 72% of billed charges with lesser of charges applied,2231.28,Pays at 72% of billed charges with lesser of charges applied,1319.24,442% of BCBS Fee Schedule,1319.24,442% of BCBS Fee Schedule,1319.24,442% of BCBS Fee Schedule,1319.24,442% of BCBS Fee Schedule,1319.24,442% of BCBS Fee Schedule,1319.24,442% of BCBS Fee Schedule,1319.24,442% of BCBS Fee Schedule,1319.24,442% of BCBS Fee Schedule,1319.24,442% of BCBS Fee Schedule,1580.6,100% of BCBS Fee Schedule,1580.6,100% of BCBS Fee Schedule,1580.6,100% of BCBS Fee Schedule,1580.6,100% of BCBS Fee Schedule,1580.6,100% of BCBS Fee Schedule,2430,Case rate,2430,Case rate,2430,Case rate,2169.3,70% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,308.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,308.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,308.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,308.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,308.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,308.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,308.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,308.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,308.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,308.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,308.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,308.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,308.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,308.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,308.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,308.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,308.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,308.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,308.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,308.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,183.55,2430.00,2324.25
Outpatient Medical Services,CT SCAN,70480,"CT ORBIT, SELLA, EAR W/O CONTRAST",351,1951.75,1405.26,Pays at 72% of billed charges with lesser of charges applied,135.84,100% OF CMS OPPS Rate,884.31,442% of BCBS Fee Schedule,135.84,100% OF CMS OPPS Rate,1055.68,100% of BCBS Fee Schedule,135.84,100% OF CMS OPPS Rate,1951.75,Case rate,1951.75,Case rate,1405.26,72% of total billed charges,135.84,100% OF CMS OPPS Rate,135.84,100% of CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,1171.05,60% of total billed charges,218.52,100% of CA Medicaid Fee Schedule with lesser of charges applied,218.52,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,123.23,100% OF CMS OPPS RATE,135.84,100% OF CMS OPPS Rate,1366.23,70% of total billed charges,135.84,100% OF CMS OPPS Rate,163.01,120% of CMS OPPS RATE,1405.26,Pays at 72% of billed charges with lesser of charges applied,1405.26,Pays at 72% of billed charges with lesser of charges applied,1405.26,Pays at 72% of billed charges with lesser of charges applied,1405.26,Pays at 72% of billed charges with lesser of charges applied,1405.26,Pays at 72% of billed charges with lesser of charges applied,1405.26,Pays at 72% of billed charges with lesser of charges applied,884.31,442% of BCBS Fee Schedule,884.31,442% of BCBS Fee Schedule,884.31,442% of BCBS Fee Schedule,884.31,442% of BCBS Fee Schedule,884.31,442% of BCBS Fee Schedule,884.31,442% of BCBS Fee Schedule,884.31,442% of BCBS Fee Schedule,884.31,442% of BCBS Fee Schedule,884.31,442% of BCBS Fee Schedule,1055.68,100% of BCBS Fee Schedule,1055.68,100% of BCBS Fee Schedule,1055.68,100% of BCBS Fee Schedule,1055.68,100% of BCBS Fee Schedule,1055.68,100% of BCBS Fee Schedule,1951.75,Case rate,1951.75,Case rate,1951.75,Case rate,1366.23,70% of total billed charges,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,218.52,100% of CA Medicaid Fee Schedule with lesser of charges applied,218.52,100% of CA Medicaid Fee Schedule with lesser of charges applied,218.52,100% of CA Medicaid Fee Schedule with lesser of charges applied,218.52,100% of CA Medicaid Fee Schedule with lesser of charges applied,218.52,100% of CA Medicaid Fee Schedule with lesser of charges applied,218.52,100% of CA Medicaid Fee Schedule with lesser of charges applied,218.52,100% of CA Medicaid Fee Schedule with lesser of charges applied,218.52,100% of CA Medicaid Fee Schedule with lesser of charges applied,218.52,100% of CA Medicaid Fee Schedule with lesser of charges applied,218.52,100% of CA Medicaid Fee Schedule with lesser of charges applied,218.52,100% of CA Medicaid Fee Schedule with lesser of charges applied,218.52,100% of CA Medicaid Fee Schedule with lesser of charges applied,218.52,100% of CA Medicaid Fee Schedule with lesser of charges applied,218.52,100% of CA Medicaid Fee Schedule with lesser of charges applied,218.52,100% of CA Medicaid Fee Schedule with lesser of charges applied,218.52,100% of CA Medicaid Fee Schedule with lesser of charges applied,218.52,100% of CA Medicaid Fee Schedule with lesser of charges applied,218.52,100% of CA Medicaid Fee Schedule with lesser of charges applied,218.52,100% of CA Medicaid Fee Schedule with lesser of charges applied,218.52,100% of CA Medicaid Fee Schedule with lesser of charges applied,123.23,1951.75,1463.81
Outpatient Medical Services,CT SCAN,70481,"CT ORBIT, SELLA, EAR WITH CONTRAST",351,2295,1652.4,Pays at 72% of billed charges with lesser of charges applied,229.22,100% OF CMS OPPS Rate,1058.32,442% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,1262.95,100% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,2295,Case rate,2295,Case rate,1652.4,72% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% of CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,1377,60% of total billed charges,251.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,251.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,159.66,100% OF CMS OPPS RATE,229.22,100% OF CMS OPPS Rate,1606.5,70% of total billed charges,229.22,100% OF CMS OPPS Rate,275.06,120% of CMS OPPS RATE,1652.4,Pays at 72% of billed charges with lesser of charges applied,1652.4,Pays at 72% of billed charges with lesser of charges applied,1652.4,Pays at 72% of billed charges with lesser of charges applied,1652.4,Pays at 72% of billed charges with lesser of charges applied,1652.4,Pays at 72% of billed charges with lesser of charges applied,1652.4,Pays at 72% of billed charges with lesser of charges applied,1058.32,442% of BCBS Fee Schedule,1058.32,442% of BCBS Fee Schedule,1058.32,442% of BCBS Fee Schedule,1058.32,442% of BCBS Fee Schedule,1058.32,442% of BCBS Fee Schedule,1058.32,442% of BCBS Fee Schedule,1058.32,442% of BCBS Fee Schedule,1058.32,442% of BCBS Fee Schedule,1058.32,442% of BCBS Fee Schedule,1262.95,100% of BCBS Fee Schedule,1262.95,100% of BCBS Fee Schedule,1262.95,100% of BCBS Fee Schedule,1262.95,100% of BCBS Fee Schedule,1262.95,100% of BCBS Fee Schedule,2295,Case rate,2295,Case rate,2295,Case rate,1606.5,70% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,251.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,251.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,251.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,251.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,251.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,251.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,251.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,251.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,251.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,251.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,251.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,251.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,251.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,251.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,251.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,251.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,251.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,251.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,251.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,251.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,159.66,2295.00,1721.25
Outpatient Medical Services,CT SCAN,70491,CT scan of neck with dye,351,2524.25,1817.46,Pays at 72% of billed charges with lesser of charges applied,229.22,100% OF CMS OPPS Rate,1058.32,442% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,1262.95,100% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,2430,Case rate,2430,Case rate,1817.46,72% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% of CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,1514.55,60% of total billed charges,256.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,256.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,150.1,100% OF CMS OPPS RATE,229.22,100% OF CMS OPPS Rate,1766.98,70% of total billed charges,229.22,100% OF CMS OPPS Rate,275.06,120% of CMS OPPS RATE,1817.46,Pays at 72% of billed charges with lesser of charges applied,1817.46,Pays at 72% of billed charges with lesser of charges applied,1817.46,Pays at 72% of billed charges with lesser of charges applied,1817.46,Pays at 72% of billed charges with lesser of charges applied,1817.46,Pays at 72% of billed charges with lesser of charges applied,1817.46,Pays at 72% of billed charges with lesser of charges applied,1058.32,442% of BCBS Fee Schedule,1058.32,442% of BCBS Fee Schedule,1058.32,442% of BCBS Fee Schedule,1058.32,442% of BCBS Fee Schedule,1058.32,442% of BCBS Fee Schedule,1058.32,442% of BCBS Fee Schedule,1058.32,442% of BCBS Fee Schedule,1058.32,442% of BCBS Fee Schedule,1058.32,442% of BCBS Fee Schedule,1262.95,100% of BCBS Fee Schedule,1262.95,100% of BCBS Fee Schedule,1262.95,100% of BCBS Fee Schedule,1262.95,100% of BCBS Fee Schedule,1262.95,100% of BCBS Fee Schedule,2430,Case rate,2430,Case rate,2430,Case rate,1766.98,70% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,256.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,256.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,256.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,256.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,256.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,256.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,256.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,256.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,256.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,256.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,256.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,256.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,256.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,256.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,256.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,256.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,256.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,256.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,256.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,256.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,150.10,2430.00,1893.19
Outpatient Medical Services,CT SCAN,70490,CT SOFT TISSUE NECK W/O CONTRAST,351,2066,1487.52,Pays at 72% of billed charges with lesser of charges applied,135.84,100% OF CMS OPPS Rate,884.31,442% of BCBS Fee Schedule,135.84,100% OF CMS OPPS Rate,1055.68,100% of BCBS Fee Schedule,135.84,100% OF CMS OPPS Rate,2066,Case rate,2066,Case rate,1487.52,72% of total billed charges,135.84,100% OF CMS OPPS Rate,135.84,100% of CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,1239.6,60% of total billed charges,206.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,206.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,112.87,100% OF CMS OPPS RATE,135.84,100% OF CMS OPPS Rate,1446.2,70% of total billed charges,135.84,100% OF CMS OPPS Rate,163.01,120% of CMS OPPS RATE,1487.52,Pays at 72% of billed charges with lesser of charges applied,1487.52,Pays at 72% of billed charges with lesser of charges applied,1487.52,Pays at 72% of billed charges with lesser of charges applied,1487.52,Pays at 72% of billed charges with lesser of charges applied,1487.52,Pays at 72% of billed charges with lesser of charges applied,1487.52,Pays at 72% of billed charges with lesser of charges applied,884.31,442% of BCBS Fee Schedule,884.31,442% of BCBS Fee Schedule,884.31,442% of BCBS Fee Schedule,884.31,442% of BCBS Fee Schedule,884.31,442% of BCBS Fee Schedule,884.31,442% of BCBS Fee Schedule,884.31,442% of BCBS Fee Schedule,884.31,442% of BCBS Fee Schedule,884.31,442% of BCBS Fee Schedule,1055.68,100% of BCBS Fee Schedule,1055.68,100% of BCBS Fee Schedule,1055.68,100% of BCBS Fee Schedule,1055.68,100% of BCBS Fee Schedule,1055.68,100% of BCBS Fee Schedule,2066,Case rate,2066,Case rate,2066,Case rate,1446.2,70% of total billed charges,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,206.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,206.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,206.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,206.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,206.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,206.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,206.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,206.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,206.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,206.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,206.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,206.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,206.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,206.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,206.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,206.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,206.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,206.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,206.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,206.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,112.87,2066.00,1549.5
Outpatient Medical Services,CT SCAN,70488,CT FACE WITH & WITHOUT CONTRAST,351,3099,2231.28,Pays at 72% of billed charges with lesser of charges applied,229.22,100% OF CMS OPPS Rate,1318.71,442% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,1580.6,100% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,2430,Case rate,2430,Case rate,2231.28,72% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% of CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,1859.4,60% of total billed charges,257.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,257.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,156.87,100% OF CMS OPPS RATE,229.22,100% OF CMS OPPS Rate,2169.3,70% of total billed charges,229.22,100% OF CMS OPPS Rate,275.06,120% of CMS OPPS RATE,2231.28,Pays at 72% of billed charges with lesser of charges applied,2231.28,Pays at 72% of billed charges with lesser of charges applied,2231.28,Pays at 72% of billed charges with lesser of charges applied,2231.28,Pays at 72% of billed charges with lesser of charges applied,2231.28,Pays at 72% of billed charges with lesser of charges applied,2231.28,Pays at 72% of billed charges with lesser of charges applied,1318.71,442% of BCBS Fee Schedule,1318.71,442% of BCBS Fee Schedule,1318.71,442% of BCBS Fee Schedule,1318.71,442% of BCBS Fee Schedule,1318.71,442% of BCBS Fee Schedule,1318.71,442% of BCBS Fee Schedule,1318.71,442% of BCBS Fee Schedule,1318.71,442% of BCBS Fee Schedule,1318.71,442% of BCBS Fee Schedule,1580.6,100% of BCBS Fee Schedule,1580.6,100% of BCBS Fee Schedule,1580.6,100% of BCBS Fee Schedule,1580.6,100% of BCBS Fee Schedule,1580.6,100% of BCBS Fee Schedule,2430,Case rate,2430,Case rate,2430,Case rate,2169.3,70% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,257.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,257.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,257.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,257.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,257.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,257.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,257.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,257.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,257.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,257.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,257.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,257.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,257.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,257.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,257.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,257.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,257.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,257.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,257.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,257.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,156.87,2430.00,2324.25
Outpatient Medical Services,CT SCAN,70470,CT HEAD WITH & WITHOUT CONTRAST,351,2754.25,1983.06,Pays at 72% of billed charges with lesser of charges applied,229.22,100% OF CMS OPPS Rate,1317.07,442% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,1580.6,100% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,2430,Case rate,2430,Case rate,1983.06,72% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% of CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,1652.55,60% of total billed charges,241.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,241.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,142.93,100% OF CMS OPPS RATE,229.22,100% OF CMS OPPS Rate,1927.98,70% of total billed charges,229.22,100% OF CMS OPPS Rate,275.06,120% of CMS OPPS RATE,1983.06,Pays at 72% of billed charges with lesser of charges applied,1983.06,Pays at 72% of billed charges with lesser of charges applied,1983.06,Pays at 72% of billed charges with lesser of charges applied,1983.06,Pays at 72% of billed charges with lesser of charges applied,1983.06,Pays at 72% of billed charges with lesser of charges applied,1983.06,Pays at 72% of billed charges with lesser of charges applied,1317.07,442% of BCBS Fee Schedule,1317.07,442% of BCBS Fee Schedule,1317.07,442% of BCBS Fee Schedule,1317.07,442% of BCBS Fee Schedule,1317.07,442% of BCBS Fee Schedule,1317.07,442% of BCBS Fee Schedule,1317.07,442% of BCBS Fee Schedule,1317.07,442% of BCBS Fee Schedule,1317.07,442% of BCBS Fee Schedule,1580.6,100% of BCBS Fee Schedule,1580.6,100% of BCBS Fee Schedule,1580.6,100% of BCBS Fee Schedule,1580.6,100% of BCBS Fee Schedule,1580.6,100% of BCBS Fee Schedule,2430,Case rate,2430,Case rate,2430,Case rate,1927.98,70% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,241.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,241.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,241.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,241.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,241.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,241.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,241.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,241.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,241.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,241.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,241.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,241.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,241.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,241.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,241.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,241.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,241.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,241.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,241.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,241.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,142.93,2430.00,2065.69
Outpatient Medical Services,CT SCAN,70487,CT FACE WITH CONTRAST,351,2524.25,1817.46,Pays at 72% of billed charges with lesser of charges applied,229.22,100% OF CMS OPPS Rate,1057.84,442% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,1262.95,100% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,2430,Case rate,2430,Case rate,1817.46,72% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% of CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,1514.55,60% of total billed charges,210.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,210.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,124.02,100% OF CMS OPPS RATE,229.22,100% OF CMS OPPS Rate,1766.98,70% of total billed charges,229.22,100% OF CMS OPPS Rate,275.06,120% of CMS OPPS RATE,1817.46,Pays at 72% of billed charges with lesser of charges applied,1817.46,Pays at 72% of billed charges with lesser of charges applied,1817.46,Pays at 72% of billed charges with lesser of charges applied,1817.46,Pays at 72% of billed charges with lesser of charges applied,1817.46,Pays at 72% of billed charges with lesser of charges applied,1817.46,Pays at 72% of billed charges with lesser of charges applied,1057.84,442% of BCBS Fee Schedule,1057.84,442% of BCBS Fee Schedule,1057.84,442% of BCBS Fee Schedule,1057.84,442% of BCBS Fee Schedule,1057.84,442% of BCBS Fee Schedule,1057.84,442% of BCBS Fee Schedule,1057.84,442% of BCBS Fee Schedule,1057.84,442% of BCBS Fee Schedule,1057.84,442% of BCBS Fee Schedule,1262.95,100% of BCBS Fee Schedule,1262.95,100% of BCBS Fee Schedule,1262.95,100% of BCBS Fee Schedule,1262.95,100% of BCBS Fee Schedule,1262.95,100% of BCBS Fee Schedule,2430,Case rate,2430,Case rate,2430,Case rate,1766.98,70% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,210.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,210.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,210.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,210.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,210.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,210.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,210.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,210.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,210.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,210.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,210.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,210.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,210.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,210.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,210.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,210.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,210.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,210.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,210.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,210.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,124.02,2430.00,1893.19
Outpatient Medical Services,CT SCAN,70460,CT HEAD WITH CONTRAST,351,2066,1487.52,Pays at 72% of billed charges with lesser of charges applied,229.22,100% OF CMS OPPS Rate,1055.72,442% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,1262.95,100% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,2066,Case rate,2066,Case rate,1487.52,72% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% of CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,1239.6,60% of total billed charges,204.88,100% of CA Medicaid Fee Schedule with lesser of charges applied,204.88,100% of CA Medicaid Fee Schedule with lesser of charges applied,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,118.85,100% OF CMS OPPS RATE,229.22,100% OF CMS OPPS Rate,1446.2,70% of total billed charges,229.22,100% OF CMS OPPS Rate,275.06,120% of CMS OPPS RATE,1487.52,Pays at 72% of billed charges with lesser of charges applied,1487.52,Pays at 72% of billed charges with lesser of charges applied,1487.52,Pays at 72% of billed charges with lesser of charges applied,1487.52,Pays at 72% of billed charges with lesser of charges applied,1487.52,Pays at 72% of billed charges with lesser of charges applied,1487.52,Pays at 72% of billed charges with lesser of charges applied,1055.72,442% of BCBS Fee Schedule,1055.72,442% of BCBS Fee Schedule,1055.72,442% of BCBS Fee Schedule,1055.72,442% of BCBS Fee Schedule,1055.72,442% of BCBS Fee Schedule,1055.72,442% of BCBS Fee Schedule,1055.72,442% of BCBS Fee Schedule,1055.72,442% of BCBS Fee Schedule,1055.72,442% of BCBS Fee Schedule,1262.95,100% of BCBS Fee Schedule,1262.95,100% of BCBS Fee Schedule,1262.95,100% of BCBS Fee Schedule,1262.95,100% of BCBS Fee Schedule,1262.95,100% of BCBS Fee Schedule,2066,Case rate,2066,Case rate,2066,Case rate,1446.2,70% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,204.88,100% of CA Medicaid Fee Schedule with lesser of charges applied,204.88,100% of CA Medicaid Fee Schedule with lesser of charges applied,204.88,100% of CA Medicaid Fee Schedule with lesser of charges applied,204.88,100% of CA Medicaid Fee Schedule with lesser of charges applied,204.88,100% of CA Medicaid Fee Schedule with lesser of charges applied,204.88,100% of CA Medicaid Fee Schedule with lesser of charges applied,204.88,100% of CA Medicaid Fee Schedule with lesser of charges applied,204.88,100% of CA Medicaid Fee Schedule with lesser of charges applied,204.88,100% of CA Medicaid Fee Schedule with lesser of charges applied,204.88,100% of CA Medicaid Fee Schedule with lesser of charges applied,204.88,100% of CA Medicaid Fee Schedule with lesser of charges applied,204.88,100% of CA Medicaid Fee Schedule with lesser of charges applied,204.88,100% of CA Medicaid Fee Schedule with lesser of charges applied,204.88,100% of CA Medicaid Fee Schedule with lesser of charges applied,204.88,100% of CA Medicaid Fee Schedule with lesser of charges applied,204.88,100% of CA Medicaid Fee Schedule with lesser of charges applied,204.88,100% of CA Medicaid Fee Schedule with lesser of charges applied,204.88,100% of CA Medicaid Fee Schedule with lesser of charges applied,204.88,100% of CA Medicaid Fee Schedule with lesser of charges applied,204.88,100% of CA Medicaid Fee Schedule with lesser of charges applied,118.85,2066.00,1549.5
Outpatient Medical Services,CT SCAN,70450,CT scan head or brain without dye,351,1722.75,1240.38,Pays at 72% of billed charges with lesser of charges applied,135.84,100% OF CMS OPPS Rate,880.02,442% of BCBS Fee Schedule,135.84,100% OF CMS OPPS Rate,1055.68,100% of BCBS Fee Schedule,135.84,100% OF CMS OPPS Rate,1722.75,Case rate,1722.75,Case rate,1240.38,72% of total billed charges,135.84,100% OF CMS OPPS Rate,135.84,100% of CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,1033.65,60% of total billed charges,145.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,145.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,83.01,100% OF CMS OPPS RATE,135.84,100% OF CMS OPPS Rate,1205.93,70% of total billed charges,135.84,100% OF CMS OPPS Rate,163.01,120% of CMS OPPS RATE,1240.38,Pays at 72% of billed charges with lesser of charges applied,1240.38,Pays at 72% of billed charges with lesser of charges applied,1240.38,Pays at 72% of billed charges with lesser of charges applied,1240.38,Pays at 72% of billed charges with lesser of charges applied,1240.38,Pays at 72% of billed charges with lesser of charges applied,1240.38,Pays at 72% of billed charges with lesser of charges applied,880.02,442% of BCBS Fee Schedule,880.02,442% of BCBS Fee Schedule,880.02,442% of BCBS Fee Schedule,880.02,442% of BCBS Fee Schedule,880.02,442% of BCBS Fee Schedule,880.02,442% of BCBS Fee Schedule,880.02,442% of BCBS Fee Schedule,880.02,442% of BCBS Fee Schedule,880.02,442% of BCBS Fee Schedule,1055.68,100% of BCBS Fee Schedule,1055.68,100% of BCBS Fee Schedule,1055.68,100% of BCBS Fee Schedule,1055.68,100% of BCBS Fee Schedule,1055.68,100% of BCBS Fee Schedule,1722.75,Case rate,1722.75,Case rate,1722.75,Case rate,1205.93,70% of total billed charges,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,145.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,145.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,145.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,145.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,145.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,145.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,145.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,145.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,145.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,145.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,145.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,145.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,145.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,145.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,145.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,145.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,145.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,145.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,145.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,145.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,83.01,1722.75,1292.06
Outpatient Medical Services,CT SCAN,70496,CT ANGIOGRAPHY HEAD,351,2550,1836,Pays at 72% of billed charges with lesser of charges applied,229.22,100% OF CMS OPPS Rate,1371.35,442% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,2374.74,100% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,2430,Case rate,2430,Case rate,1836,72% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% of CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,1530,60% of total billed charges,381.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,381.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,242.47,100% OF CMS OPPS RATE,229.22,100% OF CMS OPPS Rate,1785,70% of total billed charges,229.22,100% OF CMS OPPS Rate,275.06,120% of CMS OPPS RATE,1836,Pays at 72% of billed charges with lesser of charges applied,1836,Pays at 72% of billed charges with lesser of charges applied,1836,Pays at 72% of billed charges with lesser of charges applied,1836,Pays at 72% of billed charges with lesser of charges applied,1836,Pays at 72% of billed charges with lesser of charges applied,1836,Pays at 72% of billed charges with lesser of charges applied,1371.35,442% of BCBS Fee Schedule,1371.35,442% of BCBS Fee Schedule,1371.35,442% of BCBS Fee Schedule,1371.35,442% of BCBS Fee Schedule,1371.35,442% of BCBS Fee Schedule,1371.35,442% of BCBS Fee Schedule,1371.35,442% of BCBS Fee Schedule,1371.35,442% of BCBS Fee Schedule,1371.35,442% of BCBS Fee Schedule,2374.74,100% of BCBS Fee Schedule,2374.74,100% of BCBS Fee Schedule,2374.74,100% of BCBS Fee Schedule,2374.74,100% of BCBS Fee Schedule,2374.74,100% of BCBS Fee Schedule,2430,Case rate,2430,Case rate,2430,Case rate,1785,70% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,381.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,381.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,381.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,381.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,381.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,381.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,381.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,381.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,381.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,381.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,381.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,381.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,381.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,381.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,381.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,381.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,381.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,381.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,381.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,381.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,229.22,2430.00,1912.5
Outpatient Medical Services,CT SCAN,70498,CT ANGIOGRAPHY NECK,351,2550,1836,Pays at 72% of billed charges with lesser of charges applied,229.22,100% OF CMS OPPS Rate,1371.35,442% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,2374.74,100% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,2430,Case rate,2430,Case rate,1836,72% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% of CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,1530,60% of total billed charges,380.37,100% of CA Medicaid Fee Schedule with lesser of charges applied,380.37,100% of CA Medicaid Fee Schedule with lesser of charges applied,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,242.07,100% OF CMS OPPS RATE,229.22,100% OF CMS OPPS Rate,1785,70% of total billed charges,229.22,100% OF CMS OPPS Rate,275.06,120% of CMS OPPS RATE,1836,Pays at 72% of billed charges with lesser of charges applied,1836,Pays at 72% of billed charges with lesser of charges applied,1836,Pays at 72% of billed charges with lesser of charges applied,1836,Pays at 72% of billed charges with lesser of charges applied,1836,Pays at 72% of billed charges with lesser of charges applied,1836,Pays at 72% of billed charges with lesser of charges applied,1371.35,442% of BCBS Fee Schedule,1371.35,442% of BCBS Fee Schedule,1371.35,442% of BCBS Fee Schedule,1371.35,442% of BCBS Fee Schedule,1371.35,442% of BCBS Fee Schedule,1371.35,442% of BCBS Fee Schedule,1371.35,442% of BCBS Fee Schedule,1371.35,442% of BCBS Fee Schedule,1371.35,442% of BCBS Fee Schedule,2374.74,100% of BCBS Fee Schedule,2374.74,100% of BCBS Fee Schedule,2374.74,100% of BCBS Fee Schedule,2374.74,100% of BCBS Fee Schedule,2374.74,100% of BCBS Fee Schedule,2430,Case rate,2430,Case rate,2430,Case rate,1785,70% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,380.37,100% of CA Medicaid Fee Schedule with lesser of charges applied,380.37,100% of CA Medicaid Fee Schedule with lesser of charges applied,380.37,100% of CA Medicaid Fee Schedule with lesser of charges applied,380.37,100% of CA Medicaid Fee Schedule with lesser of charges applied,380.37,100% of CA Medicaid Fee Schedule with lesser of charges applied,380.37,100% of CA Medicaid Fee Schedule with lesser of charges applied,380.37,100% of CA Medicaid Fee Schedule with lesser of charges applied,380.37,100% of CA Medicaid Fee Schedule with lesser of charges applied,380.37,100% of CA Medicaid Fee Schedule with lesser of charges applied,380.37,100% of CA Medicaid Fee Schedule with lesser of charges applied,380.37,100% of CA Medicaid Fee Schedule with lesser of charges applied,380.37,100% of CA Medicaid Fee Schedule with lesser of charges applied,380.37,100% of CA Medicaid Fee Schedule with lesser of charges applied,380.37,100% of CA Medicaid Fee Schedule with lesser of charges applied,380.37,100% of CA Medicaid Fee Schedule with lesser of charges applied,380.37,100% of CA Medicaid Fee Schedule with lesser of charges applied,380.37,100% of CA Medicaid Fee Schedule with lesser of charges applied,380.37,100% of CA Medicaid Fee Schedule with lesser of charges applied,380.37,100% of CA Medicaid Fee Schedule with lesser of charges applied,380.37,100% of CA Medicaid Fee Schedule with lesser of charges applied,229.22,2430.00,1912.5
Outpatient Medical Services,CT SCAN,73706,"CTA LOWER EXTREMITY-BILAT w/o AND/ OR w/ CONTRAST, w/ POST PROCESSING",351,3167,2280.24,Pays at 72% of billed charges with lesser of charges applied,229.22,100% OF CMS OPPS Rate,1415.28,442% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,2420.68,100% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,2430,Case rate,2430,Case rate,2280.24,72% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% of CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,1900.2,60% of total billed charges,453.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,453.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,294.63,100% OF CMS OPPS RATE,229.22,100% OF CMS OPPS Rate,2216.9,70% of total billed charges,229.22,100% OF CMS OPPS Rate,275.06,120% of CMS OPPS RATE,2280.24,Pays at 72% of billed charges with lesser of charges applied,2280.24,Pays at 72% of billed charges with lesser of charges applied,2280.24,Pays at 72% of billed charges with lesser of charges applied,2280.24,Pays at 72% of billed charges with lesser of charges applied,2280.24,Pays at 72% of billed charges with lesser of charges applied,2280.24,Pays at 72% of billed charges with lesser of charges applied,1415.28,442% of BCBS Fee Schedule,1415.28,442% of BCBS Fee Schedule,1415.28,442% of BCBS Fee Schedule,1415.28,442% of BCBS Fee Schedule,1415.28,442% of BCBS Fee Schedule,1415.28,442% of BCBS Fee Schedule,1415.28,442% of BCBS Fee Schedule,1415.28,442% of BCBS Fee Schedule,1415.28,442% of BCBS Fee Schedule,2420.68,100% of BCBS Fee Schedule,2420.68,100% of BCBS Fee Schedule,2420.68,100% of BCBS Fee Schedule,2420.68,100% of BCBS Fee Schedule,2420.68,100% of BCBS Fee Schedule,2430,Case rate,2430,Case rate,2430,Case rate,2216.9,70% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,453.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,453.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,453.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,453.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,453.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,453.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,453.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,453.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,453.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,453.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,453.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,453.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,453.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,453.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,453.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,453.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,453.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,453.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,453.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,453.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,229.22,2430.00,2375.25
Outpatient Medical Services,CT SCAN,73206,"CTA UPPER EXTREMITY-BILAT w/o AND/ OR w/ CONTRAST, w/ POST PROCESSING",351,3167,2280.24,Pays at 72% of billed charges with lesser of charges applied,229.22,100% OF CMS OPPS Rate,1415.28,442% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,2420.68,100% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,2430,Case rate,2430,Case rate,2280.24,72% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% of CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,1900.2,60% of total billed charges,417.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,417.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,267.56,100% OF CMS OPPS RATE,229.22,100% OF CMS OPPS Rate,2216.9,70% of total billed charges,229.22,100% OF CMS OPPS Rate,275.06,120% of CMS OPPS RATE,2280.24,Pays at 72% of billed charges with lesser of charges applied,2280.24,Pays at 72% of billed charges with lesser of charges applied,2280.24,Pays at 72% of billed charges with lesser of charges applied,2280.24,Pays at 72% of billed charges with lesser of charges applied,2280.24,Pays at 72% of billed charges with lesser of charges applied,2280.24,Pays at 72% of billed charges with lesser of charges applied,1415.28,442% of BCBS Fee Schedule,1415.28,442% of BCBS Fee Schedule,1415.28,442% of BCBS Fee Schedule,1415.28,442% of BCBS Fee Schedule,1415.28,442% of BCBS Fee Schedule,1415.28,442% of BCBS Fee Schedule,1415.28,442% of BCBS Fee Schedule,1415.28,442% of BCBS Fee Schedule,1415.28,442% of BCBS Fee Schedule,2420.68,100% of BCBS Fee Schedule,2420.68,100% of BCBS Fee Schedule,2420.68,100% of BCBS Fee Schedule,2420.68,100% of BCBS Fee Schedule,2420.68,100% of BCBS Fee Schedule,2430,Case rate,2430,Case rate,2430,Case rate,2216.9,70% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,417.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,417.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,417.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,417.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,417.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,417.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,417.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,417.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,417.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,417.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,417.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,417.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,417.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,417.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,417.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,417.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,417.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,417.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,417.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,417.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,229.22,2430.00,2375.25
Outpatient Medical Services,CT SCAN,75635,"CTA ABD/PELVIS w/ LOWER EXTREMITY RUNOFF, w/ POST PROCESSING",351,2940.25,2116.98,Pays at 72% of billed charges with lesser of charges applied,229.22,100% OF CMS OPPS Rate,1612.28,442% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,2884.39,pays at 100% of bcbs fee schedule with lesser of charges applied,229.22,100% OF CMS OPPS Rate,2430,Case rate,2430,Case rate,2116.98,72% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% of CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,1764.15,60% of total billed charges,491.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,491.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,329.88,100% OF CMS OPPS RATE,229.22,100% OF CMS OPPS Rate,2058.18,70% of total billed charges,229.22,100% OF CMS OPPS Rate,275.07,120% of CMS OPPS RATE,2116.98,Pays at 72% of billed charges with lesser of charges applied,2116.98,Pays at 72% of billed charges with lesser of charges applied,2116.98,Pays at 72% of billed charges with lesser of charges applied,2116.98,Pays at 72% of billed charges with lesser of charges applied,2116.98,Pays at 72% of billed charges with lesser of charges applied,2116.98,Pays at 72% of billed charges with lesser of charges applied,1612.28,442% of BCBS Fee Schedule,1612.28,442% of BCBS Fee Schedule,1612.28,442% of BCBS Fee Schedule,1612.28,442% of BCBS Fee Schedule,1612.28,442% of BCBS Fee Schedule,1612.28,442% of BCBS Fee Schedule,1612.28,442% of BCBS Fee Schedule,1612.28,442% of BCBS Fee Schedule,1612.28,442% of BCBS Fee Schedule,2884.39,pays at 100% of bcbs fee schedule with lesser of charges applied,2884.39,pays at 100% of bcbs fee schedule with lesser of charges applied,2884.39,pays at 100% of bcbs fee schedule with lesser of charges applied,2884.39,pays at 100% of bcbs fee schedule with lesser of charges applied,2884.39,pays at 100% of bcbs fee schedule with lesser of charges applied,2430,Case rate,2430,Case rate,2430,Case rate,2058.18,70% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,491.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,491.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,491.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,491.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,491.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,491.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,491.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,491.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,491.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,491.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,491.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,491.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,491.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,491.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,491.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,491.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,491.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,491.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,491.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,491.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,229.22,2884.39,2205.19
Outpatient Medical Services,CT SCAN,73702,"CT LOWER EXTREMITY, BILAT w/o AND w/ CONTRAST",351,4958.25,3569.94,Pays at 72% of billed charges with lesser of charges applied,229.22,100% OF CMS OPPS Rate,1381.91,442% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,1658.79,100% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,2430,Case rate,2430,Case rate,3569.94,72% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% of CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,2974.95,60% of total billed charges,271.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,271.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,173.2,100% OF CMS OPPS RATE,229.22,100% OF CMS OPPS Rate,3470.78,70% of total billed charges,229.22,100% OF CMS OPPS Rate,275.06,120% of CMS OPPS RATE,3569.94,Pays at 72% of billed charges with lesser of charges applied,3569.94,Pays at 72% of billed charges with lesser of charges applied,3569.94,Pays at 72% of billed charges with lesser of charges applied,3569.94,Pays at 72% of billed charges with lesser of charges applied,3569.94,Pays at 72% of billed charges with lesser of charges applied,3569.94,Pays at 72% of billed charges with lesser of charges applied,1381.91,442% of BCBS Fee Schedule,1381.91,442% of BCBS Fee Schedule,1381.91,442% of BCBS Fee Schedule,1381.91,442% of BCBS Fee Schedule,1381.91,442% of BCBS Fee Schedule,1381.91,442% of BCBS Fee Schedule,1381.91,442% of BCBS Fee Schedule,1381.91,442% of BCBS Fee Schedule,1381.91,442% of BCBS Fee Schedule,1658.79,100% of BCBS Fee Schedule,1658.79,100% of BCBS Fee Schedule,1658.79,100% of BCBS Fee Schedule,1658.79,100% of BCBS Fee Schedule,1658.79,100% of BCBS Fee Schedule,2430,Case rate,2430,Case rate,2430,Case rate,3470.78,70% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,271.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,271.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,271.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,271.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,271.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,271.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,271.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,271.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,271.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,271.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,271.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,271.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,271.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,271.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,271.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,271.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,271.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,271.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,271.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,271.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,173.20,3569.94,3718.69
Outpatient Medical Services,CT SCAN,73202,CT UPPER EXTREMITY BILAT w/o AND w/ CONTRAST,351,6200.25,4464.18,Pays at 72% of billed charges with lesser of charges applied,229.22,100% OF CMS OPPS Rate,1381.91,442% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,1658.79,100% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,2430,Case rate,2430,Case rate,4464.18,72% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% of CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,3720.15,60% of total billed charges,354.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,354.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,241.28,100% OF CMS OPPS RATE,229.22,100% OF CMS OPPS Rate,4340.18,70% of total billed charges,229.22,100% OF CMS OPPS Rate,275.06,120% of CMS OPPS RATE,4464.18,Pays at 72% of billed charges with lesser of charges applied,4464.18,Pays at 72% of billed charges with lesser of charges applied,4464.18,Pays at 72% of billed charges with lesser of charges applied,4464.18,Pays at 72% of billed charges with lesser of charges applied,4464.18,Pays at 72% of billed charges with lesser of charges applied,4464.18,Pays at 72% of billed charges with lesser of charges applied,1381.91,442% of BCBS Fee Schedule,1381.91,442% of BCBS Fee Schedule,1381.91,442% of BCBS Fee Schedule,1381.91,442% of BCBS Fee Schedule,1381.91,442% of BCBS Fee Schedule,1381.91,442% of BCBS Fee Schedule,1381.91,442% of BCBS Fee Schedule,1381.91,442% of BCBS Fee Schedule,1381.91,442% of BCBS Fee Schedule,1658.79,100% of BCBS Fee Schedule,1658.79,100% of BCBS Fee Schedule,1658.79,100% of BCBS Fee Schedule,1658.79,100% of BCBS Fee Schedule,1658.79,100% of BCBS Fee Schedule,2430,Case rate,2430,Case rate,2430,Case rate,4340.18,70% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,354.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,354.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,354.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,354.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,354.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,354.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,354.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,354.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,354.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,354.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,354.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,354.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,354.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,354.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,354.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,354.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,354.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,354.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,354.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,354.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,229.22,4464.18,4650.19
Outpatient Medical Services,CT SCAN,73700,CT scan of leg without dye,351,3305,2379.6,Pays at 72% of billed charges with lesser of charges applied,135.84,100% OF CMS OPPS Rate,926.08,442% of BCBS Fee Schedule,135.84,100% OF CMS OPPS Rate,1105.04,100% of BCBS Fee Schedule,135.84,100% OF CMS OPPS Rate,2430,Case rate,2430,Case rate,2379.6,72% of total billed charges,135.84,100% OF CMS OPPS Rate,135.84,100% of CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,1983,60% of total billed charges,178.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,178.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,103.72,100% OF CMS OPPS RATE,135.84,100% OF CMS OPPS Rate,2313.5,70% of total billed charges,135.84,100% OF CMS OPPS Rate,163.01,120% of CMS OPPS RATE,2379.6,Pays at 72% of billed charges with lesser of charges applied,2379.6,Pays at 72% of billed charges with lesser of charges applied,2379.6,Pays at 72% of billed charges with lesser of charges applied,2379.6,Pays at 72% of billed charges with lesser of charges applied,2379.6,Pays at 72% of billed charges with lesser of charges applied,2379.6,Pays at 72% of billed charges with lesser of charges applied,926.08,442% of BCBS Fee Schedule,926.08,442% of BCBS Fee Schedule,926.08,442% of BCBS Fee Schedule,926.08,442% of BCBS Fee Schedule,926.08,442% of BCBS Fee Schedule,926.08,442% of BCBS Fee Schedule,926.08,442% of BCBS Fee Schedule,926.08,442% of BCBS Fee Schedule,926.08,442% of BCBS Fee Schedule,1105.04,100% of BCBS Fee Schedule,1105.04,100% of BCBS Fee Schedule,1105.04,100% of BCBS Fee Schedule,1105.04,100% of BCBS Fee Schedule,1105.04,100% of BCBS Fee Schedule,2430,Case rate,2430,Case rate,2430,Case rate,2313.5,70% of total billed charges,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,178.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,178.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,178.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,178.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,178.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,178.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,178.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,178.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,178.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,178.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,178.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,178.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,178.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,178.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,178.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,178.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,178.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,178.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,178.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,178.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,103.72,2430.00,2478.75
Outpatient Medical Services,CT SCAN,73701,CT LOWER EXTREMITY-BILAT w/ CONTRAST,351,4038.5,2907.72,Pays at 72% of billed charges with lesser of charges applied,229.22,100% OF CMS OPPS Rate,1101.24,442% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,1320.29,100% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,2430,Case rate,2430,Case rate,2907.72,72% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% of CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,2423.1,60% of total billed charges,231.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,231.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,140.54,100% OF CMS OPPS RATE,229.22,100% OF CMS OPPS Rate,2826.95,70% of total billed charges,229.22,100% OF CMS OPPS Rate,275.06,120% of CMS OPPS RATE,2907.72,Pays at 72% of billed charges with lesser of charges applied,2907.72,Pays at 72% of billed charges with lesser of charges applied,2907.72,Pays at 72% of billed charges with lesser of charges applied,2907.72,Pays at 72% of billed charges with lesser of charges applied,2907.72,Pays at 72% of billed charges with lesser of charges applied,2907.72,Pays at 72% of billed charges with lesser of charges applied,1101.24,442% of BCBS Fee Schedule,1101.24,442% of BCBS Fee Schedule,1101.24,442% of BCBS Fee Schedule,1101.24,442% of BCBS Fee Schedule,1101.24,442% of BCBS Fee Schedule,1101.24,442% of BCBS Fee Schedule,1101.24,442% of BCBS Fee Schedule,1101.24,442% of BCBS Fee Schedule,1101.24,442% of BCBS Fee Schedule,1320.29,100% of BCBS Fee Schedule,1320.29,100% of BCBS Fee Schedule,1320.29,100% of BCBS Fee Schedule,1320.29,100% of BCBS Fee Schedule,1320.29,100% of BCBS Fee Schedule,2430,Case rate,2430,Case rate,2430,Case rate,2826.95,70% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,231.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,231.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,231.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,231.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,231.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,231.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,231.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,231.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,231.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,231.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,231.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,231.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,231.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,231.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,231.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,231.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,231.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,231.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,231.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,231.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,140.54,2907.72,3028.88
Outpatient Medical Services,CT SCAN,73201,CT UPPER EXTREMITY-BILAT w/ CONTRAST,352,4038.5,2907.72,Pays at 72% of billed charges with lesser of charges applied,468.3,100% OF CMS OPPS Rate,1101.24,442% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,1320.29,100% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,2430,Case rate,2430,Case rate,2907.72,72% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% of CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,2423.1,60% of total billed charges,282.25,100% of CA Medicaid Fee Schedule with lesser of charges applied,282.25,100% of CA Medicaid Fee Schedule with lesser of charges applied,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,184.34,100% OF CMS OPPS RATE,468.3,100% OF CMS OPPS Rate,2826.95,70% of total billed charges,468.3,100% OF CMS OPPS Rate,561.95,120% of CMS OPPS RATE,2907.72,Pays at 72% of billed charges with lesser of charges applied,2907.72,Pays at 72% of billed charges with lesser of charges applied,2907.72,Pays at 72% of billed charges with lesser of charges applied,2907.72,Pays at 72% of billed charges with lesser of charges applied,2907.72,Pays at 72% of billed charges with lesser of charges applied,2907.72,Pays at 72% of billed charges with lesser of charges applied,1101.24,442% of BCBS Fee Schedule,1101.24,442% of BCBS Fee Schedule,1101.24,442% of BCBS Fee Schedule,1101.24,442% of BCBS Fee Schedule,1101.24,442% of BCBS Fee Schedule,1101.24,442% of BCBS Fee Schedule,1101.24,442% of BCBS Fee Schedule,1101.24,442% of BCBS Fee Schedule,1101.24,442% of BCBS Fee Schedule,1320.29,100% of BCBS Fee Schedule,1320.29,100% of BCBS Fee Schedule,1320.29,100% of BCBS Fee Schedule,1320.29,100% of BCBS Fee Schedule,1320.29,100% of BCBS Fee Schedule,2430,Case rate,2430,Case rate,2430,Case rate,2826.95,70% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,282.25,100% of CA Medicaid Fee Schedule with lesser of charges applied,282.25,100% of CA Medicaid Fee Schedule with lesser of charges applied,282.25,100% of CA Medicaid Fee Schedule with lesser of charges applied,282.25,100% of CA Medicaid Fee Schedule with lesser of charges applied,282.25,100% of CA Medicaid Fee Schedule with lesser of charges applied,282.25,100% of CA Medicaid Fee Schedule with lesser of charges applied,282.25,100% of CA Medicaid Fee Schedule with lesser of charges applied,282.25,100% of CA Medicaid Fee Schedule with lesser of charges applied,282.25,100% of CA Medicaid Fee Schedule with lesser of charges applied,282.25,100% of CA Medicaid Fee Schedule with lesser of charges applied,282.25,100% of CA Medicaid Fee Schedule with lesser of charges applied,282.25,100% of CA Medicaid Fee Schedule with lesser of charges applied,282.25,100% of CA Medicaid Fee Schedule with lesser of charges applied,282.25,100% of CA Medicaid Fee Schedule with lesser of charges applied,282.25,100% of CA Medicaid Fee Schedule with lesser of charges applied,282.25,100% of CA Medicaid Fee Schedule with lesser of charges applied,282.25,100% of CA Medicaid Fee Schedule with lesser of charges applied,282.25,100% of CA Medicaid Fee Schedule with lesser of charges applied,282.25,100% of CA Medicaid Fee Schedule with lesser of charges applied,282.25,100% of CA Medicaid Fee Schedule with lesser of charges applied,184.34,2907.72,3028.88
Outpatient Medical Services,CT SCAN,73200,CT UPPER EXTREMITY-LT w/o CONTRAST,352,2066,1487.52,Pays at 72% of billed charges with lesser of charges applied,135.84,100% OF CMS OPPS Rate,926.08,442% of BCBS Fee Schedule,135.84,100% OF CMS OPPS Rate,1105.04,100% of BCBS Fee Schedule,135.84,100% OF CMS OPPS Rate,2066,Case rate,2066,Case rate,1487.52,72% of total billed charges,135.84,100% OF CMS OPPS Rate,135.84,100% of CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,1239.6,60% of total billed charges,227.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,227.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,144.33,100% OF CMS OPPS RATE,135.84,100% OF CMS OPPS Rate,1446.2,70% of total billed charges,135.84,100% OF CMS OPPS Rate,163.01,120% of CMS OPPS RATE,1487.52,Pays at 72% of billed charges with lesser of charges applied,1487.52,Pays at 72% of billed charges with lesser of charges applied,1487.52,Pays at 72% of billed charges with lesser of charges applied,1487.52,Pays at 72% of billed charges with lesser of charges applied,1487.52,Pays at 72% of billed charges with lesser of charges applied,1487.52,Pays at 72% of billed charges with lesser of charges applied,926.08,442% of BCBS Fee Schedule,926.08,442% of BCBS Fee Schedule,926.08,442% of BCBS Fee Schedule,926.08,442% of BCBS Fee Schedule,926.08,442% of BCBS Fee Schedule,926.08,442% of BCBS Fee Schedule,926.08,442% of BCBS Fee Schedule,926.08,442% of BCBS Fee Schedule,926.08,442% of BCBS Fee Schedule,1105.04,100% of BCBS Fee Schedule,1105.04,100% of BCBS Fee Schedule,1105.04,100% of BCBS Fee Schedule,1105.04,100% of BCBS Fee Schedule,1105.04,100% of BCBS Fee Schedule,2066,Case rate,2066,Case rate,2066,Case rate,1446.2,70% of total billed charges,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,227.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,227.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,227.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,227.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,227.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,227.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,227.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,227.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,227.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,227.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,227.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,227.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,227.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,227.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,227.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,227.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,227.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,227.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,227.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,227.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.84,2066.00,1549.5
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",352,4203.5,3026.52,Pays at 72% of billed charges with lesser of charges applied,468.3,100% OF CMS OPPS Rate,1741.7,442% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,2098.33,100% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,2430,Case rate,2430,Case rate,3026.52,72% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% of CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,2522.1,60% of total billed charges,457.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,457.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,311.36,100% OF CMS OPPS RATE,468.3,100% OF CMS OPPS Rate,2942.45,70% of total billed charges,468.3,100% OF CMS OPPS Rate,561.95,120% of CMS OPPS RATE,3026.52,Pays at 72% of billed charges with lesser of charges applied,3026.52,Pays at 72% of billed charges with lesser of charges applied,3026.52,Pays at 72% of billed charges with lesser of charges applied,3026.52,Pays at 72% of billed charges with lesser of charges applied,3026.52,Pays at 72% of billed charges with lesser of charges applied,3026.52,Pays at 72% of billed charges with lesser of charges applied,1741.7,442% of BCBS Fee Schedule,1741.7,442% of BCBS Fee Schedule,1741.7,442% of BCBS Fee Schedule,1741.7,442% of BCBS Fee Schedule,1741.7,442% of BCBS Fee Schedule,1741.7,442% of BCBS Fee Schedule,1741.7,442% of BCBS Fee Schedule,1741.7,442% of BCBS Fee Schedule,1741.7,442% of BCBS Fee Schedule,2098.33,100% of BCBS Fee Schedule,2098.33,100% of BCBS Fee Schedule,2098.33,100% of BCBS Fee Schedule,2098.33,100% of BCBS Fee Schedule,2098.33,100% of BCBS Fee Schedule,2430,Case rate,2430,Case rate,2430,Case rate,2942.45,70% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,457.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,457.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,457.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,457.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,457.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,457.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,457.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,457.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,457.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,457.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,457.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,457.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,457.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,457.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,457.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,457.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,457.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,457.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,457.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,457.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,311.36,3026.52,3152.63
Outpatient Medical Services,CT SCAN,72191,CT ANGIOGRAPHY PELVIC W CONTRAST,352,2256.5,1624.68,Pays at 72% of billed charges with lesser of charges applied,229.22,100% OF CMS OPPS Rate,1612.28,442% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,2213.63,pays at 100% of bcbs fee schedule with lesser of charges applied,229.22,100% OF CMS OPPS Rate,2256.5,Case rate,2256.5,Case rate,1624.68,72% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% of CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,1353.9,60% of total billed charges,394.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,394.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,277.11,100% OF CMS OPPS RATE,229.22,100% OF CMS OPPS Rate,1579.55,70% of total billed charges,229.22,100% OF CMS OPPS Rate,275.06,120% of CMS OPPS RATE,1624.68,Pays at 72% of billed charges with lesser of charges applied,1624.68,Pays at 72% of billed charges with lesser of charges applied,1624.68,Pays at 72% of billed charges with lesser of charges applied,1624.68,Pays at 72% of billed charges with lesser of charges applied,1624.68,Pays at 72% of billed charges with lesser of charges applied,1624.68,Pays at 72% of billed charges with lesser of charges applied,1612.28,442% of BCBS Fee Schedule,1612.28,442% of BCBS Fee Schedule,1612.28,442% of BCBS Fee Schedule,1612.28,442% of BCBS Fee Schedule,1612.28,442% of BCBS Fee Schedule,1612.28,442% of BCBS Fee Schedule,1612.28,442% of BCBS Fee Schedule,1612.28,442% of BCBS Fee Schedule,1612.28,442% of BCBS Fee Schedule,2213.63,pays at 100% of bcbs fee schedule with lesser of charges applied,2213.63,pays at 100% of bcbs fee schedule with lesser of charges applied,2213.63,pays at 100% of bcbs fee schedule with lesser of charges applied,2213.63,pays at 100% of bcbs fee schedule with lesser of charges applied,2213.63,pays at 100% of bcbs fee schedule with lesser of charges applied,2256.5,Case rate,2256.5,Case rate,2256.5,Case rate,1579.55,70% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,394.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,394.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,394.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,394.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,394.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,394.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,394.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,394.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,394.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,394.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,394.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,394.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,394.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,394.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,394.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,394.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,394.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,394.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,394.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,394.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,229.22,2256.50,1692.38
Outpatient Medical Services,CT SCAN,74150,CT of abdomen without dye,352,1147.5,826.2,Pays at 72% of billed charges with lesser of charges applied,135.84,100% OF CMS OPPS Rate,1056.2,442% of BCBS Fee Schedule,135.84,100% OF CMS OPPS Rate,1125.7,pays at 100% of bcbs fee schedule with lesser of charges applied,135.84,100% OF CMS OPPS Rate,1147.5,Case rate,1147.5,Case rate,826.2,72% of total billed charges,135.84,100% OF CMS OPPS Rate,135.84,100% of CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,688.5,60% of total billed charges,188.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,188.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,101.73,100% OF CMS OPPS RATE,135.84,100% OF CMS OPPS Rate,803.25,70% of total billed charges,135.84,100% OF CMS OPPS Rate,163.01,120% of CMS OPPS RATE,826.2,Pays at 72% of billed charges with lesser of charges applied,826.2,Pays at 72% of billed charges with lesser of charges applied,826.2,Pays at 72% of billed charges with lesser of charges applied,826.2,Pays at 72% of billed charges with lesser of charges applied,826.2,Pays at 72% of billed charges with lesser of charges applied,826.2,Pays at 72% of billed charges with lesser of charges applied,1056.2,442% of BCBS Fee Schedule,1056.2,442% of BCBS Fee Schedule,1056.2,442% of BCBS Fee Schedule,1056.2,442% of BCBS Fee Schedule,1056.2,442% of BCBS Fee Schedule,1056.2,442% of BCBS Fee Schedule,1056.2,442% of BCBS Fee Schedule,1056.2,442% of BCBS Fee Schedule,1056.2,442% of BCBS Fee Schedule,1125.7,pays at 100% of bcbs fee schedule with lesser of charges applied,1125.7,pays at 100% of bcbs fee schedule with lesser of charges applied,1125.7,pays at 100% of bcbs fee schedule with lesser of charges applied,1125.7,pays at 100% of bcbs fee schedule with lesser of charges applied,1125.7,pays at 100% of bcbs fee schedule with lesser of charges applied,1147.5,Case rate,1147.5,Case rate,1147.5,Case rate,803.25,70% of total billed charges,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,188.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,188.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,188.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,188.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,188.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,188.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,188.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,188.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,188.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,188.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,188.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,188.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,188.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,188.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,188.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,188.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,188.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,188.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,188.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,188.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,101.73,1147.50,860.63
Outpatient Medical Services,CT SCAN,72192,CT of pelvis without dye,352,1147.5,826.2,Pays at 72% of billed charges with lesser of charges applied,135.84,100% OF CMS OPPS Rate,1100.67,442% of BCBS Fee Schedule,135.84,100% OF CMS OPPS Rate,1125.7,pays at 100% of bcbs fee schedule with lesser of charges applied,135.84,100% OF CMS OPPS Rate,1147.5,Case rate,1147.5,Case rate,826.2,72% of total billed charges,135.84,100% OF CMS OPPS Rate,135.84,100% of CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,688.5,60% of total billed charges,183.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,183.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,102.92,100% OF CMS OPPS RATE,135.84,100% OF CMS OPPS Rate,803.25,70% of total billed charges,135.84,100% OF CMS OPPS Rate,163.01,120% of CMS OPPS RATE,826.2,Pays at 72% of billed charges with lesser of charges applied,826.2,Pays at 72% of billed charges with lesser of charges applied,826.2,Pays at 72% of billed charges with lesser of charges applied,826.2,Pays at 72% of billed charges with lesser of charges applied,826.2,Pays at 72% of billed charges with lesser of charges applied,826.2,Pays at 72% of billed charges with lesser of charges applied,1100.67,442% of BCBS Fee Schedule,1100.67,442% of BCBS Fee Schedule,1100.67,442% of BCBS Fee Schedule,1100.67,442% of BCBS Fee Schedule,1100.67,442% of BCBS Fee Schedule,1100.67,442% of BCBS Fee Schedule,1100.67,442% of BCBS Fee Schedule,1100.67,442% of BCBS Fee Schedule,1100.67,442% of BCBS Fee Schedule,1125.7,pays at 100% of bcbs fee schedule with lesser of charges applied,1125.7,pays at 100% of bcbs fee schedule with lesser of charges applied,1125.7,pays at 100% of bcbs fee schedule with lesser of charges applied,1125.7,pays at 100% of bcbs fee schedule with lesser of charges applied,1125.7,pays at 100% of bcbs fee schedule with lesser of charges applied,1147.5,Case rate,1147.5,Case rate,1147.5,Case rate,803.25,70% of total billed charges,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,183.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,183.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,183.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,183.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,183.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,183.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,183.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,183.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,183.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,183.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,183.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,183.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,183.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,183.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,183.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,183.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,183.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,183.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,183.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,183.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,102.92,1147.50,860.63
Outpatient Medical Services,CT SCAN,74160,CT of abdomen with dye,352,1493.25,1075.14,Pays at 72% of billed charges with lesser of charges applied,229.22,100% OF CMS OPPS Rate,1273.71,442% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,1464.88,pays at 100% of bcbs fee schedule with lesser of charges applied,229.22,100% OF CMS OPPS Rate,1493.25,Case rate,1493.25,Case rate,1075.14,72% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% of CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,895.95,60% of total billed charges,299.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,299.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,219.38,100% OF CMS OPPS RATE,229.22,100% OF CMS OPPS Rate,1045.28,70% of total billed charges,229.22,100% OF CMS OPPS Rate,275.06,120% of CMS OPPS RATE,1075.14,Pays at 72% of billed charges with lesser of charges applied,1075.14,Pays at 72% of billed charges with lesser of charges applied,1075.14,Pays at 72% of billed charges with lesser of charges applied,1075.14,Pays at 72% of billed charges with lesser of charges applied,1075.14,Pays at 72% of billed charges with lesser of charges applied,1075.14,Pays at 72% of billed charges with lesser of charges applied,1273.71,442% of BCBS Fee Schedule,1273.71,442% of BCBS Fee Schedule,1273.71,442% of BCBS Fee Schedule,1273.71,442% of BCBS Fee Schedule,1273.71,442% of BCBS Fee Schedule,1273.71,442% of BCBS Fee Schedule,1273.71,442% of BCBS Fee Schedule,1273.71,442% of BCBS Fee Schedule,1273.71,442% of BCBS Fee Schedule,1464.88,pays at 100% of bcbs fee schedule with lesser of charges applied,1464.88,pays at 100% of bcbs fee schedule with lesser of charges applied,1464.88,pays at 100% of bcbs fee schedule with lesser of charges applied,1464.88,pays at 100% of bcbs fee schedule with lesser of charges applied,1464.88,pays at 100% of bcbs fee schedule with lesser of charges applied,1493.25,Case rate,1493.25,Case rate,1493.25,Case rate,1045.28,70% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,299.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,299.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,299.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,299.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,299.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,299.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,299.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,299.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,299.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,299.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,299.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,299.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,299.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,299.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,299.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,299.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,299.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,299.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,299.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,299.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,219.38,1493.25,1119.94
Outpatient Medical Services,CT SCAN,71271,CT CHEST W/O CONTRAST LUNG SCR,352,2066,1487.52,Pays at 72% of billed charges with lesser of charges applied,135.84,100% OF CMS OPPS Rate,1687.92,81.7% of total Billed charges,135.84,100% OF CMS OPPS Rate,600.31,100% of BCBS Fee Schedule,135.84,100% OF CMS OPPS Rate,2066,Case rate,2066,Case rate,1487.52,72% of total billed charges,135.84,100% OF CMS OPPS Rate,135.84,100% of CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,1239.6,60% of total billed charges,189.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,189.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,108.89,100% OF CMS OPPS RATE,135.84,100% OF CMS OPPS Rate,1446.2,70% of total billed charges,135.84,100% OF CMS OPPS Rate,163.01,120% of CMS OPPS RATE,1487.52,Pays at 72% of billed charges with lesser of charges applied,1487.52,Pays at 72% of billed charges with lesser of charges applied,1487.52,Pays at 72% of billed charges with lesser of charges applied,1487.52,Pays at 72% of billed charges with lesser of charges applied,1487.52,Pays at 72% of billed charges with lesser of charges applied,1487.52,Pays at 72% of billed charges with lesser of charges applied,1687.92,81.7% of total Billed charges,1687.92,81.7% of total Billed charges,1687.92,81.7% of total Billed charges,1687.92,81.7% of total Billed charges,1687.92,81.7% of total Billed charges,1687.92,81.7% of total Billed charges,1687.92,81.7% of total Billed charges,1687.92,81.7% of total Billed charges,1687.92,81.7% of total Billed charges,600.31,100% of BCBS Fee Schedule,600.31,100% of BCBS Fee Schedule,600.31,100% of BCBS Fee Schedule,600.31,100% of BCBS Fee Schedule,600.31,100% of BCBS Fee Schedule,2066,Case rate,2066,Case rate,2066,Case rate,1446.2,70% of total billed charges,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,189.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,189.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,189.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,189.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,189.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,189.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,189.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,189.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,189.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,189.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,189.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,189.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,189.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,189.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,189.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,189.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,189.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,189.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,189.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,189.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,108.89,2066.00,1549.5
Outpatient Medical Services,CT SCAN,71250,CT scan of the thorax without dye,352,1147.5,826.2,Pays at 72% of billed charges with lesser of charges applied,135.84,100% OF CMS OPPS Rate,1101.24,442% of BCBS Fee Schedule,135.84,100% OF CMS OPPS Rate,1125.7,pays at 100% of bcbs fee schedule with lesser of charges applied,135.84,100% OF CMS OPPS Rate,1147.5,Case rate,1147.5,Case rate,826.2,72% of total billed charges,135.84,100% OF CMS OPPS Rate,135.84,100% of CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,688.5,60% of total billed charges,182.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,182.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,103.32,100% OF CMS OPPS RATE,135.84,100% OF CMS OPPS Rate,803.25,70% of total billed charges,135.84,100% OF CMS OPPS Rate,163.01,120% of CMS OPPS RATE,826.2,Pays at 72% of billed charges with lesser of charges applied,826.2,Pays at 72% of billed charges with lesser of charges applied,826.2,Pays at 72% of billed charges with lesser of charges applied,826.2,Pays at 72% of billed charges with lesser of charges applied,826.2,Pays at 72% of billed charges with lesser of charges applied,826.2,Pays at 72% of billed charges with lesser of charges applied,1101.24,442% of BCBS Fee Schedule,1101.24,442% of BCBS Fee Schedule,1101.24,442% of BCBS Fee Schedule,1101.24,442% of BCBS Fee Schedule,1101.24,442% of BCBS Fee Schedule,1101.24,442% of BCBS Fee Schedule,1101.24,442% of BCBS Fee Schedule,1101.24,442% of BCBS Fee Schedule,1101.24,442% of BCBS Fee Schedule,1125.7,pays at 100% of bcbs fee schedule with lesser of charges applied,1125.7,pays at 100% of bcbs fee schedule with lesser of charges applied,1125.7,pays at 100% of bcbs fee schedule with lesser of charges applied,1125.7,pays at 100% of bcbs fee schedule with lesser of charges applied,1125.7,pays at 100% of bcbs fee schedule with lesser of charges applied,1147.5,Case rate,1147.5,Case rate,1147.5,Case rate,803.25,70% of total billed charges,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,182.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,182.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,182.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,182.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,182.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,182.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,182.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,182.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,182.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,182.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,182.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,182.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,182.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,182.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,182.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,182.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,182.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,182.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,182.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,182.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,103.32,1147.50,860.63
Outpatient Medical Services,CT SCAN,72127,CT C-SPINE WITH & W/O CONTRAST,352,3099,2231.28,Pays at 72% of billed charges with lesser of charges applied,229.22,100% OF CMS OPPS Rate,1640.57,442% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,1976.44,100% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,2430,Case rate,2430,Case rate,2231.28,72% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% of CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,1859.4,60% of total billed charges,275.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,275.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,172.8,100% OF CMS OPPS RATE,229.22,100% OF CMS OPPS Rate,2169.3,70% of total billed charges,229.22,100% OF CMS OPPS Rate,275.06,120% of CMS OPPS RATE,2231.28,Pays at 72% of billed charges with lesser of charges applied,2231.28,Pays at 72% of billed charges with lesser of charges applied,2231.28,Pays at 72% of billed charges with lesser of charges applied,2231.28,Pays at 72% of billed charges with lesser of charges applied,2231.28,Pays at 72% of billed charges with lesser of charges applied,2231.28,Pays at 72% of billed charges with lesser of charges applied,1640.57,442% of BCBS Fee Schedule,1640.57,442% of BCBS Fee Schedule,1640.57,442% of BCBS Fee Schedule,1640.57,442% of BCBS Fee Schedule,1640.57,442% of BCBS Fee Schedule,1640.57,442% of BCBS Fee Schedule,1640.57,442% of BCBS Fee Schedule,1640.57,442% of BCBS Fee Schedule,1640.57,442% of BCBS Fee Schedule,1976.44,100% of BCBS Fee Schedule,1976.44,100% of BCBS Fee Schedule,1976.44,100% of BCBS Fee Schedule,1976.44,100% of BCBS Fee Schedule,1976.44,100% of BCBS Fee Schedule,2430,Case rate,2430,Case rate,2430,Case rate,2169.3,70% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,275.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,275.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,275.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,275.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,275.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,275.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,275.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,275.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,275.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,275.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,275.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,275.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,275.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,275.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,275.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,275.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,275.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,275.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,275.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,275.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,172.80,2430.00,2324.25
Outpatient Medical Services,CT SCAN,72133,CT L-SPINE WITH & W/O CONTRAST,352,3099,2231.28,Pays at 72% of billed charges with lesser of charges applied,229.22,100% OF CMS OPPS Rate,1640.57,442% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,1976.44,100% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,2430,Case rate,2430,Case rate,2231.28,72% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% of CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,1859.4,60% of total billed charges,275.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,275.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,173.2,100% OF CMS OPPS RATE,229.22,100% OF CMS OPPS Rate,2169.3,70% of total billed charges,229.22,100% OF CMS OPPS Rate,275.06,120% of CMS OPPS RATE,2231.28,Pays at 72% of billed charges with lesser of charges applied,2231.28,Pays at 72% of billed charges with lesser of charges applied,2231.28,Pays at 72% of billed charges with lesser of charges applied,2231.28,Pays at 72% of billed charges with lesser of charges applied,2231.28,Pays at 72% of billed charges with lesser of charges applied,2231.28,Pays at 72% of billed charges with lesser of charges applied,1640.57,442% of BCBS Fee Schedule,1640.57,442% of BCBS Fee Schedule,1640.57,442% of BCBS Fee Schedule,1640.57,442% of BCBS Fee Schedule,1640.57,442% of BCBS Fee Schedule,1640.57,442% of BCBS Fee Schedule,1640.57,442% of BCBS Fee Schedule,1640.57,442% of BCBS Fee Schedule,1640.57,442% of BCBS Fee Schedule,1976.44,100% of BCBS Fee Schedule,1976.44,100% of BCBS Fee Schedule,1976.44,100% of BCBS Fee Schedule,1976.44,100% of BCBS Fee Schedule,1976.44,100% of BCBS Fee Schedule,2430,Case rate,2430,Case rate,2430,Case rate,2169.3,70% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,275.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,275.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,275.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,275.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,275.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,275.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,275.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,275.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,275.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,275.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,275.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,275.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,275.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,275.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,275.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,275.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,275.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,275.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,275.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,275.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,173.20,2430.00,2324.25
Outpatient Medical Services,CT SCAN,72130,CT T-SPINE WITH & W/O CONTRAST,352,3099,2231.28,Pays at 72% of billed charges with lesser of charges applied,229.22,100% OF CMS OPPS Rate,1640.57,442% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,1976.44,100% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,2430,Case rate,2430,Case rate,2231.28,72% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% of CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,1859.4,60% of total billed charges,277.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,277.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,174.79,100% OF CMS OPPS RATE,229.22,100% OF CMS OPPS Rate,2169.3,70% of total billed charges,229.22,100% OF CMS OPPS Rate,275.06,120% of CMS OPPS RATE,2231.28,Pays at 72% of billed charges with lesser of charges applied,2231.28,Pays at 72% of billed charges with lesser of charges applied,2231.28,Pays at 72% of billed charges with lesser of charges applied,2231.28,Pays at 72% of billed charges with lesser of charges applied,2231.28,Pays at 72% of billed charges with lesser of charges applied,2231.28,Pays at 72% of billed charges with lesser of charges applied,1640.57,442% of BCBS Fee Schedule,1640.57,442% of BCBS Fee Schedule,1640.57,442% of BCBS Fee Schedule,1640.57,442% of BCBS Fee Schedule,1640.57,442% of BCBS Fee Schedule,1640.57,442% of BCBS Fee Schedule,1640.57,442% of BCBS Fee Schedule,1640.57,442% of BCBS Fee Schedule,1640.57,442% of BCBS Fee Schedule,1976.44,100% of BCBS Fee Schedule,1976.44,100% of BCBS Fee Schedule,1976.44,100% of BCBS Fee Schedule,1976.44,100% of BCBS Fee Schedule,1976.44,100% of BCBS Fee Schedule,2430,Case rate,2430,Case rate,2430,Case rate,2169.3,70% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,277.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,277.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,277.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,277.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,277.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,277.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,277.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,277.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,277.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,277.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,277.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,277.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,277.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,277.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,277.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,277.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,277.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,277.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,277.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,277.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,174.79,2430.00,2324.25
Outpatient Medical Services,CT SCAN,72194,CT PELVIS WITH & W/O CONTRAST,352,3099,2231.28,Pays at 72% of billed charges with lesser of charges applied,229.22,100% OF CMS OPPS Rate,1574.71,442% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,1894.57,100% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,2430,Case rate,2430,Case rate,2231.28,72% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% of CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,1859.4,60% of total billed charges,339.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,339.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,246.86,100% OF CMS OPPS RATE,229.22,100% OF CMS OPPS Rate,2169.3,70% of total billed charges,229.22,100% OF CMS OPPS Rate,275.06,120% of CMS OPPS RATE,2231.28,Pays at 72% of billed charges with lesser of charges applied,2231.28,Pays at 72% of billed charges with lesser of charges applied,2231.28,Pays at 72% of billed charges with lesser of charges applied,2231.28,Pays at 72% of billed charges with lesser of charges applied,2231.28,Pays at 72% of billed charges with lesser of charges applied,2231.28,Pays at 72% of billed charges with lesser of charges applied,1574.71,442% of BCBS Fee Schedule,1574.71,442% of BCBS Fee Schedule,1574.71,442% of BCBS Fee Schedule,1574.71,442% of BCBS Fee Schedule,1574.71,442% of BCBS Fee Schedule,1574.71,442% of BCBS Fee Schedule,1574.71,442% of BCBS Fee Schedule,1574.71,442% of BCBS Fee Schedule,1574.71,442% of BCBS Fee Schedule,1894.57,100% of BCBS Fee Schedule,1894.57,100% of BCBS Fee Schedule,1894.57,100% of BCBS Fee Schedule,1894.57,100% of BCBS Fee Schedule,1894.57,100% of BCBS Fee Schedule,2430,Case rate,2430,Case rate,2430,Case rate,2169.3,70% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,339.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,339.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,339.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,339.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,339.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,339.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,339.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,339.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,339.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,339.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,339.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,339.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,339.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,339.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,339.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,339.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,339.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,339.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,339.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,339.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,229.22,2430.00,2324.25
Outpatient Medical Services,CT SCAN,71270,CT CHEST WITH & W/O CONTRAST,352,3099,2231.28,Pays at 72% of billed charges with lesser of charges applied,229.22,100% OF CMS OPPS Rate,1641.68,442% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,1976.44,100% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,2430,Case rate,2430,Case rate,2231.28,72% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% of CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,1859.4,60% of total billed charges,274.85,100% of CA Medicaid Fee Schedule with lesser of charges applied,274.85,100% of CA Medicaid Fee Schedule with lesser of charges applied,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,172.8,100% OF CMS OPPS RATE,229.22,100% OF CMS OPPS Rate,2169.3,70% of total billed charges,229.22,100% OF CMS OPPS Rate,275.06,120% of CMS OPPS RATE,2231.28,Pays at 72% of billed charges with lesser of charges applied,2231.28,Pays at 72% of billed charges with lesser of charges applied,2231.28,Pays at 72% of billed charges with lesser of charges applied,2231.28,Pays at 72% of billed charges with lesser of charges applied,2231.28,Pays at 72% of billed charges with lesser of charges applied,2231.28,Pays at 72% of billed charges with lesser of charges applied,1641.68,442% of BCBS Fee Schedule,1641.68,442% of BCBS Fee Schedule,1641.68,442% of BCBS Fee Schedule,1641.68,442% of BCBS Fee Schedule,1641.68,442% of BCBS Fee Schedule,1641.68,442% of BCBS Fee Schedule,1641.68,442% of BCBS Fee Schedule,1641.68,442% of BCBS Fee Schedule,1641.68,442% of BCBS Fee Schedule,1976.44,100% of BCBS Fee Schedule,1976.44,100% of BCBS Fee Schedule,1976.44,100% of BCBS Fee Schedule,1976.44,100% of BCBS Fee Schedule,1976.44,100% of BCBS Fee Schedule,2430,Case rate,2430,Case rate,2430,Case rate,2169.3,70% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,274.85,100% of CA Medicaid Fee Schedule with lesser of charges applied,274.85,100% of CA Medicaid Fee Schedule with lesser of charges applied,274.85,100% of CA Medicaid Fee Schedule with lesser of charges applied,274.85,100% of CA Medicaid Fee Schedule with lesser of charges applied,274.85,100% of CA Medicaid Fee Schedule with lesser of charges applied,274.85,100% of CA Medicaid Fee Schedule with lesser of charges applied,274.85,100% of CA Medicaid Fee Schedule with lesser of charges applied,274.85,100% of CA Medicaid Fee Schedule with lesser of charges applied,274.85,100% of CA Medicaid Fee Schedule with lesser of charges applied,274.85,100% of CA Medicaid Fee Schedule with lesser of charges applied,274.85,100% of CA Medicaid Fee Schedule with lesser of charges applied,274.85,100% of CA Medicaid Fee Schedule with lesser of charges applied,274.85,100% of CA Medicaid Fee Schedule with lesser of charges applied,274.85,100% of CA Medicaid Fee Schedule with lesser of charges applied,274.85,100% of CA Medicaid Fee Schedule with lesser of charges applied,274.85,100% of CA Medicaid Fee Schedule with lesser of charges applied,274.85,100% of CA Medicaid Fee Schedule with lesser of charges applied,274.85,100% of CA Medicaid Fee Schedule with lesser of charges applied,274.85,100% of CA Medicaid Fee Schedule with lesser of charges applied,274.85,100% of CA Medicaid Fee Schedule with lesser of charges applied,172.80,2430.00,2324.25
Outpatient Medical Services,CT SCAN,74176,CT of abdomen and pelvis without dye,352,2814.25,2026.26,Pays at 72% of billed charges with lesser of charges applied,296.82,100% OF CMS OPPS Rate,690.4,442% of BCBS Fee Schedule,296.82,100% OF CMS OPPS Rate,832.1,100% of BCBS Fee Schedule,296.82,100% OF CMS OPPS Rate,2430,Case rate,2430,Case rate,2026.26,72% of total billed charges,296.82,100% OF CMS OPPS Rate,296.82,100% of CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,1688.55,60% of total billed charges,250.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,250.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,127.41,100% OF CMS OPPS RATE,296.82,100% OF CMS OPPS Rate,1969.98,70% of total billed charges,296.82,100% OF CMS OPPS Rate,356.18,120% of CMS OPPS RATE,2026.26,Pays at 72% of billed charges with lesser of charges applied,2026.26,Pays at 72% of billed charges with lesser of charges applied,2026.26,Pays at 72% of billed charges with lesser of charges applied,2026.26,Pays at 72% of billed charges with lesser of charges applied,2026.26,Pays at 72% of billed charges with lesser of charges applied,2026.26,Pays at 72% of billed charges with lesser of charges applied,690.4,442% of BCBS Fee Schedule,690.4,442% of BCBS Fee Schedule,690.4,442% of BCBS Fee Schedule,690.4,442% of BCBS Fee Schedule,690.4,442% of BCBS Fee Schedule,690.4,442% of BCBS Fee Schedule,690.4,442% of BCBS Fee Schedule,690.4,442% of BCBS Fee Schedule,690.4,442% of BCBS Fee Schedule,832.1,100% of BCBS Fee Schedule,832.1,100% of BCBS Fee Schedule,832.1,100% of BCBS Fee Schedule,832.1,100% of BCBS Fee Schedule,832.1,100% of BCBS Fee Schedule,2430,Case rate,2430,Case rate,2430,Case rate,1969.98,70% of total billed charges,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,250.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,250.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,250.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,250.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,250.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,250.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,250.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,250.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,250.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,250.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,250.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,250.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,250.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,250.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,250.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,250.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,250.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,250.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,250.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,250.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,127.41,2430.00,2110.69
Outpatient Medical Services,CT SCAN,74170,CT of abdomen with and without dye,352,3099,2231.28,Pays at 72% of billed charges with lesser of charges applied,229.22,100% OF CMS OPPS Rate,1576.84,442% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,1894.57,100% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,2430,Case rate,2430,Case rate,2231.28,72% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% of CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,1859.4,60% of total billed charges,340.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,340.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,248.05,100% OF CMS OPPS RATE,229.22,100% OF CMS OPPS Rate,2169.3,70% of total billed charges,229.22,100% OF CMS OPPS Rate,275.06,120% of CMS OPPS RATE,2231.28,Pays at 72% of billed charges with lesser of charges applied,2231.28,Pays at 72% of billed charges with lesser of charges applied,2231.28,Pays at 72% of billed charges with lesser of charges applied,2231.28,Pays at 72% of billed charges with lesser of charges applied,2231.28,Pays at 72% of billed charges with lesser of charges applied,2231.28,Pays at 72% of billed charges with lesser of charges applied,1576.84,442% of BCBS Fee Schedule,1576.84,442% of BCBS Fee Schedule,1576.84,442% of BCBS Fee Schedule,1576.84,442% of BCBS Fee Schedule,1576.84,442% of BCBS Fee Schedule,1576.84,442% of BCBS Fee Schedule,1576.84,442% of BCBS Fee Schedule,1576.84,442% of BCBS Fee Schedule,1576.84,442% of BCBS Fee Schedule,1894.57,100% of BCBS Fee Schedule,1894.57,100% of BCBS Fee Schedule,1894.57,100% of BCBS Fee Schedule,1894.57,100% of BCBS Fee Schedule,1894.57,100% of BCBS Fee Schedule,2430,Case rate,2430,Case rate,2430,Case rate,2169.3,70% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,340.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,340.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,340.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,340.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,340.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,340.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,340.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,340.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,340.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,340.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,340.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,340.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,340.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,340.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,340.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,340.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,340.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,340.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,340.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,340.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,229.22,2430.00,2324.25
Outpatient Medical Services,CT SCAN,72126,CT C-SPINE WITH CONTRAST,352,2524.25,1817.46,Pays at 72% of billed charges with lesser of charges applied,468.3,100% OF CMS OPPS Rate,1316.59,442% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,1580.6,100% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,2430,Case rate,2430,Case rate,1817.46,72% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% of CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,1514.55,60% of total billed charges,233.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,233.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,139.75,100% OF CMS OPPS RATE,468.3,100% OF CMS OPPS Rate,1766.98,70% of total billed charges,468.3,100% OF CMS OPPS Rate,561.95,120% of CMS OPPS RATE,1817.46,Pays at 72% of billed charges with lesser of charges applied,1817.46,Pays at 72% of billed charges with lesser of charges applied,1817.46,Pays at 72% of billed charges with lesser of charges applied,1817.46,Pays at 72% of billed charges with lesser of charges applied,1817.46,Pays at 72% of billed charges with lesser of charges applied,1817.46,Pays at 72% of billed charges with lesser of charges applied,1316.59,442% of BCBS Fee Schedule,1316.59,442% of BCBS Fee Schedule,1316.59,442% of BCBS Fee Schedule,1316.59,442% of BCBS Fee Schedule,1316.59,442% of BCBS Fee Schedule,1316.59,442% of BCBS Fee Schedule,1316.59,442% of BCBS Fee Schedule,1316.59,442% of BCBS Fee Schedule,1316.59,442% of BCBS Fee Schedule,1580.6,100% of BCBS Fee Schedule,1580.6,100% of BCBS Fee Schedule,1580.6,100% of BCBS Fee Schedule,1580.6,100% of BCBS Fee Schedule,1580.6,100% of BCBS Fee Schedule,2430,Case rate,2430,Case rate,2430,Case rate,1766.98,70% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,233.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,233.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,233.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,233.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,233.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,233.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,233.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,233.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,233.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,233.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,233.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,233.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,233.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,233.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,233.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,233.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,233.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,233.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,233.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,233.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,139.75,2430.00,1893.19
Outpatient Medical Services,CT SCAN,72132,CT L-SPINE WITH CONTRAST,352,2524.25,1817.46,Pays at 72% of billed charges with lesser of charges applied,468.3,100% OF CMS OPPS Rate,1316.59,442% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,1580.6,100% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,2430,Case rate,2430,Case rate,1817.46,72% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% of CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,1514.55,60% of total billed charges,233.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,233.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,140.15,100% OF CMS OPPS RATE,468.3,100% OF CMS OPPS Rate,1766.98,70% of total billed charges,468.3,100% OF CMS OPPS Rate,561.95,120% of CMS OPPS RATE,1817.46,Pays at 72% of billed charges with lesser of charges applied,1817.46,Pays at 72% of billed charges with lesser of charges applied,1817.46,Pays at 72% of billed charges with lesser of charges applied,1817.46,Pays at 72% of billed charges with lesser of charges applied,1817.46,Pays at 72% of billed charges with lesser of charges applied,1817.46,Pays at 72% of billed charges with lesser of charges applied,1316.59,442% of BCBS Fee Schedule,1316.59,442% of BCBS Fee Schedule,1316.59,442% of BCBS Fee Schedule,1316.59,442% of BCBS Fee Schedule,1316.59,442% of BCBS Fee Schedule,1316.59,442% of BCBS Fee Schedule,1316.59,442% of BCBS Fee Schedule,1316.59,442% of BCBS Fee Schedule,1316.59,442% of BCBS Fee Schedule,1580.6,100% of BCBS Fee Schedule,1580.6,100% of BCBS Fee Schedule,1580.6,100% of BCBS Fee Schedule,1580.6,100% of BCBS Fee Schedule,1580.6,100% of BCBS Fee Schedule,2430,Case rate,2430,Case rate,2430,Case rate,1766.98,70% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,233.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,233.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,233.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,233.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,233.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,233.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,233.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,233.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,233.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,233.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,233.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,233.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,233.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,233.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,233.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,233.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,233.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,233.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,233.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,233.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,140.15,2430.00,1893.19
Outpatient Medical Services,CT SCAN,72129,CT T-SPINE WITH CONTRAST,352,2524.25,1817.46,Pays at 72% of billed charges with lesser of charges applied,229.22,100% OF CMS OPPS Rate,1316.59,442% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,1580.6,100% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,2430,Case rate,2430,Case rate,1817.46,72% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% of CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,1514.55,60% of total billed charges,235.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,235.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,140.94,100% OF CMS OPPS RATE,229.22,100% OF CMS OPPS Rate,1766.98,70% of total billed charges,229.22,100% OF CMS OPPS Rate,275.06,120% of CMS OPPS RATE,1817.46,Pays at 72% of billed charges with lesser of charges applied,1817.46,Pays at 72% of billed charges with lesser of charges applied,1817.46,Pays at 72% of billed charges with lesser of charges applied,1817.46,Pays at 72% of billed charges with lesser of charges applied,1817.46,Pays at 72% of billed charges with lesser of charges applied,1817.46,Pays at 72% of billed charges with lesser of charges applied,1316.59,442% of BCBS Fee Schedule,1316.59,442% of BCBS Fee Schedule,1316.59,442% of BCBS Fee Schedule,1316.59,442% of BCBS Fee Schedule,1316.59,442% of BCBS Fee Schedule,1316.59,442% of BCBS Fee Schedule,1316.59,442% of BCBS Fee Schedule,1316.59,442% of BCBS Fee Schedule,1316.59,442% of BCBS Fee Schedule,1580.6,100% of BCBS Fee Schedule,1580.6,100% of BCBS Fee Schedule,1580.6,100% of BCBS Fee Schedule,1580.6,100% of BCBS Fee Schedule,1580.6,100% of BCBS Fee Schedule,2430,Case rate,2430,Case rate,2430,Case rate,1766.98,70% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,235.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,235.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,235.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,235.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,235.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,235.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,235.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,235.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,235.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,235.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,235.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,235.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,235.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,235.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,235.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,235.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,235.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,235.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,235.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,235.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,140.94,2430.00,1893.19
Outpatient Medical Services,CT SCAN,74174,ANGIO CT ABD/PELV W/O&W,352,3326,2394.72,Pays at 72% of billed charges with lesser of charges applied,468.3,100% OF CMS OPPS Rate,2485.45,442% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,2877.39,100% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,2430,Case rate,2430,Case rate,2394.72,72% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% of CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,1995.6,60% of total billed charges,504.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,504.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,348.39,100% OF CMS OPPS RATE,468.3,100% OF CMS OPPS Rate,2328.2,70% of total billed charges,468.3,100% OF CMS OPPS Rate,561.95,120% of CMS OPPS RATE,2394.72,Pays at 72% of billed charges with lesser of charges applied,2394.72,Pays at 72% of billed charges with lesser of charges applied,2394.72,Pays at 72% of billed charges with lesser of charges applied,2394.72,Pays at 72% of billed charges with lesser of charges applied,2394.72,Pays at 72% of billed charges with lesser of charges applied,2394.72,Pays at 72% of billed charges with lesser of charges applied,2485.45,442% of BCBS Fee Schedule,2485.45,442% of BCBS Fee Schedule,2485.45,442% of BCBS Fee Schedule,2485.45,442% of BCBS Fee Schedule,2485.45,442% of BCBS Fee Schedule,2485.45,442% of BCBS Fee Schedule,2485.45,442% of BCBS Fee Schedule,2485.45,442% of BCBS Fee Schedule,2485.45,442% of BCBS Fee Schedule,2877.39,100% of BCBS Fee Schedule,2877.39,100% of BCBS Fee Schedule,2877.39,100% of BCBS Fee Schedule,2877.39,100% of BCBS Fee Schedule,2877.39,100% of BCBS Fee Schedule,2430,Case rate,2430,Case rate,2430,Case rate,2328.2,70% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,504.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,504.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,504.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,504.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,504.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,504.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,504.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,504.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,504.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,504.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,504.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,504.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,504.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,504.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,504.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,504.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,504.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,504.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,504.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,504.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,348.39,2877.39,2494.5
Outpatient Medical Services,CT SCAN,72125,CT C-SPINE W/O CONTRAST,352,2066,1487.52,Pays at 72% of billed charges with lesser of charges applied,135.84,100% OF CMS OPPS Rate,1101.24,442% of BCBS Fee Schedule,135.84,100% OF CMS OPPS Rate,1320.29,100% of BCBS Fee Schedule,135.84,100% OF CMS OPPS Rate,2066,Case rate,2066,Case rate,1487.52,72% of total billed charges,135.84,100% OF CMS OPPS Rate,135.84,100% of CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,1239.6,60% of total billed charges,179.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,179.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,104.11,100% OF CMS OPPS RATE,135.84,100% OF CMS OPPS Rate,1446.2,70% of total billed charges,135.84,100% OF CMS OPPS Rate,163.01,120% of CMS OPPS RATE,1487.52,Pays at 72% of billed charges with lesser of charges applied,1487.52,Pays at 72% of billed charges with lesser of charges applied,1487.52,Pays at 72% of billed charges with lesser of charges applied,1487.52,Pays at 72% of billed charges with lesser of charges applied,1487.52,Pays at 72% of billed charges with lesser of charges applied,1487.52,Pays at 72% of billed charges with lesser of charges applied,1101.24,442% of BCBS Fee Schedule,1101.24,442% of BCBS Fee Schedule,1101.24,442% of BCBS Fee Schedule,1101.24,442% of BCBS Fee Schedule,1101.24,442% of BCBS Fee Schedule,1101.24,442% of BCBS Fee Schedule,1101.24,442% of BCBS Fee Schedule,1101.24,442% of BCBS Fee Schedule,1101.24,442% of BCBS Fee Schedule,1320.29,100% of BCBS Fee Schedule,1320.29,100% of BCBS Fee Schedule,1320.29,100% of BCBS Fee Schedule,1320.29,100% of BCBS Fee Schedule,1320.29,100% of BCBS Fee Schedule,2066,Case rate,2066,Case rate,2066,Case rate,1446.2,70% of total billed charges,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,179.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,179.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,179.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,179.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,179.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,179.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,179.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,179.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,179.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,179.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,179.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,179.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,179.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,179.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,179.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,179.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,179.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,179.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,179.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,179.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,104.11,2066.00,1549.5
Outpatient Medical Services,CT SCAN,72131,CT scan of lower spine without dye,352,2066,1487.52,Pays at 72% of billed charges with lesser of charges applied,135.84,100% OF CMS OPPS Rate,1101.24,442% of BCBS Fee Schedule,135.84,100% OF CMS OPPS Rate,1320.29,100% of BCBS Fee Schedule,135.84,100% OF CMS OPPS Rate,2066,Case rate,2066,Case rate,1487.52,72% of total billed charges,135.84,100% OF CMS OPPS Rate,135.84,100% of CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,1239.6,60% of total billed charges,178.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,178.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,103.32,100% OF CMS OPPS RATE,135.84,100% OF CMS OPPS Rate,1446.2,70% of total billed charges,135.84,100% OF CMS OPPS Rate,163.01,120% of CMS OPPS RATE,1487.52,Pays at 72% of billed charges with lesser of charges applied,1487.52,Pays at 72% of billed charges with lesser of charges applied,1487.52,Pays at 72% of billed charges with lesser of charges applied,1487.52,Pays at 72% of billed charges with lesser of charges applied,1487.52,Pays at 72% of billed charges with lesser of charges applied,1487.52,Pays at 72% of billed charges with lesser of charges applied,1101.24,442% of BCBS Fee Schedule,1101.24,442% of BCBS Fee Schedule,1101.24,442% of BCBS Fee Schedule,1101.24,442% of BCBS Fee Schedule,1101.24,442% of BCBS Fee Schedule,1101.24,442% of BCBS Fee Schedule,1101.24,442% of BCBS Fee Schedule,1101.24,442% of BCBS Fee Schedule,1101.24,442% of BCBS Fee Schedule,1320.29,100% of BCBS Fee Schedule,1320.29,100% of BCBS Fee Schedule,1320.29,100% of BCBS Fee Schedule,1320.29,100% of BCBS Fee Schedule,1320.29,100% of BCBS Fee Schedule,2066,Case rate,2066,Case rate,2066,Case rate,1446.2,70% of total billed charges,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,178.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,178.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,178.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,178.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,178.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,178.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,178.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,178.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,178.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,178.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,178.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,178.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,178.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,178.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,178.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,178.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,178.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,178.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,178.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,178.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,103.32,2066.00,1549.5
Outpatient Medical Services,CT SCAN,72193,"CT scan, pelvis, with contrast",352,2524.25,1817.46,Pays at 72% of billed charges with lesser of charges applied,229.22,100% OF CMS OPPS Rate,1272.12,442% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,1529.7,100% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,2430,Case rate,2430,Case rate,1817.46,72% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% of CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,1514.55,60% of total billed charges,293.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,293.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,220.58,100% OF CMS OPPS RATE,229.22,100% OF CMS OPPS Rate,1766.98,70% of total billed charges,229.22,100% OF CMS OPPS Rate,275.06,120% of CMS OPPS RATE,1817.46,Pays at 72% of billed charges with lesser of charges applied,1817.46,Pays at 72% of billed charges with lesser of charges applied,1817.46,Pays at 72% of billed charges with lesser of charges applied,1817.46,Pays at 72% of billed charges with lesser of charges applied,1817.46,Pays at 72% of billed charges with lesser of charges applied,1817.46,Pays at 72% of billed charges with lesser of charges applied,1272.12,442% of BCBS Fee Schedule,1272.12,442% of BCBS Fee Schedule,1272.12,442% of BCBS Fee Schedule,1272.12,442% of BCBS Fee Schedule,1272.12,442% of BCBS Fee Schedule,1272.12,442% of BCBS Fee Schedule,1272.12,442% of BCBS Fee Schedule,1272.12,442% of BCBS Fee Schedule,1272.12,442% of BCBS Fee Schedule,1529.7,100% of BCBS Fee Schedule,1529.7,100% of BCBS Fee Schedule,1529.7,100% of BCBS Fee Schedule,1529.7,100% of BCBS Fee Schedule,1529.7,100% of BCBS Fee Schedule,2430,Case rate,2430,Case rate,2430,Case rate,1766.98,70% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,293.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,293.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,293.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,293.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,293.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,293.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,293.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,293.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,293.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,293.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,293.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,293.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,293.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,293.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,293.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,293.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,293.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,293.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,293.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,293.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,220.58,2430.00,1893.19
Outpatient Medical Services,CT SCAN,72128,CT T-SPINE W/O CONTRAST,352,2066,1487.52,Pays at 72% of billed charges with lesser of charges applied,135.84,100% OF CMS OPPS Rate,1101.24,442% of BCBS Fee Schedule,135.84,100% OF CMS OPPS Rate,1320.29,100% of BCBS Fee Schedule,135.84,100% OF CMS OPPS Rate,2066,Case rate,2066,Case rate,1487.52,72% of total billed charges,135.84,100% OF CMS OPPS Rate,135.84,100% of CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,1239.6,60% of total billed charges,178.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,178.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,104.11,100% OF CMS OPPS RATE,135.84,100% OF CMS OPPS Rate,1446.2,70% of total billed charges,135.84,100% OF CMS OPPS Rate,163.01,120% of CMS OPPS RATE,1487.52,Pays at 72% of billed charges with lesser of charges applied,1487.52,Pays at 72% of billed charges with lesser of charges applied,1487.52,Pays at 72% of billed charges with lesser of charges applied,1487.52,Pays at 72% of billed charges with lesser of charges applied,1487.52,Pays at 72% of billed charges with lesser of charges applied,1487.52,Pays at 72% of billed charges with lesser of charges applied,1101.24,442% of BCBS Fee Schedule,1101.24,442% of BCBS Fee Schedule,1101.24,442% of BCBS Fee Schedule,1101.24,442% of BCBS Fee Schedule,1101.24,442% of BCBS Fee Schedule,1101.24,442% of BCBS Fee Schedule,1101.24,442% of BCBS Fee Schedule,1101.24,442% of BCBS Fee Schedule,1101.24,442% of BCBS Fee Schedule,1320.29,100% of BCBS Fee Schedule,1320.29,100% of BCBS Fee Schedule,1320.29,100% of BCBS Fee Schedule,1320.29,100% of BCBS Fee Schedule,1320.29,100% of BCBS Fee Schedule,2066,Case rate,2066,Case rate,2066,Case rate,1446.2,70% of total billed charges,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,178.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,178.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,178.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,178.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,178.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,178.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,178.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,178.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,178.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,178.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,178.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,178.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,178.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,178.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,178.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,178.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,178.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,178.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,178.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,178.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,104.11,2066.00,1549.5
Outpatient Medical Services,CT SCAN,74177,CT scan of abdomen and pelvis with contrast,352,4203.5,3026.52,Pays at 72% of billed charges with lesser of charges applied,468.3,100% OF CMS OPPS Rate,1317.43,442% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,1587.55,100% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,2430,Case rate,2430,Case rate,3026.52,72% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% of CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,2522.1,60% of total billed charges,404.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,404.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,275.92,100% OF CMS OPPS RATE,468.3,100% OF CMS OPPS Rate,2942.45,70% of total billed charges,468.3,100% OF CMS OPPS Rate,561.95,120% of CMS OPPS RATE,3026.52,Pays at 72% of billed charges with lesser of charges applied,3026.52,Pays at 72% of billed charges with lesser of charges applied,3026.52,Pays at 72% of billed charges with lesser of charges applied,3026.52,Pays at 72% of billed charges with lesser of charges applied,3026.52,Pays at 72% of billed charges with lesser of charges applied,3026.52,Pays at 72% of billed charges with lesser of charges applied,1317.43,442% of BCBS Fee Schedule,1317.43,442% of BCBS Fee Schedule,1317.43,442% of BCBS Fee Schedule,1317.43,442% of BCBS Fee Schedule,1317.43,442% of BCBS Fee Schedule,1317.43,442% of BCBS Fee Schedule,1317.43,442% of BCBS Fee Schedule,1317.43,442% of BCBS Fee Schedule,1317.43,442% of BCBS Fee Schedule,1587.55,100% of BCBS Fee Schedule,1587.55,100% of BCBS Fee Schedule,1587.55,100% of BCBS Fee Schedule,1587.55,100% of BCBS Fee Schedule,1587.55,100% of BCBS Fee Schedule,2430,Case rate,2430,Case rate,2430,Case rate,2942.45,70% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,404.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,404.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,404.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,404.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,404.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,404.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,404.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,404.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,404.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,404.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,404.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,404.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,404.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,404.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,404.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,404.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,404.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,404.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,404.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,404.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,275.92,3026.52,3152.63
Outpatient Medical Services,CT SCAN,74175,CT ANGIOGRAPHY ABDOMEN,352,2694,1939.68,Pays at 72% of billed charges with lesser of charges applied,229.22,100% OF CMS OPPS Rate,1612.28,442% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,2642.81,100% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,2430,Case rate,2430,Case rate,1939.68,72% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% of CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,1616.4,60% of total billed charges,397.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,397.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,277.91,100% OF CMS OPPS RATE,229.22,100% OF CMS OPPS Rate,1885.8,70% of total billed charges,229.22,100% OF CMS OPPS Rate,275.06,120% of CMS OPPS RATE,1939.68,Pays at 72% of billed charges with lesser of charges applied,1939.68,Pays at 72% of billed charges with lesser of charges applied,1939.68,Pays at 72% of billed charges with lesser of charges applied,1939.68,Pays at 72% of billed charges with lesser of charges applied,1939.68,Pays at 72% of billed charges with lesser of charges applied,1939.68,Pays at 72% of billed charges with lesser of charges applied,1612.28,442% of BCBS Fee Schedule,1612.28,442% of BCBS Fee Schedule,1612.28,442% of BCBS Fee Schedule,1612.28,442% of BCBS Fee Schedule,1612.28,442% of BCBS Fee Schedule,1612.28,442% of BCBS Fee Schedule,1612.28,442% of BCBS Fee Schedule,1612.28,442% of BCBS Fee Schedule,1612.28,442% of BCBS Fee Schedule,2642.81,100% of BCBS Fee Schedule,2642.81,100% of BCBS Fee Schedule,2642.81,100% of BCBS Fee Schedule,2642.81,100% of BCBS Fee Schedule,2642.81,100% of BCBS Fee Schedule,2430,Case rate,2430,Case rate,2430,Case rate,1885.8,70% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,397.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,397.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,397.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,397.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,397.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,397.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,397.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,397.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,397.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,397.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,397.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,397.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,397.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,397.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,397.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,397.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,397.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,397.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,397.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,397.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,229.22,2642.81,2020.5
Outpatient Medical Services,CT SCAN,71260,CT scan of the thorax with dye,352,2524.25,1817.46,Pays at 72% of billed charges with lesser of charges applied,229.22,100% OF CMS OPPS Rate,1317.07,442% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,1580.6,100% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,2430,Case rate,2430,Case rate,1817.46,72% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% of CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,1514.55,60% of total billed charges,230.85,100% of CA Medicaid Fee Schedule with lesser of charges applied,230.85,100% of CA Medicaid Fee Schedule with lesser of charges applied,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,140.15,100% OF CMS OPPS RATE,229.22,100% OF CMS OPPS Rate,1766.98,70% of total billed charges,229.22,100% OF CMS OPPS Rate,275.06,120% of CMS OPPS RATE,1817.46,Pays at 72% of billed charges with lesser of charges applied,1817.46,Pays at 72% of billed charges with lesser of charges applied,1817.46,Pays at 72% of billed charges with lesser of charges applied,1817.46,Pays at 72% of billed charges with lesser of charges applied,1817.46,Pays at 72% of billed charges with lesser of charges applied,1817.46,Pays at 72% of billed charges with lesser of charges applied,1317.07,442% of BCBS Fee Schedule,1317.07,442% of BCBS Fee Schedule,1317.07,442% of BCBS Fee Schedule,1317.07,442% of BCBS Fee Schedule,1317.07,442% of BCBS Fee Schedule,1317.07,442% of BCBS Fee Schedule,1317.07,442% of BCBS Fee Schedule,1317.07,442% of BCBS Fee Schedule,1317.07,442% of BCBS Fee Schedule,1580.6,100% of BCBS Fee Schedule,1580.6,100% of BCBS Fee Schedule,1580.6,100% of BCBS Fee Schedule,1580.6,100% of BCBS Fee Schedule,1580.6,100% of BCBS Fee Schedule,2430,Case rate,2430,Case rate,2430,Case rate,1766.98,70% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,230.85,100% of CA Medicaid Fee Schedule with lesser of charges applied,230.85,100% of CA Medicaid Fee Schedule with lesser of charges applied,230.85,100% of CA Medicaid Fee Schedule with lesser of charges applied,230.85,100% of CA Medicaid Fee Schedule with lesser of charges applied,230.85,100% of CA Medicaid Fee Schedule with lesser of charges applied,230.85,100% of CA Medicaid Fee Schedule with lesser of charges applied,230.85,100% of CA Medicaid Fee Schedule with lesser of charges applied,230.85,100% of CA Medicaid Fee Schedule with lesser of charges applied,230.85,100% of CA Medicaid Fee Schedule with lesser of charges applied,230.85,100% of CA Medicaid Fee Schedule with lesser of charges applied,230.85,100% of CA Medicaid Fee Schedule with lesser of charges applied,230.85,100% of CA Medicaid Fee Schedule with lesser of charges applied,230.85,100% of CA Medicaid Fee Schedule with lesser of charges applied,230.85,100% of CA Medicaid Fee Schedule with lesser of charges applied,230.85,100% of CA Medicaid Fee Schedule with lesser of charges applied,230.85,100% of CA Medicaid Fee Schedule with lesser of charges applied,230.85,100% of CA Medicaid Fee Schedule with lesser of charges applied,230.85,100% of CA Medicaid Fee Schedule with lesser of charges applied,230.85,100% of CA Medicaid Fee Schedule with lesser of charges applied,230.85,100% of CA Medicaid Fee Schedule with lesser of charges applied,140.15,2430.00,1893.19
Outpatient Medical Services,CT SCAN,76497,WHOLE BODY LOW DOSE CT,352,372,267.84,Pays at 72% of billed charges with lesser of charges applied,110.43,100% OF CMS OPPS Rate,N/A,Not Separately reimbursable,110.43,100% OF CMS OPPS Rate,294.25,79.1% of total billed charges,110.43,100% OF CMS OPPS Rate,372,Case rate,372,Case rate,267.84,72% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% of CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,223.2,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,N/A,Not Separately reimbursable,110.43,100% OF CMS OPPS Rate,260.4,70% of total billed charges,110.43,100% OF CMS OPPS Rate,132.51,120% of CMS OPPS RATE,267.84,Pays at 72% of billed charges with lesser of charges applied,267.84,Pays at 72% of billed charges with lesser of charges applied,267.84,Pays at 72% of billed charges with lesser of charges applied,267.84,Pays at 72% of billed charges with lesser of charges applied,267.84,Pays at 72% of billed charges with lesser of charges applied,267.84,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,294.25,79.1% of total billed charges,294.25,79.1% of total billed charges,294.25,79.1% of total billed charges,294.25,79.1% of total billed charges,294.25,79.1% of total billed charges,372,Case rate,372,Case rate,372,Case rate,260.4,70% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,110.43,372.00,279
Outpatient Medical Services,CT SCAN,71275,Diagnostic Radiology (Diagnostic Imaging) Procedures of the Chest,352,2784,2004.48,Pays at 72% of billed charges with lesser of charges applied,229.22,100% OF CMS OPPS Rate,1677.3,442% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,2725.43,100% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,2430,Case rate,2430,Case rate,2004.48,72% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% of CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,1670.4,60% of total billed charges,388.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,388.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,245.26,100% OF CMS OPPS RATE,229.22,100% OF CMS OPPS Rate,1948.8,70% of total billed charges,229.22,100% OF CMS OPPS Rate,275.06,120% of CMS OPPS RATE,2004.48,Pays at 72% of billed charges with lesser of charges applied,2004.48,Pays at 72% of billed charges with lesser of charges applied,2004.48,Pays at 72% of billed charges with lesser of charges applied,2004.48,Pays at 72% of billed charges with lesser of charges applied,2004.48,Pays at 72% of billed charges with lesser of charges applied,2004.48,Pays at 72% of billed charges with lesser of charges applied,1677.3,442% of BCBS Fee Schedule,1677.3,442% of BCBS Fee Schedule,1677.3,442% of BCBS Fee Schedule,1677.3,442% of BCBS Fee Schedule,1677.3,442% of BCBS Fee Schedule,1677.3,442% of BCBS Fee Schedule,1677.3,442% of BCBS Fee Schedule,1677.3,442% of BCBS Fee Schedule,1677.3,442% of BCBS Fee Schedule,2725.43,100% of BCBS Fee Schedule,2725.43,100% of BCBS Fee Schedule,2725.43,100% of BCBS Fee Schedule,2725.43,100% of BCBS Fee Schedule,2725.43,100% of BCBS Fee Schedule,2430,Case rate,2430,Case rate,2430,Case rate,1948.8,70% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,388.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,388.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,388.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,388.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,388.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,388.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,388.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,388.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,388.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,388.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,388.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,388.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,388.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,388.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,388.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,388.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,388.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,388.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,388.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,388.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,229.22,2725.43,2088
Outpatient Medical Services,CT SCAN,75989,CT GUIDANCE PERC DRAINAGE,352,2066,1487.52,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,588.39,442% of BCBS Fee Schedule,N/A,Not Separately reimbursable,706.44,100% of BCBS Fee Schedule,N/A,Not Separately reimbursable,2066,Case rate,2066,Case rate,1487.52,72% of total billed charges,N/A,Not Separately reimbursable,1342.9,65% of total billed charges,N/A,Not Separately reimbursable,1239.6,60% of total billed charges,149.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,149.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,69.08,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,1446.2,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,1487.52,Pays at 72% of billed charges with lesser of charges applied,1487.52,Pays at 72% of billed charges with lesser of charges applied,1487.52,Pays at 72% of billed charges with lesser of charges applied,1487.52,Pays at 72% of billed charges with lesser of charges applied,1487.52,Pays at 72% of billed charges with lesser of charges applied,1487.52,Pays at 72% of billed charges with lesser of charges applied,588.39,442% of BCBS Fee Schedule,588.39,442% of BCBS Fee Schedule,588.39,442% of BCBS Fee Schedule,588.39,442% of BCBS Fee Schedule,588.39,442% of BCBS Fee Schedule,588.39,442% of BCBS Fee Schedule,588.39,442% of BCBS Fee Schedule,588.39,442% of BCBS Fee Schedule,588.39,442% of BCBS Fee Schedule,706.44,100% of BCBS Fee Schedule,706.44,100% of BCBS Fee Schedule,706.44,100% of BCBS Fee Schedule,706.44,100% of BCBS Fee Schedule,706.44,100% of BCBS Fee Schedule,2066,Case rate,2066,Case rate,2066,Case rate,1446.2,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,149.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,149.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,149.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,149.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,149.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,149.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,149.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,149.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,149.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,149.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,149.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,149.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,149.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,149.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,149.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,149.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,149.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,149.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,149.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,149.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,69.08,2066.00,1549.5
Outpatient Medical Services,LAB,80048,Basic metabolic panel,301,117.25,84.42,Pays at 72% of billed charges with lesser of charges applied,8.46,100% OF CMS OPPS Rate,55.56,442% of BCBS Fee Schedule,8.46,100% OF CMS OPPS Rate,13.29,112.32% OF BCBS FEE SCHEDULE,8.46,100% OF CMS OPPS Rate,98.49,84% of total billed charges,98.49,84% of total billed charges,84.42,72% of total billed charges,8.46,100% OF CMS OPPS Rate,8.46,100% of CMS OPPS Rate,8.46,100% OF CMS OPPS Rate,70.35,Not Separately reimbursable,10.43,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.43,100% of CA Medicaid Fee Schedule with lesser of charges applied,8.46,100% OF CMS OPPS Rate,8.46,100% OF CMS OPPS Rate,8.46,100% OF CMS OPPS RATE,8.46,100% OF CMS OPPS Rate,82.08,70% of total billed charges,8.46,100% OF CMS OPPS Rate,10.15,120% of CMS OPPS RATE,84.42,Pays at 72% of billed charges with lesser of charges applied,84.42,Pays at 72% of billed charges with lesser of charges applied,84.42,Pays at 72% of billed charges with lesser of charges applied,84.42,Pays at 72% of billed charges with lesser of charges applied,84.42,Pays at 72% of billed charges with lesser of charges applied,84.42,Pays at 72% of billed charges with lesser of charges applied,55.56,442% of BCBS Fee Schedule,55.56,442% of BCBS Fee Schedule,55.56,442% of BCBS Fee Schedule,55.56,442% of BCBS Fee Schedule,55.56,442% of BCBS Fee Schedule,55.56,442% of BCBS Fee Schedule,55.56,442% of BCBS Fee Schedule,55.56,442% of BCBS Fee Schedule,55.56,442% of BCBS Fee Schedule,13.29,112.32% OF BCBS FEE SCHEDULE,13.29,112.32% OF BCBS FEE SCHEDULE,13.29,112.32% OF BCBS FEE SCHEDULE,13.29,112.32% OF BCBS FEE SCHEDULE,13.29,112.32% OF BCBS FEE SCHEDULE,98.49,84% of total billed charges,98.49,84% of total billed charges,98.49,84% of total billed charges,82.08,70% of total billed charges,8.46,100% OF CMS OPPS Rate,8.46,100% OF CMS OPPS Rate,8.46,100% OF CMS OPPS Rate,8.46,100% OF CMS OPPS Rate,8.46,100% OF CMS OPPS Rate,8.46,100% OF CMS OPPS Rate,8.46,100% OF CMS OPPS Rate,8.46,100% OF CMS OPPS Rate,8.46,100% OF CMS OPPS Rate,8.46,100% OF CMS OPPS Rate,8.46,100% OF CMS OPPS Rate,8.46,100% OF CMS OPPS Rate,8.46,100% OF CMS OPPS Rate,8.46,100% OF CMS OPPS Rate,8.46,100% OF CMS OPPS Rate,8.46,100% OF CMS OPPS Rate,10.43,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.43,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.43,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.43,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.43,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.43,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.43,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.43,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.43,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.43,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.43,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.43,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.43,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.43,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.43,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.43,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.43,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.43,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.43,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.43,100% of CA Medicaid Fee Schedule with lesser of charges applied,8.46,98.49,87.94
Outpatient Medical Services,LAB,80053,"Blood test, comprehensive group of blood chemicals",301,188.75,135.9,Pays at 72% of billed charges with lesser of charges applied,10.56,100% OF CMS OPPS Rate,69.48,442% of BCBS Fee Schedule,10.56,100% OF CMS OPPS Rate,16.59,112.32% OF BCBS FEE SCHEDULE,10.56,100% OF CMS OPPS Rate,158.55,84% of total billed charges,158.55,84% of total billed charges,135.9,72% of total billed charges,10.56,100% OF CMS OPPS Rate,10.56,100% of CMS OPPS Rate,10.56,100% OF CMS OPPS Rate,113.25,Not Separately reimbursable,13.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,13.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.56,100% OF CMS OPPS Rate,10.56,100% OF CMS OPPS Rate,10.56,100% OF CMS OPPS RATE,10.56,100% OF CMS OPPS Rate,132.13,70% of total billed charges,10.56,100% OF CMS OPPS Rate,12.67,120% of CMS OPPS RATE,135.9,Pays at 72% of billed charges with lesser of charges applied,135.9,Pays at 72% of billed charges with lesser of charges applied,135.9,Pays at 72% of billed charges with lesser of charges applied,135.9,Pays at 72% of billed charges with lesser of charges applied,135.9,Pays at 72% of billed charges with lesser of charges applied,135.9,Pays at 72% of billed charges with lesser of charges applied,69.48,442% of BCBS Fee Schedule,69.48,442% of BCBS Fee Schedule,69.48,442% of BCBS Fee Schedule,69.48,442% of BCBS Fee Schedule,69.48,442% of BCBS Fee Schedule,69.48,442% of BCBS Fee Schedule,69.48,442% of BCBS Fee Schedule,69.48,442% of BCBS Fee Schedule,69.48,442% of BCBS Fee Schedule,16.59,112.32% OF BCBS FEE SCHEDULE,16.59,112.32% OF BCBS FEE SCHEDULE,16.59,112.32% OF BCBS FEE SCHEDULE,16.59,112.32% OF BCBS FEE SCHEDULE,16.59,112.32% OF BCBS FEE SCHEDULE,158.55,84% of total billed charges,158.55,84% of total billed charges,158.55,84% of total billed charges,132.13,70% of total billed charges,10.56,100% OF CMS OPPS Rate,10.56,100% OF CMS OPPS Rate,10.56,100% OF CMS OPPS Rate,10.56,100% OF CMS OPPS Rate,10.56,100% OF CMS OPPS Rate,10.56,100% OF CMS OPPS Rate,10.56,100% OF CMS OPPS Rate,10.56,100% OF CMS OPPS Rate,10.56,100% OF CMS OPPS Rate,10.56,100% OF CMS OPPS Rate,10.56,100% OF CMS OPPS Rate,10.56,100% OF CMS OPPS Rate,10.56,100% OF CMS OPPS Rate,10.56,100% OF CMS OPPS Rate,10.56,100% OF CMS OPPS Rate,10.56,100% OF CMS OPPS Rate,13.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,13.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,13.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,13.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,13.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,13.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,13.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,13.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,13.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,13.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,13.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,13.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,13.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,13.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,13.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,13.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,13.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,13.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,13.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,13.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.56,158.55,141.56
Outpatient Medical Services,LAB,80055,Obstetric blood test panel,301,176.25,126.9,Pays at 72% of billed charges with lesser of charges applied,47.81,100% OF CMS OPPS Rate,108.11,442% of BCBS Fee Schedule,47.81,100% OF CMS OPPS Rate,172.9,112.32% OF BCBS FEE SCHEDULE,47.81,100% OF CMS OPPS Rate,148.05,84% of total billed charges,148.05,84% of total billed charges,126.9,72% of total billed charges,47.81,100% OF CMS OPPS Rate,47.81,100% of CMS OPPS Rate,47.81,100% OF CMS OPPS Rate,105.75,Not Separately reimbursable,51.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,51.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,47.81,100% OF CMS OPPS Rate,47.81,100% OF CMS OPPS Rate,47.81,100% OF CMS OPPS RATE,47.81,100% OF CMS OPPS Rate,123.38,70% of total billed charges,47.81,100% OF CMS OPPS Rate,57.37,120% of CMS OPPS RATE,126.9,Pays at 72% of billed charges with lesser of charges applied,126.9,Pays at 72% of billed charges with lesser of charges applied,126.9,Pays at 72% of billed charges with lesser of charges applied,126.9,Pays at 72% of billed charges with lesser of charges applied,126.9,Pays at 72% of billed charges with lesser of charges applied,126.9,Pays at 72% of billed charges with lesser of charges applied,108.11,442% of BCBS Fee Schedule,108.11,442% of BCBS Fee Schedule,108.11,442% of BCBS Fee Schedule,108.11,442% of BCBS Fee Schedule,108.11,442% of BCBS Fee Schedule,108.11,442% of BCBS Fee Schedule,108.11,442% of BCBS Fee Schedule,108.11,442% of BCBS Fee Schedule,108.11,442% of BCBS Fee Schedule,172.9,112.32% OF BCBS FEE SCHEDULE,172.9,112.32% OF BCBS FEE SCHEDULE,172.9,112.32% OF BCBS FEE SCHEDULE,172.9,112.32% OF BCBS FEE SCHEDULE,172.9,112.32% OF BCBS FEE SCHEDULE,148.05,84% of total billed charges,148.05,84% of total billed charges,148.05,84% of total billed charges,123.38,70% of total billed charges,47.81,100% OF CMS OPPS Rate,47.81,100% OF CMS OPPS Rate,47.81,100% OF CMS OPPS Rate,47.81,100% OF CMS OPPS Rate,47.81,100% OF CMS OPPS Rate,47.81,100% OF CMS OPPS Rate,47.81,100% OF CMS OPPS Rate,47.81,100% OF CMS OPPS Rate,47.81,100% OF CMS OPPS Rate,47.81,100% OF CMS OPPS Rate,47.81,100% OF CMS OPPS Rate,47.81,100% OF CMS OPPS Rate,47.81,100% OF CMS OPPS Rate,47.81,100% OF CMS OPPS Rate,47.81,100% OF CMS OPPS Rate,47.81,100% OF CMS OPPS Rate,51.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,51.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,51.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,51.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,51.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,51.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,51.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,51.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,51.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,51.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,51.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,51.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,51.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,51.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,51.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,51.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,51.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,51.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,51.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,51.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,47.81,172.90,132.19
Outpatient Medical Services,LAB,80061,"Blood test, lipids (cholesterol and triglycerides)",301,167.5,120.6,Pays at 72% of billed charges with lesser of charges applied,13.39,100% OF CMS OPPS Rate,87.91,442% of BCBS Fee Schedule,13.39,100% OF CMS OPPS Rate,21.03,112.32% OF BCBS FEE SCHEDULE,13.39,100% OF CMS OPPS Rate,140.7,84% of total billed charges,140.7,84% of total billed charges,120.6,72% of total billed charges,13.39,100% OF CMS OPPS Rate,13.39,100% of CMS OPPS Rate,13.39,100% OF CMS OPPS Rate,100.5,Not Separately reimbursable,16.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,16.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,13.39,100% OF CMS OPPS Rate,13.39,100% OF CMS OPPS Rate,13.39,100% OF CMS OPPS RATE,13.39,100% OF CMS OPPS Rate,117.25,70% of total billed charges,13.39,100% OF CMS OPPS Rate,16.06,120% of CMS OPPS RATE,120.6,Pays at 72% of billed charges with lesser of charges applied,120.6,Pays at 72% of billed charges with lesser of charges applied,120.6,Pays at 72% of billed charges with lesser of charges applied,120.6,Pays at 72% of billed charges with lesser of charges applied,120.6,Pays at 72% of billed charges with lesser of charges applied,120.6,Pays at 72% of billed charges with lesser of charges applied,87.91,442% of BCBS Fee Schedule,87.91,442% of BCBS Fee Schedule,87.91,442% of BCBS Fee Schedule,87.91,442% of BCBS Fee Schedule,87.91,442% of BCBS Fee Schedule,87.91,442% of BCBS Fee Schedule,87.91,442% of BCBS Fee Schedule,87.91,442% of BCBS Fee Schedule,87.91,442% of BCBS Fee Schedule,21.03,112.32% OF BCBS FEE SCHEDULE,21.03,112.32% OF BCBS FEE SCHEDULE,21.03,112.32% OF BCBS FEE SCHEDULE,21.03,112.32% OF BCBS FEE SCHEDULE,21.03,112.32% OF BCBS FEE SCHEDULE,140.7,84% of total billed charges,140.7,84% of total billed charges,140.7,84% of total billed charges,117.25,70% of total billed charges,13.39,100% OF CMS OPPS Rate,13.39,100% OF CMS OPPS Rate,13.39,100% OF CMS OPPS Rate,13.39,100% OF CMS OPPS Rate,13.39,100% OF CMS OPPS Rate,13.39,100% OF CMS OPPS Rate,13.39,100% OF CMS OPPS Rate,13.39,100% OF CMS OPPS Rate,13.39,100% OF CMS OPPS Rate,13.39,100% OF CMS OPPS Rate,13.39,100% OF CMS OPPS Rate,13.39,100% OF CMS OPPS Rate,13.39,100% OF CMS OPPS Rate,13.39,100% OF CMS OPPS Rate,13.39,100% OF CMS OPPS Rate,13.39,100% OF CMS OPPS Rate,16.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,16.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,16.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,16.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,16.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,16.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,16.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,16.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,16.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,16.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,16.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,16.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,16.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,16.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,16.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,16.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,16.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,16.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,16.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,16.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,13.39,140.70,125.63
Outpatient Medical Services,LAB,80069,Kidney function panel test,301,140.5,101.16,Pays at 72% of billed charges with lesser of charges applied,8.68,100% OF CMS OPPS Rate,56.97,442% of BCBS Fee Schedule,8.68,100% OF CMS OPPS Rate,13.62,112.32% OF BCBS FEE SCHEDULE,8.68,100% OF CMS OPPS Rate,118.02,84% of total billed charges,118.02,84% of total billed charges,101.16,72% of total billed charges,8.68,100% OF CMS OPPS Rate,8.68,100% of CMS OPPS Rate,8.68,100% OF CMS OPPS Rate,84.3,Not Separately reimbursable,10.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,8.68,100% OF CMS OPPS Rate,8.68,100% OF CMS OPPS Rate,8.68,100% OF CMS OPPS RATE,8.68,100% OF CMS OPPS Rate,98.35,70% of total billed charges,8.68,100% OF CMS OPPS Rate,10.41,120% of CMS OPPS RATE,101.16,Pays at 72% of billed charges with lesser of charges applied,101.16,Pays at 72% of billed charges with lesser of charges applied,101.16,Pays at 72% of billed charges with lesser of charges applied,101.16,Pays at 72% of billed charges with lesser of charges applied,101.16,Pays at 72% of billed charges with lesser of charges applied,101.16,Pays at 72% of billed charges with lesser of charges applied,56.97,442% of BCBS Fee Schedule,56.97,442% of BCBS Fee Schedule,56.97,442% of BCBS Fee Schedule,56.97,442% of BCBS Fee Schedule,56.97,442% of BCBS Fee Schedule,56.97,442% of BCBS Fee Schedule,56.97,442% of BCBS Fee Schedule,56.97,442% of BCBS Fee Schedule,56.97,442% of BCBS Fee Schedule,13.62,112.32% OF BCBS FEE SCHEDULE,13.62,112.32% OF BCBS FEE SCHEDULE,13.62,112.32% OF BCBS FEE SCHEDULE,13.62,112.32% OF BCBS FEE SCHEDULE,13.62,112.32% OF BCBS FEE SCHEDULE,118.02,84% of total billed charges,118.02,84% of total billed charges,118.02,84% of total billed charges,98.35,70% of total billed charges,8.68,100% OF CMS OPPS Rate,8.68,100% OF CMS OPPS Rate,8.68,100% OF CMS OPPS Rate,8.68,100% OF CMS OPPS Rate,8.68,100% OF CMS OPPS Rate,8.68,100% OF CMS OPPS Rate,8.68,100% OF CMS OPPS Rate,8.68,100% OF CMS OPPS Rate,8.68,100% OF CMS OPPS Rate,8.68,100% OF CMS OPPS Rate,8.68,100% OF CMS OPPS Rate,8.68,100% OF CMS OPPS Rate,8.68,100% OF CMS OPPS Rate,8.68,100% OF CMS OPPS Rate,8.68,100% OF CMS OPPS Rate,8.68,100% OF CMS OPPS Rate,10.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,8.68,118.02,105.38
Outpatient Medical Services,LAB,80076,Liver function blood test panel,301,91.75,66.06,Pays at 72% of billed charges with lesser of charges applied,8.17,100% OF CMS OPPS Rate,53.66,442% of BCBS Fee Schedule,8.17,100% OF CMS OPPS Rate,12.83,112.32% OF BCBS FEE SCHEDULE,8.17,100% OF CMS OPPS Rate,77.07,84% of total billed charges,77.07,84% of total billed charges,66.06,72% of total billed charges,8.17,100% OF CMS OPPS Rate,8.17,100% of CMS OPPS Rate,8.17,100% OF CMS OPPS Rate,55.05,60% of total billed charges,9.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,9.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,8.17,100% OF CMS OPPS Rate,8.17,100% OF CMS OPPS Rate,8.17,100% OF CMS OPPS RATE,8.17,100% OF CMS OPPS Rate,64.23,70% of total billed charges,8.17,100% OF CMS OPPS Rate,9.8,120% of CMS OPPS RATE,66.06,Pays at 72% of billed charges with lesser of charges applied,66.06,Pays at 72% of billed charges with lesser of charges applied,66.06,Pays at 72% of billed charges with lesser of charges applied,66.06,Pays at 72% of billed charges with lesser of charges applied,66.06,Pays at 72% of billed charges with lesser of charges applied,66.06,Pays at 72% of billed charges with lesser of charges applied,53.66,442% of BCBS Fee Schedule,53.66,442% of BCBS Fee Schedule,53.66,442% of BCBS Fee Schedule,53.66,442% of BCBS Fee Schedule,53.66,442% of BCBS Fee Schedule,53.66,442% of BCBS Fee Schedule,53.66,442% of BCBS Fee Schedule,53.66,442% of BCBS Fee Schedule,53.66,442% of BCBS Fee Schedule,12.83,112.32% OF BCBS FEE SCHEDULE,12.83,112.32% OF BCBS FEE SCHEDULE,12.83,112.32% OF BCBS FEE SCHEDULE,12.83,112.32% OF BCBS FEE SCHEDULE,12.83,112.32% OF BCBS FEE SCHEDULE,77.07,84% of total billed charges,77.07,84% of total billed charges,77.07,84% of total billed charges,64.23,70% of total billed charges,8.17,100% OF CMS OPPS Rate,8.17,100% OF CMS OPPS Rate,8.17,100% OF CMS OPPS Rate,8.17,100% OF CMS OPPS Rate,8.17,100% OF CMS OPPS Rate,8.17,100% OF CMS OPPS Rate,8.17,100% OF CMS OPPS Rate,8.17,100% OF CMS OPPS Rate,8.17,100% OF CMS OPPS Rate,8.17,100% OF CMS OPPS Rate,8.17,100% OF CMS OPPS Rate,8.17,100% OF CMS OPPS Rate,8.17,100% OF CMS OPPS Rate,8.17,100% OF CMS OPPS Rate,8.17,100% OF CMS OPPS Rate,8.17,100% OF CMS OPPS Rate,9.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,9.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,9.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,9.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,9.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,9.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,9.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,9.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,9.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,9.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,9.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,9.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,9.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,9.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,9.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,9.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,9.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,9.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,9.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,9.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,8.17,77.07,68.81
Outpatient Medical Services,LAB,81001,Manual urinalysis test with examination with or without using microscope,307,46.25,33.3,Pays at 72% of billed charges with lesser of charges applied,3.17,100% OF CMS OPPS Rate,20.07,442% of BCBS Fee Schedule,3.17,100% OF CMS OPPS Rate,4.98,112.32% OF BCBS FEE SCHEDULE,3.17,100% OF CMS OPPS Rate,38.85,84% of total billed charges,38.85,84% of total billed charges,33.3,72% of total billed charges,3.17,100% OF CMS OPPS Rate,3.17,100% of CMS OPPS Rate,3.17,100% OF CMS OPPS Rate,27.75,60% of total billed charges,3.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,3.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,3.17,100% OF CMS OPPS Rate,3.17,100% OF CMS OPPS Rate,3.17,100% OF CMS OPPS RATE,3.17,100% OF CMS OPPS Rate,32.38,70% of total billed charges,3.17,100% OF CMS OPPS Rate,3.8,120% of CMS OPPS RATE,33.3,Pays at 72% of billed charges with lesser of charges applied,33.3,Pays at 72% of billed charges with lesser of charges applied,33.3,Pays at 72% of billed charges with lesser of charges applied,33.3,Pays at 72% of billed charges with lesser of charges applied,33.3,Pays at 72% of billed charges with lesser of charges applied,33.3,Pays at 72% of billed charges with lesser of charges applied,20.07,442% of BCBS Fee Schedule,20.07,442% of BCBS Fee Schedule,20.07,442% of BCBS Fee Schedule,20.07,442% of BCBS Fee Schedule,20.07,442% of BCBS Fee Schedule,20.07,442% of BCBS Fee Schedule,20.07,442% of BCBS Fee Schedule,20.07,442% of BCBS Fee Schedule,20.07,442% of BCBS Fee Schedule,4.98,112.32% OF BCBS FEE SCHEDULE,4.98,112.32% OF BCBS FEE SCHEDULE,4.98,112.32% OF BCBS FEE SCHEDULE,4.98,112.32% OF BCBS FEE SCHEDULE,4.98,112.32% OF BCBS FEE SCHEDULE,38.85,84% of total billed charges,38.85,84% of total billed charges,38.85,84% of total billed charges,32.38,70% of total billed charges,3.17,100% OF CMS OPPS Rate,3.17,100% OF CMS OPPS Rate,3.17,100% OF CMS OPPS Rate,3.17,100% OF CMS OPPS Rate,3.17,100% OF CMS OPPS Rate,3.17,100% OF CMS OPPS Rate,3.17,100% OF CMS OPPS Rate,3.17,100% OF CMS OPPS Rate,3.17,100% OF CMS OPPS Rate,3.17,100% OF CMS OPPS Rate,3.17,100% OF CMS OPPS Rate,3.17,100% OF CMS OPPS Rate,3.17,100% OF CMS OPPS Rate,3.17,100% OF CMS OPPS Rate,3.17,100% OF CMS OPPS Rate,3.17,100% OF CMS OPPS Rate,3.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,3.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,3.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,3.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,3.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,3.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,3.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,3.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,3.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,3.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,3.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,3.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,3.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,3.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,3.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,3.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,3.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,3.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,3.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,3.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,3.17,38.85,34.69
Outpatient Medical Services,LAB,81002,Manual urinalysis test with examination without using microscope,307,28.5,20.52,Pays at 72% of billed charges with lesser of charges applied,3.48,100% OF CMS OPPS Rate,15.6,442% of BCBS Fee Schedule,3.48,100% OF CMS OPPS Rate,4.01,112.32% OF BCBS FEE SCHEDULE,3.48,100% OF CMS OPPS Rate,23.94,84% of total billed charges,23.94,84% of total billed charges,20.52,72% of total billed charges,3.48,100% OF CMS OPPS Rate,3.48,100% of CMS OPPS Rate,3.48,100% OF CMS OPPS Rate,17.1,60% of total billed charges,3.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,3.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,3.48,100% OF CMS OPPS Rate,3.48,100% OF CMS OPPS Rate,3.48,100% OF CMS OPPS RATE,3.48,100% OF CMS OPPS Rate,19.95,70% of total billed charges,3.48,100% OF CMS OPPS Rate,4.17,120% of CMS OPPS RATE,20.52,Pays at 72% of billed charges with lesser of charges applied,20.52,Pays at 72% of billed charges with lesser of charges applied,20.52,Pays at 72% of billed charges with lesser of charges applied,20.52,Pays at 72% of billed charges with lesser of charges applied,20.52,Pays at 72% of billed charges with lesser of charges applied,20.52,Pays at 72% of billed charges with lesser of charges applied,15.6,442% of BCBS Fee Schedule,15.6,442% of BCBS Fee Schedule,15.6,442% of BCBS Fee Schedule,15.6,442% of BCBS Fee Schedule,15.6,442% of BCBS Fee Schedule,15.6,442% of BCBS Fee Schedule,15.6,442% of BCBS Fee Schedule,15.6,442% of BCBS Fee Schedule,15.6,442% of BCBS Fee Schedule,4.01,112.32% OF BCBS FEE SCHEDULE,4.01,112.32% OF BCBS FEE SCHEDULE,4.01,112.32% OF BCBS FEE SCHEDULE,4.01,112.32% OF BCBS FEE SCHEDULE,4.01,112.32% OF BCBS FEE SCHEDULE,23.94,84% of total billed charges,23.94,84% of total billed charges,23.94,84% of total billed charges,19.95,70% of total billed charges,3.48,100% OF CMS OPPS Rate,3.48,100% OF CMS OPPS Rate,3.48,100% OF CMS OPPS Rate,3.48,100% OF CMS OPPS Rate,3.48,100% OF CMS OPPS Rate,3.48,100% OF CMS OPPS Rate,3.48,100% OF CMS OPPS Rate,3.48,100% OF CMS OPPS Rate,3.48,100% OF CMS OPPS Rate,3.48,100% OF CMS OPPS Rate,3.48,100% OF CMS OPPS Rate,3.48,100% OF CMS OPPS Rate,3.48,100% OF CMS OPPS Rate,3.48,100% OF CMS OPPS Rate,3.48,100% OF CMS OPPS Rate,3.48,100% OF CMS OPPS Rate,3.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,3.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,3.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,3.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,3.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,3.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,3.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,3.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,3.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,3.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,3.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,3.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,3.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,3.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,3.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,3.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,3.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,3.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,3.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,3.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,3.08,23.94,21.38
Outpatient Medical Services,LAB,81003,Automated urinalysis test,307,28.5,20.52,Pays at 72% of billed charges with lesser of charges applied,2.25,100% OF CMS OPPS Rate,14.76,442% of BCBS Fee Schedule,2.25,100% OF CMS OPPS Rate,3.53,112.32% OF BCBS FEE SCHEDULE,2.25,100% OF CMS OPPS Rate,23.94,84% of total billed charges,23.94,84% of total billed charges,20.52,72% of total billed charges,2.25,100% OF CMS OPPS Rate,2.25,100% of CMS OPPS Rate,2.25,100% OF CMS OPPS Rate,17.1,60% of total billed charges,2.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,2.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,2.25,100% OF CMS OPPS Rate,2.25,100% OF CMS OPPS Rate,2.25,100% OF CMS OPPS RATE,2.25,100% OF CMS OPPS Rate,19.95,70% of total billed charges,2.25,100% OF CMS OPPS Rate,2.7,120% of CMS OPPS RATE,20.52,Pays at 72% of billed charges with lesser of charges applied,20.52,Pays at 72% of billed charges with lesser of charges applied,20.52,Pays at 72% of billed charges with lesser of charges applied,20.52,Pays at 72% of billed charges with lesser of charges applied,20.52,Pays at 72% of billed charges with lesser of charges applied,20.52,Pays at 72% of billed charges with lesser of charges applied,14.76,442% of BCBS Fee Schedule,14.76,442% of BCBS Fee Schedule,14.76,442% of BCBS Fee Schedule,14.76,442% of BCBS Fee Schedule,14.76,442% of BCBS Fee Schedule,14.76,442% of BCBS Fee Schedule,14.76,442% of BCBS Fee Schedule,14.76,442% of BCBS Fee Schedule,14.76,442% of BCBS Fee Schedule,3.53,112.32% OF BCBS FEE SCHEDULE,3.53,112.32% OF BCBS FEE SCHEDULE,3.53,112.32% OF BCBS FEE SCHEDULE,3.53,112.32% OF BCBS FEE SCHEDULE,3.53,112.32% OF BCBS FEE SCHEDULE,23.94,84% of total billed charges,23.94,84% of total billed charges,23.94,84% of total billed charges,19.95,70% of total billed charges,2.25,100% OF CMS OPPS Rate,2.25,100% OF CMS OPPS Rate,2.25,100% OF CMS OPPS Rate,2.25,100% OF CMS OPPS Rate,2.25,100% OF CMS OPPS Rate,2.25,100% OF CMS OPPS Rate,2.25,100% OF CMS OPPS Rate,2.25,100% OF CMS OPPS Rate,2.25,100% OF CMS OPPS Rate,2.25,100% OF CMS OPPS Rate,2.25,100% OF CMS OPPS Rate,2.25,100% OF CMS OPPS Rate,2.25,100% OF CMS OPPS Rate,2.25,100% OF CMS OPPS Rate,2.25,100% OF CMS OPPS Rate,2.25,100% OF CMS OPPS Rate,2.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,2.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,2.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,2.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,2.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,2.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,2.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,2.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,2.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,2.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,2.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,2.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,2.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,2.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,2.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,2.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,2.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,2.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,2.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,2.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,2.25,23.94,21.38
Outpatient Medical Services,LAB,84443,"Blood test, thyroid stimulating hormone (TSH)",300,125.25,90.18,Pays at 72% of billed charges with lesser of charges applied,16.8,100% OF CMS OPPS Rate,110.32,442% of BCBS Fee Schedule,16.8,100% OF CMS OPPS Rate,26.36,112.32% OF BCBS FEE SCHEDULE,16.8,100% OF CMS OPPS Rate,105.21,84% of total billed charges,105.21,84% of total billed charges,90.18,72% of total billed charges,16.8,100% OF CMS OPPS Rate,16.8,100% of CMS OPPS Rate,16.8,100% OF CMS OPPS Rate,75.15,60% of total billed charges,21.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,21.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,16.8,100% OF CMS OPPS Rate,16.8,100% OF CMS OPPS Rate,16.8,100% OF CMS OPPS RATE,16.8,100% OF CMS OPPS Rate,87.68,70% of total billed charges,16.8,100% OF CMS OPPS Rate,20.16,120% of CMS OPPS RATE,90.18,Pays at 72% of billed charges with lesser of charges applied,90.18,Pays at 72% of billed charges with lesser of charges applied,90.18,Pays at 72% of billed charges with lesser of charges applied,90.18,Pays at 72% of billed charges with lesser of charges applied,90.18,Pays at 72% of billed charges with lesser of charges applied,90.18,Pays at 72% of billed charges with lesser of charges applied,110.32,442% of BCBS Fee Schedule,110.32,442% of BCBS Fee Schedule,110.32,442% of BCBS Fee Schedule,110.32,442% of BCBS Fee Schedule,110.32,442% of BCBS Fee Schedule,110.32,442% of BCBS Fee Schedule,110.32,442% of BCBS Fee Schedule,110.32,442% of BCBS Fee Schedule,110.32,442% of BCBS Fee Schedule,26.36,112.32% OF BCBS FEE SCHEDULE,26.36,112.32% OF BCBS FEE SCHEDULE,26.36,112.32% OF BCBS FEE SCHEDULE,26.36,112.32% OF BCBS FEE SCHEDULE,26.36,112.32% OF BCBS FEE SCHEDULE,105.21,84% of total billed charges,105.21,84% of total billed charges,105.21,84% of total billed charges,87.68,70% of total billed charges,16.8,100% OF CMS OPPS Rate,16.8,100% OF CMS OPPS Rate,16.8,100% OF CMS OPPS Rate,16.8,100% OF CMS OPPS Rate,16.8,100% OF CMS OPPS Rate,16.8,100% OF CMS OPPS Rate,16.8,100% OF CMS OPPS Rate,16.8,100% OF CMS OPPS Rate,16.8,100% OF CMS OPPS Rate,16.8,100% OF CMS OPPS Rate,16.8,100% OF CMS OPPS Rate,16.8,100% OF CMS OPPS Rate,16.8,100% OF CMS OPPS Rate,16.8,100% OF CMS OPPS Rate,16.8,100% OF CMS OPPS Rate,16.8,100% OF CMS OPPS Rate,21.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,21.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,21.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,21.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,21.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,21.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,21.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,21.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,21.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,21.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,21.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,21.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,21.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,21.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,21.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,21.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,21.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,21.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,21.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,21.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,16.80,110.32,93.94
Outpatient Medical Services,LAB,85025,"Complete blood cell count, with differential white blood cells, automated",305,67,48.24,Pays at 72% of billed charges with lesser of charges applied,7.77,100% OF CMS OPPS Rate,51.05,442% of BCBS Fee Schedule,7.77,100% OF CMS OPPS Rate,12.2,112.32% OF BCBS FEE SCHEDULE,7.77,100% OF CMS OPPS Rate,56.28,84% of total billed charges,56.28,84% of total billed charges,48.24,72% of total billed charges,7.77,100% OF CMS OPPS Rate,7.77,100% of CMS OPPS Rate,7.77,100% OF CMS OPPS Rate,40.2,60% of total billed charges,9.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,9.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,7.77,100% OF CMS OPPS Rate,7.77,100% OF CMS OPPS Rate,7.77,100% OF CMS OPPS RATE,7.77,100% OF CMS OPPS Rate,46.9,70% of total billed charges,7.77,100% OF CMS OPPS Rate,9.32,120% of CMS OPPS RATE,48.24,Pays at 72% of billed charges with lesser of charges applied,48.24,Pays at 72% of billed charges with lesser of charges applied,48.24,Pays at 72% of billed charges with lesser of charges applied,48.24,Pays at 72% of billed charges with lesser of charges applied,48.24,Pays at 72% of billed charges with lesser of charges applied,48.24,Pays at 72% of billed charges with lesser of charges applied,51.05,442% of BCBS Fee Schedule,51.05,442% of BCBS Fee Schedule,51.05,442% of BCBS Fee Schedule,51.05,442% of BCBS Fee Schedule,51.05,442% of BCBS Fee Schedule,51.05,442% of BCBS Fee Schedule,51.05,442% of BCBS Fee Schedule,51.05,442% of BCBS Fee Schedule,51.05,442% of BCBS Fee Schedule,12.2,112.32% OF BCBS FEE SCHEDULE,12.2,112.32% OF BCBS FEE SCHEDULE,12.2,112.32% OF BCBS FEE SCHEDULE,12.2,112.32% OF BCBS FEE SCHEDULE,12.2,112.32% OF BCBS FEE SCHEDULE,56.28,84% of total billed charges,56.28,84% of total billed charges,56.28,84% of total billed charges,46.9,70% of total billed charges,7.77,100% OF CMS OPPS Rate,7.77,100% OF CMS OPPS Rate,7.77,100% OF CMS OPPS Rate,7.77,100% OF CMS OPPS Rate,7.77,100% OF CMS OPPS Rate,7.77,100% OF CMS OPPS Rate,7.77,100% OF CMS OPPS Rate,7.77,100% OF CMS OPPS Rate,7.77,100% OF CMS OPPS Rate,7.77,100% OF CMS OPPS Rate,7.77,100% OF CMS OPPS Rate,7.77,100% OF CMS OPPS Rate,7.77,100% OF CMS OPPS Rate,7.77,100% OF CMS OPPS Rate,7.77,100% OF CMS OPPS Rate,7.77,100% OF CMS OPPS Rate,9.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,9.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,9.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,9.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,9.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,9.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,9.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,9.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,9.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,9.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,9.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,9.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,9.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,9.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,9.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,9.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,9.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,9.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,9.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,9.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,7.77,56.28,50.25
Outpatient Medical Services,LAB,85027,"Complete blood count, automated",305,30.25,21.78,Pays at 72% of billed charges with lesser of charges applied,6.47,100% OF CMS OPPS Rate,30.25,BCBS Fee Schedule,6.47,100% OF CMS OPPS Rate,10.15,112.32% OF BCBS FEE SCHEDULE,6.47,100% OF CMS OPPS Rate,25.41,84% of total billed charges,25.41,84% of total billed charges,21.78,72% of total billed charges,6.47,100% OF CMS OPPS Rate,6.47,100% of CMS OPPS Rate,6.47,100% OF CMS OPPS Rate,18.15,60% of total billed charges,8.19,100% of CA Medicaid Fee Schedule with lesser of charges applied,8.19,100% of CA Medicaid Fee Schedule with lesser of charges applied,6.47,100% OF CMS OPPS Rate,6.47,100% OF CMS OPPS Rate,6.47,100% OF CMS OPPS RATE,6.47,100% OF CMS OPPS Rate,21.18,70% of total billed charges,6.47,100% OF CMS OPPS Rate,7.76,120% of CMS OPPS RATE,21.78,Pays at 72% of billed charges with lesser of charges applied,21.78,Pays at 72% of billed charges with lesser of charges applied,21.78,Pays at 72% of billed charges with lesser of charges applied,21.78,Pays at 72% of billed charges with lesser of charges applied,21.78,Pays at 72% of billed charges with lesser of charges applied,21.78,Pays at 72% of billed charges with lesser of charges applied,30.25,BCBS Fee Schedule,30.25,BCBS Fee Schedule,30.25,BCBS Fee Schedule,30.25,BCBS Fee Schedule,30.25,BCBS Fee Schedule,30.25,BCBS Fee Schedule,30.25,BCBS Fee Schedule,30.25,BCBS Fee Schedule,30.25,BCBS Fee Schedule,10.15,112.32% OF BCBS FEE SCHEDULE,10.15,112.32% OF BCBS FEE SCHEDULE,10.15,112.32% OF BCBS FEE SCHEDULE,10.15,112.32% OF BCBS FEE SCHEDULE,10.15,112.32% OF BCBS FEE SCHEDULE,25.41,84% of total billed charges,25.41,84% of total billed charges,25.41,84% of total billed charges,21.18,70% of total billed charges,6.47,100% OF CMS OPPS Rate,6.47,100% OF CMS OPPS Rate,6.47,100% OF CMS OPPS Rate,6.47,100% OF CMS OPPS Rate,6.47,100% OF CMS OPPS Rate,6.47,100% OF CMS OPPS Rate,6.47,100% OF CMS OPPS Rate,6.47,100% OF CMS OPPS Rate,6.47,100% OF CMS OPPS Rate,6.47,100% OF CMS OPPS Rate,6.47,100% OF CMS OPPS Rate,6.47,100% OF CMS OPPS Rate,6.47,100% OF CMS OPPS Rate,6.47,100% OF CMS OPPS Rate,6.47,100% OF CMS OPPS Rate,6.47,100% OF CMS OPPS Rate,8.19,100% of CA Medicaid Fee Schedule with lesser of charges applied,8.19,100% of CA Medicaid Fee Schedule with lesser of charges applied,8.19,100% of CA Medicaid Fee Schedule with lesser of charges applied,8.19,100% of CA Medicaid Fee Schedule with lesser of charges applied,8.19,100% of CA Medicaid Fee Schedule with lesser of charges applied,8.19,100% of CA Medicaid Fee Schedule with lesser of charges applied,8.19,100% of CA Medicaid Fee Schedule with lesser of charges applied,8.19,100% of CA Medicaid Fee Schedule with lesser of charges applied,8.19,100% of CA Medicaid Fee Schedule with lesser of charges applied,8.19,100% of CA Medicaid Fee Schedule with lesser of charges applied,8.19,100% of CA Medicaid Fee Schedule with lesser of charges applied,8.19,100% of CA Medicaid Fee Schedule with lesser of charges applied,8.19,100% of CA Medicaid Fee Schedule with lesser of charges applied,8.19,100% of CA Medicaid Fee Schedule with lesser of charges applied,8.19,100% of CA Medicaid Fee Schedule with lesser of charges applied,8.19,100% of CA Medicaid Fee Schedule with lesser of charges applied,8.19,100% of CA Medicaid Fee Schedule with lesser of charges applied,8.19,100% of CA Medicaid Fee Schedule with lesser of charges applied,8.19,100% of CA Medicaid Fee Schedule with lesser of charges applied,8.19,100% of CA Medicaid Fee Schedule with lesser of charges applied,6.47,30.25,22.69
Outpatient Medical Services,LAB,85610,"Blood test, clotting time",305,77,55.44,Pays at 72% of billed charges with lesser of charges applied,4.29,100% OF CMS OPPS Rate,25.86,442% of BCBS Fee Schedule,4.29,100% OF CMS OPPS Rate,6.17,112.32% OF BCBS FEE SCHEDULE,4.29,100% OF CMS OPPS Rate,64.68,84% of total billed charges,64.68,84% of total billed charges,55.44,72% of total billed charges,4.29,100% OF CMS OPPS Rate,4.29,100% of CMS OPPS Rate,4.29,100% OF CMS OPPS Rate,46.2,60% of total billed charges,5.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,5.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,4.29,100% OF CMS OPPS Rate,4.29,100% OF CMS OPPS Rate,4.29,100% OF CMS OPPS RATE,4.29,100% OF CMS OPPS Rate,53.9,70% of total billed charges,4.29,100% OF CMS OPPS Rate,5.14,120% of CMS OPPS RATE,55.44,Pays at 72% of billed charges with lesser of charges applied,55.44,Pays at 72% of billed charges with lesser of charges applied,55.44,Pays at 72% of billed charges with lesser of charges applied,55.44,Pays at 72% of billed charges with lesser of charges applied,55.44,Pays at 72% of billed charges with lesser of charges applied,55.44,Pays at 72% of billed charges with lesser of charges applied,25.86,442% of BCBS Fee Schedule,25.86,442% of BCBS Fee Schedule,25.86,442% of BCBS Fee Schedule,25.86,442% of BCBS Fee Schedule,25.86,442% of BCBS Fee Schedule,25.86,442% of BCBS Fee Schedule,25.86,442% of BCBS Fee Schedule,25.86,442% of BCBS Fee Schedule,25.86,442% of BCBS Fee Schedule,6.17,112.32% OF BCBS FEE SCHEDULE,6.17,112.32% OF BCBS FEE SCHEDULE,6.17,112.32% OF BCBS FEE SCHEDULE,6.17,112.32% OF BCBS FEE SCHEDULE,6.17,112.32% OF BCBS FEE SCHEDULE,64.68,84% of total billed charges,64.68,84% of total billed charges,64.68,84% of total billed charges,53.9,70% of total billed charges,4.29,100% OF CMS OPPS Rate,4.29,100% OF CMS OPPS Rate,4.29,100% OF CMS OPPS Rate,4.29,100% OF CMS OPPS Rate,4.29,100% OF CMS OPPS Rate,4.29,100% OF CMS OPPS Rate,4.29,100% OF CMS OPPS Rate,4.29,100% OF CMS OPPS Rate,4.29,100% OF CMS OPPS Rate,4.29,100% OF CMS OPPS Rate,4.29,100% OF CMS OPPS Rate,4.29,100% OF CMS OPPS Rate,4.29,100% OF CMS OPPS Rate,4.29,100% OF CMS OPPS Rate,4.29,100% OF CMS OPPS Rate,4.29,100% OF CMS OPPS Rate,5.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,5.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,5.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,5.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,5.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,5.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,5.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,5.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,5.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,5.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,5.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,5.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,5.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,5.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,5.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,5.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,5.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,5.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,5.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,5.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,4.29,64.68,57.75
Outpatient Medical Services,LAB,85730,Coagulation assessment blood test,305,74.5,53.64,Pays at 72% of billed charges with lesser of charges applied,6.01,100% OF CMS OPPS Rate,39.43,442% of BCBS Fee Schedule,6.01,100% OF CMS OPPS Rate,9.41,112.32% OF BCBS FEE SCHEDULE,6.01,100% OF CMS OPPS Rate,62.58,84% of total billed charges,62.58,84% of total billed charges,53.64,72% of total billed charges,6.01,100% OF CMS OPPS Rate,6.01,100% of CMS OPPS Rate,6.01,100% OF CMS OPPS Rate,44.7,60% of total billed charges,7.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,7.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,6.01,100% OF CMS OPPS Rate,6.01,100% OF CMS OPPS Rate,6.01,100% OF CMS OPPS RATE,6.01,100% OF CMS OPPS Rate,52.15,70% of total billed charges,6.01,100% OF CMS OPPS Rate,7.21,120% of CMS OPPS RATE,53.64,Pays at 72% of billed charges with lesser of charges applied,53.64,Pays at 72% of billed charges with lesser of charges applied,53.64,Pays at 72% of billed charges with lesser of charges applied,53.64,Pays at 72% of billed charges with lesser of charges applied,53.64,Pays at 72% of billed charges with lesser of charges applied,53.64,Pays at 72% of billed charges with lesser of charges applied,39.43,442% of BCBS Fee Schedule,39.43,442% of BCBS Fee Schedule,39.43,442% of BCBS Fee Schedule,39.43,442% of BCBS Fee Schedule,39.43,442% of BCBS Fee Schedule,39.43,442% of BCBS Fee Schedule,39.43,442% of BCBS Fee Schedule,39.43,442% of BCBS Fee Schedule,39.43,442% of BCBS Fee Schedule,9.41,112.32% OF BCBS FEE SCHEDULE,9.41,112.32% OF BCBS FEE SCHEDULE,9.41,112.32% OF BCBS FEE SCHEDULE,9.41,112.32% OF BCBS FEE SCHEDULE,9.41,112.32% OF BCBS FEE SCHEDULE,62.58,84% of total billed charges,62.58,84% of total billed charges,62.58,84% of total billed charges,52.15,70% of total billed charges,6.01,100% OF CMS OPPS Rate,6.01,100% OF CMS OPPS Rate,6.01,100% OF CMS OPPS Rate,6.01,100% OF CMS OPPS Rate,6.01,100% OF CMS OPPS Rate,6.01,100% OF CMS OPPS Rate,6.01,100% OF CMS OPPS Rate,6.01,100% OF CMS OPPS Rate,6.01,100% OF CMS OPPS Rate,6.01,100% OF CMS OPPS Rate,6.01,100% OF CMS OPPS Rate,6.01,100% OF CMS OPPS Rate,6.01,100% OF CMS OPPS Rate,6.01,100% OF CMS OPPS Rate,6.01,100% OF CMS OPPS Rate,6.01,100% OF CMS OPPS Rate,7.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,7.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,7.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,7.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,7.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,7.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,7.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,7.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,7.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,7.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,7.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,7.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,7.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,7.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,7.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,7.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,7.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,7.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,7.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,7.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,6.01,62.58,55.88
Outpatient Medical Services,MAMMOGRAM,77065,"Diagnostic mammography, including computer-aided detection (cad) when performed; unilateral",401,485,349.2,Pays at 72% of billed charges with lesser of charges applied,104.11,100% OF CMS OPPS Rate,485,BCBS Fee Schedule,104.11,100% OF CMS OPPS Rate,442.74,100% of BCBS Fee Schedule,104.11,100% OF CMS OPPS Rate,455,Case rate,455,Case rate,349.2,72% of total billed charges,104.11,100% OF CMS OPPS Rate,104.11,100% of CMS OPPS Rate,104.11,100% OF CMS OPPS Rate,291,60% of total billed charges,167.94,100% of CA Medicaid Fee Schedule with lesser of charges applied,167.94,100% of CA Medicaid Fee Schedule with lesser of charges applied,104.11,100% OF CMS OPPS Rate,104.11,100% OF CMS OPPS Rate,104.11,100% OF CMS OPPS RATE,104.11,100% OF CMS OPPS Rate,339.5,70% of total billed charges,104.11,100% OF CMS OPPS Rate,124.93,120% of CMS OPPS RATE,349.2,Pays at 72% of billed charges with lesser of charges applied,349.2,Pays at 72% of billed charges with lesser of charges applied,349.2,Pays at 72% of billed charges with lesser of charges applied,349.2,Pays at 72% of billed charges with lesser of charges applied,349.2,Pays at 72% of billed charges with lesser of charges applied,349.2,Pays at 72% of billed charges with lesser of charges applied,485,BCBS Fee Schedule,485,BCBS Fee Schedule,485,BCBS Fee Schedule,485,BCBS Fee Schedule,485,BCBS Fee Schedule,485,BCBS Fee Schedule,485,BCBS Fee Schedule,485,BCBS Fee Schedule,485,BCBS Fee Schedule,442.74,100% of BCBS Fee Schedule,442.74,100% of BCBS Fee Schedule,442.74,100% of BCBS Fee Schedule,442.74,100% of BCBS Fee Schedule,442.74,100% of BCBS Fee Schedule,455,Case rate,455,Case rate,455,Case rate,339.5,70% of total billed charges,104.11,100% OF CMS OPPS Rate,104.11,100% OF CMS OPPS Rate,104.11,100% OF CMS OPPS Rate,104.11,100% OF CMS OPPS Rate,104.11,100% OF CMS OPPS Rate,104.11,100% OF CMS OPPS Rate,104.11,100% OF CMS OPPS Rate,104.11,100% OF CMS OPPS Rate,104.11,100% OF CMS OPPS Rate,104.11,100% OF CMS OPPS Rate,104.11,100% OF CMS OPPS Rate,104.11,100% OF CMS OPPS Rate,104.11,100% OF CMS OPPS Rate,104.11,100% OF CMS OPPS Rate,104.11,100% OF CMS OPPS Rate,104.11,100% OF CMS OPPS Rate,167.94,100% of CA Medicaid Fee Schedule with lesser of charges applied,167.94,100% of CA Medicaid Fee Schedule with lesser of charges applied,167.94,100% of CA Medicaid Fee Schedule with lesser of charges applied,167.94,100% of CA Medicaid Fee Schedule with lesser of charges applied,167.94,100% of CA Medicaid Fee Schedule with lesser of charges applied,167.94,100% of CA Medicaid Fee Schedule with lesser of charges applied,167.94,100% of CA Medicaid Fee Schedule with lesser of charges applied,167.94,100% of CA Medicaid Fee Schedule with lesser of charges applied,167.94,100% of CA Medicaid Fee Schedule with lesser of charges applied,167.94,100% of CA Medicaid Fee Schedule with lesser of charges applied,167.94,100% of CA Medicaid Fee Schedule with lesser of charges applied,167.94,100% of CA Medicaid Fee Schedule with lesser of charges applied,167.94,100% of CA Medicaid Fee Schedule with lesser of charges applied,167.94,100% of CA Medicaid Fee Schedule with lesser of charges applied,167.94,100% of CA Medicaid Fee Schedule with lesser of charges applied,167.94,100% of CA Medicaid Fee Schedule with lesser of charges applied,167.94,100% of CA Medicaid Fee Schedule with lesser of charges applied,167.94,100% of CA Medicaid Fee Schedule with lesser of charges applied,167.94,100% of CA Medicaid Fee Schedule with lesser of charges applied,167.94,100% of CA Medicaid Fee Schedule with lesser of charges applied,104.11,485.00,363.75
Outpatient Medical Services,MAMMOGRAM,77066,"Diagnostic mammography, including computer-aided detection (cad) when performed; bilateral",401,530.5,381.96,Pays at 72% of billed charges with lesser of charges applied,132.78,100% OF CMS OPPS Rate,530.5,BCBS Fee Schedule,132.78,100% OF CMS OPPS Rate,520.42,pays at 100% of bcbs fee schedule with lesser of charges applied,132.78,100% OF CMS OPPS Rate,455,Case rate,455,Case rate,381.96,72% of total billed charges,132.78,100% OF CMS OPPS Rate,132.78,100% of CMS OPPS Rate,132.78,100% OF CMS OPPS Rate,318.3,60% of total billed charges,212.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,212.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,132.78,100% OF CMS OPPS Rate,132.78,100% OF CMS OPPS Rate,132.78,100% OF CMS OPPS RATE,132.78,100% OF CMS OPPS Rate,371.35,70% of total billed charges,132.78,100% OF CMS OPPS Rate,159.34,120% of CMS OPPS RATE,381.96,Pays at 72% of billed charges with lesser of charges applied,381.96,Pays at 72% of billed charges with lesser of charges applied,381.96,Pays at 72% of billed charges with lesser of charges applied,381.96,Pays at 72% of billed charges with lesser of charges applied,381.96,Pays at 72% of billed charges with lesser of charges applied,381.96,Pays at 72% of billed charges with lesser of charges applied,530.5,BCBS Fee Schedule,530.5,BCBS Fee Schedule,530.5,BCBS Fee Schedule,530.5,BCBS Fee Schedule,530.5,BCBS Fee Schedule,530.5,BCBS Fee Schedule,530.5,BCBS Fee Schedule,530.5,BCBS Fee Schedule,530.5,BCBS Fee Schedule,520.42,pays at 100% of bcbs fee schedule with lesser of charges applied,520.42,pays at 100% of bcbs fee schedule with lesser of charges applied,520.42,pays at 100% of bcbs fee schedule with lesser of charges applied,520.42,pays at 100% of bcbs fee schedule with lesser of charges applied,520.42,pays at 100% of bcbs fee schedule with lesser of charges applied,455,Case rate,455,Case rate,455,Case rate,371.35,70% of total billed charges,132.78,100% OF CMS OPPS Rate,132.78,100% OF CMS OPPS Rate,132.78,100% OF CMS OPPS Rate,132.78,100% OF CMS OPPS Rate,132.78,100% OF CMS OPPS Rate,132.78,100% OF CMS OPPS Rate,132.78,100% OF CMS OPPS Rate,132.78,100% OF CMS OPPS Rate,132.78,100% OF CMS OPPS Rate,132.78,100% OF CMS OPPS Rate,132.78,100% OF CMS OPPS Rate,132.78,100% OF CMS OPPS Rate,132.78,100% OF CMS OPPS Rate,132.78,100% OF CMS OPPS Rate,132.78,100% OF CMS OPPS Rate,132.78,100% OF CMS OPPS Rate,212.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,212.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,212.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,212.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,212.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,212.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,212.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,212.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,212.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,212.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,212.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,212.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,212.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,212.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,212.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,212.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,212.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,212.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,212.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,212.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,132.78,530.50,397.88
Outpatient Medical Services,MAMMOGRAM,G0279,DIAG DIGITAL BREAST TOMOSYNTH,401,116.75,84.06,Pays at 72% of billed charges with lesser of charges applied,28.66,100% OF CMS OPPS Rate,116.75,BCBS Fee Schedule,28.66,100% OF CMS OPPS Rate,92.35,79.1% of total billed charges,28.66,100% OF CMS OPPS Rate,116.75,Case rate,116.75,Case rate,84.06,72% of total billed charges,28.66,100% OF CMS OPPS Rate,28.66,100% of CMS OPPS Rate,28.66,100% OF CMS OPPS Rate,70.05,60% of total billed charges,68.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,68.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.66,100% OF CMS OPPS Rate,28.66,100% OF CMS OPPS Rate,28.66,100% OF CMS OPPS RATE,28.66,100% OF CMS OPPS Rate,81.73,70% of total billed charges,28.66,100% OF CMS OPPS Rate,34.39,120% of CMS OPPS RATE,84.06,Pays at 72% of billed charges with lesser of charges applied,84.06,Pays at 72% of billed charges with lesser of charges applied,84.06,Pays at 72% of billed charges with lesser of charges applied,84.06,Pays at 72% of billed charges with lesser of charges applied,84.06,Pays at 72% of billed charges with lesser of charges applied,84.06,Pays at 72% of billed charges with lesser of charges applied,116.75,BCBS Fee Schedule,116.75,BCBS Fee Schedule,116.75,BCBS Fee Schedule,116.75,BCBS Fee Schedule,116.75,BCBS Fee Schedule,116.75,BCBS Fee Schedule,116.75,BCBS Fee Schedule,116.75,BCBS Fee Schedule,116.75,BCBS Fee Schedule,92.35,79.1% of total billed charges,92.35,79.1% of total billed charges,92.35,79.1% of total billed charges,92.35,79.1% of total billed charges,92.35,79.1% of total billed charges,116.75,Case rate,116.75,Case rate,116.75,Case rate,81.73,70% of total billed charges,28.66,100% OF CMS OPPS Rate,28.66,100% OF CMS OPPS Rate,28.66,100% OF CMS OPPS Rate,28.66,100% OF CMS OPPS Rate,28.66,100% OF CMS OPPS Rate,28.66,100% OF CMS OPPS Rate,28.66,100% OF CMS OPPS Rate,28.66,100% OF CMS OPPS Rate,28.66,100% OF CMS OPPS Rate,28.66,100% OF CMS OPPS Rate,28.66,100% OF CMS OPPS Rate,28.66,100% OF CMS OPPS Rate,28.66,100% OF CMS OPPS Rate,28.66,100% OF CMS OPPS Rate,28.66,100% OF CMS OPPS Rate,28.66,100% OF CMS OPPS Rate,68.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,68.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,68.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,68.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,68.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,68.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,68.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,68.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,68.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,68.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,68.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,68.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,68.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,68.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,68.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,68.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,68.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,68.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,68.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,68.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.66,116.75,87.56
Outpatient Medical Services,MAMMOGRAM,77051,CAD READING DIAG MAMMOGRAM,401,116,83.52,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,77.75,442% of BCBS Fee Schedule,N/A,Not Separately reimbursable,91.76,79.1% of total billed charges,N/A,Not Separately reimbursable,116,Case rate,116,Case rate,83.52,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,69.6,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,81.2,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,83.52,Pays at 72% of billed charges with lesser of charges applied,83.52,Pays at 72% of billed charges with lesser of charges applied,83.52,Pays at 72% of billed charges with lesser of charges applied,83.52,Pays at 72% of billed charges with lesser of charges applied,83.52,Pays at 72% of billed charges with lesser of charges applied,83.52,Pays at 72% of billed charges with lesser of charges applied,77.75,442% of BCBS Fee Schedule,77.75,442% of BCBS Fee Schedule,77.75,442% of BCBS Fee Schedule,77.75,442% of BCBS Fee Schedule,77.75,442% of BCBS Fee Schedule,77.75,442% of BCBS Fee Schedule,77.75,442% of BCBS Fee Schedule,77.75,442% of BCBS Fee Schedule,77.75,442% of BCBS Fee Schedule,91.76,79.1% of total billed charges,91.76,79.1% of total billed charges,91.76,79.1% of total billed charges,91.76,79.1% of total billed charges,91.76,79.1% of total billed charges,116,Case rate,116,Case rate,116,Case rate,81.2,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,69.60,116.00,87
Outpatient Medical Services,MAMMOGRAM,77067,Mammography of both breasts-2 or more views,403,345.75,248.94,Pays at 72% of billed charges with lesser of charges applied,110.09,100% OF CMS OPPS Rate,345.75,BCBS Fee Schedule,110.09,100% OF CMS OPPS Rate,339.18,pays at 100% of bcbs fee schedule with lesser of charges applied,110.09,100% OF CMS OPPS Rate,290.43,84% of total billed charges,290.43,84% of total billed charges,248.94,72% of total billed charges,110.09,100% OF CMS OPPS Rate,110.09,100% of CMS OPPS Rate,110.09,100% OF CMS OPPS Rate,207.45,60% of total billed charges,171.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,171.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.09,100% OF CMS OPPS Rate,110.09,100% OF CMS OPPS Rate,110.09,100% OF CMS OPPS RATE,110.09,100% OF CMS OPPS Rate,242.03,70% of total billed charges,110.09,100% OF CMS OPPS Rate,132.11,120% of CMS OPPS RATE,248.94,Pays at 72% of billed charges with lesser of charges applied,248.94,Pays at 72% of billed charges with lesser of charges applied,248.94,Pays at 72% of billed charges with lesser of charges applied,248.94,Pays at 72% of billed charges with lesser of charges applied,248.94,Pays at 72% of billed charges with lesser of charges applied,248.94,Pays at 72% of billed charges with lesser of charges applied,345.75,BCBS Fee Schedule,345.75,BCBS Fee Schedule,345.75,BCBS Fee Schedule,345.75,BCBS Fee Schedule,345.75,BCBS Fee Schedule,345.75,BCBS Fee Schedule,345.75,BCBS Fee Schedule,345.75,BCBS Fee Schedule,345.75,BCBS Fee Schedule,339.18,pays at 100% of bcbs fee schedule with lesser of charges applied,339.18,pays at 100% of bcbs fee schedule with lesser of charges applied,339.18,pays at 100% of bcbs fee schedule with lesser of charges applied,339.18,pays at 100% of bcbs fee schedule with lesser of charges applied,339.18,pays at 100% of bcbs fee schedule with lesser of charges applied,290.43,84% of total billed charges,290.43,84% of total billed charges,290.43,84% of total billed charges,242.03,70% of total billed charges,110.09,100% OF CMS OPPS Rate,110.09,100% OF CMS OPPS Rate,110.09,100% OF CMS OPPS Rate,110.09,100% OF CMS OPPS Rate,110.09,100% OF CMS OPPS Rate,110.09,100% OF CMS OPPS Rate,110.09,100% OF CMS OPPS Rate,110.09,100% OF CMS OPPS Rate,110.09,100% OF CMS OPPS Rate,110.09,100% OF CMS OPPS Rate,110.09,100% OF CMS OPPS Rate,110.09,100% OF CMS OPPS Rate,110.09,100% OF CMS OPPS Rate,110.09,100% OF CMS OPPS Rate,110.09,100% OF CMS OPPS Rate,110.09,100% OF CMS OPPS Rate,171.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,171.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,171.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,171.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,171.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,171.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,171.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,171.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,171.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,171.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,171.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,171.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,171.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,171.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,171.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,171.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,171.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,171.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,171.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,171.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.09,345.75,259.31
Outpatient Medical Services,MAMMOGRAM,77063,SCREEN DIGITAL BREAST TOMOYSN,403,116.75,84.06,Pays at 72% of billed charges with lesser of charges applied,28.66,100% OF CMS OPPS Rate,116.75,BCBS Fee Schedule,28.66,100% OF CMS OPPS Rate,114.53,pays at 100% of bcbs fee schedule with lesser of charges applied,28.66,100% OF CMS OPPS Rate,98.07,84% of total billed charges,98.07,84% of total billed charges,84.06,72% of total billed charges,28.66,100% OF CMS OPPS Rate,28.66,100% of CMS OPPS Rate,28.66,100% OF CMS OPPS Rate,70.05,60% of total billed charges,68.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,68.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.66,100% OF CMS OPPS Rate,28.66,100% OF CMS OPPS Rate,28.66,100% OF CMS OPPS RATE,28.66,100% OF CMS OPPS Rate,81.73,70% of total billed charges,28.66,100% OF CMS OPPS Rate,34.39,120% of CMS OPPS RATE,84.06,Pays at 72% of billed charges with lesser of charges applied,84.06,Pays at 72% of billed charges with lesser of charges applied,84.06,Pays at 72% of billed charges with lesser of charges applied,84.06,Pays at 72% of billed charges with lesser of charges applied,84.06,Pays at 72% of billed charges with lesser of charges applied,84.06,Pays at 72% of billed charges with lesser of charges applied,116.75,BCBS Fee Schedule,116.75,BCBS Fee Schedule,116.75,BCBS Fee Schedule,116.75,BCBS Fee Schedule,116.75,BCBS Fee Schedule,116.75,BCBS Fee Schedule,116.75,BCBS Fee Schedule,116.75,BCBS Fee Schedule,116.75,BCBS Fee Schedule,114.53,pays at 100% of bcbs fee schedule with lesser of charges applied,114.53,pays at 100% of bcbs fee schedule with lesser of charges applied,114.53,pays at 100% of bcbs fee schedule with lesser of charges applied,114.53,pays at 100% of bcbs fee schedule with lesser of charges applied,114.53,pays at 100% of bcbs fee schedule with lesser of charges applied,98.07,84% of total billed charges,98.07,84% of total billed charges,98.07,84% of total billed charges,81.73,70% of total billed charges,28.66,100% OF CMS OPPS Rate,28.66,100% OF CMS OPPS Rate,28.66,100% OF CMS OPPS Rate,28.66,100% OF CMS OPPS Rate,28.66,100% OF CMS OPPS Rate,28.66,100% OF CMS OPPS Rate,28.66,100% OF CMS OPPS Rate,28.66,100% OF CMS OPPS Rate,28.66,100% OF CMS OPPS Rate,28.66,100% OF CMS OPPS Rate,28.66,100% OF CMS OPPS Rate,28.66,100% OF CMS OPPS Rate,28.66,100% OF CMS OPPS Rate,28.66,100% OF CMS OPPS Rate,28.66,100% OF CMS OPPS Rate,28.66,100% OF CMS OPPS Rate,68.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,68.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,68.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,68.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,68.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,68.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,68.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,68.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,68.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,68.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,68.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,68.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,68.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,68.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,68.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,68.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,68.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,68.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,68.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,68.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.66,116.75,87.56
Outpatient Medical Services,MEDICAL PROCEDURES,43246,EGD - GASTROSTOMY TUBE PLACEMN,750,1251.5,901.08,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,1251.5,100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,1227.72,100% of BCBS ASC Fee Schedule,N/A,Not Separately reimbursable,1251.5,100% fo CIGN ASC FEE SCHEDULE,1251.5,100% fo CIGN ASC FEE SCHEDULE,901.08,72% of total billed charges,N/A,Not Separately reimbursable,1251.5,100% of CMS OPPS Rate,N/A,Not Separately reimbursable,750.9,60% of total billed charges,347.12,100% of CA Medicaid Fee Schedule with lesser of charges applied,347.12,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,206.24,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,876.05,70% of total billed charges,1251.5,100% OF CMS OPPS Rate,1251.5,120% of CMS OPPS RATE,901.08,Pays at 72% of billed charges with lesser of charges applied,901.08,Pays at 72% of billed charges with lesser of charges applied,901.08,Pays at 72% of billed charges with lesser of charges applied,901.08,Pays at 72% of billed charges with lesser of charges applied,901.08,Pays at 72% of billed charges with lesser of charges applied,901.08,Pays at 72% of billed charges with lesser of charges applied,1251.5,100% of ASC Tier Grouping Fee Schedule,1251.5,100% of ASC Tier Grouping Fee Schedule,1251.5,100% of ASC Tier Grouping Fee Schedule,1251.5,100% of ASC Tier Grouping Fee Schedule,1251.5,100% of ASC Tier Grouping Fee Schedule,1251.5,100% of ASC Tier Grouping Fee Schedule,1251.5,100% of ASC Tier Grouping Fee Schedule,1251.5,100% of ASC Tier Grouping Fee Schedule,1251.5,100% of ASC Tier Grouping Fee Schedule,1227.72,100% of BCBS ASC Fee Schedule,1227.72,100% of BCBS ASC Fee Schedule,1227.72,100% of BCBS ASC Fee Schedule,1227.72,100% of BCBS ASC Fee Schedule,1227.72,100% of BCBS ASC Fee Schedule,1251.5,100% fo CIGN ASC FEE SCHEDULE,1251.5,100% fo CIGN ASC FEE SCHEDULE,1251.5,100% fo CIGN ASC FEE SCHEDULE,876.05,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,347.12,100% of CA Medicaid Fee Schedule with lesser of charges applied,347.12,100% of CA Medicaid Fee Schedule with lesser of charges applied,347.12,100% of CA Medicaid Fee Schedule with lesser of charges applied,347.12,100% of CA Medicaid Fee Schedule with lesser of charges applied,347.12,100% of CA Medicaid Fee Schedule with lesser of charges applied,347.12,100% of CA Medicaid Fee Schedule with lesser of charges applied,347.12,100% of CA Medicaid Fee Schedule with lesser of charges applied,347.12,100% of CA Medicaid Fee Schedule with lesser of charges applied,347.12,100% of CA Medicaid Fee Schedule with lesser of charges applied,347.12,100% of CA Medicaid Fee Schedule with lesser of charges applied,347.12,100% of CA Medicaid Fee Schedule with lesser of charges applied,347.12,100% of CA Medicaid Fee Schedule with lesser of charges applied,347.12,100% of CA Medicaid Fee Schedule with lesser of charges applied,347.12,100% of CA Medicaid Fee Schedule with lesser of charges applied,347.12,100% of CA Medicaid Fee Schedule with lesser of charges applied,347.12,100% of CA Medicaid Fee Schedule with lesser of charges applied,347.12,100% of CA Medicaid Fee Schedule with lesser of charges applied,347.12,100% of CA Medicaid Fee Schedule with lesser of charges applied,347.12,100% of CA Medicaid Fee Schedule with lesser of charges applied,347.12,100% of CA Medicaid Fee Schedule with lesser of charges applied,206.24,1251.50,938.63
Outpatient Medical Services,MEDICAL PROCEDURES,43247,EGD W FOREIGN BODY REMOVAL,750,1251.5,901.08,Pays at 72% of billed charges with lesser of charges applied,1049.28,100% OF CMS OPPS Rate,1251.5,100% of ASC Tier Grouping Fee Schedule,1049.28,100% OF CMS OPPS Rate,1227.72,100% of BCBS ASC Fee Schedule,1049.28,100% OF CMS OPPS Rate,1251.5,100% fo CIGN ASC FEE SCHEDULE,1251.5,100% fo CIGN ASC FEE SCHEDULE,901.08,72% of total billed charges,1049.28,100% OF CMS OPPS Rate,1049.28,100% of CMS OPPS Rate,1049.28,100% OF CMS OPPS Rate,750.9,60% of total billed charges,366.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,366.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,1049.28,100% OF CMS OPPS Rate,1049.28,100% OF CMS OPPS Rate,183.39,100% OF CMS OPPS RATE,1049.28,100% OF CMS OPPS Rate,876.05,70% of total billed charges,1049.28,100% OF CMS OPPS Rate,1251.5,120% of CMS OPPS RATE,901.08,Pays at 72% of billed charges with lesser of charges applied,901.08,Pays at 72% of billed charges with lesser of charges applied,901.08,Pays at 72% of billed charges with lesser of charges applied,901.08,Pays at 72% of billed charges with lesser of charges applied,901.08,Pays at 72% of billed charges with lesser of charges applied,901.08,Pays at 72% of billed charges with lesser of charges applied,1251.5,100% of ASC Tier Grouping Fee Schedule,1251.5,100% of ASC Tier Grouping Fee Schedule,1251.5,100% of ASC Tier Grouping Fee Schedule,1251.5,100% of ASC Tier Grouping Fee Schedule,1251.5,100% of ASC Tier Grouping Fee Schedule,1251.5,100% of ASC Tier Grouping Fee Schedule,1251.5,100% of ASC Tier Grouping Fee Schedule,1251.5,100% of ASC Tier Grouping Fee Schedule,1251.5,100% of ASC Tier Grouping Fee Schedule,1227.72,100% of BCBS ASC Fee Schedule,1227.72,100% of BCBS ASC Fee Schedule,1227.72,100% of BCBS ASC Fee Schedule,1227.72,100% of BCBS ASC Fee Schedule,1227.72,100% of BCBS ASC Fee Schedule,1251.5,100% fo CIGN ASC FEE SCHEDULE,1251.5,100% fo CIGN ASC FEE SCHEDULE,1251.5,100% fo CIGN ASC FEE SCHEDULE,876.05,70% of total billed charges,1049.28,100% OF CMS OPPS Rate,1049.28,100% OF CMS OPPS Rate,1049.28,100% OF CMS OPPS Rate,1049.28,100% OF CMS OPPS Rate,1049.28,100% OF CMS OPPS Rate,1049.28,100% OF CMS OPPS Rate,1049.28,100% OF CMS OPPS Rate,1049.28,100% OF CMS OPPS Rate,1049.28,100% OF CMS OPPS Rate,1049.28,100% OF CMS OPPS Rate,1049.28,100% OF CMS OPPS Rate,1049.28,100% OF CMS OPPS Rate,1049.28,100% OF CMS OPPS Rate,1049.28,100% OF CMS OPPS Rate,1049.28,100% OF CMS OPPS Rate,1049.28,100% OF CMS OPPS Rate,366.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,366.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,366.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,366.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,366.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,366.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,366.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,366.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,366.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,366.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,366.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,366.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,366.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,366.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,366.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,366.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,366.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,366.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,366.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,366.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,183.39,1251.50,938.63
Outpatient Medical Services,MEDICAL PROCEDURES,43262,"ERCP W/SPHINCT,PAPILLOTOMY",750,6978.25,5024.34,Pays at 72% of billed charges with lesser of charges applied,4144.59,100% OF CMS OPPS Rate,5266,100% of ASC Tier Grouping Fee Schedule,4144.59,100% OF CMS OPPS Rate,5698.92,100% of BCBS ASC Fee Schedule,4144.59,100% OF CMS OPPS Rate,3550,100% fo CIGN ASC FEE SCHEDULE,3550,100% fo CIGN ASC FEE SCHEDULE,5024.34,72% of total billed charges,4144.59,100% OF CMS OPPS Rate,4144.59,100% of CMS OPPS Rate,4144.59,100% OF CMS OPPS Rate,4186.95,60% of total billed charges,531.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,531.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,4144.59,100% OF CMS OPPS Rate,4144.59,100% OF CMS OPPS Rate,369.22,100% OF CMS OPPS RATE,4144.59,100% OF CMS OPPS Rate,4884.78,70% of total billed charges,4144.59,100% OF CMS OPPS Rate,4973.5,120% of CMS OPPS RATE,5024.34,Pays at 72% of billed charges with lesser of charges applied,5024.34,Pays at 72% of billed charges with lesser of charges applied,5024.34,Pays at 72% of billed charges with lesser of charges applied,5024.34,Pays at 72% of billed charges with lesser of charges applied,5024.34,Pays at 72% of billed charges with lesser of charges applied,5024.34,Pays at 72% of billed charges with lesser of charges applied,5266,100% of ASC Tier Grouping Fee Schedule,5266,100% of ASC Tier Grouping Fee Schedule,5266,100% of ASC Tier Grouping Fee Schedule,5266,100% of ASC Tier Grouping Fee Schedule,5266,100% of ASC Tier Grouping Fee Schedule,5266,100% of ASC Tier Grouping Fee Schedule,5266,100% of ASC Tier Grouping Fee Schedule,5266,100% of ASC Tier Grouping Fee Schedule,5266,100% of ASC Tier Grouping Fee Schedule,5698.92,100% of BCBS ASC Fee Schedule,5698.92,100% of BCBS ASC Fee Schedule,5698.92,100% of BCBS ASC Fee Schedule,5698.92,100% of BCBS ASC Fee Schedule,5698.92,100% of BCBS ASC Fee Schedule,3550,100% fo CIGN ASC FEE SCHEDULE,3550,100% fo CIGN ASC FEE SCHEDULE,3550,100% fo CIGN ASC FEE SCHEDULE,4884.78,70% of total billed charges,4144.59,100% OF CMS OPPS Rate,4144.59,100% OF CMS OPPS Rate,4144.59,100% OF CMS OPPS Rate,4144.59,100% OF CMS OPPS Rate,4144.59,100% OF CMS OPPS Rate,4144.59,100% OF CMS OPPS Rate,4144.59,100% OF CMS OPPS Rate,4144.59,100% OF CMS OPPS Rate,4144.59,100% OF CMS OPPS Rate,4144.59,100% OF CMS OPPS Rate,4144.59,100% OF CMS OPPS Rate,4144.59,100% OF CMS OPPS Rate,4144.59,100% OF CMS OPPS Rate,4144.59,100% OF CMS OPPS Rate,4144.59,100% OF CMS OPPS Rate,4144.59,100% OF CMS OPPS Rate,531.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,531.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,531.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,531.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,531.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,531.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,531.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,531.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,531.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,531.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,531.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,531.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,531.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,531.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,531.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,531.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,531.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,531.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,531.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,531.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,369.22,5698.92,5233.69
Outpatient Medical Services,MEDICAL PROCEDURES,43235,"Diagnostic examination of esophagus, stomach, and/or upper small bowel using an endoscope",750,1251.5,901.08,Pays at 72% of billed charges with lesser of charges applied,1049.28,100% OF CMS OPPS Rate,1251.5,100% of ASC Tier Grouping Fee Schedule,1049.28,100% OF CMS OPPS Rate,1227.72,100% of BCBS ASC Fee Schedule,1049.28,100% OF CMS OPPS Rate,1251.5,100% fo CIGN ASC FEE SCHEDULE,1251.5,100% fo CIGN ASC FEE SCHEDULE,901.08,72% of total billed charges,1049.28,100% OF CMS OPPS Rate,1049.28,100% of CMS OPPS Rate,1049.28,100% OF CMS OPPS Rate,750.9,60% of total billed charges,321.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,321.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,1049.28,100% OF CMS OPPS Rate,1049.28,100% OF CMS OPPS Rate,127.89,100% OF CMS OPPS RATE,1049.28,100% OF CMS OPPS Rate,876.05,70% of total billed charges,1049.28,100% OF CMS OPPS Rate,1251.5,120% of CMS OPPS RATE,901.08,Pays at 72% of billed charges with lesser of charges applied,901.08,Pays at 72% of billed charges with lesser of charges applied,901.08,Pays at 72% of billed charges with lesser of charges applied,901.08,Pays at 72% of billed charges with lesser of charges applied,901.08,Pays at 72% of billed charges with lesser of charges applied,901.08,Pays at 72% of billed charges with lesser of charges applied,1251.5,100% of ASC Tier Grouping Fee Schedule,1251.5,100% of ASC Tier Grouping Fee Schedule,1251.5,100% of ASC Tier Grouping Fee Schedule,1251.5,100% of ASC Tier Grouping Fee Schedule,1251.5,100% of ASC Tier Grouping Fee Schedule,1251.5,100% of ASC Tier Grouping Fee Schedule,1251.5,100% of ASC Tier Grouping Fee Schedule,1251.5,100% of ASC Tier Grouping Fee Schedule,1251.5,100% of ASC Tier Grouping Fee Schedule,1227.72,100% of BCBS ASC Fee Schedule,1227.72,100% of BCBS ASC Fee Schedule,1227.72,100% of BCBS ASC Fee Schedule,1227.72,100% of BCBS ASC Fee Schedule,1227.72,100% of BCBS ASC Fee Schedule,1251.5,100% fo CIGN ASC FEE SCHEDULE,1251.5,100% fo CIGN ASC FEE SCHEDULE,1251.5,100% fo CIGN ASC FEE SCHEDULE,876.05,70% of total billed charges,1049.28,100% OF CMS OPPS Rate,1049.28,100% OF CMS OPPS Rate,1049.28,100% OF CMS OPPS Rate,1049.28,100% OF CMS OPPS Rate,1049.28,100% OF CMS OPPS Rate,1049.28,100% OF CMS OPPS Rate,1049.28,100% OF CMS OPPS Rate,1049.28,100% OF CMS OPPS Rate,1049.28,100% OF CMS OPPS Rate,1049.28,100% OF CMS OPPS Rate,1049.28,100% OF CMS OPPS Rate,1049.28,100% OF CMS OPPS Rate,1049.28,100% OF CMS OPPS Rate,1049.28,100% OF CMS OPPS Rate,1049.28,100% OF CMS OPPS Rate,1049.28,100% OF CMS OPPS Rate,321.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,321.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,321.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,321.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,321.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,321.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,321.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,321.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,321.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,321.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,321.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,321.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,321.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,321.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,321.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,321.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,321.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,321.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,321.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,321.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,127.89,1251.50,938.63
Outpatient Medical Services,MEDICAL PROCEDURES,45385,Removal of polyps or growths of large bowel using an endoscope,750,1273.25,916.74,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,1273.25,100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,1249.06,100% of BCBS ASC Fee Schedule,N/A,Not Separately reimbursable,1273.25,100% fo CIGN ASC FEE SCHEDULE,1273.25,100% fo CIGN ASC FEE SCHEDULE,916.74,72% of total billed charges,N/A,Not Separately reimbursable,1273.25,100% of CMS OPPS Rate,N/A,Not Separately reimbursable,763.95,60% of total billed charges,574.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,574.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,263.23,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,891.28,70% of total billed charges,1273.25,100% OF CMS OPPS Rate,1273.25,120% of CMS OPPS RATE,916.74,Pays at 72% of billed charges with lesser of charges applied,916.74,Pays at 72% of billed charges with lesser of charges applied,916.74,Pays at 72% of billed charges with lesser of charges applied,916.74,Pays at 72% of billed charges with lesser of charges applied,916.74,Pays at 72% of billed charges with lesser of charges applied,916.74,Pays at 72% of billed charges with lesser of charges applied,1273.25,100% of ASC Tier Grouping Fee Schedule,1273.25,100% of ASC Tier Grouping Fee Schedule,1273.25,100% of ASC Tier Grouping Fee Schedule,1273.25,100% of ASC Tier Grouping Fee Schedule,1273.25,100% of ASC Tier Grouping Fee Schedule,1273.25,100% of ASC Tier Grouping Fee Schedule,1273.25,100% of ASC Tier Grouping Fee Schedule,1273.25,100% of ASC Tier Grouping Fee Schedule,1273.25,100% of ASC Tier Grouping Fee Schedule,1249.06,100% of BCBS ASC Fee Schedule,1249.06,100% of BCBS ASC Fee Schedule,1249.06,100% of BCBS ASC Fee Schedule,1249.06,100% of BCBS ASC Fee Schedule,1249.06,100% of BCBS ASC Fee Schedule,1273.25,100% fo CIGN ASC FEE SCHEDULE,1273.25,100% fo CIGN ASC FEE SCHEDULE,1273.25,100% fo CIGN ASC FEE SCHEDULE,891.28,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,574.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,574.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,574.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,574.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,574.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,574.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,574.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,574.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,574.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,574.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,574.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,574.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,574.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,574.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,574.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,574.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,574.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,574.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,574.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,574.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,263.23,1273.25,954.94
Outpatient Medical Services,MEDICAL PROCEDURES,45382,Control of bleeding in large bowel using an endoscope,750,909,654.48,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,909,100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,891.73,100% of BCBS ASC Fee Schedule,N/A,Not Separately reimbursable,909,100% fo CIGN ASC FEE SCHEDULE,909,100% fo CIGN ASC FEE SCHEDULE,654.48,72% of total billed charges,N/A,Not Separately reimbursable,909,100% of CMS OPPS Rate,N/A,Not Separately reimbursable,545.4,60% of total billed charges,595.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,595.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,268.36,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,636.3,70% of total billed charges,909,100% OF CMS OPPS Rate,909,120% of CMS OPPS RATE,654.48,Pays at 72% of billed charges with lesser of charges applied,654.48,Pays at 72% of billed charges with lesser of charges applied,654.48,Pays at 72% of billed charges with lesser of charges applied,654.48,Pays at 72% of billed charges with lesser of charges applied,654.48,Pays at 72% of billed charges with lesser of charges applied,654.48,Pays at 72% of billed charges with lesser of charges applied,909,100% of ASC Tier Grouping Fee Schedule,909,100% of ASC Tier Grouping Fee Schedule,909,100% of ASC Tier Grouping Fee Schedule,909,100% of ASC Tier Grouping Fee Schedule,909,100% of ASC Tier Grouping Fee Schedule,909,100% of ASC Tier Grouping Fee Schedule,909,100% of ASC Tier Grouping Fee Schedule,909,100% of ASC Tier Grouping Fee Schedule,909,100% of ASC Tier Grouping Fee Schedule,891.73,100% of BCBS ASC Fee Schedule,891.73,100% of BCBS ASC Fee Schedule,891.73,100% of BCBS ASC Fee Schedule,891.73,100% of BCBS ASC Fee Schedule,891.73,100% of BCBS ASC Fee Schedule,909,100% fo CIGN ASC FEE SCHEDULE,909,100% fo CIGN ASC FEE SCHEDULE,909,100% fo CIGN ASC FEE SCHEDULE,636.3,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,595.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,595.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,595.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,595.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,595.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,595.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,595.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,595.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,595.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,595.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,595.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,595.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,595.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,595.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,595.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,595.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,595.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,595.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,595.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,595.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,268.36,909.00,681.75
Outpatient Medical Services,MEDICAL PROCEDURES,43261,ERCP W/BIOPSY SING/MULTI,750,3376.25,2430.9,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,3376.25,100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,3312.1,100% of BCBS ASC Fee Schedule,N/A,Not Separately reimbursable,3376.25,100% fo CIGN ASC FEE SCHEDULE,3376.25,100% fo CIGN ASC FEE SCHEDULE,2430.9,72% of total billed charges,N/A,Not Separately reimbursable,3376.25,100% of CMS OPPS Rate,N/A,Not Separately reimbursable,2025.75,60% of total billed charges,489.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,489.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,350.03,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,2363.38,70% of total billed charges,3376.25,100% OF CMS OPPS Rate,3376.25,120% of CMS OPPS RATE,2430.9,Pays at 72% of billed charges with lesser of charges applied,2430.9,Pays at 72% of billed charges with lesser of charges applied,2430.9,Pays at 72% of billed charges with lesser of charges applied,2430.9,Pays at 72% of billed charges with lesser of charges applied,2430.9,Pays at 72% of billed charges with lesser of charges applied,2430.9,Pays at 72% of billed charges with lesser of charges applied,3376.25,100% of ASC Tier Grouping Fee Schedule,3376.25,100% of ASC Tier Grouping Fee Schedule,3376.25,100% of ASC Tier Grouping Fee Schedule,3376.25,100% of ASC Tier Grouping Fee Schedule,3376.25,100% of ASC Tier Grouping Fee Schedule,3376.25,100% of ASC Tier Grouping Fee Schedule,3376.25,100% of ASC Tier Grouping Fee Schedule,3376.25,100% of ASC Tier Grouping Fee Schedule,3376.25,100% of ASC Tier Grouping Fee Schedule,3312.1,100% of BCBS ASC Fee Schedule,3312.1,100% of BCBS ASC Fee Schedule,3312.1,100% of BCBS ASC Fee Schedule,3312.1,100% of BCBS ASC Fee Schedule,3312.1,100% of BCBS ASC Fee Schedule,3376.25,100% fo CIGN ASC FEE SCHEDULE,3376.25,100% fo CIGN ASC FEE SCHEDULE,3376.25,100% fo CIGN ASC FEE SCHEDULE,2363.38,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,489.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,489.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,489.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,489.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,489.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,489.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,489.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,489.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,489.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,489.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,489.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,489.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,489.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,489.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,489.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,489.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,489.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,489.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,489.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,489.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,350.03,3376.25,2532.19
Outpatient Medical Services,MEDICAL PROCEDURES,43239,"Biopsy of the esophagus, stomach, and/or upper small bowel using an endoscope",750,1251.5,901.08,Pays at 72% of billed charges with lesser of charges applied,1049.28,100% OF CMS OPPS Rate,1251.5,100% of ASC Tier Grouping Fee Schedule,1049.28,100% OF CMS OPPS Rate,1227.72,100% of BCBS ASC Fee Schedule,1049.28,100% OF CMS OPPS Rate,1251.5,100% fo CIGN ASC FEE SCHEDULE,1251.5,100% fo CIGN ASC FEE SCHEDULE,901.08,72% of total billed charges,1049.28,100% OF CMS OPPS Rate,1049.28,100% of CMS OPPS Rate,1049.28,100% OF CMS OPPS Rate,750.9,60% of total billed charges,335.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,335.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,1049.28,100% OF CMS OPPS Rate,1049.28,100% OF CMS OPPS Rate,144.13,100% OF CMS OPPS RATE,1049.28,100% OF CMS OPPS Rate,876.05,70% of total billed charges,1049.28,100% OF CMS OPPS Rate,1251.5,120% of CMS OPPS RATE,901.08,Pays at 72% of billed charges with lesser of charges applied,901.08,Pays at 72% of billed charges with lesser of charges applied,901.08,Pays at 72% of billed charges with lesser of charges applied,901.08,Pays at 72% of billed charges with lesser of charges applied,901.08,Pays at 72% of billed charges with lesser of charges applied,901.08,Pays at 72% of billed charges with lesser of charges applied,1251.5,100% of ASC Tier Grouping Fee Schedule,1251.5,100% of ASC Tier Grouping Fee Schedule,1251.5,100% of ASC Tier Grouping Fee Schedule,1251.5,100% of ASC Tier Grouping Fee Schedule,1251.5,100% of ASC Tier Grouping Fee Schedule,1251.5,100% of ASC Tier Grouping Fee Schedule,1251.5,100% of ASC Tier Grouping Fee Schedule,1251.5,100% of ASC Tier Grouping Fee Schedule,1251.5,100% of ASC Tier Grouping Fee Schedule,1227.72,100% of BCBS ASC Fee Schedule,1227.72,100% of BCBS ASC Fee Schedule,1227.72,100% of BCBS ASC Fee Schedule,1227.72,100% of BCBS ASC Fee Schedule,1227.72,100% of BCBS ASC Fee Schedule,1251.5,100% fo CIGN ASC FEE SCHEDULE,1251.5,100% fo CIGN ASC FEE SCHEDULE,1251.5,100% fo CIGN ASC FEE SCHEDULE,876.05,70% of total billed charges,1049.28,100% OF CMS OPPS Rate,1049.28,100% OF CMS OPPS Rate,1049.28,100% OF CMS OPPS Rate,1049.28,100% OF CMS OPPS Rate,1049.28,100% OF CMS OPPS Rate,1049.28,100% OF CMS OPPS Rate,1049.28,100% OF CMS OPPS Rate,1049.28,100% OF CMS OPPS Rate,1049.28,100% OF CMS OPPS Rate,1049.28,100% OF CMS OPPS Rate,1049.28,100% OF CMS OPPS Rate,1049.28,100% OF CMS OPPS Rate,1049.28,100% OF CMS OPPS Rate,1049.28,100% OF CMS OPPS Rate,1049.28,100% OF CMS OPPS Rate,1049.28,100% OF CMS OPPS Rate,335.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,335.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,335.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,335.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,335.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,335.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,335.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,335.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,335.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,335.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,335.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,335.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,335.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,335.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,335.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,335.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,335.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,335.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,335.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,335.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,144.13,1251.50,938.63
Outpatient Medical Services,MEDICAL PROCEDURES,45378,Diagnostic examination of large bowel using an endoscope,750,1443.5,1039.32,Pays at 72% of billed charges with lesser of charges applied,1056.31,100% OF CMS OPPS Rate,1443.5,100% of ASC Tier Grouping Fee Schedule,1056.31,100% OF CMS OPPS Rate,1416.07,100% of BCBS ASC Fee Schedule,1056.31,100% OF CMS OPPS Rate,1443.5,100% fo CIGN ASC FEE SCHEDULE,1443.5,100% fo CIGN ASC FEE SCHEDULE,1039.32,72% of total billed charges,1056.31,100% OF CMS OPPS Rate,1056.31,100% of CMS OPPS Rate,1056.31,100% OF CMS OPPS Rate,866.1,60% of total billed charges,423.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,423.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,1056.31,100% OF CMS OPPS Rate,1056.31,100% OF CMS OPPS Rate,191.41,100% OF CMS OPPS RATE,1056.31,100% OF CMS OPPS Rate,1010.45,70% of total billed charges,1056.31,100% OF CMS OPPS Rate,1267.57,120% of CMS OPPS RATE,1039.32,Pays at 72% of billed charges with lesser of charges applied,1039.32,Pays at 72% of billed charges with lesser of charges applied,1039.32,Pays at 72% of billed charges with lesser of charges applied,1039.32,Pays at 72% of billed charges with lesser of charges applied,1039.32,Pays at 72% of billed charges with lesser of charges applied,1039.32,Pays at 72% of billed charges with lesser of charges applied,1443.5,100% of ASC Tier Grouping Fee Schedule,1443.5,100% of ASC Tier Grouping Fee Schedule,1443.5,100% of ASC Tier Grouping Fee Schedule,1443.5,100% of ASC Tier Grouping Fee Schedule,1443.5,100% of ASC Tier Grouping Fee Schedule,1443.5,100% of ASC Tier Grouping Fee Schedule,1443.5,100% of ASC Tier Grouping Fee Schedule,1443.5,100% of ASC Tier Grouping Fee Schedule,1443.5,100% of ASC Tier Grouping Fee Schedule,1416.07,100% of BCBS ASC Fee Schedule,1416.07,100% of BCBS ASC Fee Schedule,1416.07,100% of BCBS ASC Fee Schedule,1416.07,100% of BCBS ASC Fee Schedule,1416.07,100% of BCBS ASC Fee Schedule,1443.5,100% fo CIGN ASC FEE SCHEDULE,1443.5,100% fo CIGN ASC FEE SCHEDULE,1443.5,100% fo CIGN ASC FEE SCHEDULE,1010.45,70% of total billed charges,1056.31,100% OF CMS OPPS Rate,1056.31,100% OF CMS OPPS Rate,1056.31,100% OF CMS OPPS Rate,1056.31,100% OF CMS OPPS Rate,1056.31,100% OF CMS OPPS Rate,1056.31,100% OF CMS OPPS Rate,1056.31,100% OF CMS OPPS Rate,1056.31,100% OF CMS OPPS Rate,1056.31,100% OF CMS OPPS Rate,1056.31,100% OF CMS OPPS Rate,1056.31,100% OF CMS OPPS Rate,1056.31,100% OF CMS OPPS Rate,1056.31,100% OF CMS OPPS Rate,1056.31,100% OF CMS OPPS Rate,1056.31,100% OF CMS OPPS Rate,1056.31,100% OF CMS OPPS Rate,423.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,423.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,423.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,423.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,423.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,423.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,423.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,423.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,423.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,423.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,423.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,423.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,423.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,423.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,423.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,423.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,423.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,423.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,423.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,423.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,191.41,1443.50,1082.63
Outpatient Medical Services,MEDICAL PROCEDURES,64461,LUMBAR/THORAC(PARAVERT/SYMPATH,370,1301.5,937.08,Pays at 72% of billed charges with lesser of charges applied,819,100% OF CMS OPPS Rate,1301.5,100% of ASC Tier Grouping Fee Schedule,819,100% OF CMS OPPS Rate,1029.49,79.1% of total billed charges,819,100% OF CMS OPPS Rate,1093.26,84% of total billed charges,1093.26,84% of total billed charges,937.08,72% of total billed charges,819,100% OF CMS OPPS Rate,819,100% of CMS OPPS Rate,819,100% OF CMS OPPS Rate,780.9,60% of total billed charges,188.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,188.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,819,100% OF CMS OPPS Rate,819,100% OF CMS OPPS Rate,80,100% OF CMS OPPS RATE,819,100% OF CMS OPPS Rate,911.05,70% of total billed charges,819,100% OF CMS OPPS Rate,982.79,120% of CMS OPPS RATE,937.08,Pays at 72% of billed charges with lesser of charges applied,937.08,Pays at 72% of billed charges with lesser of charges applied,937.08,Pays at 72% of billed charges with lesser of charges applied,937.08,Pays at 72% of billed charges with lesser of charges applied,937.08,Pays at 72% of billed charges with lesser of charges applied,937.08,Pays at 72% of billed charges with lesser of charges applied,1301.5,100% of ASC Tier Grouping Fee Schedule,1301.5,100% of ASC Tier Grouping Fee Schedule,1301.5,100% of ASC Tier Grouping Fee Schedule,1301.5,100% of ASC Tier Grouping Fee Schedule,1301.5,100% of ASC Tier Grouping Fee Schedule,1301.5,100% of ASC Tier Grouping Fee Schedule,1301.5,100% of ASC Tier Grouping Fee Schedule,1301.5,100% of ASC Tier Grouping Fee Schedule,1301.5,100% of ASC Tier Grouping Fee Schedule,1029.49,79.1% of total billed charges,1029.49,79.1% of total billed charges,1029.49,79.1% of total billed charges,1029.49,79.1% of total billed charges,1029.49,79.1% of total billed charges,1093.26,84% of total billed charges,1093.26,84% of total billed charges,1093.26,84% of total billed charges,911.05,70% of total billed charges,819,100% OF CMS OPPS Rate,819,100% OF CMS OPPS Rate,819,100% OF CMS OPPS Rate,819,100% OF CMS OPPS Rate,819,100% OF CMS OPPS Rate,819,100% OF CMS OPPS Rate,819,100% OF CMS OPPS Rate,819,100% OF CMS OPPS Rate,819,100% OF CMS OPPS Rate,819,100% OF CMS OPPS Rate,819,100% OF CMS OPPS Rate,819,100% OF CMS OPPS Rate,819,100% OF CMS OPPS Rate,819,100% OF CMS OPPS Rate,819,100% OF CMS OPPS Rate,819,100% OF CMS OPPS Rate,188.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,188.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,188.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,188.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,188.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,188.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,188.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,188.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,188.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,188.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,188.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,188.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,188.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,188.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,188.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,188.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,188.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,188.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,188.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,188.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,80.00,1301.50,976.13
Outpatient Medical Services,MEDICAL PROCEDURES,64479,PARACERVICAL UTERINE NRV BLOCK,370,2394.25,1723.86,Pays at 72% of billed charges with lesser of charges applied,1083.18,100% OF CMS OPPS Rate,2394.25,100% of ASC Tier Grouping Fee Schedule,1083.18,100% OF CMS OPPS Rate,1893.85,79.1% of total billed charges,1083.18,100% OF CMS OPPS Rate,2011.17,84% of total billed charges,2011.17,84% of total billed charges,1723.86,72% of total billed charges,1083.18,100% OF CMS OPPS Rate,1083.18,100% of CMS OPPS Rate,1083.18,100% OF CMS OPPS Rate,1436.55,60% of total billed charges,221.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,221.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,1083.18,100% OF CMS OPPS Rate,1083.18,100% OF CMS OPPS Rate,137.67,100% OF CMS OPPS RATE,1083.18,100% OF CMS OPPS Rate,1675.98,70% of total billed charges,1083.18,100% OF CMS OPPS Rate,1299.81,120% of CMS OPPS RATE,1723.86,Pays at 72% of billed charges with lesser of charges applied,1723.86,Pays at 72% of billed charges with lesser of charges applied,1723.86,Pays at 72% of billed charges with lesser of charges applied,1723.86,Pays at 72% of billed charges with lesser of charges applied,1723.86,Pays at 72% of billed charges with lesser of charges applied,1723.86,Pays at 72% of billed charges with lesser of charges applied,2394.25,100% of ASC Tier Grouping Fee Schedule,2394.25,100% of ASC Tier Grouping Fee Schedule,2394.25,100% of ASC Tier Grouping Fee Schedule,2394.25,100% of ASC Tier Grouping Fee Schedule,2394.25,100% of ASC Tier Grouping Fee Schedule,2394.25,100% of ASC Tier Grouping Fee Schedule,2394.25,100% of ASC Tier Grouping Fee Schedule,2394.25,100% of ASC Tier Grouping Fee Schedule,2394.25,100% of ASC Tier Grouping Fee Schedule,1893.85,79.1% of total billed charges,1893.85,79.1% of total billed charges,1893.85,79.1% of total billed charges,1893.85,79.1% of total billed charges,1893.85,79.1% of total billed charges,2011.17,84% of total billed charges,2011.17,84% of total billed charges,2011.17,84% of total billed charges,1675.98,70% of total billed charges,1083.18,100% OF CMS OPPS Rate,1083.18,100% OF CMS OPPS Rate,1083.18,100% OF CMS OPPS Rate,1083.18,100% OF CMS OPPS Rate,1083.18,100% OF CMS OPPS Rate,1083.18,100% OF CMS OPPS Rate,1083.18,100% OF CMS OPPS Rate,1083.18,100% OF CMS OPPS Rate,1083.18,100% OF CMS OPPS Rate,1083.18,100% OF CMS OPPS Rate,1083.18,100% OF CMS OPPS Rate,1083.18,100% OF CMS OPPS Rate,1083.18,100% OF CMS OPPS Rate,1083.18,100% OF CMS OPPS Rate,1083.18,100% OF CMS OPPS Rate,1083.18,100% OF CMS OPPS Rate,221.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,221.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,221.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,221.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,221.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,221.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,221.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,221.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,221.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,221.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,221.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,221.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,221.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,221.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,221.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,221.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,221.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,221.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,221.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,221.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,137.67,2394.25,1795.69
Outpatient Medical Services,MEDICAL PROCEDURES,62270,LUMBAR PUNCTURE,361,675.5,486.36,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,675.5,100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,662.67,100% of BCBS ASC Fee Schedule,N/A,Not Separately reimbursable,675.5,100% fo CIGN ASC FEE SCHEDULE,675.5,100% fo CIGN ASC FEE SCHEDULE,486.36,72% of total billed charges,N/A,Not Separately reimbursable,675.5,100% of CMS OPPS Rate,N/A,Not Separately reimbursable,405.3,60% of total billed charges,117.49,100% of CA Medicaid Fee Schedule with lesser of charges applied,117.49,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,63.46,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,472.85,70% of total billed charges,675.5,100% OF CMS OPPS Rate,675.5,120% of CMS OPPS RATE,486.36,Pays at 72% of billed charges with lesser of charges applied,486.36,Pays at 72% of billed charges with lesser of charges applied,486.36,Pays at 72% of billed charges with lesser of charges applied,486.36,Pays at 72% of billed charges with lesser of charges applied,486.36,Pays at 72% of billed charges with lesser of charges applied,486.36,Pays at 72% of billed charges with lesser of charges applied,675.5,100% of ASC Tier Grouping Fee Schedule,675.5,100% of ASC Tier Grouping Fee Schedule,675.5,100% of ASC Tier Grouping Fee Schedule,675.5,100% of ASC Tier Grouping Fee Schedule,675.5,100% of ASC Tier Grouping Fee Schedule,675.5,100% of ASC Tier Grouping Fee Schedule,675.5,100% of ASC Tier Grouping Fee Schedule,675.5,100% of ASC Tier Grouping Fee Schedule,675.5,100% of ASC Tier Grouping Fee Schedule,662.67,100% of BCBS ASC Fee Schedule,662.67,100% of BCBS ASC Fee Schedule,662.67,100% of BCBS ASC Fee Schedule,662.67,100% of BCBS ASC Fee Schedule,662.67,100% of BCBS ASC Fee Schedule,675.5,100% fo CIGN ASC FEE SCHEDULE,675.5,100% fo CIGN ASC FEE SCHEDULE,675.5,100% fo CIGN ASC FEE SCHEDULE,472.85,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,117.49,100% of CA Medicaid Fee Schedule with lesser of charges applied,117.49,100% of CA Medicaid Fee Schedule with lesser of charges applied,117.49,100% of CA Medicaid Fee Schedule with lesser of charges applied,117.49,100% of CA Medicaid Fee Schedule with lesser of charges applied,117.49,100% of CA Medicaid Fee Schedule with lesser of charges applied,117.49,100% of CA Medicaid Fee Schedule with lesser of charges applied,117.49,100% of CA Medicaid Fee Schedule with lesser of charges applied,117.49,100% of CA Medicaid Fee Schedule with lesser of charges applied,117.49,100% of CA Medicaid Fee Schedule with lesser of charges applied,117.49,100% of CA Medicaid Fee Schedule with lesser of charges applied,117.49,100% of CA Medicaid Fee Schedule with lesser of charges applied,117.49,100% of CA Medicaid Fee Schedule with lesser of charges applied,117.49,100% of CA Medicaid Fee Schedule with lesser of charges applied,117.49,100% of CA Medicaid Fee Schedule with lesser of charges applied,117.49,100% of CA Medicaid Fee Schedule with lesser of charges applied,117.49,100% of CA Medicaid Fee Schedule with lesser of charges applied,117.49,100% of CA Medicaid Fee Schedule with lesser of charges applied,117.49,100% of CA Medicaid Fee Schedule with lesser of charges applied,117.49,100% of CA Medicaid Fee Schedule with lesser of charges applied,117.49,100% of CA Medicaid Fee Schedule with lesser of charges applied,63.46,675.50,506.63
Outpatient Medical Services,MEDICAL PROCEDURES,20605,Draining or injecting medication into a large joint/bursa without ultrasound,361,1473.75,1061.1,Pays at 72% of billed charges with lesser of charges applied,345.59,100% OF CMS OPPS Rate,1473.75,100% of ASC Tier Grouping Fee Schedule,345.59,100% OF CMS OPPS Rate,1315.14,100% of BCBS ASC Fee Schedule,345.59,100% OF CMS OPPS Rate,1473.75,100% fo CIGN ASC FEE SCHEDULE,1473.75,100% fo CIGN ASC FEE SCHEDULE,1061.1,72% of total billed charges,345.59,100% OF CMS OPPS Rate,345.59,100% of CMS OPPS Rate,345.59,100% OF CMS OPPS Rate,884.25,60% of total billed charges,54.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,345.59,100% OF CMS OPPS Rate,345.59,100% OF CMS OPPS Rate,38.46,100% OF CMS OPPS RATE,345.59,100% OF CMS OPPS Rate,1031.63,70% of total billed charges,345.59,100% OF CMS OPPS Rate,414.69,120% of CMS OPPS RATE,1061.1,Pays at 72% of billed charges with lesser of charges applied,1061.1,Pays at 72% of billed charges with lesser of charges applied,1061.1,Pays at 72% of billed charges with lesser of charges applied,1061.1,Pays at 72% of billed charges with lesser of charges applied,1061.1,Pays at 72% of billed charges with lesser of charges applied,1061.1,Pays at 72% of billed charges with lesser of charges applied,1473.75,100% of ASC Tier Grouping Fee Schedule,1473.75,100% of ASC Tier Grouping Fee Schedule,1473.75,100% of ASC Tier Grouping Fee Schedule,1473.75,100% of ASC Tier Grouping Fee Schedule,1473.75,100% of ASC Tier Grouping Fee Schedule,1473.75,100% of ASC Tier Grouping Fee Schedule,1473.75,100% of ASC Tier Grouping Fee Schedule,1473.75,100% of ASC Tier Grouping Fee Schedule,1473.75,100% of ASC Tier Grouping Fee Schedule,1315.14,100% of BCBS ASC Fee Schedule,1315.14,100% of BCBS ASC Fee Schedule,1315.14,100% of BCBS ASC Fee Schedule,1315.14,100% of BCBS ASC Fee Schedule,1315.14,100% of BCBS ASC Fee Schedule,1473.75,100% fo CIGN ASC FEE SCHEDULE,1473.75,100% fo CIGN ASC FEE SCHEDULE,1473.75,100% fo CIGN ASC FEE SCHEDULE,1031.63,70% of total billed charges,345.59,100% OF CMS OPPS Rate,345.59,100% OF CMS OPPS Rate,345.59,100% OF CMS OPPS Rate,345.59,100% OF CMS OPPS Rate,345.59,100% OF CMS OPPS Rate,345.59,100% OF CMS OPPS Rate,345.59,100% OF CMS OPPS Rate,345.59,100% OF CMS OPPS Rate,345.59,100% OF CMS OPPS Rate,345.59,100% OF CMS OPPS Rate,345.59,100% OF CMS OPPS Rate,345.59,100% OF CMS OPPS Rate,345.59,100% OF CMS OPPS Rate,345.59,100% OF CMS OPPS Rate,345.59,100% OF CMS OPPS Rate,345.59,100% OF CMS OPPS Rate,54.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,38.46,1473.75,1105.31
Outpatient Medical Services,MEDICAL PROCEDURES,20610,Draining or injecting medication into a major joint/bursa without ultrasound,361,384,276.48,Pays at 72% of billed charges with lesser of charges applied,345.59,100% OF CMS OPPS Rate,384,100% of ASC Tier Grouping Fee Schedule,345.59,100% OF CMS OPPS Rate,376.7,100% of BCBS ASC Fee Schedule,345.59,100% OF CMS OPPS Rate,384,100% fo CIGN ASC FEE SCHEDULE,384,100% fo CIGN ASC FEE SCHEDULE,276.48,72% of total billed charges,345.59,100% OF CMS OPPS Rate,345.59,100% of CMS OPPS Rate,345.59,100% OF CMS OPPS Rate,230.4,60% of total billed charges,65.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,65.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,345.59,100% OF CMS OPPS Rate,345.59,100% OF CMS OPPS Rate,47.07,100% OF CMS OPPS RATE,345.59,100% OF CMS OPPS Rate,268.8,70% of total billed charges,345.59,100% OF CMS OPPS Rate,384,120% of CMS OPPS RATE,276.48,Pays at 72% of billed charges with lesser of charges applied,276.48,Pays at 72% of billed charges with lesser of charges applied,276.48,Pays at 72% of billed charges with lesser of charges applied,276.48,Pays at 72% of billed charges with lesser of charges applied,276.48,Pays at 72% of billed charges with lesser of charges applied,276.48,Pays at 72% of billed charges with lesser of charges applied,384,100% of ASC Tier Grouping Fee Schedule,384,100% of ASC Tier Grouping Fee Schedule,384,100% of ASC Tier Grouping Fee Schedule,384,100% of ASC Tier Grouping Fee Schedule,384,100% of ASC Tier Grouping Fee Schedule,384,100% of ASC Tier Grouping Fee Schedule,384,100% of ASC Tier Grouping Fee Schedule,384,100% of ASC Tier Grouping Fee Schedule,384,100% of ASC Tier Grouping Fee Schedule,376.7,100% of BCBS ASC Fee Schedule,376.7,100% of BCBS ASC Fee Schedule,376.7,100% of BCBS ASC Fee Schedule,376.7,100% of BCBS ASC Fee Schedule,376.7,100% of BCBS ASC Fee Schedule,384,100% fo CIGN ASC FEE SCHEDULE,384,100% fo CIGN ASC FEE SCHEDULE,384,100% fo CIGN ASC FEE SCHEDULE,268.8,70% of total billed charges,345.59,100% OF CMS OPPS Rate,345.59,100% OF CMS OPPS Rate,345.59,100% OF CMS OPPS Rate,345.59,100% OF CMS OPPS Rate,345.59,100% OF CMS OPPS Rate,345.59,100% OF CMS OPPS Rate,345.59,100% OF CMS OPPS Rate,345.59,100% OF CMS OPPS Rate,345.59,100% OF CMS OPPS Rate,345.59,100% OF CMS OPPS Rate,345.59,100% OF CMS OPPS Rate,345.59,100% OF CMS OPPS Rate,345.59,100% OF CMS OPPS Rate,345.59,100% OF CMS OPPS Rate,345.59,100% OF CMS OPPS Rate,345.59,100% OF CMS OPPS Rate,65.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,65.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,65.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,65.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,65.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,65.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,65.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,65.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,65.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,65.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,65.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,65.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,65.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,65.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,65.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,65.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,65.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,65.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,65.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,65.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,47.07,384.00,288
Outpatient Medical Services,MEDICAL PROCEDURES,19001,ASPIRATION OF EA ADD'L BREAST,361,1235.5,889.56,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,1235.5,100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,1212.03,100% of BCBS ASC Fee Schedule,N/A,Not Separately reimbursable,1235.5,100% fo CIGN ASC FEE SCHEDULE,1235.5,100% fo CIGN ASC FEE SCHEDULE,889.56,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,741.3,60% of total billed charges,29.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,21.43,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,864.85,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,889.56,Pays at 72% of billed charges with lesser of charges applied,889.56,Pays at 72% of billed charges with lesser of charges applied,889.56,Pays at 72% of billed charges with lesser of charges applied,889.56,Pays at 72% of billed charges with lesser of charges applied,889.56,Pays at 72% of billed charges with lesser of charges applied,889.56,Pays at 72% of billed charges with lesser of charges applied,1235.5,100% of ASC Tier Grouping Fee Schedule,1235.5,100% of ASC Tier Grouping Fee Schedule,1235.5,100% of ASC Tier Grouping Fee Schedule,1235.5,100% of ASC Tier Grouping Fee Schedule,1235.5,100% of ASC Tier Grouping Fee Schedule,1235.5,100% of ASC Tier Grouping Fee Schedule,1235.5,100% of ASC Tier Grouping Fee Schedule,1235.5,100% of ASC Tier Grouping Fee Schedule,1235.5,100% of ASC Tier Grouping Fee Schedule,1212.03,100% of BCBS ASC Fee Schedule,1212.03,100% of BCBS ASC Fee Schedule,1212.03,100% of BCBS ASC Fee Schedule,1212.03,100% of BCBS ASC Fee Schedule,1212.03,100% of BCBS ASC Fee Schedule,1235.5,100% fo CIGN ASC FEE SCHEDULE,1235.5,100% fo CIGN ASC FEE SCHEDULE,1235.5,100% fo CIGN ASC FEE SCHEDULE,864.85,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,29.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,21.43,1235.50,926.63
Outpatient Medical Services,MEDICAL PROCEDURES,54161,CIRCUMCISION >28 DAYS SURGICAL EXCISION,361,471.25,339.3,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,471.25,100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,462.3,100% of BCBS ASC Fee Schedule,N/A,Not Separately reimbursable,471.25,100% fo CIGN ASC FEE SCHEDULE,471.25,100% fo CIGN ASC FEE SCHEDULE,339.3,72% of total billed charges,N/A,Not Separately reimbursable,471.25,100% of CMS OPPS Rate,N/A,Not Separately reimbursable,282.75,60% of total billed charges,181.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,181.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,208.25,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,329.88,70% of total billed charges,471.25,100% OF CMS OPPS Rate,471.25,120% of CMS OPPS RATE,339.3,Pays at 72% of billed charges with lesser of charges applied,339.3,Pays at 72% of billed charges with lesser of charges applied,339.3,Pays at 72% of billed charges with lesser of charges applied,339.3,Pays at 72% of billed charges with lesser of charges applied,339.3,Pays at 72% of billed charges with lesser of charges applied,339.3,Pays at 72% of billed charges with lesser of charges applied,471.25,100% of ASC Tier Grouping Fee Schedule,471.25,100% of ASC Tier Grouping Fee Schedule,471.25,100% of ASC Tier Grouping Fee Schedule,471.25,100% of ASC Tier Grouping Fee Schedule,471.25,100% of ASC Tier Grouping Fee Schedule,471.25,100% of ASC Tier Grouping Fee Schedule,471.25,100% of ASC Tier Grouping Fee Schedule,471.25,100% of ASC Tier Grouping Fee Schedule,471.25,100% of ASC Tier Grouping Fee Schedule,462.3,100% of BCBS ASC Fee Schedule,462.3,100% of BCBS ASC Fee Schedule,462.3,100% of BCBS ASC Fee Schedule,462.3,100% of BCBS ASC Fee Schedule,462.3,100% of BCBS ASC Fee Schedule,471.25,100% fo CIGN ASC FEE SCHEDULE,471.25,100% fo CIGN ASC FEE SCHEDULE,471.25,100% fo CIGN ASC FEE SCHEDULE,329.88,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,181.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,181.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,181.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,181.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,181.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,181.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,181.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,181.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,181.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,181.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,181.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,181.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,181.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,181.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,181.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,181.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,181.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,181.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,181.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,181.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,181.57,471.25,353.44
Outpatient Medical Services,MRI,8765,ZUI HYST INJ,612,80,57.6,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,65.36,81.7% of total Billed charges,N/A,Not Separately reimbursable,63.28,79.1% of total billed charges,N/A,Not Separately reimbursable,67.2,84% of total billed charges,67.2,84% of total billed charges,57.6,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,48,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,56,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,57.6,Pays at 72% of billed charges with lesser of charges applied,57.6,Pays at 72% of billed charges with lesser of charges applied,57.6,Pays at 72% of billed charges with lesser of charges applied,57.6,Pays at 72% of billed charges with lesser of charges applied,57.6,Pays at 72% of billed charges with lesser of charges applied,57.6,Pays at 72% of billed charges with lesser of charges applied,65.36,81.7% of total Billed charges,65.36,81.7% of total Billed charges,65.36,81.7% of total Billed charges,65.36,81.7% of total Billed charges,65.36,81.7% of total Billed charges,65.36,81.7% of total Billed charges,65.36,81.7% of total Billed charges,65.36,81.7% of total Billed charges,65.36,81.7% of total Billed charges,63.28,79.1% of total billed charges,63.28,79.1% of total billed charges,63.28,79.1% of total billed charges,63.28,79.1% of total billed charges,63.28,79.1% of total billed charges,67.2,84% of total billed charges,67.2,84% of total billed charges,67.2,84% of total billed charges,56,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,48.00,67.20,60
Outpatient Medical Services,MRI,72158,MRI of lower back with and without dye,612,4872.75,3508.38,Pays at 72% of billed charges with lesser of charges applied,468.3,100% OF CMS OPPS Rate,4094.78,442% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,4780.17,pays at 100% of bcbs fee schedule with lesser of charges applied,468.3,100% OF CMS OPPS Rate,3131,84% of total billed charges,3131,84% of total billed charges,3508.38,72% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% of CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,2923.65,60% of total billed charges,447.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,447.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,267.95,100% OF CMS OPPS RATE,468.3,100% OF CMS OPPS Rate,3410.93,70% of total billed charges,468.3,100% OF CMS OPPS Rate,561.95,120% of CMS OPPS RATE,3508.38,Pays at 72% of billed charges with lesser of charges applied,3508.38,Pays at 72% of billed charges with lesser of charges applied,3508.38,Pays at 72% of billed charges with lesser of charges applied,3508.38,Pays at 72% of billed charges with lesser of charges applied,3508.38,Pays at 72% of billed charges with lesser of charges applied,3508.38,Pays at 72% of billed charges with lesser of charges applied,4094.78,442% of BCBS Fee Schedule,4094.78,442% of BCBS Fee Schedule,4094.78,442% of BCBS Fee Schedule,4094.78,442% of BCBS Fee Schedule,4094.78,442% of BCBS Fee Schedule,4094.78,442% of BCBS Fee Schedule,4094.78,442% of BCBS Fee Schedule,4094.78,442% of BCBS Fee Schedule,4094.78,442% of BCBS Fee Schedule,4780.17,pays at 100% of bcbs fee schedule with lesser of charges applied,4780.17,pays at 100% of bcbs fee schedule with lesser of charges applied,4780.17,pays at 100% of bcbs fee schedule with lesser of charges applied,4780.17,pays at 100% of bcbs fee schedule with lesser of charges applied,4780.17,pays at 100% of bcbs fee schedule with lesser of charges applied,3131,84% of total billed charges,3131,84% of total billed charges,3131,84% of total billed charges,3410.93,70% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,447.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,447.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,447.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,447.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,447.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,447.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,447.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,447.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,447.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,447.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,447.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,447.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,447.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,447.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,447.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,447.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,447.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,447.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,447.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,447.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,267.95,4780.17,3654.56
Outpatient Medical Services,MRI,72156,MRI of neck/spine with and without dye,612,4872.75,3508.38,Pays at 72% of billed charges with lesser of charges applied,468.3,100% OF CMS OPPS Rate,4093.19,442% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,4780.17,pays at 100% of bcbs fee schedule with lesser of charges applied,468.3,100% OF CMS OPPS Rate,3131,84% of total billed charges,3131,84% of total billed charges,3508.38,72% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% of CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,2923.65,60% of total billed charges,449.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,449.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,268.75,100% OF CMS OPPS RATE,468.3,100% OF CMS OPPS Rate,3410.93,70% of total billed charges,468.3,100% OF CMS OPPS Rate,561.95,120% of CMS OPPS RATE,3508.38,Pays at 72% of billed charges with lesser of charges applied,3508.38,Pays at 72% of billed charges with lesser of charges applied,3508.38,Pays at 72% of billed charges with lesser of charges applied,3508.38,Pays at 72% of billed charges with lesser of charges applied,3508.38,Pays at 72% of billed charges with lesser of charges applied,3508.38,Pays at 72% of billed charges with lesser of charges applied,4093.19,442% of BCBS Fee Schedule,4093.19,442% of BCBS Fee Schedule,4093.19,442% of BCBS Fee Schedule,4093.19,442% of BCBS Fee Schedule,4093.19,442% of BCBS Fee Schedule,4093.19,442% of BCBS Fee Schedule,4093.19,442% of BCBS Fee Schedule,4093.19,442% of BCBS Fee Schedule,4093.19,442% of BCBS Fee Schedule,4780.17,pays at 100% of bcbs fee schedule with lesser of charges applied,4780.17,pays at 100% of bcbs fee schedule with lesser of charges applied,4780.17,pays at 100% of bcbs fee schedule with lesser of charges applied,4780.17,pays at 100% of bcbs fee schedule with lesser of charges applied,4780.17,pays at 100% of bcbs fee schedule with lesser of charges applied,3131,84% of total billed charges,3131,84% of total billed charges,3131,84% of total billed charges,3410.93,70% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,449.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,449.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,449.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,449.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,449.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,449.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,449.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,449.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,449.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,449.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,449.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,449.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,449.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,449.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,449.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,449.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,449.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,449.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,449.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,449.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,268.75,4780.17,3654.56
Outpatient Medical Services,MRI,72157,MRI of chest and spine with and without dye,612,4872.75,3508.38,Pays at 72% of billed charges with lesser of charges applied,468.3,100% OF CMS OPPS Rate,4093.19,442% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,4780.17,pays at 100% of bcbs fee schedule with lesser of charges applied,468.3,100% OF CMS OPPS Rate,3131,84% of total billed charges,3131,84% of total billed charges,3508.38,72% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% of CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,2923.65,60% of total billed charges,449.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,449.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,269.55,100% OF CMS OPPS RATE,468.3,100% OF CMS OPPS Rate,3410.93,70% of total billed charges,468.3,100% OF CMS OPPS Rate,561.95,120% of CMS OPPS RATE,3508.38,Pays at 72% of billed charges with lesser of charges applied,3508.38,Pays at 72% of billed charges with lesser of charges applied,3508.38,Pays at 72% of billed charges with lesser of charges applied,3508.38,Pays at 72% of billed charges with lesser of charges applied,3508.38,Pays at 72% of billed charges with lesser of charges applied,3508.38,Pays at 72% of billed charges with lesser of charges applied,4093.19,442% of BCBS Fee Schedule,4093.19,442% of BCBS Fee Schedule,4093.19,442% of BCBS Fee Schedule,4093.19,442% of BCBS Fee Schedule,4093.19,442% of BCBS Fee Schedule,4093.19,442% of BCBS Fee Schedule,4093.19,442% of BCBS Fee Schedule,4093.19,442% of BCBS Fee Schedule,4093.19,442% of BCBS Fee Schedule,4780.17,pays at 100% of bcbs fee schedule with lesser of charges applied,4780.17,pays at 100% of bcbs fee schedule with lesser of charges applied,4780.17,pays at 100% of bcbs fee schedule with lesser of charges applied,4780.17,pays at 100% of bcbs fee schedule with lesser of charges applied,4780.17,pays at 100% of bcbs fee schedule with lesser of charges applied,3131,84% of total billed charges,3131,84% of total billed charges,3131,84% of total billed charges,3410.93,70% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,449.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,449.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,449.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,449.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,449.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,449.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,449.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,449.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,449.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,449.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,449.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,449.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,449.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,449.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,449.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,449.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,449.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,449.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,449.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,449.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,269.55,4780.17,3654.56
Outpatient Medical Services,MRI,72159,MRA SPI CANAL W/WO CON ADD SEQ,612,662.5,477,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,662.5,BCBS Fee Schedule,N/A,Not Separately reimbursable,649.91,pays at 100% of bcbs fee schedule with lesser of charges applied,N/A,Not Separately reimbursable,556.5,84% of total billed charges,556.5,84% of total billed charges,477,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,397.5,60% of total billed charges,489.09,100% of CA Medicaid Fee Schedule with lesser of charges applied,489.09,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,328.48,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,463.75,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,477,Pays at 72% of billed charges with lesser of charges applied,477,Pays at 72% of billed charges with lesser of charges applied,477,Pays at 72% of billed charges with lesser of charges applied,477,Pays at 72% of billed charges with lesser of charges applied,477,Pays at 72% of billed charges with lesser of charges applied,477,Pays at 72% of billed charges with lesser of charges applied,662.5,BCBS Fee Schedule,662.5,BCBS Fee Schedule,662.5,BCBS Fee Schedule,662.5,BCBS Fee Schedule,662.5,BCBS Fee Schedule,662.5,BCBS Fee Schedule,662.5,BCBS Fee Schedule,662.5,BCBS Fee Schedule,662.5,BCBS Fee Schedule,649.91,pays at 100% of bcbs fee schedule with lesser of charges applied,649.91,pays at 100% of bcbs fee schedule with lesser of charges applied,649.91,pays at 100% of bcbs fee schedule with lesser of charges applied,649.91,pays at 100% of bcbs fee schedule with lesser of charges applied,649.91,pays at 100% of bcbs fee schedule with lesser of charges applied,556.5,84% of total billed charges,556.5,84% of total billed charges,556.5,84% of total billed charges,463.75,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,489.09,100% of CA Medicaid Fee Schedule with lesser of charges applied,489.09,100% of CA Medicaid Fee Schedule with lesser of charges applied,489.09,100% of CA Medicaid Fee Schedule with lesser of charges applied,489.09,100% of CA Medicaid Fee Schedule with lesser of charges applied,489.09,100% of CA Medicaid Fee Schedule with lesser of charges applied,489.09,100% of CA Medicaid Fee Schedule with lesser of charges applied,489.09,100% of CA Medicaid Fee Schedule with lesser of charges applied,489.09,100% of CA Medicaid Fee Schedule with lesser of charges applied,489.09,100% of CA Medicaid Fee Schedule with lesser of charges applied,489.09,100% of CA Medicaid Fee Schedule with lesser of charges applied,489.09,100% of CA Medicaid Fee Schedule with lesser of charges applied,489.09,100% of CA Medicaid Fee Schedule with lesser of charges applied,489.09,100% of CA Medicaid Fee Schedule with lesser of charges applied,489.09,100% of CA Medicaid Fee Schedule with lesser of charges applied,489.09,100% of CA Medicaid Fee Schedule with lesser of charges applied,489.09,100% of CA Medicaid Fee Schedule with lesser of charges applied,489.09,100% of CA Medicaid Fee Schedule with lesser of charges applied,489.09,100% of CA Medicaid Fee Schedule with lesser of charges applied,489.09,100% of CA Medicaid Fee Schedule with lesser of charges applied,489.09,100% of CA Medicaid Fee Schedule with lesser of charges applied,328.48,662.50,496.88
Outpatient Medical Services,MRI,72147,MRI THORACIC SPINE W CONTRAST,612,4035,2905.2,Pays at 72% of billed charges with lesser of charges applied,468.3,100% OF CMS OPPS Rate,2496.5,442% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,3002.68,100% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,3131,84% of total billed charges,3131,84% of total billed charges,2905.2,72% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% of CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,2421,60% of total billed charges,384.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,384.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,238.89,100% OF CMS OPPS RATE,468.3,100% OF CMS OPPS Rate,2824.5,70% of total billed charges,468.3,100% OF CMS OPPS Rate,561.95,120% of CMS OPPS RATE,2905.2,Pays at 72% of billed charges with lesser of charges applied,2905.2,Pays at 72% of billed charges with lesser of charges applied,2905.2,Pays at 72% of billed charges with lesser of charges applied,2905.2,Pays at 72% of billed charges with lesser of charges applied,2905.2,Pays at 72% of billed charges with lesser of charges applied,2905.2,Pays at 72% of billed charges with lesser of charges applied,2496.5,442% of BCBS Fee Schedule,2496.5,442% of BCBS Fee Schedule,2496.5,442% of BCBS Fee Schedule,2496.5,442% of BCBS Fee Schedule,2496.5,442% of BCBS Fee Schedule,2496.5,442% of BCBS Fee Schedule,2496.5,442% of BCBS Fee Schedule,2496.5,442% of BCBS Fee Schedule,2496.5,442% of BCBS Fee Schedule,3002.68,100% of BCBS Fee Schedule,3002.68,100% of BCBS Fee Schedule,3002.68,100% of BCBS Fee Schedule,3002.68,100% of BCBS Fee Schedule,3002.68,100% of BCBS Fee Schedule,3131,84% of total billed charges,3131,84% of total billed charges,3131,84% of total billed charges,2824.5,70% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,384.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,384.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,384.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,384.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,384.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,384.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,384.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,384.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,384.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,384.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,384.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,384.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,384.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,384.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,384.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,384.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,384.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,384.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,384.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,384.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,238.89,3131.00,3026.25
Outpatient Medical Services,MRI,72141,MRI of the neck or spine without dye,612,3204,2306.88,Pays at 72% of billed charges with lesser of charges applied,296.82,100% OF CMS OPPS Rate,2080.32,442% of BCBS Fee Schedule,296.82,100% OF CMS OPPS Rate,2502.9,100% of BCBS Fee Schedule,296.82,100% OF CMS OPPS Rate,2691.36,84% of total billed charges,2691.36,84% of total billed charges,2306.88,72% of total billed charges,296.82,100% OF CMS OPPS Rate,296.82,100% of CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,1922.4,60% of total billed charges,266.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,266.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,152.49,100% OF CMS OPPS RATE,296.82,100% OF CMS OPPS Rate,2242.8,70% of total billed charges,296.82,100% OF CMS OPPS Rate,356.18,120% of CMS OPPS RATE,2306.88,Pays at 72% of billed charges with lesser of charges applied,2306.88,Pays at 72% of billed charges with lesser of charges applied,2306.88,Pays at 72% of billed charges with lesser of charges applied,2306.88,Pays at 72% of billed charges with lesser of charges applied,2306.88,Pays at 72% of billed charges with lesser of charges applied,2306.88,Pays at 72% of billed charges with lesser of charges applied,2080.32,442% of BCBS Fee Schedule,2080.32,442% of BCBS Fee Schedule,2080.32,442% of BCBS Fee Schedule,2080.32,442% of BCBS Fee Schedule,2080.32,442% of BCBS Fee Schedule,2080.32,442% of BCBS Fee Schedule,2080.32,442% of BCBS Fee Schedule,2080.32,442% of BCBS Fee Schedule,2080.32,442% of BCBS Fee Schedule,2502.9,100% of BCBS Fee Schedule,2502.9,100% of BCBS Fee Schedule,2502.9,100% of BCBS Fee Schedule,2502.9,100% of BCBS Fee Schedule,2502.9,100% of BCBS Fee Schedule,2691.36,84% of total billed charges,2691.36,84% of total billed charges,2691.36,84% of total billed charges,2242.8,70% of total billed charges,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,266.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,266.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,266.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,266.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,266.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,266.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,266.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,266.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,266.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,266.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,266.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,266.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,266.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,266.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,266.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,266.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,266.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,266.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,266.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,266.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,152.49,2691.36,2403
Outpatient Medical Services,MRI,72146,MRI of chest and spine without dye,612,3204,2306.88,Pays at 72% of billed charges with lesser of charges applied,296.82,100% OF CMS OPPS Rate,2307.37,442% of BCBS Fee Schedule,296.82,100% OF CMS OPPS Rate,2776.7,100% of BCBS Fee Schedule,296.82,100% OF CMS OPPS Rate,2691.36,84% of total billed charges,2691.36,84% of total billed charges,2306.88,72% of total billed charges,296.82,100% OF CMS OPPS Rate,296.82,100% of CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,1922.4,60% of total billed charges,265.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,265.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,152.49,100% OF CMS OPPS RATE,296.82,100% OF CMS OPPS Rate,2242.8,70% of total billed charges,296.82,100% OF CMS OPPS Rate,356.18,120% of CMS OPPS RATE,2306.88,Pays at 72% of billed charges with lesser of charges applied,2306.88,Pays at 72% of billed charges with lesser of charges applied,2306.88,Pays at 72% of billed charges with lesser of charges applied,2306.88,Pays at 72% of billed charges with lesser of charges applied,2306.88,Pays at 72% of billed charges with lesser of charges applied,2306.88,Pays at 72% of billed charges with lesser of charges applied,2307.37,442% of BCBS Fee Schedule,2307.37,442% of BCBS Fee Schedule,2307.37,442% of BCBS Fee Schedule,2307.37,442% of BCBS Fee Schedule,2307.37,442% of BCBS Fee Schedule,2307.37,442% of BCBS Fee Schedule,2307.37,442% of BCBS Fee Schedule,2307.37,442% of BCBS Fee Schedule,2307.37,442% of BCBS Fee Schedule,2776.7,100% of BCBS Fee Schedule,2776.7,100% of BCBS Fee Schedule,2776.7,100% of BCBS Fee Schedule,2776.7,100% of BCBS Fee Schedule,2776.7,100% of BCBS Fee Schedule,2691.36,84% of total billed charges,2691.36,84% of total billed charges,2691.36,84% of total billed charges,2242.8,70% of total billed charges,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,265.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,265.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,265.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,265.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,265.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,265.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,265.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,265.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,265.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,265.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,265.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,265.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,265.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,265.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,265.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,265.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,265.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,265.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,265.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,265.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,152.49,2776.70,2403
Outpatient Medical Services,MRI,72142,MRI CERVICAL SPINE W CONTR,612,4038,2907.36,Pays at 72% of billed charges with lesser of charges applied,468.3,100% OF CMS OPPS Rate,2496.5,442% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,3002.68,100% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,3131,84% of total billed charges,3131,84% of total billed charges,2907.36,72% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% of CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,2422.8,60% of total billed charges,388.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,388.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,241.28,100% OF CMS OPPS RATE,468.3,100% OF CMS OPPS Rate,2826.6,70% of total billed charges,468.3,100% OF CMS OPPS Rate,561.95,120% of CMS OPPS RATE,2907.36,Pays at 72% of billed charges with lesser of charges applied,2907.36,Pays at 72% of billed charges with lesser of charges applied,2907.36,Pays at 72% of billed charges with lesser of charges applied,2907.36,Pays at 72% of billed charges with lesser of charges applied,2907.36,Pays at 72% of billed charges with lesser of charges applied,2907.36,Pays at 72% of billed charges with lesser of charges applied,2496.5,442% of BCBS Fee Schedule,2496.5,442% of BCBS Fee Schedule,2496.5,442% of BCBS Fee Schedule,2496.5,442% of BCBS Fee Schedule,2496.5,442% of BCBS Fee Schedule,2496.5,442% of BCBS Fee Schedule,2496.5,442% of BCBS Fee Schedule,2496.5,442% of BCBS Fee Schedule,2496.5,442% of BCBS Fee Schedule,3002.68,100% of BCBS Fee Schedule,3002.68,100% of BCBS Fee Schedule,3002.68,100% of BCBS Fee Schedule,3002.68,100% of BCBS Fee Schedule,3002.68,100% of BCBS Fee Schedule,3131,84% of total billed charges,3131,84% of total billed charges,3131,84% of total billed charges,2826.6,70% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,388.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,388.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,388.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,388.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,388.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,388.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,388.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,388.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,388.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,388.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,388.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,388.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,388.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,388.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,388.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,388.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,388.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,388.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,388.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,388.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,241.28,3131.00,3028.5
Outpatient Medical Services,MRI,72148,MRI scan of lower spinal canal,612,3204,2306.88,Pays at 72% of billed charges with lesser of charges applied,296.82,100% OF CMS OPPS Rate,2305.25,442% of BCBS Fee Schedule,296.82,100% OF CMS OPPS Rate,2776.7,100% of BCBS Fee Schedule,296.82,100% OF CMS OPPS Rate,2691.36,84% of total billed charges,2691.36,84% of total billed charges,2306.88,72% of total billed charges,296.82,100% OF CMS OPPS Rate,296.82,100% of CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,1922.4,60% of total billed charges,266.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,266.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,153.29,100% OF CMS OPPS RATE,296.82,100% OF CMS OPPS Rate,2242.8,70% of total billed charges,296.82,100% OF CMS OPPS Rate,356.18,120% of CMS OPPS RATE,2306.88,Pays at 72% of billed charges with lesser of charges applied,2306.88,Pays at 72% of billed charges with lesser of charges applied,2306.88,Pays at 72% of billed charges with lesser of charges applied,2306.88,Pays at 72% of billed charges with lesser of charges applied,2306.88,Pays at 72% of billed charges with lesser of charges applied,2306.88,Pays at 72% of billed charges with lesser of charges applied,2305.25,442% of BCBS Fee Schedule,2305.25,442% of BCBS Fee Schedule,2305.25,442% of BCBS Fee Schedule,2305.25,442% of BCBS Fee Schedule,2305.25,442% of BCBS Fee Schedule,2305.25,442% of BCBS Fee Schedule,2305.25,442% of BCBS Fee Schedule,2305.25,442% of BCBS Fee Schedule,2305.25,442% of BCBS Fee Schedule,2776.7,100% of BCBS Fee Schedule,2776.7,100% of BCBS Fee Schedule,2776.7,100% of BCBS Fee Schedule,2776.7,100% of BCBS Fee Schedule,2776.7,100% of BCBS Fee Schedule,2691.36,84% of total billed charges,2691.36,84% of total billed charges,2691.36,84% of total billed charges,2242.8,70% of total billed charges,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,266.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,266.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,266.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,266.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,266.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,266.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,266.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,266.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,266.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,266.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,266.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,266.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,266.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,266.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,266.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,266.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,266.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,266.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,266.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,266.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,153.29,2776.70,2403
Outpatient Medical Services,MRI,72149,MRI LUMBAR SPINE W CONTR,612,4036.75,2906.46,Pays at 72% of billed charges with lesser of charges applied,468.3,100% OF CMS OPPS Rate,2494.91,442% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,3002.68,100% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,3131,84% of total billed charges,3131,84% of total billed charges,2906.46,72% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% of CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,2422.05,60% of total billed charges,380.88,100% of CA Medicaid Fee Schedule with lesser of charges applied,380.88,100% of CA Medicaid Fee Schedule with lesser of charges applied,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,235.71,100% OF CMS OPPS RATE,468.3,100% OF CMS OPPS Rate,2825.73,70% of total billed charges,468.3,100% OF CMS OPPS Rate,561.95,120% of CMS OPPS RATE,2906.46,Pays at 72% of billed charges with lesser of charges applied,2906.46,Pays at 72% of billed charges with lesser of charges applied,2906.46,Pays at 72% of billed charges with lesser of charges applied,2906.46,Pays at 72% of billed charges with lesser of charges applied,2906.46,Pays at 72% of billed charges with lesser of charges applied,2906.46,Pays at 72% of billed charges with lesser of charges applied,2494.91,442% of BCBS Fee Schedule,2494.91,442% of BCBS Fee Schedule,2494.91,442% of BCBS Fee Schedule,2494.91,442% of BCBS Fee Schedule,2494.91,442% of BCBS Fee Schedule,2494.91,442% of BCBS Fee Schedule,2494.91,442% of BCBS Fee Schedule,2494.91,442% of BCBS Fee Schedule,2494.91,442% of BCBS Fee Schedule,3002.68,100% of BCBS Fee Schedule,3002.68,100% of BCBS Fee Schedule,3002.68,100% of BCBS Fee Schedule,3002.68,100% of BCBS Fee Schedule,3002.68,100% of BCBS Fee Schedule,3131,84% of total billed charges,3131,84% of total billed charges,3131,84% of total billed charges,2825.73,70% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,380.88,100% of CA Medicaid Fee Schedule with lesser of charges applied,380.88,100% of CA Medicaid Fee Schedule with lesser of charges applied,380.88,100% of CA Medicaid Fee Schedule with lesser of charges applied,380.88,100% of CA Medicaid Fee Schedule with lesser of charges applied,380.88,100% of CA Medicaid Fee Schedule with lesser of charges applied,380.88,100% of CA Medicaid Fee Schedule with lesser of charges applied,380.88,100% of CA Medicaid Fee Schedule with lesser of charges applied,380.88,100% of CA Medicaid Fee Schedule with lesser of charges applied,380.88,100% of CA Medicaid Fee Schedule with lesser of charges applied,380.88,100% of CA Medicaid Fee Schedule with lesser of charges applied,380.88,100% of CA Medicaid Fee Schedule with lesser of charges applied,380.88,100% of CA Medicaid Fee Schedule with lesser of charges applied,380.88,100% of CA Medicaid Fee Schedule with lesser of charges applied,380.88,100% of CA Medicaid Fee Schedule with lesser of charges applied,380.88,100% of CA Medicaid Fee Schedule with lesser of charges applied,380.88,100% of CA Medicaid Fee Schedule with lesser of charges applied,380.88,100% of CA Medicaid Fee Schedule with lesser of charges applied,380.88,100% of CA Medicaid Fee Schedule with lesser of charges applied,380.88,100% of CA Medicaid Fee Schedule with lesser of charges applied,380.88,100% of CA Medicaid Fee Schedule with lesser of charges applied,235.71,3131.00,3027.56
Outpatient Medical Services,MRI,72196,MRI PEVLIS WITH ONLY,612,3918.75,2821.5,Pays at 72% of billed charges with lesser of charges applied,468.3,100% OF CMS OPPS Rate,2080.32,442% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,2975.04,100% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,3131,84% of total billed charges,3131,84% of total billed charges,2821.5,72% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% of CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,2351.25,60% of total billed charges,380.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,380.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,236.9,100% OF CMS OPPS RATE,468.3,100% OF CMS OPPS Rate,2743.13,70% of total billed charges,468.3,100% OF CMS OPPS Rate,561.95,120% of CMS OPPS RATE,2821.5,Pays at 72% of billed charges with lesser of charges applied,2821.5,Pays at 72% of billed charges with lesser of charges applied,2821.5,Pays at 72% of billed charges with lesser of charges applied,2821.5,Pays at 72% of billed charges with lesser of charges applied,2821.5,Pays at 72% of billed charges with lesser of charges applied,2821.5,Pays at 72% of billed charges with lesser of charges applied,2080.32,442% of BCBS Fee Schedule,2080.32,442% of BCBS Fee Schedule,2080.32,442% of BCBS Fee Schedule,2080.32,442% of BCBS Fee Schedule,2080.32,442% of BCBS Fee Schedule,2080.32,442% of BCBS Fee Schedule,2080.32,442% of BCBS Fee Schedule,2080.32,442% of BCBS Fee Schedule,2080.32,442% of BCBS Fee Schedule,2975.04,100% of BCBS Fee Schedule,2975.04,100% of BCBS Fee Schedule,2975.04,100% of BCBS Fee Schedule,2975.04,100% of BCBS Fee Schedule,2975.04,100% of BCBS Fee Schedule,3131,84% of total billed charges,3131,84% of total billed charges,3131,84% of total billed charges,2743.13,70% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,380.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,380.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,380.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,380.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,380.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,380.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,380.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,380.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,380.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,380.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,380.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,380.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,380.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,380.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,380.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,380.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,380.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,380.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,380.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,380.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,236.90,3131.00,2939.06
Outpatient Medical Services,MRI,C8920,MRA PELVI ADDED SEQ,612,690.25,496.98,Pays at 72% of billed charges with lesser of charges applied,468.3,100% OF CMS OPPS Rate,690.25,BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,545.99,79.1% of total billed charges,468.3,100% OF CMS OPPS Rate,579.81,84% of total billed charges,579.81,84% of total billed charges,496.98,72% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% of CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,414.15,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,N/A,Not Separately reimbursable,468.3,100% OF CMS OPPS Rate,483.18,70% of total billed charges,468.3,100% OF CMS OPPS Rate,561.95,120% of CMS OPPS RATE,496.98,Pays at 72% of billed charges with lesser of charges applied,496.98,Pays at 72% of billed charges with lesser of charges applied,496.98,Pays at 72% of billed charges with lesser of charges applied,496.98,Pays at 72% of billed charges with lesser of charges applied,496.98,Pays at 72% of billed charges with lesser of charges applied,496.98,Pays at 72% of billed charges with lesser of charges applied,690.25,BCBS Fee Schedule,690.25,BCBS Fee Schedule,690.25,BCBS Fee Schedule,690.25,BCBS Fee Schedule,690.25,BCBS Fee Schedule,690.25,BCBS Fee Schedule,690.25,BCBS Fee Schedule,690.25,BCBS Fee Schedule,690.25,BCBS Fee Schedule,545.99,79.1% of total billed charges,545.99,79.1% of total billed charges,545.99,79.1% of total billed charges,545.99,79.1% of total billed charges,545.99,79.1% of total billed charges,579.81,84% of total billed charges,579.81,84% of total billed charges,579.81,84% of total billed charges,483.18,70% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,414.15,690.25,517.69
Outpatient Medical Services,MRI,72195,MRI of pelvis without dye,612,3356.5,2416.68,Pays at 72% of billed charges with lesser of charges applied,296.82,100% OF CMS OPPS Rate,2121.16,442% of BCBS Fee Schedule,296.82,100% OF CMS OPPS Rate,2481.4,100% of BCBS Fee Schedule,296.82,100% OF CMS OPPS Rate,2819.46,84% of total billed charges,2819.46,84% of total billed charges,2416.68,72% of total billed charges,296.82,100% OF CMS OPPS Rate,296.82,100% of CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,2013.9,60% of total billed charges,324.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,324.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,202.66,100% OF CMS OPPS RATE,296.82,100% OF CMS OPPS Rate,2349.55,70% of total billed charges,296.82,100% OF CMS OPPS Rate,356.18,120% of CMS OPPS RATE,2416.68,Pays at 72% of billed charges with lesser of charges applied,2416.68,Pays at 72% of billed charges with lesser of charges applied,2416.68,Pays at 72% of billed charges with lesser of charges applied,2416.68,Pays at 72% of billed charges with lesser of charges applied,2416.68,Pays at 72% of billed charges with lesser of charges applied,2416.68,Pays at 72% of billed charges with lesser of charges applied,2121.16,442% of BCBS Fee Schedule,2121.16,442% of BCBS Fee Schedule,2121.16,442% of BCBS Fee Schedule,2121.16,442% of BCBS Fee Schedule,2121.16,442% of BCBS Fee Schedule,2121.16,442% of BCBS Fee Schedule,2121.16,442% of BCBS Fee Schedule,2121.16,442% of BCBS Fee Schedule,2121.16,442% of BCBS Fee Schedule,2481.4,100% of BCBS Fee Schedule,2481.4,100% of BCBS Fee Schedule,2481.4,100% of BCBS Fee Schedule,2481.4,100% of BCBS Fee Schedule,2481.4,100% of BCBS Fee Schedule,2819.46,84% of total billed charges,2819.46,84% of total billed charges,2819.46,84% of total billed charges,2349.55,70% of total billed charges,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,324.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,324.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,324.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,324.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,324.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,324.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,324.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,324.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,324.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,324.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,324.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,324.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,324.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,324.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,324.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,324.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,324.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,324.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,324.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,324.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,202.66,2819.46,2517.38
Outpatient Medical Services,MRI,70553,MRI scan of brain before and after contrast,611,4870.5,3506.76,Pays at 72% of billed charges with lesser of charges applied,468.3,100% OF CMS OPPS Rate,4094.78,442% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,4777.96,pays at 100% of bcbs fee schedule with lesser of charges applied,468.3,100% OF CMS OPPS Rate,3131,84% of total billed charges,3131,84% of total billed charges,3506.76,72% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% of CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,2922.3,60% of total billed charges,446.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,446.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,266.76,100% OF CMS OPPS RATE,468.3,100% OF CMS OPPS Rate,3409.35,70% of total billed charges,468.3,100% OF CMS OPPS Rate,561.95,120% of CMS OPPS RATE,3506.76,Pays at 72% of billed charges with lesser of charges applied,3506.76,Pays at 72% of billed charges with lesser of charges applied,3506.76,Pays at 72% of billed charges with lesser of charges applied,3506.76,Pays at 72% of billed charges with lesser of charges applied,3506.76,Pays at 72% of billed charges with lesser of charges applied,3506.76,Pays at 72% of billed charges with lesser of charges applied,4094.78,442% of BCBS Fee Schedule,4094.78,442% of BCBS Fee Schedule,4094.78,442% of BCBS Fee Schedule,4094.78,442% of BCBS Fee Schedule,4094.78,442% of BCBS Fee Schedule,4094.78,442% of BCBS Fee Schedule,4094.78,442% of BCBS Fee Schedule,4094.78,442% of BCBS Fee Schedule,4094.78,442% of BCBS Fee Schedule,4777.96,pays at 100% of bcbs fee schedule with lesser of charges applied,4777.96,pays at 100% of bcbs fee schedule with lesser of charges applied,4777.96,pays at 100% of bcbs fee schedule with lesser of charges applied,4777.96,pays at 100% of bcbs fee schedule with lesser of charges applied,4777.96,pays at 100% of bcbs fee schedule with lesser of charges applied,3131,84% of total billed charges,3131,84% of total billed charges,3131,84% of total billed charges,3409.35,70% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,446.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,446.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,446.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,446.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,446.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,446.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,446.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,446.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,446.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,446.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,446.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,446.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,446.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,446.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,446.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,446.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,446.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,446.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,446.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,446.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,266.76,4777.96,3652.88
Outpatient Medical Services,MRI,70551,MRI of brain stem without dye,611,3204,2306.88,Pays at 72% of billed charges with lesser of charges applied,296.82,100% OF CMS OPPS Rate,2079.26,442% of BCBS Fee Schedule,296.82,100% OF CMS OPPS Rate,2502.9,100% of BCBS Fee Schedule,296.82,100% OF CMS OPPS Rate,2691.36,84% of total billed charges,2691.36,84% of total billed charges,2306.88,72% of total billed charges,296.82,100% OF CMS OPPS Rate,296.82,100% of CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,1922.4,60% of total billed charges,272.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,272.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,159.26,100% OF CMS OPPS RATE,296.82,100% OF CMS OPPS Rate,2242.8,70% of total billed charges,296.82,100% OF CMS OPPS Rate,356.18,120% of CMS OPPS RATE,2306.88,Pays at 72% of billed charges with lesser of charges applied,2306.88,Pays at 72% of billed charges with lesser of charges applied,2306.88,Pays at 72% of billed charges with lesser of charges applied,2306.88,Pays at 72% of billed charges with lesser of charges applied,2306.88,Pays at 72% of billed charges with lesser of charges applied,2306.88,Pays at 72% of billed charges with lesser of charges applied,2079.26,442% of BCBS Fee Schedule,2079.26,442% of BCBS Fee Schedule,2079.26,442% of BCBS Fee Schedule,2079.26,442% of BCBS Fee Schedule,2079.26,442% of BCBS Fee Schedule,2079.26,442% of BCBS Fee Schedule,2079.26,442% of BCBS Fee Schedule,2079.26,442% of BCBS Fee Schedule,2079.26,442% of BCBS Fee Schedule,2502.9,100% of BCBS Fee Schedule,2502.9,100% of BCBS Fee Schedule,2502.9,100% of BCBS Fee Schedule,2502.9,100% of BCBS Fee Schedule,2502.9,100% of BCBS Fee Schedule,2691.36,84% of total billed charges,2691.36,84% of total billed charges,2691.36,84% of total billed charges,2242.8,70% of total billed charges,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,272.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,272.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,272.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,272.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,272.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,272.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,272.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,272.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,272.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,272.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,272.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,272.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,272.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,272.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,272.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,272.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,272.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,272.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,272.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,272.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,159.26,2691.36,2403
Outpatient Medical Services,MRI,70552,MRI BRAIN/STEM W CONT,611,4036.75,2906.46,Pays at 72% of billed charges with lesser of charges applied,468.3,100% OF CMS OPPS Rate,2490.63,442% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,3002.68,100% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,3131,84% of total billed charges,3131,84% of total billed charges,2906.46,72% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% of CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,2422.05,60% of total billed charges,379.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,379.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,235.3,100% OF CMS OPPS RATE,468.3,100% OF CMS OPPS Rate,2825.73,70% of total billed charges,468.3,100% OF CMS OPPS Rate,561.95,120% of CMS OPPS RATE,2906.46,Pays at 72% of billed charges with lesser of charges applied,2906.46,Pays at 72% of billed charges with lesser of charges applied,2906.46,Pays at 72% of billed charges with lesser of charges applied,2906.46,Pays at 72% of billed charges with lesser of charges applied,2906.46,Pays at 72% of billed charges with lesser of charges applied,2906.46,Pays at 72% of billed charges with lesser of charges applied,2490.63,442% of BCBS Fee Schedule,2490.63,442% of BCBS Fee Schedule,2490.63,442% of BCBS Fee Schedule,2490.63,442% of BCBS Fee Schedule,2490.63,442% of BCBS Fee Schedule,2490.63,442% of BCBS Fee Schedule,2490.63,442% of BCBS Fee Schedule,2490.63,442% of BCBS Fee Schedule,2490.63,442% of BCBS Fee Schedule,3002.68,100% of BCBS Fee Schedule,3002.68,100% of BCBS Fee Schedule,3002.68,100% of BCBS Fee Schedule,3002.68,100% of BCBS Fee Schedule,3002.68,100% of BCBS Fee Schedule,3131,84% of total billed charges,3131,84% of total billed charges,3131,84% of total billed charges,2825.73,70% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,379.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,379.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,379.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,379.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,379.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,379.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,379.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,379.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,379.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,379.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,379.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,379.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,379.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,379.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,379.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,379.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,379.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,379.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,379.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,379.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,235.30,3131.00,3027.56
Outpatient Medical Services,MRI,73725,MRA LOWER EXTREMITY RUN OFF-LT w/o AND w/ CONTRAST,610,3204,2306.88,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,2083.01,442% of BCBS Fee Schedule,N/A,Not Separately reimbursable,2502.9,100% of BCBS Fee Schedule,N/A,Not Separately reimbursable,2691.36,84% of total billed charges,2691.36,84% of total billed charges,2306.88,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,1922.4,60% of total billed charges,473.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,473.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,315.74,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,2242.8,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,2306.88,Pays at 72% of billed charges with lesser of charges applied,2306.88,Pays at 72% of billed charges with lesser of charges applied,2306.88,Pays at 72% of billed charges with lesser of charges applied,2306.88,Pays at 72% of billed charges with lesser of charges applied,2306.88,Pays at 72% of billed charges with lesser of charges applied,2306.88,Pays at 72% of billed charges with lesser of charges applied,2083.01,442% of BCBS Fee Schedule,2083.01,442% of BCBS Fee Schedule,2083.01,442% of BCBS Fee Schedule,2083.01,442% of BCBS Fee Schedule,2083.01,442% of BCBS Fee Schedule,2083.01,442% of BCBS Fee Schedule,2083.01,442% of BCBS Fee Schedule,2083.01,442% of BCBS Fee Schedule,2083.01,442% of BCBS Fee Schedule,2502.9,100% of BCBS Fee Schedule,2502.9,100% of BCBS Fee Schedule,2502.9,100% of BCBS Fee Schedule,2502.9,100% of BCBS Fee Schedule,2502.9,100% of BCBS Fee Schedule,2691.36,84% of total billed charges,2691.36,84% of total billed charges,2691.36,84% of total billed charges,2242.8,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,473.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,473.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,473.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,473.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,473.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,473.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,473.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,473.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,473.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,473.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,473.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,473.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,473.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,473.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,473.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,473.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,473.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,473.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,473.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,473.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,315.74,2691.36,2403
Outpatient Medical Services,MRI,76377,3D RENDERING TOMAGRAPHI MODALITY WITH WORK STATION,610,836.5,602.28,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,667.73,442% of BCBS Fee Schedule,N/A,Not Separately reimbursable,783.75,100% of BCBS Fee Schedule,N/A,Not Separately reimbursable,702.66,84% of total billed charges,702.66,84% of total billed charges,602.28,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,501.9,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,45.58,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,585.55,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,602.28,Pays at 72% of billed charges with lesser of charges applied,602.28,Pays at 72% of billed charges with lesser of charges applied,602.28,Pays at 72% of billed charges with lesser of charges applied,602.28,Pays at 72% of billed charges with lesser of charges applied,602.28,Pays at 72% of billed charges with lesser of charges applied,602.28,Pays at 72% of billed charges with lesser of charges applied,667.73,442% of BCBS Fee Schedule,667.73,442% of BCBS Fee Schedule,667.73,442% of BCBS Fee Schedule,667.73,442% of BCBS Fee Schedule,667.73,442% of BCBS Fee Schedule,667.73,442% of BCBS Fee Schedule,667.73,442% of BCBS Fee Schedule,667.73,442% of BCBS Fee Schedule,667.73,442% of BCBS Fee Schedule,783.75,100% of BCBS Fee Schedule,783.75,100% of BCBS Fee Schedule,783.75,100% of BCBS Fee Schedule,783.75,100% of BCBS Fee Schedule,783.75,100% of BCBS Fee Schedule,702.66,84% of total billed charges,702.66,84% of total billed charges,702.66,84% of total billed charges,585.55,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,45.58,783.75,627.38
Outpatient Medical Services,MRI,73225,MRA UPPER EXTREMITY RUN OFF-LT w/o OR w/ CONTRAST,610,3204,2306.88,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,2081.91,442% of BCBS Fee Schedule,N/A,Not Separately reimbursable,2453.54,100% of BCBS Fee Schedule,N/A,Not Separately reimbursable,2691.36,84% of total billed charges,2691.36,84% of total billed charges,2306.88,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,1922.4,60% of total billed charges,485.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,485.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,328.48,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,2242.8,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,2306.88,Pays at 72% of billed charges with lesser of charges applied,2306.88,Pays at 72% of billed charges with lesser of charges applied,2306.88,Pays at 72% of billed charges with lesser of charges applied,2306.88,Pays at 72% of billed charges with lesser of charges applied,2306.88,Pays at 72% of billed charges with lesser of charges applied,2306.88,Pays at 72% of billed charges with lesser of charges applied,2081.91,442% of BCBS Fee Schedule,2081.91,442% of BCBS Fee Schedule,2081.91,442% of BCBS Fee Schedule,2081.91,442% of BCBS Fee Schedule,2081.91,442% of BCBS Fee Schedule,2081.91,442% of BCBS Fee Schedule,2081.91,442% of BCBS Fee Schedule,2081.91,442% of BCBS Fee Schedule,2081.91,442% of BCBS Fee Schedule,2453.54,100% of BCBS Fee Schedule,2453.54,100% of BCBS Fee Schedule,2453.54,100% of BCBS Fee Schedule,2453.54,100% of BCBS Fee Schedule,2453.54,100% of BCBS Fee Schedule,2691.36,84% of total billed charges,2691.36,84% of total billed charges,2691.36,84% of total billed charges,2242.8,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,485.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,485.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,485.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,485.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,485.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,485.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,485.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,485.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,485.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,485.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,485.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,485.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,485.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,485.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,485.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,485.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,485.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,485.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,485.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,485.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,328.48,2691.36,2403
Outpatient Medical Services,MRI,77048,MRI BREAST W/OUT&WITH CONTRAST W/CAD UNILATERAL,610,5336.5,3842.28,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,1890.43,442% of BCBS Fee Schedule,N/A,Not Separately reimbursable,1752.19,100% of BCBS Fee Schedule,N/A,Not Separately reimbursable,3131,84% of total billed charges,3131,84% of total billed charges,3842.28,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,3201.9,60% of total billed charges,475.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,475.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,300.61,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,3735.55,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,3842.28,Pays at 72% of billed charges with lesser of charges applied,3842.28,Pays at 72% of billed charges with lesser of charges applied,3842.28,Pays at 72% of billed charges with lesser of charges applied,3842.28,Pays at 72% of billed charges with lesser of charges applied,3842.28,Pays at 72% of billed charges with lesser of charges applied,3842.28,Pays at 72% of billed charges with lesser of charges applied,1890.43,442% of BCBS Fee Schedule,1890.43,442% of BCBS Fee Schedule,1890.43,442% of BCBS Fee Schedule,1890.43,442% of BCBS Fee Schedule,1890.43,442% of BCBS Fee Schedule,1890.43,442% of BCBS Fee Schedule,1890.43,442% of BCBS Fee Schedule,1890.43,442% of BCBS Fee Schedule,1890.43,442% of BCBS Fee Schedule,1752.19,100% of BCBS Fee Schedule,1752.19,100% of BCBS Fee Schedule,1752.19,100% of BCBS Fee Schedule,1752.19,100% of BCBS Fee Schedule,1752.19,100% of BCBS Fee Schedule,3131,84% of total billed charges,3131,84% of total billed charges,3131,84% of total billed charges,3735.55,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,475.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,475.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,475.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,475.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,475.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,475.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,475.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,475.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,475.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,475.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,475.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,475.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,475.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,475.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,475.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,475.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,475.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,475.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,475.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,475.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,300.61,3842.28,4002.38
Outpatient Medical Services,MRI,77049,MRI BREAST WITHOUT&WITH CONTRAST W/CAD BILATERAL,610,7028.5,5060.52,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,1881.02,442% of BCBS Fee Schedule,N/A,Not Separately reimbursable,1743.61,100% of BCBS Fee Schedule,N/A,Not Separately reimbursable,3131,84% of total billed charges,3131,84% of total billed charges,5060.52,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,4217.1,60% of total billed charges,484.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,484.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,298.22,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,4919.95,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,5060.52,Pays at 72% of billed charges with lesser of charges applied,5060.52,Pays at 72% of billed charges with lesser of charges applied,5060.52,Pays at 72% of billed charges with lesser of charges applied,5060.52,Pays at 72% of billed charges with lesser of charges applied,5060.52,Pays at 72% of billed charges with lesser of charges applied,5060.52,Pays at 72% of billed charges with lesser of charges applied,1881.02,442% of BCBS Fee Schedule,1881.02,442% of BCBS Fee Schedule,1881.02,442% of BCBS Fee Schedule,1881.02,442% of BCBS Fee Schedule,1881.02,442% of BCBS Fee Schedule,1881.02,442% of BCBS Fee Schedule,1881.02,442% of BCBS Fee Schedule,1881.02,442% of BCBS Fee Schedule,1881.02,442% of BCBS Fee Schedule,1743.61,100% of BCBS Fee Schedule,1743.61,100% of BCBS Fee Schedule,1743.61,100% of BCBS Fee Schedule,1743.61,100% of BCBS Fee Schedule,1743.61,100% of BCBS Fee Schedule,3131,84% of total billed charges,3131,84% of total billed charges,3131,84% of total billed charges,4919.95,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,484.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,484.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,484.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,484.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,484.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,484.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,484.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,484.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,484.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,484.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,484.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,484.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,484.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,484.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,484.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,484.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,484.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,484.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,484.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,484.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,298.22,5060.52,5271.38
Outpatient Medical Services,MRI,73220,MRI UPPER EXTREMITY NOT JOINT W/WO CONTRAST,610,6278,4520.16,Pays at 72% of billed charges with lesser of charges applied,468.3,100% OF CMS OPPS Rate,2079.26,442% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,5490.12,100% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,3131,84% of total billed charges,3131,84% of total billed charges,4520.16,72% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% of CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,3766.8,60% of total billed charges,560.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,560.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,391.39,100% OF CMS OPPS RATE,468.3,100% OF CMS OPPS Rate,4394.6,70% of total billed charges,468.3,100% OF CMS OPPS Rate,561.95,120% of CMS OPPS RATE,4520.16,Pays at 72% of billed charges with lesser of charges applied,4520.16,Pays at 72% of billed charges with lesser of charges applied,4520.16,Pays at 72% of billed charges with lesser of charges applied,4520.16,Pays at 72% of billed charges with lesser of charges applied,4520.16,Pays at 72% of billed charges with lesser of charges applied,4520.16,Pays at 72% of billed charges with lesser of charges applied,2079.26,442% of BCBS Fee Schedule,2079.26,442% of BCBS Fee Schedule,2079.26,442% of BCBS Fee Schedule,2079.26,442% of BCBS Fee Schedule,2079.26,442% of BCBS Fee Schedule,2079.26,442% of BCBS Fee Schedule,2079.26,442% of BCBS Fee Schedule,2079.26,442% of BCBS Fee Schedule,2079.26,442% of BCBS Fee Schedule,5490.12,100% of BCBS Fee Schedule,5490.12,100% of BCBS Fee Schedule,5490.12,100% of BCBS Fee Schedule,5490.12,100% of BCBS Fee Schedule,5490.12,100% of BCBS Fee Schedule,3131,84% of total billed charges,3131,84% of total billed charges,3131,84% of total billed charges,4394.6,70% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,560.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,560.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,560.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,560.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,560.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,560.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,560.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,560.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,560.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,560.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,560.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,560.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,560.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,560.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,560.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,560.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,560.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,560.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,560.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,560.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,391.39,5490.12,4708.5
Outpatient Medical Services,MRI,71552,MRI BRACHIAL PLEXUS-LT w/o AND w/ CONTRAST,610,7180.75,5170.14,Pays at 72% of billed charges with lesser of charges applied,468.3,100% OF CMS OPPS Rate,4671.76,442% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,5465.55,100% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,3131,84% of total billed charges,3131,84% of total billed charges,5170.14,72% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% of CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,4308.45,60% of total billed charges,677.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,677.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,462.66,100% OF CMS OPPS RATE,468.3,100% OF CMS OPPS Rate,5026.53,70% of total billed charges,468.3,100% OF CMS OPPS Rate,561.95,120% of CMS OPPS RATE,5170.14,Pays at 72% of billed charges with lesser of charges applied,5170.14,Pays at 72% of billed charges with lesser of charges applied,5170.14,Pays at 72% of billed charges with lesser of charges applied,5170.14,Pays at 72% of billed charges with lesser of charges applied,5170.14,Pays at 72% of billed charges with lesser of charges applied,5170.14,Pays at 72% of billed charges with lesser of charges applied,4671.76,442% of BCBS Fee Schedule,4671.76,442% of BCBS Fee Schedule,4671.76,442% of BCBS Fee Schedule,4671.76,442% of BCBS Fee Schedule,4671.76,442% of BCBS Fee Schedule,4671.76,442% of BCBS Fee Schedule,4671.76,442% of BCBS Fee Schedule,4671.76,442% of BCBS Fee Schedule,4671.76,442% of BCBS Fee Schedule,5465.55,100% of BCBS Fee Schedule,5465.55,100% of BCBS Fee Schedule,5465.55,100% of BCBS Fee Schedule,5465.55,100% of BCBS Fee Schedule,5465.55,100% of BCBS Fee Schedule,3131,84% of total billed charges,3131,84% of total billed charges,3131,84% of total billed charges,5026.53,70% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,677.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,677.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,677.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,677.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,677.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,677.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,677.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,677.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,677.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,677.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,677.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,677.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,677.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,677.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,677.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,677.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,677.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,677.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,677.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,677.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,462.66,5465.55,5385.56
Outpatient Medical Services,MRI,73218,MRI UPPER EXTREMITY NOT JOINT WO CONTRAST,610,3345.75,2408.94,Pays at 72% of billed charges with lesser of charges applied,296.82,100% OF CMS OPPS Rate,2114,442% of BCBS Fee Schedule,296.82,100% OF CMS OPPS Rate,2472.18,100% of BCBS Fee Schedule,296.82,100% OF CMS OPPS Rate,2810.43,84% of total billed charges,2810.43,84% of total billed charges,2408.94,72% of total billed charges,296.82,100% OF CMS OPPS Rate,296.82,100% of CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,2007.45,60% of total billed charges,434.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,434.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,302.99,100% OF CMS OPPS RATE,296.82,100% OF CMS OPPS Rate,2342.03,70% of total billed charges,296.82,100% OF CMS OPPS Rate,356.18,120% of CMS OPPS RATE,2408.94,Pays at 72% of billed charges with lesser of charges applied,2408.94,Pays at 72% of billed charges with lesser of charges applied,2408.94,Pays at 72% of billed charges with lesser of charges applied,2408.94,Pays at 72% of billed charges with lesser of charges applied,2408.94,Pays at 72% of billed charges with lesser of charges applied,2408.94,Pays at 72% of billed charges with lesser of charges applied,2114,442% of BCBS Fee Schedule,2114,442% of BCBS Fee Schedule,2114,442% of BCBS Fee Schedule,2114,442% of BCBS Fee Schedule,2114,442% of BCBS Fee Schedule,2114,442% of BCBS Fee Schedule,2114,442% of BCBS Fee Schedule,2114,442% of BCBS Fee Schedule,2114,442% of BCBS Fee Schedule,2472.18,100% of BCBS Fee Schedule,2472.18,100% of BCBS Fee Schedule,2472.18,100% of BCBS Fee Schedule,2472.18,100% of BCBS Fee Schedule,2472.18,100% of BCBS Fee Schedule,2810.43,84% of total billed charges,2810.43,84% of total billed charges,2810.43,84% of total billed charges,2342.03,70% of total billed charges,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,434.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,434.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,434.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,434.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,434.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,434.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,434.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,434.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,434.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,434.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,434.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,434.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,434.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,434.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,434.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,434.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,434.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,434.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,434.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,434.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,296.82,2810.43,2509.31
Outpatient Medical Services,MRI,C8911,MRA CHEST W/WO CONTRAST (EXC MYOCARDIUM),610,3204,2306.88,Pays at 72% of billed charges with lesser of charges applied,468.3,100% OF CMS OPPS Rate,2816.42,442% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,2534.36,79.1% of total billed charges,468.3,100% OF CMS OPPS Rate,2691.36,84% of total billed charges,2691.36,84% of total billed charges,2306.88,72% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% of CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,1922.4,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,N/A,Not Separately reimbursable,468.3,100% OF CMS OPPS Rate,2242.8,70% of total billed charges,468.3,100% OF CMS OPPS Rate,561.95,120% of CMS OPPS RATE,2306.88,Pays at 72% of billed charges with lesser of charges applied,2306.88,Pays at 72% of billed charges with lesser of charges applied,2306.88,Pays at 72% of billed charges with lesser of charges applied,2306.88,Pays at 72% of billed charges with lesser of charges applied,2306.88,Pays at 72% of billed charges with lesser of charges applied,2306.88,Pays at 72% of billed charges with lesser of charges applied,2816.42,442% of BCBS Fee Schedule,2816.42,442% of BCBS Fee Schedule,2816.42,442% of BCBS Fee Schedule,2816.42,442% of BCBS Fee Schedule,2816.42,442% of BCBS Fee Schedule,2816.42,442% of BCBS Fee Schedule,2816.42,442% of BCBS Fee Schedule,2816.42,442% of BCBS Fee Schedule,2816.42,442% of BCBS Fee Schedule,2534.36,79.1% of total billed charges,2534.36,79.1% of total billed charges,2534.36,79.1% of total billed charges,2534.36,79.1% of total billed charges,2534.36,79.1% of total billed charges,2691.36,84% of total billed charges,2691.36,84% of total billed charges,2691.36,84% of total billed charges,2242.8,70% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,468.30,2816.42,2403
Outpatient Medical Services,MRI,73720,MRI FEMUR/ THIGH-RT w/o AND w/ CONTRAST,610,6275.5,4518.36,Pays at 72% of billed charges with lesser of charges applied,468.3,100% OF CMS OPPS Rate,2079.26,442% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,5490.12,100% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,3131,84% of total billed charges,3131,84% of total billed charges,4518.36,72% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% of CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,3765.3,60% of total billed charges,477.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,477.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,299.41,100% OF CMS OPPS RATE,468.3,100% OF CMS OPPS Rate,4392.85,70% of total billed charges,468.3,100% OF CMS OPPS Rate,561.95,120% of CMS OPPS RATE,4518.36,Pays at 72% of billed charges with lesser of charges applied,4518.36,Pays at 72% of billed charges with lesser of charges applied,4518.36,Pays at 72% of billed charges with lesser of charges applied,4518.36,Pays at 72% of billed charges with lesser of charges applied,4518.36,Pays at 72% of billed charges with lesser of charges applied,4518.36,Pays at 72% of billed charges with lesser of charges applied,2079.26,442% of BCBS Fee Schedule,2079.26,442% of BCBS Fee Schedule,2079.26,442% of BCBS Fee Schedule,2079.26,442% of BCBS Fee Schedule,2079.26,442% of BCBS Fee Schedule,2079.26,442% of BCBS Fee Schedule,2079.26,442% of BCBS Fee Schedule,2079.26,442% of BCBS Fee Schedule,2079.26,442% of BCBS Fee Schedule,5490.12,100% of BCBS Fee Schedule,5490.12,100% of BCBS Fee Schedule,5490.12,100% of BCBS Fee Schedule,5490.12,100% of BCBS Fee Schedule,5490.12,100% of BCBS Fee Schedule,3131,84% of total billed charges,3131,84% of total billed charges,3131,84% of total billed charges,4392.85,70% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,477.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,477.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,477.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,477.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,477.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,477.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,477.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,477.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,477.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,477.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,477.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,477.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,477.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,477.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,477.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,477.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,477.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,477.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,477.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,477.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,299.41,5490.12,4706.63
Outpatient Medical Services,MRI,73222,MRI ARTHROGRAM SHOULDER-LT w/ CONTRAST,610,3960.5,2851.56,Pays at 72% of billed charges with lesser of charges applied,941.55,100% OF CMS OPPS Rate,2534.6,442% of BCBS Fee Schedule,941.55,100% OF CMS OPPS Rate,2967.36,100% of BCBS Fee Schedule,941.55,100% OF CMS OPPS Rate,3131,84% of total billed charges,3131,84% of total billed charges,2851.56,72% of total billed charges,941.55,100% OF CMS OPPS Rate,941.55,100% of CMS OPPS Rate,941.55,100% OF CMS OPPS Rate,2376.3,60% of total billed charges,448.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,448.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,941.55,100% OF CMS OPPS Rate,941.55,100% OF CMS OPPS Rate,299.42,100% OF CMS OPPS RATE,941.55,100% OF CMS OPPS Rate,2772.35,70% of total billed charges,941.55,100% OF CMS OPPS Rate,1129.85,120% of CMS OPPS RATE,2851.56,Pays at 72% of billed charges with lesser of charges applied,2851.56,Pays at 72% of billed charges with lesser of charges applied,2851.56,Pays at 72% of billed charges with lesser of charges applied,2851.56,Pays at 72% of billed charges with lesser of charges applied,2851.56,Pays at 72% of billed charges with lesser of charges applied,2851.56,Pays at 72% of billed charges with lesser of charges applied,2534.6,442% of BCBS Fee Schedule,2534.6,442% of BCBS Fee Schedule,2534.6,442% of BCBS Fee Schedule,2534.6,442% of BCBS Fee Schedule,2534.6,442% of BCBS Fee Schedule,2534.6,442% of BCBS Fee Schedule,2534.6,442% of BCBS Fee Schedule,2534.6,442% of BCBS Fee Schedule,2534.6,442% of BCBS Fee Schedule,2967.36,100% of BCBS Fee Schedule,2967.36,100% of BCBS Fee Schedule,2967.36,100% of BCBS Fee Schedule,2967.36,100% of BCBS Fee Schedule,2967.36,100% of BCBS Fee Schedule,3131,84% of total billed charges,3131,84% of total billed charges,3131,84% of total billed charges,2772.35,70% of total billed charges,941.55,100% OF CMS OPPS Rate,941.55,100% OF CMS OPPS Rate,941.55,100% OF CMS OPPS Rate,941.55,100% OF CMS OPPS Rate,941.55,100% OF CMS OPPS Rate,941.55,100% OF CMS OPPS Rate,941.55,100% OF CMS OPPS Rate,941.55,100% OF CMS OPPS Rate,941.55,100% OF CMS OPPS Rate,941.55,100% OF CMS OPPS Rate,941.55,100% OF CMS OPPS Rate,941.55,100% OF CMS OPPS Rate,941.55,100% OF CMS OPPS Rate,941.55,100% OF CMS OPPS Rate,941.55,100% OF CMS OPPS Rate,941.55,100% OF CMS OPPS Rate,448.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,448.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,448.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,448.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,448.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,448.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,448.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,448.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,448.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,448.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,448.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,448.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,448.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,448.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,448.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,448.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,448.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,448.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,448.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,448.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,299.42,3131.00,2970.38
Outpatient Medical Services,MRI,73221,MRI of upper extremity without dye,610,3345.75,2408.94,Pays at 72% of billed charges with lesser of charges applied,296.82,100% OF CMS OPPS Rate,2071.7,442% of BCBS Fee Schedule,296.82,100% OF CMS OPPS Rate,2472.18,100% of BCBS Fee Schedule,296.82,100% OF CMS OPPS Rate,2810.43,84% of total billed charges,2810.43,84% of total billed charges,2408.94,72% of total billed charges,296.82,100% OF CMS OPPS Rate,296.82,100% of CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,2007.45,60% of total billed charges,282.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,282.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,174.39,100% OF CMS OPPS RATE,296.82,100% OF CMS OPPS Rate,2342.03,70% of total billed charges,296.82,100% OF CMS OPPS Rate,356.18,120% of CMS OPPS RATE,2408.94,Pays at 72% of billed charges with lesser of charges applied,2408.94,Pays at 72% of billed charges with lesser of charges applied,2408.94,Pays at 72% of billed charges with lesser of charges applied,2408.94,Pays at 72% of billed charges with lesser of charges applied,2408.94,Pays at 72% of billed charges with lesser of charges applied,2408.94,Pays at 72% of billed charges with lesser of charges applied,2071.7,442% of BCBS Fee Schedule,2071.7,442% of BCBS Fee Schedule,2071.7,442% of BCBS Fee Schedule,2071.7,442% of BCBS Fee Schedule,2071.7,442% of BCBS Fee Schedule,2071.7,442% of BCBS Fee Schedule,2071.7,442% of BCBS Fee Schedule,2071.7,442% of BCBS Fee Schedule,2071.7,442% of BCBS Fee Schedule,2472.18,100% of BCBS Fee Schedule,2472.18,100% of BCBS Fee Schedule,2472.18,100% of BCBS Fee Schedule,2472.18,100% of BCBS Fee Schedule,2472.18,100% of BCBS Fee Schedule,2810.43,84% of total billed charges,2810.43,84% of total billed charges,2810.43,84% of total billed charges,2342.03,70% of total billed charges,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,282.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,282.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,282.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,282.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,282.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,282.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,282.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,282.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,282.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,282.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,282.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,282.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,282.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,282.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,282.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,282.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,282.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,282.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,282.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,282.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,174.39,2810.43,2509.31
Outpatient Medical Services,MRI,19085,MRI BIOPSY BREAST-LT VACUUM BX w/CLIP,610,5240.75,3773.34,Pays at 72% of billed charges with lesser of charges applied,1906.04,100% OF CMS OPPS Rate,5240.75,100% of ASC Tier Grouping Fee Schedule,1906.04,100% OF CMS OPPS Rate,4145.43,79.1% of total billed charges,1906.04,100% OF CMS OPPS Rate,3131,84% of total billed charges,3131,84% of total billed charges,3773.34,72% of total billed charges,1906.04,100% OF CMS OPPS Rate,1906.04,100% of CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,3144.45,60% of total billed charges,238.71,100% of CA Medicaid Fee Schedule with lesser of charges applied,238.71,100% of CA Medicaid Fee Schedule with lesser of charges applied,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,185.81,100% OF CMS OPPS RATE,1906.04,100% OF CMS OPPS Rate,3668.53,70% of total billed charges,1906.04,100% OF CMS OPPS Rate,2287.25,120% of CMS OPPS RATE,3773.34,Pays at 72% of billed charges with lesser of charges applied,3773.34,Pays at 72% of billed charges with lesser of charges applied,3773.34,Pays at 72% of billed charges with lesser of charges applied,3773.34,Pays at 72% of billed charges with lesser of charges applied,3773.34,Pays at 72% of billed charges with lesser of charges applied,3773.34,Pays at 72% of billed charges with lesser of charges applied,5240.75,100% of ASC Tier Grouping Fee Schedule,5240.75,100% of ASC Tier Grouping Fee Schedule,5240.75,100% of ASC Tier Grouping Fee Schedule,5240.75,100% of ASC Tier Grouping Fee Schedule,5240.75,100% of ASC Tier Grouping Fee Schedule,5240.75,100% of ASC Tier Grouping Fee Schedule,5240.75,100% of ASC Tier Grouping Fee Schedule,5240.75,100% of ASC Tier Grouping Fee Schedule,5240.75,100% of ASC Tier Grouping Fee Schedule,4145.43,79.1% of total billed charges,4145.43,79.1% of total billed charges,4145.43,79.1% of total billed charges,4145.43,79.1% of total billed charges,4145.43,79.1% of total billed charges,3131,84% of total billed charges,3131,84% of total billed charges,3131,84% of total billed charges,3668.53,70% of total billed charges,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,238.71,100% of CA Medicaid Fee Schedule with lesser of charges applied,238.71,100% of CA Medicaid Fee Schedule with lesser of charges applied,238.71,100% of CA Medicaid Fee Schedule with lesser of charges applied,238.71,100% of CA Medicaid Fee Schedule with lesser of charges applied,238.71,100% of CA Medicaid Fee Schedule with lesser of charges applied,238.71,100% of CA Medicaid Fee Schedule with lesser of charges applied,238.71,100% of CA Medicaid Fee Schedule with lesser of charges applied,238.71,100% of CA Medicaid Fee Schedule with lesser of charges applied,238.71,100% of CA Medicaid Fee Schedule with lesser of charges applied,238.71,100% of CA Medicaid Fee Schedule with lesser of charges applied,238.71,100% of CA Medicaid Fee Schedule with lesser of charges applied,238.71,100% of CA Medicaid Fee Schedule with lesser of charges applied,238.71,100% of CA Medicaid Fee Schedule with lesser of charges applied,238.71,100% of CA Medicaid Fee Schedule with lesser of charges applied,238.71,100% of CA Medicaid Fee Schedule with lesser of charges applied,238.71,100% of CA Medicaid Fee Schedule with lesser of charges applied,238.71,100% of CA Medicaid Fee Schedule with lesser of charges applied,238.71,100% of CA Medicaid Fee Schedule with lesser of charges applied,238.71,100% of CA Medicaid Fee Schedule with lesser of charges applied,238.71,100% of CA Medicaid Fee Schedule with lesser of charges applied,185.81,5240.75,3930.56
Outpatient Medical Services,MRI,73722,MRI of lower extremity joint (knee/ankle) with dye,610,3960.5,2851.56,Pays at 72% of billed charges with lesser of charges applied,941.55,100% OF CMS OPPS Rate,2534.6,442% of BCBS Fee Schedule,941.55,100% OF CMS OPPS Rate,2967.36,100% of BCBS Fee Schedule,941.55,100% OF CMS OPPS Rate,3131,84% of total billed charges,3131,84% of total billed charges,2851.56,72% of total billed charges,941.55,100% OF CMS OPPS Rate,941.55,100% of CMS OPPS Rate,941.55,100% OF CMS OPPS Rate,2376.3,60% of total billed charges,448.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,448.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,941.55,100% OF CMS OPPS Rate,941.55,100% OF CMS OPPS Rate,299.81,100% OF CMS OPPS RATE,941.55,100% OF CMS OPPS Rate,2772.35,70% of total billed charges,941.55,100% OF CMS OPPS Rate,1129.85,120% of CMS OPPS RATE,2851.56,Pays at 72% of billed charges with lesser of charges applied,2851.56,Pays at 72% of billed charges with lesser of charges applied,2851.56,Pays at 72% of billed charges with lesser of charges applied,2851.56,Pays at 72% of billed charges with lesser of charges applied,2851.56,Pays at 72% of billed charges with lesser of charges applied,2851.56,Pays at 72% of billed charges with lesser of charges applied,2534.6,442% of BCBS Fee Schedule,2534.6,442% of BCBS Fee Schedule,2534.6,442% of BCBS Fee Schedule,2534.6,442% of BCBS Fee Schedule,2534.6,442% of BCBS Fee Schedule,2534.6,442% of BCBS Fee Schedule,2534.6,442% of BCBS Fee Schedule,2534.6,442% of BCBS Fee Schedule,2534.6,442% of BCBS Fee Schedule,2967.36,100% of BCBS Fee Schedule,2967.36,100% of BCBS Fee Schedule,2967.36,100% of BCBS Fee Schedule,2967.36,100% of BCBS Fee Schedule,2967.36,100% of BCBS Fee Schedule,3131,84% of total billed charges,3131,84% of total billed charges,3131,84% of total billed charges,2772.35,70% of total billed charges,941.55,100% OF CMS OPPS Rate,941.55,100% OF CMS OPPS Rate,941.55,100% OF CMS OPPS Rate,941.55,100% OF CMS OPPS Rate,941.55,100% OF CMS OPPS Rate,941.55,100% OF CMS OPPS Rate,941.55,100% OF CMS OPPS Rate,941.55,100% OF CMS OPPS Rate,941.55,100% OF CMS OPPS Rate,941.55,100% OF CMS OPPS Rate,941.55,100% OF CMS OPPS Rate,941.55,100% OF CMS OPPS Rate,941.55,100% OF CMS OPPS Rate,941.55,100% OF CMS OPPS Rate,941.55,100% OF CMS OPPS Rate,941.55,100% OF CMS OPPS Rate,448.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,448.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,448.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,448.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,448.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,448.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,448.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,448.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,448.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,448.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,448.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,448.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,448.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,448.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,448.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,448.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,448.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,448.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,448.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,448.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,299.81,3131.00,2970.38
Outpatient Medical Services,MRI,71550,MRI BRACHIAL PLEXUS-LT w/o CONTRAST,610,3412,2456.64,Pays at 72% of billed charges with lesser of charges applied,296.82,100% OF CMS OPPS Rate,2080.32,442% of BCBS Fee Schedule,296.82,100% OF CMS OPPS Rate,2481.4,100% of BCBS Fee Schedule,296.82,100% OF CMS OPPS Rate,2866.08,84% of total billed charges,2866.08,84% of total billed charges,2456.64,72% of total billed charges,296.82,100% OF CMS OPPS Rate,296.82,100% of CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,2047.2,60% of total billed charges,485.69,100% of CA Medicaid Fee Schedule with lesser of charges applied,485.69,100% of CA Medicaid Fee Schedule with lesser of charges applied,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,340.02,100% OF CMS OPPS RATE,296.82,100% OF CMS OPPS Rate,2388.4,70% of total billed charges,296.82,100% OF CMS OPPS Rate,356.18,120% of CMS OPPS RATE,2456.64,Pays at 72% of billed charges with lesser of charges applied,2456.64,Pays at 72% of billed charges with lesser of charges applied,2456.64,Pays at 72% of billed charges with lesser of charges applied,2456.64,Pays at 72% of billed charges with lesser of charges applied,2456.64,Pays at 72% of billed charges with lesser of charges applied,2456.64,Pays at 72% of billed charges with lesser of charges applied,2080.32,442% of BCBS Fee Schedule,2080.32,442% of BCBS Fee Schedule,2080.32,442% of BCBS Fee Schedule,2080.32,442% of BCBS Fee Schedule,2080.32,442% of BCBS Fee Schedule,2080.32,442% of BCBS Fee Schedule,2080.32,442% of BCBS Fee Schedule,2080.32,442% of BCBS Fee Schedule,2080.32,442% of BCBS Fee Schedule,2481.4,100% of BCBS Fee Schedule,2481.4,100% of BCBS Fee Schedule,2481.4,100% of BCBS Fee Schedule,2481.4,100% of BCBS Fee Schedule,2481.4,100% of BCBS Fee Schedule,2866.08,84% of total billed charges,2866.08,84% of total billed charges,2866.08,84% of total billed charges,2388.4,70% of total billed charges,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,485.69,100% of CA Medicaid Fee Schedule with lesser of charges applied,485.69,100% of CA Medicaid Fee Schedule with lesser of charges applied,485.69,100% of CA Medicaid Fee Schedule with lesser of charges applied,485.69,100% of CA Medicaid Fee Schedule with lesser of charges applied,485.69,100% of CA Medicaid Fee Schedule with lesser of charges applied,485.69,100% of CA Medicaid Fee Schedule with lesser of charges applied,485.69,100% of CA Medicaid Fee Schedule with lesser of charges applied,485.69,100% of CA Medicaid Fee Schedule with lesser of charges applied,485.69,100% of CA Medicaid Fee Schedule with lesser of charges applied,485.69,100% of CA Medicaid Fee Schedule with lesser of charges applied,485.69,100% of CA Medicaid Fee Schedule with lesser of charges applied,485.69,100% of CA Medicaid Fee Schedule with lesser of charges applied,485.69,100% of CA Medicaid Fee Schedule with lesser of charges applied,485.69,100% of CA Medicaid Fee Schedule with lesser of charges applied,485.69,100% of CA Medicaid Fee Schedule with lesser of charges applied,485.69,100% of CA Medicaid Fee Schedule with lesser of charges applied,485.69,100% of CA Medicaid Fee Schedule with lesser of charges applied,485.69,100% of CA Medicaid Fee Schedule with lesser of charges applied,485.69,100% of CA Medicaid Fee Schedule with lesser of charges applied,485.69,100% of CA Medicaid Fee Schedule with lesser of charges applied,296.82,2866.08,2559
Outpatient Medical Services,MRI,73223,MRI SHOULDER-LT w/o AND w/ CONTRAST,610,7123,5128.56,Pays at 72% of billed charges with lesser of charges applied,468.3,100% OF CMS OPPS Rate,4691.83,442% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,5490.12,100% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,3131,84% of total billed charges,3131,84% of total billed charges,5128.56,72% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% of CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,4273.8,60% of total billed charges,553.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,553.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,362.32,100% OF CMS OPPS RATE,468.3,100% OF CMS OPPS Rate,4986.1,70% of total billed charges,468.3,100% OF CMS OPPS Rate,561.95,120% of CMS OPPS RATE,5128.56,Pays at 72% of billed charges with lesser of charges applied,5128.56,Pays at 72% of billed charges with lesser of charges applied,5128.56,Pays at 72% of billed charges with lesser of charges applied,5128.56,Pays at 72% of billed charges with lesser of charges applied,5128.56,Pays at 72% of billed charges with lesser of charges applied,5128.56,Pays at 72% of billed charges with lesser of charges applied,4691.83,442% of BCBS Fee Schedule,4691.83,442% of BCBS Fee Schedule,4691.83,442% of BCBS Fee Schedule,4691.83,442% of BCBS Fee Schedule,4691.83,442% of BCBS Fee Schedule,4691.83,442% of BCBS Fee Schedule,4691.83,442% of BCBS Fee Schedule,4691.83,442% of BCBS Fee Schedule,4691.83,442% of BCBS Fee Schedule,5490.12,100% of BCBS Fee Schedule,5490.12,100% of BCBS Fee Schedule,5490.12,100% of BCBS Fee Schedule,5490.12,100% of BCBS Fee Schedule,5490.12,100% of BCBS Fee Schedule,3131,84% of total billed charges,3131,84% of total billed charges,3131,84% of total billed charges,4986.1,70% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,553.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,553.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,553.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,553.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,553.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,553.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,553.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,553.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,553.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,553.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,553.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,553.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,553.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,553.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,553.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,553.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,553.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,553.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,553.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,553.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,362.32,5490.12,5342.25
Outpatient Medical Services,MRI,70540,"MRI ORBIT, FACE, NECK W/O CONTRAST",610,3360.75,2419.74,Pays at 72% of billed charges with lesser of charges applied,296.82,100% OF CMS OPPS Rate,2079.26,442% of BCBS Fee Schedule,296.82,100% OF CMS OPPS Rate,2472.18,100% of BCBS Fee Schedule,296.82,100% OF CMS OPPS Rate,2823.03,84% of total billed charges,2823.03,84% of total billed charges,2419.74,72% of total billed charges,296.82,100% OF CMS OPPS Rate,296.82,100% of CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,2016.45,60% of total billed charges,319.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,319.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,205.85,100% OF CMS OPPS RATE,296.82,100% OF CMS OPPS Rate,2352.53,70% of total billed charges,296.82,100% OF CMS OPPS Rate,356.18,120% of CMS OPPS RATE,2419.74,Pays at 72% of billed charges with lesser of charges applied,2419.74,Pays at 72% of billed charges with lesser of charges applied,2419.74,Pays at 72% of billed charges with lesser of charges applied,2419.74,Pays at 72% of billed charges with lesser of charges applied,2419.74,Pays at 72% of billed charges with lesser of charges applied,2419.74,Pays at 72% of billed charges with lesser of charges applied,2079.26,442% of BCBS Fee Schedule,2079.26,442% of BCBS Fee Schedule,2079.26,442% of BCBS Fee Schedule,2079.26,442% of BCBS Fee Schedule,2079.26,442% of BCBS Fee Schedule,2079.26,442% of BCBS Fee Schedule,2079.26,442% of BCBS Fee Schedule,2079.26,442% of BCBS Fee Schedule,2079.26,442% of BCBS Fee Schedule,2472.18,100% of BCBS Fee Schedule,2472.18,100% of BCBS Fee Schedule,2472.18,100% of BCBS Fee Schedule,2472.18,100% of BCBS Fee Schedule,2472.18,100% of BCBS Fee Schedule,2823.03,84% of total billed charges,2823.03,84% of total billed charges,2823.03,84% of total billed charges,2352.53,70% of total billed charges,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,319.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,319.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,319.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,319.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,319.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,319.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,319.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,319.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,319.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,319.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,319.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,319.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,319.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,319.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,319.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,319.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,319.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,319.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,319.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,319.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,205.85,2823.03,2520.56
Outpatient Medical Services,MRI,71551,MRI BRACHIAL PLEXUS-LT w/ CONTRAST,610,4100.5,2952.36,Pays at 72% of billed charges with lesser of charges applied,941.55,100% OF CMS OPPS Rate,2540.4,442% of BCBS Fee Schedule,941.55,100% OF CMS OPPS Rate,2975.04,100% of BCBS Fee Schedule,941.55,100% OF CMS OPPS Rate,3131,84% of total billed charges,3131,84% of total billed charges,2952.36,72% of total billed charges,941.55,100% OF CMS OPPS Rate,941.55,100% of CMS OPPS Rate,941.55,100% OF CMS OPPS Rate,2460.3,60% of total billed charges,536.65,100% of CA Medicaid Fee Schedule with lesser of charges applied,536.65,100% of CA Medicaid Fee Schedule with lesser of charges applied,941.55,100% OF CMS OPPS Rate,941.55,100% OF CMS OPPS Rate,369.49,100% OF CMS OPPS RATE,941.55,100% OF CMS OPPS Rate,2870.35,70% of total billed charges,941.55,100% OF CMS OPPS Rate,1129.85,120% of CMS OPPS RATE,2952.36,Pays at 72% of billed charges with lesser of charges applied,2952.36,Pays at 72% of billed charges with lesser of charges applied,2952.36,Pays at 72% of billed charges with lesser of charges applied,2952.36,Pays at 72% of billed charges with lesser of charges applied,2952.36,Pays at 72% of billed charges with lesser of charges applied,2952.36,Pays at 72% of billed charges with lesser of charges applied,2540.4,442% of BCBS Fee Schedule,2540.4,442% of BCBS Fee Schedule,2540.4,442% of BCBS Fee Schedule,2540.4,442% of BCBS Fee Schedule,2540.4,442% of BCBS Fee Schedule,2540.4,442% of BCBS Fee Schedule,2540.4,442% of BCBS Fee Schedule,2540.4,442% of BCBS Fee Schedule,2540.4,442% of BCBS Fee Schedule,2975.04,100% of BCBS Fee Schedule,2975.04,100% of BCBS Fee Schedule,2975.04,100% of BCBS Fee Schedule,2975.04,100% of BCBS Fee Schedule,2975.04,100% of BCBS Fee Schedule,3131,84% of total billed charges,3131,84% of total billed charges,3131,84% of total billed charges,2870.35,70% of total billed charges,941.55,100% OF CMS OPPS Rate,941.55,100% OF CMS OPPS Rate,941.55,100% OF CMS OPPS Rate,941.55,100% OF CMS OPPS Rate,941.55,100% OF CMS OPPS Rate,941.55,100% OF CMS OPPS Rate,941.55,100% OF CMS OPPS Rate,941.55,100% OF CMS OPPS Rate,941.55,100% OF CMS OPPS Rate,941.55,100% OF CMS OPPS Rate,941.55,100% OF CMS OPPS Rate,941.55,100% OF CMS OPPS Rate,941.55,100% OF CMS OPPS Rate,941.55,100% OF CMS OPPS Rate,941.55,100% OF CMS OPPS Rate,941.55,100% OF CMS OPPS Rate,536.65,100% of CA Medicaid Fee Schedule with lesser of charges applied,536.65,100% of CA Medicaid Fee Schedule with lesser of charges applied,536.65,100% of CA Medicaid Fee Schedule with lesser of charges applied,536.65,100% of CA Medicaid Fee Schedule with lesser of charges applied,536.65,100% of CA Medicaid Fee Schedule with lesser of charges applied,536.65,100% of CA Medicaid Fee Schedule with lesser of charges applied,536.65,100% of CA Medicaid Fee Schedule with lesser of charges applied,536.65,100% of CA Medicaid Fee Schedule with lesser of charges applied,536.65,100% of CA Medicaid Fee Schedule with lesser of charges applied,536.65,100% of CA Medicaid Fee Schedule with lesser of charges applied,536.65,100% of CA Medicaid Fee Schedule with lesser of charges applied,536.65,100% of CA Medicaid Fee Schedule with lesser of charges applied,536.65,100% of CA Medicaid Fee Schedule with lesser of charges applied,536.65,100% of CA Medicaid Fee Schedule with lesser of charges applied,536.65,100% of CA Medicaid Fee Schedule with lesser of charges applied,536.65,100% of CA Medicaid Fee Schedule with lesser of charges applied,536.65,100% of CA Medicaid Fee Schedule with lesser of charges applied,536.65,100% of CA Medicaid Fee Schedule with lesser of charges applied,536.65,100% of CA Medicaid Fee Schedule with lesser of charges applied,536.65,100% of CA Medicaid Fee Schedule with lesser of charges applied,369.49,3131.00,3075.38
Outpatient Medical Services,MRI,77046,MRI BREAST IMPLANT-LT w/o CONTRAST,610,5336.5,3842.28,Pays at 72% of billed charges with lesser of charges applied,296.82,100% OF CMS OPPS Rate,1147.96,442% of BCBS Fee Schedule,296.82,100% OF CMS OPPS Rate,1063.88,100% of BCBS Fee Schedule,296.82,100% OF CMS OPPS Rate,3131,84% of total billed charges,3131,84% of total billed charges,3842.28,72% of total billed charges,296.82,100% OF CMS OPPS Rate,296.82,100% of CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,3201.9,60% of total billed charges,299.50,100% of CA Medicaid Fee Schedule with lesser of charges applied,299.50,100% of CA Medicaid Fee Schedule with lesser of charges applied,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,182.35,100% OF CMS OPPS RATE,296.82,100% OF CMS OPPS Rate,3735.55,70% of total billed charges,296.82,100% OF CMS OPPS Rate,356.18,120% of CMS OPPS RATE,3842.28,Pays at 72% of billed charges with lesser of charges applied,3842.28,Pays at 72% of billed charges with lesser of charges applied,3842.28,Pays at 72% of billed charges with lesser of charges applied,3842.28,Pays at 72% of billed charges with lesser of charges applied,3842.28,Pays at 72% of billed charges with lesser of charges applied,3842.28,Pays at 72% of billed charges with lesser of charges applied,1147.96,442% of BCBS Fee Schedule,1147.96,442% of BCBS Fee Schedule,1147.96,442% of BCBS Fee Schedule,1147.96,442% of BCBS Fee Schedule,1147.96,442% of BCBS Fee Schedule,1147.96,442% of BCBS Fee Schedule,1147.96,442% of BCBS Fee Schedule,1147.96,442% of BCBS Fee Schedule,1147.96,442% of BCBS Fee Schedule,1063.88,100% of BCBS Fee Schedule,1063.88,100% of BCBS Fee Schedule,1063.88,100% of BCBS Fee Schedule,1063.88,100% of BCBS Fee Schedule,1063.88,100% of BCBS Fee Schedule,3131,84% of total billed charges,3131,84% of total billed charges,3131,84% of total billed charges,3735.55,70% of total billed charges,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,299.50,100% of CA Medicaid Fee Schedule with lesser of charges applied,299.50,100% of CA Medicaid Fee Schedule with lesser of charges applied,299.50,100% of CA Medicaid Fee Schedule with lesser of charges applied,299.50,100% of CA Medicaid Fee Schedule with lesser of charges applied,299.50,100% of CA Medicaid Fee Schedule with lesser of charges applied,299.50,100% of CA Medicaid Fee Schedule with lesser of charges applied,299.50,100% of CA Medicaid Fee Schedule with lesser of charges applied,299.50,100% of CA Medicaid Fee Schedule with lesser of charges applied,299.50,100% of CA Medicaid Fee Schedule with lesser of charges applied,299.50,100% of CA Medicaid Fee Schedule with lesser of charges applied,299.50,100% of CA Medicaid Fee Schedule with lesser of charges applied,299.50,100% of CA Medicaid Fee Schedule with lesser of charges applied,299.50,100% of CA Medicaid Fee Schedule with lesser of charges applied,299.50,100% of CA Medicaid Fee Schedule with lesser of charges applied,299.50,100% of CA Medicaid Fee Schedule with lesser of charges applied,299.50,100% of CA Medicaid Fee Schedule with lesser of charges applied,299.50,100% of CA Medicaid Fee Schedule with lesser of charges applied,299.50,100% of CA Medicaid Fee Schedule with lesser of charges applied,299.50,100% of CA Medicaid Fee Schedule with lesser of charges applied,299.50,100% of CA Medicaid Fee Schedule with lesser of charges applied,182.35,3842.28,4002.38
Outpatient Medical Services,MRI,73723,MRI of lower extremity joint (knee/ankle) with and without dye,610,6569.75,4730.22,Pays at 72% of billed charges with lesser of charges applied,468.3,100% OF CMS OPPS Rate,4691.83,442% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,5490.12,100% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,3131,84% of total billed charges,3131,84% of total billed charges,4730.22,72% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% of CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,3941.85,60% of total billed charges,822.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,822.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,361.13,100% OF CMS OPPS RATE,468.3,100% OF CMS OPPS Rate,4598.83,70% of total billed charges,468.3,100% OF CMS OPPS Rate,561.95,120% of CMS OPPS RATE,4730.22,Pays at 72% of billed charges with lesser of charges applied,4730.22,Pays at 72% of billed charges with lesser of charges applied,4730.22,Pays at 72% of billed charges with lesser of charges applied,4730.22,Pays at 72% of billed charges with lesser of charges applied,4730.22,Pays at 72% of billed charges with lesser of charges applied,4730.22,Pays at 72% of billed charges with lesser of charges applied,4691.83,442% of BCBS Fee Schedule,4691.83,442% of BCBS Fee Schedule,4691.83,442% of BCBS Fee Schedule,4691.83,442% of BCBS Fee Schedule,4691.83,442% of BCBS Fee Schedule,4691.83,442% of BCBS Fee Schedule,4691.83,442% of BCBS Fee Schedule,4691.83,442% of BCBS Fee Schedule,4691.83,442% of BCBS Fee Schedule,5490.12,100% of BCBS Fee Schedule,5490.12,100% of BCBS Fee Schedule,5490.12,100% of BCBS Fee Schedule,5490.12,100% of BCBS Fee Schedule,5490.12,100% of BCBS Fee Schedule,3131,84% of total billed charges,3131,84% of total billed charges,3131,84% of total billed charges,4598.83,70% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,822.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,822.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,822.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,822.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,822.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,822.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,822.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,822.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,822.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,822.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,822.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,822.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,822.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,822.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,822.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,822.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,822.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,822.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,822.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,822.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,361.13,5490.12,4927.31
Outpatient Medical Services,MRI,73718,MRI of leg without dye,610,3305,2379.6,Pays at 72% of billed charges with lesser of charges applied,296.82,100% OF CMS OPPS Rate,2114,442% of BCBS Fee Schedule,296.82,100% OF CMS OPPS Rate,2472.18,100% of BCBS Fee Schedule,296.82,100% OF CMS OPPS Rate,2776.2,84% of total billed charges,2776.2,84% of total billed charges,2379.6,72% of total billed charges,296.82,100% OF CMS OPPS Rate,296.82,100% of CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,1983,60% of total billed charges,315.67,100% of CA Medicaid Fee Schedule with lesser of charges applied,315.67,100% of CA Medicaid Fee Schedule with lesser of charges applied,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,202.26,100% OF CMS OPPS RATE,296.82,100% OF CMS OPPS Rate,2313.5,70% of total billed charges,296.82,100% OF CMS OPPS Rate,356.18,120% of CMS OPPS RATE,2379.6,Pays at 72% of billed charges with lesser of charges applied,2379.6,Pays at 72% of billed charges with lesser of charges applied,2379.6,Pays at 72% of billed charges with lesser of charges applied,2379.6,Pays at 72% of billed charges with lesser of charges applied,2379.6,Pays at 72% of billed charges with lesser of charges applied,2379.6,Pays at 72% of billed charges with lesser of charges applied,2114,442% of BCBS Fee Schedule,2114,442% of BCBS Fee Schedule,2114,442% of BCBS Fee Schedule,2114,442% of BCBS Fee Schedule,2114,442% of BCBS Fee Schedule,2114,442% of BCBS Fee Schedule,2114,442% of BCBS Fee Schedule,2114,442% of BCBS Fee Schedule,2114,442% of BCBS Fee Schedule,2472.18,100% of BCBS Fee Schedule,2472.18,100% of BCBS Fee Schedule,2472.18,100% of BCBS Fee Schedule,2472.18,100% of BCBS Fee Schedule,2472.18,100% of BCBS Fee Schedule,2776.2,84% of total billed charges,2776.2,84% of total billed charges,2776.2,84% of total billed charges,2313.5,70% of total billed charges,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,315.67,100% of CA Medicaid Fee Schedule with lesser of charges applied,315.67,100% of CA Medicaid Fee Schedule with lesser of charges applied,315.67,100% of CA Medicaid Fee Schedule with lesser of charges applied,315.67,100% of CA Medicaid Fee Schedule with lesser of charges applied,315.67,100% of CA Medicaid Fee Schedule with lesser of charges applied,315.67,100% of CA Medicaid Fee Schedule with lesser of charges applied,315.67,100% of CA Medicaid Fee Schedule with lesser of charges applied,315.67,100% of CA Medicaid Fee Schedule with lesser of charges applied,315.67,100% of CA Medicaid Fee Schedule with lesser of charges applied,315.67,100% of CA Medicaid Fee Schedule with lesser of charges applied,315.67,100% of CA Medicaid Fee Schedule with lesser of charges applied,315.67,100% of CA Medicaid Fee Schedule with lesser of charges applied,315.67,100% of CA Medicaid Fee Schedule with lesser of charges applied,315.67,100% of CA Medicaid Fee Schedule with lesser of charges applied,315.67,100% of CA Medicaid Fee Schedule with lesser of charges applied,315.67,100% of CA Medicaid Fee Schedule with lesser of charges applied,315.67,100% of CA Medicaid Fee Schedule with lesser of charges applied,315.67,100% of CA Medicaid Fee Schedule with lesser of charges applied,315.67,100% of CA Medicaid Fee Schedule with lesser of charges applied,315.67,100% of CA Medicaid Fee Schedule with lesser of charges applied,202.26,2776.20,2478.75
Outpatient Medical Services,MRI,73719,MRI FEMUR/ THIGH-LT w/ CONTRAST,610,3960.5,2851.56,Pays at 72% of billed charges with lesser of charges applied,468.3,100% OF CMS OPPS Rate,2534.6,442% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,2967.36,100% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,3131,84% of total billed charges,3131,84% of total billed charges,2851.56,72% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% of CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,2376.3,60% of total billed charges,686.07,100% of CA Medicaid Fee Schedule with lesser of charges applied,686.07,100% of CA Medicaid Fee Schedule with lesser of charges applied,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,235.71,100% OF CMS OPPS RATE,468.3,100% OF CMS OPPS Rate,2772.35,70% of total billed charges,468.3,100% OF CMS OPPS Rate,561.95,120% of CMS OPPS RATE,2851.56,Pays at 72% of billed charges with lesser of charges applied,2851.56,Pays at 72% of billed charges with lesser of charges applied,2851.56,Pays at 72% of billed charges with lesser of charges applied,2851.56,Pays at 72% of billed charges with lesser of charges applied,2851.56,Pays at 72% of billed charges with lesser of charges applied,2851.56,Pays at 72% of billed charges with lesser of charges applied,2534.6,442% of BCBS Fee Schedule,2534.6,442% of BCBS Fee Schedule,2534.6,442% of BCBS Fee Schedule,2534.6,442% of BCBS Fee Schedule,2534.6,442% of BCBS Fee Schedule,2534.6,442% of BCBS Fee Schedule,2534.6,442% of BCBS Fee Schedule,2534.6,442% of BCBS Fee Schedule,2534.6,442% of BCBS Fee Schedule,2967.36,100% of BCBS Fee Schedule,2967.36,100% of BCBS Fee Schedule,2967.36,100% of BCBS Fee Schedule,2967.36,100% of BCBS Fee Schedule,2967.36,100% of BCBS Fee Schedule,3131,84% of total billed charges,3131,84% of total billed charges,3131,84% of total billed charges,2772.35,70% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,686.07,100% of CA Medicaid Fee Schedule with lesser of charges applied,686.07,100% of CA Medicaid Fee Schedule with lesser of charges applied,686.07,100% of CA Medicaid Fee Schedule with lesser of charges applied,686.07,100% of CA Medicaid Fee Schedule with lesser of charges applied,686.07,100% of CA Medicaid Fee Schedule with lesser of charges applied,686.07,100% of CA Medicaid Fee Schedule with lesser of charges applied,686.07,100% of CA Medicaid Fee Schedule with lesser of charges applied,686.07,100% of CA Medicaid Fee Schedule with lesser of charges applied,686.07,100% of CA Medicaid Fee Schedule with lesser of charges applied,686.07,100% of CA Medicaid Fee Schedule with lesser of charges applied,686.07,100% of CA Medicaid Fee Schedule with lesser of charges applied,686.07,100% of CA Medicaid Fee Schedule with lesser of charges applied,686.07,100% of CA Medicaid Fee Schedule with lesser of charges applied,686.07,100% of CA Medicaid Fee Schedule with lesser of charges applied,686.07,100% of CA Medicaid Fee Schedule with lesser of charges applied,686.07,100% of CA Medicaid Fee Schedule with lesser of charges applied,686.07,100% of CA Medicaid Fee Schedule with lesser of charges applied,686.07,100% of CA Medicaid Fee Schedule with lesser of charges applied,686.07,100% of CA Medicaid Fee Schedule with lesser of charges applied,686.07,100% of CA Medicaid Fee Schedule with lesser of charges applied,235.71,3131.00,2970.38
Outpatient Medical Services,MRI,77047,"Magnetic resonance imaging, breasts, without contrast material; bilateral",610,7028.5,5060.52,Pays at 72% of billed charges with lesser of charges applied,296.82,100% OF CMS OPPS Rate,1141.07,442% of BCBS Fee Schedule,296.82,100% OF CMS OPPS Rate,1057.45,100% of BCBS Fee Schedule,296.82,100% OF CMS OPPS Rate,3131,84% of total billed charges,3131,84% of total billed charges,5060.52,72% of total billed charges,296.82,100% OF CMS OPPS Rate,296.82,100% of CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,4217.1,60% of total billed charges,307.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,307.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,183.15,100% OF CMS OPPS RATE,296.82,100% OF CMS OPPS Rate,4919.95,70% of total billed charges,296.82,100% OF CMS OPPS Rate,356.18,120% of CMS OPPS RATE,5060.52,Pays at 72% of billed charges with lesser of charges applied,5060.52,Pays at 72% of billed charges with lesser of charges applied,5060.52,Pays at 72% of billed charges with lesser of charges applied,5060.52,Pays at 72% of billed charges with lesser of charges applied,5060.52,Pays at 72% of billed charges with lesser of charges applied,5060.52,Pays at 72% of billed charges with lesser of charges applied,1141.07,442% of BCBS Fee Schedule,1141.07,442% of BCBS Fee Schedule,1141.07,442% of BCBS Fee Schedule,1141.07,442% of BCBS Fee Schedule,1141.07,442% of BCBS Fee Schedule,1141.07,442% of BCBS Fee Schedule,1141.07,442% of BCBS Fee Schedule,1141.07,442% of BCBS Fee Schedule,1141.07,442% of BCBS Fee Schedule,1057.45,100% of BCBS Fee Schedule,1057.45,100% of BCBS Fee Schedule,1057.45,100% of BCBS Fee Schedule,1057.45,100% of BCBS Fee Schedule,1057.45,100% of BCBS Fee Schedule,3131,84% of total billed charges,3131,84% of total billed charges,3131,84% of total billed charges,4919.95,70% of total billed charges,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,307.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,307.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,307.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,307.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,307.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,307.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,307.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,307.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,307.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,307.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,307.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,307.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,307.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,307.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,307.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,307.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,307.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,307.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,307.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,307.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,183.15,5060.52,5271.38
Outpatient Medical Services,MRI,19285,LT WIRE LOC/CLIP PLACEMENT MRI,610,3573.75,2573.1,Pays at 72% of billed charges with lesser of charges applied,824.89,100% OF CMS OPPS Rate,3573.75,100% of ASC Tier Grouping Fee Schedule,824.89,100% OF CMS OPPS Rate,2826.84,79.1% of total billed charges,824.89,100% OF CMS OPPS Rate,3001.95,84% of total billed charges,3001.95,84% of total billed charges,2573.1,72% of total billed charges,824.89,100% OF CMS OPPS Rate,824.89,100% of CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,2144.25,60% of total billed charges,683.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,683.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,87.61,100% OF CMS OPPS RATE,824.89,100% OF CMS OPPS Rate,2501.63,70% of total billed charges,824.89,100% OF CMS OPPS Rate,989.87,120% of CMS OPPS RATE,2573.1,Pays at 72% of billed charges with lesser of charges applied,2573.1,Pays at 72% of billed charges with lesser of charges applied,2573.1,Pays at 72% of billed charges with lesser of charges applied,2573.1,Pays at 72% of billed charges with lesser of charges applied,2573.1,Pays at 72% of billed charges with lesser of charges applied,2573.1,Pays at 72% of billed charges with lesser of charges applied,3573.75,100% of ASC Tier Grouping Fee Schedule,3573.75,100% of ASC Tier Grouping Fee Schedule,3573.75,100% of ASC Tier Grouping Fee Schedule,3573.75,100% of ASC Tier Grouping Fee Schedule,3573.75,100% of ASC Tier Grouping Fee Schedule,3573.75,100% of ASC Tier Grouping Fee Schedule,3573.75,100% of ASC Tier Grouping Fee Schedule,3573.75,100% of ASC Tier Grouping Fee Schedule,3573.75,100% of ASC Tier Grouping Fee Schedule,2826.84,79.1% of total billed charges,2826.84,79.1% of total billed charges,2826.84,79.1% of total billed charges,2826.84,79.1% of total billed charges,2826.84,79.1% of total billed charges,3001.95,84% of total billed charges,3001.95,84% of total billed charges,3001.95,84% of total billed charges,2501.63,70% of total billed charges,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,683.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,683.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,683.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,683.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,683.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,683.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,683.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,683.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,683.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,683.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,683.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,683.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,683.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,683.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,683.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,683.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,683.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,683.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,683.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,683.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,87.61,3573.75,2680.31
Outpatient Medical Services,MRI,77021,MRI GUIDANCE NEEDLE PLACEMENT,610,2555.25,1839.78,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,2134.02,442% of BCBS Fee Schedule,N/A,Not Separately reimbursable,1964.51,100% of BCBS Fee Schedule,N/A,Not Separately reimbursable,2146.41,84% of total billed charges,2146.41,84% of total billed charges,1839.78,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,1533.15,60% of total billed charges,526.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,526.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,428.43,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,1788.68,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,1839.78,Pays at 72% of billed charges with lesser of charges applied,1839.78,Pays at 72% of billed charges with lesser of charges applied,1839.78,Pays at 72% of billed charges with lesser of charges applied,1839.78,Pays at 72% of billed charges with lesser of charges applied,1839.78,Pays at 72% of billed charges with lesser of charges applied,1839.78,Pays at 72% of billed charges with lesser of charges applied,2134.02,442% of BCBS Fee Schedule,2134.02,442% of BCBS Fee Schedule,2134.02,442% of BCBS Fee Schedule,2134.02,442% of BCBS Fee Schedule,2134.02,442% of BCBS Fee Schedule,2134.02,442% of BCBS Fee Schedule,2134.02,442% of BCBS Fee Schedule,2134.02,442% of BCBS Fee Schedule,2134.02,442% of BCBS Fee Schedule,1964.51,100% of BCBS Fee Schedule,1964.51,100% of BCBS Fee Schedule,1964.51,100% of BCBS Fee Schedule,1964.51,100% of BCBS Fee Schedule,1964.51,100% of BCBS Fee Schedule,2146.41,84% of total billed charges,2146.41,84% of total billed charges,2146.41,84% of total billed charges,1788.68,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,526.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,526.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,526.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,526.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,526.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,526.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,526.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,526.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,526.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,526.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,526.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,526.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,526.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,526.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,526.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,526.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,526.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,526.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,526.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,526.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,428.43,2146.41,1916.44
Outpatient Medical Services,MRI,70543,"MRI SOFT TISSUE NECK W/O,W/C+",610,7123,5128.56,Pays at 72% of billed charges with lesser of charges applied,468.3,100% OF CMS OPPS Rate,4691.83,442% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,5490.12,100% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,3131,84% of total billed charges,3131,84% of total billed charges,5128.56,72% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% of CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,4273.8,60% of total billed charges,478.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,478.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,301.4,100% OF CMS OPPS RATE,468.3,100% OF CMS OPPS Rate,4986.1,70% of total billed charges,468.3,100% OF CMS OPPS Rate,561.95,120% of CMS OPPS RATE,5128.56,Pays at 72% of billed charges with lesser of charges applied,5128.56,Pays at 72% of billed charges with lesser of charges applied,5128.56,Pays at 72% of billed charges with lesser of charges applied,5128.56,Pays at 72% of billed charges with lesser of charges applied,5128.56,Pays at 72% of billed charges with lesser of charges applied,5128.56,Pays at 72% of billed charges with lesser of charges applied,4691.83,442% of BCBS Fee Schedule,4691.83,442% of BCBS Fee Schedule,4691.83,442% of BCBS Fee Schedule,4691.83,442% of BCBS Fee Schedule,4691.83,442% of BCBS Fee Schedule,4691.83,442% of BCBS Fee Schedule,4691.83,442% of BCBS Fee Schedule,4691.83,442% of BCBS Fee Schedule,4691.83,442% of BCBS Fee Schedule,5490.12,100% of BCBS Fee Schedule,5490.12,100% of BCBS Fee Schedule,5490.12,100% of BCBS Fee Schedule,5490.12,100% of BCBS Fee Schedule,5490.12,100% of BCBS Fee Schedule,3131,84% of total billed charges,3131,84% of total billed charges,3131,84% of total billed charges,4986.1,70% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,478.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,478.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,478.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,478.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,478.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,478.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,478.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,478.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,478.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,478.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,478.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,478.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,478.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,478.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,478.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,478.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,478.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,478.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,478.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,478.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,301.40,5490.12,5342.25
Outpatient Medical Services,MRI,77058,MRI BREAST UNILAT W\WO CONTR,610,5336.5,3842.28,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,1799.65,442% of BCBS Fee Schedule,N/A,Not Separately reimbursable,4221.17,79.1% of total billed charges,N/A,Not Separately reimbursable,3131,84% of total billed charges,3131,84% of total billed charges,3842.28,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,3201.9,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,3735.55,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,3842.28,Pays at 72% of billed charges with lesser of charges applied,3842.28,Pays at 72% of billed charges with lesser of charges applied,3842.28,Pays at 72% of billed charges with lesser of charges applied,3842.28,Pays at 72% of billed charges with lesser of charges applied,3842.28,Pays at 72% of billed charges with lesser of charges applied,3842.28,Pays at 72% of billed charges with lesser of charges applied,1799.65,442% of BCBS Fee Schedule,1799.65,442% of BCBS Fee Schedule,1799.65,442% of BCBS Fee Schedule,1799.65,442% of BCBS Fee Schedule,1799.65,442% of BCBS Fee Schedule,1799.65,442% of BCBS Fee Schedule,1799.65,442% of BCBS Fee Schedule,1799.65,442% of BCBS Fee Schedule,1799.65,442% of BCBS Fee Schedule,4221.17,79.1% of total billed charges,4221.17,79.1% of total billed charges,4221.17,79.1% of total billed charges,4221.17,79.1% of total billed charges,4221.17,79.1% of total billed charges,3131,84% of total billed charges,3131,84% of total billed charges,3131,84% of total billed charges,3735.55,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,1799.65,4221.17,4002.38
Outpatient Medical Services,MRI,73721,MRI of lower extremity joint (knee/ankle) without dye,610,3345.75,2408.94,Pays at 72% of billed charges with lesser of charges applied,296.82,100% OF CMS OPPS Rate,2071.7,442% of BCBS Fee Schedule,296.82,100% OF CMS OPPS Rate,2472.18,100% of BCBS Fee Schedule,296.82,100% OF CMS OPPS Rate,2810.43,84% of total billed charges,2810.43,84% of total billed charges,2408.94,72% of total billed charges,296.82,100% OF CMS OPPS Rate,296.82,100% of CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,2007.45,60% of total billed charges,560.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,560.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,174.39,100% OF CMS OPPS RATE,296.82,100% OF CMS OPPS Rate,2342.03,70% of total billed charges,296.82,100% OF CMS OPPS Rate,356.18,120% of CMS OPPS RATE,2408.94,Pays at 72% of billed charges with lesser of charges applied,2408.94,Pays at 72% of billed charges with lesser of charges applied,2408.94,Pays at 72% of billed charges with lesser of charges applied,2408.94,Pays at 72% of billed charges with lesser of charges applied,2408.94,Pays at 72% of billed charges with lesser of charges applied,2408.94,Pays at 72% of billed charges with lesser of charges applied,2071.7,442% of BCBS Fee Schedule,2071.7,442% of BCBS Fee Schedule,2071.7,442% of BCBS Fee Schedule,2071.7,442% of BCBS Fee Schedule,2071.7,442% of BCBS Fee Schedule,2071.7,442% of BCBS Fee Schedule,2071.7,442% of BCBS Fee Schedule,2071.7,442% of BCBS Fee Schedule,2071.7,442% of BCBS Fee Schedule,2472.18,100% of BCBS Fee Schedule,2472.18,100% of BCBS Fee Schedule,2472.18,100% of BCBS Fee Schedule,2472.18,100% of BCBS Fee Schedule,2472.18,100% of BCBS Fee Schedule,2810.43,84% of total billed charges,2810.43,84% of total billed charges,2810.43,84% of total billed charges,2342.03,70% of total billed charges,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,560.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,560.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,560.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,560.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,560.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,560.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,560.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,560.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,560.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,560.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,560.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,560.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,560.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,560.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,560.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,560.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,560.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,560.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,560.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,560.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,174.39,2810.43,2509.31
Outpatient Medical Services,MRI,C8914,MRA LWR EXTREMITY W/WO CONT,610,3204,2306.88,Pays at 72% of billed charges with lesser of charges applied,468.3,100% OF CMS OPPS Rate,2804.49,442% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,2534.36,79.1% of total billed charges,468.3,100% OF CMS OPPS Rate,2691.36,84% of total billed charges,2691.36,84% of total billed charges,2306.88,72% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% of CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,1922.4,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,N/A,Not Separately reimbursable,468.3,100% OF CMS OPPS Rate,2242.8,70% of total billed charges,468.3,100% OF CMS OPPS Rate,561.95,120% of CMS OPPS RATE,2306.88,Pays at 72% of billed charges with lesser of charges applied,2306.88,Pays at 72% of billed charges with lesser of charges applied,2306.88,Pays at 72% of billed charges with lesser of charges applied,2306.88,Pays at 72% of billed charges with lesser of charges applied,2306.88,Pays at 72% of billed charges with lesser of charges applied,2306.88,Pays at 72% of billed charges with lesser of charges applied,2804.49,442% of BCBS Fee Schedule,2804.49,442% of BCBS Fee Schedule,2804.49,442% of BCBS Fee Schedule,2804.49,442% of BCBS Fee Schedule,2804.49,442% of BCBS Fee Schedule,2804.49,442% of BCBS Fee Schedule,2804.49,442% of BCBS Fee Schedule,2804.49,442% of BCBS Fee Schedule,2804.49,442% of BCBS Fee Schedule,2534.36,79.1% of total billed charges,2534.36,79.1% of total billed charges,2534.36,79.1% of total billed charges,2534.36,79.1% of total billed charges,2534.36,79.1% of total billed charges,2691.36,84% of total billed charges,2691.36,84% of total billed charges,2691.36,84% of total billed charges,2242.8,70% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,468.30,2804.49,2403
Outpatient Medical Services,MRI,70542,"MRI ORB,FACE,NECK WITH CONT",610,3418.5,2461.32,Pays at 72% of billed charges with lesser of charges applied,468.3,100% OF CMS OPPS Rate,2534.6,442% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,2967.36,100% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,2871.54,84% of total billed charges,2871.54,84% of total billed charges,2461.32,72% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% of CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,2051.1,60% of total billed charges,379.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,379.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,243.27,100% OF CMS OPPS RATE,468.3,100% OF CMS OPPS Rate,2392.95,70% of total billed charges,468.3,100% OF CMS OPPS Rate,561.95,120% of CMS OPPS RATE,2461.32,Pays at 72% of billed charges with lesser of charges applied,2461.32,Pays at 72% of billed charges with lesser of charges applied,2461.32,Pays at 72% of billed charges with lesser of charges applied,2461.32,Pays at 72% of billed charges with lesser of charges applied,2461.32,Pays at 72% of billed charges with lesser of charges applied,2461.32,Pays at 72% of billed charges with lesser of charges applied,2534.6,442% of BCBS Fee Schedule,2534.6,442% of BCBS Fee Schedule,2534.6,442% of BCBS Fee Schedule,2534.6,442% of BCBS Fee Schedule,2534.6,442% of BCBS Fee Schedule,2534.6,442% of BCBS Fee Schedule,2534.6,442% of BCBS Fee Schedule,2534.6,442% of BCBS Fee Schedule,2534.6,442% of BCBS Fee Schedule,2967.36,100% of BCBS Fee Schedule,2967.36,100% of BCBS Fee Schedule,2967.36,100% of BCBS Fee Schedule,2967.36,100% of BCBS Fee Schedule,2967.36,100% of BCBS Fee Schedule,2871.54,84% of total billed charges,2871.54,84% of total billed charges,2871.54,84% of total billed charges,2392.95,70% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,379.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,379.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,379.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,379.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,379.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,379.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,379.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,379.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,379.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,379.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,379.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,379.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,379.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,379.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,379.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,379.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,379.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,379.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,379.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,379.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,243.27,2967.36,2563.88
Outpatient Medical Services,MRI,70336,MRI TEMPROMANDIBULAR JOINTS,610,2818.75,2029.5,Pays at 72% of billed charges with lesser of charges applied,296.82,100% OF CMS OPPS Rate,1844.64,442% of BCBS Fee Schedule,296.82,100% OF CMS OPPS Rate,2502.9,100% of BCBS Fee Schedule,296.82,100% OF CMS OPPS Rate,2367.75,84% of total billed charges,2367.75,84% of total billed charges,2029.5,72% of total billed charges,296.82,100% OF CMS OPPS Rate,296.82,100% of CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,1691.25,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,247.65,100% OF CMS OPPS RATE,296.82,100% OF CMS OPPS Rate,1973.13,70% of total billed charges,296.82,100% OF CMS OPPS Rate,356.18,120% of CMS OPPS RATE,2029.5,Pays at 72% of billed charges with lesser of charges applied,2029.5,Pays at 72% of billed charges with lesser of charges applied,2029.5,Pays at 72% of billed charges with lesser of charges applied,2029.5,Pays at 72% of billed charges with lesser of charges applied,2029.5,Pays at 72% of billed charges with lesser of charges applied,2029.5,Pays at 72% of billed charges with lesser of charges applied,1844.64,442% of BCBS Fee Schedule,1844.64,442% of BCBS Fee Schedule,1844.64,442% of BCBS Fee Schedule,1844.64,442% of BCBS Fee Schedule,1844.64,442% of BCBS Fee Schedule,1844.64,442% of BCBS Fee Schedule,1844.64,442% of BCBS Fee Schedule,1844.64,442% of BCBS Fee Schedule,1844.64,442% of BCBS Fee Schedule,2502.9,100% of BCBS Fee Schedule,2502.9,100% of BCBS Fee Schedule,2502.9,100% of BCBS Fee Schedule,2502.9,100% of BCBS Fee Schedule,2502.9,100% of BCBS Fee Schedule,2367.75,84% of total billed charges,2367.75,84% of total billed charges,2367.75,84% of total billed charges,1973.13,70% of total billed charges,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,247.65,2502.90,2114.06
Outpatient Medical Services,MRI,73219,MRI UPPER EXTREMITY W/C BIL,610,6337.75,4563.18,Pays at 72% of billed charges with lesser of charges applied,468.3,100% OF CMS OPPS Rate,2547.86,442% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,2967.36,100% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,3131,84% of total billed charges,3131,84% of total billed charges,4563.18,72% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% of CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,3802.65,60% of total billed charges,473.25,100% of CA Medicaid Fee Schedule with lesser of charges applied,473.25,100% of CA Medicaid Fee Schedule with lesser of charges applied,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,323.3,100% OF CMS OPPS RATE,468.3,100% OF CMS OPPS Rate,4436.43,70% of total billed charges,468.3,100% OF CMS OPPS Rate,561.95,120% of CMS OPPS RATE,4563.18,Pays at 72% of billed charges with lesser of charges applied,4563.18,Pays at 72% of billed charges with lesser of charges applied,4563.18,Pays at 72% of billed charges with lesser of charges applied,4563.18,Pays at 72% of billed charges with lesser of charges applied,4563.18,Pays at 72% of billed charges with lesser of charges applied,4563.18,Pays at 72% of billed charges with lesser of charges applied,2547.86,442% of BCBS Fee Schedule,2547.86,442% of BCBS Fee Schedule,2547.86,442% of BCBS Fee Schedule,2547.86,442% of BCBS Fee Schedule,2547.86,442% of BCBS Fee Schedule,2547.86,442% of BCBS Fee Schedule,2547.86,442% of BCBS Fee Schedule,2547.86,442% of BCBS Fee Schedule,2547.86,442% of BCBS Fee Schedule,2967.36,100% of BCBS Fee Schedule,2967.36,100% of BCBS Fee Schedule,2967.36,100% of BCBS Fee Schedule,2967.36,100% of BCBS Fee Schedule,2967.36,100% of BCBS Fee Schedule,3131,84% of total billed charges,3131,84% of total billed charges,3131,84% of total billed charges,4436.43,70% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,473.25,100% of CA Medicaid Fee Schedule with lesser of charges applied,473.25,100% of CA Medicaid Fee Schedule with lesser of charges applied,473.25,100% of CA Medicaid Fee Schedule with lesser of charges applied,473.25,100% of CA Medicaid Fee Schedule with lesser of charges applied,473.25,100% of CA Medicaid Fee Schedule with lesser of charges applied,473.25,100% of CA Medicaid Fee Schedule with lesser of charges applied,473.25,100% of CA Medicaid Fee Schedule with lesser of charges applied,473.25,100% of CA Medicaid Fee Schedule with lesser of charges applied,473.25,100% of CA Medicaid Fee Schedule with lesser of charges applied,473.25,100% of CA Medicaid Fee Schedule with lesser of charges applied,473.25,100% of CA Medicaid Fee Schedule with lesser of charges applied,473.25,100% of CA Medicaid Fee Schedule with lesser of charges applied,473.25,100% of CA Medicaid Fee Schedule with lesser of charges applied,473.25,100% of CA Medicaid Fee Schedule with lesser of charges applied,473.25,100% of CA Medicaid Fee Schedule with lesser of charges applied,473.25,100% of CA Medicaid Fee Schedule with lesser of charges applied,473.25,100% of CA Medicaid Fee Schedule with lesser of charges applied,473.25,100% of CA Medicaid Fee Schedule with lesser of charges applied,473.25,100% of CA Medicaid Fee Schedule with lesser of charges applied,473.25,100% of CA Medicaid Fee Schedule with lesser of charges applied,323.30,4563.18,4753.31
Outpatient Medical Services,MRI,75559,MRI CARDIAC W/STRESS IMG,610,3205.5,2307.96,Pays at 72% of billed charges with lesser of charges applied,639.51,100% OF CMS OPPS Rate,2921.66,442% of BCBS Fee Schedule,639.51,100% OF CMS OPPS Rate,3144.6,pays at 100% of bcbs fee schedule with lesser of charges applied,639.51,100% OF CMS OPPS Rate,2692.62,84% of total billed charges,2692.62,84% of total billed charges,2307.96,72% of total billed charges,639.51,100% OF CMS OPPS Rate,639.51,100% of CMS OPPS Rate,639.51,100% OF CMS OPPS Rate,1923.3,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,639.51,100% OF CMS OPPS Rate,639.51,100% OF CMS OPPS Rate,302.2,100% OF CMS OPPS RATE,639.51,100% OF CMS OPPS Rate,2243.85,70% of total billed charges,639.51,100% OF CMS OPPS Rate,767.41,120% of CMS OPPS RATE,2307.96,Pays at 72% of billed charges with lesser of charges applied,2307.96,Pays at 72% of billed charges with lesser of charges applied,2307.96,Pays at 72% of billed charges with lesser of charges applied,2307.96,Pays at 72% of billed charges with lesser of charges applied,2307.96,Pays at 72% of billed charges with lesser of charges applied,2307.96,Pays at 72% of billed charges with lesser of charges applied,2921.66,442% of BCBS Fee Schedule,2921.66,442% of BCBS Fee Schedule,2921.66,442% of BCBS Fee Schedule,2921.66,442% of BCBS Fee Schedule,2921.66,442% of BCBS Fee Schedule,2921.66,442% of BCBS Fee Schedule,2921.66,442% of BCBS Fee Schedule,2921.66,442% of BCBS Fee Schedule,2921.66,442% of BCBS Fee Schedule,3144.6,pays at 100% of bcbs fee schedule with lesser of charges applied,3144.6,pays at 100% of bcbs fee schedule with lesser of charges applied,3144.6,pays at 100% of bcbs fee schedule with lesser of charges applied,3144.6,pays at 100% of bcbs fee schedule with lesser of charges applied,3144.6,pays at 100% of bcbs fee schedule with lesser of charges applied,2692.62,84% of total billed charges,2692.62,84% of total billed charges,2692.62,84% of total billed charges,2243.85,70% of total billed charges,639.51,100% OF CMS OPPS Rate,639.51,100% OF CMS OPPS Rate,639.51,100% OF CMS OPPS Rate,639.51,100% OF CMS OPPS Rate,639.51,100% OF CMS OPPS Rate,639.51,100% OF CMS OPPS Rate,639.51,100% OF CMS OPPS Rate,639.51,100% OF CMS OPPS Rate,639.51,100% OF CMS OPPS Rate,639.51,100% OF CMS OPPS Rate,639.51,100% OF CMS OPPS Rate,639.51,100% OF CMS OPPS Rate,639.51,100% OF CMS OPPS Rate,639.51,100% OF CMS OPPS Rate,639.51,100% OF CMS OPPS Rate,639.51,100% OF CMS OPPS Rate,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,302.20,3144.60,2404.13
Outpatient Medical Services,MRI,C8902,MRA ABDOMEN WO CONTRAST,610,3204,2306.88,Pays at 72% of billed charges with lesser of charges applied,468.3,100% OF CMS OPPS Rate,2814.66,442% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,2534.36,79.1% of total billed charges,468.3,100% OF CMS OPPS Rate,2691.36,84% of total billed charges,2691.36,84% of total billed charges,2306.88,72% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% of CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,1922.4,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,N/A,Not Separately reimbursable,468.3,100% OF CMS OPPS Rate,2242.8,70% of total billed charges,468.3,100% OF CMS OPPS Rate,561.95,120% of CMS OPPS RATE,2306.88,Pays at 72% of billed charges with lesser of charges applied,2306.88,Pays at 72% of billed charges with lesser of charges applied,2306.88,Pays at 72% of billed charges with lesser of charges applied,2306.88,Pays at 72% of billed charges with lesser of charges applied,2306.88,Pays at 72% of billed charges with lesser of charges applied,2306.88,Pays at 72% of billed charges with lesser of charges applied,2814.66,442% of BCBS Fee Schedule,2814.66,442% of BCBS Fee Schedule,2814.66,442% of BCBS Fee Schedule,2814.66,442% of BCBS Fee Schedule,2814.66,442% of BCBS Fee Schedule,2814.66,442% of BCBS Fee Schedule,2814.66,442% of BCBS Fee Schedule,2814.66,442% of BCBS Fee Schedule,2814.66,442% of BCBS Fee Schedule,2534.36,79.1% of total billed charges,2534.36,79.1% of total billed charges,2534.36,79.1% of total billed charges,2534.36,79.1% of total billed charges,2534.36,79.1% of total billed charges,2691.36,84% of total billed charges,2691.36,84% of total billed charges,2691.36,84% of total billed charges,2242.8,70% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,468.30,2814.66,2403
Outpatient Medical Services,MRI,75552,MRI MYOCARDIUM W/O CONT,610,3204,2306.88,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,2617.67,81.7% of total Billed charges,N/A,Not Separately reimbursable,2534.36,79.1% of total billed charges,N/A,Not Separately reimbursable,2691.36,84% of total billed charges,2691.36,84% of total billed charges,2306.88,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,1922.4,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,2242.8,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,2306.88,Pays at 72% of billed charges with lesser of charges applied,2306.88,Pays at 72% of billed charges with lesser of charges applied,2306.88,Pays at 72% of billed charges with lesser of charges applied,2306.88,Pays at 72% of billed charges with lesser of charges applied,2306.88,Pays at 72% of billed charges with lesser of charges applied,2306.88,Pays at 72% of billed charges with lesser of charges applied,2617.67,81.7% of total Billed charges,2617.67,81.7% of total Billed charges,2617.67,81.7% of total Billed charges,2617.67,81.7% of total Billed charges,2617.67,81.7% of total Billed charges,2617.67,81.7% of total Billed charges,2617.67,81.7% of total Billed charges,2617.67,81.7% of total Billed charges,2617.67,81.7% of total Billed charges,2534.36,79.1% of total billed charges,2534.36,79.1% of total billed charges,2534.36,79.1% of total billed charges,2534.36,79.1% of total billed charges,2534.36,79.1% of total billed charges,2691.36,84% of total billed charges,2691.36,84% of total billed charges,2691.36,84% of total billed charges,2242.8,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,1922.40,2691.36,2403
Outpatient Medical Services,MRI,C8919,MRA CHEST ADD SEQUENCE,610,975.5,702.36,Pays at 72% of billed charges with lesser of charges applied,296.82,100% OF CMS OPPS Rate,975.5,BCBS Fee Schedule,296.82,100% OF CMS OPPS Rate,771.62,79.1% of total billed charges,296.82,100% OF CMS OPPS Rate,819.42,84% of total billed charges,819.42,84% of total billed charges,702.36,72% of total billed charges,296.82,100% OF CMS OPPS Rate,296.82,100% of CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,585.3,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,N/A,Not Separately reimbursable,296.82,100% OF CMS OPPS Rate,682.85,70% of total billed charges,296.82,100% OF CMS OPPS Rate,356.18,120% of CMS OPPS RATE,702.36,Pays at 72% of billed charges with lesser of charges applied,702.36,Pays at 72% of billed charges with lesser of charges applied,702.36,Pays at 72% of billed charges with lesser of charges applied,702.36,Pays at 72% of billed charges with lesser of charges applied,702.36,Pays at 72% of billed charges with lesser of charges applied,702.36,Pays at 72% of billed charges with lesser of charges applied,975.5,BCBS Fee Schedule,975.5,BCBS Fee Schedule,975.5,BCBS Fee Schedule,975.5,BCBS Fee Schedule,975.5,BCBS Fee Schedule,975.5,BCBS Fee Schedule,975.5,BCBS Fee Schedule,975.5,BCBS Fee Schedule,975.5,BCBS Fee Schedule,771.62,79.1% of total billed charges,771.62,79.1% of total billed charges,771.62,79.1% of total billed charges,771.62,79.1% of total billed charges,771.62,79.1% of total billed charges,819.42,84% of total billed charges,819.42,84% of total billed charges,819.42,84% of total billed charges,682.85,70% of total billed charges,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,296.82,975.50,731.63
Outpatient Medical Services,MRI,74182,MRI ABDOMEN WITH ONLY,610,4096.25,2949.3,Pays at 72% of billed charges with lesser of charges applied,468.3,100% OF CMS OPPS Rate,2540.4,442% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,2975.04,100% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,3131,84% of total billed charges,3131,84% of total billed charges,2949.3,72% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% of CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,2457.75,60% of total billed charges,429.20,100% of CA Medicaid Fee Schedule with lesser of charges applied,429.20,100% of CA Medicaid Fee Schedule with lesser of charges applied,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,279.9,100% OF CMS OPPS RATE,468.3,100% OF CMS OPPS Rate,2867.38,70% of total billed charges,468.3,100% OF CMS OPPS Rate,561.95,120% of CMS OPPS RATE,2949.3,Pays at 72% of billed charges with lesser of charges applied,2949.3,Pays at 72% of billed charges with lesser of charges applied,2949.3,Pays at 72% of billed charges with lesser of charges applied,2949.3,Pays at 72% of billed charges with lesser of charges applied,2949.3,Pays at 72% of billed charges with lesser of charges applied,2949.3,Pays at 72% of billed charges with lesser of charges applied,2540.4,442% of BCBS Fee Schedule,2540.4,442% of BCBS Fee Schedule,2540.4,442% of BCBS Fee Schedule,2540.4,442% of BCBS Fee Schedule,2540.4,442% of BCBS Fee Schedule,2540.4,442% of BCBS Fee Schedule,2540.4,442% of BCBS Fee Schedule,2540.4,442% of BCBS Fee Schedule,2540.4,442% of BCBS Fee Schedule,2975.04,100% of BCBS Fee Schedule,2975.04,100% of BCBS Fee Schedule,2975.04,100% of BCBS Fee Schedule,2975.04,100% of BCBS Fee Schedule,2975.04,100% of BCBS Fee Schedule,3131,84% of total billed charges,3131,84% of total billed charges,3131,84% of total billed charges,2867.38,70% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,429.20,100% of CA Medicaid Fee Schedule with lesser of charges applied,429.20,100% of CA Medicaid Fee Schedule with lesser of charges applied,429.20,100% of CA Medicaid Fee Schedule with lesser of charges applied,429.20,100% of CA Medicaid Fee Schedule with lesser of charges applied,429.20,100% of CA Medicaid Fee Schedule with lesser of charges applied,429.20,100% of CA Medicaid Fee Schedule with lesser of charges applied,429.20,100% of CA Medicaid Fee Schedule with lesser of charges applied,429.20,100% of CA Medicaid Fee Schedule with lesser of charges applied,429.20,100% of CA Medicaid Fee Schedule with lesser of charges applied,429.20,100% of CA Medicaid Fee Schedule with lesser of charges applied,429.20,100% of CA Medicaid Fee Schedule with lesser of charges applied,429.20,100% of CA Medicaid Fee Schedule with lesser of charges applied,429.20,100% of CA Medicaid Fee Schedule with lesser of charges applied,429.20,100% of CA Medicaid Fee Schedule with lesser of charges applied,429.20,100% of CA Medicaid Fee Schedule with lesser of charges applied,429.20,100% of CA Medicaid Fee Schedule with lesser of charges applied,429.20,100% of CA Medicaid Fee Schedule with lesser of charges applied,429.20,100% of CA Medicaid Fee Schedule with lesser of charges applied,429.20,100% of CA Medicaid Fee Schedule with lesser of charges applied,429.20,100% of CA Medicaid Fee Schedule with lesser of charges applied,279.90,3131.00,3072.19
Outpatient Medical Services,MRI,75557,MRI CARDIAC FOR MORPH,610,3205.5,2307.96,Pays at 72% of billed charges with lesser of charges applied,296.82,100% OF CMS OPPS Rate,1882.65,442% of BCBS Fee Schedule,296.82,100% OF CMS OPPS Rate,2350.61,100% of BCBS Fee Schedule,296.82,100% OF CMS OPPS Rate,2692.62,84% of total billed charges,2692.62,84% of total billed charges,2307.96,72% of total billed charges,296.82,100% OF CMS OPPS Rate,296.82,100% of CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,1923.3,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,215,100% OF CMS OPPS RATE,296.82,100% OF CMS OPPS Rate,2243.85,70% of total billed charges,296.82,100% OF CMS OPPS Rate,356.18,120% of CMS OPPS RATE,2307.96,Pays at 72% of billed charges with lesser of charges applied,2307.96,Pays at 72% of billed charges with lesser of charges applied,2307.96,Pays at 72% of billed charges with lesser of charges applied,2307.96,Pays at 72% of billed charges with lesser of charges applied,2307.96,Pays at 72% of billed charges with lesser of charges applied,2307.96,Pays at 72% of billed charges with lesser of charges applied,1882.65,442% of BCBS Fee Schedule,1882.65,442% of BCBS Fee Schedule,1882.65,442% of BCBS Fee Schedule,1882.65,442% of BCBS Fee Schedule,1882.65,442% of BCBS Fee Schedule,1882.65,442% of BCBS Fee Schedule,1882.65,442% of BCBS Fee Schedule,1882.65,442% of BCBS Fee Schedule,1882.65,442% of BCBS Fee Schedule,2350.61,100% of BCBS Fee Schedule,2350.61,100% of BCBS Fee Schedule,2350.61,100% of BCBS Fee Schedule,2350.61,100% of BCBS Fee Schedule,2350.61,100% of BCBS Fee Schedule,2692.62,84% of total billed charges,2692.62,84% of total billed charges,2692.62,84% of total billed charges,2243.85,70% of total billed charges,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,215.00,2692.62,2404.13
Outpatient Medical Services,MRI,74181,MRI of abdomen without dye,610,3412,2456.64,Pays at 72% of billed charges with lesser of charges applied,296.82,100% OF CMS OPPS Rate,2080.32,442% of BCBS Fee Schedule,296.82,100% OF CMS OPPS Rate,2481.4,100% of BCBS Fee Schedule,296.82,100% OF CMS OPPS Rate,2866.08,84% of total billed charges,2866.08,84% of total billed charges,2456.64,72% of total billed charges,296.82,100% OF CMS OPPS Rate,296.82,100% of CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,2047.2,60% of total billed charges,273.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,273.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,161.25,100% OF CMS OPPS RATE,296.82,100% OF CMS OPPS Rate,2388.4,70% of total billed charges,296.82,100% OF CMS OPPS Rate,356.18,120% of CMS OPPS RATE,2456.64,Pays at 72% of billed charges with lesser of charges applied,2456.64,Pays at 72% of billed charges with lesser of charges applied,2456.64,Pays at 72% of billed charges with lesser of charges applied,2456.64,Pays at 72% of billed charges with lesser of charges applied,2456.64,Pays at 72% of billed charges with lesser of charges applied,2456.64,Pays at 72% of billed charges with lesser of charges applied,2080.32,442% of BCBS Fee Schedule,2080.32,442% of BCBS Fee Schedule,2080.32,442% of BCBS Fee Schedule,2080.32,442% of BCBS Fee Schedule,2080.32,442% of BCBS Fee Schedule,2080.32,442% of BCBS Fee Schedule,2080.32,442% of BCBS Fee Schedule,2080.32,442% of BCBS Fee Schedule,2080.32,442% of BCBS Fee Schedule,2481.4,100% of BCBS Fee Schedule,2481.4,100% of BCBS Fee Schedule,2481.4,100% of BCBS Fee Schedule,2481.4,100% of BCBS Fee Schedule,2481.4,100% of BCBS Fee Schedule,2866.08,84% of total billed charges,2866.08,84% of total billed charges,2866.08,84% of total billed charges,2388.4,70% of total billed charges,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,273.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,273.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,273.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,273.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,273.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,273.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,273.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,273.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,273.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,273.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,273.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,273.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,273.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,273.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,273.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,273.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,273.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,273.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,273.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,273.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,161.25,2866.08,2559
Outpatient Medical Services,MRI,70545,MRA HEAD WITH ONLY,610,4106.75,2956.86,Pays at 72% of billed charges with lesser of charges applied,468.3,100% OF CMS OPPS Rate,2138.31,442% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,2502.9,100% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,3131,84% of total billed charges,3131,84% of total billed charges,2956.86,72% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% of CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,2464.05,60% of total billed charges,319.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,319.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,214.6,100% OF CMS OPPS RATE,468.3,100% OF CMS OPPS Rate,2874.73,70% of total billed charges,468.3,100% OF CMS OPPS Rate,561.95,120% of CMS OPPS RATE,2956.86,Pays at 72% of billed charges with lesser of charges applied,2956.86,Pays at 72% of billed charges with lesser of charges applied,2956.86,Pays at 72% of billed charges with lesser of charges applied,2956.86,Pays at 72% of billed charges with lesser of charges applied,2956.86,Pays at 72% of billed charges with lesser of charges applied,2956.86,Pays at 72% of billed charges with lesser of charges applied,2138.31,442% of BCBS Fee Schedule,2138.31,442% of BCBS Fee Schedule,2138.31,442% of BCBS Fee Schedule,2138.31,442% of BCBS Fee Schedule,2138.31,442% of BCBS Fee Schedule,2138.31,442% of BCBS Fee Schedule,2138.31,442% of BCBS Fee Schedule,2138.31,442% of BCBS Fee Schedule,2138.31,442% of BCBS Fee Schedule,2502.9,100% of BCBS Fee Schedule,2502.9,100% of BCBS Fee Schedule,2502.9,100% of BCBS Fee Schedule,2502.9,100% of BCBS Fee Schedule,2502.9,100% of BCBS Fee Schedule,3131,84% of total billed charges,3131,84% of total billed charges,3131,84% of total billed charges,2874.73,70% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,319.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,319.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,319.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,319.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,319.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,319.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,319.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,319.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,319.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,319.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,319.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,319.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,319.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,319.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,319.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,319.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,319.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,319.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,319.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,319.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,214.60,3131.00,3080.06
Outpatient Medical Services,MRI,70548,MRA NECK WITH ONLY,610,4106.75,2956.86,Pays at 72% of billed charges with lesser of charges applied,468.3,100% OF CMS OPPS Rate,2138.31,442% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,2502.9,100% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,3131,84% of total billed charges,3131,84% of total billed charges,2956.86,72% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% of CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,2464.05,60% of total billed charges,345.09,100% of CA Medicaid Fee Schedule with lesser of charges applied,345.09,100% of CA Medicaid Fee Schedule with lesser of charges applied,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,220.57,100% OF CMS OPPS RATE,468.3,100% OF CMS OPPS Rate,2874.73,70% of total billed charges,468.3,100% OF CMS OPPS Rate,561.95,120% of CMS OPPS RATE,2956.86,Pays at 72% of billed charges with lesser of charges applied,2956.86,Pays at 72% of billed charges with lesser of charges applied,2956.86,Pays at 72% of billed charges with lesser of charges applied,2956.86,Pays at 72% of billed charges with lesser of charges applied,2956.86,Pays at 72% of billed charges with lesser of charges applied,2956.86,Pays at 72% of billed charges with lesser of charges applied,2138.31,442% of BCBS Fee Schedule,2138.31,442% of BCBS Fee Schedule,2138.31,442% of BCBS Fee Schedule,2138.31,442% of BCBS Fee Schedule,2138.31,442% of BCBS Fee Schedule,2138.31,442% of BCBS Fee Schedule,2138.31,442% of BCBS Fee Schedule,2138.31,442% of BCBS Fee Schedule,2138.31,442% of BCBS Fee Schedule,2502.9,100% of BCBS Fee Schedule,2502.9,100% of BCBS Fee Schedule,2502.9,100% of BCBS Fee Schedule,2502.9,100% of BCBS Fee Schedule,2502.9,100% of BCBS Fee Schedule,3131,84% of total billed charges,3131,84% of total billed charges,3131,84% of total billed charges,2874.73,70% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,345.09,100% of CA Medicaid Fee Schedule with lesser of charges applied,345.09,100% of CA Medicaid Fee Schedule with lesser of charges applied,345.09,100% of CA Medicaid Fee Schedule with lesser of charges applied,345.09,100% of CA Medicaid Fee Schedule with lesser of charges applied,345.09,100% of CA Medicaid Fee Schedule with lesser of charges applied,345.09,100% of CA Medicaid Fee Schedule with lesser of charges applied,345.09,100% of CA Medicaid Fee Schedule with lesser of charges applied,345.09,100% of CA Medicaid Fee Schedule with lesser of charges applied,345.09,100% of CA Medicaid Fee Schedule with lesser of charges applied,345.09,100% of CA Medicaid Fee Schedule with lesser of charges applied,345.09,100% of CA Medicaid Fee Schedule with lesser of charges applied,345.09,100% of CA Medicaid Fee Schedule with lesser of charges applied,345.09,100% of CA Medicaid Fee Schedule with lesser of charges applied,345.09,100% of CA Medicaid Fee Schedule with lesser of charges applied,345.09,100% of CA Medicaid Fee Schedule with lesser of charges applied,345.09,100% of CA Medicaid Fee Schedule with lesser of charges applied,345.09,100% of CA Medicaid Fee Schedule with lesser of charges applied,345.09,100% of CA Medicaid Fee Schedule with lesser of charges applied,345.09,100% of CA Medicaid Fee Schedule with lesser of charges applied,345.09,100% of CA Medicaid Fee Schedule with lesser of charges applied,220.57,3131.00,3080.06
Outpatient Medical Services,MRI,70544,MRA HEAD WITHOUT,610,3418.5,2461.32,Pays at 72% of billed charges with lesser of charges applied,296.82,100% OF CMS OPPS Rate,2138.31,442% of BCBS Fee Schedule,296.82,100% OF CMS OPPS Rate,2502.9,100% of BCBS Fee Schedule,296.82,100% OF CMS OPPS Rate,2871.54,84% of total billed charges,2871.54,84% of total billed charges,2461.32,72% of total billed charges,296.82,100% OF CMS OPPS Rate,296.82,100% of CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,2051.1,60% of total billed charges,302.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,302.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,199.47,100% OF CMS OPPS RATE,296.82,100% OF CMS OPPS Rate,2392.95,70% of total billed charges,296.82,100% OF CMS OPPS Rate,356.18,120% of CMS OPPS RATE,2461.32,Pays at 72% of billed charges with lesser of charges applied,2461.32,Pays at 72% of billed charges with lesser of charges applied,2461.32,Pays at 72% of billed charges with lesser of charges applied,2461.32,Pays at 72% of billed charges with lesser of charges applied,2461.32,Pays at 72% of billed charges with lesser of charges applied,2461.32,Pays at 72% of billed charges with lesser of charges applied,2138.31,442% of BCBS Fee Schedule,2138.31,442% of BCBS Fee Schedule,2138.31,442% of BCBS Fee Schedule,2138.31,442% of BCBS Fee Schedule,2138.31,442% of BCBS Fee Schedule,2138.31,442% of BCBS Fee Schedule,2138.31,442% of BCBS Fee Schedule,2138.31,442% of BCBS Fee Schedule,2138.31,442% of BCBS Fee Schedule,2502.9,100% of BCBS Fee Schedule,2502.9,100% of BCBS Fee Schedule,2502.9,100% of BCBS Fee Schedule,2502.9,100% of BCBS Fee Schedule,2502.9,100% of BCBS Fee Schedule,2871.54,84% of total billed charges,2871.54,84% of total billed charges,2871.54,84% of total billed charges,2392.95,70% of total billed charges,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,302.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,302.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,302.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,302.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,302.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,302.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,302.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,302.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,302.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,302.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,302.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,302.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,302.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,302.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,302.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,302.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,302.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,302.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,302.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,302.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,199.47,2871.54,2563.88
Outpatient Medical Services,MRI,70547,MRA NECK WITHOUT,610,3418.5,2461.32,Pays at 72% of billed charges with lesser of charges applied,296.82,100% OF CMS OPPS Rate,2138.31,442% of BCBS Fee Schedule,296.82,100% OF CMS OPPS Rate,2502.9,100% of BCBS Fee Schedule,296.82,100% OF CMS OPPS Rate,2871.54,84% of total billed charges,2871.54,84% of total billed charges,2461.32,72% of total billed charges,296.82,100% OF CMS OPPS Rate,296.82,100% of CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,2051.1,60% of total billed charges,303.50,100% of CA Medicaid Fee Schedule with lesser of charges applied,303.50,100% of CA Medicaid Fee Schedule with lesser of charges applied,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,199.87,100% OF CMS OPPS RATE,296.82,100% OF CMS OPPS Rate,2392.95,70% of total billed charges,296.82,100% OF CMS OPPS Rate,356.18,120% of CMS OPPS RATE,2461.32,Pays at 72% of billed charges with lesser of charges applied,2461.32,Pays at 72% of billed charges with lesser of charges applied,2461.32,Pays at 72% of billed charges with lesser of charges applied,2461.32,Pays at 72% of billed charges with lesser of charges applied,2461.32,Pays at 72% of billed charges with lesser of charges applied,2461.32,Pays at 72% of billed charges with lesser of charges applied,2138.31,442% of BCBS Fee Schedule,2138.31,442% of BCBS Fee Schedule,2138.31,442% of BCBS Fee Schedule,2138.31,442% of BCBS Fee Schedule,2138.31,442% of BCBS Fee Schedule,2138.31,442% of BCBS Fee Schedule,2138.31,442% of BCBS Fee Schedule,2138.31,442% of BCBS Fee Schedule,2138.31,442% of BCBS Fee Schedule,2502.9,100% of BCBS Fee Schedule,2502.9,100% of BCBS Fee Schedule,2502.9,100% of BCBS Fee Schedule,2502.9,100% of BCBS Fee Schedule,2502.9,100% of BCBS Fee Schedule,2871.54,84% of total billed charges,2871.54,84% of total billed charges,2871.54,84% of total billed charges,2392.95,70% of total billed charges,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,303.50,100% of CA Medicaid Fee Schedule with lesser of charges applied,303.50,100% of CA Medicaid Fee Schedule with lesser of charges applied,303.50,100% of CA Medicaid Fee Schedule with lesser of charges applied,303.50,100% of CA Medicaid Fee Schedule with lesser of charges applied,303.50,100% of CA Medicaid Fee Schedule with lesser of charges applied,303.50,100% of CA Medicaid Fee Schedule with lesser of charges applied,303.50,100% of CA Medicaid Fee Schedule with lesser of charges applied,303.50,100% of CA Medicaid Fee Schedule with lesser of charges applied,303.50,100% of CA Medicaid Fee Schedule with lesser of charges applied,303.50,100% of CA Medicaid Fee Schedule with lesser of charges applied,303.50,100% of CA Medicaid Fee Schedule with lesser of charges applied,303.50,100% of CA Medicaid Fee Schedule with lesser of charges applied,303.50,100% of CA Medicaid Fee Schedule with lesser of charges applied,303.50,100% of CA Medicaid Fee Schedule with lesser of charges applied,303.50,100% of CA Medicaid Fee Schedule with lesser of charges applied,303.50,100% of CA Medicaid Fee Schedule with lesser of charges applied,303.50,100% of CA Medicaid Fee Schedule with lesser of charges applied,303.50,100% of CA Medicaid Fee Schedule with lesser of charges applied,303.50,100% of CA Medicaid Fee Schedule with lesser of charges applied,303.50,100% of CA Medicaid Fee Schedule with lesser of charges applied,199.87,2871.54,2563.88
Outpatient Medical Services,MRI,74183,MRI of abdomen without and with dye,610,7180.75,5170.14,Pays at 72% of billed charges with lesser of charges applied,468.3,100% OF CMS OPPS Rate,4700.4,442% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,5502.41,100% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,3131,84% of total billed charges,3131,84% of total billed charges,5170.14,72% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% of CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,4308.45,60% of total billed charges,478.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,478.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,298.22,100% OF CMS OPPS RATE,468.3,100% OF CMS OPPS Rate,5026.53,70% of total billed charges,468.3,100% OF CMS OPPS Rate,561.95,120% of CMS OPPS RATE,5170.14,Pays at 72% of billed charges with lesser of charges applied,5170.14,Pays at 72% of billed charges with lesser of charges applied,5170.14,Pays at 72% of billed charges with lesser of charges applied,5170.14,Pays at 72% of billed charges with lesser of charges applied,5170.14,Pays at 72% of billed charges with lesser of charges applied,5170.14,Pays at 72% of billed charges with lesser of charges applied,4700.4,442% of BCBS Fee Schedule,4700.4,442% of BCBS Fee Schedule,4700.4,442% of BCBS Fee Schedule,4700.4,442% of BCBS Fee Schedule,4700.4,442% of BCBS Fee Schedule,4700.4,442% of BCBS Fee Schedule,4700.4,442% of BCBS Fee Schedule,4700.4,442% of BCBS Fee Schedule,4700.4,442% of BCBS Fee Schedule,5502.41,100% of BCBS Fee Schedule,5502.41,100% of BCBS Fee Schedule,5502.41,100% of BCBS Fee Schedule,5502.41,100% of BCBS Fee Schedule,5502.41,100% of BCBS Fee Schedule,3131,84% of total billed charges,3131,84% of total billed charges,3131,84% of total billed charges,5026.53,70% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,478.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,478.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,478.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,478.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,478.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,478.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,478.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,478.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,478.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,478.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,478.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,478.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,478.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,478.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,478.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,478.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,478.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,478.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,478.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,478.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,298.22,5502.41,5385.56
Outpatient Medical Services,MRI,77084,MRI BONE MARROW,610,4036.75,2906.46,Pays at 72% of billed charges with lesser of charges applied,296.82,100% OF CMS OPPS Rate,2080.36,442% of BCBS Fee Schedule,296.82,100% OF CMS OPPS Rate,2951.45,100% of BCBS Fee Schedule,296.82,100% OF CMS OPPS Rate,3131,84% of total billed charges,3131,84% of total billed charges,2906.46,72% of total billed charges,296.82,100% OF CMS OPPS Rate,296.82,100% of CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,2422.05,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,305.78,100% OF CMS OPPS RATE,296.82,100% OF CMS OPPS Rate,2825.73,70% of total billed charges,296.82,100% OF CMS OPPS Rate,356.18,120% of CMS OPPS RATE,2906.46,Pays at 72% of billed charges with lesser of charges applied,2906.46,Pays at 72% of billed charges with lesser of charges applied,2906.46,Pays at 72% of billed charges with lesser of charges applied,2906.46,Pays at 72% of billed charges with lesser of charges applied,2906.46,Pays at 72% of billed charges with lesser of charges applied,2906.46,Pays at 72% of billed charges with lesser of charges applied,2080.36,442% of BCBS Fee Schedule,2080.36,442% of BCBS Fee Schedule,2080.36,442% of BCBS Fee Schedule,2080.36,442% of BCBS Fee Schedule,2080.36,442% of BCBS Fee Schedule,2080.36,442% of BCBS Fee Schedule,2080.36,442% of BCBS Fee Schedule,2080.36,442% of BCBS Fee Schedule,2080.36,442% of BCBS Fee Schedule,2951.45,100% of BCBS Fee Schedule,2951.45,100% of BCBS Fee Schedule,2951.45,100% of BCBS Fee Schedule,2951.45,100% of BCBS Fee Schedule,2951.45,100% of BCBS Fee Schedule,3131,84% of total billed charges,3131,84% of total billed charges,3131,84% of total billed charges,2825.73,70% of total billed charges,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,296.82,3131.00,3027.56
Outpatient Medical Services,MRI,72197,MRI of pelvis before and after dye,610,7180.75,5170.14,Pays at 72% of billed charges with lesser of charges applied,468.3,100% OF CMS OPPS Rate,4700.4,442% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,5502.41,100% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,3131,84% of total billed charges,3131,84% of total billed charges,5170.14,72% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% of CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,4308.45,60% of total billed charges,477.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,477.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,296.62,100% OF CMS OPPS RATE,468.3,100% OF CMS OPPS Rate,5026.53,70% of total billed charges,468.3,100% OF CMS OPPS Rate,561.95,120% of CMS OPPS RATE,5170.14,Pays at 72% of billed charges with lesser of charges applied,5170.14,Pays at 72% of billed charges with lesser of charges applied,5170.14,Pays at 72% of billed charges with lesser of charges applied,5170.14,Pays at 72% of billed charges with lesser of charges applied,5170.14,Pays at 72% of billed charges with lesser of charges applied,5170.14,Pays at 72% of billed charges with lesser of charges applied,4700.4,442% of BCBS Fee Schedule,4700.4,442% of BCBS Fee Schedule,4700.4,442% of BCBS Fee Schedule,4700.4,442% of BCBS Fee Schedule,4700.4,442% of BCBS Fee Schedule,4700.4,442% of BCBS Fee Schedule,4700.4,442% of BCBS Fee Schedule,4700.4,442% of BCBS Fee Schedule,4700.4,442% of BCBS Fee Schedule,5502.41,100% of BCBS Fee Schedule,5502.41,100% of BCBS Fee Schedule,5502.41,100% of BCBS Fee Schedule,5502.41,100% of BCBS Fee Schedule,5502.41,100% of BCBS Fee Schedule,3131,84% of total billed charges,3131,84% of total billed charges,3131,84% of total billed charges,5026.53,70% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,477.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,477.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,477.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,477.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,477.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,477.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,477.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,477.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,477.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,477.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,477.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,477.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,477.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,477.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,477.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,477.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,477.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,477.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,477.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,477.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,296.62,5502.41,5385.56
Outpatient Medical Services,MRI,70546,MRA HEAD +/-C,610,6522.25,4696.02,Pays at 72% of billed charges with lesser of charges applied,468.3,100% OF CMS OPPS Rate,4204.61,442% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,4917.33,100% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,3131,84% of total billed charges,3131,84% of total billed charges,4696.02,72% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% of CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,3913.35,60% of total billed charges,464.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,464.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,325.69,100% OF CMS OPPS RATE,468.3,100% OF CMS OPPS Rate,4565.58,70% of total billed charges,468.3,100% OF CMS OPPS Rate,561.95,120% of CMS OPPS RATE,4696.02,Pays at 72% of billed charges with lesser of charges applied,4696.02,Pays at 72% of billed charges with lesser of charges applied,4696.02,Pays at 72% of billed charges with lesser of charges applied,4696.02,Pays at 72% of billed charges with lesser of charges applied,4696.02,Pays at 72% of billed charges with lesser of charges applied,4696.02,Pays at 72% of billed charges with lesser of charges applied,4204.61,442% of BCBS Fee Schedule,4204.61,442% of BCBS Fee Schedule,4204.61,442% of BCBS Fee Schedule,4204.61,442% of BCBS Fee Schedule,4204.61,442% of BCBS Fee Schedule,4204.61,442% of BCBS Fee Schedule,4204.61,442% of BCBS Fee Schedule,4204.61,442% of BCBS Fee Schedule,4204.61,442% of BCBS Fee Schedule,4917.33,100% of BCBS Fee Schedule,4917.33,100% of BCBS Fee Schedule,4917.33,100% of BCBS Fee Schedule,4917.33,100% of BCBS Fee Schedule,4917.33,100% of BCBS Fee Schedule,3131,84% of total billed charges,3131,84% of total billed charges,3131,84% of total billed charges,4565.58,70% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,464.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,464.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,464.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,464.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,464.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,464.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,464.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,464.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,464.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,464.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,464.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,464.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,464.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,464.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,464.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,464.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,464.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,464.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,464.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,464.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,325.69,4917.33,4891.69
Outpatient Medical Services,MRI,70549,MRA NECK +/-C,610,6522.25,4696.02,Pays at 72% of billed charges with lesser of charges applied,468.3,100% OF CMS OPPS Rate,4204.61,442% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,4917.33,100% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,3131,84% of total billed charges,3131,84% of total billed charges,4696.02,72% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% of CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,3913.35,60% of total billed charges,486.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,486.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,327.28,100% OF CMS OPPS RATE,468.3,100% OF CMS OPPS Rate,4565.58,70% of total billed charges,468.3,100% OF CMS OPPS Rate,561.95,120% of CMS OPPS RATE,4696.02,Pays at 72% of billed charges with lesser of charges applied,4696.02,Pays at 72% of billed charges with lesser of charges applied,4696.02,Pays at 72% of billed charges with lesser of charges applied,4696.02,Pays at 72% of billed charges with lesser of charges applied,4696.02,Pays at 72% of billed charges with lesser of charges applied,4696.02,Pays at 72% of billed charges with lesser of charges applied,4204.61,442% of BCBS Fee Schedule,4204.61,442% of BCBS Fee Schedule,4204.61,442% of BCBS Fee Schedule,4204.61,442% of BCBS Fee Schedule,4204.61,442% of BCBS Fee Schedule,4204.61,442% of BCBS Fee Schedule,4204.61,442% of BCBS Fee Schedule,4204.61,442% of BCBS Fee Schedule,4204.61,442% of BCBS Fee Schedule,4917.33,100% of BCBS Fee Schedule,4917.33,100% of BCBS Fee Schedule,4917.33,100% of BCBS Fee Schedule,4917.33,100% of BCBS Fee Schedule,4917.33,100% of BCBS Fee Schedule,3131,84% of total billed charges,3131,84% of total billed charges,3131,84% of total billed charges,4565.58,70% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,486.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,486.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,486.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,486.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,486.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,486.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,486.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,486.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,486.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,486.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,486.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,486.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,486.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,486.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,486.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,486.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,486.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,486.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,486.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,486.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,327.28,4917.33,4891.69
Outpatient Medical Services,OCCUPATIONAL THERAPY,97760,OT-APPLICATION FINGER SPLINT-STATIC,430,44.25,31.86,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,44.25,Case rate,N/A,Not Separately reimbursable,43.41,Case rate,N/A,Not Separately reimbursable,37.17,84% of total billed charges,37.17,84% of total billed charges,31.86,72% of total billed charges,N/A,Not Separately reimbursable,44.25,100% of CMS OPPS Rate,N/A,Not Separately reimbursable,26.55,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,55.09,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,30.98,70% of total billed charges,44.25,100% OF CMS OPPS Rate,44.25,120% of CMS OPPS RATE,31.86,Pays at 72% of billed charges with lesser of charges applied,31.86,Pays at 72% of billed charges with lesser of charges applied,31.86,Pays at 72% of billed charges with lesser of charges applied,31.86,Pays at 72% of billed charges with lesser of charges applied,31.86,Pays at 72% of billed charges with lesser of charges applied,31.86,Pays at 72% of billed charges with lesser of charges applied,44.25,Case rate,44.25,Case rate,44.25,Case rate,44.25,Case rate,44.25,Case rate,44.25,Case rate,44.25,Case rate,44.25,Case rate,44.25,Case rate,43.41,Case rate,43.41,Case rate,43.41,Case rate,43.41,Case rate,43.41,Case rate,37.17,84% of total billed charges,37.17,84% of total billed charges,37.17,84% of total billed charges,30.98,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,26.55,55.09,33.19
Outpatient Medical Services,OCCUPATIONAL THERAPY,95831,"AOT-MMT,EXTREMITY OR TRUNK",430,49,35.28,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,49,Case rate,N/A,Not Separately reimbursable,48.07,Case rate,N/A,Not Separately reimbursable,41.16,84% of total billed charges,41.16,84% of total billed charges,35.28,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,29.4,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,34.3,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,35.28,Pays at 72% of billed charges with lesser of charges applied,35.28,Pays at 72% of billed charges with lesser of charges applied,35.28,Pays at 72% of billed charges with lesser of charges applied,35.28,Pays at 72% of billed charges with lesser of charges applied,35.28,Pays at 72% of billed charges with lesser of charges applied,35.28,Pays at 72% of billed charges with lesser of charges applied,49,Case rate,49,Case rate,49,Case rate,49,Case rate,49,Case rate,49,Case rate,49,Case rate,49,Case rate,49,Case rate,48.07,Case rate,48.07,Case rate,48.07,Case rate,48.07,Case rate,48.07,Case rate,41.16,84% of total billed charges,41.16,84% of total billed charges,41.16,84% of total billed charges,34.3,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,29.40,49.00,36.75
Outpatient Medical Services,OCCUPATIONAL THERAPY,95832,AOT-MMT HAND,430,49,35.28,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,49,Case rate,N/A,Not Separately reimbursable,48.07,Case rate,N/A,Not Separately reimbursable,41.16,84% of total billed charges,41.16,84% of total billed charges,35.28,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,29.4,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,34.3,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,35.28,Pays at 72% of billed charges with lesser of charges applied,35.28,Pays at 72% of billed charges with lesser of charges applied,35.28,Pays at 72% of billed charges with lesser of charges applied,35.28,Pays at 72% of billed charges with lesser of charges applied,35.28,Pays at 72% of billed charges with lesser of charges applied,35.28,Pays at 72% of billed charges with lesser of charges applied,49,Case rate,49,Case rate,49,Case rate,49,Case rate,49,Case rate,49,Case rate,49,Case rate,49,Case rate,49,Case rate,48.07,Case rate,48.07,Case rate,48.07,Case rate,48.07,Case rate,48.07,Case rate,41.16,84% of total billed charges,41.16,84% of total billed charges,41.16,84% of total billed charges,34.3,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,29.40,49.00,36.75
Outpatient Medical Services,OCCUPATIONAL THERAPY,11001,OT-NONSURG DEBRID INF SKIN ADDIT 10%,430,59.5,42.84,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,59.5,100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,58.37,Case rate,N/A,Not Separately reimbursable,49.98,84% of total billed charges,49.98,84% of total billed charges,42.84,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,35.7,60% of total billed charges,14.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,15.24,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,41.65,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,42.84,Pays at 72% of billed charges with lesser of charges applied,42.84,Pays at 72% of billed charges with lesser of charges applied,42.84,Pays at 72% of billed charges with lesser of charges applied,42.84,Pays at 72% of billed charges with lesser of charges applied,42.84,Pays at 72% of billed charges with lesser of charges applied,42.84,Pays at 72% of billed charges with lesser of charges applied,59.5,100% of ASC Tier Grouping Fee Schedule,59.5,100% of ASC Tier Grouping Fee Schedule,59.5,100% of ASC Tier Grouping Fee Schedule,59.5,100% of ASC Tier Grouping Fee Schedule,59.5,100% of ASC Tier Grouping Fee Schedule,59.5,100% of ASC Tier Grouping Fee Schedule,59.5,100% of ASC Tier Grouping Fee Schedule,59.5,100% of ASC Tier Grouping Fee Schedule,59.5,100% of ASC Tier Grouping Fee Schedule,58.37,Case rate,58.37,Case rate,58.37,Case rate,58.37,Case rate,58.37,Case rate,49.98,84% of total billed charges,49.98,84% of total billed charges,49.98,84% of total billed charges,41.65,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,14.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.95,59.50,44.63
Outpatient Medical Services,OCCUPATIONAL THERAPY,97014,One time use unattended,430,66.5,47.88,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,66.5,Case rate,N/A,Not Separately reimbursable,65.24,Case rate,N/A,Not Separately reimbursable,55.86,84% of total billed charges,55.86,84% of total billed charges,47.88,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,39.9,60% of total billed charges,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,13.65,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,46.55,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,47.88,Pays at 72% of billed charges with lesser of charges applied,47.88,Pays at 72% of billed charges with lesser of charges applied,47.88,Pays at 72% of billed charges with lesser of charges applied,47.88,Pays at 72% of billed charges with lesser of charges applied,47.88,Pays at 72% of billed charges with lesser of charges applied,47.88,Pays at 72% of billed charges with lesser of charges applied,66.5,Case rate,66.5,Case rate,66.5,Case rate,66.5,Case rate,66.5,Case rate,66.5,Case rate,66.5,Case rate,66.5,Case rate,66.5,Case rate,65.24,Case rate,65.24,Case rate,65.24,Case rate,65.24,Case rate,65.24,Case rate,55.86,84% of total billed charges,55.86,84% of total billed charges,55.86,84% of total billed charges,46.55,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,13.65,66.50,49.88
Outpatient Medical Services,OCCUPATIONAL THERAPY,97150,"AOT-THERAPEUTIC PROC,GROUP",430,66.5,47.88,Pays at 72% of billed charges with lesser of charges applied,19.48,100% OF CMS OPPS Rate,66.5,Case rate,19.48,100% OF CMS OPPS Rate,65.24,Case rate,19.48,100% OF CMS OPPS Rate,55.86,84% of total billed charges,55.86,84% of total billed charges,47.88,72% of total billed charges,19.48,100% OF CMS OPPS Rate,19.48,100% of CMS OPPS Rate,19.48,100% OF CMS OPPS Rate,39.9,60% of total billed charges,19.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,19.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,19.48,100% OF CMS OPPS Rate,19.48,100% OF CMS OPPS Rate,19.48,100% OF CMS OPPS RATE,19.48,100% OF CMS OPPS Rate,46.55,70% of total billed charges,19.48,100% OF CMS OPPS Rate,23.38,120% of CMS OPPS RATE,47.88,Pays at 72% of billed charges with lesser of charges applied,47.88,Pays at 72% of billed charges with lesser of charges applied,47.88,Pays at 72% of billed charges with lesser of charges applied,47.88,Pays at 72% of billed charges with lesser of charges applied,47.88,Pays at 72% of billed charges with lesser of charges applied,47.88,Pays at 72% of billed charges with lesser of charges applied,66.5,Case rate,66.5,Case rate,66.5,Case rate,66.5,Case rate,66.5,Case rate,66.5,Case rate,66.5,Case rate,66.5,Case rate,66.5,Case rate,65.24,Case rate,65.24,Case rate,65.24,Case rate,65.24,Case rate,65.24,Case rate,55.86,84% of total billed charges,55.86,84% of total billed charges,55.86,84% of total billed charges,46.55,70% of total billed charges,19.48,100% OF CMS OPPS Rate,19.48,100% OF CMS OPPS Rate,19.48,100% OF CMS OPPS Rate,19.48,100% OF CMS OPPS Rate,19.48,100% OF CMS OPPS Rate,19.48,100% OF CMS OPPS Rate,19.48,100% OF CMS OPPS Rate,19.48,100% OF CMS OPPS Rate,19.48,100% OF CMS OPPS Rate,19.48,100% OF CMS OPPS Rate,19.48,100% OF CMS OPPS Rate,19.48,100% OF CMS OPPS Rate,19.48,100% OF CMS OPPS Rate,19.48,100% OF CMS OPPS Rate,19.48,100% OF CMS OPPS Rate,19.48,100% OF CMS OPPS Rate,19.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,19.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,19.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,19.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,19.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,19.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,19.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,19.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,19.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,19.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,19.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,19.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,19.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,19.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,19.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,19.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,19.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,19.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,19.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,19.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,19.42,66.50,49.88
Outpatient Medical Services,OCCUPATIONAL THERAPY,97124,Use of massage,430,66.5,47.88,Pays at 72% of billed charges with lesser of charges applied,33.92,100% OF CMS OPPS Rate,66.5,Case rate,33.92,100% OF CMS OPPS Rate,65.24,Case rate,33.92,100% OF CMS OPPS Rate,55.86,84% of total billed charges,55.86,84% of total billed charges,47.88,72% of total billed charges,33.92,100% OF CMS OPPS Rate,33.92,100% of CMS OPPS Rate,33.92,100% OF CMS OPPS Rate,39.9,60% of total billed charges,14.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,33.92,100% OF CMS OPPS Rate,33.92,100% OF CMS OPPS Rate,33.92,100% OF CMS OPPS RATE,33.92,100% OF CMS OPPS Rate,46.55,70% of total billed charges,33.92,100% OF CMS OPPS Rate,40.7,120% of CMS OPPS RATE,47.88,Pays at 72% of billed charges with lesser of charges applied,47.88,Pays at 72% of billed charges with lesser of charges applied,47.88,Pays at 72% of billed charges with lesser of charges applied,47.88,Pays at 72% of billed charges with lesser of charges applied,47.88,Pays at 72% of billed charges with lesser of charges applied,47.88,Pays at 72% of billed charges with lesser of charges applied,66.5,Case rate,66.5,Case rate,66.5,Case rate,66.5,Case rate,66.5,Case rate,66.5,Case rate,66.5,Case rate,66.5,Case rate,66.5,Case rate,65.24,Case rate,65.24,Case rate,65.24,Case rate,65.24,Case rate,65.24,Case rate,55.86,84% of total billed charges,55.86,84% of total billed charges,55.86,84% of total billed charges,46.55,70% of total billed charges,33.92,100% OF CMS OPPS Rate,33.92,100% OF CMS OPPS Rate,33.92,100% OF CMS OPPS Rate,33.92,100% OF CMS OPPS Rate,33.92,100% OF CMS OPPS Rate,33.92,100% OF CMS OPPS Rate,33.92,100% OF CMS OPPS Rate,33.92,100% OF CMS OPPS Rate,33.92,100% OF CMS OPPS Rate,33.92,100% OF CMS OPPS Rate,33.92,100% OF CMS OPPS Rate,33.92,100% OF CMS OPPS Rate,33.92,100% OF CMS OPPS Rate,33.92,100% OF CMS OPPS Rate,33.92,100% OF CMS OPPS Rate,33.92,100% OF CMS OPPS Rate,14.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.76,66.50,49.88
Outpatient Medical Services,OCCUPATIONAL THERAPY,97018,AOT-PARAFFIN,430,66.5,47.88,Pays at 72% of billed charges with lesser of charges applied,6.27,100% OF CMS OPPS Rate,66.5,Case rate,6.27,100% OF CMS OPPS Rate,65.24,Case rate,6.27,100% OF CMS OPPS Rate,55.86,84% of total billed charges,55.86,84% of total billed charges,47.88,72% of total billed charges,6.27,100% OF CMS OPPS Rate,6.27,100% of CMS OPPS Rate,6.27,100% OF CMS OPPS Rate,39.9,60% of total billed charges,14.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,6.27,100% OF CMS OPPS Rate,6.27,100% OF CMS OPPS Rate,6.27,100% OF CMS OPPS RATE,6.27,100% OF CMS OPPS Rate,46.55,70% of total billed charges,6.27,100% OF CMS OPPS Rate,7.52,120% of CMS OPPS RATE,47.88,Pays at 72% of billed charges with lesser of charges applied,47.88,Pays at 72% of billed charges with lesser of charges applied,47.88,Pays at 72% of billed charges with lesser of charges applied,47.88,Pays at 72% of billed charges with lesser of charges applied,47.88,Pays at 72% of billed charges with lesser of charges applied,47.88,Pays at 72% of billed charges with lesser of charges applied,66.5,Case rate,66.5,Case rate,66.5,Case rate,66.5,Case rate,66.5,Case rate,66.5,Case rate,66.5,Case rate,66.5,Case rate,66.5,Case rate,65.24,Case rate,65.24,Case rate,65.24,Case rate,65.24,Case rate,65.24,Case rate,55.86,84% of total billed charges,55.86,84% of total billed charges,55.86,84% of total billed charges,46.55,70% of total billed charges,6.27,100% OF CMS OPPS Rate,6.27,100% OF CMS OPPS Rate,6.27,100% OF CMS OPPS Rate,6.27,100% OF CMS OPPS Rate,6.27,100% OF CMS OPPS Rate,6.27,100% OF CMS OPPS Rate,6.27,100% OF CMS OPPS Rate,6.27,100% OF CMS OPPS Rate,6.27,100% OF CMS OPPS Rate,6.27,100% OF CMS OPPS Rate,6.27,100% OF CMS OPPS Rate,6.27,100% OF CMS OPPS Rate,6.27,100% OF CMS OPPS Rate,6.27,100% OF CMS OPPS Rate,6.27,100% OF CMS OPPS Rate,6.27,100% OF CMS OPPS Rate,14.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,6.27,66.50,49.88
Outpatient Medical Services,OCCUPATIONAL THERAPY,97537,"OT-COMMUNITY/WORK INTERGRATION, 15 MIN",430,71.25,51.3,Pays at 72% of billed charges with lesser of charges applied,35.28,100% OF CMS OPPS Rate,71.25,Case rate,35.28,100% OF CMS OPPS Rate,69.9,Case rate,35.28,100% OF CMS OPPS Rate,59.85,84% of total billed charges,59.85,84% of total billed charges,51.3,72% of total billed charges,35.28,100% OF CMS OPPS Rate,35.28,100% of CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,42.75,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS RATE,35.28,100% OF CMS OPPS Rate,49.88,70% of total billed charges,35.28,100% OF CMS OPPS Rate,42.34,120% of CMS OPPS RATE,51.3,Pays at 72% of billed charges with lesser of charges applied,51.3,Pays at 72% of billed charges with lesser of charges applied,51.3,Pays at 72% of billed charges with lesser of charges applied,51.3,Pays at 72% of billed charges with lesser of charges applied,51.3,Pays at 72% of billed charges with lesser of charges applied,51.3,Pays at 72% of billed charges with lesser of charges applied,71.25,Case rate,71.25,Case rate,71.25,Case rate,71.25,Case rate,71.25,Case rate,71.25,Case rate,71.25,Case rate,71.25,Case rate,71.25,Case rate,69.9,Case rate,69.9,Case rate,69.9,Case rate,69.9,Case rate,69.9,Case rate,59.85,84% of total billed charges,59.85,84% of total billed charges,59.85,84% of total billed charges,49.88,70% of total billed charges,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,35.28,71.25,53.44
Outpatient Medical Services,OCCUPATIONAL THERAPY,97535,Occupational therapy,430,83.75,60.3,Pays at 72% of billed charges with lesser of charges applied,36.62,100% OF CMS OPPS Rate,83.75,Case rate,36.62,100% OF CMS OPPS Rate,82.16,Case rate,36.62,100% OF CMS OPPS Rate,70.35,84% of total billed charges,70.35,84% of total billed charges,60.3,72% of total billed charges,36.62,100% OF CMS OPPS Rate,36.62,100% of CMS OPPS Rate,36.62,100% OF CMS OPPS Rate,50.25,60% of total billed charges,7.62,100% of CA Medicaid Fee Schedule with lesser of charges applied,7.62,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.62,100% OF CMS OPPS Rate,36.62,100% OF CMS OPPS Rate,36.62,100% OF CMS OPPS RATE,36.62,100% OF CMS OPPS Rate,58.63,70% of total billed charges,36.62,100% OF CMS OPPS Rate,43.94,120% of CMS OPPS RATE,60.3,Pays at 72% of billed charges with lesser of charges applied,60.3,Pays at 72% of billed charges with lesser of charges applied,60.3,Pays at 72% of billed charges with lesser of charges applied,60.3,Pays at 72% of billed charges with lesser of charges applied,60.3,Pays at 72% of billed charges with lesser of charges applied,60.3,Pays at 72% of billed charges with lesser of charges applied,83.75,Case rate,83.75,Case rate,83.75,Case rate,83.75,Case rate,83.75,Case rate,83.75,Case rate,83.75,Case rate,83.75,Case rate,83.75,Case rate,82.16,Case rate,82.16,Case rate,82.16,Case rate,82.16,Case rate,82.16,Case rate,70.35,84% of total billed charges,70.35,84% of total billed charges,70.35,84% of total billed charges,58.63,70% of total billed charges,36.62,100% OF CMS OPPS Rate,36.62,100% OF CMS OPPS Rate,36.62,100% OF CMS OPPS Rate,36.62,100% OF CMS OPPS Rate,36.62,100% OF CMS OPPS Rate,36.62,100% OF CMS OPPS Rate,36.62,100% OF CMS OPPS Rate,36.62,100% OF CMS OPPS Rate,36.62,100% OF CMS OPPS Rate,36.62,100% OF CMS OPPS Rate,36.62,100% OF CMS OPPS Rate,36.62,100% OF CMS OPPS Rate,36.62,100% OF CMS OPPS Rate,36.62,100% OF CMS OPPS Rate,36.62,100% OF CMS OPPS Rate,36.62,100% OF CMS OPPS Rate,7.62,100% of CA Medicaid Fee Schedule with lesser of charges applied,7.62,100% of CA Medicaid Fee Schedule with lesser of charges applied,7.62,100% of CA Medicaid Fee Schedule with lesser of charges applied,7.62,100% of CA Medicaid Fee Schedule with lesser of charges applied,7.62,100% of CA Medicaid Fee Schedule with lesser of charges applied,7.62,100% of CA Medicaid Fee Schedule with lesser of charges applied,7.62,100% of CA Medicaid Fee Schedule with lesser of charges applied,7.62,100% of CA Medicaid Fee Schedule with lesser of charges applied,7.62,100% of CA Medicaid Fee Schedule with lesser of charges applied,7.62,100% of CA Medicaid Fee Schedule with lesser of charges applied,7.62,100% of CA Medicaid Fee Schedule with lesser of charges applied,7.62,100% of CA Medicaid Fee Schedule with lesser of charges applied,7.62,100% of CA Medicaid Fee Schedule with lesser of charges applied,7.62,100% of CA Medicaid Fee Schedule with lesser of charges applied,7.62,100% of CA Medicaid Fee Schedule with lesser of charges applied,7.62,100% of CA Medicaid Fee Schedule with lesser of charges applied,7.62,100% of CA Medicaid Fee Schedule with lesser of charges applied,7.62,100% of CA Medicaid Fee Schedule with lesser of charges applied,7.62,100% of CA Medicaid Fee Schedule with lesser of charges applied,7.62,100% of CA Medicaid Fee Schedule with lesser of charges applied,7.62,83.75,62.81
Outpatient Medical Services,OCCUPATIONAL THERAPY,97542,OT-WHEELCHAIR MANAGEMENT (15 MIN),430,93,66.96,Pays at 72% of billed charges with lesser of charges applied,35.28,100% OF CMS OPPS Rate,93,Case rate,35.28,100% OF CMS OPPS Rate,91.23,Case rate,35.28,100% OF CMS OPPS Rate,78.12,84% of total billed charges,78.12,84% of total billed charges,66.96,72% of total billed charges,35.28,100% OF CMS OPPS Rate,35.28,100% of CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,55.8,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS RATE,35.28,100% OF CMS OPPS Rate,65.1,70% of total billed charges,35.28,100% OF CMS OPPS Rate,42.34,120% of CMS OPPS RATE,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,91.23,Case rate,91.23,Case rate,91.23,Case rate,91.23,Case rate,91.23,Case rate,78.12,84% of total billed charges,78.12,84% of total billed charges,78.12,84% of total billed charges,65.1,70% of total billed charges,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,35.28,93.00,69.75
Outpatient Medical Services,OCCUPATIONAL THERAPY,97110,"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",430,93,66.96,Pays at 72% of billed charges with lesser of charges applied,32.64,100% OF CMS OPPS Rate,93,Case rate,32.64,100% OF CMS OPPS Rate,91.23,Case rate,32.64,100% OF CMS OPPS Rate,78.12,84% of total billed charges,78.12,84% of total billed charges,66.96,72% of total billed charges,32.64,100% OF CMS OPPS Rate,32.64,100% of CMS OPPS Rate,32.64,100% OF CMS OPPS Rate,55.8,60% of total billed charges,15.72,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.72,100% of CA Medicaid Fee Schedule with lesser of charges applied,32.64,100% OF CMS OPPS Rate,32.64,100% OF CMS OPPS Rate,32.64,100% OF CMS OPPS RATE,32.64,100% OF CMS OPPS Rate,65.1,70% of total billed charges,32.64,100% OF CMS OPPS Rate,39.17,120% of CMS OPPS RATE,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,91.23,Case rate,91.23,Case rate,91.23,Case rate,91.23,Case rate,91.23,Case rate,78.12,84% of total billed charges,78.12,84% of total billed charges,78.12,84% of total billed charges,65.1,70% of total billed charges,32.64,100% OF CMS OPPS Rate,32.64,100% OF CMS OPPS Rate,32.64,100% OF CMS OPPS Rate,32.64,100% OF CMS OPPS Rate,32.64,100% OF CMS OPPS Rate,32.64,100% OF CMS OPPS Rate,32.64,100% OF CMS OPPS Rate,32.64,100% OF CMS OPPS Rate,32.64,100% OF CMS OPPS Rate,32.64,100% OF CMS OPPS Rate,32.64,100% OF CMS OPPS Rate,32.64,100% OF CMS OPPS Rate,32.64,100% OF CMS OPPS Rate,32.64,100% OF CMS OPPS Rate,32.64,100% OF CMS OPPS Rate,32.64,100% OF CMS OPPS Rate,15.72,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.72,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.72,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.72,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.72,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.72,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.72,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.72,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.72,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.72,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.72,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.72,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.72,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.72,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.72,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.72,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.72,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.72,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.72,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.72,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.72,93.00,69.75
Outpatient Medical Services,OCCUPATIONAL THERAPY,97532,AOT-DEVELOPMENT COGNITIVE SKILL,430,93,66.96,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,93,Case rate,N/A,Not Separately reimbursable,91.23,Case rate,N/A,Not Separately reimbursable,78.12,84% of total billed charges,78.12,84% of total billed charges,66.96,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,55.8,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,65.1,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,91.23,Case rate,91.23,Case rate,91.23,Case rate,91.23,Case rate,91.23,Case rate,78.12,84% of total billed charges,78.12,84% of total billed charges,78.12,84% of total billed charges,65.1,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,55.80,93.00,69.75
Outpatient Medical Services,OCCUPATIONAL THERAPY,97127,OT-DEVELOPMENT COGNITIVE SKILLS,430,93,66.96,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,93,Case rate,N/A,Not Separately reimbursable,91.23,Case rate,N/A,Not Separately reimbursable,78.12,84% of total billed charges,78.12,84% of total billed charges,66.96,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,55.8,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,65.1,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,91.23,Case rate,91.23,Case rate,91.23,Case rate,91.23,Case rate,91.23,Case rate,78.12,84% of total billed charges,78.12,84% of total billed charges,78.12,84% of total billed charges,65.1,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,55.80,93.00,69.75
Outpatient Medical Services,OCCUPATIONAL THERAPY,97530,"Incorporates the use of multiple parameters, such as balance, strength, and range of motion, for a functional activity",430,93,66.96,Pays at 72% of billed charges with lesser of charges applied,41.84,100% OF CMS OPPS Rate,93,Case rate,41.84,100% OF CMS OPPS Rate,91.23,Case rate,41.84,100% OF CMS OPPS Rate,78.12,84% of total billed charges,78.12,84% of total billed charges,66.96,72% of total billed charges,41.84,100% OF CMS OPPS Rate,41.84,100% of CMS OPPS Rate,41.84,100% OF CMS OPPS Rate,55.8,60% of total billed charges,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,41.84,100% OF CMS OPPS Rate,41.84,100% OF CMS OPPS Rate,41.84,100% OF CMS OPPS RATE,41.84,100% OF CMS OPPS Rate,65.1,70% of total billed charges,41.84,100% OF CMS OPPS Rate,50.21,120% of CMS OPPS RATE,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,91.23,Case rate,91.23,Case rate,91.23,Case rate,91.23,Case rate,91.23,Case rate,78.12,84% of total billed charges,78.12,84% of total billed charges,78.12,84% of total billed charges,65.1,70% of total billed charges,41.84,100% OF CMS OPPS Rate,41.84,100% OF CMS OPPS Rate,41.84,100% OF CMS OPPS Rate,41.84,100% OF CMS OPPS Rate,41.84,100% OF CMS OPPS Rate,41.84,100% OF CMS OPPS Rate,41.84,100% OF CMS OPPS Rate,41.84,100% OF CMS OPPS Rate,41.84,100% OF CMS OPPS Rate,41.84,100% OF CMS OPPS Rate,41.84,100% OF CMS OPPS Rate,41.84,100% OF CMS OPPS Rate,41.84,100% OF CMS OPPS Rate,41.84,100% OF CMS OPPS Rate,41.84,100% OF CMS OPPS Rate,41.84,100% OF CMS OPPS Rate,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,93.00,69.75
Outpatient Medical Services,OCCUPATIONAL THERAPY,97762,AOT-ORTHOTIC/PROSTHETHIC CHECK,430,93,66.96,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,93,Case rate,N/A,Not Separately reimbursable,91.23,Case rate,N/A,Not Separately reimbursable,78.12,84% of total billed charges,78.12,84% of total billed charges,66.96,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,55.8,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,65.1,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,91.23,Case rate,91.23,Case rate,91.23,Case rate,91.23,Case rate,91.23,Case rate,78.12,84% of total billed charges,78.12,84% of total billed charges,78.12,84% of total billed charges,65.1,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,55.80,93.00,69.75
Outpatient Medical Services,OCCUPATIONAL THERAPY,97140,Manipulation of 1 or more regions of the body,430,93,66.96,Pays at 72% of billed charges with lesser of charges applied,29.95,100% OF CMS OPPS Rate,93,Case rate,29.95,100% OF CMS OPPS Rate,91.23,Case rate,29.95,100% OF CMS OPPS Rate,78.12,84% of total billed charges,78.12,84% of total billed charges,66.96,72% of total billed charges,29.95,100% OF CMS OPPS Rate,29.95,100% of CMS OPPS Rate,29.95,100% OF CMS OPPS Rate,55.8,60% of total billed charges,31.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.95,100% OF CMS OPPS Rate,29.95,100% OF CMS OPPS Rate,29.95,100% OF CMS OPPS RATE,29.95,100% OF CMS OPPS Rate,65.1,70% of total billed charges,29.95,100% OF CMS OPPS Rate,35.94,120% of CMS OPPS RATE,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,91.23,Case rate,91.23,Case rate,91.23,Case rate,91.23,Case rate,91.23,Case rate,78.12,84% of total billed charges,78.12,84% of total billed charges,78.12,84% of total billed charges,65.1,70% of total billed charges,29.95,100% OF CMS OPPS Rate,29.95,100% OF CMS OPPS Rate,29.95,100% OF CMS OPPS Rate,29.95,100% OF CMS OPPS Rate,29.95,100% OF CMS OPPS Rate,29.95,100% OF CMS OPPS Rate,29.95,100% OF CMS OPPS Rate,29.95,100% OF CMS OPPS Rate,29.95,100% OF CMS OPPS Rate,29.95,100% OF CMS OPPS Rate,29.95,100% OF CMS OPPS Rate,29.95,100% OF CMS OPPS Rate,29.95,100% OF CMS OPPS Rate,29.95,100% OF CMS OPPS Rate,29.95,100% OF CMS OPPS Rate,29.95,100% OF CMS OPPS Rate,31.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.95,93.00,69.75
Outpatient Medical Services,OCCUPATIONAL THERAPY,97112,A technique used by physical therapists to restore normal body movement patterns,430,93,66.96,Pays at 72% of billed charges with lesser of charges applied,37.57,100% OF CMS OPPS Rate,93,Case rate,37.57,100% OF CMS OPPS Rate,91.23,Case rate,37.57,100% OF CMS OPPS Rate,78.12,84% of total billed charges,78.12,84% of total billed charges,66.96,72% of total billed charges,37.57,100% OF CMS OPPS Rate,37.57,100% of CMS OPPS Rate,37.57,100% OF CMS OPPS Rate,55.8,60% of total billed charges,17.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,17.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.57,100% OF CMS OPPS Rate,37.57,100% OF CMS OPPS Rate,37.57,100% OF CMS OPPS RATE,37.57,100% OF CMS OPPS Rate,65.1,70% of total billed charges,37.57,100% OF CMS OPPS Rate,45.08,120% of CMS OPPS RATE,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,91.23,Case rate,91.23,Case rate,91.23,Case rate,91.23,Case rate,91.23,Case rate,78.12,84% of total billed charges,78.12,84% of total billed charges,78.12,84% of total billed charges,65.1,70% of total billed charges,37.57,100% OF CMS OPPS Rate,37.57,100% OF CMS OPPS Rate,37.57,100% OF CMS OPPS Rate,37.57,100% OF CMS OPPS Rate,37.57,100% OF CMS OPPS Rate,37.57,100% OF CMS OPPS Rate,37.57,100% OF CMS OPPS Rate,37.57,100% OF CMS OPPS Rate,37.57,100% OF CMS OPPS Rate,37.57,100% OF CMS OPPS Rate,37.57,100% OF CMS OPPS Rate,37.57,100% OF CMS OPPS Rate,37.57,100% OF CMS OPPS Rate,37.57,100% OF CMS OPPS Rate,37.57,100% OF CMS OPPS Rate,37.57,100% OF CMS OPPS Rate,17.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,17.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,17.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,17.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,17.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,17.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,17.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,17.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,17.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,17.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,17.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,17.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,17.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,17.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,17.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,17.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,17.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,17.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,17.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,17.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,17.53,93.00,69.75
Outpatient Medical Services,OCCUPATIONAL THERAPY,97034,"OT-CONTRAST BATH, EA 15 MIN",430,93,66.96,Pays at 72% of billed charges with lesser of charges applied,15.89,100% OF CMS OPPS Rate,93,Case rate,15.89,100% OF CMS OPPS Rate,91.23,Case rate,15.89,100% OF CMS OPPS Rate,78.12,84% of total billed charges,78.12,84% of total billed charges,66.96,72% of total billed charges,15.89,100% OF CMS OPPS Rate,15.89,100% of CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,55.8,60% of total billed charges,11.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS RATE,15.89,100% OF CMS OPPS Rate,65.1,70% of total billed charges,15.89,100% OF CMS OPPS Rate,19.07,120% of CMS OPPS RATE,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,91.23,Case rate,91.23,Case rate,91.23,Case rate,91.23,Case rate,91.23,Case rate,78.12,84% of total billed charges,78.12,84% of total billed charges,78.12,84% of total billed charges,65.1,70% of total billed charges,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,11.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.23,93.00,69.75
Outpatient Medical Services,OCCUPATIONAL THERAPY,97032,Repeated application to one or more parts of the body,430,93,66.96,Pays at 72% of billed charges with lesser of charges applied,15.69,100% OF CMS OPPS Rate,93,Case rate,15.69,100% OF CMS OPPS Rate,91.23,Case rate,15.69,100% OF CMS OPPS Rate,78.12,84% of total billed charges,78.12,84% of total billed charges,66.96,72% of total billed charges,15.69,100% OF CMS OPPS Rate,15.69,100% of CMS OPPS Rate,15.69,100% OF CMS OPPS Rate,55.8,60% of total billed charges,12.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,12.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.69,100% OF CMS OPPS Rate,15.69,100% OF CMS OPPS Rate,15.69,100% OF CMS OPPS RATE,15.69,100% OF CMS OPPS Rate,65.1,70% of total billed charges,15.69,100% OF CMS OPPS Rate,18.83,120% of CMS OPPS RATE,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,91.23,Case rate,91.23,Case rate,91.23,Case rate,91.23,Case rate,91.23,Case rate,78.12,84% of total billed charges,78.12,84% of total billed charges,78.12,84% of total billed charges,65.1,70% of total billed charges,15.69,100% OF CMS OPPS Rate,15.69,100% OF CMS OPPS Rate,15.69,100% OF CMS OPPS Rate,15.69,100% OF CMS OPPS Rate,15.69,100% OF CMS OPPS Rate,15.69,100% OF CMS OPPS Rate,15.69,100% OF CMS OPPS Rate,15.69,100% OF CMS OPPS Rate,15.69,100% OF CMS OPPS Rate,15.69,100% OF CMS OPPS Rate,15.69,100% OF CMS OPPS Rate,15.69,100% OF CMS OPPS Rate,15.69,100% OF CMS OPPS Rate,15.69,100% OF CMS OPPS Rate,15.69,100% OF CMS OPPS Rate,15.69,100% OF CMS OPPS Rate,12.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,12.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,12.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,12.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,12.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,12.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,12.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,12.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,12.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,12.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,12.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,12.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,12.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,12.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,12.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,12.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,12.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,12.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,12.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,12.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,12.42,93.00,69.75
Outpatient Medical Services,OCCUPATIONAL THERAPY,97761,AOT-PROSTETIC TRAINING,430,93,66.96,Pays at 72% of billed charges with lesser of charges applied,47.12,100% OF CMS OPPS Rate,93,Case rate,47.12,100% OF CMS OPPS Rate,91.23,Case rate,47.12,100% OF CMS OPPS Rate,78.12,84% of total billed charges,78.12,84% of total billed charges,66.96,72% of total billed charges,47.12,100% OF CMS OPPS Rate,47.12,100% of CMS OPPS Rate,47.12,100% OF CMS OPPS Rate,55.8,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,47.12,100% OF CMS OPPS Rate,47.12,100% OF CMS OPPS Rate,47.12,100% OF CMS OPPS RATE,47.12,100% OF CMS OPPS Rate,65.1,70% of total billed charges,47.12,100% OF CMS OPPS Rate,56.54,120% of CMS OPPS RATE,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,91.23,Case rate,91.23,Case rate,91.23,Case rate,91.23,Case rate,91.23,Case rate,78.12,84% of total billed charges,78.12,84% of total billed charges,78.12,84% of total billed charges,65.1,70% of total billed charges,47.12,100% OF CMS OPPS Rate,47.12,100% OF CMS OPPS Rate,47.12,100% OF CMS OPPS Rate,47.12,100% OF CMS OPPS Rate,47.12,100% OF CMS OPPS Rate,47.12,100% OF CMS OPPS Rate,47.12,100% OF CMS OPPS Rate,47.12,100% OF CMS OPPS Rate,47.12,100% OF CMS OPPS Rate,47.12,100% OF CMS OPPS Rate,47.12,100% OF CMS OPPS Rate,47.12,100% OF CMS OPPS Rate,47.12,100% OF CMS OPPS Rate,47.12,100% OF CMS OPPS Rate,47.12,100% OF CMS OPPS Rate,47.12,100% OF CMS OPPS Rate,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,47.12,93.00,69.75
Outpatient Medical Services,OCCUPATIONAL THERAPY,97035,"Use of sound waves to treat medical problems, especially musculoskeletal problems like inflammation from injuries",430,93,66.96,Pays at 72% of billed charges with lesser of charges applied,15.89,100% OF CMS OPPS Rate,93,Case rate,15.89,100% OF CMS OPPS Rate,91.23,Case rate,15.89,100% OF CMS OPPS Rate,78.12,84% of total billed charges,78.12,84% of total billed charges,66.96,72% of total billed charges,15.89,100% OF CMS OPPS Rate,15.89,100% of CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,55.8,60% of total billed charges,10.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS RATE,15.89,100% OF CMS OPPS Rate,65.1,70% of total billed charges,15.89,100% OF CMS OPPS Rate,19.07,120% of CMS OPPS RATE,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,91.23,Case rate,91.23,Case rate,91.23,Case rate,91.23,Case rate,91.23,Case rate,78.12,84% of total billed charges,78.12,84% of total billed charges,78.12,84% of total billed charges,65.1,70% of total billed charges,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,10.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.66,93.00,69.75
Outpatient Medical Services,OCCUPATIONAL THERAPY,90901,AOT-EMG BIOFEEDBACK,430,93,66.96,Pays at 72% of billed charges with lesser of charges applied,20.09,100% OF CMS OPPS Rate,93,Case rate,20.09,100% OF CMS OPPS Rate,91.23,Case rate,20.09,100% OF CMS OPPS Rate,78.12,84% of total billed charges,78.12,84% of total billed charges,66.96,72% of total billed charges,20.09,100% OF CMS OPPS Rate,20.09,100% of CMS OPPS Rate,20.09,100% OF CMS OPPS Rate,55.8,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,20.09,100% OF CMS OPPS Rate,20.09,100% OF CMS OPPS Rate,20.09,100% OF CMS OPPS RATE,20.09,100% OF CMS OPPS Rate,65.1,70% of total billed charges,20.09,100% OF CMS OPPS Rate,24.11,120% of CMS OPPS RATE,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,91.23,Case rate,91.23,Case rate,91.23,Case rate,91.23,Case rate,91.23,Case rate,78.12,84% of total billed charges,78.12,84% of total billed charges,78.12,84% of total billed charges,65.1,70% of total billed charges,20.09,100% OF CMS OPPS Rate,20.09,100% OF CMS OPPS Rate,20.09,100% OF CMS OPPS Rate,20.09,100% OF CMS OPPS Rate,20.09,100% OF CMS OPPS Rate,20.09,100% OF CMS OPPS Rate,20.09,100% OF CMS OPPS Rate,20.09,100% OF CMS OPPS Rate,20.09,100% OF CMS OPPS Rate,20.09,100% OF CMS OPPS Rate,20.09,100% OF CMS OPPS Rate,20.09,100% OF CMS OPPS Rate,20.09,100% OF CMS OPPS Rate,20.09,100% OF CMS OPPS Rate,20.09,100% OF CMS OPPS Rate,20.09,100% OF CMS OPPS Rate,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,20.09,93.00,69.75
Outpatient Medical Services,OCCUPATIONAL THERAPY,95852,AOT-ROM MEAS HAND,430,93,66.96,Pays at 72% of billed charges with lesser of charges applied,5.63,100% OF CMS OPPS Rate,93,Case rate,5.63,100% OF CMS OPPS Rate,91.23,Case rate,5.63,100% OF CMS OPPS Rate,78.12,84% of total billed charges,78.12,84% of total billed charges,66.96,72% of total billed charges,5.63,100% OF CMS OPPS Rate,5.63,100% of CMS OPPS Rate,5.63,100% OF CMS OPPS Rate,55.8,60% of total billed charges,11.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,5.63,100% OF CMS OPPS Rate,5.63,100% OF CMS OPPS Rate,5.63,100% OF CMS OPPS RATE,5.63,100% OF CMS OPPS Rate,65.1,70% of total billed charges,5.63,100% OF CMS OPPS Rate,6.76,120% of CMS OPPS RATE,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,91.23,Case rate,91.23,Case rate,91.23,Case rate,91.23,Case rate,91.23,Case rate,78.12,84% of total billed charges,78.12,84% of total billed charges,78.12,84% of total billed charges,65.1,70% of total billed charges,5.63,100% OF CMS OPPS Rate,5.63,100% OF CMS OPPS Rate,5.63,100% OF CMS OPPS Rate,5.63,100% OF CMS OPPS Rate,5.63,100% OF CMS OPPS Rate,5.63,100% OF CMS OPPS Rate,5.63,100% OF CMS OPPS Rate,5.63,100% OF CMS OPPS Rate,5.63,100% OF CMS OPPS Rate,5.63,100% OF CMS OPPS Rate,5.63,100% OF CMS OPPS Rate,5.63,100% OF CMS OPPS Rate,5.63,100% OF CMS OPPS Rate,5.63,100% OF CMS OPPS Rate,5.63,100% OF CMS OPPS Rate,5.63,100% OF CMS OPPS Rate,11.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,5.63,93.00,69.75
Outpatient Medical Services,OCCUPATIONAL THERAPY,97033,Psychiatric treatment in which seizures are electrically induced in patients to provide relief from mental disorders,430,93,66.96,Pays at 72% of billed charges with lesser of charges applied,22.02,100% OF CMS OPPS Rate,93,Case rate,22.02,100% OF CMS OPPS Rate,91.23,Case rate,22.02,100% OF CMS OPPS Rate,78.12,84% of total billed charges,78.12,84% of total billed charges,66.96,72% of total billed charges,22.02,100% OF CMS OPPS Rate,22.02,100% of CMS OPPS Rate,22.02,100% OF CMS OPPS Rate,55.8,60% of total billed charges,13.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,13.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,22.02,100% OF CMS OPPS Rate,22.02,100% OF CMS OPPS Rate,22.02,100% OF CMS OPPS RATE,22.02,100% OF CMS OPPS Rate,65.1,70% of total billed charges,22.02,100% OF CMS OPPS Rate,26.42,120% of CMS OPPS RATE,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,91.23,Case rate,91.23,Case rate,91.23,Case rate,91.23,Case rate,91.23,Case rate,78.12,84% of total billed charges,78.12,84% of total billed charges,78.12,84% of total billed charges,65.1,70% of total billed charges,22.02,100% OF CMS OPPS Rate,22.02,100% OF CMS OPPS Rate,22.02,100% OF CMS OPPS Rate,22.02,100% OF CMS OPPS Rate,22.02,100% OF CMS OPPS Rate,22.02,100% OF CMS OPPS Rate,22.02,100% OF CMS OPPS Rate,22.02,100% OF CMS OPPS Rate,22.02,100% OF CMS OPPS Rate,22.02,100% OF CMS OPPS Rate,22.02,100% OF CMS OPPS Rate,22.02,100% OF CMS OPPS Rate,22.02,100% OF CMS OPPS Rate,22.02,100% OF CMS OPPS Rate,22.02,100% OF CMS OPPS Rate,22.02,100% OF CMS OPPS Rate,13.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,13.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,13.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,13.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,13.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,13.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,13.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,13.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,13.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,13.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,13.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,13.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,13.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,13.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,13.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,13.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,13.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,13.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,13.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,13.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,13.17,93.00,69.75
Outpatient Medical Services,OCCUPATIONAL THERAPY,97022,AOT-WHIRLPOOL,430,93,66.96,Pays at 72% of billed charges with lesser of charges applied,19.27,100% OF CMS OPPS Rate,93,Case rate,19.27,100% OF CMS OPPS Rate,91.23,Case rate,19.27,100% OF CMS OPPS Rate,78.12,84% of total billed charges,78.12,84% of total billed charges,66.96,72% of total billed charges,19.27,100% OF CMS OPPS Rate,19.27,100% of CMS OPPS Rate,19.27,100% OF CMS OPPS Rate,55.8,60% of total billed charges,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,19.27,100% OF CMS OPPS Rate,19.27,100% OF CMS OPPS Rate,19.27,100% OF CMS OPPS RATE,19.27,100% OF CMS OPPS Rate,65.1,70% of total billed charges,19.27,100% OF CMS OPPS Rate,23.12,120% of CMS OPPS RATE,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,66.96,Pays at 72% of billed charges with lesser of charges applied,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,93,Case rate,91.23,Case rate,91.23,Case rate,91.23,Case rate,91.23,Case rate,91.23,Case rate,78.12,84% of total billed charges,78.12,84% of total billed charges,78.12,84% of total billed charges,65.1,70% of total billed charges,19.27,100% OF CMS OPPS Rate,19.27,100% OF CMS OPPS Rate,19.27,100% OF CMS OPPS Rate,19.27,100% OF CMS OPPS Rate,19.27,100% OF CMS OPPS Rate,19.27,100% OF CMS OPPS Rate,19.27,100% OF CMS OPPS Rate,19.27,100% OF CMS OPPS Rate,19.27,100% OF CMS OPPS Rate,19.27,100% OF CMS OPPS Rate,19.27,100% OF CMS OPPS Rate,19.27,100% OF CMS OPPS Rate,19.27,100% OF CMS OPPS Rate,19.27,100% OF CMS OPPS Rate,19.27,100% OF CMS OPPS Rate,19.27,100% OF CMS OPPS Rate,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,93.00,69.75
Outpatient Medical Services,OCCUPATIONAL THERAPY,97546,AOT-WORKING HARDENING EA ADD HR,430,118.75,85.5,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,118.75,Case rate,N/A,Not Separately reimbursable,116.49,Case rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,85.5,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,71.25,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,83.13,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,85.5,Pays at 72% of billed charges with lesser of charges applied,85.5,Pays at 72% of billed charges with lesser of charges applied,85.5,Pays at 72% of billed charges with lesser of charges applied,85.5,Pays at 72% of billed charges with lesser of charges applied,85.5,Pays at 72% of billed charges with lesser of charges applied,85.5,Pays at 72% of billed charges with lesser of charges applied,118.75,Case rate,118.75,Case rate,118.75,Case rate,118.75,Case rate,118.75,Case rate,118.75,Case rate,118.75,Case rate,118.75,Case rate,118.75,Case rate,116.49,Case rate,116.49,Case rate,116.49,Case rate,116.49,Case rate,116.49,Case rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,83.13,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,71.25,118.75,89.06
Outpatient Medical Services,OCCUPATIONAL THERAPY,16020,AOT-BURN TREATMENT SMALL,430,130.5,93.96,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,130.5,Case rate,N/A,Not Separately reimbursable,128.02,Case rate,N/A,Not Separately reimbursable,109.62,84% of total billed charges,109.62,84% of total billed charges,93.96,72% of total billed charges,N/A,Not Separately reimbursable,130.5,100% of CMS OPPS Rate,N/A,Not Separately reimbursable,78.3,60% of total billed charges,45.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,59.81,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,91.35,70% of total billed charges,130.5,100% OF CMS OPPS Rate,130.5,120% of CMS OPPS RATE,93.96,Pays at 72% of billed charges with lesser of charges applied,93.96,Pays at 72% of billed charges with lesser of charges applied,93.96,Pays at 72% of billed charges with lesser of charges applied,93.96,Pays at 72% of billed charges with lesser of charges applied,93.96,Pays at 72% of billed charges with lesser of charges applied,93.96,Pays at 72% of billed charges with lesser of charges applied,130.5,Case rate,130.5,Case rate,130.5,Case rate,130.5,Case rate,130.5,Case rate,130.5,Case rate,130.5,Case rate,130.5,Case rate,130.5,Case rate,128.02,Case rate,128.02,Case rate,128.02,Case rate,128.02,Case rate,128.02,Case rate,109.62,84% of total billed charges,109.62,84% of total billed charges,109.62,84% of total billed charges,91.35,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,45.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.40,130.50,97.88
Outpatient Medical Services,OCCUPATIONAL THERAPY,97165,AOT-LOW EVALUATION,434,137.25,98.82,Pays at 72% of billed charges with lesser of charges applied,111.12,100% OF CMS OPPS Rate,137.25,Case rate,111.12,100% OF CMS OPPS Rate,134.64,Case rate,111.12,100% OF CMS OPPS Rate,115.29,84% of total billed charges,115.29,84% of total billed charges,98.82,72% of total billed charges,111.12,100% OF CMS OPPS Rate,111.12,100% of CMS OPPS Rate,111.12,100% OF CMS OPPS Rate,82.35,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,111.12,100% OF CMS OPPS Rate,111.12,100% OF CMS OPPS Rate,111.12,100% OF CMS OPPS RATE,111.12,100% OF CMS OPPS Rate,96.08,70% of total billed charges,111.12,100% OF CMS OPPS Rate,133.34,120% of CMS OPPS RATE,98.82,Pays at 72% of billed charges with lesser of charges applied,98.82,Pays at 72% of billed charges with lesser of charges applied,98.82,Pays at 72% of billed charges with lesser of charges applied,98.82,Pays at 72% of billed charges with lesser of charges applied,98.82,Pays at 72% of billed charges with lesser of charges applied,98.82,Pays at 72% of billed charges with lesser of charges applied,137.25,Case rate,137.25,Case rate,137.25,Case rate,137.25,Case rate,137.25,Case rate,137.25,Case rate,137.25,Case rate,137.25,Case rate,137.25,Case rate,134.64,Case rate,134.64,Case rate,134.64,Case rate,134.64,Case rate,134.64,Case rate,115.29,84% of total billed charges,115.29,84% of total billed charges,115.29,84% of total billed charges,96.08,70% of total billed charges,111.12,100% OF CMS OPPS Rate,111.12,100% OF CMS OPPS Rate,111.12,100% OF CMS OPPS Rate,111.12,100% OF CMS OPPS Rate,111.12,100% OF CMS OPPS Rate,111.12,100% OF CMS OPPS Rate,111.12,100% OF CMS OPPS Rate,111.12,100% OF CMS OPPS Rate,111.12,100% OF CMS OPPS Rate,111.12,100% OF CMS OPPS Rate,111.12,100% OF CMS OPPS Rate,111.12,100% OF CMS OPPS Rate,111.12,100% OF CMS OPPS Rate,111.12,100% OF CMS OPPS Rate,111.12,100% OF CMS OPPS Rate,111.12,100% OF CMS OPPS Rate,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,82.35,137.25,102.94
Outpatient Medical Services,OCCUPATIONAL THERAPY,29125,OT-APPLICATION SHORT ARM SPLT-STATIC,430,159,114.48,Pays at 72% of billed charges with lesser of charges applied,147.58,100% OF CMS OPPS Rate,159,Case rate,147.58,100% OF CMS OPPS Rate,155.98,Case rate,147.58,100% OF CMS OPPS Rate,133.56,84% of total billed charges,133.56,84% of total billed charges,114.48,72% of total billed charges,147.58,100% OF CMS OPPS Rate,147.58,100% of CMS OPPS Rate,147.58,100% OF CMS OPPS Rate,95.4,60% of total billed charges,75.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,147.58,100% OF CMS OPPS Rate,147.58,100% OF CMS OPPS Rate,43.71,100% OF CMS OPPS RATE,147.58,100% OF CMS OPPS Rate,111.3,70% of total billed charges,147.58,100% OF CMS OPPS Rate,159,120% of CMS OPPS RATE,114.48,Pays at 72% of billed charges with lesser of charges applied,114.48,Pays at 72% of billed charges with lesser of charges applied,114.48,Pays at 72% of billed charges with lesser of charges applied,114.48,Pays at 72% of billed charges with lesser of charges applied,114.48,Pays at 72% of billed charges with lesser of charges applied,114.48,Pays at 72% of billed charges with lesser of charges applied,159,Case rate,159,Case rate,159,Case rate,159,Case rate,159,Case rate,159,Case rate,159,Case rate,159,Case rate,159,Case rate,155.98,Case rate,155.98,Case rate,155.98,Case rate,155.98,Case rate,155.98,Case rate,133.56,84% of total billed charges,133.56,84% of total billed charges,133.56,84% of total billed charges,111.3,70% of total billed charges,147.58,100% OF CMS OPPS Rate,147.58,100% OF CMS OPPS Rate,147.58,100% OF CMS OPPS Rate,147.58,100% OF CMS OPPS Rate,147.58,100% OF CMS OPPS Rate,147.58,100% OF CMS OPPS Rate,147.58,100% OF CMS OPPS Rate,147.58,100% OF CMS OPPS Rate,147.58,100% OF CMS OPPS Rate,147.58,100% OF CMS OPPS Rate,147.58,100% OF CMS OPPS Rate,147.58,100% OF CMS OPPS Rate,147.58,100% OF CMS OPPS Rate,147.58,100% OF CMS OPPS Rate,147.58,100% OF CMS OPPS Rate,147.58,100% OF CMS OPPS Rate,75.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,43.71,159.00,119.25
Outpatient Medical Services,OCCUPATIONAL THERAPY,97166,AOT-MOD EVALUATION,434,171.75,123.66,Pays at 72% of billed charges with lesser of charges applied,111.12,100% OF CMS OPPS Rate,171.75,Case rate,111.12,100% OF CMS OPPS Rate,168.49,Case rate,111.12,100% OF CMS OPPS Rate,144.27,84% of total billed charges,144.27,84% of total billed charges,123.66,72% of total billed charges,111.12,100% OF CMS OPPS Rate,111.12,100% of CMS OPPS Rate,111.12,100% OF CMS OPPS Rate,103.05,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,111.12,100% OF CMS OPPS Rate,111.12,100% OF CMS OPPS Rate,111.12,100% OF CMS OPPS RATE,111.12,100% OF CMS OPPS Rate,120.23,70% of total billed charges,111.12,100% OF CMS OPPS Rate,133.34,120% of CMS OPPS RATE,123.66,Pays at 72% of billed charges with lesser of charges applied,123.66,Pays at 72% of billed charges with lesser of charges applied,123.66,Pays at 72% of billed charges with lesser of charges applied,123.66,Pays at 72% of billed charges with lesser of charges applied,123.66,Pays at 72% of billed charges with lesser of charges applied,123.66,Pays at 72% of billed charges with lesser of charges applied,171.75,Case rate,171.75,Case rate,171.75,Case rate,171.75,Case rate,171.75,Case rate,171.75,Case rate,171.75,Case rate,171.75,Case rate,171.75,Case rate,168.49,Case rate,168.49,Case rate,168.49,Case rate,168.49,Case rate,168.49,Case rate,144.27,84% of total billed charges,144.27,84% of total billed charges,144.27,84% of total billed charges,120.23,70% of total billed charges,111.12,100% OF CMS OPPS Rate,111.12,100% OF CMS OPPS Rate,111.12,100% OF CMS OPPS Rate,111.12,100% OF CMS OPPS Rate,111.12,100% OF CMS OPPS Rate,111.12,100% OF CMS OPPS Rate,111.12,100% OF CMS OPPS Rate,111.12,100% OF CMS OPPS Rate,111.12,100% OF CMS OPPS Rate,111.12,100% OF CMS OPPS Rate,111.12,100% OF CMS OPPS Rate,111.12,100% OF CMS OPPS Rate,111.12,100% OF CMS OPPS Rate,111.12,100% OF CMS OPPS Rate,111.12,100% OF CMS OPPS Rate,111.12,100% OF CMS OPPS Rate,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,103.05,171.75,128.81
Outpatient Medical Services,OCCUPATIONAL THERAPY,97168,AOT-RE-EVALUATION,434,190.25,136.98,Pays at 72% of billed charges with lesser of charges applied,76.92,100% OF CMS OPPS Rate,190.25,Case rate,76.92,100% OF CMS OPPS Rate,186.64,Case rate,76.92,100% OF CMS OPPS Rate,159.81,84% of total billed charges,159.81,84% of total billed charges,136.98,72% of total billed charges,76.92,100% OF CMS OPPS Rate,76.92,100% of CMS OPPS Rate,76.92,100% OF CMS OPPS Rate,114.15,60% of total billed charges,125.25,100% of CA Medicaid Fee Schedule with lesser of charges applied,125.25,100% of CA Medicaid Fee Schedule with lesser of charges applied,76.92,100% OF CMS OPPS Rate,76.92,100% OF CMS OPPS Rate,76.92,100% OF CMS OPPS RATE,76.92,100% OF CMS OPPS Rate,133.18,70% of total billed charges,76.92,100% OF CMS OPPS Rate,92.3,120% of CMS OPPS RATE,136.98,Pays at 72% of billed charges with lesser of charges applied,136.98,Pays at 72% of billed charges with lesser of charges applied,136.98,Pays at 72% of billed charges with lesser of charges applied,136.98,Pays at 72% of billed charges with lesser of charges applied,136.98,Pays at 72% of billed charges with lesser of charges applied,136.98,Pays at 72% of billed charges with lesser of charges applied,190.25,Case rate,190.25,Case rate,190.25,Case rate,190.25,Case rate,190.25,Case rate,190.25,Case rate,190.25,Case rate,190.25,Case rate,190.25,Case rate,186.64,Case rate,186.64,Case rate,186.64,Case rate,186.64,Case rate,186.64,Case rate,159.81,84% of total billed charges,159.81,84% of total billed charges,159.81,84% of total billed charges,133.18,70% of total billed charges,76.92,100% OF CMS OPPS Rate,76.92,100% OF CMS OPPS Rate,76.92,100% OF CMS OPPS Rate,76.92,100% OF CMS OPPS Rate,76.92,100% OF CMS OPPS Rate,76.92,100% OF CMS OPPS Rate,76.92,100% OF CMS OPPS Rate,76.92,100% OF CMS OPPS Rate,76.92,100% OF CMS OPPS Rate,76.92,100% OF CMS OPPS Rate,76.92,100% OF CMS OPPS Rate,76.92,100% OF CMS OPPS Rate,76.92,100% OF CMS OPPS Rate,76.92,100% OF CMS OPPS Rate,76.92,100% OF CMS OPPS Rate,76.92,100% OF CMS OPPS Rate,125.25,100% of CA Medicaid Fee Schedule with lesser of charges applied,125.25,100% of CA Medicaid Fee Schedule with lesser of charges applied,125.25,100% of CA Medicaid Fee Schedule with lesser of charges applied,125.25,100% of CA Medicaid Fee Schedule with lesser of charges applied,125.25,100% of CA Medicaid Fee Schedule with lesser of charges applied,125.25,100% of CA Medicaid Fee Schedule with lesser of charges applied,125.25,100% of CA Medicaid Fee Schedule with lesser of charges applied,125.25,100% of CA Medicaid Fee Schedule with lesser of charges applied,125.25,100% of CA Medicaid Fee Schedule with lesser of charges applied,125.25,100% of CA Medicaid Fee Schedule with lesser of charges applied,125.25,100% of CA Medicaid Fee Schedule with lesser of charges applied,125.25,100% of CA Medicaid Fee Schedule with lesser of charges applied,125.25,100% of CA Medicaid Fee Schedule with lesser of charges applied,125.25,100% of CA Medicaid Fee Schedule with lesser of charges applied,125.25,100% of CA Medicaid Fee Schedule with lesser of charges applied,125.25,100% of CA Medicaid Fee Schedule with lesser of charges applied,125.25,100% of CA Medicaid Fee Schedule with lesser of charges applied,125.25,100% of CA Medicaid Fee Schedule with lesser of charges applied,125.25,100% of CA Medicaid Fee Schedule with lesser of charges applied,125.25,100% of CA Medicaid Fee Schedule with lesser of charges applied,76.92,190.25,142.69
Outpatient Medical Services,OCCUPATIONAL THERAPY,97167,AOT-HI EVALUATION,434,205.75,148.14,Pays at 72% of billed charges with lesser of charges applied,111.12,100% OF CMS OPPS Rate,205.75,Case rate,111.12,100% OF CMS OPPS Rate,201.84,Case rate,111.12,100% OF CMS OPPS Rate,172.83,84% of total billed charges,172.83,84% of total billed charges,148.14,72% of total billed charges,111.12,100% OF CMS OPPS Rate,111.12,100% of CMS OPPS Rate,111.12,100% OF CMS OPPS Rate,123.45,60% of total billed charges,180.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,180.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,111.12,100% OF CMS OPPS Rate,111.12,100% OF CMS OPPS Rate,111.12,100% OF CMS OPPS RATE,111.12,100% OF CMS OPPS Rate,144.03,70% of total billed charges,111.12,100% OF CMS OPPS Rate,133.34,120% of CMS OPPS RATE,148.14,Pays at 72% of billed charges with lesser of charges applied,148.14,Pays at 72% of billed charges with lesser of charges applied,148.14,Pays at 72% of billed charges with lesser of charges applied,148.14,Pays at 72% of billed charges with lesser of charges applied,148.14,Pays at 72% of billed charges with lesser of charges applied,148.14,Pays at 72% of billed charges with lesser of charges applied,205.75,Case rate,205.75,Case rate,205.75,Case rate,205.75,Case rate,205.75,Case rate,205.75,Case rate,205.75,Case rate,205.75,Case rate,205.75,Case rate,201.84,Case rate,201.84,Case rate,201.84,Case rate,201.84,Case rate,201.84,Case rate,172.83,84% of total billed charges,172.83,84% of total billed charges,172.83,84% of total billed charges,144.03,70% of total billed charges,111.12,100% OF CMS OPPS Rate,111.12,100% OF CMS OPPS Rate,111.12,100% OF CMS OPPS Rate,111.12,100% OF CMS OPPS Rate,111.12,100% OF CMS OPPS Rate,111.12,100% OF CMS OPPS Rate,111.12,100% OF CMS OPPS Rate,111.12,100% OF CMS OPPS Rate,111.12,100% OF CMS OPPS Rate,111.12,100% OF CMS OPPS Rate,111.12,100% OF CMS OPPS Rate,111.12,100% OF CMS OPPS Rate,111.12,100% OF CMS OPPS Rate,111.12,100% OF CMS OPPS Rate,111.12,100% OF CMS OPPS Rate,111.12,100% OF CMS OPPS Rate,180.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,180.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,180.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,180.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,180.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,180.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,180.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,180.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,180.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,180.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,180.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,180.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,180.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,180.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,180.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,180.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,180.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,180.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,180.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,180.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,111.12,205.75,154.31
Outpatient Medical Services,OCCUPATIONAL THERAPY,29131,OT-APPLICATION FINGER SPLINT-DYANMIC,430,206.5,148.68,Pays at 72% of billed charges with lesser of charges applied,73.06,100% OF CMS OPPS Rate,206.5,Case rate,73.06,100% OF CMS OPPS Rate,202.58,Case rate,73.06,100% OF CMS OPPS Rate,173.46,84% of total billed charges,173.46,84% of total billed charges,148.68,72% of total billed charges,73.06,100% OF CMS OPPS Rate,73.06,100% of CMS OPPS Rate,73.06,100% OF CMS OPPS Rate,123.9,60% of total billed charges,48.07,100% of CA Medicaid Fee Schedule with lesser of charges applied,48.07,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.06,100% OF CMS OPPS Rate,73.06,100% OF CMS OPPS Rate,36.7,100% OF CMS OPPS RATE,73.06,100% OF CMS OPPS Rate,144.55,70% of total billed charges,73.06,100% OF CMS OPPS Rate,87.67,120% of CMS OPPS RATE,148.68,Pays at 72% of billed charges with lesser of charges applied,148.68,Pays at 72% of billed charges with lesser of charges applied,148.68,Pays at 72% of billed charges with lesser of charges applied,148.68,Pays at 72% of billed charges with lesser of charges applied,148.68,Pays at 72% of billed charges with lesser of charges applied,148.68,Pays at 72% of billed charges with lesser of charges applied,206.5,Case rate,206.5,Case rate,206.5,Case rate,206.5,Case rate,206.5,Case rate,206.5,Case rate,206.5,Case rate,206.5,Case rate,206.5,Case rate,202.58,Case rate,202.58,Case rate,202.58,Case rate,202.58,Case rate,202.58,Case rate,173.46,84% of total billed charges,173.46,84% of total billed charges,173.46,84% of total billed charges,144.55,70% of total billed charges,73.06,100% OF CMS OPPS Rate,73.06,100% OF CMS OPPS Rate,73.06,100% OF CMS OPPS Rate,73.06,100% OF CMS OPPS Rate,73.06,100% OF CMS OPPS Rate,73.06,100% OF CMS OPPS Rate,73.06,100% OF CMS OPPS Rate,73.06,100% OF CMS OPPS Rate,73.06,100% OF CMS OPPS Rate,73.06,100% OF CMS OPPS Rate,73.06,100% OF CMS OPPS Rate,73.06,100% OF CMS OPPS Rate,73.06,100% OF CMS OPPS Rate,73.06,100% OF CMS OPPS Rate,73.06,100% OF CMS OPPS Rate,73.06,100% OF CMS OPPS Rate,48.07,100% of CA Medicaid Fee Schedule with lesser of charges applied,48.07,100% of CA Medicaid Fee Schedule with lesser of charges applied,48.07,100% of CA Medicaid Fee Schedule with lesser of charges applied,48.07,100% of CA Medicaid Fee Schedule with lesser of charges applied,48.07,100% of CA Medicaid Fee Schedule with lesser of charges applied,48.07,100% of CA Medicaid Fee Schedule with lesser of charges applied,48.07,100% of CA Medicaid Fee Schedule with lesser of charges applied,48.07,100% of CA Medicaid Fee Schedule with lesser of charges applied,48.07,100% of CA Medicaid Fee Schedule with lesser of charges applied,48.07,100% of CA Medicaid Fee Schedule with lesser of charges applied,48.07,100% of CA Medicaid Fee Schedule with lesser of charges applied,48.07,100% of CA Medicaid Fee Schedule with lesser of charges applied,48.07,100% of CA Medicaid Fee Schedule with lesser of charges applied,48.07,100% of CA Medicaid Fee Schedule with lesser of charges applied,48.07,100% of CA Medicaid Fee Schedule with lesser of charges applied,48.07,100% of CA Medicaid Fee Schedule with lesser of charges applied,48.07,100% of CA Medicaid Fee Schedule with lesser of charges applied,48.07,100% of CA Medicaid Fee Schedule with lesser of charges applied,48.07,100% of CA Medicaid Fee Schedule with lesser of charges applied,48.07,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.70,206.50,154.88
Outpatient Medical Services,OCCUPATIONAL THERAPY,29126,OT-APPLICATION SHORT ARM SPLT-DYN,430,206.5,148.68,Pays at 72% of billed charges with lesser of charges applied,147.58,100% OF CMS OPPS Rate,206.5,Case rate,147.58,100% OF CMS OPPS Rate,202.58,Case rate,147.58,100% OF CMS OPPS Rate,173.46,84% of total billed charges,173.46,84% of total billed charges,148.68,72% of total billed charges,147.58,100% OF CMS OPPS Rate,147.58,100% of CMS OPPS Rate,147.58,100% OF CMS OPPS Rate,123.9,60% of total billed charges,92.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,92.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,147.58,100% OF CMS OPPS Rate,147.58,100% OF CMS OPPS Rate,53.19,100% OF CMS OPPS RATE,147.58,100% OF CMS OPPS Rate,144.55,70% of total billed charges,147.58,100% OF CMS OPPS Rate,177.1,120% of CMS OPPS RATE,148.68,Pays at 72% of billed charges with lesser of charges applied,148.68,Pays at 72% of billed charges with lesser of charges applied,148.68,Pays at 72% of billed charges with lesser of charges applied,148.68,Pays at 72% of billed charges with lesser of charges applied,148.68,Pays at 72% of billed charges with lesser of charges applied,148.68,Pays at 72% of billed charges with lesser of charges applied,206.5,Case rate,206.5,Case rate,206.5,Case rate,206.5,Case rate,206.5,Case rate,206.5,Case rate,206.5,Case rate,206.5,Case rate,206.5,Case rate,202.58,Case rate,202.58,Case rate,202.58,Case rate,202.58,Case rate,202.58,Case rate,173.46,84% of total billed charges,173.46,84% of total billed charges,173.46,84% of total billed charges,144.55,70% of total billed charges,147.58,100% OF CMS OPPS Rate,147.58,100% OF CMS OPPS Rate,147.58,100% OF CMS OPPS Rate,147.58,100% OF CMS OPPS Rate,147.58,100% OF CMS OPPS Rate,147.58,100% OF CMS OPPS Rate,147.58,100% OF CMS OPPS Rate,147.58,100% OF CMS OPPS Rate,147.58,100% OF CMS OPPS Rate,147.58,100% OF CMS OPPS Rate,147.58,100% OF CMS OPPS Rate,147.58,100% OF CMS OPPS Rate,147.58,100% OF CMS OPPS Rate,147.58,100% OF CMS OPPS Rate,147.58,100% OF CMS OPPS Rate,147.58,100% OF CMS OPPS Rate,92.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,92.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,92.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,92.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,92.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,92.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,92.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,92.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,92.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,92.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,92.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,92.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,92.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,92.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,92.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,92.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,92.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,92.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,92.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,92.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,53.19,206.50,154.88
Outpatient Medical Services,OCCUPATIONAL THERAPY,29105,AOT-APPLICATION LONG ARM SPLINT,430,206.5,148.68,Pays at 72% of billed charges with lesser of charges applied,185.26,100% OF CMS OPPS Rate,206.5,Case rate,185.26,100% OF CMS OPPS Rate,202.58,Case rate,185.26,100% OF CMS OPPS Rate,173.46,84% of total billed charges,173.46,84% of total billed charges,148.68,72% of total billed charges,185.26,100% OF CMS OPPS Rate,185.26,100% of CMS OPPS Rate,185.26,100% OF CMS OPPS Rate,123.9,60% of total billed charges,95.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,95.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,185.26,100% OF CMS OPPS Rate,185.26,100% OF CMS OPPS Rate,42.83,100% OF CMS OPPS RATE,185.26,100% OF CMS OPPS Rate,144.55,70% of total billed charges,185.26,100% OF CMS OPPS Rate,206.5,120% of CMS OPPS RATE,148.68,Pays at 72% of billed charges with lesser of charges applied,148.68,Pays at 72% of billed charges with lesser of charges applied,148.68,Pays at 72% of billed charges with lesser of charges applied,148.68,Pays at 72% of billed charges with lesser of charges applied,148.68,Pays at 72% of billed charges with lesser of charges applied,148.68,Pays at 72% of billed charges with lesser of charges applied,206.5,Case rate,206.5,Case rate,206.5,Case rate,206.5,Case rate,206.5,Case rate,206.5,Case rate,206.5,Case rate,206.5,Case rate,206.5,Case rate,202.58,Case rate,202.58,Case rate,202.58,Case rate,202.58,Case rate,202.58,Case rate,173.46,84% of total billed charges,173.46,84% of total billed charges,173.46,84% of total billed charges,144.55,70% of total billed charges,185.26,100% OF CMS OPPS Rate,185.26,100% OF CMS OPPS Rate,185.26,100% OF CMS OPPS Rate,185.26,100% OF CMS OPPS Rate,185.26,100% OF CMS OPPS Rate,185.26,100% OF CMS OPPS Rate,185.26,100% OF CMS OPPS Rate,185.26,100% OF CMS OPPS Rate,185.26,100% OF CMS OPPS Rate,185.26,100% OF CMS OPPS Rate,185.26,100% OF CMS OPPS Rate,185.26,100% OF CMS OPPS Rate,185.26,100% OF CMS OPPS Rate,185.26,100% OF CMS OPPS Rate,185.26,100% OF CMS OPPS Rate,185.26,100% OF CMS OPPS Rate,95.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,95.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,95.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,95.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,95.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,95.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,95.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,95.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,95.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,95.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,95.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,95.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,95.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,95.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,95.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,95.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,95.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,95.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,95.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,95.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,42.83,206.50,154.88
Outpatient Medical Services,OCCUPATIONAL THERAPY,16025,AOT-BURN TREATMENT MEDIUM,430,235.75,169.74,Pays at 72% of billed charges with lesser of charges applied,229.52,100% OF CMS OPPS Rate,235.75,100% of ASC Tier Grouping Fee Schedule,229.52,100% OF CMS OPPS Rate,231.27,Case rate,229.52,100% OF CMS OPPS Rate,198.03,84% of total billed charges,198.03,84% of total billed charges,169.74,72% of total billed charges,229.52,100% OF CMS OPPS Rate,229.52,100% of CMS OPPS Rate,229.52,100% OF CMS OPPS Rate,141.45,60% of total billed charges,86.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,86.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,229.52,100% OF CMS OPPS Rate,229.52,100% OF CMS OPPS Rate,116.65,100% OF CMS OPPS RATE,229.52,100% OF CMS OPPS Rate,165.03,70% of total billed charges,229.52,100% OF CMS OPPS Rate,235.75,120% of CMS OPPS RATE,169.74,Pays at 72% of billed charges with lesser of charges applied,169.74,Pays at 72% of billed charges with lesser of charges applied,169.74,Pays at 72% of billed charges with lesser of charges applied,169.74,Pays at 72% of billed charges with lesser of charges applied,169.74,Pays at 72% of billed charges with lesser of charges applied,169.74,Pays at 72% of billed charges with lesser of charges applied,235.75,100% of ASC Tier Grouping Fee Schedule,235.75,100% of ASC Tier Grouping Fee Schedule,235.75,100% of ASC Tier Grouping Fee Schedule,235.75,100% of ASC Tier Grouping Fee Schedule,235.75,100% of ASC Tier Grouping Fee Schedule,235.75,100% of ASC Tier Grouping Fee Schedule,235.75,100% of ASC Tier Grouping Fee Schedule,235.75,100% of ASC Tier Grouping Fee Schedule,235.75,100% of ASC Tier Grouping Fee Schedule,231.27,Case rate,231.27,Case rate,231.27,Case rate,231.27,Case rate,231.27,Case rate,198.03,84% of total billed charges,198.03,84% of total billed charges,198.03,84% of total billed charges,165.03,70% of total billed charges,229.52,100% OF CMS OPPS Rate,229.52,100% OF CMS OPPS Rate,229.52,100% OF CMS OPPS Rate,229.52,100% OF CMS OPPS Rate,229.52,100% OF CMS OPPS Rate,229.52,100% OF CMS OPPS Rate,229.52,100% OF CMS OPPS Rate,229.52,100% OF CMS OPPS Rate,229.52,100% OF CMS OPPS Rate,229.52,100% OF CMS OPPS Rate,229.52,100% OF CMS OPPS Rate,229.52,100% OF CMS OPPS Rate,229.52,100% OF CMS OPPS Rate,229.52,100% OF CMS OPPS Rate,229.52,100% OF CMS OPPS Rate,229.52,100% OF CMS OPPS Rate,86.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,86.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,86.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,86.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,86.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,86.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,86.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,86.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,86.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,86.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,86.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,86.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,86.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,86.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,86.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,86.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,86.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,86.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,86.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,86.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,86.51,235.75,176.81
Outpatient Medical Services,OCCUPATIONAL THERAPY,97164,AOT-COMPREHENSIVE EVALUATION,434,259.75,187.02,Pays at 72% of billed charges with lesser of charges applied,77.32,100% OF CMS OPPS Rate,259.75,Case rate,77.32,100% OF CMS OPPS Rate,254.81,Case rate,77.32,100% OF CMS OPPS Rate,218.19,84% of total billed charges,218.19,84% of total billed charges,187.02,72% of total billed charges,77.32,100% OF CMS OPPS Rate,77.32,100% of CMS OPPS Rate,77.32,100% OF CMS OPPS Rate,155.85,60% of total billed charges,135.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,77.32,100% OF CMS OPPS Rate,77.32,100% OF CMS OPPS Rate,77.32,100% OF CMS OPPS RATE,77.32,100% OF CMS OPPS Rate,181.83,70% of total billed charges,77.32,100% OF CMS OPPS Rate,92.78,120% of CMS OPPS RATE,187.02,Pays at 72% of billed charges with lesser of charges applied,187.02,Pays at 72% of billed charges with lesser of charges applied,187.02,Pays at 72% of billed charges with lesser of charges applied,187.02,Pays at 72% of billed charges with lesser of charges applied,187.02,Pays at 72% of billed charges with lesser of charges applied,187.02,Pays at 72% of billed charges with lesser of charges applied,259.75,Case rate,259.75,Case rate,259.75,Case rate,259.75,Case rate,259.75,Case rate,259.75,Case rate,259.75,Case rate,259.75,Case rate,259.75,Case rate,254.81,Case rate,254.81,Case rate,254.81,Case rate,254.81,Case rate,254.81,Case rate,218.19,84% of total billed charges,218.19,84% of total billed charges,218.19,84% of total billed charges,181.83,70% of total billed charges,77.32,100% OF CMS OPPS Rate,77.32,100% OF CMS OPPS Rate,77.32,100% OF CMS OPPS Rate,77.32,100% OF CMS OPPS Rate,77.32,100% OF CMS OPPS Rate,77.32,100% OF CMS OPPS Rate,77.32,100% OF CMS OPPS Rate,77.32,100% OF CMS OPPS Rate,77.32,100% OF CMS OPPS Rate,77.32,100% OF CMS OPPS Rate,77.32,100% OF CMS OPPS Rate,77.32,100% OF CMS OPPS Rate,77.32,100% OF CMS OPPS Rate,77.32,100% OF CMS OPPS Rate,77.32,100% OF CMS OPPS Rate,77.32,100% OF CMS OPPS Rate,135.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,77.32,259.75,194.81
Outpatient Medical Services,OCCUPATIONAL THERAPY,97545,OT-WORK HARDENING (INIT 2 HRS),430,284.25,204.66,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,284.25,Case rate,N/A,Not Separately reimbursable,278.85,Case rate,N/A,Not Separately reimbursable,238.77,84% of total billed charges,238.77,84% of total billed charges,204.66,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,170.55,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,198.98,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,204.66,Pays at 72% of billed charges with lesser of charges applied,204.66,Pays at 72% of billed charges with lesser of charges applied,204.66,Pays at 72% of billed charges with lesser of charges applied,204.66,Pays at 72% of billed charges with lesser of charges applied,204.66,Pays at 72% of billed charges with lesser of charges applied,204.66,Pays at 72% of billed charges with lesser of charges applied,284.25,Case rate,284.25,Case rate,284.25,Case rate,284.25,Case rate,284.25,Case rate,284.25,Case rate,284.25,Case rate,284.25,Case rate,284.25,Case rate,278.85,Case rate,278.85,Case rate,278.85,Case rate,278.85,Case rate,278.85,Case rate,238.77,84% of total billed charges,238.77,84% of total billed charges,238.77,84% of total billed charges,198.98,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,170.55,284.25,213.19
Outpatient Medical Services,OCCUPATIONAL THERAPY,11042,"OT-NONSUSRG DEBRIDEMENT, SKIN & SUBQ",430,379.75,273.42,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,379.75,100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,372.53,Case rate,N/A,Not Separately reimbursable,318.99,84% of total billed charges,318.99,84% of total billed charges,273.42,72% of total billed charges,N/A,Not Separately reimbursable,379.75,100% of CMS OPPS Rate,N/A,Not Separately reimbursable,227.85,60% of total billed charges,148.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,148.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,63.12,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,265.83,70% of total billed charges,379.75,100% OF CMS OPPS Rate,379.75,120% of CMS OPPS RATE,273.42,Pays at 72% of billed charges with lesser of charges applied,273.42,Pays at 72% of billed charges with lesser of charges applied,273.42,Pays at 72% of billed charges with lesser of charges applied,273.42,Pays at 72% of billed charges with lesser of charges applied,273.42,Pays at 72% of billed charges with lesser of charges applied,273.42,Pays at 72% of billed charges with lesser of charges applied,379.75,100% of ASC Tier Grouping Fee Schedule,379.75,100% of ASC Tier Grouping Fee Schedule,379.75,100% of ASC Tier Grouping Fee Schedule,379.75,100% of ASC Tier Grouping Fee Schedule,379.75,100% of ASC Tier Grouping Fee Schedule,379.75,100% of ASC Tier Grouping Fee Schedule,379.75,100% of ASC Tier Grouping Fee Schedule,379.75,100% of ASC Tier Grouping Fee Schedule,379.75,100% of ASC Tier Grouping Fee Schedule,372.53,Case rate,372.53,Case rate,372.53,Case rate,372.53,Case rate,372.53,Case rate,318.99,84% of total billed charges,318.99,84% of total billed charges,318.99,84% of total billed charges,265.83,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,148.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,148.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,148.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,148.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,148.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,148.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,148.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,148.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,148.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,148.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,148.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,148.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,148.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,148.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,148.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,148.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,148.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,148.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,148.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,148.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,63.12,379.75,284.81
Outpatient Medical Services,OCCUPATIONAL THERAPY,97598,AOT-RMVL DEVITAL TIS ADDL 20CM<,430,573.75,413.1,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,420,Case rate,N/A,Not Separately reimbursable,537,Case rate,N/A,Not Separately reimbursable,481.95,84% of total billed charges,481.95,84% of total billed charges,413.1,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,344.25,60% of total billed charges,76.70,100% of CA Medicaid Fee Schedule with lesser of charges applied,76.70,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,25.41,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,401.63,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,413.1,Pays at 72% of billed charges with lesser of charges applied,413.1,Pays at 72% of billed charges with lesser of charges applied,413.1,Pays at 72% of billed charges with lesser of charges applied,413.1,Pays at 72% of billed charges with lesser of charges applied,413.1,Pays at 72% of billed charges with lesser of charges applied,413.1,Pays at 72% of billed charges with lesser of charges applied,420,Case rate,420,Case rate,420,Case rate,420,Case rate,420,Case rate,420,Case rate,420,Case rate,420,Case rate,420,Case rate,537,Case rate,537,Case rate,537,Case rate,537,Case rate,537,Case rate,481.95,84% of total billed charges,481.95,84% of total billed charges,481.95,84% of total billed charges,401.63,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,76.70,100% of CA Medicaid Fee Schedule with lesser of charges applied,76.70,100% of CA Medicaid Fee Schedule with lesser of charges applied,76.70,100% of CA Medicaid Fee Schedule with lesser of charges applied,76.70,100% of CA Medicaid Fee Schedule with lesser of charges applied,76.70,100% of CA Medicaid Fee Schedule with lesser of charges applied,76.70,100% of CA Medicaid Fee Schedule with lesser of charges applied,76.70,100% of CA Medicaid Fee Schedule with lesser of charges applied,76.70,100% of CA Medicaid Fee Schedule with lesser of charges applied,76.70,100% of CA Medicaid Fee Schedule with lesser of charges applied,76.70,100% of CA Medicaid Fee Schedule with lesser of charges applied,76.70,100% of CA Medicaid Fee Schedule with lesser of charges applied,76.70,100% of CA Medicaid Fee Schedule with lesser of charges applied,76.70,100% of CA Medicaid Fee Schedule with lesser of charges applied,76.70,100% of CA Medicaid Fee Schedule with lesser of charges applied,76.70,100% of CA Medicaid Fee Schedule with lesser of charges applied,76.70,100% of CA Medicaid Fee Schedule with lesser of charges applied,76.70,100% of CA Medicaid Fee Schedule with lesser of charges applied,76.70,100% of CA Medicaid Fee Schedule with lesser of charges applied,76.70,100% of CA Medicaid Fee Schedule with lesser of charges applied,76.70,100% of CA Medicaid Fee Schedule with lesser of charges applied,25.41,537.00,430.31
Outpatient Medical Services,OCCUPATIONAL THERAPY,97597,"Debridement (for example, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps)",430,573.75,413.1,Pays at 72% of billed charges with lesser of charges applied,229.52,100% OF CMS OPPS Rate,420,Case rate,229.52,100% OF CMS OPPS Rate,537,Case rate,229.52,100% OF CMS OPPS Rate,481.95,84% of total billed charges,481.95,84% of total billed charges,413.1,72% of total billed charges,229.52,100% OF CMS OPPS Rate,229.52,100% of CMS OPPS Rate,229.52,100% OF CMS OPPS Rate,344.25,60% of total billed charges,60.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,229.52,100% OF CMS OPPS Rate,229.52,100% OF CMS OPPS Rate,36.83,100% OF CMS OPPS RATE,229.52,100% OF CMS OPPS Rate,401.63,70% of total billed charges,229.52,100% OF CMS OPPS Rate,275.42,120% of CMS OPPS RATE,413.1,Pays at 72% of billed charges with lesser of charges applied,413.1,Pays at 72% of billed charges with lesser of charges applied,413.1,Pays at 72% of billed charges with lesser of charges applied,413.1,Pays at 72% of billed charges with lesser of charges applied,413.1,Pays at 72% of billed charges with lesser of charges applied,413.1,Pays at 72% of billed charges with lesser of charges applied,420,Case rate,420,Case rate,420,Case rate,420,Case rate,420,Case rate,420,Case rate,420,Case rate,420,Case rate,420,Case rate,537,Case rate,537,Case rate,537,Case rate,537,Case rate,537,Case rate,481.95,84% of total billed charges,481.95,84% of total billed charges,481.95,84% of total billed charges,401.63,70% of total billed charges,229.52,100% OF CMS OPPS Rate,229.52,100% OF CMS OPPS Rate,229.52,100% OF CMS OPPS Rate,229.52,100% OF CMS OPPS Rate,229.52,100% OF CMS OPPS Rate,229.52,100% OF CMS OPPS Rate,229.52,100% OF CMS OPPS Rate,229.52,100% OF CMS OPPS Rate,229.52,100% OF CMS OPPS Rate,229.52,100% OF CMS OPPS Rate,229.52,100% OF CMS OPPS Rate,229.52,100% OF CMS OPPS Rate,229.52,100% OF CMS OPPS Rate,229.52,100% OF CMS OPPS Rate,229.52,100% OF CMS OPPS Rate,229.52,100% OF CMS OPPS Rate,60.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.83,537.00,430.31
Outpatient Medical Services,PHYSICAL THERAPY,95831,"MANUAL MUSCLE TESTING, EXTREM/TRUNK",420,47,33.84,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,47,Case rate,N/A,Not Separately reimbursable,46.11,Case rate,N/A,Not Separately reimbursable,39.48,84% of total billed charges,39.48,84% of total billed charges,33.84,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,28.2,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,32.9,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,33.84,Pays at 72% of billed charges with lesser of charges applied,33.84,Pays at 72% of billed charges with lesser of charges applied,33.84,Pays at 72% of billed charges with lesser of charges applied,33.84,Pays at 72% of billed charges with lesser of charges applied,33.84,Pays at 72% of billed charges with lesser of charges applied,33.84,Pays at 72% of billed charges with lesser of charges applied,47,Case rate,47,Case rate,47,Case rate,47,Case rate,47,Case rate,47,Case rate,47,Case rate,47,Case rate,47,Case rate,46.11,Case rate,46.11,Case rate,46.11,Case rate,46.11,Case rate,46.11,Case rate,39.48,84% of total billed charges,39.48,84% of total billed charges,39.48,84% of total billed charges,32.9,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,28.20,47.00,35.25
Outpatient Medical Services,PHYSICAL THERAPY,95832,"TA-MANUAL MUSCLE TESTING,HAND",420,47,33.84,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,47,Case rate,N/A,Not Separately reimbursable,46.11,Case rate,N/A,Not Separately reimbursable,39.48,84% of total billed charges,39.48,84% of total billed charges,33.84,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,28.2,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,32.9,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,33.84,Pays at 72% of billed charges with lesser of charges applied,33.84,Pays at 72% of billed charges with lesser of charges applied,33.84,Pays at 72% of billed charges with lesser of charges applied,33.84,Pays at 72% of billed charges with lesser of charges applied,33.84,Pays at 72% of billed charges with lesser of charges applied,33.84,Pays at 72% of billed charges with lesser of charges applied,47,Case rate,47,Case rate,47,Case rate,47,Case rate,47,Case rate,47,Case rate,47,Case rate,47,Case rate,47,Case rate,46.11,Case rate,46.11,Case rate,46.11,Case rate,46.11,Case rate,46.11,Case rate,39.48,84% of total billed charges,39.48,84% of total billed charges,39.48,84% of total billed charges,32.9,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,28.20,47.00,35.25
Outpatient Medical Services,PHYSICAL THERAPY,11001,"NON-SUR DEBRID, INFECT SKIN ADDL 10%",420,58,41.76,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,58,100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,56.9,Case rate,N/A,Not Separately reimbursable,48.72,84% of total billed charges,48.72,84% of total billed charges,41.76,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,34.8,60% of total billed charges,14.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,15.24,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,40.6,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,41.76,Pays at 72% of billed charges with lesser of charges applied,41.76,Pays at 72% of billed charges with lesser of charges applied,41.76,Pays at 72% of billed charges with lesser of charges applied,41.76,Pays at 72% of billed charges with lesser of charges applied,41.76,Pays at 72% of billed charges with lesser of charges applied,41.76,Pays at 72% of billed charges with lesser of charges applied,58,100% of ASC Tier Grouping Fee Schedule,58,100% of ASC Tier Grouping Fee Schedule,58,100% of ASC Tier Grouping Fee Schedule,58,100% of ASC Tier Grouping Fee Schedule,58,100% of ASC Tier Grouping Fee Schedule,58,100% of ASC Tier Grouping Fee Schedule,58,100% of ASC Tier Grouping Fee Schedule,58,100% of ASC Tier Grouping Fee Schedule,58,100% of ASC Tier Grouping Fee Schedule,56.9,Case rate,56.9,Case rate,56.9,Case rate,56.9,Case rate,56.9,Case rate,48.72,84% of total billed charges,48.72,84% of total billed charges,48.72,84% of total billed charges,40.6,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,14.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.95,58.00,43.5
Outpatient Medical Services,PHYSICAL THERAPY,97014,One time use unattended,420,63.75,45.9,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,63.75,Case rate,N/A,Not Separately reimbursable,62.54,Case rate,N/A,Not Separately reimbursable,53.55,84% of total billed charges,53.55,84% of total billed charges,45.9,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,38.25,60% of total billed charges,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,13.65,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,44.63,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,45.9,Pays at 72% of billed charges with lesser of charges applied,45.9,Pays at 72% of billed charges with lesser of charges applied,45.9,Pays at 72% of billed charges with lesser of charges applied,45.9,Pays at 72% of billed charges with lesser of charges applied,45.9,Pays at 72% of billed charges with lesser of charges applied,45.9,Pays at 72% of billed charges with lesser of charges applied,63.75,Case rate,63.75,Case rate,63.75,Case rate,63.75,Case rate,63.75,Case rate,63.75,Case rate,63.75,Case rate,63.75,Case rate,63.75,Case rate,62.54,Case rate,62.54,Case rate,62.54,Case rate,62.54,Case rate,62.54,Case rate,53.55,84% of total billed charges,53.55,84% of total billed charges,53.55,84% of total billed charges,44.63,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,13.65,63.75,47.81
Outpatient Medical Services,PHYSICAL THERAPY,97014,One time use unattended,420,63.75,45.9,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,63.75,Case rate,N/A,Not Separately reimbursable,62.54,Case rate,N/A,Not Separately reimbursable,53.55,84% of total billed charges,53.55,84% of total billed charges,45.9,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,38.25,60% of total billed charges,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,13.65,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,44.63,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,45.9,Pays at 72% of billed charges with lesser of charges applied,45.9,Pays at 72% of billed charges with lesser of charges applied,45.9,Pays at 72% of billed charges with lesser of charges applied,45.9,Pays at 72% of billed charges with lesser of charges applied,45.9,Pays at 72% of billed charges with lesser of charges applied,45.9,Pays at 72% of billed charges with lesser of charges applied,63.75,Case rate,63.75,Case rate,63.75,Case rate,63.75,Case rate,63.75,Case rate,63.75,Case rate,63.75,Case rate,63.75,Case rate,63.75,Case rate,62.54,Case rate,62.54,Case rate,62.54,Case rate,62.54,Case rate,62.54,Case rate,53.55,84% of total billed charges,53.55,84% of total billed charges,53.55,84% of total billed charges,44.63,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,13.65,63.75,47.81
Outpatient Medical Services,PHYSICAL THERAPY,97012,Form of decompression therapy of the spine,420,63.75,45.9,Pays at 72% of billed charges with lesser of charges applied,15.69,100% OF CMS OPPS Rate,63.75,Case rate,15.69,100% OF CMS OPPS Rate,62.54,Case rate,15.69,100% OF CMS OPPS Rate,53.55,84% of total billed charges,53.55,84% of total billed charges,45.9,72% of total billed charges,15.69,100% OF CMS OPPS Rate,15.69,100% of CMS OPPS Rate,15.69,100% OF CMS OPPS Rate,38.25,60% of total billed charges,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.69,100% OF CMS OPPS Rate,15.69,100% OF CMS OPPS Rate,15.69,100% OF CMS OPPS RATE,15.69,100% OF CMS OPPS Rate,44.63,70% of total billed charges,15.69,100% OF CMS OPPS Rate,18.83,120% of CMS OPPS RATE,45.9,Pays at 72% of billed charges with lesser of charges applied,45.9,Pays at 72% of billed charges with lesser of charges applied,45.9,Pays at 72% of billed charges with lesser of charges applied,45.9,Pays at 72% of billed charges with lesser of charges applied,45.9,Pays at 72% of billed charges with lesser of charges applied,45.9,Pays at 72% of billed charges with lesser of charges applied,63.75,Case rate,63.75,Case rate,63.75,Case rate,63.75,Case rate,63.75,Case rate,63.75,Case rate,63.75,Case rate,63.75,Case rate,63.75,Case rate,62.54,Case rate,62.54,Case rate,62.54,Case rate,62.54,Case rate,62.54,Case rate,53.55,84% of total billed charges,53.55,84% of total billed charges,53.55,84% of total billed charges,44.63,70% of total billed charges,15.69,100% OF CMS OPPS Rate,15.69,100% OF CMS OPPS Rate,15.69,100% OF CMS OPPS Rate,15.69,100% OF CMS OPPS Rate,15.69,100% OF CMS OPPS Rate,15.69,100% OF CMS OPPS Rate,15.69,100% OF CMS OPPS Rate,15.69,100% OF CMS OPPS Rate,15.69,100% OF CMS OPPS Rate,15.69,100% OF CMS OPPS Rate,15.69,100% OF CMS OPPS Rate,15.69,100% OF CMS OPPS Rate,15.69,100% OF CMS OPPS Rate,15.69,100% OF CMS OPPS Rate,15.69,100% OF CMS OPPS Rate,15.69,100% OF CMS OPPS Rate,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.69,63.75,47.81
Outpatient Medical Services,PHYSICAL THERAPY,97124,Use of massage,420,63.75,45.9,Pays at 72% of billed charges with lesser of charges applied,33.92,100% OF CMS OPPS Rate,63.75,Case rate,33.92,100% OF CMS OPPS Rate,62.54,Case rate,33.92,100% OF CMS OPPS Rate,53.55,84% of total billed charges,53.55,84% of total billed charges,45.9,72% of total billed charges,33.92,100% OF CMS OPPS Rate,33.92,100% of CMS OPPS Rate,33.92,100% OF CMS OPPS Rate,38.25,60% of total billed charges,14.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,33.92,100% OF CMS OPPS Rate,33.92,100% OF CMS OPPS Rate,33.92,100% OF CMS OPPS RATE,33.92,100% OF CMS OPPS Rate,44.63,70% of total billed charges,33.92,100% OF CMS OPPS Rate,40.7,120% of CMS OPPS RATE,45.9,Pays at 72% of billed charges with lesser of charges applied,45.9,Pays at 72% of billed charges with lesser of charges applied,45.9,Pays at 72% of billed charges with lesser of charges applied,45.9,Pays at 72% of billed charges with lesser of charges applied,45.9,Pays at 72% of billed charges with lesser of charges applied,45.9,Pays at 72% of billed charges with lesser of charges applied,63.75,Case rate,63.75,Case rate,63.75,Case rate,63.75,Case rate,63.75,Case rate,63.75,Case rate,63.75,Case rate,63.75,Case rate,63.75,Case rate,62.54,Case rate,62.54,Case rate,62.54,Case rate,62.54,Case rate,62.54,Case rate,53.55,84% of total billed charges,53.55,84% of total billed charges,53.55,84% of total billed charges,44.63,70% of total billed charges,33.92,100% OF CMS OPPS Rate,33.92,100% OF CMS OPPS Rate,33.92,100% OF CMS OPPS Rate,33.92,100% OF CMS OPPS Rate,33.92,100% OF CMS OPPS Rate,33.92,100% OF CMS OPPS Rate,33.92,100% OF CMS OPPS Rate,33.92,100% OF CMS OPPS Rate,33.92,100% OF CMS OPPS Rate,33.92,100% OF CMS OPPS Rate,33.92,100% OF CMS OPPS Rate,33.92,100% OF CMS OPPS Rate,33.92,100% OF CMS OPPS Rate,33.92,100% OF CMS OPPS Rate,33.92,100% OF CMS OPPS Rate,33.92,100% OF CMS OPPS Rate,14.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.76,63.75,47.81
Outpatient Medical Services,PHYSICAL THERAPY,97018,PARAFFIN (30 MINS),420,63.75,45.9,Pays at 72% of billed charges with lesser of charges applied,6.27,100% OF CMS OPPS Rate,63.75,Case rate,6.27,100% OF CMS OPPS Rate,62.54,Case rate,6.27,100% OF CMS OPPS Rate,53.55,84% of total billed charges,53.55,84% of total billed charges,45.9,72% of total billed charges,6.27,100% OF CMS OPPS Rate,6.27,100% of CMS OPPS Rate,6.27,100% OF CMS OPPS Rate,38.25,60% of total billed charges,14.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,6.27,100% OF CMS OPPS Rate,6.27,100% OF CMS OPPS Rate,6.27,100% OF CMS OPPS RATE,6.27,100% OF CMS OPPS Rate,44.63,70% of total billed charges,6.27,100% OF CMS OPPS Rate,7.52,120% of CMS OPPS RATE,45.9,Pays at 72% of billed charges with lesser of charges applied,45.9,Pays at 72% of billed charges with lesser of charges applied,45.9,Pays at 72% of billed charges with lesser of charges applied,45.9,Pays at 72% of billed charges with lesser of charges applied,45.9,Pays at 72% of billed charges with lesser of charges applied,45.9,Pays at 72% of billed charges with lesser of charges applied,63.75,Case rate,63.75,Case rate,63.75,Case rate,63.75,Case rate,63.75,Case rate,63.75,Case rate,63.75,Case rate,63.75,Case rate,63.75,Case rate,62.54,Case rate,62.54,Case rate,62.54,Case rate,62.54,Case rate,62.54,Case rate,53.55,84% of total billed charges,53.55,84% of total billed charges,53.55,84% of total billed charges,44.63,70% of total billed charges,6.27,100% OF CMS OPPS Rate,6.27,100% OF CMS OPPS Rate,6.27,100% OF CMS OPPS Rate,6.27,100% OF CMS OPPS Rate,6.27,100% OF CMS OPPS Rate,6.27,100% OF CMS OPPS Rate,6.27,100% OF CMS OPPS Rate,6.27,100% OF CMS OPPS Rate,6.27,100% OF CMS OPPS Rate,6.27,100% OF CMS OPPS Rate,6.27,100% OF CMS OPPS Rate,6.27,100% OF CMS OPPS Rate,6.27,100% OF CMS OPPS Rate,6.27,100% OF CMS OPPS Rate,6.27,100% OF CMS OPPS Rate,6.27,100% OF CMS OPPS Rate,14.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,14.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,6.27,63.75,47.81
Outpatient Medical Services,PHYSICAL THERAPY,97150,TA-THERAPY GROUP (2+IND),423,63.75,45.9,Pays at 72% of billed charges with lesser of charges applied,19.48,100% OF CMS OPPS Rate,63.75,Case rate,19.48,100% OF CMS OPPS Rate,62.54,Case rate,19.48,100% OF CMS OPPS Rate,53.55,84% of total billed charges,53.55,84% of total billed charges,45.9,72% of total billed charges,19.48,100% OF CMS OPPS Rate,19.48,100% of CMS OPPS Rate,19.48,100% OF CMS OPPS Rate,38.25,60% of total billed charges,19.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,19.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,19.48,100% OF CMS OPPS Rate,19.48,100% OF CMS OPPS Rate,19.48,100% OF CMS OPPS RATE,19.48,100% OF CMS OPPS Rate,44.63,70% of total billed charges,19.48,100% OF CMS OPPS Rate,23.38,120% of CMS OPPS RATE,45.9,Pays at 72% of billed charges with lesser of charges applied,45.9,Pays at 72% of billed charges with lesser of charges applied,45.9,Pays at 72% of billed charges with lesser of charges applied,45.9,Pays at 72% of billed charges with lesser of charges applied,45.9,Pays at 72% of billed charges with lesser of charges applied,45.9,Pays at 72% of billed charges with lesser of charges applied,63.75,Case rate,63.75,Case rate,63.75,Case rate,63.75,Case rate,63.75,Case rate,63.75,Case rate,63.75,Case rate,63.75,Case rate,63.75,Case rate,62.54,Case rate,62.54,Case rate,62.54,Case rate,62.54,Case rate,62.54,Case rate,53.55,84% of total billed charges,53.55,84% of total billed charges,53.55,84% of total billed charges,44.63,70% of total billed charges,19.48,100% OF CMS OPPS Rate,19.48,100% OF CMS OPPS Rate,19.48,100% OF CMS OPPS Rate,19.48,100% OF CMS OPPS Rate,19.48,100% OF CMS OPPS Rate,19.48,100% OF CMS OPPS Rate,19.48,100% OF CMS OPPS Rate,19.48,100% OF CMS OPPS Rate,19.48,100% OF CMS OPPS Rate,19.48,100% OF CMS OPPS Rate,19.48,100% OF CMS OPPS Rate,19.48,100% OF CMS OPPS Rate,19.48,100% OF CMS OPPS Rate,19.48,100% OF CMS OPPS Rate,19.48,100% OF CMS OPPS Rate,19.48,100% OF CMS OPPS Rate,19.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,19.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,19.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,19.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,19.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,19.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,19.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,19.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,19.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,19.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,19.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,19.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,19.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,19.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,19.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,19.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,19.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,19.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,19.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,19.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,19.42,63.75,47.81
Outpatient Medical Services,PHYSICAL THERAPY,95833,"MAN MUSCLE TEST, TOT BODY (EXCEPT HAND)",420,71.25,51.3,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,71.25,Case rate,N/A,Not Separately reimbursable,69.9,Case rate,N/A,Not Separately reimbursable,59.85,84% of total billed charges,59.85,84% of total billed charges,51.3,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,42.75,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,49.88,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,51.3,Pays at 72% of billed charges with lesser of charges applied,51.3,Pays at 72% of billed charges with lesser of charges applied,51.3,Pays at 72% of billed charges with lesser of charges applied,51.3,Pays at 72% of billed charges with lesser of charges applied,51.3,Pays at 72% of billed charges with lesser of charges applied,51.3,Pays at 72% of billed charges with lesser of charges applied,71.25,Case rate,71.25,Case rate,71.25,Case rate,71.25,Case rate,71.25,Case rate,71.25,Case rate,71.25,Case rate,71.25,Case rate,71.25,Case rate,69.9,Case rate,69.9,Case rate,69.9,Case rate,69.9,Case rate,69.9,Case rate,59.85,84% of total billed charges,59.85,84% of total billed charges,59.85,84% of total billed charges,49.88,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,42.75,71.25,53.44
Outpatient Medical Services,PHYSICAL THERAPY,97537,COMMUNITY/WORK INTEGRATION TRAIN-15,420,90.5,65.16,Pays at 72% of billed charges with lesser of charges applied,35.28,100% OF CMS OPPS Rate,90.5,Case rate,35.28,100% OF CMS OPPS Rate,88.78,Case rate,35.28,100% OF CMS OPPS Rate,76.02,84% of total billed charges,76.02,84% of total billed charges,65.16,72% of total billed charges,35.28,100% OF CMS OPPS Rate,35.28,100% of CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,54.3,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS RATE,35.28,100% OF CMS OPPS Rate,63.35,70% of total billed charges,35.28,100% OF CMS OPPS Rate,42.34,120% of CMS OPPS RATE,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,76.02,84% of total billed charges,76.02,84% of total billed charges,76.02,84% of total billed charges,63.35,70% of total billed charges,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,35.28,90.50,67.88
Outpatient Medical Services,PHYSICAL THERAPY,97762,ORTHOTIC/PROSTHETIC CHECK OUT-15 MIN,420,90.5,65.16,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,90.5,Case rate,N/A,Not Separately reimbursable,88.78,Case rate,N/A,Not Separately reimbursable,76.02,84% of total billed charges,76.02,84% of total billed charges,65.16,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,54.3,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,63.35,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,76.02,84% of total billed charges,76.02,84% of total billed charges,76.02,84% of total billed charges,63.35,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,54.30,90.50,67.88
Outpatient Medical Services,PHYSICAL THERAPY,97140,Manipulation of 1 or more regions of the body,420,90.5,65.16,Pays at 72% of billed charges with lesser of charges applied,29.95,100% OF CMS OPPS Rate,90.5,Case rate,29.95,100% OF CMS OPPS Rate,88.78,Case rate,29.95,100% OF CMS OPPS Rate,76.02,84% of total billed charges,76.02,84% of total billed charges,65.16,72% of total billed charges,29.95,100% OF CMS OPPS Rate,29.95,100% of CMS OPPS Rate,29.95,100% OF CMS OPPS Rate,54.3,60% of total billed charges,31.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.95,100% OF CMS OPPS Rate,29.95,100% OF CMS OPPS Rate,29.95,100% OF CMS OPPS RATE,29.95,100% OF CMS OPPS Rate,63.35,70% of total billed charges,29.95,100% OF CMS OPPS Rate,35.94,120% of CMS OPPS RATE,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,76.02,84% of total billed charges,76.02,84% of total billed charges,76.02,84% of total billed charges,63.35,70% of total billed charges,29.95,100% OF CMS OPPS Rate,29.95,100% OF CMS OPPS Rate,29.95,100% OF CMS OPPS Rate,29.95,100% OF CMS OPPS Rate,29.95,100% OF CMS OPPS Rate,29.95,100% OF CMS OPPS Rate,29.95,100% OF CMS OPPS Rate,29.95,100% OF CMS OPPS Rate,29.95,100% OF CMS OPPS Rate,29.95,100% OF CMS OPPS Rate,29.95,100% OF CMS OPPS Rate,29.95,100% OF CMS OPPS Rate,29.95,100% OF CMS OPPS Rate,29.95,100% OF CMS OPPS Rate,29.95,100% OF CMS OPPS Rate,29.95,100% OF CMS OPPS Rate,31.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.95,90.50,67.88
Outpatient Medical Services,PHYSICAL THERAPY,97532,"COGNITIVE SKILLS, DIRECT (15 MIN)",420,90.5,65.16,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,90.5,Case rate,N/A,Not Separately reimbursable,88.78,Case rate,N/A,Not Separately reimbursable,76.02,84% of total billed charges,76.02,84% of total billed charges,65.16,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,54.3,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,63.35,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,76.02,84% of total billed charges,76.02,84% of total billed charges,76.02,84% of total billed charges,63.35,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,54.30,90.50,67.88
Outpatient Medical Services,PHYSICAL THERAPY,95834,"MANUAL MUSCLE TESTING, TOTAL BODY",420,90.5,65.16,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,90.5,Case rate,N/A,Not Separately reimbursable,88.78,Case rate,N/A,Not Separately reimbursable,76.02,84% of total billed charges,76.02,84% of total billed charges,65.16,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,54.3,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,63.35,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,76.02,84% of total billed charges,76.02,84% of total billed charges,76.02,84% of total billed charges,63.35,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,54.30,90.50,67.88
Outpatient Medical Services,PHYSICAL THERAPY,97542,WHEELCHAIR MGMT/PROPULSION TRAIN,420,90.5,65.16,Pays at 72% of billed charges with lesser of charges applied,35.28,100% OF CMS OPPS Rate,90.5,Case rate,35.28,100% OF CMS OPPS Rate,88.78,Case rate,35.28,100% OF CMS OPPS Rate,76.02,84% of total billed charges,76.02,84% of total billed charges,65.16,72% of total billed charges,35.28,100% OF CMS OPPS Rate,35.28,100% of CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,54.3,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS RATE,35.28,100% OF CMS OPPS Rate,63.35,70% of total billed charges,35.28,100% OF CMS OPPS Rate,42.34,120% of CMS OPPS RATE,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,76.02,84% of total billed charges,76.02,84% of total billed charges,76.02,84% of total billed charges,63.35,70% of total billed charges,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,35.28,100% OF CMS OPPS Rate,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,35.28,90.50,67.88
Outpatient Medical Services,PHYSICAL THERAPY,97110,"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",420,90.5,65.16,Pays at 72% of billed charges with lesser of charges applied,32.64,100% OF CMS OPPS Rate,90.5,Case rate,32.64,100% OF CMS OPPS Rate,88.78,Case rate,32.64,100% OF CMS OPPS Rate,76.02,84% of total billed charges,76.02,84% of total billed charges,65.16,72% of total billed charges,32.64,100% OF CMS OPPS Rate,32.64,100% of CMS OPPS Rate,32.64,100% OF CMS OPPS Rate,54.3,60% of total billed charges,15.72,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.72,100% of CA Medicaid Fee Schedule with lesser of charges applied,32.64,100% OF CMS OPPS Rate,32.64,100% OF CMS OPPS Rate,32.64,100% OF CMS OPPS RATE,32.64,100% OF CMS OPPS Rate,63.35,70% of total billed charges,32.64,100% OF CMS OPPS Rate,39.17,120% of CMS OPPS RATE,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,76.02,84% of total billed charges,76.02,84% of total billed charges,76.02,84% of total billed charges,63.35,70% of total billed charges,32.64,100% OF CMS OPPS Rate,32.64,100% OF CMS OPPS Rate,32.64,100% OF CMS OPPS Rate,32.64,100% OF CMS OPPS Rate,32.64,100% OF CMS OPPS Rate,32.64,100% OF CMS OPPS Rate,32.64,100% OF CMS OPPS Rate,32.64,100% OF CMS OPPS Rate,32.64,100% OF CMS OPPS Rate,32.64,100% OF CMS OPPS Rate,32.64,100% OF CMS OPPS Rate,32.64,100% OF CMS OPPS Rate,32.64,100% OF CMS OPPS Rate,32.64,100% OF CMS OPPS Rate,32.64,100% OF CMS OPPS Rate,32.64,100% OF CMS OPPS Rate,15.72,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.72,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.72,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.72,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.72,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.72,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.72,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.72,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.72,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.72,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.72,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.72,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.72,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.72,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.72,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.72,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.72,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.72,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.72,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.72,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.72,90.50,67.88
Outpatient Medical Services,PHYSICAL THERAPY,95851,RANGE OF MOTIONS MEAS. EXTREM/,420,90.5,65.16,Pays at 72% of billed charges with lesser of charges applied,8.17,100% OF CMS OPPS Rate,90.5,Case rate,8.17,100% OF CMS OPPS Rate,88.78,Case rate,8.17,100% OF CMS OPPS Rate,76.02,84% of total billed charges,76.02,84% of total billed charges,65.16,72% of total billed charges,8.17,100% OF CMS OPPS Rate,8.17,100% of CMS OPPS Rate,8.17,100% OF CMS OPPS Rate,54.3,60% of total billed charges,21.32,100% of CA Medicaid Fee Schedule with lesser of charges applied,21.32,100% of CA Medicaid Fee Schedule with lesser of charges applied,8.17,100% OF CMS OPPS Rate,8.17,100% OF CMS OPPS Rate,8.17,100% OF CMS OPPS RATE,8.17,100% OF CMS OPPS Rate,63.35,70% of total billed charges,8.17,100% OF CMS OPPS Rate,9.8,120% of CMS OPPS RATE,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,76.02,84% of total billed charges,76.02,84% of total billed charges,76.02,84% of total billed charges,63.35,70% of total billed charges,8.17,100% OF CMS OPPS Rate,8.17,100% OF CMS OPPS Rate,8.17,100% OF CMS OPPS Rate,8.17,100% OF CMS OPPS Rate,8.17,100% OF CMS OPPS Rate,8.17,100% OF CMS OPPS Rate,8.17,100% OF CMS OPPS Rate,8.17,100% OF CMS OPPS Rate,8.17,100% OF CMS OPPS Rate,8.17,100% OF CMS OPPS Rate,8.17,100% OF CMS OPPS Rate,8.17,100% OF CMS OPPS Rate,8.17,100% OF CMS OPPS Rate,8.17,100% OF CMS OPPS Rate,8.17,100% OF CMS OPPS Rate,8.17,100% OF CMS OPPS Rate,21.32,100% of CA Medicaid Fee Schedule with lesser of charges applied,21.32,100% of CA Medicaid Fee Schedule with lesser of charges applied,21.32,100% of CA Medicaid Fee Schedule with lesser of charges applied,21.32,100% of CA Medicaid Fee Schedule with lesser of charges applied,21.32,100% of CA Medicaid Fee Schedule with lesser of charges applied,21.32,100% of CA Medicaid Fee Schedule with lesser of charges applied,21.32,100% of CA Medicaid Fee Schedule with lesser of charges applied,21.32,100% of CA Medicaid Fee Schedule with lesser of charges applied,21.32,100% of CA Medicaid Fee Schedule with lesser of charges applied,21.32,100% of CA Medicaid Fee Schedule with lesser of charges applied,21.32,100% of CA Medicaid Fee Schedule with lesser of charges applied,21.32,100% of CA Medicaid Fee Schedule with lesser of charges applied,21.32,100% of CA Medicaid Fee Schedule with lesser of charges applied,21.32,100% of CA Medicaid Fee Schedule with lesser of charges applied,21.32,100% of CA Medicaid Fee Schedule with lesser of charges applied,21.32,100% of CA Medicaid Fee Schedule with lesser of charges applied,21.32,100% of CA Medicaid Fee Schedule with lesser of charges applied,21.32,100% of CA Medicaid Fee Schedule with lesser of charges applied,21.32,100% of CA Medicaid Fee Schedule with lesser of charges applied,21.32,100% of CA Medicaid Fee Schedule with lesser of charges applied,8.17,90.50,67.88
Outpatient Medical Services,PHYSICAL THERAPY,97530,"Incorporates the use of multiple parameters, such as balance, strength, and range of motion, for a functional activity",420,90.5,65.16,Pays at 72% of billed charges with lesser of charges applied,41.84,100% OF CMS OPPS Rate,90.5,Case rate,41.84,100% OF CMS OPPS Rate,88.78,Case rate,41.84,100% OF CMS OPPS Rate,76.02,84% of total billed charges,76.02,84% of total billed charges,65.16,72% of total billed charges,41.84,100% OF CMS OPPS Rate,41.84,100% of CMS OPPS Rate,41.84,100% OF CMS OPPS Rate,54.3,60% of total billed charges,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,41.84,100% OF CMS OPPS Rate,41.84,100% OF CMS OPPS Rate,41.84,100% OF CMS OPPS RATE,41.84,100% OF CMS OPPS Rate,63.35,70% of total billed charges,41.84,100% OF CMS OPPS Rate,50.21,120% of CMS OPPS RATE,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,76.02,84% of total billed charges,76.02,84% of total billed charges,76.02,84% of total billed charges,63.35,70% of total billed charges,41.84,100% OF CMS OPPS Rate,41.84,100% OF CMS OPPS Rate,41.84,100% OF CMS OPPS Rate,41.84,100% OF CMS OPPS Rate,41.84,100% OF CMS OPPS Rate,41.84,100% OF CMS OPPS Rate,41.84,100% OF CMS OPPS Rate,41.84,100% OF CMS OPPS Rate,41.84,100% OF CMS OPPS Rate,41.84,100% OF CMS OPPS Rate,41.84,100% OF CMS OPPS Rate,41.84,100% OF CMS OPPS Rate,41.84,100% OF CMS OPPS Rate,41.84,100% OF CMS OPPS Rate,41.84,100% OF CMS OPPS Rate,41.84,100% OF CMS OPPS Rate,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,90.50,67.88
Outpatient Medical Services,PHYSICAL THERAPY,97535,Occupational therapy,420,90.5,65.16,Pays at 72% of billed charges with lesser of charges applied,36.62,100% OF CMS OPPS Rate,90.5,Case rate,36.62,100% OF CMS OPPS Rate,88.78,Case rate,36.62,100% OF CMS OPPS Rate,76.02,84% of total billed charges,76.02,84% of total billed charges,65.16,72% of total billed charges,36.62,100% OF CMS OPPS Rate,36.62,100% of CMS OPPS Rate,36.62,100% OF CMS OPPS Rate,54.3,60% of total billed charges,7.62,100% of CA Medicaid Fee Schedule with lesser of charges applied,7.62,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.62,100% OF CMS OPPS Rate,36.62,100% OF CMS OPPS Rate,36.62,100% OF CMS OPPS RATE,36.62,100% OF CMS OPPS Rate,63.35,70% of total billed charges,36.62,100% OF CMS OPPS Rate,43.94,120% of CMS OPPS RATE,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,76.02,84% of total billed charges,76.02,84% of total billed charges,76.02,84% of total billed charges,63.35,70% of total billed charges,36.62,100% OF CMS OPPS Rate,36.62,100% OF CMS OPPS Rate,36.62,100% OF CMS OPPS Rate,36.62,100% OF CMS OPPS Rate,36.62,100% OF CMS OPPS Rate,36.62,100% OF CMS OPPS Rate,36.62,100% OF CMS OPPS Rate,36.62,100% OF CMS OPPS Rate,36.62,100% OF CMS OPPS Rate,36.62,100% OF CMS OPPS Rate,36.62,100% OF CMS OPPS Rate,36.62,100% OF CMS OPPS Rate,36.62,100% OF CMS OPPS Rate,36.62,100% OF CMS OPPS Rate,36.62,100% OF CMS OPPS Rate,36.62,100% OF CMS OPPS Rate,7.62,100% of CA Medicaid Fee Schedule with lesser of charges applied,7.62,100% of CA Medicaid Fee Schedule with lesser of charges applied,7.62,100% of CA Medicaid Fee Schedule with lesser of charges applied,7.62,100% of CA Medicaid Fee Schedule with lesser of charges applied,7.62,100% of CA Medicaid Fee Schedule with lesser of charges applied,7.62,100% of CA Medicaid Fee Schedule with lesser of charges applied,7.62,100% of CA Medicaid Fee Schedule with lesser of charges applied,7.62,100% of CA Medicaid Fee Schedule with lesser of charges applied,7.62,100% of CA Medicaid Fee Schedule with lesser of charges applied,7.62,100% of CA Medicaid Fee Schedule with lesser of charges applied,7.62,100% of CA Medicaid Fee Schedule with lesser of charges applied,7.62,100% of CA Medicaid Fee Schedule with lesser of charges applied,7.62,100% of CA Medicaid Fee Schedule with lesser of charges applied,7.62,100% of CA Medicaid Fee Schedule with lesser of charges applied,7.62,100% of CA Medicaid Fee Schedule with lesser of charges applied,7.62,100% of CA Medicaid Fee Schedule with lesser of charges applied,7.62,100% of CA Medicaid Fee Schedule with lesser of charges applied,7.62,100% of CA Medicaid Fee Schedule with lesser of charges applied,7.62,100% of CA Medicaid Fee Schedule with lesser of charges applied,7.62,100% of CA Medicaid Fee Schedule with lesser of charges applied,7.62,90.50,67.88
Outpatient Medical Services,PHYSICAL THERAPY,97760,ORTHOTIC FIT/TRAIN (15 MIN),420,90.5,65.16,Pays at 72% of billed charges with lesser of charges applied,55.09,100% OF CMS OPPS Rate,90.5,Case rate,55.09,100% OF CMS OPPS Rate,88.78,Case rate,55.09,100% OF CMS OPPS Rate,76.02,84% of total billed charges,76.02,84% of total billed charges,65.16,72% of total billed charges,55.09,100% OF CMS OPPS Rate,55.09,100% of CMS OPPS Rate,55.09,100% OF CMS OPPS Rate,54.3,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,55.09,100% OF CMS OPPS Rate,55.09,100% OF CMS OPPS Rate,55.09,100% OF CMS OPPS RATE,55.09,100% OF CMS OPPS Rate,63.35,70% of total billed charges,55.09,100% OF CMS OPPS Rate,66.11,120% of CMS OPPS RATE,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,76.02,84% of total billed charges,76.02,84% of total billed charges,76.02,84% of total billed charges,63.35,70% of total billed charges,55.09,100% OF CMS OPPS Rate,55.09,100% OF CMS OPPS Rate,55.09,100% OF CMS OPPS Rate,55.09,100% OF CMS OPPS Rate,55.09,100% OF CMS OPPS Rate,55.09,100% OF CMS OPPS Rate,55.09,100% OF CMS OPPS Rate,55.09,100% OF CMS OPPS Rate,55.09,100% OF CMS OPPS Rate,55.09,100% OF CMS OPPS Rate,55.09,100% OF CMS OPPS Rate,55.09,100% OF CMS OPPS Rate,55.09,100% OF CMS OPPS Rate,55.09,100% OF CMS OPPS Rate,55.09,100% OF CMS OPPS Rate,55.09,100% OF CMS OPPS Rate,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,54.30,90.50,67.88
Outpatient Medical Services,PHYSICAL THERAPY,97761,TA-PROST FIT/TRAIN (15 MIN),420,90.5,65.16,Pays at 72% of billed charges with lesser of charges applied,47.12,100% OF CMS OPPS Rate,90.5,Case rate,47.12,100% OF CMS OPPS Rate,88.78,Case rate,47.12,100% OF CMS OPPS Rate,76.02,84% of total billed charges,76.02,84% of total billed charges,65.16,72% of total billed charges,47.12,100% OF CMS OPPS Rate,47.12,100% of CMS OPPS Rate,47.12,100% OF CMS OPPS Rate,54.3,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,47.12,100% OF CMS OPPS Rate,47.12,100% OF CMS OPPS Rate,47.12,100% OF CMS OPPS RATE,47.12,100% OF CMS OPPS Rate,63.35,70% of total billed charges,47.12,100% OF CMS OPPS Rate,56.54,120% of CMS OPPS RATE,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,76.02,84% of total billed charges,76.02,84% of total billed charges,76.02,84% of total billed charges,63.35,70% of total billed charges,47.12,100% OF CMS OPPS Rate,47.12,100% OF CMS OPPS Rate,47.12,100% OF CMS OPPS Rate,47.12,100% OF CMS OPPS Rate,47.12,100% OF CMS OPPS Rate,47.12,100% OF CMS OPPS Rate,47.12,100% OF CMS OPPS Rate,47.12,100% OF CMS OPPS Rate,47.12,100% OF CMS OPPS Rate,47.12,100% OF CMS OPPS Rate,47.12,100% OF CMS OPPS Rate,47.12,100% OF CMS OPPS Rate,47.12,100% OF CMS OPPS Rate,47.12,100% OF CMS OPPS Rate,47.12,100% OF CMS OPPS Rate,47.12,100% OF CMS OPPS Rate,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,47.12,90.50,67.88
Outpatient Medical Services,PHYSICAL THERAPY,97032,Repeated application to one or more parts of the body,420,90.5,65.16,Pays at 72% of billed charges with lesser of charges applied,15.69,100% OF CMS OPPS Rate,90.5,Case rate,15.69,100% OF CMS OPPS Rate,88.78,Case rate,15.69,100% OF CMS OPPS Rate,76.02,84% of total billed charges,76.02,84% of total billed charges,65.16,72% of total billed charges,15.69,100% OF CMS OPPS Rate,15.69,100% of CMS OPPS Rate,15.69,100% OF CMS OPPS Rate,54.3,60% of total billed charges,12.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,12.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.69,100% OF CMS OPPS Rate,15.69,100% OF CMS OPPS Rate,15.69,100% OF CMS OPPS RATE,15.69,100% OF CMS OPPS Rate,63.35,70% of total billed charges,15.69,100% OF CMS OPPS Rate,18.83,120% of CMS OPPS RATE,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,76.02,84% of total billed charges,76.02,84% of total billed charges,76.02,84% of total billed charges,63.35,70% of total billed charges,15.69,100% OF CMS OPPS Rate,15.69,100% OF CMS OPPS Rate,15.69,100% OF CMS OPPS Rate,15.69,100% OF CMS OPPS Rate,15.69,100% OF CMS OPPS Rate,15.69,100% OF CMS OPPS Rate,15.69,100% OF CMS OPPS Rate,15.69,100% OF CMS OPPS Rate,15.69,100% OF CMS OPPS Rate,15.69,100% OF CMS OPPS Rate,15.69,100% OF CMS OPPS Rate,15.69,100% OF CMS OPPS Rate,15.69,100% OF CMS OPPS Rate,15.69,100% OF CMS OPPS Rate,15.69,100% OF CMS OPPS Rate,15.69,100% OF CMS OPPS Rate,12.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,12.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,12.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,12.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,12.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,12.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,12.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,12.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,12.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,12.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,12.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,12.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,12.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,12.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,12.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,12.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,12.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,12.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,12.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,12.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,12.42,90.50,67.88
Outpatient Medical Services,PHYSICAL THERAPY,97112,A technique used by physical therapists to restore normal body movement patterns,420,90.5,65.16,Pays at 72% of billed charges with lesser of charges applied,37.57,100% OF CMS OPPS Rate,90.5,Case rate,37.57,100% OF CMS OPPS Rate,88.78,Case rate,37.57,100% OF CMS OPPS Rate,76.02,84% of total billed charges,76.02,84% of total billed charges,65.16,72% of total billed charges,37.57,100% OF CMS OPPS Rate,37.57,100% of CMS OPPS Rate,37.57,100% OF CMS OPPS Rate,54.3,60% of total billed charges,17.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,17.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.57,100% OF CMS OPPS Rate,37.57,100% OF CMS OPPS Rate,37.57,100% OF CMS OPPS RATE,37.57,100% OF CMS OPPS Rate,63.35,70% of total billed charges,37.57,100% OF CMS OPPS Rate,45.08,120% of CMS OPPS RATE,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,76.02,84% of total billed charges,76.02,84% of total billed charges,76.02,84% of total billed charges,63.35,70% of total billed charges,37.57,100% OF CMS OPPS Rate,37.57,100% OF CMS OPPS Rate,37.57,100% OF CMS OPPS Rate,37.57,100% OF CMS OPPS Rate,37.57,100% OF CMS OPPS Rate,37.57,100% OF CMS OPPS Rate,37.57,100% OF CMS OPPS Rate,37.57,100% OF CMS OPPS Rate,37.57,100% OF CMS OPPS Rate,37.57,100% OF CMS OPPS Rate,37.57,100% OF CMS OPPS Rate,37.57,100% OF CMS OPPS Rate,37.57,100% OF CMS OPPS Rate,37.57,100% OF CMS OPPS Rate,37.57,100% OF CMS OPPS Rate,37.57,100% OF CMS OPPS Rate,17.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,17.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,17.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,17.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,17.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,17.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,17.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,17.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,17.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,17.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,17.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,17.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,17.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,17.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,17.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,17.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,17.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,17.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,17.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,17.53,100% of CA Medicaid Fee Schedule with lesser of charges applied,17.53,90.50,67.88
Outpatient Medical Services,PHYSICAL THERAPY,97116,A type of physical therapy,420,90.5,65.16,Pays at 72% of billed charges with lesser of charges applied,32.64,100% OF CMS OPPS Rate,90.5,Case rate,32.64,100% OF CMS OPPS Rate,88.78,Case rate,32.64,100% OF CMS OPPS Rate,76.02,84% of total billed charges,76.02,84% of total billed charges,65.16,72% of total billed charges,32.64,100% OF CMS OPPS Rate,32.64,100% of CMS OPPS Rate,32.64,100% OF CMS OPPS Rate,54.3,60% of total billed charges,16.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,16.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,32.64,100% OF CMS OPPS Rate,32.64,100% OF CMS OPPS Rate,32.64,100% OF CMS OPPS RATE,32.64,100% OF CMS OPPS Rate,63.35,70% of total billed charges,32.64,100% OF CMS OPPS Rate,39.17,120% of CMS OPPS RATE,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,76.02,84% of total billed charges,76.02,84% of total billed charges,76.02,84% of total billed charges,63.35,70% of total billed charges,32.64,100% OF CMS OPPS Rate,32.64,100% OF CMS OPPS Rate,32.64,100% OF CMS OPPS Rate,32.64,100% OF CMS OPPS Rate,32.64,100% OF CMS OPPS Rate,32.64,100% OF CMS OPPS Rate,32.64,100% OF CMS OPPS Rate,32.64,100% OF CMS OPPS Rate,32.64,100% OF CMS OPPS Rate,32.64,100% OF CMS OPPS Rate,32.64,100% OF CMS OPPS Rate,32.64,100% OF CMS OPPS Rate,32.64,100% OF CMS OPPS Rate,32.64,100% OF CMS OPPS Rate,32.64,100% OF CMS OPPS Rate,32.64,100% OF CMS OPPS Rate,16.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,16.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,16.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,16.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,16.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,16.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,16.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,16.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,16.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,16.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,16.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,16.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,16.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,16.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,16.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,16.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,16.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,16.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,16.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,16.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,16.18,90.50,67.88
Outpatient Medical Services,PHYSICAL THERAPY,97033,Psychiatric treatment in which seizures are electrically induced in patients to provide relief from mental disorders,420,90.5,65.16,Pays at 72% of billed charges with lesser of charges applied,22.02,100% OF CMS OPPS Rate,90.5,Case rate,22.02,100% OF CMS OPPS Rate,88.78,Case rate,22.02,100% OF CMS OPPS Rate,76.02,84% of total billed charges,76.02,84% of total billed charges,65.16,72% of total billed charges,22.02,100% OF CMS OPPS Rate,22.02,100% of CMS OPPS Rate,22.02,100% OF CMS OPPS Rate,54.3,60% of total billed charges,13.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,13.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,22.02,100% OF CMS OPPS Rate,22.02,100% OF CMS OPPS Rate,22.02,100% OF CMS OPPS RATE,22.02,100% OF CMS OPPS Rate,63.35,70% of total billed charges,22.02,100% OF CMS OPPS Rate,26.42,120% of CMS OPPS RATE,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,76.02,84% of total billed charges,76.02,84% of total billed charges,76.02,84% of total billed charges,63.35,70% of total billed charges,22.02,100% OF CMS OPPS Rate,22.02,100% OF CMS OPPS Rate,22.02,100% OF CMS OPPS Rate,22.02,100% OF CMS OPPS Rate,22.02,100% OF CMS OPPS Rate,22.02,100% OF CMS OPPS Rate,22.02,100% OF CMS OPPS Rate,22.02,100% OF CMS OPPS Rate,22.02,100% OF CMS OPPS Rate,22.02,100% OF CMS OPPS Rate,22.02,100% OF CMS OPPS Rate,22.02,100% OF CMS OPPS Rate,22.02,100% OF CMS OPPS Rate,22.02,100% OF CMS OPPS Rate,22.02,100% OF CMS OPPS Rate,22.02,100% OF CMS OPPS Rate,13.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,13.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,13.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,13.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,13.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,13.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,13.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,13.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,13.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,13.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,13.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,13.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,13.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,13.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,13.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,13.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,13.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,13.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,13.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,13.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,13.17,90.50,67.88
Outpatient Medical Services,PHYSICAL THERAPY,97035,"Use of sound waves to treat medical problems, especially musculoskeletal problems like inflammation from injuries",420,90.5,65.16,Pays at 72% of billed charges with lesser of charges applied,15.89,100% OF CMS OPPS Rate,90.5,Case rate,15.89,100% OF CMS OPPS Rate,88.78,Case rate,15.89,100% OF CMS OPPS Rate,76.02,84% of total billed charges,76.02,84% of total billed charges,65.16,72% of total billed charges,15.89,100% OF CMS OPPS Rate,15.89,100% of CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,54.3,60% of total billed charges,10.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS RATE,15.89,100% OF CMS OPPS Rate,63.35,70% of total billed charges,15.89,100% OF CMS OPPS Rate,19.07,120% of CMS OPPS RATE,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,76.02,84% of total billed charges,76.02,84% of total billed charges,76.02,84% of total billed charges,63.35,70% of total billed charges,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,10.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.66,90.50,67.88
Outpatient Medical Services,PHYSICAL THERAPY,97022,TA-WHIRLPOOL PROC 30 MIN,420,90.5,65.16,Pays at 72% of billed charges with lesser of charges applied,19.27,100% OF CMS OPPS Rate,90.5,Case rate,19.27,100% OF CMS OPPS Rate,88.78,Case rate,19.27,100% OF CMS OPPS Rate,76.02,84% of total billed charges,76.02,84% of total billed charges,65.16,72% of total billed charges,19.27,100% OF CMS OPPS Rate,19.27,100% of CMS OPPS Rate,19.27,100% OF CMS OPPS Rate,54.3,60% of total billed charges,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,19.27,100% OF CMS OPPS Rate,19.27,100% OF CMS OPPS Rate,19.27,100% OF CMS OPPS RATE,19.27,100% OF CMS OPPS Rate,63.35,70% of total billed charges,19.27,100% OF CMS OPPS Rate,23.12,120% of CMS OPPS RATE,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,76.02,84% of total billed charges,76.02,84% of total billed charges,76.02,84% of total billed charges,63.35,70% of total billed charges,19.27,100% OF CMS OPPS Rate,19.27,100% OF CMS OPPS Rate,19.27,100% OF CMS OPPS Rate,19.27,100% OF CMS OPPS Rate,19.27,100% OF CMS OPPS Rate,19.27,100% OF CMS OPPS Rate,19.27,100% OF CMS OPPS Rate,19.27,100% OF CMS OPPS Rate,19.27,100% OF CMS OPPS Rate,19.27,100% OF CMS OPPS Rate,19.27,100% OF CMS OPPS Rate,19.27,100% OF CMS OPPS Rate,19.27,100% OF CMS OPPS Rate,19.27,100% OF CMS OPPS Rate,19.27,100% OF CMS OPPS Rate,19.27,100% OF CMS OPPS Rate,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.98,90.50,67.88
Outpatient Medical Services,PHYSICAL THERAPY,97034,TA-CONTRAST BATH 15 MIN,420,90.5,65.16,Pays at 72% of billed charges with lesser of charges applied,15.89,100% OF CMS OPPS Rate,90.5,Case rate,15.89,100% OF CMS OPPS Rate,88.78,Case rate,15.89,100% OF CMS OPPS Rate,76.02,84% of total billed charges,76.02,84% of total billed charges,65.16,72% of total billed charges,15.89,100% OF CMS OPPS Rate,15.89,100% of CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,54.3,60% of total billed charges,11.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS RATE,15.89,100% OF CMS OPPS Rate,63.35,70% of total billed charges,15.89,100% OF CMS OPPS Rate,19.07,120% of CMS OPPS RATE,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,76.02,84% of total billed charges,76.02,84% of total billed charges,76.02,84% of total billed charges,63.35,70% of total billed charges,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,15.89,100% OF CMS OPPS Rate,11.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.23,90.50,67.88
Outpatient Medical Services,PHYSICAL THERAPY,95852,TA-RANGE OF MOTION HAND,420,90.5,65.16,Pays at 72% of billed charges with lesser of charges applied,5.63,100% OF CMS OPPS Rate,90.5,Case rate,5.63,100% OF CMS OPPS Rate,88.78,Case rate,5.63,100% OF CMS OPPS Rate,76.02,84% of total billed charges,76.02,84% of total billed charges,65.16,72% of total billed charges,5.63,100% OF CMS OPPS Rate,5.63,100% of CMS OPPS Rate,5.63,100% OF CMS OPPS Rate,54.3,60% of total billed charges,11.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,5.63,100% OF CMS OPPS Rate,5.63,100% OF CMS OPPS Rate,5.63,100% OF CMS OPPS RATE,5.63,100% OF CMS OPPS Rate,63.35,70% of total billed charges,5.63,100% OF CMS OPPS Rate,6.76,120% of CMS OPPS RATE,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,76.02,84% of total billed charges,76.02,84% of total billed charges,76.02,84% of total billed charges,63.35,70% of total billed charges,5.63,100% OF CMS OPPS Rate,5.63,100% OF CMS OPPS Rate,5.63,100% OF CMS OPPS Rate,5.63,100% OF CMS OPPS Rate,5.63,100% OF CMS OPPS Rate,5.63,100% OF CMS OPPS Rate,5.63,100% OF CMS OPPS Rate,5.63,100% OF CMS OPPS Rate,5.63,100% OF CMS OPPS Rate,5.63,100% OF CMS OPPS Rate,5.63,100% OF CMS OPPS Rate,5.63,100% OF CMS OPPS Rate,5.63,100% OF CMS OPPS Rate,5.63,100% OF CMS OPPS Rate,5.63,100% OF CMS OPPS Rate,5.63,100% OF CMS OPPS Rate,11.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,11.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,5.63,90.50,67.88
Outpatient Medical Services,PHYSICAL THERAPY,97039,TA-TILT TABLE (15 MIN),420,90.5,65.16,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,90.5,Case rate,N/A,Not Separately reimbursable,88.78,Case rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,65.16,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,54.3,60% of total billed charges,20.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,63.35,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,63.35,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,20.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.47,90.50,67.88
Outpatient Medical Services,PHYSICAL THERAPY,90901,TA-EMG BIOFEEDBACK,420,90.5,65.16,Pays at 72% of billed charges with lesser of charges applied,20.09,100% OF CMS OPPS Rate,90.5,Case rate,20.09,100% OF CMS OPPS Rate,88.78,Case rate,20.09,100% OF CMS OPPS Rate,76.02,84% of total billed charges,76.02,84% of total billed charges,65.16,72% of total billed charges,20.09,100% OF CMS OPPS Rate,20.09,100% of CMS OPPS Rate,20.09,100% OF CMS OPPS Rate,54.3,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,20.09,100% OF CMS OPPS Rate,20.09,100% OF CMS OPPS Rate,20.09,100% OF CMS OPPS RATE,20.09,100% OF CMS OPPS Rate,63.35,70% of total billed charges,20.09,100% OF CMS OPPS Rate,24.11,120% of CMS OPPS RATE,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,90.5,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,76.02,84% of total billed charges,76.02,84% of total billed charges,76.02,84% of total billed charges,63.35,70% of total billed charges,20.09,100% OF CMS OPPS Rate,20.09,100% OF CMS OPPS Rate,20.09,100% OF CMS OPPS Rate,20.09,100% OF CMS OPPS Rate,20.09,100% OF CMS OPPS Rate,20.09,100% OF CMS OPPS Rate,20.09,100% OF CMS OPPS Rate,20.09,100% OF CMS OPPS Rate,20.09,100% OF CMS OPPS Rate,20.09,100% OF CMS OPPS Rate,20.09,100% OF CMS OPPS Rate,20.09,100% OF CMS OPPS Rate,20.09,100% OF CMS OPPS Rate,20.09,100% OF CMS OPPS Rate,20.09,100% OF CMS OPPS Rate,20.09,100% OF CMS OPPS Rate,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,20.09,90.50,67.88
Outpatient Medical Services,PHYSICAL THERAPY,64550,TA-TENS,420,90.5,65.16,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,90.5,100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,88.78,Case rate,N/A,Not Separately reimbursable,76.02,84% of total billed charges,76.02,84% of total billed charges,65.16,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,54.3,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,63.35,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,65.16,Pays at 72% of billed charges with lesser of charges applied,90.5,100% of ASC Tier Grouping Fee Schedule,90.5,100% of ASC Tier Grouping Fee Schedule,90.5,100% of ASC Tier Grouping Fee Schedule,90.5,100% of ASC Tier Grouping Fee Schedule,90.5,100% of ASC Tier Grouping Fee Schedule,90.5,100% of ASC Tier Grouping Fee Schedule,90.5,100% of ASC Tier Grouping Fee Schedule,90.5,100% of ASC Tier Grouping Fee Schedule,90.5,100% of ASC Tier Grouping Fee Schedule,88.78,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,88.78,Case rate,76.02,84% of total billed charges,76.02,84% of total billed charges,76.02,84% of total billed charges,63.35,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,54.30,90.50,67.88
Outpatient Medical Services,PHYSICAL THERAPY,96125,TA-COGNITIVE TEST BY HC PRO,420,109,78.48,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,109,Case rate,N/A,Not Separately reimbursable,106.93,Case rate,N/A,Not Separately reimbursable,91.56,84% of total billed charges,91.56,84% of total billed charges,78.48,72% of total billed charges,N/A,Not Separately reimbursable,109,100% of CMS OPPS Rate,N/A,Not Separately reimbursable,65.4,60% of total billed charges,131.20,100% of CA Medicaid Fee Schedule with lesser of charges applied,131.20,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,111.93,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,76.3,70% of total billed charges,109,100% OF CMS OPPS Rate,109,120% of CMS OPPS RATE,78.48,Pays at 72% of billed charges with lesser of charges applied,78.48,Pays at 72% of billed charges with lesser of charges applied,78.48,Pays at 72% of billed charges with lesser of charges applied,78.48,Pays at 72% of billed charges with lesser of charges applied,78.48,Pays at 72% of billed charges with lesser of charges applied,78.48,Pays at 72% of billed charges with lesser of charges applied,109,Case rate,109,Case rate,109,Case rate,109,Case rate,109,Case rate,109,Case rate,109,Case rate,109,Case rate,109,Case rate,106.93,Case rate,106.93,Case rate,106.93,Case rate,106.93,Case rate,106.93,Case rate,91.56,84% of total billed charges,91.56,84% of total billed charges,91.56,84% of total billed charges,76.3,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,131.20,100% of CA Medicaid Fee Schedule with lesser of charges applied,131.20,100% of CA Medicaid Fee Schedule with lesser of charges applied,131.20,100% of CA Medicaid Fee Schedule with lesser of charges applied,131.20,100% of CA Medicaid Fee Schedule with lesser of charges applied,131.20,100% of CA Medicaid Fee Schedule with lesser of charges applied,131.20,100% of CA Medicaid Fee Schedule with lesser of charges applied,131.20,100% of CA Medicaid Fee Schedule with lesser of charges applied,131.20,100% of CA Medicaid Fee Schedule with lesser of charges applied,131.20,100% of CA Medicaid Fee Schedule with lesser of charges applied,131.20,100% of CA Medicaid Fee Schedule with lesser of charges applied,131.20,100% of CA Medicaid Fee Schedule with lesser of charges applied,131.20,100% of CA Medicaid Fee Schedule with lesser of charges applied,131.20,100% of CA Medicaid Fee Schedule with lesser of charges applied,131.20,100% of CA Medicaid Fee Schedule with lesser of charges applied,131.20,100% of CA Medicaid Fee Schedule with lesser of charges applied,131.20,100% of CA Medicaid Fee Schedule with lesser of charges applied,131.20,100% of CA Medicaid Fee Schedule with lesser of charges applied,131.20,100% of CA Medicaid Fee Schedule with lesser of charges applied,131.20,100% of CA Medicaid Fee Schedule with lesser of charges applied,131.20,100% of CA Medicaid Fee Schedule with lesser of charges applied,65.40,131.20,81.75
Outpatient Medical Services,PHYSICIAN CLINIC,46220,EXCISION SINGLE EXT TAG/PAPILLA ANUS,510,2247.34,1618.08,Pays at 72% of billed charges with lesser of charges applied,1376.46,100% OF CMS OPPS Rate,2247.34,100% of ASC Tier Grouping Fee Schedule,1376.46,100% OF CMS OPPS Rate,1777.65,79.1% of total billed charges,1376.46,100% OF CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,1618.08,72% of total billed charges,1376.46,100% OF CMS OPPS Rate,1376.46,100% of CMS OPPS Rate,1376.46,100% OF CMS OPPS Rate,1348.4,60% of total billed charges,71.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,71.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,1376.46,100% OF CMS OPPS Rate,1376.46,100% OF CMS OPPS Rate,131.22,100% OF CMS OPPS RATE,1376.46,100% OF CMS OPPS Rate,1573.14,70% of total billed charges,1376.46,100% OF CMS OPPS Rate,1651.75,120% of CMS OPPS RATE,1618.08,Pays at 72% of billed charges with lesser of charges applied,1618.08,Pays at 72% of billed charges with lesser of charges applied,1618.08,Pays at 72% of billed charges with lesser of charges applied,1618.08,Pays at 72% of billed charges with lesser of charges applied,1618.08,Pays at 72% of billed charges with lesser of charges applied,1618.08,Pays at 72% of billed charges with lesser of charges applied,2247.34,100% of ASC Tier Grouping Fee Schedule,2247.34,100% of ASC Tier Grouping Fee Schedule,2247.34,100% of ASC Tier Grouping Fee Schedule,2247.34,100% of ASC Tier Grouping Fee Schedule,2247.34,100% of ASC Tier Grouping Fee Schedule,2247.34,100% of ASC Tier Grouping Fee Schedule,2247.34,100% of ASC Tier Grouping Fee Schedule,2247.34,100% of ASC Tier Grouping Fee Schedule,2247.34,100% of ASC Tier Grouping Fee Schedule,1777.65,79.1% of total billed charges,1777.65,79.1% of total billed charges,1777.65,79.1% of total billed charges,1777.65,79.1% of total billed charges,1777.65,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,1573.14,70% of total billed charges,1376.46,100% OF CMS OPPS Rate,1376.46,100% OF CMS OPPS Rate,1376.46,100% OF CMS OPPS Rate,1376.46,100% OF CMS OPPS Rate,1376.46,100% OF CMS OPPS Rate,1376.46,100% OF CMS OPPS Rate,1376.46,100% OF CMS OPPS Rate,1376.46,100% OF CMS OPPS Rate,1376.46,100% OF CMS OPPS Rate,1376.46,100% OF CMS OPPS Rate,1376.46,100% OF CMS OPPS Rate,1376.46,100% OF CMS OPPS Rate,1376.46,100% OF CMS OPPS Rate,1376.46,100% OF CMS OPPS Rate,1376.46,100% OF CMS OPPS Rate,1376.46,100% OF CMS OPPS Rate,71.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,71.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,71.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,71.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,71.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,71.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,71.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,71.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,71.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,71.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,71.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,71.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,71.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,71.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,71.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,71.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,71.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,71.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,71.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,71.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,71.56,2247.34,1685.51
Outpatient Medical Services,PHYSICIAN CLINIC,11426,EXC B9 LESION MRGN XDP SK/TG >4.0CM,510,3235.28,2329.4,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,3235.28,100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,2559.11,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,2329.4,72% of total billed charges,N/A,Not Separately reimbursable,3235.28,100% of CMS OPPS Rate,N/A,Not Separately reimbursable,1941.17,60% of total billed charges,344.44,100% of CA Medicaid Fee Schedule with lesser of charges applied,344.44,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,287.04,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,2264.7,70% of total billed charges,3235.28,100% OF CMS OPPS Rate,3235.28,120% of CMS OPPS RATE,2329.4,Pays at 72% of billed charges with lesser of charges applied,2329.4,Pays at 72% of billed charges with lesser of charges applied,2329.4,Pays at 72% of billed charges with lesser of charges applied,2329.4,Pays at 72% of billed charges with lesser of charges applied,2329.4,Pays at 72% of billed charges with lesser of charges applied,2329.4,Pays at 72% of billed charges with lesser of charges applied,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,2559.11,79.1% of total billed charges,2559.11,79.1% of total billed charges,2559.11,79.1% of total billed charges,2559.11,79.1% of total billed charges,2559.11,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,2264.7,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,344.44,100% of CA Medicaid Fee Schedule with lesser of charges applied,344.44,100% of CA Medicaid Fee Schedule with lesser of charges applied,344.44,100% of CA Medicaid Fee Schedule with lesser of charges applied,344.44,100% of CA Medicaid Fee Schedule with lesser of charges applied,344.44,100% of CA Medicaid Fee Schedule with lesser of charges applied,344.44,100% of CA Medicaid Fee Schedule with lesser of charges applied,344.44,100% of CA Medicaid Fee Schedule with lesser of charges applied,344.44,100% of CA Medicaid Fee Schedule with lesser of charges applied,344.44,100% of CA Medicaid Fee Schedule with lesser of charges applied,344.44,100% of CA Medicaid Fee Schedule with lesser of charges applied,344.44,100% of CA Medicaid Fee Schedule with lesser of charges applied,344.44,100% of CA Medicaid Fee Schedule with lesser of charges applied,344.44,100% of CA Medicaid Fee Schedule with lesser of charges applied,344.44,100% of CA Medicaid Fee Schedule with lesser of charges applied,344.44,100% of CA Medicaid Fee Schedule with lesser of charges applied,344.44,100% of CA Medicaid Fee Schedule with lesser of charges applied,344.44,100% of CA Medicaid Fee Schedule with lesser of charges applied,344.44,100% of CA Medicaid Fee Schedule with lesser of charges applied,344.44,100% of CA Medicaid Fee Schedule with lesser of charges applied,344.44,100% of CA Medicaid Fee Schedule with lesser of charges applied,287.04,3235.28,2426.46
Outpatient Medical Services,PHYSICIAN CLINIC,11424,EXC H-F-NK-SP B9+MARG 3.1-4.0CM,510,3235.28,2329.4,Pays at 72% of billed charges with lesser of charges applied,1906.04,100% OF CMS OPPS Rate,3235.28,100% of ASC Tier Grouping Fee Schedule,1906.04,100% OF CMS OPPS Rate,2559.11,79.1% of total billed charges,1906.04,100% OF CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,2329.4,72% of total billed charges,1906.04,100% OF CMS OPPS Rate,1906.04,100% of CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1941.17,60% of total billed charges,145.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,145.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,192.65,100% OF CMS OPPS RATE,1906.04,100% OF CMS OPPS Rate,2264.7,70% of total billed charges,1906.04,100% OF CMS OPPS Rate,2287.25,120% of CMS OPPS RATE,2329.4,Pays at 72% of billed charges with lesser of charges applied,2329.4,Pays at 72% of billed charges with lesser of charges applied,2329.4,Pays at 72% of billed charges with lesser of charges applied,2329.4,Pays at 72% of billed charges with lesser of charges applied,2329.4,Pays at 72% of billed charges with lesser of charges applied,2329.4,Pays at 72% of billed charges with lesser of charges applied,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,2559.11,79.1% of total billed charges,2559.11,79.1% of total billed charges,2559.11,79.1% of total billed charges,2559.11,79.1% of total billed charges,2559.11,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,2264.7,70% of total billed charges,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,145.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,145.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,145.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,145.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,145.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,145.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,145.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,145.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,145.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,145.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,145.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,145.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,145.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,145.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,145.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,145.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,145.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,145.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,145.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,145.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,145.26,3235.28,2426.46
Outpatient Medical Services,PHYSICIAN CLINIC,99212,Outpatient visit of established patient requiring a physician,510,245.1,176.47,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,200.25,81.7% of total Billed charges,N/A,Not Separately reimbursable,193.87,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,176.47,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,147.06,60% of total billed charges,16.37,100% of CA Medicaid Fee Schedule with lesser of charges applied,16.37,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,37.18,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,171.57,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,176.47,Pays at 72% of billed charges with lesser of charges applied,176.47,Pays at 72% of billed charges with lesser of charges applied,176.47,Pays at 72% of billed charges with lesser of charges applied,176.47,Pays at 72% of billed charges with lesser of charges applied,176.47,Pays at 72% of billed charges with lesser of charges applied,176.47,Pays at 72% of billed charges with lesser of charges applied,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,193.87,79.1% of total billed charges,193.87,79.1% of total billed charges,193.87,79.1% of total billed charges,193.87,79.1% of total billed charges,193.87,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,171.57,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,16.37,100% of CA Medicaid Fee Schedule with lesser of charges applied,16.37,100% of CA Medicaid Fee Schedule with lesser of charges applied,16.37,100% of CA Medicaid Fee Schedule with lesser of charges applied,16.37,100% of CA Medicaid Fee Schedule with lesser of charges applied,16.37,100% of CA Medicaid Fee Schedule with lesser of charges applied,16.37,100% of CA Medicaid Fee Schedule with lesser of charges applied,16.37,100% of CA Medicaid Fee Schedule with lesser of charges applied,16.37,100% of CA Medicaid Fee Schedule with lesser of charges applied,16.37,100% of CA Medicaid Fee Schedule with lesser of charges applied,16.37,100% of CA Medicaid Fee Schedule with lesser of charges applied,16.37,100% of CA Medicaid Fee Schedule with lesser of charges applied,16.37,100% of CA Medicaid Fee Schedule with lesser of charges applied,16.37,100% of CA Medicaid Fee Schedule with lesser of charges applied,16.37,100% of CA Medicaid Fee Schedule with lesser of charges applied,16.37,100% of CA Medicaid Fee Schedule with lesser of charges applied,16.37,100% of CA Medicaid Fee Schedule with lesser of charges applied,16.37,100% of CA Medicaid Fee Schedule with lesser of charges applied,16.37,100% of CA Medicaid Fee Schedule with lesser of charges applied,16.37,100% of CA Medicaid Fee Schedule with lesser of charges applied,16.37,100% of CA Medicaid Fee Schedule with lesser of charges applied,16.37,200.25,183.83
Outpatient Medical Services,PHYSICIAN CLINIC,99213,"Established patient office or other outpatient visit, typically 15 minutes",510,245.1,176.47,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,200.25,81.7% of total Billed charges,N/A,Not Separately reimbursable,193.87,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,176.47,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,147.06,60% of total billed charges,34.43,100% of CA Medicaid Fee Schedule with lesser of charges applied,34.43,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,69.28,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,171.57,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,176.47,Pays at 72% of billed charges with lesser of charges applied,176.47,Pays at 72% of billed charges with lesser of charges applied,176.47,Pays at 72% of billed charges with lesser of charges applied,176.47,Pays at 72% of billed charges with lesser of charges applied,176.47,Pays at 72% of billed charges with lesser of charges applied,176.47,Pays at 72% of billed charges with lesser of charges applied,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,193.87,79.1% of total billed charges,193.87,79.1% of total billed charges,193.87,79.1% of total billed charges,193.87,79.1% of total billed charges,193.87,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,171.57,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,34.43,100% of CA Medicaid Fee Schedule with lesser of charges applied,34.43,100% of CA Medicaid Fee Schedule with lesser of charges applied,34.43,100% of CA Medicaid Fee Schedule with lesser of charges applied,34.43,100% of CA Medicaid Fee Schedule with lesser of charges applied,34.43,100% of CA Medicaid Fee Schedule with lesser of charges applied,34.43,100% of CA Medicaid Fee Schedule with lesser of charges applied,34.43,100% of CA Medicaid Fee Schedule with lesser of charges applied,34.43,100% of CA Medicaid Fee Schedule with lesser of charges applied,34.43,100% of CA Medicaid Fee Schedule with lesser of charges applied,34.43,100% of CA Medicaid Fee Schedule with lesser of charges applied,34.43,100% of CA Medicaid Fee Schedule with lesser of charges applied,34.43,100% of CA Medicaid Fee Schedule with lesser of charges applied,34.43,100% of CA Medicaid Fee Schedule with lesser of charges applied,34.43,100% of CA Medicaid Fee Schedule with lesser of charges applied,34.43,100% of CA Medicaid Fee Schedule with lesser of charges applied,34.43,100% of CA Medicaid Fee Schedule with lesser of charges applied,34.43,100% of CA Medicaid Fee Schedule with lesser of charges applied,34.43,100% of CA Medicaid Fee Schedule with lesser of charges applied,34.43,100% of CA Medicaid Fee Schedule with lesser of charges applied,34.43,100% of CA Medicaid Fee Schedule with lesser of charges applied,34.43,200.25,183.83
Outpatient Medical Services,PHYSICIAN CLINIC,99214,"Established patient office or other outpatient visit, typically 25 minutes",510,245.1,176.47,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,200.25,81.7% of total Billed charges,N/A,Not Separately reimbursable,193.87,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,176.47,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,147.06,60% of total billed charges,53.79,100% of CA Medicaid Fee Schedule with lesser of charges applied,53.79,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,102.47,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,171.57,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,176.47,Pays at 72% of billed charges with lesser of charges applied,176.47,Pays at 72% of billed charges with lesser of charges applied,176.47,Pays at 72% of billed charges with lesser of charges applied,176.47,Pays at 72% of billed charges with lesser of charges applied,176.47,Pays at 72% of billed charges with lesser of charges applied,176.47,Pays at 72% of billed charges with lesser of charges applied,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,193.87,79.1% of total billed charges,193.87,79.1% of total billed charges,193.87,79.1% of total billed charges,193.87,79.1% of total billed charges,193.87,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,171.57,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,53.79,100% of CA Medicaid Fee Schedule with lesser of charges applied,53.79,100% of CA Medicaid Fee Schedule with lesser of charges applied,53.79,100% of CA Medicaid Fee Schedule with lesser of charges applied,53.79,100% of CA Medicaid Fee Schedule with lesser of charges applied,53.79,100% of CA Medicaid Fee Schedule with lesser of charges applied,53.79,100% of CA Medicaid Fee Schedule with lesser of charges applied,53.79,100% of CA Medicaid Fee Schedule with lesser of charges applied,53.79,100% of CA Medicaid Fee Schedule with lesser of charges applied,53.79,100% of CA Medicaid Fee Schedule with lesser of charges applied,53.79,100% of CA Medicaid Fee Schedule with lesser of charges applied,53.79,100% of CA Medicaid Fee Schedule with lesser of charges applied,53.79,100% of CA Medicaid Fee Schedule with lesser of charges applied,53.79,100% of CA Medicaid Fee Schedule with lesser of charges applied,53.79,100% of CA Medicaid Fee Schedule with lesser of charges applied,53.79,100% of CA Medicaid Fee Schedule with lesser of charges applied,53.79,100% of CA Medicaid Fee Schedule with lesser of charges applied,53.79,100% of CA Medicaid Fee Schedule with lesser of charges applied,53.79,100% of CA Medicaid Fee Schedule with lesser of charges applied,53.79,100% of CA Medicaid Fee Schedule with lesser of charges applied,53.79,100% of CA Medicaid Fee Schedule with lesser of charges applied,53.79,200.25,183.83
Outpatient Medical Services,PHYSICIAN CLINIC,99215,"Established patient office or other outpatient, visit typically 40 minutes",510,245.1,176.47,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,200.25,81.7% of total Billed charges,N/A,Not Separately reimbursable,193.87,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,176.47,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,147.06,60% of total billed charges,82.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,82.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,150.72,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,171.57,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,176.47,Pays at 72% of billed charges with lesser of charges applied,176.47,Pays at 72% of billed charges with lesser of charges applied,176.47,Pays at 72% of billed charges with lesser of charges applied,176.47,Pays at 72% of billed charges with lesser of charges applied,176.47,Pays at 72% of billed charges with lesser of charges applied,176.47,Pays at 72% of billed charges with lesser of charges applied,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,193.87,79.1% of total billed charges,193.87,79.1% of total billed charges,193.87,79.1% of total billed charges,193.87,79.1% of total billed charges,193.87,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,171.57,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,82.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,82.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,82.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,82.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,82.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,82.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,82.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,82.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,82.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,82.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,82.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,82.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,82.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,82.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,82.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,82.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,82.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,82.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,82.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,82.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,82.05,200.25,183.83
Outpatient Medical Services,PHYSICIAN CLINIC,11620,EXC S-N-H-F-G MAL+MARG 0.5CM/<,510,3235.28,2329.4,Pays at 72% of billed charges with lesser of charges applied,1906.04,100% OF CMS OPPS Rate,3235.28,100% of ASC Tier Grouping Fee Schedule,1906.04,100% OF CMS OPPS Rate,2559.11,79.1% of total billed charges,1906.04,100% OF CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,2329.4,72% of total billed charges,1906.04,100% OF CMS OPPS Rate,1906.04,100% of CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1941.17,60% of total billed charges,121.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,121.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,133.28,100% OF CMS OPPS RATE,1906.04,100% OF CMS OPPS Rate,2264.7,70% of total billed charges,1906.04,100% OF CMS OPPS Rate,2287.25,120% of CMS OPPS RATE,2329.4,Pays at 72% of billed charges with lesser of charges applied,2329.4,Pays at 72% of billed charges with lesser of charges applied,2329.4,Pays at 72% of billed charges with lesser of charges applied,2329.4,Pays at 72% of billed charges with lesser of charges applied,2329.4,Pays at 72% of billed charges with lesser of charges applied,2329.4,Pays at 72% of billed charges with lesser of charges applied,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,2559.11,79.1% of total billed charges,2559.11,79.1% of total billed charges,2559.11,79.1% of total billed charges,2559.11,79.1% of total billed charges,2559.11,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,2264.7,70% of total billed charges,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,121.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,121.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,121.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,121.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,121.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,121.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,121.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,121.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,121.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,121.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,121.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,121.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,121.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,121.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,121.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,121.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,121.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,121.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,121.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,121.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,121.22,3235.28,2426.46
Outpatient Medical Services,PHYSICIAN CLINIC,99211,Outpatient visit of established patient not requiring a physician,510,245.1,176.47,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,200.25,81.7% of total Billed charges,N/A,Not Separately reimbursable,193.87,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,176.47,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,147.06,60% of total billed charges,17.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,17.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,9.27,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,171.57,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,176.47,Pays at 72% of billed charges with lesser of charges applied,176.47,Pays at 72% of billed charges with lesser of charges applied,176.47,Pays at 72% of billed charges with lesser of charges applied,176.47,Pays at 72% of billed charges with lesser of charges applied,176.47,Pays at 72% of billed charges with lesser of charges applied,176.47,Pays at 72% of billed charges with lesser of charges applied,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,193.87,79.1% of total billed charges,193.87,79.1% of total billed charges,193.87,79.1% of total billed charges,193.87,79.1% of total billed charges,193.87,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,171.57,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,17.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,17.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,17.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,17.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,17.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,17.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,17.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,17.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,17.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,17.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,17.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,17.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,17.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,17.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,17.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,17.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,17.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,17.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,17.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,17.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,9.27,200.25,183.83
Outpatient Medical Services,PHYSICIAN CLINIC,99201,OFFICE VISIT NEW 10 MIN 99201,510,245.1,176.47,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,200.25,81.7% of total Billed charges,N/A,Not Separately reimbursable,193.87,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,176.47,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,147.06,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,171.57,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,176.47,Pays at 72% of billed charges with lesser of charges applied,176.47,Pays at 72% of billed charges with lesser of charges applied,176.47,Pays at 72% of billed charges with lesser of charges applied,176.47,Pays at 72% of billed charges with lesser of charges applied,176.47,Pays at 72% of billed charges with lesser of charges applied,176.47,Pays at 72% of billed charges with lesser of charges applied,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,193.87,79.1% of total billed charges,193.87,79.1% of total billed charges,193.87,79.1% of total billed charges,193.87,79.1% of total billed charges,193.87,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,171.57,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,147.06,200.25,183.83
Outpatient Medical Services,PHYSICIAN CLINIC,99202,"New patient office or other outpatient visit, typically 10 minutes",510,250,180,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,204.25,81.7% of total Billed charges,N/A,Not Separately reimbursable,197.75,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,180,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,150,60% of total billed charges,49.20,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.20,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,50.38,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,175,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,180,Pays at 72% of billed charges with lesser of charges applied,180,Pays at 72% of billed charges with lesser of charges applied,180,Pays at 72% of billed charges with lesser of charges applied,180,Pays at 72% of billed charges with lesser of charges applied,180,Pays at 72% of billed charges with lesser of charges applied,180,Pays at 72% of billed charges with lesser of charges applied,204.25,81.7% of total Billed charges,204.25,81.7% of total Billed charges,204.25,81.7% of total Billed charges,204.25,81.7% of total Billed charges,204.25,81.7% of total Billed charges,204.25,81.7% of total Billed charges,204.25,81.7% of total Billed charges,204.25,81.7% of total Billed charges,204.25,81.7% of total Billed charges,197.75,79.1% of total billed charges,197.75,79.1% of total billed charges,197.75,79.1% of total billed charges,197.75,79.1% of total billed charges,197.75,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,175,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,49.20,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.20,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.20,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.20,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.20,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.20,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.20,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.20,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.20,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.20,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.20,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.20,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.20,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.20,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.20,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.20,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.20,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.20,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.20,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.20,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.20,204.25,187.5
Outpatient Medical Services,PHYSICIAN CLINIC,99203,"New patient office or other outpatient visit, typically 30 min",510,245.1,176.47,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,200.25,81.7% of total Billed charges,N/A,Not Separately reimbursable,193.87,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,176.47,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,147.06,60% of total billed charges,82.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,82.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,86.31,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,171.57,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,176.47,Pays at 72% of billed charges with lesser of charges applied,176.47,Pays at 72% of billed charges with lesser of charges applied,176.47,Pays at 72% of billed charges with lesser of charges applied,176.47,Pays at 72% of billed charges with lesser of charges applied,176.47,Pays at 72% of billed charges with lesser of charges applied,176.47,Pays at 72% of billed charges with lesser of charges applied,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,193.87,79.1% of total billed charges,193.87,79.1% of total billed charges,193.87,79.1% of total billed charges,193.87,79.1% of total billed charges,193.87,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,171.57,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,82.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,82.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,82.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,82.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,82.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,82.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,82.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,82.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,82.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,82.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,82.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,82.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,82.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,82.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,82.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,82.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,82.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,82.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,82.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,82.05,100% of CA Medicaid Fee Schedule with lesser of charges applied,82.05,200.25,183.83
Outpatient Medical Services,PHYSICIAN CLINIC,99204,"New patient office of other outpatient visit, typically 45 min",510,245.1,176.47,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,200.25,81.7% of total Billed charges,N/A,Not Separately reimbursable,193.87,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,176.47,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,147.06,60% of total billed charges,98.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,98.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,139.54,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,171.57,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,176.47,Pays at 72% of billed charges with lesser of charges applied,176.47,Pays at 72% of billed charges with lesser of charges applied,176.47,Pays at 72% of billed charges with lesser of charges applied,176.47,Pays at 72% of billed charges with lesser of charges applied,176.47,Pays at 72% of billed charges with lesser of charges applied,176.47,Pays at 72% of billed charges with lesser of charges applied,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,193.87,79.1% of total billed charges,193.87,79.1% of total billed charges,193.87,79.1% of total billed charges,193.87,79.1% of total billed charges,193.87,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,171.57,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,98.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,98.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,98.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,98.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,98.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,98.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,98.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,98.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,98.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,98.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,98.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,98.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,98.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,98.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,98.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,98.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,98.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,98.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,98.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,98.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,98.83,200.25,183.83
Outpatient Medical Services,PHYSICIAN CLINIC,99205,"New patient office of other outpatient visit, typically 60 min",510,245.1,176.47,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,200.25,81.7% of total Billed charges,N/A,Not Separately reimbursable,193.87,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,176.47,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,147.06,60% of total billed charges,118.62,100% of CA Medicaid Fee Schedule with lesser of charges applied,118.62,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,189.68,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,171.57,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,176.47,Pays at 72% of billed charges with lesser of charges applied,176.47,Pays at 72% of billed charges with lesser of charges applied,176.47,Pays at 72% of billed charges with lesser of charges applied,176.47,Pays at 72% of billed charges with lesser of charges applied,176.47,Pays at 72% of billed charges with lesser of charges applied,176.47,Pays at 72% of billed charges with lesser of charges applied,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,200.25,81.7% of total Billed charges,193.87,79.1% of total billed charges,193.87,79.1% of total billed charges,193.87,79.1% of total billed charges,193.87,79.1% of total billed charges,193.87,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,171.57,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,118.62,100% of CA Medicaid Fee Schedule with lesser of charges applied,118.62,100% of CA Medicaid Fee Schedule with lesser of charges applied,118.62,100% of CA Medicaid Fee Schedule with lesser of charges applied,118.62,100% of CA Medicaid Fee Schedule with lesser of charges applied,118.62,100% of CA Medicaid Fee Schedule with lesser of charges applied,118.62,100% of CA Medicaid Fee Schedule with lesser of charges applied,118.62,100% of CA Medicaid Fee Schedule with lesser of charges applied,118.62,100% of CA Medicaid Fee Schedule with lesser of charges applied,118.62,100% of CA Medicaid Fee Schedule with lesser of charges applied,118.62,100% of CA Medicaid Fee Schedule with lesser of charges applied,118.62,100% of CA Medicaid Fee Schedule with lesser of charges applied,118.62,100% of CA Medicaid Fee Schedule with lesser of charges applied,118.62,100% of CA Medicaid Fee Schedule with lesser of charges applied,118.62,100% of CA Medicaid Fee Schedule with lesser of charges applied,118.62,100% of CA Medicaid Fee Schedule with lesser of charges applied,118.62,100% of CA Medicaid Fee Schedule with lesser of charges applied,118.62,100% of CA Medicaid Fee Schedule with lesser of charges applied,118.62,100% of CA Medicaid Fee Schedule with lesser of charges applied,118.62,100% of CA Medicaid Fee Schedule with lesser of charges applied,118.62,100% of CA Medicaid Fee Schedule with lesser of charges applied,118.62,200.25,183.83
Outpatient Medical Services,PHYSICIAN CLINIC,11601,EXC TR-EXT MAL+MARG 0.6-1.0CM,510,1171.68,843.61,Pays at 72% of billed charges with lesser of charges applied,824.89,100% OF CMS OPPS Rate,1171.68,100% of ASC Tier Grouping Fee Schedule,824.89,100% OF CMS OPPS Rate,926.8,79.1% of total billed charges,824.89,100% OF CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,843.61,72% of total billed charges,824.89,100% OF CMS OPPS Rate,824.89,100% of CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,703.01,60% of total billed charges,113.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,113.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,160.44,100% OF CMS OPPS RATE,824.89,100% OF CMS OPPS Rate,820.18,70% of total billed charges,824.89,100% OF CMS OPPS Rate,989.86,120% of CMS OPPS RATE,843.61,Pays at 72% of billed charges with lesser of charges applied,843.61,Pays at 72% of billed charges with lesser of charges applied,843.61,Pays at 72% of billed charges with lesser of charges applied,843.61,Pays at 72% of billed charges with lesser of charges applied,843.61,Pays at 72% of billed charges with lesser of charges applied,843.61,Pays at 72% of billed charges with lesser of charges applied,1171.68,100% of ASC Tier Grouping Fee Schedule,1171.68,100% of ASC Tier Grouping Fee Schedule,1171.68,100% of ASC Tier Grouping Fee Schedule,1171.68,100% of ASC Tier Grouping Fee Schedule,1171.68,100% of ASC Tier Grouping Fee Schedule,1171.68,100% of ASC Tier Grouping Fee Schedule,1171.68,100% of ASC Tier Grouping Fee Schedule,1171.68,100% of ASC Tier Grouping Fee Schedule,1171.68,100% of ASC Tier Grouping Fee Schedule,926.8,79.1% of total billed charges,926.8,79.1% of total billed charges,926.8,79.1% of total billed charges,926.8,79.1% of total billed charges,926.8,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,820.18,70% of total billed charges,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,113.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,113.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,113.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,113.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,113.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,113.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,113.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,113.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,113.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,113.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,113.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,113.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,113.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,113.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,113.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,113.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,113.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,113.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,113.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,113.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,113.75,1171.68,878.76
Outpatient Medical Services,PHYSICIAN CLINIC,11602,Excision-Malignant Lesions,510,1171.68,843.61,Pays at 72% of billed charges with lesser of charges applied,474.2,100% OF CMS OPPS Rate,1171.68,100% of ASC Tier Grouping Fee Schedule,474.2,100% OF CMS OPPS Rate,926.8,79.1% of total billed charges,474.2,100% OF CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,843.61,72% of total billed charges,474.2,100% OF CMS OPPS Rate,474.2,100% of CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,703.01,60% of total billed charges,121.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,121.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,174.59,100% OF CMS OPPS RATE,474.2,100% OF CMS OPPS Rate,820.18,70% of total billed charges,474.2,100% OF CMS OPPS Rate,569.03,120% of CMS OPPS RATE,843.61,Pays at 72% of billed charges with lesser of charges applied,843.61,Pays at 72% of billed charges with lesser of charges applied,843.61,Pays at 72% of billed charges with lesser of charges applied,843.61,Pays at 72% of billed charges with lesser of charges applied,843.61,Pays at 72% of billed charges with lesser of charges applied,843.61,Pays at 72% of billed charges with lesser of charges applied,1171.68,100% of ASC Tier Grouping Fee Schedule,1171.68,100% of ASC Tier Grouping Fee Schedule,1171.68,100% of ASC Tier Grouping Fee Schedule,1171.68,100% of ASC Tier Grouping Fee Schedule,1171.68,100% of ASC Tier Grouping Fee Schedule,1171.68,100% of ASC Tier Grouping Fee Schedule,1171.68,100% of ASC Tier Grouping Fee Schedule,1171.68,100% of ASC Tier Grouping Fee Schedule,1171.68,100% of ASC Tier Grouping Fee Schedule,926.8,79.1% of total billed charges,926.8,79.1% of total billed charges,926.8,79.1% of total billed charges,926.8,79.1% of total billed charges,926.8,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,820.18,70% of total billed charges,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,121.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,121.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,121.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,121.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,121.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,121.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,121.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,121.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,121.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,121.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,121.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,121.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,121.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,121.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,121.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,121.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,121.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,121.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,121.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,121.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,121.22,1171.68,878.76
Outpatient Medical Services,PHYSICIAN CLINIC,11604,EXC TR-EXT MAL-MARG 3.1-4.0CM,510,1374.84,989.88,Pays at 72% of billed charges with lesser of charges applied,824.89,100% OF CMS OPPS Rate,1374.84,100% of ASC Tier Grouping Fee Schedule,824.89,100% OF CMS OPPS Rate,1087.5,79.1% of total billed charges,824.89,100% OF CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,989.88,72% of total billed charges,824.89,100% OF CMS OPPS Rate,824.89,100% of CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.9,60% of total billed charges,260.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,260.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,227.69,100% OF CMS OPPS RATE,824.89,100% OF CMS OPPS Rate,962.39,70% of total billed charges,824.89,100% OF CMS OPPS Rate,989.86,120% of CMS OPPS RATE,989.88,Pays at 72% of billed charges with lesser of charges applied,989.88,Pays at 72% of billed charges with lesser of charges applied,989.88,Pays at 72% of billed charges with lesser of charges applied,989.88,Pays at 72% of billed charges with lesser of charges applied,989.88,Pays at 72% of billed charges with lesser of charges applied,989.88,Pays at 72% of billed charges with lesser of charges applied,1374.84,100% of ASC Tier Grouping Fee Schedule,1374.84,100% of ASC Tier Grouping Fee Schedule,1374.84,100% of ASC Tier Grouping Fee Schedule,1374.84,100% of ASC Tier Grouping Fee Schedule,1374.84,100% of ASC Tier Grouping Fee Schedule,1374.84,100% of ASC Tier Grouping Fee Schedule,1374.84,100% of ASC Tier Grouping Fee Schedule,1374.84,100% of ASC Tier Grouping Fee Schedule,1374.84,100% of ASC Tier Grouping Fee Schedule,1087.5,79.1% of total billed charges,1087.5,79.1% of total billed charges,1087.5,79.1% of total billed charges,1087.5,79.1% of total billed charges,1087.5,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,962.39,70% of total billed charges,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,260.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,260.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,260.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,260.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,260.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,260.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,260.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,260.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,260.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,260.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,260.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,260.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,260.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,260.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,260.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,260.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,260.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,260.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,260.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,260.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,227.69,1374.84,1031.13
Outpatient Medical Services,PHYSICIAN CLINIC,12032,INTMD RPR S/A/T/EXT 2.6-7.5CM,510,745.92,537.06,Pays at 72% of billed charges with lesser of charges applied,474.2,100% OF CMS OPPS Rate,745.92,100% of ASC Tier Grouping Fee Schedule,474.2,100% OF CMS OPPS Rate,590.02,79.1% of total billed charges,474.2,100% OF CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,537.06,72% of total billed charges,474.2,100% OF CMS OPPS Rate,474.2,100% of CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,447.55,60% of total billed charges,131.38,100% of CA Medicaid Fee Schedule with lesser of charges applied,131.38,100% of CA Medicaid Fee Schedule with lesser of charges applied,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,206.41,100% OF CMS OPPS RATE,474.2,100% OF CMS OPPS Rate,522.14,70% of total billed charges,474.2,100% OF CMS OPPS Rate,569.03,120% of CMS OPPS RATE,537.06,Pays at 72% of billed charges with lesser of charges applied,537.06,Pays at 72% of billed charges with lesser of charges applied,537.06,Pays at 72% of billed charges with lesser of charges applied,537.06,Pays at 72% of billed charges with lesser of charges applied,537.06,Pays at 72% of billed charges with lesser of charges applied,537.06,Pays at 72% of billed charges with lesser of charges applied,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,590.02,79.1% of total billed charges,590.02,79.1% of total billed charges,590.02,79.1% of total billed charges,590.02,79.1% of total billed charges,590.02,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,522.14,70% of total billed charges,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,131.38,100% of CA Medicaid Fee Schedule with lesser of charges applied,131.38,100% of CA Medicaid Fee Schedule with lesser of charges applied,131.38,100% of CA Medicaid Fee Schedule with lesser of charges applied,131.38,100% of CA Medicaid Fee Schedule with lesser of charges applied,131.38,100% of CA Medicaid Fee Schedule with lesser of charges applied,131.38,100% of CA Medicaid Fee Schedule with lesser of charges applied,131.38,100% of CA Medicaid Fee Schedule with lesser of charges applied,131.38,100% of CA Medicaid Fee Schedule with lesser of charges applied,131.38,100% of CA Medicaid Fee Schedule with lesser of charges applied,131.38,100% of CA Medicaid Fee Schedule with lesser of charges applied,131.38,100% of CA Medicaid Fee Schedule with lesser of charges applied,131.38,100% of CA Medicaid Fee Schedule with lesser of charges applied,131.38,100% of CA Medicaid Fee Schedule with lesser of charges applied,131.38,100% of CA Medicaid Fee Schedule with lesser of charges applied,131.38,100% of CA Medicaid Fee Schedule with lesser of charges applied,131.38,100% of CA Medicaid Fee Schedule with lesser of charges applied,131.38,100% of CA Medicaid Fee Schedule with lesser of charges applied,131.38,100% of CA Medicaid Fee Schedule with lesser of charges applied,131.38,100% of CA Medicaid Fee Schedule with lesser of charges applied,131.38,100% of CA Medicaid Fee Schedule with lesser of charges applied,131.38,745.92,559.44
Outpatient Medical Services,PHYSICIAN CLINIC,12002,RPR S/N/AX/GEN/TRNK 2.6-7.5CM,510,405.48,291.95,Pays at 72% of billed charges with lesser of charges applied,229.53,100% OF CMS OPPS Rate,405.48,100% of ASC Tier Grouping Fee Schedule,229.53,100% OF CMS OPPS Rate,320.73,79.1% of total billed charges,229.53,100% OF CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,291.95,72% of total billed charges,229.53,100% OF CMS OPPS Rate,229.53,100% of CMS OPPS Rate,229.53,100% OF CMS OPPS Rate,243.29,60% of total billed charges,106.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,106.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,229.53,100% OF CMS OPPS Rate,229.53,100% OF CMS OPPS Rate,59.67,100% OF CMS OPPS RATE,229.53,100% OF CMS OPPS Rate,283.84,70% of total billed charges,229.53,100% OF CMS OPPS Rate,275.43,120% of CMS OPPS RATE,291.95,Pays at 72% of billed charges with lesser of charges applied,291.95,Pays at 72% of billed charges with lesser of charges applied,291.95,Pays at 72% of billed charges with lesser of charges applied,291.95,Pays at 72% of billed charges with lesser of charges applied,291.95,Pays at 72% of billed charges with lesser of charges applied,291.95,Pays at 72% of billed charges with lesser of charges applied,405.48,100% of ASC Tier Grouping Fee Schedule,405.48,100% of ASC Tier Grouping Fee Schedule,405.48,100% of ASC Tier Grouping Fee Schedule,405.48,100% of ASC Tier Grouping Fee Schedule,405.48,100% of ASC Tier Grouping Fee Schedule,405.48,100% of ASC Tier Grouping Fee Schedule,405.48,100% of ASC Tier Grouping Fee Schedule,405.48,100% of ASC Tier Grouping Fee Schedule,405.48,100% of ASC Tier Grouping Fee Schedule,320.73,79.1% of total billed charges,320.73,79.1% of total billed charges,320.73,79.1% of total billed charges,320.73,79.1% of total billed charges,320.73,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,283.84,70% of total billed charges,229.53,100% OF CMS OPPS Rate,229.53,100% OF CMS OPPS Rate,229.53,100% OF CMS OPPS Rate,229.53,100% OF CMS OPPS Rate,229.53,100% OF CMS OPPS Rate,229.53,100% OF CMS OPPS Rate,229.53,100% OF CMS OPPS Rate,229.53,100% OF CMS OPPS Rate,229.53,100% OF CMS OPPS Rate,229.53,100% OF CMS OPPS Rate,229.53,100% OF CMS OPPS Rate,229.53,100% OF CMS OPPS Rate,229.53,100% OF CMS OPPS Rate,229.53,100% OF CMS OPPS Rate,229.53,100% OF CMS OPPS Rate,229.53,100% OF CMS OPPS Rate,106.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,106.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,106.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,106.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,106.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,106.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,106.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,106.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,106.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,106.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,106.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,106.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,106.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,106.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,106.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,106.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,106.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,106.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,106.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,106.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.67,405.48,304.11
Outpatient Medical Services,PHYSICIAN CLINIC,11422,Under Excision-Benign Lesions Procedures on the Skin 1.1-2 CM,510,3235.28,2329.4,Pays at 72% of billed charges with lesser of charges applied,1906.04,100% OF CMS OPPS Rate,3235.28,100% of ASC Tier Grouping Fee Schedule,1906.04,100% OF CMS OPPS Rate,2559.11,79.1% of total billed charges,1906.04,100% OF CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,2329.4,72% of total billed charges,1906.04,100% OF CMS OPPS Rate,1906.04,100% of CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1941.17,60% of total billed charges,106.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,106.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,148.61,100% OF CMS OPPS RATE,1906.04,100% OF CMS OPPS Rate,2264.7,70% of total billed charges,1906.04,100% OF CMS OPPS Rate,2287.25,120% of CMS OPPS RATE,2329.4,Pays at 72% of billed charges with lesser of charges applied,2329.4,Pays at 72% of billed charges with lesser of charges applied,2329.4,Pays at 72% of billed charges with lesser of charges applied,2329.4,Pays at 72% of billed charges with lesser of charges applied,2329.4,Pays at 72% of billed charges with lesser of charges applied,2329.4,Pays at 72% of billed charges with lesser of charges applied,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,2559.11,79.1% of total billed charges,2559.11,79.1% of total billed charges,2559.11,79.1% of total billed charges,2559.11,79.1% of total billed charges,2559.11,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,2264.7,70% of total billed charges,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,106.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,106.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,106.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,106.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,106.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,106.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,106.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,106.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,106.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,106.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,106.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,106.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,106.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,106.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,106.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,106.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,106.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,106.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,106.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,106.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,106.27,3235.28,2426.46
Outpatient Medical Services,PHYSICIAN CLINIC,11404,EXT TR-EXT B9+MARG 3.1-4.0CM,510,3235.28,2329.4,Pays at 72% of billed charges with lesser of charges applied,1906.04,100% OF CMS OPPS Rate,3235.28,100% of ASC Tier Grouping Fee Schedule,1906.04,100% OF CMS OPPS Rate,2559.11,79.1% of total billed charges,1906.04,100% OF CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,2329.4,72% of total billed charges,1906.04,100% OF CMS OPPS Rate,1906.04,100% of CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1941.17,60% of total billed charges,127.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,127.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,178.13,100% OF CMS OPPS RATE,1906.04,100% OF CMS OPPS Rate,2264.7,70% of total billed charges,1906.04,100% OF CMS OPPS Rate,2287.25,120% of CMS OPPS RATE,2329.4,Pays at 72% of billed charges with lesser of charges applied,2329.4,Pays at 72% of billed charges with lesser of charges applied,2329.4,Pays at 72% of billed charges with lesser of charges applied,2329.4,Pays at 72% of billed charges with lesser of charges applied,2329.4,Pays at 72% of billed charges with lesser of charges applied,2329.4,Pays at 72% of billed charges with lesser of charges applied,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,2559.11,79.1% of total billed charges,2559.11,79.1% of total billed charges,2559.11,79.1% of total billed charges,2559.11,79.1% of total billed charges,2559.11,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,2264.7,70% of total billed charges,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,127.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,127.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,127.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,127.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,127.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,127.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,127.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,127.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,127.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,127.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,127.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,127.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,127.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,127.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,127.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,127.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,127.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,127.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,127.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,127.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,127.10,3235.28,2426.46
Outpatient Medical Services,PHYSICIAN CLINIC,12041,INTMD RPR N-HF/GENIT 2.5CM/<,510,745.92,537.06,Pays at 72% of billed charges with lesser of charges applied,474.2,100% OF CMS OPPS Rate,745.92,100% of ASC Tier Grouping Fee Schedule,474.2,100% OF CMS OPPS Rate,590.02,79.1% of total billed charges,474.2,100% OF CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,537.06,72% of total billed charges,474.2,100% OF CMS OPPS Rate,474.2,100% of CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,447.55,60% of total billed charges,134.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,134.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,156.11,100% OF CMS OPPS RATE,474.2,100% OF CMS OPPS Rate,522.14,70% of total billed charges,474.2,100% OF CMS OPPS Rate,569.04,120% of CMS OPPS RATE,537.06,Pays at 72% of billed charges with lesser of charges applied,537.06,Pays at 72% of billed charges with lesser of charges applied,537.06,Pays at 72% of billed charges with lesser of charges applied,537.06,Pays at 72% of billed charges with lesser of charges applied,537.06,Pays at 72% of billed charges with lesser of charges applied,537.06,Pays at 72% of billed charges with lesser of charges applied,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,590.02,79.1% of total billed charges,590.02,79.1% of total billed charges,590.02,79.1% of total billed charges,590.02,79.1% of total billed charges,590.02,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,522.14,70% of total billed charges,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,134.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,134.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,134.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,134.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,134.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,134.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,134.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,134.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,134.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,134.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,134.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,134.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,134.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,134.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,134.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,134.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,134.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,134.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,134.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,134.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,134.58,745.92,559.44
Outpatient Medical Services,PHYSICIAN CLINIC,12001,"Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities",510,405.48,291.95,Pays at 72% of billed charges with lesser of charges applied,229.53,100% OF CMS OPPS Rate,405.48,100% of ASC Tier Grouping Fee Schedule,229.53,100% OF CMS OPPS Rate,320.73,79.1% of total billed charges,229.53,100% OF CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,291.95,72% of total billed charges,229.53,100% OF CMS OPPS Rate,229.53,100% of CMS OPPS Rate,229.53,100% OF CMS OPPS Rate,243.29,60% of total billed charges,100.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,100.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,229.53,100% OF CMS OPPS Rate,229.53,100% OF CMS OPPS Rate,45.82,100% OF CMS OPPS RATE,229.53,100% OF CMS OPPS Rate,283.84,70% of total billed charges,229.53,100% OF CMS OPPS Rate,275.43,120% of CMS OPPS RATE,291.95,Pays at 72% of billed charges with lesser of charges applied,291.95,Pays at 72% of billed charges with lesser of charges applied,291.95,Pays at 72% of billed charges with lesser of charges applied,291.95,Pays at 72% of billed charges with lesser of charges applied,291.95,Pays at 72% of billed charges with lesser of charges applied,291.95,Pays at 72% of billed charges with lesser of charges applied,405.48,100% of ASC Tier Grouping Fee Schedule,405.48,100% of ASC Tier Grouping Fee Schedule,405.48,100% of ASC Tier Grouping Fee Schedule,405.48,100% of ASC Tier Grouping Fee Schedule,405.48,100% of ASC Tier Grouping Fee Schedule,405.48,100% of ASC Tier Grouping Fee Schedule,405.48,100% of ASC Tier Grouping Fee Schedule,405.48,100% of ASC Tier Grouping Fee Schedule,405.48,100% of ASC Tier Grouping Fee Schedule,320.73,79.1% of total billed charges,320.73,79.1% of total billed charges,320.73,79.1% of total billed charges,320.73,79.1% of total billed charges,320.73,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,283.84,70% of total billed charges,229.53,100% OF CMS OPPS Rate,229.53,100% OF CMS OPPS Rate,229.53,100% OF CMS OPPS Rate,229.53,100% OF CMS OPPS Rate,229.53,100% OF CMS OPPS Rate,229.53,100% OF CMS OPPS Rate,229.53,100% OF CMS OPPS Rate,229.53,100% OF CMS OPPS Rate,229.53,100% OF CMS OPPS Rate,229.53,100% OF CMS OPPS Rate,229.53,100% OF CMS OPPS Rate,229.53,100% OF CMS OPPS Rate,229.53,100% OF CMS OPPS Rate,229.53,100% OF CMS OPPS Rate,229.53,100% OF CMS OPPS Rate,229.53,100% OF CMS OPPS Rate,100.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,100.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,100.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,100.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,100.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,100.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,100.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,100.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,100.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,100.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,100.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,100.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,100.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,100.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,100.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,100.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,100.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,100.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,100.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,100.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.82,405.48,304.11
Outpatient Medical Services,PHYSICIAN CLINIC,11440,EXC FACE-MM B9+MARG 0.5CM/<,510,745.92,537.06,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,745.92,100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,590.02,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,537.06,72% of total billed charges,N/A,Not Separately reimbursable,745.92,100% of CMS OPPS Rate,N/A,Not Separately reimbursable,447.55,60% of total billed charges,92.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,92.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,118.87,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,522.14,70% of total billed charges,745.92,100% OF CMS OPPS Rate,745.92,120% of CMS OPPS RATE,537.06,Pays at 72% of billed charges with lesser of charges applied,537.06,Pays at 72% of billed charges with lesser of charges applied,537.06,Pays at 72% of billed charges with lesser of charges applied,537.06,Pays at 72% of billed charges with lesser of charges applied,537.06,Pays at 72% of billed charges with lesser of charges applied,537.06,Pays at 72% of billed charges with lesser of charges applied,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,590.02,79.1% of total billed charges,590.02,79.1% of total billed charges,590.02,79.1% of total billed charges,590.02,79.1% of total billed charges,590.02,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,522.14,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,92.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,92.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,92.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,92.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,92.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,92.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,92.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,92.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,92.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,92.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,92.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,92.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,92.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,92.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,92.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,92.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,92.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,92.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,92.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,92.39,100% of CA Medicaid Fee Schedule with lesser of charges applied,92.39,745.92,559.44
Outpatient Medical Services,PHYSICIAN CLINIC,11420,EXC H-F-NK-SP B9+MARG 0.5/<,510,745.92,537.06,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,745.92,100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,590.02,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,537.06,72% of total billed charges,N/A,Not Separately reimbursable,745.92,100% of CMS OPPS Rate,N/A,Not Separately reimbursable,447.55,60% of total billed charges,76.37,100% of CA Medicaid Fee Schedule with lesser of charges applied,76.37,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,90.3,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,522.14,70% of total billed charges,745.92,100% OF CMS OPPS Rate,745.92,120% of CMS OPPS RATE,537.06,Pays at 72% of billed charges with lesser of charges applied,537.06,Pays at 72% of billed charges with lesser of charges applied,537.06,Pays at 72% of billed charges with lesser of charges applied,537.06,Pays at 72% of billed charges with lesser of charges applied,537.06,Pays at 72% of billed charges with lesser of charges applied,537.06,Pays at 72% of billed charges with lesser of charges applied,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,590.02,79.1% of total billed charges,590.02,79.1% of total billed charges,590.02,79.1% of total billed charges,590.02,79.1% of total billed charges,590.02,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,522.14,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,76.37,100% of CA Medicaid Fee Schedule with lesser of charges applied,76.37,100% of CA Medicaid Fee Schedule with lesser of charges applied,76.37,100% of CA Medicaid Fee Schedule with lesser of charges applied,76.37,100% of CA Medicaid Fee Schedule with lesser of charges applied,76.37,100% of CA Medicaid Fee Schedule with lesser of charges applied,76.37,100% of CA Medicaid Fee Schedule with lesser of charges applied,76.37,100% of CA Medicaid Fee Schedule with lesser of charges applied,76.37,100% of CA Medicaid Fee Schedule with lesser of charges applied,76.37,100% of CA Medicaid Fee Schedule with lesser of charges applied,76.37,100% of CA Medicaid Fee Schedule with lesser of charges applied,76.37,100% of CA Medicaid Fee Schedule with lesser of charges applied,76.37,100% of CA Medicaid Fee Schedule with lesser of charges applied,76.37,100% of CA Medicaid Fee Schedule with lesser of charges applied,76.37,100% of CA Medicaid Fee Schedule with lesser of charges applied,76.37,100% of CA Medicaid Fee Schedule with lesser of charges applied,76.37,100% of CA Medicaid Fee Schedule with lesser of charges applied,76.37,100% of CA Medicaid Fee Schedule with lesser of charges applied,76.37,100% of CA Medicaid Fee Schedule with lesser of charges applied,76.37,100% of CA Medicaid Fee Schedule with lesser of charges applied,76.37,100% of CA Medicaid Fee Schedule with lesser of charges applied,76.37,745.92,559.44
Outpatient Medical Services,PHYSICIAN CLINIC,11421,EXC H-F-NK-SP B9+MARG 0.6-1,510,1374.84,989.88,Pays at 72% of billed charges with lesser of charges applied,824.89,100% OF CMS OPPS Rate,1374.84,100% of ASC Tier Grouping Fee Schedule,824.89,100% OF CMS OPPS Rate,1087.5,79.1% of total billed charges,824.89,100% OF CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,989.88,72% of total billed charges,824.89,100% OF CMS OPPS Rate,824.89,100% of CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.9,60% of total billed charges,96.12,100% of CA Medicaid Fee Schedule with lesser of charges applied,96.12,100% of CA Medicaid Fee Schedule with lesser of charges applied,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,119.39,100% OF CMS OPPS RATE,824.89,100% OF CMS OPPS Rate,962.39,70% of total billed charges,824.89,100% OF CMS OPPS Rate,989.86,120% of CMS OPPS RATE,989.88,Pays at 72% of billed charges with lesser of charges applied,989.88,Pays at 72% of billed charges with lesser of charges applied,989.88,Pays at 72% of billed charges with lesser of charges applied,989.88,Pays at 72% of billed charges with lesser of charges applied,989.88,Pays at 72% of billed charges with lesser of charges applied,989.88,Pays at 72% of billed charges with lesser of charges applied,1374.84,100% of ASC Tier Grouping Fee Schedule,1374.84,100% of ASC Tier Grouping Fee Schedule,1374.84,100% of ASC Tier Grouping Fee Schedule,1374.84,100% of ASC Tier Grouping Fee Schedule,1374.84,100% of ASC Tier Grouping Fee Schedule,1374.84,100% of ASC Tier Grouping Fee Schedule,1374.84,100% of ASC Tier Grouping Fee Schedule,1374.84,100% of ASC Tier Grouping Fee Schedule,1374.84,100% of ASC Tier Grouping Fee Schedule,1087.5,79.1% of total billed charges,1087.5,79.1% of total billed charges,1087.5,79.1% of total billed charges,1087.5,79.1% of total billed charges,1087.5,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,962.39,70% of total billed charges,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,96.12,100% of CA Medicaid Fee Schedule with lesser of charges applied,96.12,100% of CA Medicaid Fee Schedule with lesser of charges applied,96.12,100% of CA Medicaid Fee Schedule with lesser of charges applied,96.12,100% of CA Medicaid Fee Schedule with lesser of charges applied,96.12,100% of CA Medicaid Fee Schedule with lesser of charges applied,96.12,100% of CA Medicaid Fee Schedule with lesser of charges applied,96.12,100% of CA Medicaid Fee Schedule with lesser of charges applied,96.12,100% of CA Medicaid Fee Schedule with lesser of charges applied,96.12,100% of CA Medicaid Fee Schedule with lesser of charges applied,96.12,100% of CA Medicaid Fee Schedule with lesser of charges applied,96.12,100% of CA Medicaid Fee Schedule with lesser of charges applied,96.12,100% of CA Medicaid Fee Schedule with lesser of charges applied,96.12,100% of CA Medicaid Fee Schedule with lesser of charges applied,96.12,100% of CA Medicaid Fee Schedule with lesser of charges applied,96.12,100% of CA Medicaid Fee Schedule with lesser of charges applied,96.12,100% of CA Medicaid Fee Schedule with lesser of charges applied,96.12,100% of CA Medicaid Fee Schedule with lesser of charges applied,96.12,100% of CA Medicaid Fee Schedule with lesser of charges applied,96.12,100% of CA Medicaid Fee Schedule with lesser of charges applied,96.12,100% of CA Medicaid Fee Schedule with lesser of charges applied,96.12,1374.84,1031.13
Outpatient Medical Services,PHYSICIAN CLINIC,11423,EXC H-F-NK-SP B9+MARG 2.1-3,510,3235.28,2329.4,Pays at 72% of billed charges with lesser of charges applied,1906.04,100% OF CMS OPPS Rate,3235.28,100% of ASC Tier Grouping Fee Schedule,1906.04,100% OF CMS OPPS Rate,2559.11,79.1% of total billed charges,1906.04,100% OF CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,2329.4,72% of total billed charges,1906.04,100% OF CMS OPPS Rate,1906.04,100% of CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1941.17,60% of total billed charges,124.43,100% of CA Medicaid Fee Schedule with lesser of charges applied,124.43,100% of CA Medicaid Fee Schedule with lesser of charges applied,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,170.04,100% OF CMS OPPS RATE,1906.04,100% OF CMS OPPS Rate,2264.7,70% of total billed charges,1906.04,100% OF CMS OPPS Rate,2287.25,120% of CMS OPPS RATE,2329.4,Pays at 72% of billed charges with lesser of charges applied,2329.4,Pays at 72% of billed charges with lesser of charges applied,2329.4,Pays at 72% of billed charges with lesser of charges applied,2329.4,Pays at 72% of billed charges with lesser of charges applied,2329.4,Pays at 72% of billed charges with lesser of charges applied,2329.4,Pays at 72% of billed charges with lesser of charges applied,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,2559.11,79.1% of total billed charges,2559.11,79.1% of total billed charges,2559.11,79.1% of total billed charges,2559.11,79.1% of total billed charges,2559.11,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,2264.7,70% of total billed charges,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,124.43,100% of CA Medicaid Fee Schedule with lesser of charges applied,124.43,100% of CA Medicaid Fee Schedule with lesser of charges applied,124.43,100% of CA Medicaid Fee Schedule with lesser of charges applied,124.43,100% of CA Medicaid Fee Schedule with lesser of charges applied,124.43,100% of CA Medicaid Fee Schedule with lesser of charges applied,124.43,100% of CA Medicaid Fee Schedule with lesser of charges applied,124.43,100% of CA Medicaid Fee Schedule with lesser of charges applied,124.43,100% of CA Medicaid Fee Schedule with lesser of charges applied,124.43,100% of CA Medicaid Fee Schedule with lesser of charges applied,124.43,100% of CA Medicaid Fee Schedule with lesser of charges applied,124.43,100% of CA Medicaid Fee Schedule with lesser of charges applied,124.43,100% of CA Medicaid Fee Schedule with lesser of charges applied,124.43,100% of CA Medicaid Fee Schedule with lesser of charges applied,124.43,100% of CA Medicaid Fee Schedule with lesser of charges applied,124.43,100% of CA Medicaid Fee Schedule with lesser of charges applied,124.43,100% of CA Medicaid Fee Schedule with lesser of charges applied,124.43,100% of CA Medicaid Fee Schedule with lesser of charges applied,124.43,100% of CA Medicaid Fee Schedule with lesser of charges applied,124.43,100% of CA Medicaid Fee Schedule with lesser of charges applied,124.43,100% of CA Medicaid Fee Schedule with lesser of charges applied,124.43,3235.28,2426.46
Outpatient Medical Services,PHYSICIAN CLINIC,11600,EXC TR-EXT MAL+MARG 0.5CM/<,510,745.92,537.06,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,745.92,100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,590.02,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,537.06,72% of total billed charges,N/A,Not Separately reimbursable,745.92,100% of CMS OPPS Rate,N/A,Not Separately reimbursable,447.55,60% of total billed charges,99.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,99.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,132.53,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,522.14,70% of total billed charges,745.92,100% OF CMS OPPS Rate,745.92,120% of CMS OPPS RATE,537.06,Pays at 72% of billed charges with lesser of charges applied,537.06,Pays at 72% of billed charges with lesser of charges applied,537.06,Pays at 72% of billed charges with lesser of charges applied,537.06,Pays at 72% of billed charges with lesser of charges applied,537.06,Pays at 72% of billed charges with lesser of charges applied,537.06,Pays at 72% of billed charges with lesser of charges applied,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,590.02,79.1% of total billed charges,590.02,79.1% of total billed charges,590.02,79.1% of total billed charges,590.02,79.1% of total billed charges,590.02,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,522.14,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,99.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,99.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,99.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,99.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,99.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,99.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,99.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,99.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,99.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,99.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,99.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,99.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,99.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,99.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,99.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,99.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,99.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,99.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,99.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,99.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,99.33,745.92,559.44
Outpatient Medical Services,PHYSICIAN CLINIC,11603,EXC TR-EXT MAL+MARG 2.1-3CM,510,1374.84,989.88,Pays at 72% of billed charges with lesser of charges applied,824.89,100% OF CMS OPPS Rate,1374.84,100% of ASC Tier Grouping Fee Schedule,824.89,100% OF CMS OPPS Rate,1087.5,79.1% of total billed charges,824.89,100% OF CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,989.88,72% of total billed charges,824.89,100% OF CMS OPPS Rate,824.89,100% of CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.9,60% of total billed charges,241.38,100% of CA Medicaid Fee Schedule with lesser of charges applied,241.38,100% of CA Medicaid Fee Schedule with lesser of charges applied,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,207.72,100% OF CMS OPPS RATE,824.89,100% OF CMS OPPS Rate,962.39,70% of total billed charges,824.89,100% OF CMS OPPS Rate,989.86,120% of CMS OPPS RATE,989.88,Pays at 72% of billed charges with lesser of charges applied,989.88,Pays at 72% of billed charges with lesser of charges applied,989.88,Pays at 72% of billed charges with lesser of charges applied,989.88,Pays at 72% of billed charges with lesser of charges applied,989.88,Pays at 72% of billed charges with lesser of charges applied,989.88,Pays at 72% of billed charges with lesser of charges applied,1374.84,100% of ASC Tier Grouping Fee Schedule,1374.84,100% of ASC Tier Grouping Fee Schedule,1374.84,100% of ASC Tier Grouping Fee Schedule,1374.84,100% of ASC Tier Grouping Fee Schedule,1374.84,100% of ASC Tier Grouping Fee Schedule,1374.84,100% of ASC Tier Grouping Fee Schedule,1374.84,100% of ASC Tier Grouping Fee Schedule,1374.84,100% of ASC Tier Grouping Fee Schedule,1374.84,100% of ASC Tier Grouping Fee Schedule,1087.5,79.1% of total billed charges,1087.5,79.1% of total billed charges,1087.5,79.1% of total billed charges,1087.5,79.1% of total billed charges,1087.5,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,962.39,70% of total billed charges,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,241.38,100% of CA Medicaid Fee Schedule with lesser of charges applied,241.38,100% of CA Medicaid Fee Schedule with lesser of charges applied,241.38,100% of CA Medicaid Fee Schedule with lesser of charges applied,241.38,100% of CA Medicaid Fee Schedule with lesser of charges applied,241.38,100% of CA Medicaid Fee Schedule with lesser of charges applied,241.38,100% of CA Medicaid Fee Schedule with lesser of charges applied,241.38,100% of CA Medicaid Fee Schedule with lesser of charges applied,241.38,100% of CA Medicaid Fee Schedule with lesser of charges applied,241.38,100% of CA Medicaid Fee Schedule with lesser of charges applied,241.38,100% of CA Medicaid Fee Schedule with lesser of charges applied,241.38,100% of CA Medicaid Fee Schedule with lesser of charges applied,241.38,100% of CA Medicaid Fee Schedule with lesser of charges applied,241.38,100% of CA Medicaid Fee Schedule with lesser of charges applied,241.38,100% of CA Medicaid Fee Schedule with lesser of charges applied,241.38,100% of CA Medicaid Fee Schedule with lesser of charges applied,241.38,100% of CA Medicaid Fee Schedule with lesser of charges applied,241.38,100% of CA Medicaid Fee Schedule with lesser of charges applied,241.38,100% of CA Medicaid Fee Schedule with lesser of charges applied,241.38,100% of CA Medicaid Fee Schedule with lesser of charges applied,241.38,100% of CA Medicaid Fee Schedule with lesser of charges applied,207.72,1374.84,1031.13
Outpatient Medical Services,PHYSICIAN CLINIC,99241,OFFICE CONSULT 15 MIN 99241,510,114.25,82.26,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,93.34,81.7% of total Billed charges,N/A,Not Separately reimbursable,90.37,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,82.26,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,68.55,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,79.98,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,82.26,Pays at 72% of billed charges with lesser of charges applied,82.26,Pays at 72% of billed charges with lesser of charges applied,82.26,Pays at 72% of billed charges with lesser of charges applied,82.26,Pays at 72% of billed charges with lesser of charges applied,82.26,Pays at 72% of billed charges with lesser of charges applied,82.26,Pays at 72% of billed charges with lesser of charges applied,93.34,81.7% of total Billed charges,93.34,81.7% of total Billed charges,93.34,81.7% of total Billed charges,93.34,81.7% of total Billed charges,93.34,81.7% of total Billed charges,93.34,81.7% of total Billed charges,93.34,81.7% of total Billed charges,93.34,81.7% of total Billed charges,93.34,81.7% of total Billed charges,90.37,79.1% of total billed charges,90.37,79.1% of total billed charges,90.37,79.1% of total billed charges,90.37,79.1% of total billed charges,90.37,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,79.98,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,68.55,93.34,85.69
Outpatient Medical Services,PHYSICIAN CLINIC,99242,OFFICE CONSULT 30 MIN 99242,510,157.25,113.22,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,128.47,81.7% of total Billed charges,N/A,Not Separately reimbursable,124.38,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,113.22,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,94.35,60% of total billed charges,67.70,100% of CA Medicaid Fee Schedule with lesser of charges applied,67.70,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,59.41,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,110.08,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,113.22,Pays at 72% of billed charges with lesser of charges applied,113.22,Pays at 72% of billed charges with lesser of charges applied,113.22,Pays at 72% of billed charges with lesser of charges applied,113.22,Pays at 72% of billed charges with lesser of charges applied,113.22,Pays at 72% of billed charges with lesser of charges applied,113.22,Pays at 72% of billed charges with lesser of charges applied,128.47,81.7% of total Billed charges,128.47,81.7% of total Billed charges,128.47,81.7% of total Billed charges,128.47,81.7% of total Billed charges,128.47,81.7% of total Billed charges,128.47,81.7% of total Billed charges,128.47,81.7% of total Billed charges,128.47,81.7% of total Billed charges,128.47,81.7% of total Billed charges,124.38,79.1% of total billed charges,124.38,79.1% of total billed charges,124.38,79.1% of total billed charges,124.38,79.1% of total billed charges,124.38,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,110.08,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,67.70,100% of CA Medicaid Fee Schedule with lesser of charges applied,67.70,100% of CA Medicaid Fee Schedule with lesser of charges applied,67.70,100% of CA Medicaid Fee Schedule with lesser of charges applied,67.70,100% of CA Medicaid Fee Schedule with lesser of charges applied,67.70,100% of CA Medicaid Fee Schedule with lesser of charges applied,67.70,100% of CA Medicaid Fee Schedule with lesser of charges applied,67.70,100% of CA Medicaid Fee Schedule with lesser of charges applied,67.70,100% of CA Medicaid Fee Schedule with lesser of charges applied,67.70,100% of CA Medicaid Fee Schedule with lesser of charges applied,67.70,100% of CA Medicaid Fee Schedule with lesser of charges applied,67.70,100% of CA Medicaid Fee Schedule with lesser of charges applied,67.70,100% of CA Medicaid Fee Schedule with lesser of charges applied,67.70,100% of CA Medicaid Fee Schedule with lesser of charges applied,67.70,100% of CA Medicaid Fee Schedule with lesser of charges applied,67.70,100% of CA Medicaid Fee Schedule with lesser of charges applied,67.70,100% of CA Medicaid Fee Schedule with lesser of charges applied,67.70,100% of CA Medicaid Fee Schedule with lesser of charges applied,67.70,100% of CA Medicaid Fee Schedule with lesser of charges applied,67.70,100% of CA Medicaid Fee Schedule with lesser of charges applied,67.70,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.41,128.47,117.94
Outpatient Medical Services,PHYSICIAN CLINIC,99243,"Patient office consultation, typically 40 min",510,228.75,164.7,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,186.89,81.7% of total Billed charges,N/A,Not Separately reimbursable,180.94,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,164.7,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,137.25,60% of total billed charges,85.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,85.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,93.31,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,160.13,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,164.7,Pays at 72% of billed charges with lesser of charges applied,164.7,Pays at 72% of billed charges with lesser of charges applied,164.7,Pays at 72% of billed charges with lesser of charges applied,164.7,Pays at 72% of billed charges with lesser of charges applied,164.7,Pays at 72% of billed charges with lesser of charges applied,164.7,Pays at 72% of billed charges with lesser of charges applied,186.89,81.7% of total Billed charges,186.89,81.7% of total Billed charges,186.89,81.7% of total Billed charges,186.89,81.7% of total Billed charges,186.89,81.7% of total Billed charges,186.89,81.7% of total Billed charges,186.89,81.7% of total Billed charges,186.89,81.7% of total Billed charges,186.89,81.7% of total Billed charges,180.94,79.1% of total billed charges,180.94,79.1% of total billed charges,180.94,79.1% of total billed charges,180.94,79.1% of total billed charges,180.94,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,160.13,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,85.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,85.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,85.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,85.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,85.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,85.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,85.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,85.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,85.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,85.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,85.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,85.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,85.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,85.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,85.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,85.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,85.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,85.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,85.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,85.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,85.35,186.89,171.56
Outpatient Medical Services,PHYSICIAN CLINIC,99244,"Patient office consultation, typically 60 min",510,371.5,267.48,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,303.52,81.7% of total Billed charges,N/A,Not Separately reimbursable,293.86,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,267.48,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,222.9,60% of total billed charges,116.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,142.7,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,260.05,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,267.48,Pays at 72% of billed charges with lesser of charges applied,267.48,Pays at 72% of billed charges with lesser of charges applied,267.48,Pays at 72% of billed charges with lesser of charges applied,267.48,Pays at 72% of billed charges with lesser of charges applied,267.48,Pays at 72% of billed charges with lesser of charges applied,267.48,Pays at 72% of billed charges with lesser of charges applied,303.52,81.7% of total Billed charges,303.52,81.7% of total Billed charges,303.52,81.7% of total Billed charges,303.52,81.7% of total Billed charges,303.52,81.7% of total Billed charges,303.52,81.7% of total Billed charges,303.52,81.7% of total Billed charges,303.52,81.7% of total Billed charges,303.52,81.7% of total Billed charges,293.86,79.1% of total billed charges,293.86,79.1% of total billed charges,293.86,79.1% of total billed charges,293.86,79.1% of total billed charges,293.86,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,260.05,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,116.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.76,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.76,303.52,278.63
Outpatient Medical Services,PHYSICIAN CLINIC,99245,OFFICE CONSULT 80 MIN 99245,510,628.75,452.7,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,513.69,81.7% of total Billed charges,N/A,Not Separately reimbursable,497.34,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,452.7,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,377.25,60% of total billed charges,146.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,146.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,190.28,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,440.13,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,452.7,Pays at 72% of billed charges with lesser of charges applied,452.7,Pays at 72% of billed charges with lesser of charges applied,452.7,Pays at 72% of billed charges with lesser of charges applied,452.7,Pays at 72% of billed charges with lesser of charges applied,452.7,Pays at 72% of billed charges with lesser of charges applied,452.7,Pays at 72% of billed charges with lesser of charges applied,513.69,81.7% of total Billed charges,513.69,81.7% of total Billed charges,513.69,81.7% of total Billed charges,513.69,81.7% of total Billed charges,513.69,81.7% of total Billed charges,513.69,81.7% of total Billed charges,513.69,81.7% of total Billed charges,513.69,81.7% of total Billed charges,513.69,81.7% of total Billed charges,497.34,79.1% of total billed charges,497.34,79.1% of total billed charges,497.34,79.1% of total billed charges,497.34,79.1% of total billed charges,497.34,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,440.13,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,146.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,146.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,146.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,146.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,146.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,146.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,146.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,146.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,146.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,146.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,146.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,146.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,146.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,146.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,146.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,146.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,146.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,146.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,146.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,146.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,146.60,513.69,471.56
Outpatient Medical Services,PHYSICIAN CLINIC,10080,DRAINAGE OF PILONIDAL CYST,510,1374.84,989.88,Pays at 72% of billed charges with lesser of charges applied,824.89,100% OF CMS OPPS Rate,1123.24,81.7% of total Billed charges,824.89,100% OF CMS OPPS Rate,1087.5,79.1% of total billed charges,824.89,100% OF CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,989.88,72% of total billed charges,824.89,100% OF CMS OPPS Rate,824.89,100% of CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.9,60% of total billed charges,79.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,79.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,114.43,100% OF CMS OPPS RATE,824.89,100% OF CMS OPPS Rate,962.39,70% of total billed charges,824.89,100% OF CMS OPPS Rate,989.86,120% of CMS OPPS RATE,989.88,Pays at 72% of billed charges with lesser of charges applied,989.88,Pays at 72% of billed charges with lesser of charges applied,989.88,Pays at 72% of billed charges with lesser of charges applied,989.88,Pays at 72% of billed charges with lesser of charges applied,989.88,Pays at 72% of billed charges with lesser of charges applied,989.88,Pays at 72% of billed charges with lesser of charges applied,1123.24,81.7% of total Billed charges,1123.24,81.7% of total Billed charges,1123.24,81.7% of total Billed charges,1123.24,81.7% of total Billed charges,1123.24,81.7% of total Billed charges,1123.24,81.7% of total Billed charges,1123.24,81.7% of total Billed charges,1123.24,81.7% of total Billed charges,1123.24,81.7% of total Billed charges,1087.5,79.1% of total billed charges,1087.5,79.1% of total billed charges,1087.5,79.1% of total billed charges,1087.5,79.1% of total billed charges,1087.5,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,962.39,70% of total billed charges,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,79.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,79.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,79.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,79.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,79.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,79.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,79.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,79.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,79.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,79.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,79.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,79.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,79.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,79.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,79.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,79.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,79.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,79.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,79.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,79.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,79.04,1123.24,1031.13
Outpatient Medical Services,PHYSICIAN CLINIC,23075,EXC SHOULDER LES SC < 3 CM,510,3236.84,2330.52,Pays at 72% of billed charges with lesser of charges applied,1906.04,100% OF CMS OPPS Rate,3236.84,100% of ASC Tier Grouping Fee Schedule,1906.04,100% OF CMS OPPS Rate,2560.34,79.1% of total billed charges,1906.04,100% OF CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,2330.52,72% of total billed charges,1906.04,100% OF CMS OPPS Rate,1906.04,100% of CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1942.1,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,355.47,100% OF CMS OPPS RATE,1906.04,100% OF CMS OPPS Rate,2265.79,70% of total billed charges,1906.04,100% OF CMS OPPS Rate,2287.25,120% of CMS OPPS RATE,2330.52,Pays at 72% of billed charges with lesser of charges applied,2330.52,Pays at 72% of billed charges with lesser of charges applied,2330.52,Pays at 72% of billed charges with lesser of charges applied,2330.52,Pays at 72% of billed charges with lesser of charges applied,2330.52,Pays at 72% of billed charges with lesser of charges applied,2330.52,Pays at 72% of billed charges with lesser of charges applied,3236.84,100% of ASC Tier Grouping Fee Schedule,3236.84,100% of ASC Tier Grouping Fee Schedule,3236.84,100% of ASC Tier Grouping Fee Schedule,3236.84,100% of ASC Tier Grouping Fee Schedule,3236.84,100% of ASC Tier Grouping Fee Schedule,3236.84,100% of ASC Tier Grouping Fee Schedule,3236.84,100% of ASC Tier Grouping Fee Schedule,3236.84,100% of ASC Tier Grouping Fee Schedule,3236.84,100% of ASC Tier Grouping Fee Schedule,2560.34,79.1% of total billed charges,2560.34,79.1% of total billed charges,2560.34,79.1% of total billed charges,2560.34,79.1% of total billed charges,2560.34,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,2265.79,70% of total billed charges,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,355.47,3236.84,2427.63
Outpatient Medical Services,PHYSICIAN CLINIC,11400,EXC TR-EXT B9+MARG 0.5 CM<,510,745.92,537.06,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,745.92,100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,590.02,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,537.06,72% of total billed charges,N/A,Not Separately reimbursable,745.92,100% of CMS OPPS Rate,N/A,Not Separately reimbursable,447.55,60% of total billed charges,83.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,83.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,93.12,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,522.14,70% of total billed charges,745.92,100% OF CMS OPPS Rate,745.92,120% of CMS OPPS RATE,537.06,Pays at 72% of billed charges with lesser of charges applied,537.06,Pays at 72% of billed charges with lesser of charges applied,537.06,Pays at 72% of billed charges with lesser of charges applied,537.06,Pays at 72% of billed charges with lesser of charges applied,537.06,Pays at 72% of billed charges with lesser of charges applied,537.06,Pays at 72% of billed charges with lesser of charges applied,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,590.02,79.1% of total billed charges,590.02,79.1% of total billed charges,590.02,79.1% of total billed charges,590.02,79.1% of total billed charges,590.02,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,522.14,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,83.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,83.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,83.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,83.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,83.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,83.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,83.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,83.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,83.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,83.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,83.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,83.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,83.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,83.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,83.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,83.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,83.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,83.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,83.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,83.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,83.31,745.92,559.44
Outpatient Medical Services,PHYSICIAN CLINIC,11403,EXC TR-EXT B9+MARG 2.1-3CM,510,1374.84,989.88,Pays at 72% of billed charges with lesser of charges applied,824.89,100% OF CMS OPPS Rate,1374.84,100% of ASC Tier Grouping Fee Schedule,824.89,100% OF CMS OPPS Rate,1087.5,79.1% of total billed charges,824.89,100% OF CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,989.88,72% of total billed charges,824.89,100% OF CMS OPPS Rate,824.89,100% of CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.9,60% of total billed charges,116.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,162.75,100% OF CMS OPPS RATE,824.89,100% OF CMS OPPS Rate,962.39,70% of total billed charges,824.89,100% OF CMS OPPS Rate,989.86,120% of CMS OPPS RATE,989.88,Pays at 72% of billed charges with lesser of charges applied,989.88,Pays at 72% of billed charges with lesser of charges applied,989.88,Pays at 72% of billed charges with lesser of charges applied,989.88,Pays at 72% of billed charges with lesser of charges applied,989.88,Pays at 72% of billed charges with lesser of charges applied,989.88,Pays at 72% of billed charges with lesser of charges applied,1374.84,100% of ASC Tier Grouping Fee Schedule,1374.84,100% of ASC Tier Grouping Fee Schedule,1374.84,100% of ASC Tier Grouping Fee Schedule,1374.84,100% of ASC Tier Grouping Fee Schedule,1374.84,100% of ASC Tier Grouping Fee Schedule,1374.84,100% of ASC Tier Grouping Fee Schedule,1374.84,100% of ASC Tier Grouping Fee Schedule,1374.84,100% of ASC Tier Grouping Fee Schedule,1374.84,100% of ASC Tier Grouping Fee Schedule,1087.5,79.1% of total billed charges,1087.5,79.1% of total billed charges,1087.5,79.1% of total billed charges,1087.5,79.1% of total billed charges,1087.5,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,962.39,70% of total billed charges,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,116.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.42,1374.84,1031.13
Outpatient Medical Services,PHYSICIAN CLINIC,11606,EXC TR-EXT MAL+MARG >4.0CM,510,1374.84,989.88,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,1374.84,100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,1087.5,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,989.88,72% of total billed charges,N/A,Not Separately reimbursable,1374.84,100% of CMS OPPS Rate,N/A,Not Separately reimbursable,824.9,60% of total billed charges,325.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,325.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,332.62,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,962.39,70% of total billed charges,1374.84,100% OF CMS OPPS Rate,1374.84,120% of CMS OPPS RATE,989.88,Pays at 72% of billed charges with lesser of charges applied,989.88,Pays at 72% of billed charges with lesser of charges applied,989.88,Pays at 72% of billed charges with lesser of charges applied,989.88,Pays at 72% of billed charges with lesser of charges applied,989.88,Pays at 72% of billed charges with lesser of charges applied,989.88,Pays at 72% of billed charges with lesser of charges applied,1374.84,100% of ASC Tier Grouping Fee Schedule,1374.84,100% of ASC Tier Grouping Fee Schedule,1374.84,100% of ASC Tier Grouping Fee Schedule,1374.84,100% of ASC Tier Grouping Fee Schedule,1374.84,100% of ASC Tier Grouping Fee Schedule,1374.84,100% of ASC Tier Grouping Fee Schedule,1374.84,100% of ASC Tier Grouping Fee Schedule,1374.84,100% of ASC Tier Grouping Fee Schedule,1374.84,100% of ASC Tier Grouping Fee Schedule,1087.5,79.1% of total billed charges,1087.5,79.1% of total billed charges,1087.5,79.1% of total billed charges,1087.5,79.1% of total billed charges,1087.5,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,962.39,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,325.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,325.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,325.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,325.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,325.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,325.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,325.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,325.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,325.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,325.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,325.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,325.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,325.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,325.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,325.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,325.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,325.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,325.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,325.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,325.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,325.75,1374.84,1031.13
Outpatient Medical Services,PHYSICIAN CLINIC,12031,INTMD RPR S/A/T/EXT 2.5CM<,510,745.92,537.06,Pays at 72% of billed charges with lesser of charges applied,474.2,100% OF CMS OPPS Rate,745.92,100% of ASC Tier Grouping Fee Schedule,474.2,100% OF CMS OPPS Rate,590.02,79.1% of total billed charges,474.2,100% OF CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,537.06,72% of total billed charges,474.2,100% OF CMS OPPS Rate,474.2,100% of CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,447.55,60% of total billed charges,121.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,121.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,164.76,100% OF CMS OPPS RATE,474.2,100% OF CMS OPPS Rate,522.14,70% of total billed charges,474.2,100% OF CMS OPPS Rate,569.03,120% of CMS OPPS RATE,537.06,Pays at 72% of billed charges with lesser of charges applied,537.06,Pays at 72% of billed charges with lesser of charges applied,537.06,Pays at 72% of billed charges with lesser of charges applied,537.06,Pays at 72% of billed charges with lesser of charges applied,537.06,Pays at 72% of billed charges with lesser of charges applied,537.06,Pays at 72% of billed charges with lesser of charges applied,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,590.02,79.1% of total billed charges,590.02,79.1% of total billed charges,590.02,79.1% of total billed charges,590.02,79.1% of total billed charges,590.02,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,522.14,70% of total billed charges,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,121.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,121.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,121.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,121.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,121.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,121.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,121.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,121.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,121.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,121.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,121.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,121.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,121.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,121.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,121.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,121.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,121.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,121.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,121.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,121.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,121.22,745.92,559.44
Outpatient Medical Services,PHYSICIAN CLINIC,11200,"Removal of skin tags, multiple fibrocutaneous tags, any area",510,405.68,292.09,Pays at 72% of billed charges with lesser of charges applied,229.53,100% OF CMS OPPS Rate,331.44,81.7% of total Billed charges,229.53,100% OF CMS OPPS Rate,320.89,79.1% of total billed charges,229.53,100% OF CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,292.09,72% of total billed charges,229.53,100% OF CMS OPPS Rate,229.53,100% of CMS OPPS Rate,229.53,100% OF CMS OPPS Rate,243.41,60% of total billed charges,45.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,229.53,100% OF CMS OPPS Rate,229.53,100% OF CMS OPPS Rate,84.76,100% OF CMS OPPS RATE,229.53,100% OF CMS OPPS Rate,283.98,70% of total billed charges,229.53,100% OF CMS OPPS Rate,275.43,120% of CMS OPPS RATE,292.09,Pays at 72% of billed charges with lesser of charges applied,292.09,Pays at 72% of billed charges with lesser of charges applied,292.09,Pays at 72% of billed charges with lesser of charges applied,292.09,Pays at 72% of billed charges with lesser of charges applied,292.09,Pays at 72% of billed charges with lesser of charges applied,292.09,Pays at 72% of billed charges with lesser of charges applied,331.44,81.7% of total Billed charges,331.44,81.7% of total Billed charges,331.44,81.7% of total Billed charges,331.44,81.7% of total Billed charges,331.44,81.7% of total Billed charges,331.44,81.7% of total Billed charges,331.44,81.7% of total Billed charges,331.44,81.7% of total Billed charges,331.44,81.7% of total Billed charges,320.89,79.1% of total billed charges,320.89,79.1% of total billed charges,320.89,79.1% of total billed charges,320.89,79.1% of total billed charges,320.89,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,283.98,70% of total billed charges,229.53,100% OF CMS OPPS Rate,229.53,100% OF CMS OPPS Rate,229.53,100% OF CMS OPPS Rate,229.53,100% OF CMS OPPS Rate,229.53,100% OF CMS OPPS Rate,229.53,100% OF CMS OPPS Rate,229.53,100% OF CMS OPPS Rate,229.53,100% OF CMS OPPS Rate,229.53,100% OF CMS OPPS Rate,229.53,100% OF CMS OPPS Rate,229.53,100% OF CMS OPPS Rate,229.53,100% OF CMS OPPS Rate,229.53,100% OF CMS OPPS Rate,229.53,100% OF CMS OPPS Rate,229.53,100% OF CMS OPPS Rate,229.53,100% OF CMS OPPS Rate,45.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.40,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.40,331.44,304.26
Outpatient Medical Services,PHYSICIAN CLINIC,11042,DEB SUBQ TISSUE 20SQ CM/<,510,745.92,537.06,Pays at 72% of billed charges with lesser of charges applied,474.2,100% OF CMS OPPS Rate,745.92,100% of ASC Tier Grouping Fee Schedule,474.2,100% OF CMS OPPS Rate,590.02,79.1% of total billed charges,474.2,100% OF CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,537.06,72% of total billed charges,474.2,100% OF CMS OPPS Rate,474.2,100% of CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,447.55,60% of total billed charges,148.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,148.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,63.12,100% OF CMS OPPS RATE,474.2,100% OF CMS OPPS Rate,522.14,70% of total billed charges,474.2,100% OF CMS OPPS Rate,569.03,120% of CMS OPPS RATE,537.06,Pays at 72% of billed charges with lesser of charges applied,537.06,Pays at 72% of billed charges with lesser of charges applied,537.06,Pays at 72% of billed charges with lesser of charges applied,537.06,Pays at 72% of billed charges with lesser of charges applied,537.06,Pays at 72% of billed charges with lesser of charges applied,537.06,Pays at 72% of billed charges with lesser of charges applied,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,590.02,79.1% of total billed charges,590.02,79.1% of total billed charges,590.02,79.1% of total billed charges,590.02,79.1% of total billed charges,590.02,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,522.14,70% of total billed charges,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,148.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,148.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,148.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,148.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,148.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,148.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,148.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,148.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,148.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,148.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,148.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,148.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,148.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,148.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,148.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,148.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,148.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,148.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,148.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,148.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,63.12,745.92,559.44
Outpatient Medical Services,PHYSICIAN CLINIC,19000,DRAINAGE OF BREAST LESION,510,3235.28,2329.4,Pays at 72% of billed charges with lesser of charges applied,824.89,100% OF CMS OPPS Rate,3235.28,100% of ASC Tier Grouping Fee Schedule,824.89,100% OF CMS OPPS Rate,2559.11,79.1% of total billed charges,824.89,100% OF CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,2329.4,72% of total billed charges,824.89,100% OF CMS OPPS Rate,824.89,100% of CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,1941.17,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,43.84,100% OF CMS OPPS RATE,824.89,100% OF CMS OPPS Rate,2264.7,70% of total billed charges,824.89,100% OF CMS OPPS Rate,989.86,120% of CMS OPPS RATE,2329.4,Pays at 72% of billed charges with lesser of charges applied,2329.4,Pays at 72% of billed charges with lesser of charges applied,2329.4,Pays at 72% of billed charges with lesser of charges applied,2329.4,Pays at 72% of billed charges with lesser of charges applied,2329.4,Pays at 72% of billed charges with lesser of charges applied,2329.4,Pays at 72% of billed charges with lesser of charges applied,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,2559.11,79.1% of total billed charges,2559.11,79.1% of total billed charges,2559.11,79.1% of total billed charges,2559.11,79.1% of total billed charges,2559.11,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,2264.7,70% of total billed charges,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,43.84,3235.28,2426.46
Outpatient Medical Services,PHYSICIAN CLINIC,24075,EXC ARM ELBOW LES SC <3CM,510,3235.28,2329.4,Pays at 72% of billed charges with lesser of charges applied,1906.04,100% OF CMS OPPS Rate,3235.28,100% of ASC Tier Grouping Fee Schedule,1906.04,100% OF CMS OPPS Rate,2559.11,79.1% of total billed charges,1906.04,100% OF CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,2329.4,72% of total billed charges,1906.04,100% OF CMS OPPS Rate,1906.04,100% of CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1941.17,60% of total billed charges,96.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,96.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,357.91,100% OF CMS OPPS RATE,1906.04,100% OF CMS OPPS Rate,2264.7,70% of total billed charges,1906.04,100% OF CMS OPPS Rate,2287.25,120% of CMS OPPS RATE,2329.4,Pays at 72% of billed charges with lesser of charges applied,2329.4,Pays at 72% of billed charges with lesser of charges applied,2329.4,Pays at 72% of billed charges with lesser of charges applied,2329.4,Pays at 72% of billed charges with lesser of charges applied,2329.4,Pays at 72% of billed charges with lesser of charges applied,2329.4,Pays at 72% of billed charges with lesser of charges applied,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,2559.11,79.1% of total billed charges,2559.11,79.1% of total billed charges,2559.11,79.1% of total billed charges,2559.11,79.1% of total billed charges,2559.11,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,2264.7,70% of total billed charges,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,96.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,96.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,96.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,96.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,96.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,96.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,96.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,96.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,96.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,96.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,96.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,96.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,96.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,96.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,96.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,96.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,96.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,96.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,96.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,96.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,96.66,3235.28,2426.46
Outpatient Medical Services,PHYSICIAN CLINIC,23071,EXC SHOULDER LES SC 3CM/>,510,3235.28,2329.4,Pays at 72% of billed charges with lesser of charges applied,1906.04,100% OF CMS OPPS Rate,3235.28,100% of ASC Tier Grouping Fee Schedule,1906.04,100% OF CMS OPPS Rate,2559.11,79.1% of total billed charges,1906.04,100% OF CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,2329.4,72% of total billed charges,1906.04,100% OF CMS OPPS Rate,1906.04,100% of CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1941.17,60% of total billed charges,98.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,98.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,447.19,100% OF CMS OPPS RATE,1906.04,100% OF CMS OPPS Rate,2264.7,70% of total billed charges,1906.04,100% OF CMS OPPS Rate,2287.25,120% of CMS OPPS RATE,2329.4,Pays at 72% of billed charges with lesser of charges applied,2329.4,Pays at 72% of billed charges with lesser of charges applied,2329.4,Pays at 72% of billed charges with lesser of charges applied,2329.4,Pays at 72% of billed charges with lesser of charges applied,2329.4,Pays at 72% of billed charges with lesser of charges applied,2329.4,Pays at 72% of billed charges with lesser of charges applied,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,2559.11,79.1% of total billed charges,2559.11,79.1% of total billed charges,2559.11,79.1% of total billed charges,2559.11,79.1% of total billed charges,2559.11,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,2264.7,70% of total billed charges,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,98.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,98.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,98.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,98.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,98.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,98.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,98.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,98.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,98.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,98.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,98.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,98.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,98.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,98.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,98.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,98.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,98.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,98.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,98.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,98.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,98.80,3235.28,2426.46
Outpatient Medical Services,PHYSICIAN CLINIC,27327,EXC THIGH/KNEE LES SC<3CM,510,3235.28,2329.4,Pays at 72% of billed charges with lesser of charges applied,1906.04,100% OF CMS OPPS Rate,3235.28,100% of ASC Tier Grouping Fee Schedule,1906.04,100% OF CMS OPPS Rate,2559.11,79.1% of total billed charges,1906.04,100% OF CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,2329.4,72% of total billed charges,1906.04,100% OF CMS OPPS Rate,1906.04,100% of CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1941.17,60% of total billed charges,110.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,341.78,100% OF CMS OPPS RATE,1906.04,100% OF CMS OPPS Rate,2264.7,70% of total billed charges,1906.04,100% OF CMS OPPS Rate,2287.25,120% of CMS OPPS RATE,2329.4,Pays at 72% of billed charges with lesser of charges applied,2329.4,Pays at 72% of billed charges with lesser of charges applied,2329.4,Pays at 72% of billed charges with lesser of charges applied,2329.4,Pays at 72% of billed charges with lesser of charges applied,2329.4,Pays at 72% of billed charges with lesser of charges applied,2329.4,Pays at 72% of billed charges with lesser of charges applied,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,2559.11,79.1% of total billed charges,2559.11,79.1% of total billed charges,2559.11,79.1% of total billed charges,2559.11,79.1% of total billed charges,2559.11,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,2264.7,70% of total billed charges,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,110.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.55,3235.28,2426.46
Outpatient Medical Services,PHYSICIAN CLINIC,11402,EXC TR-EXT B9+MAG 1.1-2CM,510,1374.84,989.88,Pays at 72% of billed charges with lesser of charges applied,824.89,100% OF CMS OPPS Rate,1374.84,100% of ASC Tier Grouping Fee Schedule,824.89,100% OF CMS OPPS Rate,1087.5,79.1% of total billed charges,824.89,100% OF CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,989.88,72% of total billed charges,824.89,100% OF CMS OPPS Rate,824.89,100% of CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.9,60% of total billed charges,103.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,103.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,126.45,100% OF CMS OPPS RATE,824.89,100% OF CMS OPPS Rate,962.39,70% of total billed charges,824.89,100% OF CMS OPPS Rate,989.86,120% of CMS OPPS RATE,989.88,Pays at 72% of billed charges with lesser of charges applied,989.88,Pays at 72% of billed charges with lesser of charges applied,989.88,Pays at 72% of billed charges with lesser of charges applied,989.88,Pays at 72% of billed charges with lesser of charges applied,989.88,Pays at 72% of billed charges with lesser of charges applied,989.88,Pays at 72% of billed charges with lesser of charges applied,1374.84,100% of ASC Tier Grouping Fee Schedule,1374.84,100% of ASC Tier Grouping Fee Schedule,1374.84,100% of ASC Tier Grouping Fee Schedule,1374.84,100% of ASC Tier Grouping Fee Schedule,1374.84,100% of ASC Tier Grouping Fee Schedule,1374.84,100% of ASC Tier Grouping Fee Schedule,1374.84,100% of ASC Tier Grouping Fee Schedule,1374.84,100% of ASC Tier Grouping Fee Schedule,1374.84,100% of ASC Tier Grouping Fee Schedule,1087.5,79.1% of total billed charges,1087.5,79.1% of total billed charges,1087.5,79.1% of total billed charges,1087.5,79.1% of total billed charges,1087.5,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,962.39,70% of total billed charges,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,103.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,103.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,103.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,103.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,103.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,103.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,103.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,103.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,103.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,103.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,103.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,103.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,103.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,103.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,103.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,103.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,103.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,103.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,103.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,103.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,103.06,1374.84,1031.13
Outpatient Medical Services,PHYSICIAN CLINIC,11406,EXC TR-EXT B9+MARG >4.0CM,510,3235.28,2329.4,Pays at 72% of billed charges with lesser of charges applied,1906.04,100% OF CMS OPPS Rate,3235.28,100% of ASC Tier Grouping Fee Schedule,1906.04,100% OF CMS OPPS Rate,2559.11,79.1% of total billed charges,1906.04,100% OF CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,2329.4,72% of total billed charges,1906.04,100% OF CMS OPPS Rate,1906.04,100% of CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1941.17,60% of total billed charges,277.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,277.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,263.94,100% OF CMS OPPS RATE,1906.04,100% OF CMS OPPS Rate,2264.7,70% of total billed charges,1906.04,100% OF CMS OPPS Rate,2287.25,120% of CMS OPPS RATE,2329.4,Pays at 72% of billed charges with lesser of charges applied,2329.4,Pays at 72% of billed charges with lesser of charges applied,2329.4,Pays at 72% of billed charges with lesser of charges applied,2329.4,Pays at 72% of billed charges with lesser of charges applied,2329.4,Pays at 72% of billed charges with lesser of charges applied,2329.4,Pays at 72% of billed charges with lesser of charges applied,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,2559.11,79.1% of total billed charges,2559.11,79.1% of total billed charges,2559.11,79.1% of total billed charges,2559.11,79.1% of total billed charges,2559.11,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,2264.7,70% of total billed charges,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,277.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,277.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,277.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,277.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,277.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,277.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,277.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,277.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,277.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,277.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,277.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,277.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,277.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,277.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,277.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,277.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,277.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,277.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,277.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,277.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,263.94,3235.28,2426.46
Outpatient Medical Services,PHYSICIAN CLINIC,11401,Under Excision-Benign Lesions Procedures on the Skin 0.6-1 CM,510,745.92,537.06,Pays at 72% of billed charges with lesser of charges applied,474.2,100% OF CMS OPPS Rate,745.92,100% of ASC Tier Grouping Fee Schedule,474.2,100% OF CMS OPPS Rate,590.02,79.1% of total billed charges,474.2,100% OF CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,537.06,72% of total billed charges,474.2,100% OF CMS OPPS Rate,474.2,100% of CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,447.55,60% of total billed charges,93.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,93.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,116.33,100% OF CMS OPPS RATE,474.2,100% OF CMS OPPS Rate,522.14,70% of total billed charges,474.2,100% OF CMS OPPS Rate,569.03,120% of CMS OPPS RATE,537.06,Pays at 72% of billed charges with lesser of charges applied,537.06,Pays at 72% of billed charges with lesser of charges applied,537.06,Pays at 72% of billed charges with lesser of charges applied,537.06,Pays at 72% of billed charges with lesser of charges applied,537.06,Pays at 72% of billed charges with lesser of charges applied,537.06,Pays at 72% of billed charges with lesser of charges applied,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,745.92,100% of ASC Tier Grouping Fee Schedule,590.02,79.1% of total billed charges,590.02,79.1% of total billed charges,590.02,79.1% of total billed charges,590.02,79.1% of total billed charges,590.02,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,522.14,70% of total billed charges,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,93.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,93.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,93.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,93.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,93.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,93.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,93.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,93.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,93.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,93.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,93.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,93.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,93.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,93.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,93.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,93.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,93.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,93.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,93.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,93.98,100% of CA Medicaid Fee Schedule with lesser of charges applied,93.98,745.92,559.44
Outpatient Medical Services,PHYSICIAN CLINIC,19120,REMOVAL OF BREAST LESION,510,6546.82,4713.71,Pays at 72% of billed charges with lesser of charges applied,4369.71,100% OF CMS OPPS Rate,6546.82,100% of ASC Tier Grouping Fee Schedule,4369.71,100% OF CMS OPPS Rate,5178.53,79.1% of total billed charges,4369.71,100% OF CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,4713.71,72% of total billed charges,4369.71,100% OF CMS OPPS Rate,4369.71,100% of CMS OPPS Rate,4369.71,100% OF CMS OPPS Rate,3928.09,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,4369.71,100% OF CMS OPPS Rate,4369.71,100% OF CMS OPPS Rate,441.33,100% OF CMS OPPS RATE,4369.71,100% OF CMS OPPS Rate,4582.77,70% of total billed charges,4369.71,100% OF CMS OPPS Rate,5243.65,120% of CMS OPPS RATE,4713.71,Pays at 72% of billed charges with lesser of charges applied,4713.71,Pays at 72% of billed charges with lesser of charges applied,4713.71,Pays at 72% of billed charges with lesser of charges applied,4713.71,Pays at 72% of billed charges with lesser of charges applied,4713.71,Pays at 72% of billed charges with lesser of charges applied,4713.71,Pays at 72% of billed charges with lesser of charges applied,6546.82,100% of ASC Tier Grouping Fee Schedule,6546.82,100% of ASC Tier Grouping Fee Schedule,6546.82,100% of ASC Tier Grouping Fee Schedule,6546.82,100% of ASC Tier Grouping Fee Schedule,6546.82,100% of ASC Tier Grouping Fee Schedule,6546.82,100% of ASC Tier Grouping Fee Schedule,6546.82,100% of ASC Tier Grouping Fee Schedule,6546.82,100% of ASC Tier Grouping Fee Schedule,6546.82,100% of ASC Tier Grouping Fee Schedule,5178.53,79.1% of total billed charges,5178.53,79.1% of total billed charges,5178.53,79.1% of total billed charges,5178.53,79.1% of total billed charges,5178.53,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,4582.77,70% of total billed charges,4369.71,100% OF CMS OPPS Rate,4369.71,100% OF CMS OPPS Rate,4369.71,100% OF CMS OPPS Rate,4369.71,100% OF CMS OPPS Rate,4369.71,100% OF CMS OPPS Rate,4369.71,100% OF CMS OPPS Rate,4369.71,100% OF CMS OPPS Rate,4369.71,100% OF CMS OPPS Rate,4369.71,100% OF CMS OPPS Rate,4369.71,100% OF CMS OPPS Rate,4369.71,100% OF CMS OPPS Rate,4369.71,100% OF CMS OPPS Rate,4369.71,100% OF CMS OPPS Rate,4369.71,100% OF CMS OPPS Rate,4369.71,100% OF CMS OPPS Rate,4369.71,100% OF CMS OPPS Rate,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,441.33,6546.82,4910.12
Outpatient Medical Services,PHYSICIAN CLINIC,36556,INSERT NON TUNNEL CV CATH,510,2359.14,1698.58,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,2359.14,100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,1866.08,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,1698.58,72% of total billed charges,N/A,Not Separately reimbursable,2359.14,100% of CMS OPPS Rate,N/A,Not Separately reimbursable,1415.48,60% of total billed charges,106.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,106.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,85.76,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,1651.4,70% of total billed charges,2359.14,100% OF CMS OPPS Rate,2359.14,120% of CMS OPPS RATE,1698.58,Pays at 72% of billed charges with lesser of charges applied,1698.58,Pays at 72% of billed charges with lesser of charges applied,1698.58,Pays at 72% of billed charges with lesser of charges applied,1698.58,Pays at 72% of billed charges with lesser of charges applied,1698.58,Pays at 72% of billed charges with lesser of charges applied,1698.58,Pays at 72% of billed charges with lesser of charges applied,2359.14,100% of ASC Tier Grouping Fee Schedule,2359.14,100% of ASC Tier Grouping Fee Schedule,2359.14,100% of ASC Tier Grouping Fee Schedule,2359.14,100% of ASC Tier Grouping Fee Schedule,2359.14,100% of ASC Tier Grouping Fee Schedule,2359.14,100% of ASC Tier Grouping Fee Schedule,2359.14,100% of ASC Tier Grouping Fee Schedule,2359.14,100% of ASC Tier Grouping Fee Schedule,2359.14,100% of ASC Tier Grouping Fee Schedule,1866.08,79.1% of total billed charges,1866.08,79.1% of total billed charges,1866.08,79.1% of total billed charges,1866.08,79.1% of total billed charges,1866.08,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,1651.4,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,106.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,106.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,106.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,106.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,106.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,106.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,106.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,106.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,106.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,106.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,106.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,106.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,106.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,106.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,106.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,106.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,106.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,106.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,106.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,106.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,85.76,2359.14,1769.36
Outpatient Medical Services,PHYSICIAN CLINIC,96372,THER/PROPH/DIAG INJ SC/IM,510,74.25,53.46,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,74.25,Case rate,N/A,Not Separately reimbursable,58.73,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,53.46,72% of total billed charges,N/A,Not Separately reimbursable,74.25,100% of CMS OPPS Rate,N/A,Not Separately reimbursable,44.55,60% of total billed charges,26.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,26.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,15.69,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,51.98,70% of total billed charges,74.25,100% OF CMS OPPS Rate,74.25,120% of CMS OPPS RATE,53.46,Pays at 72% of billed charges with lesser of charges applied,53.46,Pays at 72% of billed charges with lesser of charges applied,53.46,Pays at 72% of billed charges with lesser of charges applied,53.46,Pays at 72% of billed charges with lesser of charges applied,53.46,Pays at 72% of billed charges with lesser of charges applied,53.46,Pays at 72% of billed charges with lesser of charges applied,74.25,Case rate,74.25,Case rate,74.25,Case rate,74.25,Case rate,74.25,Case rate,74.25,Case rate,74.25,Case rate,74.25,Case rate,74.25,Case rate,58.73,79.1% of total billed charges,58.73,79.1% of total billed charges,58.73,79.1% of total billed charges,58.73,79.1% of total billed charges,58.73,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,51.98,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,26.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,26.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,26.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,26.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,26.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,26.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,26.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,26.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,26.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,26.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,26.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,26.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,26.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,26.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,26.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,26.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,26.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,26.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,26.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,26.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,15.69,74.25,55.69
Outpatient Medical Services,PHYSICIAN CLINIC,46615,ANOSCOPY ABLATION LESION,510,5557.52,4001.41,Pays at 72% of billed charges with lesser of charges applied,3265.98,100% OF CMS OPPS Rate,3809,100% of ASC Tier Grouping Fee Schedule,3265.98,100% OF CMS OPPS Rate,4396,79.1% of total billed charges,3265.98,100% OF CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,4001.41,72% of total billed charges,3265.98,100% OF CMS OPPS Rate,3265.98,100% of CMS OPPS Rate,3265.98,100% OF CMS OPPS Rate,3334.51,60% of total billed charges,195.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,195.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,3265.98,100% OF CMS OPPS Rate,3265.98,100% OF CMS OPPS Rate,95.15,100% OF CMS OPPS RATE,3265.98,100% OF CMS OPPS Rate,3890.26,70% of total billed charges,3265.98,100% OF CMS OPPS Rate,3919.19,120% of CMS OPPS RATE,4001.41,Pays at 72% of billed charges with lesser of charges applied,4001.41,Pays at 72% of billed charges with lesser of charges applied,4001.41,Pays at 72% of billed charges with lesser of charges applied,4001.41,Pays at 72% of billed charges with lesser of charges applied,4001.41,Pays at 72% of billed charges with lesser of charges applied,4001.41,Pays at 72% of billed charges with lesser of charges applied,3809,100% of ASC Tier Grouping Fee Schedule,3809,100% of ASC Tier Grouping Fee Schedule,3809,100% of ASC Tier Grouping Fee Schedule,3809,100% of ASC Tier Grouping Fee Schedule,3809,100% of ASC Tier Grouping Fee Schedule,3809,100% of ASC Tier Grouping Fee Schedule,3809,100% of ASC Tier Grouping Fee Schedule,3809,100% of ASC Tier Grouping Fee Schedule,3809,100% of ASC Tier Grouping Fee Schedule,4396,79.1% of total billed charges,4396,79.1% of total billed charges,4396,79.1% of total billed charges,4396,79.1% of total billed charges,4396,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,3890.26,70% of total billed charges,3265.98,100% OF CMS OPPS Rate,3265.98,100% OF CMS OPPS Rate,3265.98,100% OF CMS OPPS Rate,3265.98,100% OF CMS OPPS Rate,3265.98,100% OF CMS OPPS Rate,3265.98,100% OF CMS OPPS Rate,3265.98,100% OF CMS OPPS Rate,3265.98,100% OF CMS OPPS Rate,3265.98,100% OF CMS OPPS Rate,3265.98,100% OF CMS OPPS Rate,3265.98,100% OF CMS OPPS Rate,3265.98,100% OF CMS OPPS Rate,3265.98,100% OF CMS OPPS Rate,3265.98,100% OF CMS OPPS Rate,3265.98,100% OF CMS OPPS Rate,3265.98,100% OF CMS OPPS Rate,195.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,195.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,195.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,195.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,195.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,195.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,195.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,195.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,195.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,195.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,195.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,195.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,195.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,195.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,195.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,195.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,195.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,195.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,195.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,195.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,95.15,4396.00,4168.14
Outpatient Medical Services,PHYSICIAN CLINIC,10060,Incision and drainage of abscess; simple or single and complex or multiple,510,405.48,291.95,Pays at 72% of billed charges with lesser of charges applied,229.52,100% OF CMS OPPS Rate,405.48,100% of ASC Tier Grouping Fee Schedule,229.52,100% OF CMS OPPS Rate,320.73,79.1% of total billed charges,229.52,100% OF CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,291.95,72% of total billed charges,229.52,100% OF CMS OPPS Rate,229.52,100% of CMS OPPS Rate,229.52,100% OF CMS OPPS Rate,243.29,60% of total billed charges,60.88,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.88,100% of CA Medicaid Fee Schedule with lesser of charges applied,229.52,100% OF CMS OPPS Rate,229.52,100% OF CMS OPPS Rate,116.64,100% OF CMS OPPS RATE,229.52,100% OF CMS OPPS Rate,283.84,70% of total billed charges,229.52,100% OF CMS OPPS Rate,275.42,120% of CMS OPPS RATE,291.95,Pays at 72% of billed charges with lesser of charges applied,291.95,Pays at 72% of billed charges with lesser of charges applied,291.95,Pays at 72% of billed charges with lesser of charges applied,291.95,Pays at 72% of billed charges with lesser of charges applied,291.95,Pays at 72% of billed charges with lesser of charges applied,291.95,Pays at 72% of billed charges with lesser of charges applied,405.48,100% of ASC Tier Grouping Fee Schedule,405.48,100% of ASC Tier Grouping Fee Schedule,405.48,100% of ASC Tier Grouping Fee Schedule,405.48,100% of ASC Tier Grouping Fee Schedule,405.48,100% of ASC Tier Grouping Fee Schedule,405.48,100% of ASC Tier Grouping Fee Schedule,405.48,100% of ASC Tier Grouping Fee Schedule,405.48,100% of ASC Tier Grouping Fee Schedule,405.48,100% of ASC Tier Grouping Fee Schedule,320.73,79.1% of total billed charges,320.73,79.1% of total billed charges,320.73,79.1% of total billed charges,320.73,79.1% of total billed charges,320.73,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,283.84,70% of total billed charges,229.52,100% OF CMS OPPS Rate,229.52,100% OF CMS OPPS Rate,229.52,100% OF CMS OPPS Rate,229.52,100% OF CMS OPPS Rate,229.52,100% OF CMS OPPS Rate,229.52,100% OF CMS OPPS Rate,229.52,100% OF CMS OPPS Rate,229.52,100% OF CMS OPPS Rate,229.52,100% OF CMS OPPS Rate,229.52,100% OF CMS OPPS Rate,229.52,100% OF CMS OPPS Rate,229.52,100% OF CMS OPPS Rate,229.52,100% OF CMS OPPS Rate,229.52,100% OF CMS OPPS Rate,229.52,100% OF CMS OPPS Rate,229.52,100% OF CMS OPPS Rate,60.88,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.88,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.88,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.88,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.88,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.88,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.88,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.88,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.88,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.88,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.88,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.88,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.88,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.88,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.88,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.88,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.88,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.88,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.88,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.88,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.88,405.48,304.11
Outpatient Medical Services,PHYSICIAN CLINIC,21552,EXC NECK LES SC 3 CM/>,510,5579.7,4017.38,Pays at 72% of billed charges with lesser of charges applied,3283.51,100% OF CMS OPPS Rate,5266,100% of ASC Tier Grouping Fee Schedule,3283.51,100% OF CMS OPPS Rate,4413.54,79.1% of total billed charges,3283.51,100% OF CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,4017.38,72% of total billed charges,3283.51,100% OF CMS OPPS Rate,3283.51,100% of CMS OPPS Rate,3283.51,100% OF CMS OPPS Rate,3347.82,60% of total billed charges,530.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,530.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,3283.51,100% OF CMS OPPS Rate,3283.51,100% OF CMS OPPS Rate,473.58,100% OF CMS OPPS RATE,3283.51,100% OF CMS OPPS Rate,3905.79,70% of total billed charges,3283.51,100% OF CMS OPPS Rate,3940.22,120% of CMS OPPS RATE,4017.38,Pays at 72% of billed charges with lesser of charges applied,4017.38,Pays at 72% of billed charges with lesser of charges applied,4017.38,Pays at 72% of billed charges with lesser of charges applied,4017.38,Pays at 72% of billed charges with lesser of charges applied,4017.38,Pays at 72% of billed charges with lesser of charges applied,4017.38,Pays at 72% of billed charges with lesser of charges applied,5266,100% of ASC Tier Grouping Fee Schedule,5266,100% of ASC Tier Grouping Fee Schedule,5266,100% of ASC Tier Grouping Fee Schedule,5266,100% of ASC Tier Grouping Fee Schedule,5266,100% of ASC Tier Grouping Fee Schedule,5266,100% of ASC Tier Grouping Fee Schedule,5266,100% of ASC Tier Grouping Fee Schedule,5266,100% of ASC Tier Grouping Fee Schedule,5266,100% of ASC Tier Grouping Fee Schedule,4413.54,79.1% of total billed charges,4413.54,79.1% of total billed charges,4413.54,79.1% of total billed charges,4413.54,79.1% of total billed charges,4413.54,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,3905.79,70% of total billed charges,3283.51,100% OF CMS OPPS Rate,3283.51,100% OF CMS OPPS Rate,3283.51,100% OF CMS OPPS Rate,3283.51,100% OF CMS OPPS Rate,3283.51,100% OF CMS OPPS Rate,3283.51,100% OF CMS OPPS Rate,3283.51,100% OF CMS OPPS Rate,3283.51,100% OF CMS OPPS Rate,3283.51,100% OF CMS OPPS Rate,3283.51,100% OF CMS OPPS Rate,3283.51,100% OF CMS OPPS Rate,3283.51,100% OF CMS OPPS Rate,3283.51,100% OF CMS OPPS Rate,3283.51,100% OF CMS OPPS Rate,3283.51,100% OF CMS OPPS Rate,3283.51,100% OF CMS OPPS Rate,530.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,530.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,530.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,530.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,530.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,530.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,530.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,530.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,530.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,530.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,530.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,530.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,530.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,530.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,530.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,530.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,530.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,530.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,530.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,530.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,473.58,5266.00,4184.78
Outpatient Medical Services,PHYSICIAN CLINIC,11000,Removal of infected skin,510,1171.68,843.61,Pays at 72% of billed charges with lesser of charges applied,738.43,100% OF CMS OPPS Rate,1171.68,100% of ASC Tier Grouping Fee Schedule,738.43,100% OF CMS OPPS Rate,926.8,79.1% of total billed charges,738.43,100% OF CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,843.61,72% of total billed charges,738.43,100% OF CMS OPPS Rate,738.43,100% of CMS OPPS Rate,738.43,100% OF CMS OPPS Rate,703.01,60% of total billed charges,28.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,738.43,100% OF CMS OPPS Rate,738.43,100% OF CMS OPPS Rate,28.11,100% OF CMS OPPS RATE,738.43,100% OF CMS OPPS Rate,820.18,70% of total billed charges,738.43,100% OF CMS OPPS Rate,886.11,120% of CMS OPPS RATE,843.61,Pays at 72% of billed charges with lesser of charges applied,843.61,Pays at 72% of billed charges with lesser of charges applied,843.61,Pays at 72% of billed charges with lesser of charges applied,843.61,Pays at 72% of billed charges with lesser of charges applied,843.61,Pays at 72% of billed charges with lesser of charges applied,843.61,Pays at 72% of billed charges with lesser of charges applied,1171.68,100% of ASC Tier Grouping Fee Schedule,1171.68,100% of ASC Tier Grouping Fee Schedule,1171.68,100% of ASC Tier Grouping Fee Schedule,1171.68,100% of ASC Tier Grouping Fee Schedule,1171.68,100% of ASC Tier Grouping Fee Schedule,1171.68,100% of ASC Tier Grouping Fee Schedule,1171.68,100% of ASC Tier Grouping Fee Schedule,1171.68,100% of ASC Tier Grouping Fee Schedule,1171.68,100% of ASC Tier Grouping Fee Schedule,926.8,79.1% of total billed charges,926.8,79.1% of total billed charges,926.8,79.1% of total billed charges,926.8,79.1% of total billed charges,926.8,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,820.18,70% of total billed charges,738.43,100% OF CMS OPPS Rate,738.43,100% OF CMS OPPS Rate,738.43,100% OF CMS OPPS Rate,738.43,100% OF CMS OPPS Rate,738.43,100% OF CMS OPPS Rate,738.43,100% OF CMS OPPS Rate,738.43,100% OF CMS OPPS Rate,738.43,100% OF CMS OPPS Rate,738.43,100% OF CMS OPPS Rate,738.43,100% OF CMS OPPS Rate,738.43,100% OF CMS OPPS Rate,738.43,100% OF CMS OPPS Rate,738.43,100% OF CMS OPPS Rate,738.43,100% OF CMS OPPS Rate,738.43,100% OF CMS OPPS Rate,738.43,100% OF CMS OPPS Rate,28.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.11,1171.68,878.76
Outpatient Medical Services,PHYSICIAN CLINIC,21930,EXC BACK LES SC <3 CM,510,3235.28,2329.4,Pays at 72% of billed charges with lesser of charges applied,1906.04,100% OF CMS OPPS Rate,3235.28,100% of ASC Tier Grouping Fee Schedule,1906.04,100% OF CMS OPPS Rate,2559.11,79.1% of total billed charges,1906.04,100% OF CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,2329.4,72% of total billed charges,1906.04,100% OF CMS OPPS Rate,1906.04,100% of CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1941.17,60% of total billed charges,532.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,532.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,390.88,100% OF CMS OPPS RATE,1906.04,100% OF CMS OPPS Rate,2264.7,70% of total billed charges,1906.04,100% OF CMS OPPS Rate,2287.25,120% of CMS OPPS RATE,2329.4,Pays at 72% of billed charges with lesser of charges applied,2329.4,Pays at 72% of billed charges with lesser of charges applied,2329.4,Pays at 72% of billed charges with lesser of charges applied,2329.4,Pays at 72% of billed charges with lesser of charges applied,2329.4,Pays at 72% of billed charges with lesser of charges applied,2329.4,Pays at 72% of billed charges with lesser of charges applied,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,2559.11,79.1% of total billed charges,2559.11,79.1% of total billed charges,2559.11,79.1% of total billed charges,2559.11,79.1% of total billed charges,2559.11,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,2264.7,70% of total billed charges,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,532.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,532.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,532.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,532.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,532.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,532.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,532.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,532.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,532.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,532.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,532.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,532.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,532.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,532.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,532.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,532.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,532.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,532.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,532.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,532.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,390.88,3235.28,2426.46
Outpatient Medical Services,PHYSICIAN CLINIC,21931,EXC BACK LES SC 3CM/>,510,3235.28,2329.4,Pays at 72% of billed charges with lesser of charges applied,1906.04,100% OF CMS OPPS Rate,3235.28,100% of ASC Tier Grouping Fee Schedule,1906.04,100% OF CMS OPPS Rate,2559.11,79.1% of total billed charges,1906.04,100% OF CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,2329.4,72% of total billed charges,1906.04,100% OF CMS OPPS Rate,1906.04,100% of CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1941.17,60% of total billed charges,110.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,495.93,100% OF CMS OPPS RATE,1906.04,100% OF CMS OPPS Rate,2264.7,70% of total billed charges,1906.04,100% OF CMS OPPS Rate,2287.25,120% of CMS OPPS RATE,2329.4,Pays at 72% of billed charges with lesser of charges applied,2329.4,Pays at 72% of billed charges with lesser of charges applied,2329.4,Pays at 72% of billed charges with lesser of charges applied,2329.4,Pays at 72% of billed charges with lesser of charges applied,2329.4,Pays at 72% of billed charges with lesser of charges applied,2329.4,Pays at 72% of billed charges with lesser of charges applied,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,3235.28,100% of ASC Tier Grouping Fee Schedule,2559.11,79.1% of total billed charges,2559.11,79.1% of total billed charges,2559.11,79.1% of total billed charges,2559.11,79.1% of total billed charges,2559.11,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,2264.7,70% of total billed charges,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,110.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.55,3235.28,2426.46
Outpatient Medical Services,PHYSICIAN CLINIC,46050,I&D PERIANAL ABSCESS,510,1703.96,1226.85,Pays at 72% of billed charges with lesser of charges applied,1056.31,100% OF CMS OPPS Rate,1703.96,100% of ASC Tier Grouping Fee Schedule,1056.31,100% OF CMS OPPS Rate,1347.83,79.1% of total billed charges,1056.31,100% OF CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,1226.85,72% of total billed charges,1056.31,100% OF CMS OPPS Rate,1056.31,100% of CMS OPPS Rate,1056.31,100% OF CMS OPPS Rate,1022.38,60% of total billed charges,114.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,114.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,1056.31,100% OF CMS OPPS Rate,1056.31,100% OF CMS OPPS Rate,109.94,100% OF CMS OPPS RATE,1056.31,100% OF CMS OPPS Rate,1192.77,70% of total billed charges,1056.31,100% OF CMS OPPS Rate,1267.57,120% of CMS OPPS RATE,1226.85,Pays at 72% of billed charges with lesser of charges applied,1226.85,Pays at 72% of billed charges with lesser of charges applied,1226.85,Pays at 72% of billed charges with lesser of charges applied,1226.85,Pays at 72% of billed charges with lesser of charges applied,1226.85,Pays at 72% of billed charges with lesser of charges applied,1226.85,Pays at 72% of billed charges with lesser of charges applied,1703.96,100% of ASC Tier Grouping Fee Schedule,1703.96,100% of ASC Tier Grouping Fee Schedule,1703.96,100% of ASC Tier Grouping Fee Schedule,1703.96,100% of ASC Tier Grouping Fee Schedule,1703.96,100% of ASC Tier Grouping Fee Schedule,1703.96,100% of ASC Tier Grouping Fee Schedule,1703.96,100% of ASC Tier Grouping Fee Schedule,1703.96,100% of ASC Tier Grouping Fee Schedule,1703.96,100% of ASC Tier Grouping Fee Schedule,1347.83,79.1% of total billed charges,1347.83,79.1% of total billed charges,1347.83,79.1% of total billed charges,1347.83,79.1% of total billed charges,1347.83,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,1192.77,70% of total billed charges,1056.31,100% OF CMS OPPS Rate,1056.31,100% OF CMS OPPS Rate,1056.31,100% OF CMS OPPS Rate,1056.31,100% OF CMS OPPS Rate,1056.31,100% OF CMS OPPS Rate,1056.31,100% OF CMS OPPS Rate,1056.31,100% OF CMS OPPS Rate,1056.31,100% OF CMS OPPS Rate,1056.31,100% OF CMS OPPS Rate,1056.31,100% OF CMS OPPS Rate,1056.31,100% OF CMS OPPS Rate,1056.31,100% OF CMS OPPS Rate,1056.31,100% OF CMS OPPS Rate,1056.31,100% OF CMS OPPS Rate,1056.31,100% OF CMS OPPS Rate,1056.31,100% OF CMS OPPS Rate,114.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,114.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,114.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,114.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,114.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,114.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,114.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,114.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,114.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,114.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,114.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,114.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,114.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,114.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,114.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,114.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,114.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,114.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,114.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,114.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,109.94,1703.96,1277.97
Outpatient Medical Services,PHYSICIAN CLINIC,10120,REMOVE FOREIGN BODY,510,1345.92,969.06,Pays at 72% of billed charges with lesser of charges applied,474.2,100% OF CMS OPPS Rate,1345.92,100% of ASC Tier Grouping Fee Schedule,474.2,100% OF CMS OPPS Rate,1064.62,79.1% of total billed charges,474.2,100% OF CMS OPPS Rate,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,969.06,72% of total billed charges,474.2,100% OF CMS OPPS Rate,474.2,100% of CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,807.55,60% of total billed charges,74.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,115.64,100% OF CMS OPPS RATE,474.2,100% OF CMS OPPS Rate,942.14,70% of total billed charges,474.2,100% OF CMS OPPS Rate,569.03,120% of CMS OPPS RATE,969.06,Pays at 72% of billed charges with lesser of charges applied,969.06,Pays at 72% of billed charges with lesser of charges applied,969.06,Pays at 72% of billed charges with lesser of charges applied,969.06,Pays at 72% of billed charges with lesser of charges applied,969.06,Pays at 72% of billed charges with lesser of charges applied,969.06,Pays at 72% of billed charges with lesser of charges applied,1345.92,100% of ASC Tier Grouping Fee Schedule,1345.92,100% of ASC Tier Grouping Fee Schedule,1345.92,100% of ASC Tier Grouping Fee Schedule,1345.92,100% of ASC Tier Grouping Fee Schedule,1345.92,100% of ASC Tier Grouping Fee Schedule,1345.92,100% of ASC Tier Grouping Fee Schedule,1345.92,100% of ASC Tier Grouping Fee Schedule,1345.92,100% of ASC Tier Grouping Fee Schedule,1345.92,100% of ASC Tier Grouping Fee Schedule,1064.62,79.1% of total billed charges,1064.62,79.1% of total billed charges,1064.62,79.1% of total billed charges,1064.62,79.1% of total billed charges,1064.62,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,942.14,70% of total billed charges,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,474.2,100% OF CMS OPPS Rate,74.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.23,1345.92,1009.44
Outpatient Medical Services,PHYSICIAN CLINIC,11101,BIOPSY SKIN ADD-ON,510,745.92,537.06,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,609.42,81.7% of total Billed charges,N/A,Not Separately reimbursable,590.02,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,537.06,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,447.55,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,522.14,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,537.06,Pays at 72% of billed charges with lesser of charges applied,537.06,Pays at 72% of billed charges with lesser of charges applied,537.06,Pays at 72% of billed charges with lesser of charges applied,537.06,Pays at 72% of billed charges with lesser of charges applied,537.06,Pays at 72% of billed charges with lesser of charges applied,537.06,Pays at 72% of billed charges with lesser of charges applied,609.42,81.7% of total Billed charges,609.42,81.7% of total Billed charges,609.42,81.7% of total Billed charges,609.42,81.7% of total Billed charges,609.42,81.7% of total Billed charges,609.42,81.7% of total Billed charges,609.42,81.7% of total Billed charges,609.42,81.7% of total Billed charges,609.42,81.7% of total Billed charges,590.02,79.1% of total billed charges,590.02,79.1% of total billed charges,590.02,79.1% of total billed charges,590.02,79.1% of total billed charges,590.02,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,522.14,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,447.55,609.42,559.44
Outpatient Medical Services,PHYSICIAN CLINIC,11100,BIOPSY SKIN LESION,510,745.92,537.06,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,609.42,81.7% of total Billed charges,N/A,Not Separately reimbursable,590.02,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,537.06,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,447.55,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,522.14,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,537.06,Pays at 72% of billed charges with lesser of charges applied,537.06,Pays at 72% of billed charges with lesser of charges applied,537.06,Pays at 72% of billed charges with lesser of charges applied,537.06,Pays at 72% of billed charges with lesser of charges applied,537.06,Pays at 72% of billed charges with lesser of charges applied,537.06,Pays at 72% of billed charges with lesser of charges applied,609.42,81.7% of total Billed charges,609.42,81.7% of total Billed charges,609.42,81.7% of total Billed charges,609.42,81.7% of total Billed charges,609.42,81.7% of total Billed charges,609.42,81.7% of total Billed charges,609.42,81.7% of total Billed charges,609.42,81.7% of total Billed charges,609.42,81.7% of total Billed charges,590.02,79.1% of total billed charges,590.02,79.1% of total billed charges,590.02,79.1% of total billed charges,590.02,79.1% of total billed charges,590.02,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,522.14,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,447.55,609.42,559.44
Outpatient Medical Services,PHYSICIAN CLINIC,99385,Initial new patient preventive medicine evaluation (18?9 years),510,290,208.8,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,236.93,81.7% of total Billed charges,N/A,Not Separately reimbursable,229.39,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,208.8,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,174,60% of total billed charges,163.67,100% of CA Medicaid Fee Schedule with lesser of charges applied,163.67,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,98.89,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,203,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,208.8,Pays at 72% of billed charges with lesser of charges applied,208.8,Pays at 72% of billed charges with lesser of charges applied,208.8,Pays at 72% of billed charges with lesser of charges applied,208.8,Pays at 72% of billed charges with lesser of charges applied,208.8,Pays at 72% of billed charges with lesser of charges applied,208.8,Pays at 72% of billed charges with lesser of charges applied,236.93,81.7% of total Billed charges,236.93,81.7% of total Billed charges,236.93,81.7% of total Billed charges,236.93,81.7% of total Billed charges,236.93,81.7% of total Billed charges,236.93,81.7% of total Billed charges,236.93,81.7% of total Billed charges,236.93,81.7% of total Billed charges,236.93,81.7% of total Billed charges,229.39,79.1% of total billed charges,229.39,79.1% of total billed charges,229.39,79.1% of total billed charges,229.39,79.1% of total billed charges,229.39,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,203,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,163.67,100% of CA Medicaid Fee Schedule with lesser of charges applied,163.67,100% of CA Medicaid Fee Schedule with lesser of charges applied,163.67,100% of CA Medicaid Fee Schedule with lesser of charges applied,163.67,100% of CA Medicaid Fee Schedule with lesser of charges applied,163.67,100% of CA Medicaid Fee Schedule with lesser of charges applied,163.67,100% of CA Medicaid Fee Schedule with lesser of charges applied,163.67,100% of CA Medicaid Fee Schedule with lesser of charges applied,163.67,100% of CA Medicaid Fee Schedule with lesser of charges applied,163.67,100% of CA Medicaid Fee Schedule with lesser of charges applied,163.67,100% of CA Medicaid Fee Schedule with lesser of charges applied,163.67,100% of CA Medicaid Fee Schedule with lesser of charges applied,163.67,100% of CA Medicaid Fee Schedule with lesser of charges applied,163.67,100% of CA Medicaid Fee Schedule with lesser of charges applied,163.67,100% of CA Medicaid Fee Schedule with lesser of charges applied,163.67,100% of CA Medicaid Fee Schedule with lesser of charges applied,163.67,100% of CA Medicaid Fee Schedule with lesser of charges applied,163.67,100% of CA Medicaid Fee Schedule with lesser of charges applied,163.67,100% of CA Medicaid Fee Schedule with lesser of charges applied,163.67,100% of CA Medicaid Fee Schedule with lesser of charges applied,163.67,100% of CA Medicaid Fee Schedule with lesser of charges applied,98.89,236.93,217.5
Outpatient Medical Services,PHYSICIAN CLINIC,99386,Initial new patient preventive medicine evaluation (40?4 years),510,300,216,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,245.1,81.7% of total Billed charges,N/A,Not Separately reimbursable,237.3,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,216,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,180,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,119.98,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,210,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,216,Pays at 72% of billed charges with lesser of charges applied,216,Pays at 72% of billed charges with lesser of charges applied,216,Pays at 72% of billed charges with lesser of charges applied,216,Pays at 72% of billed charges with lesser of charges applied,216,Pays at 72% of billed charges with lesser of charges applied,216,Pays at 72% of billed charges with lesser of charges applied,245.1,81.7% of total Billed charges,245.1,81.7% of total Billed charges,245.1,81.7% of total Billed charges,245.1,81.7% of total Billed charges,245.1,81.7% of total Billed charges,245.1,81.7% of total Billed charges,245.1,81.7% of total Billed charges,245.1,81.7% of total Billed charges,245.1,81.7% of total Billed charges,237.3,79.1% of total billed charges,237.3,79.1% of total billed charges,237.3,79.1% of total billed charges,237.3,79.1% of total billed charges,237.3,79.1% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,210,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,119.98,245.10,225
Outpatient Medical Services,Psychotherapy,90832,"Psychotherapy, 30 min",900,164,118.08,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,133.99,81.7% of total Billed charges,N/A,Not Separately reimbursable,129.72,79.1% of total billed charges,N/A,Not Separately reimbursable,137.76,84% of total billed charges,137.76,84% of total billed charges,118.08,72% of total billed charges,N/A,Not Separately reimbursable,164,100% of CMS OPPS Rate,N/A,Not Separately reimbursable,98.4,60% of total billed charges,75.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,68.93,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,114.8,70% of total billed charges,164,100% OF CMS OPPS Rate,164,120% of CMS OPPS RATE,118.08,Pays at 72% of billed charges with lesser of charges applied,118.08,Pays at 72% of billed charges with lesser of charges applied,118.08,Pays at 72% of billed charges with lesser of charges applied,118.08,Pays at 72% of billed charges with lesser of charges applied,118.08,Pays at 72% of billed charges with lesser of charges applied,118.08,Pays at 72% of billed charges with lesser of charges applied,133.99,81.7% of total Billed charges,133.99,81.7% of total Billed charges,133.99,81.7% of total Billed charges,133.99,81.7% of total Billed charges,133.99,81.7% of total Billed charges,133.99,81.7% of total Billed charges,133.99,81.7% of total Billed charges,133.99,81.7% of total Billed charges,133.99,81.7% of total Billed charges,129.72,79.1% of total billed charges,129.72,79.1% of total billed charges,129.72,79.1% of total billed charges,129.72,79.1% of total billed charges,129.72,79.1% of total billed charges,137.76,84% of total billed charges,137.76,84% of total billed charges,137.76,84% of total billed charges,114.8,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,75.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,68.93,164.00,123
Outpatient Medical Services,Psychotherapy,90834,"Psychotherapy, 45 min",900,217,156.24,Pays at 72% of billed charges with lesser of charges applied,185.18,100% OF CMS OPPS Rate,177.29,81.7% of total Billed charges,185.18,100% OF CMS OPPS Rate,171.65,79.1% of total billed charges,185.18,100% OF CMS OPPS Rate,182.28,84% of total billed charges,182.28,84% of total billed charges,156.24,72% of total billed charges,185.18,100% OF CMS OPPS Rate,185.18,100% of CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,130.2,60% of total billed charges,96.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,96.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,185.18,100% OF CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,91.38,100% OF CMS OPPS RATE,185.18,100% OF CMS OPPS Rate,151.9,70% of total billed charges,185.18,100% OF CMS OPPS Rate,217,120% of CMS OPPS RATE,156.24,Pays at 72% of billed charges with lesser of charges applied,156.24,Pays at 72% of billed charges with lesser of charges applied,156.24,Pays at 72% of billed charges with lesser of charges applied,156.24,Pays at 72% of billed charges with lesser of charges applied,156.24,Pays at 72% of billed charges with lesser of charges applied,156.24,Pays at 72% of billed charges with lesser of charges applied,177.29,81.7% of total Billed charges,177.29,81.7% of total Billed charges,177.29,81.7% of total Billed charges,177.29,81.7% of total Billed charges,177.29,81.7% of total Billed charges,177.29,81.7% of total Billed charges,177.29,81.7% of total Billed charges,177.29,81.7% of total Billed charges,177.29,81.7% of total Billed charges,171.65,79.1% of total billed charges,171.65,79.1% of total billed charges,171.65,79.1% of total billed charges,171.65,79.1% of total billed charges,171.65,79.1% of total billed charges,182.28,84% of total billed charges,182.28,84% of total billed charges,182.28,84% of total billed charges,151.9,70% of total billed charges,185.18,100% OF CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,96.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,96.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,96.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,96.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,96.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,96.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,96.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,96.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,96.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,96.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,96.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,96.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,96.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,96.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,96.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,96.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,96.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,96.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,96.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,96.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,91.38,217.00,162.75
Outpatient Medical Services,Psychotherapy,90837,"Psychotherapy, 60 min",900,319,229.68,Pays at 72% of billed charges with lesser of charges applied,185.18,100% OF CMS OPPS Rate,260.62,81.7% of total Billed charges,185.18,100% OF CMS OPPS Rate,252.33,79.1% of total billed charges,185.18,100% OF CMS OPPS Rate,267.96,84% of total billed charges,267.96,84% of total billed charges,229.68,72% of total billed charges,185.18,100% OF CMS OPPS Rate,185.18,100% of CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,191.4,60% of total billed charges,140.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,140.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,185.18,100% OF CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,134.33,100% OF CMS OPPS RATE,185.18,100% OF CMS OPPS Rate,223.3,70% of total billed charges,185.18,100% OF CMS OPPS Rate,222.23,120% of CMS OPPS RATE,229.68,Pays at 72% of billed charges with lesser of charges applied,229.68,Pays at 72% of billed charges with lesser of charges applied,229.68,Pays at 72% of billed charges with lesser of charges applied,229.68,Pays at 72% of billed charges with lesser of charges applied,229.68,Pays at 72% of billed charges with lesser of charges applied,229.68,Pays at 72% of billed charges with lesser of charges applied,260.62,81.7% of total Billed charges,260.62,81.7% of total Billed charges,260.62,81.7% of total Billed charges,260.62,81.7% of total Billed charges,260.62,81.7% of total Billed charges,260.62,81.7% of total Billed charges,260.62,81.7% of total Billed charges,260.62,81.7% of total Billed charges,260.62,81.7% of total Billed charges,252.33,79.1% of total billed charges,252.33,79.1% of total billed charges,252.33,79.1% of total billed charges,252.33,79.1% of total billed charges,252.33,79.1% of total billed charges,267.96,84% of total billed charges,267.96,84% of total billed charges,267.96,84% of total billed charges,223.3,70% of total billed charges,185.18,100% OF CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,140.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,140.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,140.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,140.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,140.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,140.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,140.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,140.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,140.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,140.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,140.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,140.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,140.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,140.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,140.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,140.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,140.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,140.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,140.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,140.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,134.33,267.96,239.25
Outpatient Medical Services,Psychotherapy,90846,"Family psychotherapy, not including patient, 50 min",900,205,147.6,Pays at 72% of billed charges with lesser of charges applied,185.18,100% OF CMS OPPS Rate,167.49,81.7% of total Billed charges,185.18,100% OF CMS OPPS Rate,162.16,79.1% of total billed charges,185.18,100% OF CMS OPPS Rate,172.2,84% of total billed charges,172.2,84% of total billed charges,147.6,72% of total billed charges,185.18,100% OF CMS OPPS Rate,185.18,100% of CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,123,60% of total billed charges,124.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,124.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,185.18,100% OF CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,98.76,100% OF CMS OPPS RATE,185.18,100% OF CMS OPPS Rate,143.5,70% of total billed charges,185.18,100% OF CMS OPPS Rate,205,120% of CMS OPPS RATE,147.6,Pays at 72% of billed charges with lesser of charges applied,147.6,Pays at 72% of billed charges with lesser of charges applied,147.6,Pays at 72% of billed charges with lesser of charges applied,147.6,Pays at 72% of billed charges with lesser of charges applied,147.6,Pays at 72% of billed charges with lesser of charges applied,147.6,Pays at 72% of billed charges with lesser of charges applied,167.49,81.7% of total Billed charges,167.49,81.7% of total Billed charges,167.49,81.7% of total Billed charges,167.49,81.7% of total Billed charges,167.49,81.7% of total Billed charges,167.49,81.7% of total Billed charges,167.49,81.7% of total Billed charges,167.49,81.7% of total Billed charges,167.49,81.7% of total Billed charges,162.16,79.1% of total billed charges,162.16,79.1% of total billed charges,162.16,79.1% of total billed charges,162.16,79.1% of total billed charges,162.16,79.1% of total billed charges,172.2,84% of total billed charges,172.2,84% of total billed charges,172.2,84% of total billed charges,143.5,70% of total billed charges,185.18,100% OF CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,124.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,124.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,124.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,124.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,124.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,124.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,124.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,124.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,124.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,124.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,124.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,124.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,124.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,124.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,124.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,124.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,124.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,124.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,124.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,124.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,98.76,205.00,153.75
Outpatient Medical Services,Psychotherapy,90847,"Family psychotherapy, including patient, 50 min",900,212,152.64,Pays at 72% of billed charges with lesser of charges applied,185.18,100% OF CMS OPPS Rate,173.2,81.7% of total Billed charges,185.18,100% OF CMS OPPS Rate,167.69,79.1% of total billed charges,185.18,100% OF CMS OPPS Rate,178.08,84% of total billed charges,178.08,84% of total billed charges,152.64,72% of total billed charges,185.18,100% OF CMS OPPS Rate,185.18,100% of CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,127.2,60% of total billed charges,73.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,185.18,100% OF CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,103.05,100% OF CMS OPPS RATE,185.18,100% OF CMS OPPS Rate,148.4,70% of total billed charges,185.18,100% OF CMS OPPS Rate,212,120% of CMS OPPS RATE,152.64,Pays at 72% of billed charges with lesser of charges applied,152.64,Pays at 72% of billed charges with lesser of charges applied,152.64,Pays at 72% of billed charges with lesser of charges applied,152.64,Pays at 72% of billed charges with lesser of charges applied,152.64,Pays at 72% of billed charges with lesser of charges applied,152.64,Pays at 72% of billed charges with lesser of charges applied,173.2,81.7% of total Billed charges,173.2,81.7% of total Billed charges,173.2,81.7% of total Billed charges,173.2,81.7% of total Billed charges,173.2,81.7% of total Billed charges,173.2,81.7% of total Billed charges,173.2,81.7% of total Billed charges,173.2,81.7% of total Billed charges,173.2,81.7% of total Billed charges,167.69,79.1% of total billed charges,167.69,79.1% of total billed charges,167.69,79.1% of total billed charges,167.69,79.1% of total billed charges,167.69,79.1% of total billed charges,178.08,84% of total billed charges,178.08,84% of total billed charges,178.08,84% of total billed charges,148.4,70% of total billed charges,185.18,100% OF CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,185.18,100% OF CMS OPPS Rate,73.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.15,212.00,159
Outpatient Medical Services,Psychotherapy,90853,Group psychotherapy,900,58,41.76,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,47.39,81.7% of total Billed charges,N/A,Not Separately reimbursable,45.88,79.1% of total billed charges,N/A,Not Separately reimbursable,48.72,84% of total billed charges,48.72,84% of total billed charges,41.76,72% of total billed charges,N/A,Not Separately reimbursable,58,100% of CMS OPPS Rate,N/A,Not Separately reimbursable,34.8,60% of total billed charges,20.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,24.19,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,40.6,70% of total billed charges,58,100% OF CMS OPPS Rate,58,120% of CMS OPPS RATE,41.76,Pays at 72% of billed charges with lesser of charges applied,41.76,Pays at 72% of billed charges with lesser of charges applied,41.76,Pays at 72% of billed charges with lesser of charges applied,41.76,Pays at 72% of billed charges with lesser of charges applied,41.76,Pays at 72% of billed charges with lesser of charges applied,41.76,Pays at 72% of billed charges with lesser of charges applied,47.39,81.7% of total Billed charges,47.39,81.7% of total Billed charges,47.39,81.7% of total Billed charges,47.39,81.7% of total Billed charges,47.39,81.7% of total Billed charges,47.39,81.7% of total Billed charges,47.39,81.7% of total Billed charges,47.39,81.7% of total Billed charges,47.39,81.7% of total Billed charges,45.88,79.1% of total billed charges,45.88,79.1% of total billed charges,45.88,79.1% of total billed charges,45.88,79.1% of total billed charges,45.88,79.1% of total billed charges,48.72,84% of total billed charges,48.72,84% of total billed charges,48.72,84% of total billed charges,40.6,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,20.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.77,58.00,43.5
Outpatient Medical Services,RADIOLOGY,19281,"MG WIRE LOCALIZATION, w/CLIP-MAMMO GUIDED BREAST-RT",320,313.75,225.9,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,313.75,100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,248.18,79.1% of total billed charges,N/A,Not Separately reimbursable,263.55,84% of total billed charges,263.55,84% of total billed charges,225.9,72% of total billed charges,N/A,Not Separately reimbursable,313.75,100% of CMS OPPS Rate,N/A,Not Separately reimbursable,188.25,60% of total billed charges,309.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,309.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,102.47,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,219.63,70% of total billed charges,313.75,100% OF CMS OPPS Rate,313.75,120% of CMS OPPS RATE,225.9,Pays at 72% of billed charges with lesser of charges applied,225.9,Pays at 72% of billed charges with lesser of charges applied,225.9,Pays at 72% of billed charges with lesser of charges applied,225.9,Pays at 72% of billed charges with lesser of charges applied,225.9,Pays at 72% of billed charges with lesser of charges applied,225.9,Pays at 72% of billed charges with lesser of charges applied,313.75,100% of ASC Tier Grouping Fee Schedule,313.75,100% of ASC Tier Grouping Fee Schedule,313.75,100% of ASC Tier Grouping Fee Schedule,313.75,100% of ASC Tier Grouping Fee Schedule,313.75,100% of ASC Tier Grouping Fee Schedule,313.75,100% of ASC Tier Grouping Fee Schedule,313.75,100% of ASC Tier Grouping Fee Schedule,313.75,100% of ASC Tier Grouping Fee Schedule,313.75,100% of ASC Tier Grouping Fee Schedule,248.18,79.1% of total billed charges,248.18,79.1% of total billed charges,248.18,79.1% of total billed charges,248.18,79.1% of total billed charges,248.18,79.1% of total billed charges,263.55,84% of total billed charges,263.55,84% of total billed charges,263.55,84% of total billed charges,219.63,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,309.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,309.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,309.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,309.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,309.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,309.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,309.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,309.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,309.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,309.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,309.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,309.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,309.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,309.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,309.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,309.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,309.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,309.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,309.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,309.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,102.47,313.75,235.31
Outpatient Medical Services,RADIOLOGY,73592,XR LOWER EXTREMITY INFANT YOUNGER THAN 12 MONTHS-LT,320,223,160.56,Pays at 72% of billed charges with lesser of charges applied,110.43,100% OF CMS OPPS Rate,92.64,442% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,108.23,100% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,187.32,84% of total billed charges,187.32,84% of total billed charges,160.56,72% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% of CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,133.8,60% of total billed charges,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,28.46,100% OF CMS OPPS RATE,110.43,100% OF CMS OPPS Rate,156.1,70% of total billed charges,110.43,100% OF CMS OPPS Rate,132.51,120% of CMS OPPS RATE,160.56,Pays at 72% of billed charges with lesser of charges applied,160.56,Pays at 72% of billed charges with lesser of charges applied,160.56,Pays at 72% of billed charges with lesser of charges applied,160.56,Pays at 72% of billed charges with lesser of charges applied,160.56,Pays at 72% of billed charges with lesser of charges applied,160.56,Pays at 72% of billed charges with lesser of charges applied,92.64,442% of BCBS Fee Schedule,92.64,442% of BCBS Fee Schedule,92.64,442% of BCBS Fee Schedule,92.64,442% of BCBS Fee Schedule,92.64,442% of BCBS Fee Schedule,92.64,442% of BCBS Fee Schedule,92.64,442% of BCBS Fee Schedule,92.64,442% of BCBS Fee Schedule,92.64,442% of BCBS Fee Schedule,108.23,100% of BCBS Fee Schedule,108.23,100% of BCBS Fee Schedule,108.23,100% of BCBS Fee Schedule,108.23,100% of BCBS Fee Schedule,108.23,100% of BCBS Fee Schedule,187.32,84% of total billed charges,187.32,84% of total billed charges,187.32,84% of total billed charges,156.1,70% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.46,187.32,167.25
Outpatient Medical Services,RADIOLOGY,73092,XR UPPER EXTREMITY-INFANT YOUNGER THAN 12 MONTHS-LT,320,181.75,130.86,Pays at 72% of billed charges with lesser of charges applied,135.85,100% OF CMS OPPS Rate,92.64,442% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,108.23,100% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,152.67,84% of total billed charges,152.67,84% of total billed charges,130.86,72% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% of CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,109.05,60% of total billed charges,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,28.46,100% OF CMS OPPS RATE,135.85,100% OF CMS OPPS Rate,127.23,70% of total billed charges,135.85,100% OF CMS OPPS Rate,163.02,120% of CMS OPPS RATE,130.86,Pays at 72% of billed charges with lesser of charges applied,130.86,Pays at 72% of billed charges with lesser of charges applied,130.86,Pays at 72% of billed charges with lesser of charges applied,130.86,Pays at 72% of billed charges with lesser of charges applied,130.86,Pays at 72% of billed charges with lesser of charges applied,130.86,Pays at 72% of billed charges with lesser of charges applied,92.64,442% of BCBS Fee Schedule,92.64,442% of BCBS Fee Schedule,92.64,442% of BCBS Fee Schedule,92.64,442% of BCBS Fee Schedule,92.64,442% of BCBS Fee Schedule,92.64,442% of BCBS Fee Schedule,92.64,442% of BCBS Fee Schedule,92.64,442% of BCBS Fee Schedule,92.64,442% of BCBS Fee Schedule,108.23,100% of BCBS Fee Schedule,108.23,100% of BCBS Fee Schedule,108.23,100% of BCBS Fee Schedule,108.23,100% of BCBS Fee Schedule,108.23,100% of BCBS Fee Schedule,152.67,84% of total billed charges,152.67,84% of total billed charges,152.67,84% of total billed charges,127.23,70% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.46,163.02,136.31
Outpatient Medical Services,RADIOLOGY,73551,XR LOWER EXTREMITY-TODDLER OLDER THAN 12 MONTHS-LT,320,330.5,237.96,Pays at 72% of billed charges with lesser of charges applied,110.43,100% OF CMS OPPS Rate,146.26,442% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,115.28,100% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,277.62,84% of total billed charges,277.62,84% of total billed charges,237.96,72% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% of CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,198.3,60% of total billed charges,35.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,25.28,100% OF CMS OPPS RATE,110.43,100% OF CMS OPPS Rate,231.35,70% of total billed charges,110.43,100% OF CMS OPPS Rate,132.51,120% of CMS OPPS RATE,237.96,Pays at 72% of billed charges with lesser of charges applied,237.96,Pays at 72% of billed charges with lesser of charges applied,237.96,Pays at 72% of billed charges with lesser of charges applied,237.96,Pays at 72% of billed charges with lesser of charges applied,237.96,Pays at 72% of billed charges with lesser of charges applied,237.96,Pays at 72% of billed charges with lesser of charges applied,146.26,442% of BCBS Fee Schedule,146.26,442% of BCBS Fee Schedule,146.26,442% of BCBS Fee Schedule,146.26,442% of BCBS Fee Schedule,146.26,442% of BCBS Fee Schedule,146.26,442% of BCBS Fee Schedule,146.26,442% of BCBS Fee Schedule,146.26,442% of BCBS Fee Schedule,146.26,442% of BCBS Fee Schedule,115.28,100% of BCBS Fee Schedule,115.28,100% of BCBS Fee Schedule,115.28,100% of BCBS Fee Schedule,115.28,100% of BCBS Fee Schedule,115.28,100% of BCBS Fee Schedule,277.62,84% of total billed charges,277.62,84% of total billed charges,277.62,84% of total billed charges,231.35,70% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,35.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,25.28,277.62,247.88
Outpatient Medical Services,RADIOLOGY,74019,XR ABDOMEN COMPLETE INC DECUB/ERECT VIEWS-PORTABLE,320,499.75,359.82,Pays at 72% of billed charges with lesser of charges applied,135.85,100% OF CMS OPPS Rate,155.01,442% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,130.31,100% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,419.79,84% of total billed charges,419.79,84% of total billed charges,359.82,72% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% of CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,299.85,60% of total billed charges,43.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,43.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,30.85,100% OF CMS OPPS RATE,135.85,100% OF CMS OPPS Rate,349.83,70% of total billed charges,135.85,100% OF CMS OPPS Rate,163.02,120% of CMS OPPS RATE,359.82,Pays at 72% of billed charges with lesser of charges applied,359.82,Pays at 72% of billed charges with lesser of charges applied,359.82,Pays at 72% of billed charges with lesser of charges applied,359.82,Pays at 72% of billed charges with lesser of charges applied,359.82,Pays at 72% of billed charges with lesser of charges applied,359.82,Pays at 72% of billed charges with lesser of charges applied,155.01,442% of BCBS Fee Schedule,155.01,442% of BCBS Fee Schedule,155.01,442% of BCBS Fee Schedule,155.01,442% of BCBS Fee Schedule,155.01,442% of BCBS Fee Schedule,155.01,442% of BCBS Fee Schedule,155.01,442% of BCBS Fee Schedule,155.01,442% of BCBS Fee Schedule,155.01,442% of BCBS Fee Schedule,130.31,100% of BCBS Fee Schedule,130.31,100% of BCBS Fee Schedule,130.31,100% of BCBS Fee Schedule,130.31,100% of BCBS Fee Schedule,130.31,100% of BCBS Fee Schedule,419.79,84% of total billed charges,419.79,84% of total billed charges,419.79,84% of total billed charges,349.83,70% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,43.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,43.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,43.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,43.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,43.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,43.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,43.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,43.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,43.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,43.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,43.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,43.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,43.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,43.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,43.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,43.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,43.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,43.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,43.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,43.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,30.85,419.79,374.81
Outpatient Medical Services,RADIOLOGY,74022,Serial radiologic examination of the abdomen,320,604.25,435.06,Pays at 72% of billed charges with lesser of charges applied,135.85,100% OF CMS OPPS Rate,139.27,442% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,166.5,100% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,507.57,84% of total billed charges,507.57,84% of total billed charges,435.06,72% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% of CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,362.55,60% of total billed charges,56.54,100% of CA Medicaid Fee Schedule with lesser of charges applied,56.54,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,41.2,100% OF CMS OPPS RATE,135.85,100% OF CMS OPPS Rate,422.98,70% of total billed charges,135.85,100% OF CMS OPPS Rate,163.02,120% of CMS OPPS RATE,435.06,Pays at 72% of billed charges with lesser of charges applied,435.06,Pays at 72% of billed charges with lesser of charges applied,435.06,Pays at 72% of billed charges with lesser of charges applied,435.06,Pays at 72% of billed charges with lesser of charges applied,435.06,Pays at 72% of billed charges with lesser of charges applied,435.06,Pays at 72% of billed charges with lesser of charges applied,139.27,442% of BCBS Fee Schedule,139.27,442% of BCBS Fee Schedule,139.27,442% of BCBS Fee Schedule,139.27,442% of BCBS Fee Schedule,139.27,442% of BCBS Fee Schedule,139.27,442% of BCBS Fee Schedule,139.27,442% of BCBS Fee Schedule,139.27,442% of BCBS Fee Schedule,139.27,442% of BCBS Fee Schedule,166.5,100% of BCBS Fee Schedule,166.5,100% of BCBS Fee Schedule,166.5,100% of BCBS Fee Schedule,166.5,100% of BCBS Fee Schedule,166.5,100% of BCBS Fee Schedule,507.57,84% of total billed charges,507.57,84% of total billed charges,507.57,84% of total billed charges,422.98,70% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,56.54,100% of CA Medicaid Fee Schedule with lesser of charges applied,56.54,100% of CA Medicaid Fee Schedule with lesser of charges applied,56.54,100% of CA Medicaid Fee Schedule with lesser of charges applied,56.54,100% of CA Medicaid Fee Schedule with lesser of charges applied,56.54,100% of CA Medicaid Fee Schedule with lesser of charges applied,56.54,100% of CA Medicaid Fee Schedule with lesser of charges applied,56.54,100% of CA Medicaid Fee Schedule with lesser of charges applied,56.54,100% of CA Medicaid Fee Schedule with lesser of charges applied,56.54,100% of CA Medicaid Fee Schedule with lesser of charges applied,56.54,100% of CA Medicaid Fee Schedule with lesser of charges applied,56.54,100% of CA Medicaid Fee Schedule with lesser of charges applied,56.54,100% of CA Medicaid Fee Schedule with lesser of charges applied,56.54,100% of CA Medicaid Fee Schedule with lesser of charges applied,56.54,100% of CA Medicaid Fee Schedule with lesser of charges applied,56.54,100% of CA Medicaid Fee Schedule with lesser of charges applied,56.54,100% of CA Medicaid Fee Schedule with lesser of charges applied,56.54,100% of CA Medicaid Fee Schedule with lesser of charges applied,56.54,100% of CA Medicaid Fee Schedule with lesser of charges applied,56.54,100% of CA Medicaid Fee Schedule with lesser of charges applied,56.54,100% of CA Medicaid Fee Schedule with lesser of charges applied,41.20,507.57,453.19
Outpatient Medical Services,RADIOLOGY,77031,STEREO LOCAL BREAST BX/NEEDLE LOC EA LESION S & I,320,662.5,477,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,662.5,BCBS Fee Schedule,N/A,Not Separately reimbursable,524.04,79.1% of total billed charges,N/A,Not Separately reimbursable,556.5,84% of total billed charges,556.5,84% of total billed charges,477,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,397.5,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,463.75,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,477,Pays at 72% of billed charges with lesser of charges applied,477,Pays at 72% of billed charges with lesser of charges applied,477,Pays at 72% of billed charges with lesser of charges applied,477,Pays at 72% of billed charges with lesser of charges applied,477,Pays at 72% of billed charges with lesser of charges applied,477,Pays at 72% of billed charges with lesser of charges applied,662.5,BCBS Fee Schedule,662.5,BCBS Fee Schedule,662.5,BCBS Fee Schedule,662.5,BCBS Fee Schedule,662.5,BCBS Fee Schedule,662.5,BCBS Fee Schedule,662.5,BCBS Fee Schedule,662.5,BCBS Fee Schedule,662.5,BCBS Fee Schedule,524.04,79.1% of total billed charges,524.04,79.1% of total billed charges,524.04,79.1% of total billed charges,524.04,79.1% of total billed charges,524.04,79.1% of total billed charges,556.5,84% of total billed charges,556.5,84% of total billed charges,556.5,84% of total billed charges,463.75,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,397.50,662.50,496.88
Outpatient Medical Services,RADIOLOGY,73510,XR HIP UNILATERAL COMPLETE MIN 2 VIEWS-PORTABLE,320,343,246.96,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,107.67,442% of BCBS Fee Schedule,N/A,Not Separately reimbursable,271.31,79.1% of total billed charges,N/A,Not Separately reimbursable,288.12,84% of total billed charges,288.12,84% of total billed charges,246.96,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,205.8,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,240.1,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,246.96,Pays at 72% of billed charges with lesser of charges applied,246.96,Pays at 72% of billed charges with lesser of charges applied,246.96,Pays at 72% of billed charges with lesser of charges applied,246.96,Pays at 72% of billed charges with lesser of charges applied,246.96,Pays at 72% of billed charges with lesser of charges applied,246.96,Pays at 72% of billed charges with lesser of charges applied,107.67,442% of BCBS Fee Schedule,107.67,442% of BCBS Fee Schedule,107.67,442% of BCBS Fee Schedule,107.67,442% of BCBS Fee Schedule,107.67,442% of BCBS Fee Schedule,107.67,442% of BCBS Fee Schedule,107.67,442% of BCBS Fee Schedule,107.67,442% of BCBS Fee Schedule,107.67,442% of BCBS Fee Schedule,271.31,79.1% of total billed charges,271.31,79.1% of total billed charges,271.31,79.1% of total billed charges,271.31,79.1% of total billed charges,271.31,79.1% of total billed charges,288.12,84% of total billed charges,288.12,84% of total billed charges,288.12,84% of total billed charges,240.1,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,107.67,288.12,257.25
Outpatient Medical Services,RADIOLOGY,76000,"Flouroscopy, or x-ray ""movie"" that takes less than an hour",320,341.5,245.88,Pays at 72% of billed charges with lesser of charges applied,296.82,100% OF CMS OPPS Rate,213.71,442% of BCBS Fee Schedule,296.82,100% OF CMS OPPS Rate,291.9,100% of BCBS Fee Schedule,296.82,100% OF CMS OPPS Rate,286.86,84% of total billed charges,286.86,84% of total billed charges,245.88,72% of total billed charges,296.82,100% OF CMS OPPS Rate,296.82,100% of CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,204.9,60% of total billed charges,40.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,40.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,33.24,100% OF CMS OPPS RATE,296.82,100% OF CMS OPPS Rate,239.05,70% of total billed charges,296.82,100% OF CMS OPPS Rate,341.5,120% of CMS OPPS RATE,245.88,Pays at 72% of billed charges with lesser of charges applied,245.88,Pays at 72% of billed charges with lesser of charges applied,245.88,Pays at 72% of billed charges with lesser of charges applied,245.88,Pays at 72% of billed charges with lesser of charges applied,245.88,Pays at 72% of billed charges with lesser of charges applied,245.88,Pays at 72% of billed charges with lesser of charges applied,213.71,442% of BCBS Fee Schedule,213.71,442% of BCBS Fee Schedule,213.71,442% of BCBS Fee Schedule,213.71,442% of BCBS Fee Schedule,213.71,442% of BCBS Fee Schedule,213.71,442% of BCBS Fee Schedule,213.71,442% of BCBS Fee Schedule,213.71,442% of BCBS Fee Schedule,213.71,442% of BCBS Fee Schedule,291.9,100% of BCBS Fee Schedule,291.9,100% of BCBS Fee Schedule,291.9,100% of BCBS Fee Schedule,291.9,100% of BCBS Fee Schedule,291.9,100% of BCBS Fee Schedule,286.86,84% of total billed charges,286.86,84% of total billed charges,286.86,84% of total billed charges,239.05,70% of total billed charges,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,40.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,40.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,40.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,40.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,40.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,40.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,40.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,40.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,40.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,40.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,40.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,40.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,40.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,40.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,40.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,40.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,40.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,40.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,40.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,40.11,100% of CA Medicaid Fee Schedule with lesser of charges applied,33.24,341.50,256.13
Outpatient Medical Services,RADIOLOGY,75980,PERC TRANSHEPATIC BILILARY DRAINAGE RAD S&I,320,1595.75,1148.94,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,1017.84,442% of BCBS Fee Schedule,N/A,Not Separately reimbursable,1262.24,79.1% of total billed charges,N/A,Not Separately reimbursable,1340.43,84% of total billed charges,1340.43,84% of total billed charges,1148.94,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,957.45,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,1117.03,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,1148.94,Pays at 72% of billed charges with lesser of charges applied,1148.94,Pays at 72% of billed charges with lesser of charges applied,1148.94,Pays at 72% of billed charges with lesser of charges applied,1148.94,Pays at 72% of billed charges with lesser of charges applied,1148.94,Pays at 72% of billed charges with lesser of charges applied,1148.94,Pays at 72% of billed charges with lesser of charges applied,1017.84,442% of BCBS Fee Schedule,1017.84,442% of BCBS Fee Schedule,1017.84,442% of BCBS Fee Schedule,1017.84,442% of BCBS Fee Schedule,1017.84,442% of BCBS Fee Schedule,1017.84,442% of BCBS Fee Schedule,1017.84,442% of BCBS Fee Schedule,1017.84,442% of BCBS Fee Schedule,1017.84,442% of BCBS Fee Schedule,1262.24,79.1% of total billed charges,1262.24,79.1% of total billed charges,1262.24,79.1% of total billed charges,1262.24,79.1% of total billed charges,1262.24,79.1% of total billed charges,1340.43,84% of total billed charges,1340.43,84% of total billed charges,1340.43,84% of total billed charges,1117.03,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,957.45,1340.43,1196.81
Outpatient Medical Services,RADIOLOGY,72020,XR SPINE SINGLE VIEW SPECIFY LEVEL-PORTABLE,320,292,210.24,Pays at 72% of billed charges with lesser of charges applied,110.43,100% OF CMS OPPS Rate,79.83,442% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,91.06,100% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,245.28,84% of total billed charges,245.28,84% of total billed charges,210.24,72% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% of CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,175.2,60% of total billed charges,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,20.1,100% OF CMS OPPS RATE,110.43,100% OF CMS OPPS Rate,204.4,70% of total billed charges,110.43,100% OF CMS OPPS Rate,132.51,120% of CMS OPPS RATE,210.24,Pays at 72% of billed charges with lesser of charges applied,210.24,Pays at 72% of billed charges with lesser of charges applied,210.24,Pays at 72% of billed charges with lesser of charges applied,210.24,Pays at 72% of billed charges with lesser of charges applied,210.24,Pays at 72% of billed charges with lesser of charges applied,210.24,Pays at 72% of billed charges with lesser of charges applied,79.83,442% of BCBS Fee Schedule,79.83,442% of BCBS Fee Schedule,79.83,442% of BCBS Fee Schedule,79.83,442% of BCBS Fee Schedule,79.83,442% of BCBS Fee Schedule,79.83,442% of BCBS Fee Schedule,79.83,442% of BCBS Fee Schedule,79.83,442% of BCBS Fee Schedule,79.83,442% of BCBS Fee Schedule,91.06,100% of BCBS Fee Schedule,91.06,100% of BCBS Fee Schedule,91.06,100% of BCBS Fee Schedule,91.06,100% of BCBS Fee Schedule,91.06,100% of BCBS Fee Schedule,245.28,84% of total billed charges,245.28,84% of total billed charges,245.28,84% of total billed charges,204.4,70% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.10,245.28,219
Outpatient Medical Services,RADIOLOGY,70260,XR SKULL COMPLETE MIN 4 VIEWS W/WO STEREO,320,611,439.92,Pays at 72% of billed charges with lesser of charges applied,135.85,100% OF CMS OPPS Rate,168.71,442% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,200.22,100% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,513.24,84% of total billed charges,513.24,84% of total billed charges,439.92,72% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% of CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,366.6,60% of total billed charges,57.69,100% of CA Medicaid Fee Schedule with lesser of charges applied,57.69,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,37.22,100% OF CMS OPPS RATE,135.85,100% OF CMS OPPS Rate,427.7,70% of total billed charges,135.85,100% OF CMS OPPS Rate,163.02,120% of CMS OPPS RATE,439.92,Pays at 72% of billed charges with lesser of charges applied,439.92,Pays at 72% of billed charges with lesser of charges applied,439.92,Pays at 72% of billed charges with lesser of charges applied,439.92,Pays at 72% of billed charges with lesser of charges applied,439.92,Pays at 72% of billed charges with lesser of charges applied,439.92,Pays at 72% of billed charges with lesser of charges applied,168.71,442% of BCBS Fee Schedule,168.71,442% of BCBS Fee Schedule,168.71,442% of BCBS Fee Schedule,168.71,442% of BCBS Fee Schedule,168.71,442% of BCBS Fee Schedule,168.71,442% of BCBS Fee Schedule,168.71,442% of BCBS Fee Schedule,168.71,442% of BCBS Fee Schedule,168.71,442% of BCBS Fee Schedule,200.22,100% of BCBS Fee Schedule,200.22,100% of BCBS Fee Schedule,200.22,100% of BCBS Fee Schedule,200.22,100% of BCBS Fee Schedule,200.22,100% of BCBS Fee Schedule,513.24,84% of total billed charges,513.24,84% of total billed charges,513.24,84% of total billed charges,427.7,70% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,57.69,100% of CA Medicaid Fee Schedule with lesser of charges applied,57.69,100% of CA Medicaid Fee Schedule with lesser of charges applied,57.69,100% of CA Medicaid Fee Schedule with lesser of charges applied,57.69,100% of CA Medicaid Fee Schedule with lesser of charges applied,57.69,100% of CA Medicaid Fee Schedule with lesser of charges applied,57.69,100% of CA Medicaid Fee Schedule with lesser of charges applied,57.69,100% of CA Medicaid Fee Schedule with lesser of charges applied,57.69,100% of CA Medicaid Fee Schedule with lesser of charges applied,57.69,100% of CA Medicaid Fee Schedule with lesser of charges applied,57.69,100% of CA Medicaid Fee Schedule with lesser of charges applied,57.69,100% of CA Medicaid Fee Schedule with lesser of charges applied,57.69,100% of CA Medicaid Fee Schedule with lesser of charges applied,57.69,100% of CA Medicaid Fee Schedule with lesser of charges applied,57.69,100% of CA Medicaid Fee Schedule with lesser of charges applied,57.69,100% of CA Medicaid Fee Schedule with lesser of charges applied,57.69,100% of CA Medicaid Fee Schedule with lesser of charges applied,57.69,100% of CA Medicaid Fee Schedule with lesser of charges applied,57.69,100% of CA Medicaid Fee Schedule with lesser of charges applied,57.69,100% of CA Medicaid Fee Schedule with lesser of charges applied,57.69,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.22,513.24,458.25
Outpatient Medical Services,RADIOLOGY,75989,RAD GUIDE PERC DRAIN W/CATH PLACE RAD S&I,320,928.5,668.52,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,588.39,442% of BCBS Fee Schedule,N/A,Not Separately reimbursable,706.44,100% of BCBS Fee Schedule,N/A,Not Separately reimbursable,779.94,84% of total billed charges,779.94,84% of total billed charges,668.52,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,557.1,60% of total billed charges,149.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,149.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,69.08,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,649.95,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,668.52,Pays at 72% of billed charges with lesser of charges applied,668.52,Pays at 72% of billed charges with lesser of charges applied,668.52,Pays at 72% of billed charges with lesser of charges applied,668.52,Pays at 72% of billed charges with lesser of charges applied,668.52,Pays at 72% of billed charges with lesser of charges applied,668.52,Pays at 72% of billed charges with lesser of charges applied,588.39,442% of BCBS Fee Schedule,588.39,442% of BCBS Fee Schedule,588.39,442% of BCBS Fee Schedule,588.39,442% of BCBS Fee Schedule,588.39,442% of BCBS Fee Schedule,588.39,442% of BCBS Fee Schedule,588.39,442% of BCBS Fee Schedule,588.39,442% of BCBS Fee Schedule,588.39,442% of BCBS Fee Schedule,706.44,100% of BCBS Fee Schedule,706.44,100% of BCBS Fee Schedule,706.44,100% of BCBS Fee Schedule,706.44,100% of BCBS Fee Schedule,706.44,100% of BCBS Fee Schedule,779.94,84% of total billed charges,779.94,84% of total billed charges,779.94,84% of total billed charges,649.95,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,149.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,149.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,149.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,149.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,149.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,149.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,149.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,149.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,149.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,149.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,149.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,149.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,149.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,149.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,149.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,149.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,149.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,149.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,149.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,149.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,69.08,779.94,696.38
Outpatient Medical Services,RADIOLOGY,19081,BIOPSY STEREOTACTIC BREAST-VAC w/CLIP-LT,320,3348.75,2411.1,Pays at 72% of billed charges with lesser of charges applied,1906.04,100% OF CMS OPPS Rate,3348.75,100% of ASC Tier Grouping Fee Schedule,1906.04,100% OF CMS OPPS Rate,2648.86,79.1% of total billed charges,1906.04,100% OF CMS OPPS Rate,2812.95,84% of total billed charges,2812.95,84% of total billed charges,2411.1,72% of total billed charges,1906.04,100% OF CMS OPPS Rate,1906.04,100% of CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,2009.25,60% of total billed charges,906.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,906.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,168.99,100% OF CMS OPPS RATE,1906.04,100% OF CMS OPPS Rate,2344.13,70% of total billed charges,1906.04,100% OF CMS OPPS Rate,2287.25,120% of CMS OPPS RATE,2411.1,Pays at 72% of billed charges with lesser of charges applied,2411.1,Pays at 72% of billed charges with lesser of charges applied,2411.1,Pays at 72% of billed charges with lesser of charges applied,2411.1,Pays at 72% of billed charges with lesser of charges applied,2411.1,Pays at 72% of billed charges with lesser of charges applied,2411.1,Pays at 72% of billed charges with lesser of charges applied,3348.75,100% of ASC Tier Grouping Fee Schedule,3348.75,100% of ASC Tier Grouping Fee Schedule,3348.75,100% of ASC Tier Grouping Fee Schedule,3348.75,100% of ASC Tier Grouping Fee Schedule,3348.75,100% of ASC Tier Grouping Fee Schedule,3348.75,100% of ASC Tier Grouping Fee Schedule,3348.75,100% of ASC Tier Grouping Fee Schedule,3348.75,100% of ASC Tier Grouping Fee Schedule,3348.75,100% of ASC Tier Grouping Fee Schedule,2648.86,79.1% of total billed charges,2648.86,79.1% of total billed charges,2648.86,79.1% of total billed charges,2648.86,79.1% of total billed charges,2648.86,79.1% of total billed charges,2812.95,84% of total billed charges,2812.95,84% of total billed charges,2812.95,84% of total billed charges,2344.13,70% of total billed charges,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,906.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,906.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,906.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,906.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,906.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,906.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,906.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,906.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,906.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,906.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,906.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,906.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,906.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,906.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,906.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,906.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,906.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,906.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,906.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,906.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,168.99,3348.75,2511.56
Outpatient Medical Services,RADIOLOGY,75984,CHANGE PERQ TUBE/DRAIN CATHETHER RAD S&I,320,928.5,668.52,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,367.04,442% of BCBS Fee Schedule,N/A,Not Separately reimbursable,437.54,100% of BCBS Fee Schedule,N/A,Not Separately reimbursable,779.94,84% of total billed charges,779.94,84% of total billed charges,668.52,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,557.1,60% of total billed charges,97.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,70.27,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,649.95,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,668.52,Pays at 72% of billed charges with lesser of charges applied,668.52,Pays at 72% of billed charges with lesser of charges applied,668.52,Pays at 72% of billed charges with lesser of charges applied,668.52,Pays at 72% of billed charges with lesser of charges applied,668.52,Pays at 72% of billed charges with lesser of charges applied,668.52,Pays at 72% of billed charges with lesser of charges applied,367.04,442% of BCBS Fee Schedule,367.04,442% of BCBS Fee Schedule,367.04,442% of BCBS Fee Schedule,367.04,442% of BCBS Fee Schedule,367.04,442% of BCBS Fee Schedule,367.04,442% of BCBS Fee Schedule,367.04,442% of BCBS Fee Schedule,367.04,442% of BCBS Fee Schedule,367.04,442% of BCBS Fee Schedule,437.54,100% of BCBS Fee Schedule,437.54,100% of BCBS Fee Schedule,437.54,100% of BCBS Fee Schedule,437.54,100% of BCBS Fee Schedule,437.54,100% of BCBS Fee Schedule,779.94,84% of total billed charges,779.94,84% of total billed charges,779.94,84% of total billed charges,649.95,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,97.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,70.27,779.94,696.38
Outpatient Medical Services,RADIOLOGY,77053,MG DUCTOGRAM OR GALACTOGRAM (SINGLE)-LT,320,467,336.24,Pays at 72% of billed charges with lesser of charges applied,296.82,100% OF CMS OPPS Rate,467,BCBS Fee Schedule,296.82,100% OF CMS OPPS Rate,126.66,100% of BCBS Fee Schedule,296.82,100% OF CMS OPPS Rate,392.28,84% of total billed charges,392.28,84% of total billed charges,336.24,72% of total billed charges,296.82,100% OF CMS OPPS Rate,296.82,100% of CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,280.2,60% of total billed charges,70.74,100% of CA Medicaid Fee Schedule with lesser of charges applied,70.74,100% of CA Medicaid Fee Schedule with lesser of charges applied,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,43.19,100% OF CMS OPPS RATE,296.82,100% OF CMS OPPS Rate,326.9,70% of total billed charges,296.82,100% OF CMS OPPS Rate,356.18,120% of CMS OPPS RATE,336.24,Pays at 72% of billed charges with lesser of charges applied,336.24,Pays at 72% of billed charges with lesser of charges applied,336.24,Pays at 72% of billed charges with lesser of charges applied,336.24,Pays at 72% of billed charges with lesser of charges applied,336.24,Pays at 72% of billed charges with lesser of charges applied,336.24,Pays at 72% of billed charges with lesser of charges applied,467,BCBS Fee Schedule,467,BCBS Fee Schedule,467,BCBS Fee Schedule,467,BCBS Fee Schedule,467,BCBS Fee Schedule,467,BCBS Fee Schedule,467,BCBS Fee Schedule,467,BCBS Fee Schedule,467,BCBS Fee Schedule,126.66,100% of BCBS Fee Schedule,126.66,100% of BCBS Fee Schedule,126.66,100% of BCBS Fee Schedule,126.66,100% of BCBS Fee Schedule,126.66,100% of BCBS Fee Schedule,392.28,84% of total billed charges,392.28,84% of total billed charges,392.28,84% of total billed charges,326.9,70% of total billed charges,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,70.74,100% of CA Medicaid Fee Schedule with lesser of charges applied,70.74,100% of CA Medicaid Fee Schedule with lesser of charges applied,70.74,100% of CA Medicaid Fee Schedule with lesser of charges applied,70.74,100% of CA Medicaid Fee Schedule with lesser of charges applied,70.74,100% of CA Medicaid Fee Schedule with lesser of charges applied,70.74,100% of CA Medicaid Fee Schedule with lesser of charges applied,70.74,100% of CA Medicaid Fee Schedule with lesser of charges applied,70.74,100% of CA Medicaid Fee Schedule with lesser of charges applied,70.74,100% of CA Medicaid Fee Schedule with lesser of charges applied,70.74,100% of CA Medicaid Fee Schedule with lesser of charges applied,70.74,100% of CA Medicaid Fee Schedule with lesser of charges applied,70.74,100% of CA Medicaid Fee Schedule with lesser of charges applied,70.74,100% of CA Medicaid Fee Schedule with lesser of charges applied,70.74,100% of CA Medicaid Fee Schedule with lesser of charges applied,70.74,100% of CA Medicaid Fee Schedule with lesser of charges applied,70.74,100% of CA Medicaid Fee Schedule with lesser of charges applied,70.74,100% of CA Medicaid Fee Schedule with lesser of charges applied,70.74,100% of CA Medicaid Fee Schedule with lesser of charges applied,70.74,100% of CA Medicaid Fee Schedule with lesser of charges applied,70.74,100% of CA Medicaid Fee Schedule with lesser of charges applied,43.19,467.00,350.25
Outpatient Medical Services,RADIOLOGY,77054,DUCTOGRAM OR GALACTOGRAM (MULTIPLE)-LT,320,520,374.4,Pays at 72% of billed charges with lesser of charges applied,296.82,100% OF CMS OPPS Rate,520,BCBS Fee Schedule,296.82,100% OF CMS OPPS Rate,336.08,100% of BCBS Fee Schedule,296.82,100% OF CMS OPPS Rate,436.8,84% of total billed charges,436.8,84% of total billed charges,374.4,72% of total billed charges,296.82,100% OF CMS OPPS Rate,296.82,100% of CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,312,60% of total billed charges,91.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,91.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,57.13,100% OF CMS OPPS RATE,296.82,100% OF CMS OPPS Rate,364,70% of total billed charges,296.82,100% OF CMS OPPS Rate,356.18,120% of CMS OPPS RATE,374.4,Pays at 72% of billed charges with lesser of charges applied,374.4,Pays at 72% of billed charges with lesser of charges applied,374.4,Pays at 72% of billed charges with lesser of charges applied,374.4,Pays at 72% of billed charges with lesser of charges applied,374.4,Pays at 72% of billed charges with lesser of charges applied,374.4,Pays at 72% of billed charges with lesser of charges applied,520,BCBS Fee Schedule,520,BCBS Fee Schedule,520,BCBS Fee Schedule,520,BCBS Fee Schedule,520,BCBS Fee Schedule,520,BCBS Fee Schedule,520,BCBS Fee Schedule,520,BCBS Fee Schedule,520,BCBS Fee Schedule,336.08,100% of BCBS Fee Schedule,336.08,100% of BCBS Fee Schedule,336.08,100% of BCBS Fee Schedule,336.08,100% of BCBS Fee Schedule,336.08,100% of BCBS Fee Schedule,436.8,84% of total billed charges,436.8,84% of total billed charges,436.8,84% of total billed charges,364,70% of total billed charges,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,91.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,91.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,91.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,91.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,91.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,91.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,91.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,91.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,91.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,91.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,91.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,91.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,91.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,91.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,91.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,91.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,91.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,91.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,91.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,91.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,57.13,520.00,390
Outpatient Medical Services,RADIOLOGY,80307,Testing for presence of drug,320,595.88,429.03,Pays at 72% of billed charges with lesser of charges applied,62.14,100% OF CMS OPPS Rate,404.56,442% of BCBS Fee Schedule,62.14,100% OF CMS OPPS Rate,89.64,112.32% OF BCBS FEE SCHEDULE,62.14,100% OF CMS OPPS Rate,500.54,84% of total billed charges,500.54,84% of total billed charges,429.03,72% of total billed charges,62.14,100% OF CMS OPPS Rate,62.14,100% of CMS OPPS Rate,62.14,100% OF CMS OPPS Rate,357.53,60% of total billed charges,74.19,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.19,100% of CA Medicaid Fee Schedule with lesser of charges applied,62.14,100% OF CMS OPPS Rate,62.14,100% OF CMS OPPS Rate,N/A,Not Separately reimbursable,62.14,100% OF CMS OPPS Rate,417.12,70% of total billed charges,62.14,100% OF CMS OPPS Rate,74.56,120% of CMS OPPS RATE,429.03,Pays at 72% of billed charges with lesser of charges applied,429.03,Pays at 72% of billed charges with lesser of charges applied,429.03,Pays at 72% of billed charges with lesser of charges applied,429.03,Pays at 72% of billed charges with lesser of charges applied,429.03,Pays at 72% of billed charges with lesser of charges applied,429.03,Pays at 72% of billed charges with lesser of charges applied,404.56,442% of BCBS Fee Schedule,404.56,442% of BCBS Fee Schedule,404.56,442% of BCBS Fee Schedule,404.56,442% of BCBS Fee Schedule,404.56,442% of BCBS Fee Schedule,404.56,442% of BCBS Fee Schedule,404.56,442% of BCBS Fee Schedule,404.56,442% of BCBS Fee Schedule,404.56,442% of BCBS Fee Schedule,89.64,112.32% OF BCBS FEE SCHEDULE,89.64,112.32% OF BCBS FEE SCHEDULE,89.64,112.32% OF BCBS FEE SCHEDULE,89.64,112.32% OF BCBS FEE SCHEDULE,89.64,112.32% OF BCBS FEE SCHEDULE,500.54,84% of total billed charges,500.54,84% of total billed charges,500.54,84% of total billed charges,417.12,70% of total billed charges,62.14,100% OF CMS OPPS Rate,62.14,100% OF CMS OPPS Rate,62.14,100% OF CMS OPPS Rate,62.14,100% OF CMS OPPS Rate,62.14,100% OF CMS OPPS Rate,62.14,100% OF CMS OPPS Rate,62.14,100% OF CMS OPPS Rate,62.14,100% OF CMS OPPS Rate,62.14,100% OF CMS OPPS Rate,62.14,100% OF CMS OPPS Rate,62.14,100% OF CMS OPPS Rate,62.14,100% OF CMS OPPS Rate,62.14,100% OF CMS OPPS Rate,62.14,100% OF CMS OPPS Rate,62.14,100% OF CMS OPPS Rate,62.14,100% OF CMS OPPS Rate,74.19,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.19,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.19,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.19,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.19,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.19,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.19,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.19,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.19,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.19,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.19,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.19,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.19,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.19,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.19,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.19,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.19,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.19,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.19,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.19,100% of CA Medicaid Fee Schedule with lesser of charges applied,62.14,500.54,446.91
Outpatient Medical Services,RADIOLOGY,73120,X-ray of the hand with 2 views,320,259.75,187.02,Pays at 72% of billed charges with lesser of charges applied,135.85,100% OF CMS OPPS Rate,92.64,442% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,108.23,100% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,218.19,84% of total billed charges,218.19,84% of total billed charges,187.02,72% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% of CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,155.85,60% of total billed charges,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,27.67,100% OF CMS OPPS RATE,135.85,100% OF CMS OPPS Rate,181.83,70% of total billed charges,135.85,100% OF CMS OPPS Rate,163.02,120% of CMS OPPS RATE,187.02,Pays at 72% of billed charges with lesser of charges applied,187.02,Pays at 72% of billed charges with lesser of charges applied,187.02,Pays at 72% of billed charges with lesser of charges applied,187.02,Pays at 72% of billed charges with lesser of charges applied,187.02,Pays at 72% of billed charges with lesser of charges applied,187.02,Pays at 72% of billed charges with lesser of charges applied,92.64,442% of BCBS Fee Schedule,92.64,442% of BCBS Fee Schedule,92.64,442% of BCBS Fee Schedule,92.64,442% of BCBS Fee Schedule,92.64,442% of BCBS Fee Schedule,92.64,442% of BCBS Fee Schedule,92.64,442% of BCBS Fee Schedule,92.64,442% of BCBS Fee Schedule,92.64,442% of BCBS Fee Schedule,108.23,100% of BCBS Fee Schedule,108.23,100% of BCBS Fee Schedule,108.23,100% of BCBS Fee Schedule,108.23,100% of BCBS Fee Schedule,108.23,100% of BCBS Fee Schedule,218.19,84% of total billed charges,218.19,84% of total billed charges,218.19,84% of total billed charges,181.83,70% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,218.19,194.81
Outpatient Medical Services,RADIOLOGY,74340,INTRO LONG GI TUBE W/FLUOR &MX FILMS,320,229.5,165.24,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,229.5,BCBS Fee Schedule,N/A,Not Separately reimbursable,225.14,pays at 100% of bcbs fee schedule with lesser of charges applied,N/A,Not Separately reimbursable,192.78,84% of total billed charges,192.78,84% of total billed charges,165.24,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,137.7,60% of total billed charges,90.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,90.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,160.65,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,165.24,Pays at 72% of billed charges with lesser of charges applied,165.24,Pays at 72% of billed charges with lesser of charges applied,165.24,Pays at 72% of billed charges with lesser of charges applied,165.24,Pays at 72% of billed charges with lesser of charges applied,165.24,Pays at 72% of billed charges with lesser of charges applied,165.24,Pays at 72% of billed charges with lesser of charges applied,229.5,BCBS Fee Schedule,229.5,BCBS Fee Schedule,229.5,BCBS Fee Schedule,229.5,BCBS Fee Schedule,229.5,BCBS Fee Schedule,229.5,BCBS Fee Schedule,229.5,BCBS Fee Schedule,229.5,BCBS Fee Schedule,229.5,BCBS Fee Schedule,225.14,pays at 100% of bcbs fee schedule with lesser of charges applied,225.14,pays at 100% of bcbs fee schedule with lesser of charges applied,225.14,pays at 100% of bcbs fee schedule with lesser of charges applied,225.14,pays at 100% of bcbs fee schedule with lesser of charges applied,225.14,pays at 100% of bcbs fee schedule with lesser of charges applied,192.78,84% of total billed charges,192.78,84% of total billed charges,192.78,84% of total billed charges,160.65,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,90.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,90.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,90.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,90.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,90.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,90.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,90.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,90.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,90.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,90.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,90.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,90.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,90.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,90.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,90.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,90.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,90.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,90.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,90.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,90.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,90.63,229.50,172.13
Outpatient Medical Services,RADIOLOGY,74249,UGI AIR W SMALL BOWEL FOLLOW THROUGH,320,1699,1223.28,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,483.68,442% of BCBS Fee Schedule,N/A,Not Separately reimbursable,1343.91,79.1% of total billed charges,N/A,Not Separately reimbursable,1427.16,84% of total billed charges,1427.16,84% of total billed charges,1223.28,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,1019.4,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,1189.3,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,1223.28,Pays at 72% of billed charges with lesser of charges applied,1223.28,Pays at 72% of billed charges with lesser of charges applied,1223.28,Pays at 72% of billed charges with lesser of charges applied,1223.28,Pays at 72% of billed charges with lesser of charges applied,1223.28,Pays at 72% of billed charges with lesser of charges applied,1223.28,Pays at 72% of billed charges with lesser of charges applied,483.68,442% of BCBS Fee Schedule,483.68,442% of BCBS Fee Schedule,483.68,442% of BCBS Fee Schedule,483.68,442% of BCBS Fee Schedule,483.68,442% of BCBS Fee Schedule,483.68,442% of BCBS Fee Schedule,483.68,442% of BCBS Fee Schedule,483.68,442% of BCBS Fee Schedule,483.68,442% of BCBS Fee Schedule,1343.91,79.1% of total billed charges,1343.91,79.1% of total billed charges,1343.91,79.1% of total billed charges,1343.91,79.1% of total billed charges,1343.91,79.1% of total billed charges,1427.16,84% of total billed charges,1427.16,84% of total billed charges,1427.16,84% of total billed charges,1189.3,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,483.68,1427.16,1274.25
Outpatient Medical Services,RADIOLOGY,74410,UROGRAPHY INFUSION DRIP AND/OR BOLUS,320,772,555.84,Pays at 72% of billed charges with lesser of charges applied,229.22,100% OF CMS OPPS Rate,365.27,442% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,437.54,100% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,648.48,84% of total billed charges,648.48,84% of total billed charges,555.84,72% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% of CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,463.2,60% of total billed charges,124.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,124.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,141.74,100% OF CMS OPPS RATE,229.22,100% OF CMS OPPS Rate,540.4,70% of total billed charges,229.22,100% OF CMS OPPS Rate,275.06,120% of CMS OPPS RATE,555.84,Pays at 72% of billed charges with lesser of charges applied,555.84,Pays at 72% of billed charges with lesser of charges applied,555.84,Pays at 72% of billed charges with lesser of charges applied,555.84,Pays at 72% of billed charges with lesser of charges applied,555.84,Pays at 72% of billed charges with lesser of charges applied,555.84,Pays at 72% of billed charges with lesser of charges applied,365.27,442% of BCBS Fee Schedule,365.27,442% of BCBS Fee Schedule,365.27,442% of BCBS Fee Schedule,365.27,442% of BCBS Fee Schedule,365.27,442% of BCBS Fee Schedule,365.27,442% of BCBS Fee Schedule,365.27,442% of BCBS Fee Schedule,365.27,442% of BCBS Fee Schedule,365.27,442% of BCBS Fee Schedule,437.54,100% of BCBS Fee Schedule,437.54,100% of BCBS Fee Schedule,437.54,100% of BCBS Fee Schedule,437.54,100% of BCBS Fee Schedule,437.54,100% of BCBS Fee Schedule,648.48,84% of total billed charges,648.48,84% of total billed charges,648.48,84% of total billed charges,540.4,70% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,124.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,124.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,124.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,124.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,124.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,124.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,124.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,124.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,124.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,124.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,124.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,124.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,124.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,124.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,124.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,124.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,124.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,124.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,124.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,124.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,124.10,648.48,579
Outpatient Medical Services,RADIOLOGY,74250,"SMALL BOWEL SERIES (LTD, 1-3 VIEWS)",320,461,331.92,Pays at 72% of billed charges with lesser of charges applied,229.22,100% OF CMS OPPS Rate,244.78,442% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,291.9,100% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,387.24,84% of total billed charges,387.24,84% of total billed charges,331.92,72% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% of CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,276.6,60% of total billed charges,135.72,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.72,100% of CA Medicaid Fee Schedule with lesser of charges applied,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,102.52,100% OF CMS OPPS RATE,229.22,100% OF CMS OPPS Rate,322.7,70% of total billed charges,229.22,100% OF CMS OPPS Rate,275.07,120% of CMS OPPS RATE,331.92,Pays at 72% of billed charges with lesser of charges applied,331.92,Pays at 72% of billed charges with lesser of charges applied,331.92,Pays at 72% of billed charges with lesser of charges applied,331.92,Pays at 72% of billed charges with lesser of charges applied,331.92,Pays at 72% of billed charges with lesser of charges applied,331.92,Pays at 72% of billed charges with lesser of charges applied,244.78,442% of BCBS Fee Schedule,244.78,442% of BCBS Fee Schedule,244.78,442% of BCBS Fee Schedule,244.78,442% of BCBS Fee Schedule,244.78,442% of BCBS Fee Schedule,244.78,442% of BCBS Fee Schedule,244.78,442% of BCBS Fee Schedule,244.78,442% of BCBS Fee Schedule,244.78,442% of BCBS Fee Schedule,291.9,100% of BCBS Fee Schedule,291.9,100% of BCBS Fee Schedule,291.9,100% of BCBS Fee Schedule,291.9,100% of BCBS Fee Schedule,291.9,100% of BCBS Fee Schedule,387.24,84% of total billed charges,387.24,84% of total billed charges,387.24,84% of total billed charges,322.7,70% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,135.72,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.72,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.72,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.72,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.72,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.72,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.72,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.72,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.72,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.72,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.72,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.72,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.72,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.72,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.72,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.72,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.72,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.72,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.72,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.72,100% of CA Medicaid Fee Schedule with lesser of charges applied,102.52,387.24,345.75
Outpatient Medical Services,RADIOLOGY,74018,XR ABDOMEN SINGLE AP VIEW-PORTABLE,320,283.25,203.94,Pays at 72% of billed charges with lesser of charges applied,110.43,100% OF CMS OPPS Rate,129.29,442% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,108.84,100% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,237.93,84% of total billed charges,237.93,84% of total billed charges,203.94,72% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% of CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,169.95,60% of total billed charges,35.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,25.28,100% OF CMS OPPS RATE,110.43,100% OF CMS OPPS Rate,198.28,70% of total billed charges,110.43,100% OF CMS OPPS Rate,132.51,120% of CMS OPPS RATE,203.94,Pays at 72% of billed charges with lesser of charges applied,203.94,Pays at 72% of billed charges with lesser of charges applied,203.94,Pays at 72% of billed charges with lesser of charges applied,203.94,Pays at 72% of billed charges with lesser of charges applied,203.94,Pays at 72% of billed charges with lesser of charges applied,203.94,Pays at 72% of billed charges with lesser of charges applied,129.29,442% of BCBS Fee Schedule,129.29,442% of BCBS Fee Schedule,129.29,442% of BCBS Fee Schedule,129.29,442% of BCBS Fee Schedule,129.29,442% of BCBS Fee Schedule,129.29,442% of BCBS Fee Schedule,129.29,442% of BCBS Fee Schedule,129.29,442% of BCBS Fee Schedule,129.29,442% of BCBS Fee Schedule,108.84,100% of BCBS Fee Schedule,108.84,100% of BCBS Fee Schedule,108.84,100% of BCBS Fee Schedule,108.84,100% of BCBS Fee Schedule,108.84,100% of BCBS Fee Schedule,237.93,84% of total billed charges,237.93,84% of total billed charges,237.93,84% of total billed charges,198.28,70% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,35.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,25.28,237.93,212.44
Outpatient Medical Services,RADIOLOGY,76098,RADIOLOGIC EXAM BREAST SURG SPEC,320,225,162,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,79.87,442% of BCBS Fee Schedule,N/A,Not Separately reimbursable,91.06,100% of BCBS Fee Schedule,N/A,Not Separately reimbursable,189,84% of total billed charges,189,84% of total billed charges,162,72% of total billed charges,N/A,Not Separately reimbursable,225,100% of CMS OPPS Rate,N/A,Not Separately reimbursable,135,60% of total billed charges,20.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,32.05,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,157.5,70% of total billed charges,225,100% OF CMS OPPS Rate,225,120% of CMS OPPS RATE,162,Pays at 72% of billed charges with lesser of charges applied,162,Pays at 72% of billed charges with lesser of charges applied,162,Pays at 72% of billed charges with lesser of charges applied,162,Pays at 72% of billed charges with lesser of charges applied,162,Pays at 72% of billed charges with lesser of charges applied,162,Pays at 72% of billed charges with lesser of charges applied,79.87,442% of BCBS Fee Schedule,79.87,442% of BCBS Fee Schedule,79.87,442% of BCBS Fee Schedule,79.87,442% of BCBS Fee Schedule,79.87,442% of BCBS Fee Schedule,79.87,442% of BCBS Fee Schedule,79.87,442% of BCBS Fee Schedule,79.87,442% of BCBS Fee Schedule,79.87,442% of BCBS Fee Schedule,91.06,100% of BCBS Fee Schedule,91.06,100% of BCBS Fee Schedule,91.06,100% of BCBS Fee Schedule,91.06,100% of BCBS Fee Schedule,91.06,100% of BCBS Fee Schedule,189,84% of total billed charges,189,84% of total billed charges,189,84% of total billed charges,157.5,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,20.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.77,225.00,168.75
Outpatient Medical Services,RADIOLOGY,72040,"Radiologic examination of the neck/spine, 2-3 views",320,355.75,256.14,Pays at 72% of billed charges with lesser of charges applied,110.43,100% OF CMS OPPS Rate,113.06,442% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,134.91,100% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,298.83,84% of total billed charges,298.83,84% of total billed charges,256.14,72% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% of CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,213.45,60% of total billed charges,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,34.43,100% OF CMS OPPS RATE,110.43,100% OF CMS OPPS Rate,249.03,70% of total billed charges,110.43,100% OF CMS OPPS Rate,132.51,120% of CMS OPPS RATE,256.14,Pays at 72% of billed charges with lesser of charges applied,256.14,Pays at 72% of billed charges with lesser of charges applied,256.14,Pays at 72% of billed charges with lesser of charges applied,256.14,Pays at 72% of billed charges with lesser of charges applied,256.14,Pays at 72% of billed charges with lesser of charges applied,256.14,Pays at 72% of billed charges with lesser of charges applied,113.06,442% of BCBS Fee Schedule,113.06,442% of BCBS Fee Schedule,113.06,442% of BCBS Fee Schedule,113.06,442% of BCBS Fee Schedule,113.06,442% of BCBS Fee Schedule,113.06,442% of BCBS Fee Schedule,113.06,442% of BCBS Fee Schedule,113.06,442% of BCBS Fee Schedule,113.06,442% of BCBS Fee Schedule,134.91,100% of BCBS Fee Schedule,134.91,100% of BCBS Fee Schedule,134.91,100% of BCBS Fee Schedule,134.91,100% of BCBS Fee Schedule,134.91,100% of BCBS Fee Schedule,298.83,84% of total billed charges,298.83,84% of total billed charges,298.83,84% of total billed charges,249.03,70% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,34.43,298.83,266.81
Outpatient Medical Services,RADIOLOGY,74485,DILATION OF NEPHROSTOMY W FLUORO,320,882.75,635.58,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,591.53,442% of BCBS Fee Schedule,N/A,Not Separately reimbursable,706.44,100% of BCBS Fee Schedule,N/A,Not Separately reimbursable,741.51,84% of total billed charges,741.51,84% of total billed charges,635.58,72% of total billed charges,N/A,Not Separately reimbursable,882.75,100% of CMS OPPS Rate,N/A,Not Separately reimbursable,529.65,60% of total billed charges,119.07,100% of CA Medicaid Fee Schedule with lesser of charges applied,119.07,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,96.15,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,617.93,70% of total billed charges,882.75,100% OF CMS OPPS Rate,882.75,120% of CMS OPPS RATE,635.58,Pays at 72% of billed charges with lesser of charges applied,635.58,Pays at 72% of billed charges with lesser of charges applied,635.58,Pays at 72% of billed charges with lesser of charges applied,635.58,Pays at 72% of billed charges with lesser of charges applied,635.58,Pays at 72% of billed charges with lesser of charges applied,635.58,Pays at 72% of billed charges with lesser of charges applied,591.53,442% of BCBS Fee Schedule,591.53,442% of BCBS Fee Schedule,591.53,442% of BCBS Fee Schedule,591.53,442% of BCBS Fee Schedule,591.53,442% of BCBS Fee Schedule,591.53,442% of BCBS Fee Schedule,591.53,442% of BCBS Fee Schedule,591.53,442% of BCBS Fee Schedule,591.53,442% of BCBS Fee Schedule,706.44,100% of BCBS Fee Schedule,706.44,100% of BCBS Fee Schedule,706.44,100% of BCBS Fee Schedule,706.44,100% of BCBS Fee Schedule,706.44,100% of BCBS Fee Schedule,741.51,84% of total billed charges,741.51,84% of total billed charges,741.51,84% of total billed charges,617.93,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,119.07,100% of CA Medicaid Fee Schedule with lesser of charges applied,119.07,100% of CA Medicaid Fee Schedule with lesser of charges applied,119.07,100% of CA Medicaid Fee Schedule with lesser of charges applied,119.07,100% of CA Medicaid Fee Schedule with lesser of charges applied,119.07,100% of CA Medicaid Fee Schedule with lesser of charges applied,119.07,100% of CA Medicaid Fee Schedule with lesser of charges applied,119.07,100% of CA Medicaid Fee Schedule with lesser of charges applied,119.07,100% of CA Medicaid Fee Schedule with lesser of charges applied,119.07,100% of CA Medicaid Fee Schedule with lesser of charges applied,119.07,100% of CA Medicaid Fee Schedule with lesser of charges applied,119.07,100% of CA Medicaid Fee Schedule with lesser of charges applied,119.07,100% of CA Medicaid Fee Schedule with lesser of charges applied,119.07,100% of CA Medicaid Fee Schedule with lesser of charges applied,119.07,100% of CA Medicaid Fee Schedule with lesser of charges applied,119.07,100% of CA Medicaid Fee Schedule with lesser of charges applied,119.07,100% of CA Medicaid Fee Schedule with lesser of charges applied,119.07,100% of CA Medicaid Fee Schedule with lesser of charges applied,119.07,100% of CA Medicaid Fee Schedule with lesser of charges applied,119.07,100% of CA Medicaid Fee Schedule with lesser of charges applied,119.07,100% of CA Medicaid Fee Schedule with lesser of charges applied,96.15,882.75,662.06
Outpatient Medical Services,RADIOLOGY,73564,Radiologic examination of the knee with 4 or more views,320,353.5,254.52,Pays at 72% of billed charges with lesser of charges applied,135.85,100% OF CMS OPPS Rate,116.78,442% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,139.21,100% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,296.94,84% of total billed charges,296.94,84% of total billed charges,254.52,72% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% of CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,212.1,60% of total billed charges,39.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,42.4,100% OF CMS OPPS RATE,135.85,100% OF CMS OPPS Rate,247.45,70% of total billed charges,135.85,100% OF CMS OPPS Rate,163.02,120% of CMS OPPS RATE,254.52,Pays at 72% of billed charges with lesser of charges applied,254.52,Pays at 72% of billed charges with lesser of charges applied,254.52,Pays at 72% of billed charges with lesser of charges applied,254.52,Pays at 72% of billed charges with lesser of charges applied,254.52,Pays at 72% of billed charges with lesser of charges applied,254.52,Pays at 72% of billed charges with lesser of charges applied,116.78,442% of BCBS Fee Schedule,116.78,442% of BCBS Fee Schedule,116.78,442% of BCBS Fee Schedule,116.78,442% of BCBS Fee Schedule,116.78,442% of BCBS Fee Schedule,116.78,442% of BCBS Fee Schedule,116.78,442% of BCBS Fee Schedule,116.78,442% of BCBS Fee Schedule,116.78,442% of BCBS Fee Schedule,139.21,100% of BCBS Fee Schedule,139.21,100% of BCBS Fee Schedule,139.21,100% of BCBS Fee Schedule,139.21,100% of BCBS Fee Schedule,139.21,100% of BCBS Fee Schedule,296.94,84% of total billed charges,296.94,84% of total billed charges,296.94,84% of total billed charges,247.45,70% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,39.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.73,296.94,265.13
Outpatient Medical Services,RADIOLOGY,47532,FL CHOLANGIOGRAM-INTRAOPERATIVE,320,654,470.88,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,654,100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,517.31,79.1% of total billed charges,N/A,Not Separately reimbursable,549.36,84% of total billed charges,549.36,84% of total billed charges,470.88,72% of total billed charges,N/A,Not Separately reimbursable,654,100% of CMS OPPS Rate,N/A,Not Separately reimbursable,392.4,60% of total billed charges,1074.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,1074.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,214.85,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,457.8,70% of total billed charges,654,100% OF CMS OPPS Rate,654,120% of CMS OPPS RATE,470.88,Pays at 72% of billed charges with lesser of charges applied,470.88,Pays at 72% of billed charges with lesser of charges applied,470.88,Pays at 72% of billed charges with lesser of charges applied,470.88,Pays at 72% of billed charges with lesser of charges applied,470.88,Pays at 72% of billed charges with lesser of charges applied,470.88,Pays at 72% of billed charges with lesser of charges applied,654,100% of ASC Tier Grouping Fee Schedule,654,100% of ASC Tier Grouping Fee Schedule,654,100% of ASC Tier Grouping Fee Schedule,654,100% of ASC Tier Grouping Fee Schedule,654,100% of ASC Tier Grouping Fee Schedule,654,100% of ASC Tier Grouping Fee Schedule,654,100% of ASC Tier Grouping Fee Schedule,654,100% of ASC Tier Grouping Fee Schedule,654,100% of ASC Tier Grouping Fee Schedule,517.31,79.1% of total billed charges,517.31,79.1% of total billed charges,517.31,79.1% of total billed charges,517.31,79.1% of total billed charges,517.31,79.1% of total billed charges,549.36,84% of total billed charges,549.36,84% of total billed charges,549.36,84% of total billed charges,457.8,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,1074.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,1074.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,1074.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,1074.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,1074.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,1074.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,1074.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,1074.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,1074.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,1074.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,1074.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,1074.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,1074.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,1074.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,1074.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,1074.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,1074.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,1074.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,1074.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,1074.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,214.85,1074.47,490.5
Outpatient Medical Services,RADIOLOGY,73615,ANKLE ARTHROGRAM S&I BILATERAL,320,911,655.92,Pays at 72% of billed charges with lesser of charges applied,468.3,100% OF CMS OPPS Rate,392.81,442% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,469.12,100% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,765.24,84% of total billed charges,765.24,84% of total billed charges,655.92,72% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% of CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,546.6,60% of total billed charges,108.00,100% of CA Medicaid Fee Schedule with lesser of charges applied,108.00,100% of CA Medicaid Fee Schedule with lesser of charges applied,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,122.83,100% OF CMS OPPS RATE,468.3,100% OF CMS OPPS Rate,637.7,70% of total billed charges,468.3,100% OF CMS OPPS Rate,561.96,120% of CMS OPPS RATE,655.92,Pays at 72% of billed charges with lesser of charges applied,655.92,Pays at 72% of billed charges with lesser of charges applied,655.92,Pays at 72% of billed charges with lesser of charges applied,655.92,Pays at 72% of billed charges with lesser of charges applied,655.92,Pays at 72% of billed charges with lesser of charges applied,655.92,Pays at 72% of billed charges with lesser of charges applied,392.81,442% of BCBS Fee Schedule,392.81,442% of BCBS Fee Schedule,392.81,442% of BCBS Fee Schedule,392.81,442% of BCBS Fee Schedule,392.81,442% of BCBS Fee Schedule,392.81,442% of BCBS Fee Schedule,392.81,442% of BCBS Fee Schedule,392.81,442% of BCBS Fee Schedule,392.81,442% of BCBS Fee Schedule,469.12,100% of BCBS Fee Schedule,469.12,100% of BCBS Fee Schedule,469.12,100% of BCBS Fee Schedule,469.12,100% of BCBS Fee Schedule,469.12,100% of BCBS Fee Schedule,765.24,84% of total billed charges,765.24,84% of total billed charges,765.24,84% of total billed charges,637.7,70% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,108.00,100% of CA Medicaid Fee Schedule with lesser of charges applied,108.00,100% of CA Medicaid Fee Schedule with lesser of charges applied,108.00,100% of CA Medicaid Fee Schedule with lesser of charges applied,108.00,100% of CA Medicaid Fee Schedule with lesser of charges applied,108.00,100% of CA Medicaid Fee Schedule with lesser of charges applied,108.00,100% of CA Medicaid Fee Schedule with lesser of charges applied,108.00,100% of CA Medicaid Fee Schedule with lesser of charges applied,108.00,100% of CA Medicaid Fee Schedule with lesser of charges applied,108.00,100% of CA Medicaid Fee Schedule with lesser of charges applied,108.00,100% of CA Medicaid Fee Schedule with lesser of charges applied,108.00,100% of CA Medicaid Fee Schedule with lesser of charges applied,108.00,100% of CA Medicaid Fee Schedule with lesser of charges applied,108.00,100% of CA Medicaid Fee Schedule with lesser of charges applied,108.00,100% of CA Medicaid Fee Schedule with lesser of charges applied,108.00,100% of CA Medicaid Fee Schedule with lesser of charges applied,108.00,100% of CA Medicaid Fee Schedule with lesser of charges applied,108.00,100% of CA Medicaid Fee Schedule with lesser of charges applied,108.00,100% of CA Medicaid Fee Schedule with lesser of charges applied,108.00,100% of CA Medicaid Fee Schedule with lesser of charges applied,108.00,100% of CA Medicaid Fee Schedule with lesser of charges applied,108.00,765.24,683.25
Outpatient Medical Services,RADIOLOGY,74283,BE THERAPEUTIC-REDUC INTUSLEPT,320,734.25,528.66,Pays at 72% of billed charges with lesser of charges applied,229.22,100% OF CMS OPPS Rate,414.02,442% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,575.21,100% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,616.77,84% of total billed charges,616.77,84% of total billed charges,528.66,72% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% of CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,440.55,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,188.53,100% OF CMS OPPS RATE,229.22,100% OF CMS OPPS Rate,513.98,70% of total billed charges,229.22,100% OF CMS OPPS Rate,275.06,120% of CMS OPPS RATE,528.66,Pays at 72% of billed charges with lesser of charges applied,528.66,Pays at 72% of billed charges with lesser of charges applied,528.66,Pays at 72% of billed charges with lesser of charges applied,528.66,Pays at 72% of billed charges with lesser of charges applied,528.66,Pays at 72% of billed charges with lesser of charges applied,528.66,Pays at 72% of billed charges with lesser of charges applied,414.02,442% of BCBS Fee Schedule,414.02,442% of BCBS Fee Schedule,414.02,442% of BCBS Fee Schedule,414.02,442% of BCBS Fee Schedule,414.02,442% of BCBS Fee Schedule,414.02,442% of BCBS Fee Schedule,414.02,442% of BCBS Fee Schedule,414.02,442% of BCBS Fee Schedule,414.02,442% of BCBS Fee Schedule,575.21,100% of BCBS Fee Schedule,575.21,100% of BCBS Fee Schedule,575.21,100% of BCBS Fee Schedule,575.21,100% of BCBS Fee Schedule,575.21,100% of BCBS Fee Schedule,616.77,84% of total billed charges,616.77,84% of total billed charges,616.77,84% of total billed charges,513.98,70% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,188.53,616.77,550.69
Outpatient Medical Services,RADIOLOGY,73521,HIPS BILA 2V (AP PELVIS/FROGLE,320,350,252,Pays at 72% of billed charges with lesser of charges applied,135.85,100% OF CMS OPPS Rate,214.64,442% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,168.94,100% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,294,84% of total billed charges,294,84% of total billed charges,252,72% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% of CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,210,60% of total billed charges,49.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,36.43,100% OF CMS OPPS RATE,135.85,100% OF CMS OPPS Rate,245,70% of total billed charges,135.85,100% OF CMS OPPS Rate,163.02,120% of CMS OPPS RATE,252,Pays at 72% of billed charges with lesser of charges applied,252,Pays at 72% of billed charges with lesser of charges applied,252,Pays at 72% of billed charges with lesser of charges applied,252,Pays at 72% of billed charges with lesser of charges applied,252,Pays at 72% of billed charges with lesser of charges applied,252,Pays at 72% of billed charges with lesser of charges applied,214.64,442% of BCBS Fee Schedule,214.64,442% of BCBS Fee Schedule,214.64,442% of BCBS Fee Schedule,214.64,442% of BCBS Fee Schedule,214.64,442% of BCBS Fee Schedule,214.64,442% of BCBS Fee Schedule,214.64,442% of BCBS Fee Schedule,214.64,442% of BCBS Fee Schedule,214.64,442% of BCBS Fee Schedule,168.94,100% of BCBS Fee Schedule,168.94,100% of BCBS Fee Schedule,168.94,100% of BCBS Fee Schedule,168.94,100% of BCBS Fee Schedule,168.94,100% of BCBS Fee Schedule,294,84% of total billed charges,294,84% of total billed charges,294,84% of total billed charges,245,70% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,49.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.92,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.43,294.00,262.5
Outpatient Medical Services,RADIOLOGY,73523,HIPS BILAT 2V EACH + AP PELVIS,320,666.25,479.7,Pays at 72% of billed charges with lesser of charges applied,135.84,100% OF CMS OPPS Rate,308.16,442% of BCBS Fee Schedule,135.84,100% OF CMS OPPS Rate,241.91,100% of BCBS Fee Schedule,135.84,100% OF CMS OPPS Rate,559.65,84% of total billed charges,559.65,84% of total billed charges,479.7,72% of total billed charges,135.84,100% OF CMS OPPS Rate,135.84,100% of CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,399.75,60% of total billed charges,73.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,55.94,100% OF CMS OPPS RATE,135.84,100% OF CMS OPPS Rate,466.38,70% of total billed charges,135.84,100% OF CMS OPPS Rate,163.01,120% of CMS OPPS RATE,479.7,Pays at 72% of billed charges with lesser of charges applied,479.7,Pays at 72% of billed charges with lesser of charges applied,479.7,Pays at 72% of billed charges with lesser of charges applied,479.7,Pays at 72% of billed charges with lesser of charges applied,479.7,Pays at 72% of billed charges with lesser of charges applied,479.7,Pays at 72% of billed charges with lesser of charges applied,308.16,442% of BCBS Fee Schedule,308.16,442% of BCBS Fee Schedule,308.16,442% of BCBS Fee Schedule,308.16,442% of BCBS Fee Schedule,308.16,442% of BCBS Fee Schedule,308.16,442% of BCBS Fee Schedule,308.16,442% of BCBS Fee Schedule,308.16,442% of BCBS Fee Schedule,308.16,442% of BCBS Fee Schedule,241.91,100% of BCBS Fee Schedule,241.91,100% of BCBS Fee Schedule,241.91,100% of BCBS Fee Schedule,241.91,100% of BCBS Fee Schedule,241.91,100% of BCBS Fee Schedule,559.65,84% of total billed charges,559.65,84% of total billed charges,559.65,84% of total billed charges,466.38,70% of total billed charges,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,73.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,55.94,559.65,499.69
Outpatient Medical Services,RADIOLOGY,71101,Radiologic examination of one side of the chest/ribs,320,458.75,330.3,Pays at 72% of billed charges with lesser of charges applied,135.85,100% OF CMS OPPS Rate,126.46,442% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,149.94,100% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,385.35,84% of total billed charges,385.35,84% of total billed charges,330.3,72% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% of CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,275.25,60% of total billed charges,46.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,46.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,35.23,100% OF CMS OPPS RATE,135.85,100% OF CMS OPPS Rate,321.13,70% of total billed charges,135.85,100% OF CMS OPPS Rate,163.02,120% of CMS OPPS RATE,330.3,Pays at 72% of billed charges with lesser of charges applied,330.3,Pays at 72% of billed charges with lesser of charges applied,330.3,Pays at 72% of billed charges with lesser of charges applied,330.3,Pays at 72% of billed charges with lesser of charges applied,330.3,Pays at 72% of billed charges with lesser of charges applied,330.3,Pays at 72% of billed charges with lesser of charges applied,126.46,442% of BCBS Fee Schedule,126.46,442% of BCBS Fee Schedule,126.46,442% of BCBS Fee Schedule,126.46,442% of BCBS Fee Schedule,126.46,442% of BCBS Fee Schedule,126.46,442% of BCBS Fee Schedule,126.46,442% of BCBS Fee Schedule,126.46,442% of BCBS Fee Schedule,126.46,442% of BCBS Fee Schedule,149.94,100% of BCBS Fee Schedule,149.94,100% of BCBS Fee Schedule,149.94,100% of BCBS Fee Schedule,149.94,100% of BCBS Fee Schedule,149.94,100% of BCBS Fee Schedule,385.35,84% of total billed charges,385.35,84% of total billed charges,385.35,84% of total billed charges,321.13,70% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,46.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,46.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,46.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,46.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,46.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,46.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,46.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,46.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,46.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,46.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,46.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,46.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,46.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,46.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,46.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,46.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,46.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,46.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,46.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,46.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.23,385.35,344.06
Outpatient Medical Services,RADIOLOGY,70371,XR (CINE/VIDEO) CX SPEECH EVAL,320,461,331.92,Pays at 72% of billed charges with lesser of charges applied,296.82,100% OF CMS OPPS Rate,389.36,442% of BCBS Fee Schedule,296.82,100% OF CMS OPPS Rate,452.24,pays at 100% of bcbs fee schedule with lesser of charges applied,296.82,100% OF CMS OPPS Rate,387.24,84% of total billed charges,387.24,84% of total billed charges,331.92,72% of total billed charges,296.82,100% OF CMS OPPS Rate,296.82,100% of CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,276.6,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,80.62,100% OF CMS OPPS RATE,296.82,100% OF CMS OPPS Rate,322.7,70% of total billed charges,296.82,100% OF CMS OPPS Rate,356.18,120% of CMS OPPS RATE,331.92,Pays at 72% of billed charges with lesser of charges applied,331.92,Pays at 72% of billed charges with lesser of charges applied,331.92,Pays at 72% of billed charges with lesser of charges applied,331.92,Pays at 72% of billed charges with lesser of charges applied,331.92,Pays at 72% of billed charges with lesser of charges applied,331.92,Pays at 72% of billed charges with lesser of charges applied,389.36,442% of BCBS Fee Schedule,389.36,442% of BCBS Fee Schedule,389.36,442% of BCBS Fee Schedule,389.36,442% of BCBS Fee Schedule,389.36,442% of BCBS Fee Schedule,389.36,442% of BCBS Fee Schedule,389.36,442% of BCBS Fee Schedule,389.36,442% of BCBS Fee Schedule,389.36,442% of BCBS Fee Schedule,452.24,pays at 100% of bcbs fee schedule with lesser of charges applied,452.24,pays at 100% of bcbs fee schedule with lesser of charges applied,452.24,pays at 100% of bcbs fee schedule with lesser of charges applied,452.24,pays at 100% of bcbs fee schedule with lesser of charges applied,452.24,pays at 100% of bcbs fee schedule with lesser of charges applied,387.24,84% of total billed charges,387.24,84% of total billed charges,387.24,84% of total billed charges,322.7,70% of total billed charges,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,80.62,452.24,345.75
Outpatient Medical Services,RADIOLOGY,72050,"Radiologic examination of the neck/spine, 4-5 views",320,576.75,415.26,Pays at 72% of billed charges with lesser of charges applied,135.85,100% OF CMS OPPS Rate,168.71,442% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,200.22,100% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,484.47,84% of total billed charges,484.47,84% of total billed charges,415.26,72% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% of CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,346.05,60% of total billed charges,57.38,100% of CA Medicaid Fee Schedule with lesser of charges applied,57.38,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,47.97,100% OF CMS OPPS RATE,135.85,100% OF CMS OPPS Rate,403.73,70% of total billed charges,135.85,100% OF CMS OPPS Rate,163.02,120% of CMS OPPS RATE,415.26,Pays at 72% of billed charges with lesser of charges applied,415.26,Pays at 72% of billed charges with lesser of charges applied,415.26,Pays at 72% of billed charges with lesser of charges applied,415.26,Pays at 72% of billed charges with lesser of charges applied,415.26,Pays at 72% of billed charges with lesser of charges applied,415.26,Pays at 72% of billed charges with lesser of charges applied,168.71,442% of BCBS Fee Schedule,168.71,442% of BCBS Fee Schedule,168.71,442% of BCBS Fee Schedule,168.71,442% of BCBS Fee Schedule,168.71,442% of BCBS Fee Schedule,168.71,442% of BCBS Fee Schedule,168.71,442% of BCBS Fee Schedule,168.71,442% of BCBS Fee Schedule,168.71,442% of BCBS Fee Schedule,200.22,100% of BCBS Fee Schedule,200.22,100% of BCBS Fee Schedule,200.22,100% of BCBS Fee Schedule,200.22,100% of BCBS Fee Schedule,200.22,100% of BCBS Fee Schedule,484.47,84% of total billed charges,484.47,84% of total billed charges,484.47,84% of total billed charges,403.73,70% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,57.38,100% of CA Medicaid Fee Schedule with lesser of charges applied,57.38,100% of CA Medicaid Fee Schedule with lesser of charges applied,57.38,100% of CA Medicaid Fee Schedule with lesser of charges applied,57.38,100% of CA Medicaid Fee Schedule with lesser of charges applied,57.38,100% of CA Medicaid Fee Schedule with lesser of charges applied,57.38,100% of CA Medicaid Fee Schedule with lesser of charges applied,57.38,100% of CA Medicaid Fee Schedule with lesser of charges applied,57.38,100% of CA Medicaid Fee Schedule with lesser of charges applied,57.38,100% of CA Medicaid Fee Schedule with lesser of charges applied,57.38,100% of CA Medicaid Fee Schedule with lesser of charges applied,57.38,100% of CA Medicaid Fee Schedule with lesser of charges applied,57.38,100% of CA Medicaid Fee Schedule with lesser of charges applied,57.38,100% of CA Medicaid Fee Schedule with lesser of charges applied,57.38,100% of CA Medicaid Fee Schedule with lesser of charges applied,57.38,100% of CA Medicaid Fee Schedule with lesser of charges applied,57.38,100% of CA Medicaid Fee Schedule with lesser of charges applied,57.38,100% of CA Medicaid Fee Schedule with lesser of charges applied,57.38,100% of CA Medicaid Fee Schedule with lesser of charges applied,57.38,100% of CA Medicaid Fee Schedule with lesser of charges applied,57.38,100% of CA Medicaid Fee Schedule with lesser of charges applied,47.97,484.47,432.56
Outpatient Medical Services,RADIOLOGY,70330,TM JOINTS BILAT OPEN & CLOSED,320,589.75,424.62,Pays at 72% of billed charges with lesser of charges applied,110.43,100% OF CMS OPPS Rate,156.95,442% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,190.1,100% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,495.39,84% of total billed charges,495.39,84% of total billed charges,424.62,72% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% of CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,353.85,60% of total billed charges,54.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,49.56,100% OF CMS OPPS RATE,110.43,100% OF CMS OPPS Rate,412.83,70% of total billed charges,110.43,100% OF CMS OPPS Rate,132.51,120% of CMS OPPS RATE,424.62,Pays at 72% of billed charges with lesser of charges applied,424.62,Pays at 72% of billed charges with lesser of charges applied,424.62,Pays at 72% of billed charges with lesser of charges applied,424.62,Pays at 72% of billed charges with lesser of charges applied,424.62,Pays at 72% of billed charges with lesser of charges applied,424.62,Pays at 72% of billed charges with lesser of charges applied,156.95,442% of BCBS Fee Schedule,156.95,442% of BCBS Fee Schedule,156.95,442% of BCBS Fee Schedule,156.95,442% of BCBS Fee Schedule,156.95,442% of BCBS Fee Schedule,156.95,442% of BCBS Fee Schedule,156.95,442% of BCBS Fee Schedule,156.95,442% of BCBS Fee Schedule,156.95,442% of BCBS Fee Schedule,190.1,100% of BCBS Fee Schedule,190.1,100% of BCBS Fee Schedule,190.1,100% of BCBS Fee Schedule,190.1,100% of BCBS Fee Schedule,190.1,100% of BCBS Fee Schedule,495.39,84% of total billed charges,495.39,84% of total billed charges,495.39,84% of total billed charges,412.83,70% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,54.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.56,495.39,442.31
Outpatient Medical Services,RADIOLOGY,74245,UGI & SMALL BOWEL NO AIR CONT,320,1493.25,1075.14,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,417.78,442% of BCBS Fee Schedule,N/A,Not Separately reimbursable,1181.16,79.1% of total billed charges,N/A,Not Separately reimbursable,1254.33,84% of total billed charges,1254.33,84% of total billed charges,1075.14,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,895.95,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,1045.28,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,1075.14,Pays at 72% of billed charges with lesser of charges applied,1075.14,Pays at 72% of billed charges with lesser of charges applied,1075.14,Pays at 72% of billed charges with lesser of charges applied,1075.14,Pays at 72% of billed charges with lesser of charges applied,1075.14,Pays at 72% of billed charges with lesser of charges applied,1075.14,Pays at 72% of billed charges with lesser of charges applied,417.78,442% of BCBS Fee Schedule,417.78,442% of BCBS Fee Schedule,417.78,442% of BCBS Fee Schedule,417.78,442% of BCBS Fee Schedule,417.78,442% of BCBS Fee Schedule,417.78,442% of BCBS Fee Schedule,417.78,442% of BCBS Fee Schedule,417.78,442% of BCBS Fee Schedule,417.78,442% of BCBS Fee Schedule,1181.16,79.1% of total billed charges,1181.16,79.1% of total billed charges,1181.16,79.1% of total billed charges,1181.16,79.1% of total billed charges,1181.16,79.1% of total billed charges,1254.33,84% of total billed charges,1254.33,84% of total billed charges,1254.33,84% of total billed charges,1045.28,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,417.78,1254.33,1119.94
Outpatient Medical Services,RADIOLOGY,73630,Radiologic examination of the foot with 3 or more views,320,268,192.96,Pays at 72% of billed charges with lesser of charges applied,110.43,100% OF CMS OPPS Rate,99.63,442% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,116.82,100% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,225.12,84% of total billed charges,225.12,84% of total billed charges,192.96,72% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% of CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,160.8,60% of total billed charges,34.74,100% of CA Medicaid Fee Schedule with lesser of charges applied,34.74,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,31.25,100% OF CMS OPPS RATE,110.43,100% OF CMS OPPS Rate,187.6,70% of total billed charges,110.43,100% OF CMS OPPS Rate,132.51,120% of CMS OPPS RATE,192.96,Pays at 72% of billed charges with lesser of charges applied,192.96,Pays at 72% of billed charges with lesser of charges applied,192.96,Pays at 72% of billed charges with lesser of charges applied,192.96,Pays at 72% of billed charges with lesser of charges applied,192.96,Pays at 72% of billed charges with lesser of charges applied,192.96,Pays at 72% of billed charges with lesser of charges applied,99.63,442% of BCBS Fee Schedule,99.63,442% of BCBS Fee Schedule,99.63,442% of BCBS Fee Schedule,99.63,442% of BCBS Fee Schedule,99.63,442% of BCBS Fee Schedule,99.63,442% of BCBS Fee Schedule,99.63,442% of BCBS Fee Schedule,99.63,442% of BCBS Fee Schedule,99.63,442% of BCBS Fee Schedule,116.82,100% of BCBS Fee Schedule,116.82,100% of BCBS Fee Schedule,116.82,100% of BCBS Fee Schedule,116.82,100% of BCBS Fee Schedule,116.82,100% of BCBS Fee Schedule,225.12,84% of total billed charges,225.12,84% of total billed charges,225.12,84% of total billed charges,187.6,70% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,34.74,100% of CA Medicaid Fee Schedule with lesser of charges applied,34.74,100% of CA Medicaid Fee Schedule with lesser of charges applied,34.74,100% of CA Medicaid Fee Schedule with lesser of charges applied,34.74,100% of CA Medicaid Fee Schedule with lesser of charges applied,34.74,100% of CA Medicaid Fee Schedule with lesser of charges applied,34.74,100% of CA Medicaid Fee Schedule with lesser of charges applied,34.74,100% of CA Medicaid Fee Schedule with lesser of charges applied,34.74,100% of CA Medicaid Fee Schedule with lesser of charges applied,34.74,100% of CA Medicaid Fee Schedule with lesser of charges applied,34.74,100% of CA Medicaid Fee Schedule with lesser of charges applied,34.74,100% of CA Medicaid Fee Schedule with lesser of charges applied,34.74,100% of CA Medicaid Fee Schedule with lesser of charges applied,34.74,100% of CA Medicaid Fee Schedule with lesser of charges applied,34.74,100% of CA Medicaid Fee Schedule with lesser of charges applied,34.74,100% of CA Medicaid Fee Schedule with lesser of charges applied,34.74,100% of CA Medicaid Fee Schedule with lesser of charges applied,34.74,100% of CA Medicaid Fee Schedule with lesser of charges applied,34.74,100% of CA Medicaid Fee Schedule with lesser of charges applied,34.74,100% of CA Medicaid Fee Schedule with lesser of charges applied,34.74,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.25,225.12,201
Outpatient Medical Services,RADIOLOGY,73500,XR HIP UNILATERAL 1 VIEW-PORT,320,259,186.48,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,88.93,442% of BCBS Fee Schedule,N/A,Not Separately reimbursable,204.87,79.1% of total billed charges,N/A,Not Separately reimbursable,217.56,84% of total billed charges,217.56,84% of total billed charges,186.48,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,155.4,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,181.3,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,186.48,Pays at 72% of billed charges with lesser of charges applied,186.48,Pays at 72% of billed charges with lesser of charges applied,186.48,Pays at 72% of billed charges with lesser of charges applied,186.48,Pays at 72% of billed charges with lesser of charges applied,186.48,Pays at 72% of billed charges with lesser of charges applied,186.48,Pays at 72% of billed charges with lesser of charges applied,88.93,442% of BCBS Fee Schedule,88.93,442% of BCBS Fee Schedule,88.93,442% of BCBS Fee Schedule,88.93,442% of BCBS Fee Schedule,88.93,442% of BCBS Fee Schedule,88.93,442% of BCBS Fee Schedule,88.93,442% of BCBS Fee Schedule,88.93,442% of BCBS Fee Schedule,88.93,442% of BCBS Fee Schedule,204.87,79.1% of total billed charges,204.87,79.1% of total billed charges,204.87,79.1% of total billed charges,204.87,79.1% of total billed charges,204.87,79.1% of total billed charges,217.56,84% of total billed charges,217.56,84% of total billed charges,217.56,84% of total billed charges,181.3,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,88.93,217.56,194.25
Outpatient Medical Services,RADIOLOGY,73560,Radiologic examination of the knee with 1 or 2 views,320,292,210.24,Pays at 72% of billed charges with lesser of charges applied,110.43,100% OF CMS OPPS Rate,98.04,442% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,114.67,100% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,245.28,84% of total billed charges,245.28,84% of total billed charges,210.24,72% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% of CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,175.2,60% of total billed charges,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,31.25,100% OF CMS OPPS RATE,110.43,100% OF CMS OPPS Rate,204.4,70% of total billed charges,110.43,100% OF CMS OPPS Rate,132.51,120% of CMS OPPS RATE,210.24,Pays at 72% of billed charges with lesser of charges applied,210.24,Pays at 72% of billed charges with lesser of charges applied,210.24,Pays at 72% of billed charges with lesser of charges applied,210.24,Pays at 72% of billed charges with lesser of charges applied,210.24,Pays at 72% of billed charges with lesser of charges applied,210.24,Pays at 72% of billed charges with lesser of charges applied,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,114.67,100% of BCBS Fee Schedule,114.67,100% of BCBS Fee Schedule,114.67,100% of BCBS Fee Schedule,114.67,100% of BCBS Fee Schedule,114.67,100% of BCBS Fee Schedule,245.28,84% of total billed charges,245.28,84% of total billed charges,245.28,84% of total billed charges,204.4,70% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,245.28,219
Outpatient Medical Services,RADIOLOGY,71111,XR RIBS BILAT W PA CXR MIN 4V,320,540.5,389.16,Pays at 72% of billed charges with lesser of charges applied,135.85,100% OF CMS OPPS Rate,168.18,442% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,200.22,100% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,454.02,84% of total billed charges,454.02,84% of total billed charges,389.16,72% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% of CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,324.3,60% of total billed charges,60.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,44.39,100% OF CMS OPPS RATE,135.85,100% OF CMS OPPS Rate,378.35,70% of total billed charges,135.85,100% OF CMS OPPS Rate,163.02,120% of CMS OPPS RATE,389.16,Pays at 72% of billed charges with lesser of charges applied,389.16,Pays at 72% of billed charges with lesser of charges applied,389.16,Pays at 72% of billed charges with lesser of charges applied,389.16,Pays at 72% of billed charges with lesser of charges applied,389.16,Pays at 72% of billed charges with lesser of charges applied,389.16,Pays at 72% of billed charges with lesser of charges applied,168.18,442% of BCBS Fee Schedule,168.18,442% of BCBS Fee Schedule,168.18,442% of BCBS Fee Schedule,168.18,442% of BCBS Fee Schedule,168.18,442% of BCBS Fee Schedule,168.18,442% of BCBS Fee Schedule,168.18,442% of BCBS Fee Schedule,168.18,442% of BCBS Fee Schedule,168.18,442% of BCBS Fee Schedule,200.22,100% of BCBS Fee Schedule,200.22,100% of BCBS Fee Schedule,200.22,100% of BCBS Fee Schedule,200.22,100% of BCBS Fee Schedule,200.22,100% of BCBS Fee Schedule,454.02,84% of total billed charges,454.02,84% of total billed charges,454.02,84% of total billed charges,378.35,70% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,60.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,44.39,454.02,405.38
Outpatient Medical Services,RADIOLOGY,72202,XR SACROILIAC JT 3 PLUS VIEWS,320,341.5,245.88,Pays at 72% of billed charges with lesser of charges applied,135.85,100% OF CMS OPPS Rate,116.29,442% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,139.21,100% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,286.86,84% of total billed charges,286.86,84% of total billed charges,245.88,72% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% of CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,204.9,60% of total billed charges,42.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,42.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,34.04,100% OF CMS OPPS RATE,135.85,100% OF CMS OPPS Rate,239.05,70% of total billed charges,135.85,100% OF CMS OPPS Rate,163.02,120% of CMS OPPS RATE,245.88,Pays at 72% of billed charges with lesser of charges applied,245.88,Pays at 72% of billed charges with lesser of charges applied,245.88,Pays at 72% of billed charges with lesser of charges applied,245.88,Pays at 72% of billed charges with lesser of charges applied,245.88,Pays at 72% of billed charges with lesser of charges applied,245.88,Pays at 72% of billed charges with lesser of charges applied,116.29,442% of BCBS Fee Schedule,116.29,442% of BCBS Fee Schedule,116.29,442% of BCBS Fee Schedule,116.29,442% of BCBS Fee Schedule,116.29,442% of BCBS Fee Schedule,116.29,442% of BCBS Fee Schedule,116.29,442% of BCBS Fee Schedule,116.29,442% of BCBS Fee Schedule,116.29,442% of BCBS Fee Schedule,139.21,100% of BCBS Fee Schedule,139.21,100% of BCBS Fee Schedule,139.21,100% of BCBS Fee Schedule,139.21,100% of BCBS Fee Schedule,139.21,100% of BCBS Fee Schedule,286.86,84% of total billed charges,286.86,84% of total billed charges,286.86,84% of total billed charges,239.05,70% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,42.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,42.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,42.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,42.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,42.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,42.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,42.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,42.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,42.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,42.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,42.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,42.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,42.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,42.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,42.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,42.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,42.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,42.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,42.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,42.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,34.04,286.86,256.13
Outpatient Medical Services,RADIOLOGY,72080,XR SPINE THORACOLUMBAR AP&LAT,320,380.25,273.78,Pays at 72% of billed charges with lesser of charges applied,110.43,100% OF CMS OPPS Rate,125.88,442% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,149.94,100% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,319.41,84% of total billed charges,319.41,84% of total billed charges,273.78,72% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% of CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,228.15,60% of total billed charges,39.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,29.26,100% OF CMS OPPS RATE,110.43,100% OF CMS OPPS Rate,266.18,70% of total billed charges,110.43,100% OF CMS OPPS Rate,132.51,120% of CMS OPPS RATE,273.78,Pays at 72% of billed charges with lesser of charges applied,273.78,Pays at 72% of billed charges with lesser of charges applied,273.78,Pays at 72% of billed charges with lesser of charges applied,273.78,Pays at 72% of billed charges with lesser of charges applied,273.78,Pays at 72% of billed charges with lesser of charges applied,273.78,Pays at 72% of billed charges with lesser of charges applied,125.88,442% of BCBS Fee Schedule,125.88,442% of BCBS Fee Schedule,125.88,442% of BCBS Fee Schedule,125.88,442% of BCBS Fee Schedule,125.88,442% of BCBS Fee Schedule,125.88,442% of BCBS Fee Schedule,125.88,442% of BCBS Fee Schedule,125.88,442% of BCBS Fee Schedule,125.88,442% of BCBS Fee Schedule,149.94,100% of BCBS Fee Schedule,149.94,100% of BCBS Fee Schedule,149.94,100% of BCBS Fee Schedule,149.94,100% of BCBS Fee Schedule,149.94,100% of BCBS Fee Schedule,319.41,84% of total billed charges,319.41,84% of total billed charges,319.41,84% of total billed charges,266.18,70% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,39.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.26,319.41,285.19
Outpatient Medical Services,RADIOLOGY,71130,XR STERNOCLAVICULAR JT MIN 3V,320,246.5,177.48,Pays at 72% of billed charges with lesser of charges applied,110.43,100% OF CMS OPPS Rate,131.23,442% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,158.52,100% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,207.06,84% of total billed charges,207.06,84% of total billed charges,177.48,72% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% of CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,147.9,60% of total billed charges,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,36.82,100% OF CMS OPPS RATE,110.43,100% OF CMS OPPS Rate,172.55,70% of total billed charges,110.43,100% OF CMS OPPS Rate,132.51,120% of CMS OPPS RATE,177.48,Pays at 72% of billed charges with lesser of charges applied,177.48,Pays at 72% of billed charges with lesser of charges applied,177.48,Pays at 72% of billed charges with lesser of charges applied,177.48,Pays at 72% of billed charges with lesser of charges applied,177.48,Pays at 72% of billed charges with lesser of charges applied,177.48,Pays at 72% of billed charges with lesser of charges applied,131.23,442% of BCBS Fee Schedule,131.23,442% of BCBS Fee Schedule,131.23,442% of BCBS Fee Schedule,131.23,442% of BCBS Fee Schedule,131.23,442% of BCBS Fee Schedule,131.23,442% of BCBS Fee Schedule,131.23,442% of BCBS Fee Schedule,131.23,442% of BCBS Fee Schedule,131.23,442% of BCBS Fee Schedule,158.52,100% of BCBS Fee Schedule,158.52,100% of BCBS Fee Schedule,158.52,100% of BCBS Fee Schedule,158.52,100% of BCBS Fee Schedule,158.52,100% of BCBS Fee Schedule,207.06,84% of total billed charges,207.06,84% of total billed charges,207.06,84% of total billed charges,172.55,70% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.82,207.06,184.88
Outpatient Medical Services,RADIOLOGY,19000,MG ASPIRATION BREAST CYST-LT,320,714.5,514.44,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,714.5,100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,565.17,79.1% of total billed charges,N/A,Not Separately reimbursable,600.18,84% of total billed charges,600.18,84% of total billed charges,514.44,72% of total billed charges,N/A,Not Separately reimbursable,714.5,100% of CMS OPPS Rate,N/A,Not Separately reimbursable,428.7,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,43.84,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,500.15,70% of total billed charges,714.5,100% OF CMS OPPS Rate,714.5,120% of CMS OPPS RATE,514.44,Pays at 72% of billed charges with lesser of charges applied,514.44,Pays at 72% of billed charges with lesser of charges applied,514.44,Pays at 72% of billed charges with lesser of charges applied,514.44,Pays at 72% of billed charges with lesser of charges applied,514.44,Pays at 72% of billed charges with lesser of charges applied,514.44,Pays at 72% of billed charges with lesser of charges applied,714.5,100% of ASC Tier Grouping Fee Schedule,714.5,100% of ASC Tier Grouping Fee Schedule,714.5,100% of ASC Tier Grouping Fee Schedule,714.5,100% of ASC Tier Grouping Fee Schedule,714.5,100% of ASC Tier Grouping Fee Schedule,714.5,100% of ASC Tier Grouping Fee Schedule,714.5,100% of ASC Tier Grouping Fee Schedule,714.5,100% of ASC Tier Grouping Fee Schedule,714.5,100% of ASC Tier Grouping Fee Schedule,565.17,79.1% of total billed charges,565.17,79.1% of total billed charges,565.17,79.1% of total billed charges,565.17,79.1% of total billed charges,565.17,79.1% of total billed charges,600.18,84% of total billed charges,600.18,84% of total billed charges,600.18,84% of total billed charges,500.15,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,43.84,714.50,535.88
Outpatient Medical Services,RADIOLOGY,74305,CHOLANGIOGRAM-T-TUBE POST OP,320,684.75,493.02,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,147.5,442% of BCBS Fee Schedule,N/A,Not Separately reimbursable,541.64,79.1% of total billed charges,N/A,Not Separately reimbursable,575.19,84% of total billed charges,575.19,84% of total billed charges,493.02,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,410.85,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,479.33,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,493.02,Pays at 72% of billed charges with lesser of charges applied,493.02,Pays at 72% of billed charges with lesser of charges applied,493.02,Pays at 72% of billed charges with lesser of charges applied,493.02,Pays at 72% of billed charges with lesser of charges applied,493.02,Pays at 72% of billed charges with lesser of charges applied,493.02,Pays at 72% of billed charges with lesser of charges applied,147.5,442% of BCBS Fee Schedule,147.5,442% of BCBS Fee Schedule,147.5,442% of BCBS Fee Schedule,147.5,442% of BCBS Fee Schedule,147.5,442% of BCBS Fee Schedule,147.5,442% of BCBS Fee Schedule,147.5,442% of BCBS Fee Schedule,147.5,442% of BCBS Fee Schedule,147.5,442% of BCBS Fee Schedule,541.64,79.1% of total billed charges,541.64,79.1% of total billed charges,541.64,79.1% of total billed charges,541.64,79.1% of total billed charges,541.64,79.1% of total billed charges,575.19,84% of total billed charges,575.19,84% of total billed charges,575.19,84% of total billed charges,479.33,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,147.50,575.19,513.56
Outpatient Medical Services,RADIOLOGY,75822,EXTREMITY BILATERAL VENOGRAM,320,1419.75,1022.22,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,276.65,442% of BCBS Fee Schedule,N/A,Not Separately reimbursable,329.92,100% of BCBS Fee Schedule,N/A,Not Separately reimbursable,1192.59,84% of total billed charges,1192.59,84% of total billed charges,1022.22,72% of total billed charges,N/A,Not Separately reimbursable,1419.75,100% of CMS OPPS Rate,N/A,Not Separately reimbursable,851.85,60% of total billed charges,134.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,134.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,77.84,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,993.83,70% of total billed charges,1419.75,100% OF CMS OPPS Rate,1419.75,120% of CMS OPPS RATE,1022.22,Pays at 72% of billed charges with lesser of charges applied,1022.22,Pays at 72% of billed charges with lesser of charges applied,1022.22,Pays at 72% of billed charges with lesser of charges applied,1022.22,Pays at 72% of billed charges with lesser of charges applied,1022.22,Pays at 72% of billed charges with lesser of charges applied,1022.22,Pays at 72% of billed charges with lesser of charges applied,276.65,442% of BCBS Fee Schedule,276.65,442% of BCBS Fee Schedule,276.65,442% of BCBS Fee Schedule,276.65,442% of BCBS Fee Schedule,276.65,442% of BCBS Fee Schedule,276.65,442% of BCBS Fee Schedule,276.65,442% of BCBS Fee Schedule,276.65,442% of BCBS Fee Schedule,276.65,442% of BCBS Fee Schedule,329.92,100% of BCBS Fee Schedule,329.92,100% of BCBS Fee Schedule,329.92,100% of BCBS Fee Schedule,329.92,100% of BCBS Fee Schedule,329.92,100% of BCBS Fee Schedule,1192.59,84% of total billed charges,1192.59,84% of total billed charges,1192.59,84% of total billed charges,993.83,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,134.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,134.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,134.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,134.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,134.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,134.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,134.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,134.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,134.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,134.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,134.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,134.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,134.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,134.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,134.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,134.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,134.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,134.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,134.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,134.58,100% of CA Medicaid Fee Schedule with lesser of charges applied,77.84,1419.75,1064.81
Outpatient Medical Services,RADIOLOGY,77074,BONE SURVEY (METASTASES)LIM,320,744.25,535.86,Pays at 72% of billed charges with lesser of charges applied,135.85,100% OF CMS OPPS Rate,187.98,442% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,268.9,100% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,625.17,84% of total billed charges,625.17,84% of total billed charges,535.86,72% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% of CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,446.55,60% of total billed charges,80.93,100% of CA Medicaid Fee Schedule with lesser of charges applied,80.93,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,52.75,100% OF CMS OPPS RATE,135.85,100% OF CMS OPPS Rate,520.98,70% of total billed charges,135.85,100% OF CMS OPPS Rate,163.02,120% of CMS OPPS RATE,535.86,Pays at 72% of billed charges with lesser of charges applied,535.86,Pays at 72% of billed charges with lesser of charges applied,535.86,Pays at 72% of billed charges with lesser of charges applied,535.86,Pays at 72% of billed charges with lesser of charges applied,535.86,Pays at 72% of billed charges with lesser of charges applied,535.86,Pays at 72% of billed charges with lesser of charges applied,187.98,442% of BCBS Fee Schedule,187.98,442% of BCBS Fee Schedule,187.98,442% of BCBS Fee Schedule,187.98,442% of BCBS Fee Schedule,187.98,442% of BCBS Fee Schedule,187.98,442% of BCBS Fee Schedule,187.98,442% of BCBS Fee Schedule,187.98,442% of BCBS Fee Schedule,187.98,442% of BCBS Fee Schedule,268.9,100% of BCBS Fee Schedule,268.9,100% of BCBS Fee Schedule,268.9,100% of BCBS Fee Schedule,268.9,100% of BCBS Fee Schedule,268.9,100% of BCBS Fee Schedule,625.17,84% of total billed charges,625.17,84% of total billed charges,625.17,84% of total billed charges,520.98,70% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,80.93,100% of CA Medicaid Fee Schedule with lesser of charges applied,80.93,100% of CA Medicaid Fee Schedule with lesser of charges applied,80.93,100% of CA Medicaid Fee Schedule with lesser of charges applied,80.93,100% of CA Medicaid Fee Schedule with lesser of charges applied,80.93,100% of CA Medicaid Fee Schedule with lesser of charges applied,80.93,100% of CA Medicaid Fee Schedule with lesser of charges applied,80.93,100% of CA Medicaid Fee Schedule with lesser of charges applied,80.93,100% of CA Medicaid Fee Schedule with lesser of charges applied,80.93,100% of CA Medicaid Fee Schedule with lesser of charges applied,80.93,100% of CA Medicaid Fee Schedule with lesser of charges applied,80.93,100% of CA Medicaid Fee Schedule with lesser of charges applied,80.93,100% of CA Medicaid Fee Schedule with lesser of charges applied,80.93,100% of CA Medicaid Fee Schedule with lesser of charges applied,80.93,100% of CA Medicaid Fee Schedule with lesser of charges applied,80.93,100% of CA Medicaid Fee Schedule with lesser of charges applied,80.93,100% of CA Medicaid Fee Schedule with lesser of charges applied,80.93,100% of CA Medicaid Fee Schedule with lesser of charges applied,80.93,100% of CA Medicaid Fee Schedule with lesser of charges applied,80.93,100% of CA Medicaid Fee Schedule with lesser of charges applied,80.93,100% of CA Medicaid Fee Schedule with lesser of charges applied,52.75,625.17,558.19
Outpatient Medical Services,RADIOLOGY,76010,CHILD FOR FB NOSE TO RECTUM,320,189,136.08,Pays at 72% of billed charges with lesser of charges applied,110.43,100% OF CMS OPPS Rate,103.74,442% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,114.67,100% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,158.76,84% of total billed charges,158.76,84% of total billed charges,136.08,72% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% of CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,113.4,60% of total billed charges,33.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,33.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,25.28,100% OF CMS OPPS RATE,110.43,100% OF CMS OPPS Rate,132.3,70% of total billed charges,110.43,100% OF CMS OPPS Rate,132.51,120% of CMS OPPS RATE,136.08,Pays at 72% of billed charges with lesser of charges applied,136.08,Pays at 72% of billed charges with lesser of charges applied,136.08,Pays at 72% of billed charges with lesser of charges applied,136.08,Pays at 72% of billed charges with lesser of charges applied,136.08,Pays at 72% of billed charges with lesser of charges applied,136.08,Pays at 72% of billed charges with lesser of charges applied,103.74,442% of BCBS Fee Schedule,103.74,442% of BCBS Fee Schedule,103.74,442% of BCBS Fee Schedule,103.74,442% of BCBS Fee Schedule,103.74,442% of BCBS Fee Schedule,103.74,442% of BCBS Fee Schedule,103.74,442% of BCBS Fee Schedule,103.74,442% of BCBS Fee Schedule,103.74,442% of BCBS Fee Schedule,114.67,100% of BCBS Fee Schedule,114.67,100% of BCBS Fee Schedule,114.67,100% of BCBS Fee Schedule,114.67,100% of BCBS Fee Schedule,114.67,100% of BCBS Fee Schedule,158.76,84% of total billed charges,158.76,84% of total billed charges,158.76,84% of total billed charges,132.3,70% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,33.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,33.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,33.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,33.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,33.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,33.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,33.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,33.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,33.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,33.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,33.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,33.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,33.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,33.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,33.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,33.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,33.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,33.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,33.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,33.48,100% of CA Medicaid Fee Schedule with lesser of charges applied,25.28,158.76,141.75
Outpatient Medical Services,RADIOLOGY,72010,"COMP SPINE, SURVEY AP & LAT",320,802.75,577.98,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,193.38,442% of BCBS Fee Schedule,N/A,Not Separately reimbursable,634.98,79.1% of total billed charges,N/A,Not Separately reimbursable,674.31,84% of total billed charges,674.31,84% of total billed charges,577.98,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,481.65,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,561.93,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,577.98,Pays at 72% of billed charges with lesser of charges applied,577.98,Pays at 72% of billed charges with lesser of charges applied,577.98,Pays at 72% of billed charges with lesser of charges applied,577.98,Pays at 72% of billed charges with lesser of charges applied,577.98,Pays at 72% of billed charges with lesser of charges applied,577.98,Pays at 72% of billed charges with lesser of charges applied,193.38,442% of BCBS Fee Schedule,193.38,442% of BCBS Fee Schedule,193.38,442% of BCBS Fee Schedule,193.38,442% of BCBS Fee Schedule,193.38,442% of BCBS Fee Schedule,193.38,442% of BCBS Fee Schedule,193.38,442% of BCBS Fee Schedule,193.38,442% of BCBS Fee Schedule,193.38,442% of BCBS Fee Schedule,634.98,79.1% of total billed charges,634.98,79.1% of total billed charges,634.98,79.1% of total billed charges,634.98,79.1% of total billed charges,634.98,79.1% of total billed charges,674.31,84% of total billed charges,674.31,84% of total billed charges,674.31,84% of total billed charges,561.93,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,193.38,674.31,602.06
Outpatient Medical Services,RADIOLOGY,73030,Radiologic examination of the shoulder,320,529,380.88,Pays at 72% of billed charges with lesser of charges applied,110.43,100% OF CMS OPPS Rate,107.14,442% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,128.47,100% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,444.36,84% of total billed charges,444.36,84% of total billed charges,380.88,72% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% of CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,317.4,60% of total billed charges,37.09,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.09,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,30.45,100% OF CMS OPPS RATE,110.43,100% OF CMS OPPS Rate,370.3,70% of total billed charges,110.43,100% OF CMS OPPS Rate,132.51,120% of CMS OPPS RATE,380.88,Pays at 72% of billed charges with lesser of charges applied,380.88,Pays at 72% of billed charges with lesser of charges applied,380.88,Pays at 72% of billed charges with lesser of charges applied,380.88,Pays at 72% of billed charges with lesser of charges applied,380.88,Pays at 72% of billed charges with lesser of charges applied,380.88,Pays at 72% of billed charges with lesser of charges applied,107.14,442% of BCBS Fee Schedule,107.14,442% of BCBS Fee Schedule,107.14,442% of BCBS Fee Schedule,107.14,442% of BCBS Fee Schedule,107.14,442% of BCBS Fee Schedule,107.14,442% of BCBS Fee Schedule,107.14,442% of BCBS Fee Schedule,107.14,442% of BCBS Fee Schedule,107.14,442% of BCBS Fee Schedule,128.47,100% of BCBS Fee Schedule,128.47,100% of BCBS Fee Schedule,128.47,100% of BCBS Fee Schedule,128.47,100% of BCBS Fee Schedule,128.47,100% of BCBS Fee Schedule,444.36,84% of total billed charges,444.36,84% of total billed charges,444.36,84% of total billed charges,370.3,70% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,37.09,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.09,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.09,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.09,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.09,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.09,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.09,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.09,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.09,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.09,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.09,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.09,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.09,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.09,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.09,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.09,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.09,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.09,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.09,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.09,100% of CA Medicaid Fee Schedule with lesser of charges applied,30.45,444.36,396.75
Outpatient Medical Services,RADIOLOGY,72100,X-ray of the lower spine 2-3 views,320,380.25,273.78,Pays at 72% of billed charges with lesser of charges applied,135.85,100% OF CMS OPPS Rate,125.88,442% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,149.94,100% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,319.41,84% of total billed charges,319.41,84% of total billed charges,273.78,72% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% of CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,228.15,60% of total billed charges,43.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,43.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,34.83,100% OF CMS OPPS RATE,135.85,100% OF CMS OPPS Rate,266.18,70% of total billed charges,135.85,100% OF CMS OPPS Rate,163.02,120% of CMS OPPS RATE,273.78,Pays at 72% of billed charges with lesser of charges applied,273.78,Pays at 72% of billed charges with lesser of charges applied,273.78,Pays at 72% of billed charges with lesser of charges applied,273.78,Pays at 72% of billed charges with lesser of charges applied,273.78,Pays at 72% of billed charges with lesser of charges applied,273.78,Pays at 72% of billed charges with lesser of charges applied,125.88,442% of BCBS Fee Schedule,125.88,442% of BCBS Fee Schedule,125.88,442% of BCBS Fee Schedule,125.88,442% of BCBS Fee Schedule,125.88,442% of BCBS Fee Schedule,125.88,442% of BCBS Fee Schedule,125.88,442% of BCBS Fee Schedule,125.88,442% of BCBS Fee Schedule,125.88,442% of BCBS Fee Schedule,149.94,100% of BCBS Fee Schedule,149.94,100% of BCBS Fee Schedule,149.94,100% of BCBS Fee Schedule,149.94,100% of BCBS Fee Schedule,149.94,100% of BCBS Fee Schedule,319.41,84% of total billed charges,319.41,84% of total billed charges,319.41,84% of total billed charges,266.18,70% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,43.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,43.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,43.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,43.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,43.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,43.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,43.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,43.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,43.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,43.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,43.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,43.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,43.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,43.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,43.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,43.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,43.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,43.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,43.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,43.45,100% of CA Medicaid Fee Schedule with lesser of charges applied,34.83,319.41,285.19
Outpatient Medical Services,RADIOLOGY,74301,CHOLANGIOGRAM OP ADDED SET,320,109.25,78.66,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,109.25,BCBS Fee Schedule,N/A,Not Separately reimbursable,107.17,pays at 100% of bcbs fee schedule with lesser of charges applied,N/A,Not Separately reimbursable,91.77,84% of total billed charges,91.77,84% of total billed charges,78.66,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,65.55,60% of total billed charges,31.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,76.48,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,78.66,Pays at 72% of billed charges with lesser of charges applied,78.66,Pays at 72% of billed charges with lesser of charges applied,78.66,Pays at 72% of billed charges with lesser of charges applied,78.66,Pays at 72% of billed charges with lesser of charges applied,78.66,Pays at 72% of billed charges with lesser of charges applied,78.66,Pays at 72% of billed charges with lesser of charges applied,109.25,BCBS Fee Schedule,109.25,BCBS Fee Schedule,109.25,BCBS Fee Schedule,109.25,BCBS Fee Schedule,109.25,BCBS Fee Schedule,109.25,BCBS Fee Schedule,109.25,BCBS Fee Schedule,109.25,BCBS Fee Schedule,109.25,BCBS Fee Schedule,107.17,pays at 100% of bcbs fee schedule with lesser of charges applied,107.17,pays at 100% of bcbs fee schedule with lesser of charges applied,107.17,pays at 100% of bcbs fee schedule with lesser of charges applied,107.17,pays at 100% of bcbs fee schedule with lesser of charges applied,107.17,pays at 100% of bcbs fee schedule with lesser of charges applied,91.77,84% of total billed charges,91.77,84% of total billed charges,91.77,84% of total billed charges,76.48,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,31.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.01,109.25,81.94
Outpatient Medical Services,RADIOLOGY,74220,ESOPHAGRAM SINGLE CONTRAST,320,467,336.24,Pays at 72% of billed charges with lesser of charges applied,229.22,100% OF CMS OPPS Rate,208.89,442% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,264.61,100% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,392.28,84% of total billed charges,392.28,84% of total billed charges,336.24,72% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% of CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,280.2,60% of total billed charges,54.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,84.6,100% OF CMS OPPS RATE,229.22,100% OF CMS OPPS Rate,326.9,70% of total billed charges,229.22,100% OF CMS OPPS Rate,275.07,120% of CMS OPPS RATE,336.24,Pays at 72% of billed charges with lesser of charges applied,336.24,Pays at 72% of billed charges with lesser of charges applied,336.24,Pays at 72% of billed charges with lesser of charges applied,336.24,Pays at 72% of billed charges with lesser of charges applied,336.24,Pays at 72% of billed charges with lesser of charges applied,336.24,Pays at 72% of billed charges with lesser of charges applied,208.89,442% of BCBS Fee Schedule,208.89,442% of BCBS Fee Schedule,208.89,442% of BCBS Fee Schedule,208.89,442% of BCBS Fee Schedule,208.89,442% of BCBS Fee Schedule,208.89,442% of BCBS Fee Schedule,208.89,442% of BCBS Fee Schedule,208.89,442% of BCBS Fee Schedule,208.89,442% of BCBS Fee Schedule,264.61,100% of BCBS Fee Schedule,264.61,100% of BCBS Fee Schedule,264.61,100% of BCBS Fee Schedule,264.61,100% of BCBS Fee Schedule,264.61,100% of BCBS Fee Schedule,392.28,84% of total billed charges,392.28,84% of total billed charges,392.28,84% of total billed charges,326.9,70% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,54.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.64,392.28,350.25
Outpatient Medical Services,RADIOLOGY,73620,"Radiologic examination, foot; 2 views",320,439.25,316.26,Pays at 72% of billed charges with lesser of charges applied,110.43,100% OF CMS OPPS Rate,92.64,442% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,108.23,100% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,368.97,84% of total billed charges,368.97,84% of total billed charges,316.26,72% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% of CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,263.55,60% of total billed charges,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,24.88,100% OF CMS OPPS RATE,110.43,100% OF CMS OPPS Rate,307.48,70% of total billed charges,110.43,100% OF CMS OPPS Rate,132.51,120% of CMS OPPS RATE,316.26,Pays at 72% of billed charges with lesser of charges applied,316.26,Pays at 72% of billed charges with lesser of charges applied,316.26,Pays at 72% of billed charges with lesser of charges applied,316.26,Pays at 72% of billed charges with lesser of charges applied,316.26,Pays at 72% of billed charges with lesser of charges applied,316.26,Pays at 72% of billed charges with lesser of charges applied,92.64,442% of BCBS Fee Schedule,92.64,442% of BCBS Fee Schedule,92.64,442% of BCBS Fee Schedule,92.64,442% of BCBS Fee Schedule,92.64,442% of BCBS Fee Schedule,92.64,442% of BCBS Fee Schedule,92.64,442% of BCBS Fee Schedule,92.64,442% of BCBS Fee Schedule,92.64,442% of BCBS Fee Schedule,108.23,100% of BCBS Fee Schedule,108.23,100% of BCBS Fee Schedule,108.23,100% of BCBS Fee Schedule,108.23,100% of BCBS Fee Schedule,108.23,100% of BCBS Fee Schedule,368.97,84% of total billed charges,368.97,84% of total billed charges,368.97,84% of total billed charges,307.48,70% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,368.97,329.44
Outpatient Medical Services,RADIOLOGY,70210,XR SINUS LESS THAN 3 VIEWS,320,341.5,245.88,Pays at 72% of billed charges with lesser of charges applied,110.43,100% OF CMS OPPS Rate,116.25,442% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,139.21,100% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,286.86,84% of total billed charges,286.86,84% of total billed charges,245.88,72% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% of CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,204.9,60% of total billed charges,31.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,28.46,100% OF CMS OPPS RATE,110.43,100% OF CMS OPPS Rate,239.05,70% of total billed charges,110.43,100% OF CMS OPPS Rate,132.51,120% of CMS OPPS RATE,245.88,Pays at 72% of billed charges with lesser of charges applied,245.88,Pays at 72% of billed charges with lesser of charges applied,245.88,Pays at 72% of billed charges with lesser of charges applied,245.88,Pays at 72% of billed charges with lesser of charges applied,245.88,Pays at 72% of billed charges with lesser of charges applied,245.88,Pays at 72% of billed charges with lesser of charges applied,116.25,442% of BCBS Fee Schedule,116.25,442% of BCBS Fee Schedule,116.25,442% of BCBS Fee Schedule,116.25,442% of BCBS Fee Schedule,116.25,442% of BCBS Fee Schedule,116.25,442% of BCBS Fee Schedule,116.25,442% of BCBS Fee Schedule,116.25,442% of BCBS Fee Schedule,116.25,442% of BCBS Fee Schedule,139.21,100% of BCBS Fee Schedule,139.21,100% of BCBS Fee Schedule,139.21,100% of BCBS Fee Schedule,139.21,100% of BCBS Fee Schedule,139.21,100% of BCBS Fee Schedule,286.86,84% of total billed charges,286.86,84% of total billed charges,286.86,84% of total billed charges,239.05,70% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,31.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.46,286.86,256.13
Outpatient Medical Services,RADIOLOGY,72070,"Radiologic examination of the middle spine, 2 views",320,345.25,248.58,Pays at 72% of billed charges with lesser of charges applied,135.85,100% OF CMS OPPS Rate,122.12,442% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,145.64,100% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,290.01,84% of total billed charges,290.01,84% of total billed charges,248.58,72% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% of CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,207.15,60% of total billed charges,40.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,40.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,27.67,100% OF CMS OPPS RATE,135.85,100% OF CMS OPPS Rate,241.68,70% of total billed charges,135.85,100% OF CMS OPPS Rate,163.02,120% of CMS OPPS RATE,248.58,Pays at 72% of billed charges with lesser of charges applied,248.58,Pays at 72% of billed charges with lesser of charges applied,248.58,Pays at 72% of billed charges with lesser of charges applied,248.58,Pays at 72% of billed charges with lesser of charges applied,248.58,Pays at 72% of billed charges with lesser of charges applied,248.58,Pays at 72% of billed charges with lesser of charges applied,122.12,442% of BCBS Fee Schedule,122.12,442% of BCBS Fee Schedule,122.12,442% of BCBS Fee Schedule,122.12,442% of BCBS Fee Schedule,122.12,442% of BCBS Fee Schedule,122.12,442% of BCBS Fee Schedule,122.12,442% of BCBS Fee Schedule,122.12,442% of BCBS Fee Schedule,122.12,442% of BCBS Fee Schedule,145.64,100% of BCBS Fee Schedule,145.64,100% of BCBS Fee Schedule,145.64,100% of BCBS Fee Schedule,145.64,100% of BCBS Fee Schedule,145.64,100% of BCBS Fee Schedule,290.01,84% of total billed charges,290.01,84% of total billed charges,290.01,84% of total billed charges,241.68,70% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,40.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,40.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,40.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,40.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,40.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,40.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,40.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,40.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,40.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,40.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,40.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,40.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,40.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,40.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,40.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,40.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,40.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,40.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,40.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,40.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.67,290.01,258.94
Outpatient Medical Services,RADIOLOGY,74425,XR UROGRAPHY ANTEGRADE S&I,320,355.75,256.14,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,243.41,442% of BCBS Fee Schedule,N/A,Not Separately reimbursable,291.9,100% of BCBS Fee Schedule,N/A,Not Separately reimbursable,298.83,84% of total billed charges,298.83,84% of total billed charges,256.14,72% of total billed charges,N/A,Not Separately reimbursable,355.75,100% of CMS OPPS Rate,N/A,Not Separately reimbursable,213.45,60% of total billed charges,71.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,71.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,135.57,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,249.03,70% of total billed charges,355.75,100% OF CMS OPPS Rate,355.75,120% of CMS OPPS RATE,256.14,Pays at 72% of billed charges with lesser of charges applied,256.14,Pays at 72% of billed charges with lesser of charges applied,256.14,Pays at 72% of billed charges with lesser of charges applied,256.14,Pays at 72% of billed charges with lesser of charges applied,256.14,Pays at 72% of billed charges with lesser of charges applied,256.14,Pays at 72% of billed charges with lesser of charges applied,243.41,442% of BCBS Fee Schedule,243.41,442% of BCBS Fee Schedule,243.41,442% of BCBS Fee Schedule,243.41,442% of BCBS Fee Schedule,243.41,442% of BCBS Fee Schedule,243.41,442% of BCBS Fee Schedule,243.41,442% of BCBS Fee Schedule,243.41,442% of BCBS Fee Schedule,243.41,442% of BCBS Fee Schedule,291.9,100% of BCBS Fee Schedule,291.9,100% of BCBS Fee Schedule,291.9,100% of BCBS Fee Schedule,291.9,100% of BCBS Fee Schedule,291.9,100% of BCBS Fee Schedule,298.83,84% of total billed charges,298.83,84% of total billed charges,298.83,84% of total billed charges,249.03,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,71.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,71.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,71.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,71.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,71.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,71.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,71.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,71.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,71.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,71.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,71.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,71.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,71.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,71.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,71.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,71.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,71.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,71.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,71.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,71.99,100% of CA Medicaid Fee Schedule with lesser of charges applied,71.99,355.75,266.81
Outpatient Medical Services,RADIOLOGY,73502,XR HIP 1V-LT  + AP PELVIS,320,350,252,Pays at 72% of billed charges with lesser of charges applied,110.43,100% OF CMS OPPS Rate,228.47,442% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,179.67,100% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,294,84% of total billed charges,294,84% of total billed charges,252,72% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% of CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,210,60% of total billed charges,53.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,53.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,43.19,100% OF CMS OPPS RATE,110.43,100% OF CMS OPPS Rate,245,70% of total billed charges,110.43,100% OF CMS OPPS Rate,132.51,120% of CMS OPPS RATE,252,Pays at 72% of billed charges with lesser of charges applied,252,Pays at 72% of billed charges with lesser of charges applied,252,Pays at 72% of billed charges with lesser of charges applied,252,Pays at 72% of billed charges with lesser of charges applied,252,Pays at 72% of billed charges with lesser of charges applied,252,Pays at 72% of billed charges with lesser of charges applied,228.47,442% of BCBS Fee Schedule,228.47,442% of BCBS Fee Schedule,228.47,442% of BCBS Fee Schedule,228.47,442% of BCBS Fee Schedule,228.47,442% of BCBS Fee Schedule,228.47,442% of BCBS Fee Schedule,228.47,442% of BCBS Fee Schedule,228.47,442% of BCBS Fee Schedule,228.47,442% of BCBS Fee Schedule,179.67,100% of BCBS Fee Schedule,179.67,100% of BCBS Fee Schedule,179.67,100% of BCBS Fee Schedule,179.67,100% of BCBS Fee Schedule,179.67,100% of BCBS Fee Schedule,294,84% of total billed charges,294,84% of total billed charges,294,84% of total billed charges,245,70% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,53.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,53.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,53.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,53.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,53.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,53.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,53.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,53.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,53.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,53.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,53.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,53.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,53.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,53.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,53.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,53.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,53.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,53.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,53.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,53.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,43.19,294.00,262.5
Outpatient Medical Services,RADIOLOGY,13940,DUPLICATION (PER FILM) #1,320,51.5,37.08,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,42.08,81.7% of total Billed charges,N/A,Not Separately reimbursable,40.74,79.1% of total billed charges,N/A,Not Separately reimbursable,43.26,84% of total billed charges,43.26,84% of total billed charges,37.08,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,30.9,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,36.05,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,37.08,Pays at 72% of billed charges with lesser of charges applied,37.08,Pays at 72% of billed charges with lesser of charges applied,37.08,Pays at 72% of billed charges with lesser of charges applied,37.08,Pays at 72% of billed charges with lesser of charges applied,37.08,Pays at 72% of billed charges with lesser of charges applied,37.08,Pays at 72% of billed charges with lesser of charges applied,42.08,81.7% of total Billed charges,42.08,81.7% of total Billed charges,42.08,81.7% of total Billed charges,42.08,81.7% of total Billed charges,42.08,81.7% of total Billed charges,42.08,81.7% of total Billed charges,42.08,81.7% of total Billed charges,42.08,81.7% of total Billed charges,42.08,81.7% of total Billed charges,40.74,79.1% of total billed charges,40.74,79.1% of total billed charges,40.74,79.1% of total billed charges,40.74,79.1% of total billed charges,40.74,79.1% of total billed charges,43.26,84% of total billed charges,43.26,84% of total billed charges,43.26,84% of total billed charges,36.05,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,30.90,43.26,38.63
Outpatient Medical Services,RADIOLOGY,74328,ERCP BILIARY DUCT IMAGING,320,2416,1739.52,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,588.39,442% of BCBS Fee Schedule,N/A,Not Separately reimbursable,706.44,100% of BCBS Fee Schedule,N/A,Not Separately reimbursable,2029.44,84% of total billed charges,2029.44,84% of total billed charges,1739.52,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,1449.6,60% of total billed charges,165.14,100% of CA Medicaid Fee Schedule with lesser of charges applied,165.14,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,1691.2,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,1739.52,Pays at 72% of billed charges with lesser of charges applied,1739.52,Pays at 72% of billed charges with lesser of charges applied,1739.52,Pays at 72% of billed charges with lesser of charges applied,1739.52,Pays at 72% of billed charges with lesser of charges applied,1739.52,Pays at 72% of billed charges with lesser of charges applied,1739.52,Pays at 72% of billed charges with lesser of charges applied,588.39,442% of BCBS Fee Schedule,588.39,442% of BCBS Fee Schedule,588.39,442% of BCBS Fee Schedule,588.39,442% of BCBS Fee Schedule,588.39,442% of BCBS Fee Schedule,588.39,442% of BCBS Fee Schedule,588.39,442% of BCBS Fee Schedule,588.39,442% of BCBS Fee Schedule,588.39,442% of BCBS Fee Schedule,706.44,100% of BCBS Fee Schedule,706.44,100% of BCBS Fee Schedule,706.44,100% of BCBS Fee Schedule,706.44,100% of BCBS Fee Schedule,706.44,100% of BCBS Fee Schedule,2029.44,84% of total billed charges,2029.44,84% of total billed charges,2029.44,84% of total billed charges,1691.2,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,165.14,100% of CA Medicaid Fee Schedule with lesser of charges applied,165.14,100% of CA Medicaid Fee Schedule with lesser of charges applied,165.14,100% of CA Medicaid Fee Schedule with lesser of charges applied,165.14,100% of CA Medicaid Fee Schedule with lesser of charges applied,165.14,100% of CA Medicaid Fee Schedule with lesser of charges applied,165.14,100% of CA Medicaid Fee Schedule with lesser of charges applied,165.14,100% of CA Medicaid Fee Schedule with lesser of charges applied,165.14,100% of CA Medicaid Fee Schedule with lesser of charges applied,165.14,100% of CA Medicaid Fee Schedule with lesser of charges applied,165.14,100% of CA Medicaid Fee Schedule with lesser of charges applied,165.14,100% of CA Medicaid Fee Schedule with lesser of charges applied,165.14,100% of CA Medicaid Fee Schedule with lesser of charges applied,165.14,100% of CA Medicaid Fee Schedule with lesser of charges applied,165.14,100% of CA Medicaid Fee Schedule with lesser of charges applied,165.14,100% of CA Medicaid Fee Schedule with lesser of charges applied,165.14,100% of CA Medicaid Fee Schedule with lesser of charges applied,165.14,100% of CA Medicaid Fee Schedule with lesser of charges applied,165.14,100% of CA Medicaid Fee Schedule with lesser of charges applied,165.14,100% of CA Medicaid Fee Schedule with lesser of charges applied,165.14,100% of CA Medicaid Fee Schedule with lesser of charges applied,165.14,2029.44,1812
Outpatient Medical Services,RADIOLOGY,73522,HIPS BILAT 1V + AP PELVIS,320,377,271.44,Pays at 72% of billed charges with lesser of charges applied,135.85,100% OF CMS OPPS Rate,256.09,442% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,201.13,100% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,316.68,84% of total billed charges,316.68,84% of total billed charges,271.44,72% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% of CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,226.2,60% of total billed charges,62.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,62.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,47.18,100% OF CMS OPPS RATE,135.85,100% OF CMS OPPS Rate,263.9,70% of total billed charges,135.85,100% OF CMS OPPS Rate,163.02,120% of CMS OPPS RATE,271.44,Pays at 72% of billed charges with lesser of charges applied,271.44,Pays at 72% of billed charges with lesser of charges applied,271.44,Pays at 72% of billed charges with lesser of charges applied,271.44,Pays at 72% of billed charges with lesser of charges applied,271.44,Pays at 72% of billed charges with lesser of charges applied,271.44,Pays at 72% of billed charges with lesser of charges applied,256.09,442% of BCBS Fee Schedule,256.09,442% of BCBS Fee Schedule,256.09,442% of BCBS Fee Schedule,256.09,442% of BCBS Fee Schedule,256.09,442% of BCBS Fee Schedule,256.09,442% of BCBS Fee Schedule,256.09,442% of BCBS Fee Schedule,256.09,442% of BCBS Fee Schedule,256.09,442% of BCBS Fee Schedule,201.13,100% of BCBS Fee Schedule,201.13,100% of BCBS Fee Schedule,201.13,100% of BCBS Fee Schedule,201.13,100% of BCBS Fee Schedule,201.13,100% of BCBS Fee Schedule,316.68,84% of total billed charges,316.68,84% of total billed charges,316.68,84% of total billed charges,263.9,70% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,62.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,62.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,62.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,62.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,62.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,62.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,62.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,62.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,62.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,62.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,62.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,62.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,62.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,62.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,62.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,62.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,62.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,62.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,62.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,62.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,47.18,316.68,282.75
Outpatient Medical Services,RADIOLOGY,74210,PHARANX OR CERVICAL ESOPH,320,324,233.28,Pays at 72% of billed charges with lesser of charges applied,229.22,100% OF CMS OPPS Rate,204.6,442% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,264.61,100% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,272.16,84% of total billed charges,272.16,84% of total billed charges,233.28,72% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% of CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,194.4,60% of total billed charges,54.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,82.61,100% OF CMS OPPS RATE,229.22,100% OF CMS OPPS Rate,226.8,70% of total billed charges,229.22,100% OF CMS OPPS Rate,275.07,120% of CMS OPPS RATE,233.28,Pays at 72% of billed charges with lesser of charges applied,233.28,Pays at 72% of billed charges with lesser of charges applied,233.28,Pays at 72% of billed charges with lesser of charges applied,233.28,Pays at 72% of billed charges with lesser of charges applied,233.28,Pays at 72% of billed charges with lesser of charges applied,233.28,Pays at 72% of billed charges with lesser of charges applied,204.6,442% of BCBS Fee Schedule,204.6,442% of BCBS Fee Schedule,204.6,442% of BCBS Fee Schedule,204.6,442% of BCBS Fee Schedule,204.6,442% of BCBS Fee Schedule,204.6,442% of BCBS Fee Schedule,204.6,442% of BCBS Fee Schedule,204.6,442% of BCBS Fee Schedule,204.6,442% of BCBS Fee Schedule,264.61,100% of BCBS Fee Schedule,264.61,100% of BCBS Fee Schedule,264.61,100% of BCBS Fee Schedule,264.61,100% of BCBS Fee Schedule,264.61,100% of BCBS Fee Schedule,272.16,84% of total billed charges,272.16,84% of total billed charges,272.16,84% of total billed charges,226.8,70% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,54.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.64,275.07,243
Outpatient Medical Services,RADIOLOGY,74360,XR INTRALUMINAL DILAT S&I,320,442.5,318.6,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,442.5,BCBS Fee Schedule,N/A,Not Separately reimbursable,434.09,pays at 100% of bcbs fee schedule with lesser of charges applied,N/A,Not Separately reimbursable,371.7,84% of total billed charges,371.7,84% of total billed charges,318.6,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,265.5,60% of total billed charges,156.32,100% of CA Medicaid Fee Schedule with lesser of charges applied,156.32,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,309.75,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,318.6,Pays at 72% of billed charges with lesser of charges applied,318.6,Pays at 72% of billed charges with lesser of charges applied,318.6,Pays at 72% of billed charges with lesser of charges applied,318.6,Pays at 72% of billed charges with lesser of charges applied,318.6,Pays at 72% of billed charges with lesser of charges applied,318.6,Pays at 72% of billed charges with lesser of charges applied,442.5,BCBS Fee Schedule,442.5,BCBS Fee Schedule,442.5,BCBS Fee Schedule,442.5,BCBS Fee Schedule,442.5,BCBS Fee Schedule,442.5,BCBS Fee Schedule,442.5,BCBS Fee Schedule,442.5,BCBS Fee Schedule,442.5,BCBS Fee Schedule,434.09,pays at 100% of bcbs fee schedule with lesser of charges applied,434.09,pays at 100% of bcbs fee schedule with lesser of charges applied,434.09,pays at 100% of bcbs fee schedule with lesser of charges applied,434.09,pays at 100% of bcbs fee schedule with lesser of charges applied,434.09,pays at 100% of bcbs fee schedule with lesser of charges applied,371.7,84% of total billed charges,371.7,84% of total billed charges,371.7,84% of total billed charges,309.75,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,156.32,100% of CA Medicaid Fee Schedule with lesser of charges applied,156.32,100% of CA Medicaid Fee Schedule with lesser of charges applied,156.32,100% of CA Medicaid Fee Schedule with lesser of charges applied,156.32,100% of CA Medicaid Fee Schedule with lesser of charges applied,156.32,100% of CA Medicaid Fee Schedule with lesser of charges applied,156.32,100% of CA Medicaid Fee Schedule with lesser of charges applied,156.32,100% of CA Medicaid Fee Schedule with lesser of charges applied,156.32,100% of CA Medicaid Fee Schedule with lesser of charges applied,156.32,100% of CA Medicaid Fee Schedule with lesser of charges applied,156.32,100% of CA Medicaid Fee Schedule with lesser of charges applied,156.32,100% of CA Medicaid Fee Schedule with lesser of charges applied,156.32,100% of CA Medicaid Fee Schedule with lesser of charges applied,156.32,100% of CA Medicaid Fee Schedule with lesser of charges applied,156.32,100% of CA Medicaid Fee Schedule with lesser of charges applied,156.32,100% of CA Medicaid Fee Schedule with lesser of charges applied,156.32,100% of CA Medicaid Fee Schedule with lesser of charges applied,156.32,100% of CA Medicaid Fee Schedule with lesser of charges applied,156.32,100% of CA Medicaid Fee Schedule with lesser of charges applied,156.32,100% of CA Medicaid Fee Schedule with lesser of charges applied,156.32,100% of CA Medicaid Fee Schedule with lesser of charges applied,156.32,442.50,331.88
Outpatient Medical Services,RADIOLOGY,73050,A-C JTS BILAT. W=W\O WTS,320,380.25,273.78,Pays at 72% of billed charges with lesser of charges applied,110.43,100% OF CMS OPPS Rate,125.88,442% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,149.94,100% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,319.41,84% of total billed charges,319.41,84% of total billed charges,273.78,72% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% of CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,228.15,60% of total billed charges,37.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,23.29,100% OF CMS OPPS RATE,110.43,100% OF CMS OPPS Rate,266.18,70% of total billed charges,110.43,100% OF CMS OPPS Rate,132.51,120% of CMS OPPS RATE,273.78,Pays at 72% of billed charges with lesser of charges applied,273.78,Pays at 72% of billed charges with lesser of charges applied,273.78,Pays at 72% of billed charges with lesser of charges applied,273.78,Pays at 72% of billed charges with lesser of charges applied,273.78,Pays at 72% of billed charges with lesser of charges applied,273.78,Pays at 72% of billed charges with lesser of charges applied,125.88,442% of BCBS Fee Schedule,125.88,442% of BCBS Fee Schedule,125.88,442% of BCBS Fee Schedule,125.88,442% of BCBS Fee Schedule,125.88,442% of BCBS Fee Schedule,125.88,442% of BCBS Fee Schedule,125.88,442% of BCBS Fee Schedule,125.88,442% of BCBS Fee Schedule,125.88,442% of BCBS Fee Schedule,149.94,100% of BCBS Fee Schedule,149.94,100% of BCBS Fee Schedule,149.94,100% of BCBS Fee Schedule,149.94,100% of BCBS Fee Schedule,149.94,100% of BCBS Fee Schedule,319.41,84% of total billed charges,319.41,84% of total billed charges,319.41,84% of total billed charges,266.18,70% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,37.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.15,100% of CA Medicaid Fee Schedule with lesser of charges applied,23.29,319.41,285.19
Outpatient Medical Services,RADIOLOGY,73610,Radiologic examination of the ankle with 3 views,320,498.25,358.74,Pays at 72% of billed charges with lesser of charges applied,110.43,100% OF CMS OPPS Rate,99.63,442% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,116.82,100% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,418.53,84% of total billed charges,418.53,84% of total billed charges,358.74,72% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% of CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,298.95,60% of total billed charges,36.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,34.04,100% OF CMS OPPS RATE,110.43,100% OF CMS OPPS Rate,348.78,70% of total billed charges,110.43,100% OF CMS OPPS Rate,132.51,120% of CMS OPPS RATE,358.74,Pays at 72% of billed charges with lesser of charges applied,358.74,Pays at 72% of billed charges with lesser of charges applied,358.74,Pays at 72% of billed charges with lesser of charges applied,358.74,Pays at 72% of billed charges with lesser of charges applied,358.74,Pays at 72% of billed charges with lesser of charges applied,358.74,Pays at 72% of billed charges with lesser of charges applied,99.63,442% of BCBS Fee Schedule,99.63,442% of BCBS Fee Schedule,99.63,442% of BCBS Fee Schedule,99.63,442% of BCBS Fee Schedule,99.63,442% of BCBS Fee Schedule,99.63,442% of BCBS Fee Schedule,99.63,442% of BCBS Fee Schedule,99.63,442% of BCBS Fee Schedule,99.63,442% of BCBS Fee Schedule,116.82,100% of BCBS Fee Schedule,116.82,100% of BCBS Fee Schedule,116.82,100% of BCBS Fee Schedule,116.82,100% of BCBS Fee Schedule,116.82,100% of BCBS Fee Schedule,418.53,84% of total billed charges,418.53,84% of total billed charges,418.53,84% of total billed charges,348.78,70% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,36.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,34.04,418.53,373.69
Outpatient Medical Services,RADIOLOGY,73080,"Radiologic examination, elbow; 3 or more views",320,529,380.88,Pays at 72% of billed charges with lesser of charges applied,110.43,100% OF CMS OPPS Rate,107.14,442% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,128.47,100% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,444.36,84% of total billed charges,444.36,84% of total billed charges,380.88,72% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% of CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,317.4,60% of total billed charges,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,28.86,100% OF CMS OPPS RATE,110.43,100% OF CMS OPPS Rate,370.3,70% of total billed charges,110.43,100% OF CMS OPPS Rate,132.51,120% of CMS OPPS RATE,380.88,Pays at 72% of billed charges with lesser of charges applied,380.88,Pays at 72% of billed charges with lesser of charges applied,380.88,Pays at 72% of billed charges with lesser of charges applied,380.88,Pays at 72% of billed charges with lesser of charges applied,380.88,Pays at 72% of billed charges with lesser of charges applied,380.88,Pays at 72% of billed charges with lesser of charges applied,107.14,442% of BCBS Fee Schedule,107.14,442% of BCBS Fee Schedule,107.14,442% of BCBS Fee Schedule,107.14,442% of BCBS Fee Schedule,107.14,442% of BCBS Fee Schedule,107.14,442% of BCBS Fee Schedule,107.14,442% of BCBS Fee Schedule,107.14,442% of BCBS Fee Schedule,107.14,442% of BCBS Fee Schedule,128.47,100% of BCBS Fee Schedule,128.47,100% of BCBS Fee Schedule,128.47,100% of BCBS Fee Schedule,128.47,100% of BCBS Fee Schedule,128.47,100% of BCBS Fee Schedule,444.36,84% of total billed charges,444.36,84% of total billed charges,444.36,84% of total billed charges,370.3,70% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.86,444.36,396.75
Outpatient Medical Services,RADIOLOGY,70380,SALIVARY GLAND R/O STONE,320,246.5,177.48,Pays at 72% of billed charges with lesser of charges applied,110.43,100% OF CMS OPPS Rate,125.31,442% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,149.94,100% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,207.06,84% of total billed charges,207.06,84% of total billed charges,177.48,72% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% of CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,147.9,60% of total billed charges,39.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,35.23,100% OF CMS OPPS RATE,110.43,100% OF CMS OPPS Rate,172.55,70% of total billed charges,110.43,100% OF CMS OPPS Rate,132.51,120% of CMS OPPS RATE,177.48,Pays at 72% of billed charges with lesser of charges applied,177.48,Pays at 72% of billed charges with lesser of charges applied,177.48,Pays at 72% of billed charges with lesser of charges applied,177.48,Pays at 72% of billed charges with lesser of charges applied,177.48,Pays at 72% of billed charges with lesser of charges applied,177.48,Pays at 72% of billed charges with lesser of charges applied,125.31,442% of BCBS Fee Schedule,125.31,442% of BCBS Fee Schedule,125.31,442% of BCBS Fee Schedule,125.31,442% of BCBS Fee Schedule,125.31,442% of BCBS Fee Schedule,125.31,442% of BCBS Fee Schedule,125.31,442% of BCBS Fee Schedule,125.31,442% of BCBS Fee Schedule,125.31,442% of BCBS Fee Schedule,149.94,100% of BCBS Fee Schedule,149.94,100% of BCBS Fee Schedule,149.94,100% of BCBS Fee Schedule,149.94,100% of BCBS Fee Schedule,149.94,100% of BCBS Fee Schedule,207.06,84% of total billed charges,207.06,84% of total billed charges,207.06,84% of total billed charges,172.55,70% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,39.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.73,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.23,207.06,184.88
Outpatient Medical Services,RADIOLOGY,75896,TRANS CATH THERAPY - SNI,320,467,336.24,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,467,BCBS Fee Schedule,N/A,Not Separately reimbursable,369.4,79.1% of total billed charges,N/A,Not Separately reimbursable,392.28,84% of total billed charges,392.28,84% of total billed charges,336.24,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,280.2,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,326.9,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,336.24,Pays at 72% of billed charges with lesser of charges applied,336.24,Pays at 72% of billed charges with lesser of charges applied,336.24,Pays at 72% of billed charges with lesser of charges applied,336.24,Pays at 72% of billed charges with lesser of charges applied,336.24,Pays at 72% of billed charges with lesser of charges applied,336.24,Pays at 72% of billed charges with lesser of charges applied,467,BCBS Fee Schedule,467,BCBS Fee Schedule,467,BCBS Fee Schedule,467,BCBS Fee Schedule,467,BCBS Fee Schedule,467,BCBS Fee Schedule,467,BCBS Fee Schedule,467,BCBS Fee Schedule,467,BCBS Fee Schedule,369.4,79.1% of total billed charges,369.4,79.1% of total billed charges,369.4,79.1% of total billed charges,369.4,79.1% of total billed charges,369.4,79.1% of total billed charges,392.28,84% of total billed charges,392.28,84% of total billed charges,392.28,84% of total billed charges,326.9,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,280.20,467.00,350.25
Outpatient Medical Services,RADIOLOGY,74455,VOIDING CYSTOURETHROGRAM,320,752.25,541.62,Pays at 72% of billed charges with lesser of charges applied,296.82,100% OF CMS OPPS Rate,296.41,442% of BCBS Fee Schedule,296.82,100% OF CMS OPPS Rate,354.45,100% of BCBS Fee Schedule,296.82,100% OF CMS OPPS Rate,631.89,84% of total billed charges,631.89,84% of total billed charges,541.62,72% of total billed charges,296.82,100% OF CMS OPPS Rate,296.82,100% of CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,451.35,60% of total billed charges,86.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,86.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,106.9,100% OF CMS OPPS RATE,296.82,100% OF CMS OPPS Rate,526.58,70% of total billed charges,296.82,100% OF CMS OPPS Rate,356.18,120% of CMS OPPS RATE,541.62,Pays at 72% of billed charges with lesser of charges applied,541.62,Pays at 72% of billed charges with lesser of charges applied,541.62,Pays at 72% of billed charges with lesser of charges applied,541.62,Pays at 72% of billed charges with lesser of charges applied,541.62,Pays at 72% of billed charges with lesser of charges applied,541.62,Pays at 72% of billed charges with lesser of charges applied,296.41,442% of BCBS Fee Schedule,296.41,442% of BCBS Fee Schedule,296.41,442% of BCBS Fee Schedule,296.41,442% of BCBS Fee Schedule,296.41,442% of BCBS Fee Schedule,296.41,442% of BCBS Fee Schedule,296.41,442% of BCBS Fee Schedule,296.41,442% of BCBS Fee Schedule,296.41,442% of BCBS Fee Schedule,354.45,100% of BCBS Fee Schedule,354.45,100% of BCBS Fee Schedule,354.45,100% of BCBS Fee Schedule,354.45,100% of BCBS Fee Schedule,354.45,100% of BCBS Fee Schedule,631.89,84% of total billed charges,631.89,84% of total billed charges,631.89,84% of total billed charges,526.58,70% of total billed charges,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,86.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,86.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,86.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,86.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,86.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,86.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,86.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,86.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,86.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,86.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,86.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,86.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,86.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,86.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,86.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,86.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,86.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,86.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,86.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,86.91,100% of CA Medicaid Fee Schedule with lesser of charges applied,86.91,631.89,564.19
Outpatient Medical Services,RADIOLOGY,73110,Up to 3 views,320,529,380.88,Pays at 72% of billed charges with lesser of charges applied,110.43,100% OF CMS OPPS Rate,99.63,442% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,116.82,100% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,444.36,84% of total billed charges,444.36,84% of total billed charges,380.88,72% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% of CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,317.4,60% of total billed charges,36.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,38.81,100% OF CMS OPPS RATE,110.43,100% OF CMS OPPS Rate,370.3,70% of total billed charges,110.43,100% OF CMS OPPS Rate,132.51,120% of CMS OPPS RATE,380.88,Pays at 72% of billed charges with lesser of charges applied,380.88,Pays at 72% of billed charges with lesser of charges applied,380.88,Pays at 72% of billed charges with lesser of charges applied,380.88,Pays at 72% of billed charges with lesser of charges applied,380.88,Pays at 72% of billed charges with lesser of charges applied,380.88,Pays at 72% of billed charges with lesser of charges applied,99.63,442% of BCBS Fee Schedule,99.63,442% of BCBS Fee Schedule,99.63,442% of BCBS Fee Schedule,99.63,442% of BCBS Fee Schedule,99.63,442% of BCBS Fee Schedule,99.63,442% of BCBS Fee Schedule,99.63,442% of BCBS Fee Schedule,99.63,442% of BCBS Fee Schedule,99.63,442% of BCBS Fee Schedule,116.82,100% of BCBS Fee Schedule,116.82,100% of BCBS Fee Schedule,116.82,100% of BCBS Fee Schedule,116.82,100% of BCBS Fee Schedule,116.82,100% of BCBS Fee Schedule,444.36,84% of total billed charges,444.36,84% of total billed charges,444.36,84% of total billed charges,370.3,70% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,36.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.06,444.36,396.75
Outpatient Medical Services,RADIOLOGY,74280,BARIUM ENEMA W/AIR CONT,320,948,682.56,Pays at 72% of billed charges with lesser of charges applied,229.22,100% OF CMS OPPS Rate,363.15,442% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,500.71,100% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,796.32,84% of total billed charges,796.32,84% of total billed charges,682.56,72% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% of CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,568.8,60% of total billed charges,90.14,100% of CA Medicaid Fee Schedule with lesser of charges applied,90.14,100% of CA Medicaid Fee Schedule with lesser of charges applied,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,196.69,100% OF CMS OPPS RATE,229.22,100% OF CMS OPPS Rate,663.6,70% of total billed charges,229.22,100% OF CMS OPPS Rate,275.07,120% of CMS OPPS RATE,682.56,Pays at 72% of billed charges with lesser of charges applied,682.56,Pays at 72% of billed charges with lesser of charges applied,682.56,Pays at 72% of billed charges with lesser of charges applied,682.56,Pays at 72% of billed charges with lesser of charges applied,682.56,Pays at 72% of billed charges with lesser of charges applied,682.56,Pays at 72% of billed charges with lesser of charges applied,363.15,442% of BCBS Fee Schedule,363.15,442% of BCBS Fee Schedule,363.15,442% of BCBS Fee Schedule,363.15,442% of BCBS Fee Schedule,363.15,442% of BCBS Fee Schedule,363.15,442% of BCBS Fee Schedule,363.15,442% of BCBS Fee Schedule,363.15,442% of BCBS Fee Schedule,363.15,442% of BCBS Fee Schedule,500.71,100% of BCBS Fee Schedule,500.71,100% of BCBS Fee Schedule,500.71,100% of BCBS Fee Schedule,500.71,100% of BCBS Fee Schedule,500.71,100% of BCBS Fee Schedule,796.32,84% of total billed charges,796.32,84% of total billed charges,796.32,84% of total billed charges,663.6,70% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,90.14,100% of CA Medicaid Fee Schedule with lesser of charges applied,90.14,100% of CA Medicaid Fee Schedule with lesser of charges applied,90.14,100% of CA Medicaid Fee Schedule with lesser of charges applied,90.14,100% of CA Medicaid Fee Schedule with lesser of charges applied,90.14,100% of CA Medicaid Fee Schedule with lesser of charges applied,90.14,100% of CA Medicaid Fee Schedule with lesser of charges applied,90.14,100% of CA Medicaid Fee Schedule with lesser of charges applied,90.14,100% of CA Medicaid Fee Schedule with lesser of charges applied,90.14,100% of CA Medicaid Fee Schedule with lesser of charges applied,90.14,100% of CA Medicaid Fee Schedule with lesser of charges applied,90.14,100% of CA Medicaid Fee Schedule with lesser of charges applied,90.14,100% of CA Medicaid Fee Schedule with lesser of charges applied,90.14,100% of CA Medicaid Fee Schedule with lesser of charges applied,90.14,100% of CA Medicaid Fee Schedule with lesser of charges applied,90.14,100% of CA Medicaid Fee Schedule with lesser of charges applied,90.14,100% of CA Medicaid Fee Schedule with lesser of charges applied,90.14,100% of CA Medicaid Fee Schedule with lesser of charges applied,90.14,100% of CA Medicaid Fee Schedule with lesser of charges applied,90.14,100% of CA Medicaid Fee Schedule with lesser of charges applied,90.14,100% of CA Medicaid Fee Schedule with lesser of charges applied,90.14,796.32,711
Outpatient Medical Services,RADIOLOGY,77075,BONE SURVEY (METS) COMP,320,882.75,635.58,Pays at 72% of billed charges with lesser of charges applied,135.85,100% OF CMS OPPS Rate,271.03,442% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,437.23,100% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,741.51,84% of total billed charges,741.51,84% of total billed charges,635.58,72% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% of CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,529.65,60% of total billed charges,112.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,112.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,87.59,100% OF CMS OPPS RATE,135.85,100% OF CMS OPPS Rate,617.93,70% of total billed charges,135.85,100% OF CMS OPPS Rate,163.02,120% of CMS OPPS RATE,635.58,Pays at 72% of billed charges with lesser of charges applied,635.58,Pays at 72% of billed charges with lesser of charges applied,635.58,Pays at 72% of billed charges with lesser of charges applied,635.58,Pays at 72% of billed charges with lesser of charges applied,635.58,Pays at 72% of billed charges with lesser of charges applied,635.58,Pays at 72% of billed charges with lesser of charges applied,271.03,442% of BCBS Fee Schedule,271.03,442% of BCBS Fee Schedule,271.03,442% of BCBS Fee Schedule,271.03,442% of BCBS Fee Schedule,271.03,442% of BCBS Fee Schedule,271.03,442% of BCBS Fee Schedule,271.03,442% of BCBS Fee Schedule,271.03,442% of BCBS Fee Schedule,271.03,442% of BCBS Fee Schedule,437.23,100% of BCBS Fee Schedule,437.23,100% of BCBS Fee Schedule,437.23,100% of BCBS Fee Schedule,437.23,100% of BCBS Fee Schedule,437.23,100% of BCBS Fee Schedule,741.51,84% of total billed charges,741.51,84% of total billed charges,741.51,84% of total billed charges,617.93,70% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,112.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,112.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,112.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,112.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,112.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,112.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,112.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,112.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,112.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,112.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,112.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,112.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,112.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,112.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,112.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,112.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,112.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,112.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,112.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,112.60,100% of CA Medicaid Fee Schedule with lesser of charges applied,87.59,741.51,662.06
Outpatient Medical Services,RADIOLOGY,74221,ESOPHAGRAM AIR CONTRAST,320,467,336.24,Pays at 72% of billed charges with lesser of charges applied,229.22,100% OF CMS OPPS Rate,371.55,442% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,443.64,100% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,392.28,84% of total billed charges,392.28,84% of total billed charges,336.24,72% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% of CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,280.2,60% of total billed charges,142.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,142.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,94.16,100% OF CMS OPPS RATE,229.22,100% OF CMS OPPS Rate,326.9,70% of total billed charges,229.22,100% OF CMS OPPS Rate,275.07,120% of CMS OPPS RATE,336.24,Pays at 72% of billed charges with lesser of charges applied,336.24,Pays at 72% of billed charges with lesser of charges applied,336.24,Pays at 72% of billed charges with lesser of charges applied,336.24,Pays at 72% of billed charges with lesser of charges applied,336.24,Pays at 72% of billed charges with lesser of charges applied,336.24,Pays at 72% of billed charges with lesser of charges applied,371.55,442% of BCBS Fee Schedule,371.55,442% of BCBS Fee Schedule,371.55,442% of BCBS Fee Schedule,371.55,442% of BCBS Fee Schedule,371.55,442% of BCBS Fee Schedule,371.55,442% of BCBS Fee Schedule,371.55,442% of BCBS Fee Schedule,371.55,442% of BCBS Fee Schedule,371.55,442% of BCBS Fee Schedule,443.64,100% of BCBS Fee Schedule,443.64,100% of BCBS Fee Schedule,443.64,100% of BCBS Fee Schedule,443.64,100% of BCBS Fee Schedule,443.64,100% of BCBS Fee Schedule,392.28,84% of total billed charges,392.28,84% of total billed charges,392.28,84% of total billed charges,326.9,70% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,142.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,142.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,142.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,142.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,142.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,142.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,142.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,142.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,142.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,142.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,142.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,142.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,142.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,142.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,142.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,142.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,142.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,142.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,142.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,142.57,100% of CA Medicaid Fee Schedule with lesser of charges applied,94.16,443.64,350.25
Outpatient Medical Services,RADIOLOGY,73130,X-ray of the hand with 3 or more views,320,529,380.88,Pays at 72% of billed charges with lesser of charges applied,110.43,100% OF CMS OPPS Rate,99.63,442% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,116.82,100% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,444.36,84% of total billed charges,444.36,84% of total billed charges,380.88,72% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% of CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,317.4,60% of total billed charges,36.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,34.04,100% OF CMS OPPS RATE,110.43,100% OF CMS OPPS Rate,370.3,70% of total billed charges,110.43,100% OF CMS OPPS Rate,132.51,120% of CMS OPPS RATE,380.88,Pays at 72% of billed charges with lesser of charges applied,380.88,Pays at 72% of billed charges with lesser of charges applied,380.88,Pays at 72% of billed charges with lesser of charges applied,380.88,Pays at 72% of billed charges with lesser of charges applied,380.88,Pays at 72% of billed charges with lesser of charges applied,380.88,Pays at 72% of billed charges with lesser of charges applied,99.63,442% of BCBS Fee Schedule,99.63,442% of BCBS Fee Schedule,99.63,442% of BCBS Fee Schedule,99.63,442% of BCBS Fee Schedule,99.63,442% of BCBS Fee Schedule,99.63,442% of BCBS Fee Schedule,99.63,442% of BCBS Fee Schedule,99.63,442% of BCBS Fee Schedule,99.63,442% of BCBS Fee Schedule,116.82,100% of BCBS Fee Schedule,116.82,100% of BCBS Fee Schedule,116.82,100% of BCBS Fee Schedule,116.82,100% of BCBS Fee Schedule,116.82,100% of BCBS Fee Schedule,444.36,84% of total billed charges,444.36,84% of total billed charges,444.36,84% of total billed charges,370.3,70% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,36.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,34.04,444.36,396.75
Outpatient Medical Services,RADIOLOGY,71110,RIBS COMPLETE BILATERAL,320,585.5,421.56,Pays at 72% of billed charges with lesser of charges applied,135.85,100% OF CMS OPPS Rate,148.38,442% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,177.23,100% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,491.82,84% of total billed charges,491.82,84% of total billed charges,421.56,72% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% of CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,351.3,60% of total billed charges,47.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,47.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,36.03,100% OF CMS OPPS RATE,135.85,100% OF CMS OPPS Rate,409.85,70% of total billed charges,135.85,100% OF CMS OPPS Rate,163.02,120% of CMS OPPS RATE,421.56,Pays at 72% of billed charges with lesser of charges applied,421.56,Pays at 72% of billed charges with lesser of charges applied,421.56,Pays at 72% of billed charges with lesser of charges applied,421.56,Pays at 72% of billed charges with lesser of charges applied,421.56,Pays at 72% of billed charges with lesser of charges applied,421.56,Pays at 72% of billed charges with lesser of charges applied,148.38,442% of BCBS Fee Schedule,148.38,442% of BCBS Fee Schedule,148.38,442% of BCBS Fee Schedule,148.38,442% of BCBS Fee Schedule,148.38,442% of BCBS Fee Schedule,148.38,442% of BCBS Fee Schedule,148.38,442% of BCBS Fee Schedule,148.38,442% of BCBS Fee Schedule,148.38,442% of BCBS Fee Schedule,177.23,100% of BCBS Fee Schedule,177.23,100% of BCBS Fee Schedule,177.23,100% of BCBS Fee Schedule,177.23,100% of BCBS Fee Schedule,177.23,100% of BCBS Fee Schedule,491.82,84% of total billed charges,491.82,84% of total billed charges,491.82,84% of total billed charges,409.85,70% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,47.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,47.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,47.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,47.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,47.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,47.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,47.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,47.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,47.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,47.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,47.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,47.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,47.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,47.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,47.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,47.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,47.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,47.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,47.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,47.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.03,491.82,439.13
Outpatient Medical Services,RADIOLOGY,72081,SCOLIOSIS SERIES 2 VIEW,320,286.5,206.28,Pays at 72% of billed charges with lesser of charges applied,110.43,100% OF CMS OPPS Rate,192.67,442% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,151.77,100% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,240.66,84% of total billed charges,240.66,84% of total billed charges,206.28,72% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% of CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,171.9,60% of total billed charges,49.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,36.03,100% OF CMS OPPS RATE,110.43,100% OF CMS OPPS Rate,200.55,70% of total billed charges,110.43,100% OF CMS OPPS Rate,132.51,120% of CMS OPPS RATE,206.28,Pays at 72% of billed charges with lesser of charges applied,206.28,Pays at 72% of billed charges with lesser of charges applied,206.28,Pays at 72% of billed charges with lesser of charges applied,206.28,Pays at 72% of billed charges with lesser of charges applied,206.28,Pays at 72% of billed charges with lesser of charges applied,206.28,Pays at 72% of billed charges with lesser of charges applied,192.67,442% of BCBS Fee Schedule,192.67,442% of BCBS Fee Schedule,192.67,442% of BCBS Fee Schedule,192.67,442% of BCBS Fee Schedule,192.67,442% of BCBS Fee Schedule,192.67,442% of BCBS Fee Schedule,192.67,442% of BCBS Fee Schedule,192.67,442% of BCBS Fee Schedule,192.67,442% of BCBS Fee Schedule,151.77,100% of BCBS Fee Schedule,151.77,100% of BCBS Fee Schedule,151.77,100% of BCBS Fee Schedule,151.77,100% of BCBS Fee Schedule,151.77,100% of BCBS Fee Schedule,240.66,84% of total billed charges,240.66,84% of total billed charges,240.66,84% of total billed charges,200.55,70% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,49.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.80,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.03,240.66,214.88
Outpatient Medical Services,RADIOLOGY,72082,SCOLIOSIS SERIES 2 VIEW,320,330.5,237.96,Pays at 72% of billed charges with lesser of charges applied,135.85,100% OF CMS OPPS Rate,330.5,BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,276.24,100% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,277.62,84% of total billed charges,277.62,84% of total billed charges,237.96,72% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% of CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,198.3,60% of total billed charges,80.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,80.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,65.89,100% OF CMS OPPS RATE,135.85,100% OF CMS OPPS Rate,231.35,70% of total billed charges,135.85,100% OF CMS OPPS Rate,163.02,120% of CMS OPPS RATE,237.96,Pays at 72% of billed charges with lesser of charges applied,237.96,Pays at 72% of billed charges with lesser of charges applied,237.96,Pays at 72% of billed charges with lesser of charges applied,237.96,Pays at 72% of billed charges with lesser of charges applied,237.96,Pays at 72% of billed charges with lesser of charges applied,237.96,Pays at 72% of billed charges with lesser of charges applied,330.5,BCBS Fee Schedule,330.5,BCBS Fee Schedule,330.5,BCBS Fee Schedule,330.5,BCBS Fee Schedule,330.5,BCBS Fee Schedule,330.5,BCBS Fee Schedule,330.5,BCBS Fee Schedule,330.5,BCBS Fee Schedule,330.5,BCBS Fee Schedule,276.24,100% of BCBS Fee Schedule,276.24,100% of BCBS Fee Schedule,276.24,100% of BCBS Fee Schedule,276.24,100% of BCBS Fee Schedule,276.24,100% of BCBS Fee Schedule,277.62,84% of total billed charges,277.62,84% of total billed charges,277.62,84% of total billed charges,231.35,70% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,80.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,80.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,80.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,80.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,80.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,80.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,80.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,80.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,80.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,80.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,80.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,80.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,80.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,80.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,80.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,80.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,80.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,80.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,80.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,80.77,100% of CA Medicaid Fee Schedule with lesser of charges applied,65.89,330.50,247.88
Outpatient Medical Services,RADIOLOGY,74240,UGI W/O KUB NO AIR CONT,320,461,331.92,Pays at 72% of billed charges with lesser of charges applied,229.22,100% OF CMS OPPS Rate,275.32,442% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,325.63,100% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,387.24,84% of total billed charges,387.24,84% of total billed charges,331.92,72% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% of CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,276.6,60% of total billed charges,146.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,146.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,103.32,100% OF CMS OPPS RATE,229.22,100% OF CMS OPPS Rate,322.7,70% of total billed charges,229.22,100% OF CMS OPPS Rate,275.07,120% of CMS OPPS RATE,331.92,Pays at 72% of billed charges with lesser of charges applied,331.92,Pays at 72% of billed charges with lesser of charges applied,331.92,Pays at 72% of billed charges with lesser of charges applied,331.92,Pays at 72% of billed charges with lesser of charges applied,331.92,Pays at 72% of billed charges with lesser of charges applied,331.92,Pays at 72% of billed charges with lesser of charges applied,275.32,442% of BCBS Fee Schedule,275.32,442% of BCBS Fee Schedule,275.32,442% of BCBS Fee Schedule,275.32,442% of BCBS Fee Schedule,275.32,442% of BCBS Fee Schedule,275.32,442% of BCBS Fee Schedule,275.32,442% of BCBS Fee Schedule,275.32,442% of BCBS Fee Schedule,275.32,442% of BCBS Fee Schedule,325.63,100% of BCBS Fee Schedule,325.63,100% of BCBS Fee Schedule,325.63,100% of BCBS Fee Schedule,325.63,100% of BCBS Fee Schedule,325.63,100% of BCBS Fee Schedule,387.24,84% of total billed charges,387.24,84% of total billed charges,387.24,84% of total billed charges,322.7,70% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,146.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,146.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,146.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,146.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,146.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,146.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,146.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,146.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,146.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,146.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,146.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,146.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,146.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,146.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,146.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,146.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,146.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,146.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,146.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,146.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,103.32,387.24,345.75
Outpatient Medical Services,RADIOLOGY,74420,XR UROGRAPHY RETROGRADE,320,647.75,466.38,Pays at 72% of billed charges with lesser of charges applied,468.3,100% OF CMS OPPS Rate,432.23,442% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,583.8,100% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,544.11,84% of total billed charges,544.11,84% of total billed charges,466.38,72% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% of CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,388.65,60% of total billed charges,80.93,100% of CA Medicaid Fee Schedule with lesser of charges applied,80.93,100% of CA Medicaid Fee Schedule with lesser of charges applied,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,63.1,100% OF CMS OPPS RATE,468.3,100% OF CMS OPPS Rate,453.43,70% of total billed charges,468.3,100% OF CMS OPPS Rate,561.95,120% of CMS OPPS RATE,466.38,Pays at 72% of billed charges with lesser of charges applied,466.38,Pays at 72% of billed charges with lesser of charges applied,466.38,Pays at 72% of billed charges with lesser of charges applied,466.38,Pays at 72% of billed charges with lesser of charges applied,466.38,Pays at 72% of billed charges with lesser of charges applied,466.38,Pays at 72% of billed charges with lesser of charges applied,432.23,442% of BCBS Fee Schedule,432.23,442% of BCBS Fee Schedule,432.23,442% of BCBS Fee Schedule,432.23,442% of BCBS Fee Schedule,432.23,442% of BCBS Fee Schedule,432.23,442% of BCBS Fee Schedule,432.23,442% of BCBS Fee Schedule,432.23,442% of BCBS Fee Schedule,432.23,442% of BCBS Fee Schedule,583.8,100% of BCBS Fee Schedule,583.8,100% of BCBS Fee Schedule,583.8,100% of BCBS Fee Schedule,583.8,100% of BCBS Fee Schedule,583.8,100% of BCBS Fee Schedule,544.11,84% of total billed charges,544.11,84% of total billed charges,544.11,84% of total billed charges,453.43,70% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,80.93,100% of CA Medicaid Fee Schedule with lesser of charges applied,80.93,100% of CA Medicaid Fee Schedule with lesser of charges applied,80.93,100% of CA Medicaid Fee Schedule with lesser of charges applied,80.93,100% of CA Medicaid Fee Schedule with lesser of charges applied,80.93,100% of CA Medicaid Fee Schedule with lesser of charges applied,80.93,100% of CA Medicaid Fee Schedule with lesser of charges applied,80.93,100% of CA Medicaid Fee Schedule with lesser of charges applied,80.93,100% of CA Medicaid Fee Schedule with lesser of charges applied,80.93,100% of CA Medicaid Fee Schedule with lesser of charges applied,80.93,100% of CA Medicaid Fee Schedule with lesser of charges applied,80.93,100% of CA Medicaid Fee Schedule with lesser of charges applied,80.93,100% of CA Medicaid Fee Schedule with lesser of charges applied,80.93,100% of CA Medicaid Fee Schedule with lesser of charges applied,80.93,100% of CA Medicaid Fee Schedule with lesser of charges applied,80.93,100% of CA Medicaid Fee Schedule with lesser of charges applied,80.93,100% of CA Medicaid Fee Schedule with lesser of charges applied,80.93,100% of CA Medicaid Fee Schedule with lesser of charges applied,80.93,100% of CA Medicaid Fee Schedule with lesser of charges applied,80.93,100% of CA Medicaid Fee Schedule with lesser of charges applied,80.93,100% of CA Medicaid Fee Schedule with lesser of charges applied,63.10,583.80,485.81
Outpatient Medical Services,RADIOLOGY,73565,Radiologic examination of both knees,320,181.75,130.86,Pays at 72% of billed charges with lesser of charges applied,110.43,100% OF CMS OPPS Rate,92.69,442% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,108.23,100% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,152.67,84% of total billed charges,152.67,84% of total billed charges,130.86,72% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% of CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,109.05,60% of total billed charges,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,37.62,100% OF CMS OPPS RATE,110.43,100% OF CMS OPPS Rate,127.23,70% of total billed charges,110.43,100% OF CMS OPPS Rate,132.51,120% of CMS OPPS RATE,130.86,Pays at 72% of billed charges with lesser of charges applied,130.86,Pays at 72% of billed charges with lesser of charges applied,130.86,Pays at 72% of billed charges with lesser of charges applied,130.86,Pays at 72% of billed charges with lesser of charges applied,130.86,Pays at 72% of billed charges with lesser of charges applied,130.86,Pays at 72% of billed charges with lesser of charges applied,92.69,442% of BCBS Fee Schedule,92.69,442% of BCBS Fee Schedule,92.69,442% of BCBS Fee Schedule,92.69,442% of BCBS Fee Schedule,92.69,442% of BCBS Fee Schedule,92.69,442% of BCBS Fee Schedule,92.69,442% of BCBS Fee Schedule,92.69,442% of BCBS Fee Schedule,92.69,442% of BCBS Fee Schedule,108.23,100% of BCBS Fee Schedule,108.23,100% of BCBS Fee Schedule,108.23,100% of BCBS Fee Schedule,108.23,100% of BCBS Fee Schedule,108.23,100% of BCBS Fee Schedule,152.67,84% of total billed charges,152.67,84% of total billed charges,152.67,84% of total billed charges,127.23,70% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,152.67,136.31
Outpatient Medical Services,RADIOLOGY,73140,Radiologic examination of the finger(s),320,319.5,230.04,Pays at 72% of billed charges with lesser of charges applied,110.43,100% OF CMS OPPS Rate,79.25,442% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,91.06,100% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,268.38,84% of total billed charges,268.38,84% of total billed charges,230.04,72% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% of CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,191.7,60% of total billed charges,22.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,22.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,37.22,100% OF CMS OPPS RATE,110.43,100% OF CMS OPPS Rate,223.65,70% of total billed charges,110.43,100% OF CMS OPPS Rate,132.51,120% of CMS OPPS RATE,230.04,Pays at 72% of billed charges with lesser of charges applied,230.04,Pays at 72% of billed charges with lesser of charges applied,230.04,Pays at 72% of billed charges with lesser of charges applied,230.04,Pays at 72% of billed charges with lesser of charges applied,230.04,Pays at 72% of billed charges with lesser of charges applied,230.04,Pays at 72% of billed charges with lesser of charges applied,79.25,442% of BCBS Fee Schedule,79.25,442% of BCBS Fee Schedule,79.25,442% of BCBS Fee Schedule,79.25,442% of BCBS Fee Schedule,79.25,442% of BCBS Fee Schedule,79.25,442% of BCBS Fee Schedule,79.25,442% of BCBS Fee Schedule,79.25,442% of BCBS Fee Schedule,79.25,442% of BCBS Fee Schedule,91.06,100% of BCBS Fee Schedule,91.06,100% of BCBS Fee Schedule,91.06,100% of BCBS Fee Schedule,91.06,100% of BCBS Fee Schedule,91.06,100% of BCBS Fee Schedule,268.38,84% of total billed charges,268.38,84% of total billed charges,268.38,84% of total billed charges,223.65,70% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,22.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,22.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,22.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,22.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,22.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,22.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,22.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,22.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,22.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,22.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,22.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,22.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,22.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,22.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,22.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,22.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,22.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,22.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,22.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,22.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,22.36,268.38,239.63
Outpatient Medical Services,RADIOLOGY,76080,FISTULA OR SINUS TRACT,320,467,336.24,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,197.22,442% of BCBS Fee Schedule,N/A,Not Separately reimbursable,236.71,100% of BCBS Fee Schedule,N/A,Not Separately reimbursable,392.28,84% of total billed charges,392.28,84% of total billed charges,336.24,72% of total billed charges,N/A,Not Separately reimbursable,467,100% of CMS OPPS Rate,N/A,Not Separately reimbursable,280.2,60% of total billed charges,59.94,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.94,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,42,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,326.9,70% of total billed charges,467,100% OF CMS OPPS Rate,467,120% of CMS OPPS RATE,336.24,Pays at 72% of billed charges with lesser of charges applied,336.24,Pays at 72% of billed charges with lesser of charges applied,336.24,Pays at 72% of billed charges with lesser of charges applied,336.24,Pays at 72% of billed charges with lesser of charges applied,336.24,Pays at 72% of billed charges with lesser of charges applied,336.24,Pays at 72% of billed charges with lesser of charges applied,197.22,442% of BCBS Fee Schedule,197.22,442% of BCBS Fee Schedule,197.22,442% of BCBS Fee Schedule,197.22,442% of BCBS Fee Schedule,197.22,442% of BCBS Fee Schedule,197.22,442% of BCBS Fee Schedule,197.22,442% of BCBS Fee Schedule,197.22,442% of BCBS Fee Schedule,197.22,442% of BCBS Fee Schedule,236.71,100% of BCBS Fee Schedule,236.71,100% of BCBS Fee Schedule,236.71,100% of BCBS Fee Schedule,236.71,100% of BCBS Fee Schedule,236.71,100% of BCBS Fee Schedule,392.28,84% of total billed charges,392.28,84% of total billed charges,392.28,84% of total billed charges,326.9,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,59.94,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.94,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.94,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.94,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.94,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.94,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.94,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.94,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.94,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.94,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.94,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.94,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.94,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.94,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.94,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.94,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.94,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.94,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.94,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.94,100% of CA Medicaid Fee Schedule with lesser of charges applied,42.00,467.00,350.25
Outpatient Medical Services,RADIOLOGY,73520,HIP COMPLETE BILATERAL,320,456.75,328.86,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,125.88,442% of BCBS Fee Schedule,N/A,Not Separately reimbursable,361.29,79.1% of total billed charges,N/A,Not Separately reimbursable,383.67,84% of total billed charges,383.67,84% of total billed charges,328.86,72% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,274.05,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,319.73,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,328.86,Pays at 72% of billed charges with lesser of charges applied,328.86,Pays at 72% of billed charges with lesser of charges applied,328.86,Pays at 72% of billed charges with lesser of charges applied,328.86,Pays at 72% of billed charges with lesser of charges applied,328.86,Pays at 72% of billed charges with lesser of charges applied,328.86,Pays at 72% of billed charges with lesser of charges applied,125.88,442% of BCBS Fee Schedule,125.88,442% of BCBS Fee Schedule,125.88,442% of BCBS Fee Schedule,125.88,442% of BCBS Fee Schedule,125.88,442% of BCBS Fee Schedule,125.88,442% of BCBS Fee Schedule,125.88,442% of BCBS Fee Schedule,125.88,442% of BCBS Fee Schedule,125.88,442% of BCBS Fee Schedule,361.29,79.1% of total billed charges,361.29,79.1% of total billed charges,361.29,79.1% of total billed charges,361.29,79.1% of total billed charges,361.29,79.1% of total billed charges,383.67,84% of total billed charges,383.67,84% of total billed charges,383.67,84% of total billed charges,319.73,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,125.88,383.67,342.56
Outpatient Medical Services,RADIOLOGY,72265,"MYELOGRAM, LUMBOSACRAL",320,765.75,551.34,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,761.74,442% of BCBS Fee Schedule,N/A,Not Separately reimbursable,751.2,pays at 100% of bcbs fee schedule with lesser of charges applied,N/A,Not Separately reimbursable,643.23,84% of total billed charges,643.23,84% of total billed charges,551.34,72% of total billed charges,N/A,Not Separately reimbursable,765.75,100% of CMS OPPS Rate,N/A,Not Separately reimbursable,459.45,60% of total billed charges,117.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,117.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,83.81,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,536.03,70% of total billed charges,765.75,100% OF CMS OPPS Rate,765.75,120% of CMS OPPS RATE,551.34,Pays at 72% of billed charges with lesser of charges applied,551.34,Pays at 72% of billed charges with lesser of charges applied,551.34,Pays at 72% of billed charges with lesser of charges applied,551.34,Pays at 72% of billed charges with lesser of charges applied,551.34,Pays at 72% of billed charges with lesser of charges applied,551.34,Pays at 72% of billed charges with lesser of charges applied,761.74,442% of BCBS Fee Schedule,761.74,442% of BCBS Fee Schedule,761.74,442% of BCBS Fee Schedule,761.74,442% of BCBS Fee Schedule,761.74,442% of BCBS Fee Schedule,761.74,442% of BCBS Fee Schedule,761.74,442% of BCBS Fee Schedule,761.74,442% of BCBS Fee Schedule,761.74,442% of BCBS Fee Schedule,751.2,pays at 100% of bcbs fee schedule with lesser of charges applied,751.2,pays at 100% of bcbs fee schedule with lesser of charges applied,751.2,pays at 100% of bcbs fee schedule with lesser of charges applied,751.2,pays at 100% of bcbs fee schedule with lesser of charges applied,751.2,pays at 100% of bcbs fee schedule with lesser of charges applied,643.23,84% of total billed charges,643.23,84% of total billed charges,643.23,84% of total billed charges,536.03,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,117.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,117.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,117.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,117.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,117.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,117.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,117.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,117.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,117.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,117.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,117.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,117.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,117.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,117.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,117.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,117.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,117.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,117.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,117.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,117.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,83.81,765.75,574.31
Outpatient Medical Services,RADIOLOGY,70360,NECK-SOFT TISSUE OR FB,320,234.5,168.84,Pays at 72% of billed charges with lesser of charges applied,110.43,100% OF CMS OPPS Rate,79.83,442% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,91.06,100% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,196.98,84% of total billed charges,196.98,84% of total billed charges,168.84,72% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% of CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,140.7,60% of total billed charges,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,27.27,100% OF CMS OPPS RATE,110.43,100% OF CMS OPPS Rate,164.15,70% of total billed charges,110.43,100% OF CMS OPPS Rate,132.51,120% of CMS OPPS RATE,168.84,Pays at 72% of billed charges with lesser of charges applied,168.84,Pays at 72% of billed charges with lesser of charges applied,168.84,Pays at 72% of billed charges with lesser of charges applied,168.84,Pays at 72% of billed charges with lesser of charges applied,168.84,Pays at 72% of billed charges with lesser of charges applied,168.84,Pays at 72% of billed charges with lesser of charges applied,79.83,442% of BCBS Fee Schedule,79.83,442% of BCBS Fee Schedule,79.83,442% of BCBS Fee Schedule,79.83,442% of BCBS Fee Schedule,79.83,442% of BCBS Fee Schedule,79.83,442% of BCBS Fee Schedule,79.83,442% of BCBS Fee Schedule,79.83,442% of BCBS Fee Schedule,79.83,442% of BCBS Fee Schedule,91.06,100% of BCBS Fee Schedule,91.06,100% of BCBS Fee Schedule,91.06,100% of BCBS Fee Schedule,91.06,100% of BCBS Fee Schedule,91.06,100% of BCBS Fee Schedule,196.98,84% of total billed charges,196.98,84% of total billed charges,196.98,84% of total billed charges,164.15,70% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,196.98,175.88
Outpatient Medical Services,RADIOLOGY,72170,Radiologic examination of the pelvis,320,268,192.96,Pays at 72% of billed charges with lesser of charges applied,135.85,100% OF CMS OPPS Rate,98.04,442% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,114.67,100% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,225.12,84% of total billed charges,225.12,84% of total billed charges,192.96,72% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% of CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,160.8,60% of total billed charges,31.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,23.29,100% OF CMS OPPS RATE,135.85,100% OF CMS OPPS Rate,187.6,70% of total billed charges,135.85,100% OF CMS OPPS Rate,163.02,120% of CMS OPPS RATE,192.96,Pays at 72% of billed charges with lesser of charges applied,192.96,Pays at 72% of billed charges with lesser of charges applied,192.96,Pays at 72% of billed charges with lesser of charges applied,192.96,Pays at 72% of billed charges with lesser of charges applied,192.96,Pays at 72% of billed charges with lesser of charges applied,192.96,Pays at 72% of billed charges with lesser of charges applied,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,114.67,100% of BCBS Fee Schedule,114.67,100% of BCBS Fee Schedule,114.67,100% of BCBS Fee Schedule,114.67,100% of BCBS Fee Schedule,114.67,100% of BCBS Fee Schedule,225.12,84% of total billed charges,225.12,84% of total billed charges,225.12,84% of total billed charges,187.6,70% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,31.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,23.29,225.12,201
Outpatient Medical Services,RADIOLOGY,73501,XR HIP 1V PORTABLE-LT,320,259,186.48,Pays at 72% of billed charges with lesser of charges applied,110.43,100% OF CMS OPPS Rate,154.39,442% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,121.72,100% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,217.56,84% of total billed charges,217.56,84% of total billed charges,186.48,72% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% of CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,155.4,60% of total billed charges,38.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,38.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,28.46,100% OF CMS OPPS RATE,110.43,100% OF CMS OPPS Rate,181.3,70% of total billed charges,110.43,100% OF CMS OPPS Rate,132.51,120% of CMS OPPS RATE,186.48,Pays at 72% of billed charges with lesser of charges applied,186.48,Pays at 72% of billed charges with lesser of charges applied,186.48,Pays at 72% of billed charges with lesser of charges applied,186.48,Pays at 72% of billed charges with lesser of charges applied,186.48,Pays at 72% of billed charges with lesser of charges applied,186.48,Pays at 72% of billed charges with lesser of charges applied,154.39,442% of BCBS Fee Schedule,154.39,442% of BCBS Fee Schedule,154.39,442% of BCBS Fee Schedule,154.39,442% of BCBS Fee Schedule,154.39,442% of BCBS Fee Schedule,154.39,442% of BCBS Fee Schedule,154.39,442% of BCBS Fee Schedule,154.39,442% of BCBS Fee Schedule,154.39,442% of BCBS Fee Schedule,121.72,100% of BCBS Fee Schedule,121.72,100% of BCBS Fee Schedule,121.72,100% of BCBS Fee Schedule,121.72,100% of BCBS Fee Schedule,121.72,100% of BCBS Fee Schedule,217.56,84% of total billed charges,217.56,84% of total billed charges,217.56,84% of total billed charges,181.3,70% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,38.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,38.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,38.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,38.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,38.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,38.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,38.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,38.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,38.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,38.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,38.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,38.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,38.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,38.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,38.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,38.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,38.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,38.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,38.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,38.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.46,217.56,194.25
Outpatient Medical Services,RADIOLOGY,73000,Radiologic examination of the collar bone,320,429,308.88,Pays at 72% of billed charges with lesser of charges applied,110.43,100% OF CMS OPPS Rate,98.04,442% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,114.67,100% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,360.36,84% of total billed charges,360.36,84% of total billed charges,308.88,72% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% of CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,257.4,60% of total billed charges,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,28.86,100% OF CMS OPPS RATE,110.43,100% OF CMS OPPS Rate,300.3,70% of total billed charges,110.43,100% OF CMS OPPS Rate,132.51,120% of CMS OPPS RATE,308.88,Pays at 72% of billed charges with lesser of charges applied,308.88,Pays at 72% of billed charges with lesser of charges applied,308.88,Pays at 72% of billed charges with lesser of charges applied,308.88,Pays at 72% of billed charges with lesser of charges applied,308.88,Pays at 72% of billed charges with lesser of charges applied,308.88,Pays at 72% of billed charges with lesser of charges applied,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,114.67,100% of BCBS Fee Schedule,114.67,100% of BCBS Fee Schedule,114.67,100% of BCBS Fee Schedule,114.67,100% of BCBS Fee Schedule,114.67,100% of BCBS Fee Schedule,360.36,84% of total billed charges,360.36,84% of total billed charges,360.36,84% of total billed charges,300.3,70% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.86,360.36,321.75
Outpatient Medical Services,RADIOLOGY,70170,DACROCYSTOGRAM S&I LT,320,882.75,635.58,Pays at 72% of billed charges with lesser of charges applied,296.82,100% OF CMS OPPS Rate,176.98,442% of BCBS Fee Schedule,296.82,100% OF CMS OPPS Rate,213.1,100% of BCBS Fee Schedule,296.82,100% OF CMS OPPS Rate,741.51,84% of total billed charges,741.51,84% of total billed charges,635.58,72% of total billed charges,296.82,100% OF CMS OPPS Rate,296.82,100% of CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,529.65,60% of total billed charges,62.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,62.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,N/A,Not Separately reimbursable,296.82,100% OF CMS OPPS Rate,617.93,70% of total billed charges,296.82,100% OF CMS OPPS Rate,356.18,120% of CMS OPPS RATE,635.58,Pays at 72% of billed charges with lesser of charges applied,635.58,Pays at 72% of billed charges with lesser of charges applied,635.58,Pays at 72% of billed charges with lesser of charges applied,635.58,Pays at 72% of billed charges with lesser of charges applied,635.58,Pays at 72% of billed charges with lesser of charges applied,635.58,Pays at 72% of billed charges with lesser of charges applied,176.98,442% of BCBS Fee Schedule,176.98,442% of BCBS Fee Schedule,176.98,442% of BCBS Fee Schedule,176.98,442% of BCBS Fee Schedule,176.98,442% of BCBS Fee Schedule,176.98,442% of BCBS Fee Schedule,176.98,442% of BCBS Fee Schedule,176.98,442% of BCBS Fee Schedule,176.98,442% of BCBS Fee Schedule,213.1,100% of BCBS Fee Schedule,213.1,100% of BCBS Fee Schedule,213.1,100% of BCBS Fee Schedule,213.1,100% of BCBS Fee Schedule,213.1,100% of BCBS Fee Schedule,741.51,84% of total billed charges,741.51,84% of total billed charges,741.51,84% of total billed charges,617.93,70% of total billed charges,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,62.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,62.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,62.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,62.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,62.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,62.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,62.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,62.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,62.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,62.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,62.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,62.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,62.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,62.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,62.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,62.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,62.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,62.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,62.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,62.08,100% of CA Medicaid Fee Schedule with lesser of charges applied,62.08,741.51,662.06
Outpatient Medical Services,RADIOLOGY,70150,FACIAL BONES COMPLETE,320,553,398.16,Pays at 72% of billed charges with lesser of charges applied,135.85,100% OF CMS OPPS Rate,147.85,442% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,177.23,100% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,464.52,84% of total billed charges,464.52,84% of total billed charges,398.16,72% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% of CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,331.8,60% of total billed charges,53.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,53.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,41.2,100% OF CMS OPPS RATE,135.85,100% OF CMS OPPS Rate,387.1,70% of total billed charges,135.85,100% OF CMS OPPS Rate,163.02,120% of CMS OPPS RATE,398.16,Pays at 72% of billed charges with lesser of charges applied,398.16,Pays at 72% of billed charges with lesser of charges applied,398.16,Pays at 72% of billed charges with lesser of charges applied,398.16,Pays at 72% of billed charges with lesser of charges applied,398.16,Pays at 72% of billed charges with lesser of charges applied,398.16,Pays at 72% of billed charges with lesser of charges applied,147.85,442% of BCBS Fee Schedule,147.85,442% of BCBS Fee Schedule,147.85,442% of BCBS Fee Schedule,147.85,442% of BCBS Fee Schedule,147.85,442% of BCBS Fee Schedule,147.85,442% of BCBS Fee Schedule,147.85,442% of BCBS Fee Schedule,147.85,442% of BCBS Fee Schedule,147.85,442% of BCBS Fee Schedule,177.23,100% of BCBS Fee Schedule,177.23,100% of BCBS Fee Schedule,177.23,100% of BCBS Fee Schedule,177.23,100% of BCBS Fee Schedule,177.23,100% of BCBS Fee Schedule,464.52,84% of total billed charges,464.52,84% of total billed charges,464.52,84% of total billed charges,387.1,70% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,53.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,53.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,53.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,53.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,53.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,53.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,53.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,53.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,53.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,53.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,53.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,53.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,53.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,53.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,53.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,53.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,53.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,53.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,53.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,53.47,100% of CA Medicaid Fee Schedule with lesser of charges applied,41.20,464.52,414.75
Outpatient Medical Services,RADIOLOGY,73020,SHOULDER 1V BILATERAL,320,377,271.44,Pays at 72% of billed charges with lesser of charges applied,110.43,100% OF CMS OPPS Rate,88.93,442% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,103.94,100% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,316.68,84% of total billed charges,316.68,84% of total billed charges,271.44,72% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% of CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,226.2,60% of total billed charges,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,16.91,100% OF CMS OPPS RATE,110.43,100% OF CMS OPPS Rate,263.9,70% of total billed charges,110.43,100% OF CMS OPPS Rate,132.51,120% of CMS OPPS RATE,271.44,Pays at 72% of billed charges with lesser of charges applied,271.44,Pays at 72% of billed charges with lesser of charges applied,271.44,Pays at 72% of billed charges with lesser of charges applied,271.44,Pays at 72% of billed charges with lesser of charges applied,271.44,Pays at 72% of billed charges with lesser of charges applied,271.44,Pays at 72% of billed charges with lesser of charges applied,88.93,442% of BCBS Fee Schedule,88.93,442% of BCBS Fee Schedule,88.93,442% of BCBS Fee Schedule,88.93,442% of BCBS Fee Schedule,88.93,442% of BCBS Fee Schedule,88.93,442% of BCBS Fee Schedule,88.93,442% of BCBS Fee Schedule,88.93,442% of BCBS Fee Schedule,88.93,442% of BCBS Fee Schedule,103.94,100% of BCBS Fee Schedule,103.94,100% of BCBS Fee Schedule,103.94,100% of BCBS Fee Schedule,103.94,100% of BCBS Fee Schedule,103.94,100% of BCBS Fee Schedule,316.68,84% of total billed charges,316.68,84% of total billed charges,316.68,84% of total billed charges,263.9,70% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,16.91,316.68,282.75
Outpatient Medical Services,RADIOLOGY,72072,"Radiologic examination of the middle spine, 3 views",320,498.25,358.74,Pays at 72% of billed charges with lesser of charges applied,135.85,100% OF CMS OPPS Rate,138.79,442% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,166.5,100% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,418.53,84% of total billed charges,418.53,84% of total billed charges,358.74,72% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% of CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,298.95,60% of total billed charges,44.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,44.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,34.04,100% OF CMS OPPS RATE,135.85,100% OF CMS OPPS Rate,348.78,70% of total billed charges,135.85,100% OF CMS OPPS Rate,163.02,120% of CMS OPPS RATE,358.74,Pays at 72% of billed charges with lesser of charges applied,358.74,Pays at 72% of billed charges with lesser of charges applied,358.74,Pays at 72% of billed charges with lesser of charges applied,358.74,Pays at 72% of billed charges with lesser of charges applied,358.74,Pays at 72% of billed charges with lesser of charges applied,358.74,Pays at 72% of billed charges with lesser of charges applied,138.79,442% of BCBS Fee Schedule,138.79,442% of BCBS Fee Schedule,138.79,442% of BCBS Fee Schedule,138.79,442% of BCBS Fee Schedule,138.79,442% of BCBS Fee Schedule,138.79,442% of BCBS Fee Schedule,138.79,442% of BCBS Fee Schedule,138.79,442% of BCBS Fee Schedule,138.79,442% of BCBS Fee Schedule,166.5,100% of BCBS Fee Schedule,166.5,100% of BCBS Fee Schedule,166.5,100% of BCBS Fee Schedule,166.5,100% of BCBS Fee Schedule,166.5,100% of BCBS Fee Schedule,418.53,84% of total billed charges,418.53,84% of total billed charges,418.53,84% of total billed charges,348.78,70% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,44.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,44.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,44.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,44.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,44.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,44.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,44.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,44.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,44.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,44.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,44.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,44.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,44.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,44.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,44.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,44.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,44.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,44.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,44.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,44.22,100% of CA Medicaid Fee Schedule with lesser of charges applied,34.04,418.53,373.69
Outpatient Medical Services,RADIOLOGY,74241,UGI W/KUB-NO AIR CONT,320,785.5,565.56,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,280.67,442% of BCBS Fee Schedule,N/A,Not Separately reimbursable,621.33,79.1% of total billed charges,N/A,Not Separately reimbursable,659.82,84% of total billed charges,659.82,84% of total billed charges,565.56,72% of total billed charges,N/A,Not Separately reimbursable,510.58,65% of total billed charges,N/A,Not Separately reimbursable,471.3,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,549.85,70% of total billed charges,785.5,100% OF CMS OPPS Rate,785.5,120% of CMS OPPS RATE,565.56,Pays at 72% of billed charges with lesser of charges applied,565.56,Pays at 72% of billed charges with lesser of charges applied,565.56,Pays at 72% of billed charges with lesser of charges applied,565.56,Pays at 72% of billed charges with lesser of charges applied,565.56,Pays at 72% of billed charges with lesser of charges applied,565.56,Pays at 72% of billed charges with lesser of charges applied,280.67,442% of BCBS Fee Schedule,280.67,442% of BCBS Fee Schedule,280.67,442% of BCBS Fee Schedule,280.67,442% of BCBS Fee Schedule,280.67,442% of BCBS Fee Schedule,280.67,442% of BCBS Fee Schedule,280.67,442% of BCBS Fee Schedule,280.67,442% of BCBS Fee Schedule,280.67,442% of BCBS Fee Schedule,621.33,79.1% of total billed charges,621.33,79.1% of total billed charges,621.33,79.1% of total billed charges,621.33,79.1% of total billed charges,621.33,79.1% of total billed charges,659.82,84% of total billed charges,659.82,84% of total billed charges,659.82,84% of total billed charges,549.85,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,280.67,785.50,589.13
Outpatient Medical Services,RADIOLOGY,73530,XR HIP INTRAOPERATIVE,320,285.5,205.56,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,99.1,442% of BCBS Fee Schedule,N/A,Not Separately reimbursable,225.83,79.1% of total billed charges,N/A,Not Separately reimbursable,239.82,84% of total billed charges,239.82,84% of total billed charges,205.56,72% of total billed charges,N/A,Not Separately reimbursable,185.58,65% of total billed charges,N/A,Not Separately reimbursable,171.3,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,199.85,70% of total billed charges,285.5,100% OF CMS OPPS Rate,285.5,120% of CMS OPPS RATE,205.56,Pays at 72% of billed charges with lesser of charges applied,205.56,Pays at 72% of billed charges with lesser of charges applied,205.56,Pays at 72% of billed charges with lesser of charges applied,205.56,Pays at 72% of billed charges with lesser of charges applied,205.56,Pays at 72% of billed charges with lesser of charges applied,205.56,Pays at 72% of billed charges with lesser of charges applied,99.1,442% of BCBS Fee Schedule,99.1,442% of BCBS Fee Schedule,99.1,442% of BCBS Fee Schedule,99.1,442% of BCBS Fee Schedule,99.1,442% of BCBS Fee Schedule,99.1,442% of BCBS Fee Schedule,99.1,442% of BCBS Fee Schedule,99.1,442% of BCBS Fee Schedule,99.1,442% of BCBS Fee Schedule,225.83,79.1% of total billed charges,225.83,79.1% of total billed charges,225.83,79.1% of total billed charges,225.83,79.1% of total billed charges,225.83,79.1% of total billed charges,239.82,84% of total billed charges,239.82,84% of total billed charges,239.82,84% of total billed charges,199.85,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,99.10,285.50,214.13
Outpatient Medical Services,RADIOLOGY,74270,BARIUM ENEMA W/O AIR,320,484.75,349.02,Pays at 72% of billed charges with lesser of charges applied,229.22,100% OF CMS OPPS Rate,311.21,442% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,383.89,100% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,407.19,84% of total billed charges,407.19,84% of total billed charges,349.02,72% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% of CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,290.85,60% of total billed charges,74.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,127.61,100% OF CMS OPPS RATE,229.22,100% OF CMS OPPS Rate,339.33,70% of total billed charges,229.22,100% OF CMS OPPS Rate,275.07,120% of CMS OPPS RATE,349.02,Pays at 72% of billed charges with lesser of charges applied,349.02,Pays at 72% of billed charges with lesser of charges applied,349.02,Pays at 72% of billed charges with lesser of charges applied,349.02,Pays at 72% of billed charges with lesser of charges applied,349.02,Pays at 72% of billed charges with lesser of charges applied,349.02,Pays at 72% of billed charges with lesser of charges applied,311.21,442% of BCBS Fee Schedule,311.21,442% of BCBS Fee Schedule,311.21,442% of BCBS Fee Schedule,311.21,442% of BCBS Fee Schedule,311.21,442% of BCBS Fee Schedule,311.21,442% of BCBS Fee Schedule,311.21,442% of BCBS Fee Schedule,311.21,442% of BCBS Fee Schedule,311.21,442% of BCBS Fee Schedule,383.89,100% of BCBS Fee Schedule,383.89,100% of BCBS Fee Schedule,383.89,100% of BCBS Fee Schedule,383.89,100% of BCBS Fee Schedule,383.89,100% of BCBS Fee Schedule,407.19,84% of total billed charges,407.19,84% of total billed charges,407.19,84% of total billed charges,339.33,70% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,74.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.46,407.19,363.56
Outpatient Medical Services,RADIOLOGY,74230,ESOPHAGUS WITH VIDEO,320,589.75,424.62,Pays at 72% of billed charges with lesser of charges applied,229.22,100% OF CMS OPPS Rate,245.31,442% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,291.9,100% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,495.39,84% of total billed charges,495.39,84% of total billed charges,424.62,72% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% of CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,353.85,60% of total billed charges,74.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,121.63,100% OF CMS OPPS RATE,229.22,100% OF CMS OPPS Rate,412.83,70% of total billed charges,229.22,100% OF CMS OPPS Rate,275.07,120% of CMS OPPS RATE,424.62,Pays at 72% of billed charges with lesser of charges applied,424.62,Pays at 72% of billed charges with lesser of charges applied,424.62,Pays at 72% of billed charges with lesser of charges applied,424.62,Pays at 72% of billed charges with lesser of charges applied,424.62,Pays at 72% of billed charges with lesser of charges applied,424.62,Pays at 72% of billed charges with lesser of charges applied,245.31,442% of BCBS Fee Schedule,245.31,442% of BCBS Fee Schedule,245.31,442% of BCBS Fee Schedule,245.31,442% of BCBS Fee Schedule,245.31,442% of BCBS Fee Schedule,245.31,442% of BCBS Fee Schedule,245.31,442% of BCBS Fee Schedule,245.31,442% of BCBS Fee Schedule,245.31,442% of BCBS Fee Schedule,291.9,100% of BCBS Fee Schedule,291.9,100% of BCBS Fee Schedule,291.9,100% of BCBS Fee Schedule,291.9,100% of BCBS Fee Schedule,291.9,100% of BCBS Fee Schedule,495.39,84% of total billed charges,495.39,84% of total billed charges,495.39,84% of total billed charges,412.83,70% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,74.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.46,495.39,442.31
Outpatient Medical Services,RADIOLOGY,70140,FACIAL BONES LIMITED,320,380.25,273.78,Pays at 72% of billed charges with lesser of charges applied,110.43,100% OF CMS OPPS Rate,116.29,442% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,139.21,100% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,319.41,84% of total billed charges,319.41,84% of total billed charges,273.78,72% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% of CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,228.15,60% of total billed charges,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,26.87,100% OF CMS OPPS RATE,110.43,100% OF CMS OPPS Rate,266.18,70% of total billed charges,110.43,100% OF CMS OPPS Rate,132.51,120% of CMS OPPS RATE,273.78,Pays at 72% of billed charges with lesser of charges applied,273.78,Pays at 72% of billed charges with lesser of charges applied,273.78,Pays at 72% of billed charges with lesser of charges applied,273.78,Pays at 72% of billed charges with lesser of charges applied,273.78,Pays at 72% of billed charges with lesser of charges applied,273.78,Pays at 72% of billed charges with lesser of charges applied,116.29,442% of BCBS Fee Schedule,116.29,442% of BCBS Fee Schedule,116.29,442% of BCBS Fee Schedule,116.29,442% of BCBS Fee Schedule,116.29,442% of BCBS Fee Schedule,116.29,442% of BCBS Fee Schedule,116.29,442% of BCBS Fee Schedule,116.29,442% of BCBS Fee Schedule,116.29,442% of BCBS Fee Schedule,139.21,100% of BCBS Fee Schedule,139.21,100% of BCBS Fee Schedule,139.21,100% of BCBS Fee Schedule,139.21,100% of BCBS Fee Schedule,139.21,100% of BCBS Fee Schedule,319.41,84% of total billed charges,319.41,84% of total billed charges,319.41,84% of total billed charges,266.18,70% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,26.87,319.41,285.19
Outpatient Medical Services,RADIOLOGY,72120,"LUMBAR, BENDING ONLY",320,313.75,225.9,Pays at 72% of billed charges with lesser of charges applied,135.85,100% OF CMS OPPS Rate,167.65,442% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,200.22,100% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,263.55,84% of total billed charges,263.55,84% of total billed charges,225.9,72% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% of CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,188.25,60% of total billed charges,49.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,35.63,100% OF CMS OPPS RATE,135.85,100% OF CMS OPPS Rate,219.63,70% of total billed charges,135.85,100% OF CMS OPPS Rate,163.02,120% of CMS OPPS RATE,225.9,Pays at 72% of billed charges with lesser of charges applied,225.9,Pays at 72% of billed charges with lesser of charges applied,225.9,Pays at 72% of billed charges with lesser of charges applied,225.9,Pays at 72% of billed charges with lesser of charges applied,225.9,Pays at 72% of billed charges with lesser of charges applied,225.9,Pays at 72% of billed charges with lesser of charges applied,167.65,442% of BCBS Fee Schedule,167.65,442% of BCBS Fee Schedule,167.65,442% of BCBS Fee Schedule,167.65,442% of BCBS Fee Schedule,167.65,442% of BCBS Fee Schedule,167.65,442% of BCBS Fee Schedule,167.65,442% of BCBS Fee Schedule,167.65,442% of BCBS Fee Schedule,167.65,442% of BCBS Fee Schedule,200.22,100% of BCBS Fee Schedule,200.22,100% of BCBS Fee Schedule,200.22,100% of BCBS Fee Schedule,200.22,100% of BCBS Fee Schedule,200.22,100% of BCBS Fee Schedule,263.55,84% of total billed charges,263.55,84% of total billed charges,263.55,84% of total billed charges,219.63,70% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,49.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.64,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.63,263.55,235.31
Outpatient Medical Services,RADIOLOGY,73590,Radiologic examination of the lower leg,320,429,308.88,Pays at 72% of billed charges with lesser of charges applied,110.43,100% OF CMS OPPS Rate,98.04,442% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,114.67,100% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,360.36,84% of total billed charges,360.36,84% of total billed charges,308.88,72% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% of CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,257.4,60% of total billed charges,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,28.46,100% OF CMS OPPS RATE,110.43,100% OF CMS OPPS Rate,300.3,70% of total billed charges,110.43,100% OF CMS OPPS Rate,132.51,120% of CMS OPPS RATE,308.88,Pays at 72% of billed charges with lesser of charges applied,308.88,Pays at 72% of billed charges with lesser of charges applied,308.88,Pays at 72% of billed charges with lesser of charges applied,308.88,Pays at 72% of billed charges with lesser of charges applied,308.88,Pays at 72% of billed charges with lesser of charges applied,308.88,Pays at 72% of billed charges with lesser of charges applied,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,114.67,100% of BCBS Fee Schedule,114.67,100% of BCBS Fee Schedule,114.67,100% of BCBS Fee Schedule,114.67,100% of BCBS Fee Schedule,114.67,100% of BCBS Fee Schedule,360.36,84% of total billed charges,360.36,84% of total billed charges,360.36,84% of total billed charges,300.3,70% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.46,360.36,321.75
Outpatient Medical Services,RADIOLOGY,74246,UGI W/O KUB AIR CONT,320,853.25,614.34,Pays at 72% of billed charges with lesser of charges applied,229.22,100% OF CMS OPPS Rate,310.64,442% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,369.48,100% of BCBS Fee Schedule,229.22,100% OF CMS OPPS Rate,716.73,84% of total billed charges,716.73,84% of total billed charges,614.34,72% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% of CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,511.95,60% of total billed charges,165.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,165.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,118.45,100% OF CMS OPPS RATE,229.22,100% OF CMS OPPS Rate,597.28,70% of total billed charges,229.22,100% OF CMS OPPS Rate,275.07,120% of CMS OPPS RATE,614.34,Pays at 72% of billed charges with lesser of charges applied,614.34,Pays at 72% of billed charges with lesser of charges applied,614.34,Pays at 72% of billed charges with lesser of charges applied,614.34,Pays at 72% of billed charges with lesser of charges applied,614.34,Pays at 72% of billed charges with lesser of charges applied,614.34,Pays at 72% of billed charges with lesser of charges applied,310.64,442% of BCBS Fee Schedule,310.64,442% of BCBS Fee Schedule,310.64,442% of BCBS Fee Schedule,310.64,442% of BCBS Fee Schedule,310.64,442% of BCBS Fee Schedule,310.64,442% of BCBS Fee Schedule,310.64,442% of BCBS Fee Schedule,310.64,442% of BCBS Fee Schedule,310.64,442% of BCBS Fee Schedule,369.48,100% of BCBS Fee Schedule,369.48,100% of BCBS Fee Schedule,369.48,100% of BCBS Fee Schedule,369.48,100% of BCBS Fee Schedule,369.48,100% of BCBS Fee Schedule,716.73,84% of total billed charges,716.73,84% of total billed charges,716.73,84% of total billed charges,597.28,70% of total billed charges,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,229.22,100% OF CMS OPPS Rate,165.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,165.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,165.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,165.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,165.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,165.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,165.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,165.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,165.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,165.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,165.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,165.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,165.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,165.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,165.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,165.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,165.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,165.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,165.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,165.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,118.45,716.73,639.94
Outpatient Medical Services,RADIOLOGY,74740,HYSTEROSALPINGOGRAM,320,568,408.96,Pays at 72% of billed charges with lesser of charges applied,296.82,100% OF CMS OPPS Rate,243.45,442% of BCBS Fee Schedule,296.82,100% OF CMS OPPS Rate,291.9,100% of BCBS Fee Schedule,296.82,100% OF CMS OPPS Rate,477.12,84% of total billed charges,477.12,84% of total billed charges,408.96,72% of total billed charges,296.82,100% OF CMS OPPS Rate,296.82,100% of CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,340.8,60% of total billed charges,67.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,67.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,92.97,100% OF CMS OPPS RATE,296.82,100% OF CMS OPPS Rate,397.6,70% of total billed charges,296.82,100% OF CMS OPPS Rate,356.18,120% of CMS OPPS RATE,408.96,Pays at 72% of billed charges with lesser of charges applied,408.96,Pays at 72% of billed charges with lesser of charges applied,408.96,Pays at 72% of billed charges with lesser of charges applied,408.96,Pays at 72% of billed charges with lesser of charges applied,408.96,Pays at 72% of billed charges with lesser of charges applied,408.96,Pays at 72% of billed charges with lesser of charges applied,243.45,442% of BCBS Fee Schedule,243.45,442% of BCBS Fee Schedule,243.45,442% of BCBS Fee Schedule,243.45,442% of BCBS Fee Schedule,243.45,442% of BCBS Fee Schedule,243.45,442% of BCBS Fee Schedule,243.45,442% of BCBS Fee Schedule,243.45,442% of BCBS Fee Schedule,243.45,442% of BCBS Fee Schedule,291.9,100% of BCBS Fee Schedule,291.9,100% of BCBS Fee Schedule,291.9,100% of BCBS Fee Schedule,291.9,100% of BCBS Fee Schedule,291.9,100% of BCBS Fee Schedule,477.12,84% of total billed charges,477.12,84% of total billed charges,477.12,84% of total billed charges,397.6,70% of total billed charges,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,67.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,67.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,67.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,67.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,67.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,67.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,67.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,67.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,67.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,67.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,67.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,67.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,67.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,67.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,67.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,67.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,67.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,67.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,67.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,67.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,67.02,477.12,426
Outpatient Medical Services,RADIOLOGY,73660,Radiologic examination of the toe(s),320,319.5,230.04,Pays at 72% of billed charges with lesser of charges applied,110.43,100% OF CMS OPPS Rate,79.25,442% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,91.06,100% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,268.38,84% of total billed charges,268.38,84% of total billed charges,230.04,72% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% of CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,191.7,60% of total billed charges,22.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,22.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,27.27,100% OF CMS OPPS RATE,110.43,100% OF CMS OPPS Rate,223.65,70% of total billed charges,110.43,100% OF CMS OPPS Rate,132.51,120% of CMS OPPS RATE,230.04,Pays at 72% of billed charges with lesser of charges applied,230.04,Pays at 72% of billed charges with lesser of charges applied,230.04,Pays at 72% of billed charges with lesser of charges applied,230.04,Pays at 72% of billed charges with lesser of charges applied,230.04,Pays at 72% of billed charges with lesser of charges applied,230.04,Pays at 72% of billed charges with lesser of charges applied,79.25,442% of BCBS Fee Schedule,79.25,442% of BCBS Fee Schedule,79.25,442% of BCBS Fee Schedule,79.25,442% of BCBS Fee Schedule,79.25,442% of BCBS Fee Schedule,79.25,442% of BCBS Fee Schedule,79.25,442% of BCBS Fee Schedule,79.25,442% of BCBS Fee Schedule,79.25,442% of BCBS Fee Schedule,91.06,100% of BCBS Fee Schedule,91.06,100% of BCBS Fee Schedule,91.06,100% of BCBS Fee Schedule,91.06,100% of BCBS Fee Schedule,91.06,100% of BCBS Fee Schedule,268.38,84% of total billed charges,268.38,84% of total billed charges,268.38,84% of total billed charges,223.65,70% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,22.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,22.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,22.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,22.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,22.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,22.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,22.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,22.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,22.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,22.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,22.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,22.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,22.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,22.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,22.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,22.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,22.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,22.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,22.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,22.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,22.36,268.38,239.63
Outpatient Medical Services,RADIOLOGY,73090,Radiologic examination of the forearm,320,259,186.48,Pays at 72% of billed charges with lesser of charges applied,110.43,100% OF CMS OPPS Rate,98.04,442% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,114.67,100% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,217.56,84% of total billed charges,217.56,84% of total billed charges,186.48,72% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% of CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,155.4,60% of total billed charges,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,25.67,100% OF CMS OPPS RATE,110.43,100% OF CMS OPPS Rate,181.3,70% of total billed charges,110.43,100% OF CMS OPPS Rate,132.51,120% of CMS OPPS RATE,186.48,Pays at 72% of billed charges with lesser of charges applied,186.48,Pays at 72% of billed charges with lesser of charges applied,186.48,Pays at 72% of billed charges with lesser of charges applied,186.48,Pays at 72% of billed charges with lesser of charges applied,186.48,Pays at 72% of billed charges with lesser of charges applied,186.48,Pays at 72% of billed charges with lesser of charges applied,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,114.67,100% of BCBS Fee Schedule,114.67,100% of BCBS Fee Schedule,114.67,100% of BCBS Fee Schedule,114.67,100% of BCBS Fee Schedule,114.67,100% of BCBS Fee Schedule,217.56,84% of total billed charges,217.56,84% of total billed charges,217.56,84% of total billed charges,181.3,70% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,25.67,217.56,194.25
Outpatient Medical Services,RADIOLOGY,70350,XR HEAD ORTHODONTIA,320,164.75,118.62,Pays at 72% of billed charges with lesser of charges applied,110.43,100% OF CMS OPPS Rate,70.68,442% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,82.48,100% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,138.39,84% of total billed charges,138.39,84% of total billed charges,118.62,72% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% of CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,98.85,60% of total billed charges,20.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,9.35,100% OF CMS OPPS RATE,110.43,100% OF CMS OPPS Rate,115.33,70% of total billed charges,110.43,100% OF CMS OPPS Rate,132.51,120% of CMS OPPS RATE,118.62,Pays at 72% of billed charges with lesser of charges applied,118.62,Pays at 72% of billed charges with lesser of charges applied,118.62,Pays at 72% of billed charges with lesser of charges applied,118.62,Pays at 72% of billed charges with lesser of charges applied,118.62,Pays at 72% of billed charges with lesser of charges applied,118.62,Pays at 72% of billed charges with lesser of charges applied,70.68,442% of BCBS Fee Schedule,70.68,442% of BCBS Fee Schedule,70.68,442% of BCBS Fee Schedule,70.68,442% of BCBS Fee Schedule,70.68,442% of BCBS Fee Schedule,70.68,442% of BCBS Fee Schedule,70.68,442% of BCBS Fee Schedule,70.68,442% of BCBS Fee Schedule,70.68,442% of BCBS Fee Schedule,82.48,100% of BCBS Fee Schedule,82.48,100% of BCBS Fee Schedule,82.48,100% of BCBS Fee Schedule,82.48,100% of BCBS Fee Schedule,82.48,100% of BCBS Fee Schedule,138.39,84% of total billed charges,138.39,84% of total billed charges,138.39,84% of total billed charges,115.33,70% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,20.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,9.35,138.39,123.56
Outpatient Medical Services,RADIOLOGY,73100,3 or more views,320,216.25,155.7,Pays at 72% of billed charges with lesser of charges applied,110.43,100% OF CMS OPPS Rate,92.64,442% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,108.23,100% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,181.65,84% of total billed charges,181.65,84% of total billed charges,155.7,72% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% of CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,129.75,60% of total billed charges,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,30.85,100% OF CMS OPPS RATE,110.43,100% OF CMS OPPS Rate,151.38,70% of total billed charges,110.43,100% OF CMS OPPS Rate,132.51,120% of CMS OPPS RATE,155.7,Pays at 72% of billed charges with lesser of charges applied,155.7,Pays at 72% of billed charges with lesser of charges applied,155.7,Pays at 72% of billed charges with lesser of charges applied,155.7,Pays at 72% of billed charges with lesser of charges applied,155.7,Pays at 72% of billed charges with lesser of charges applied,155.7,Pays at 72% of billed charges with lesser of charges applied,92.64,442% of BCBS Fee Schedule,92.64,442% of BCBS Fee Schedule,92.64,442% of BCBS Fee Schedule,92.64,442% of BCBS Fee Schedule,92.64,442% of BCBS Fee Schedule,92.64,442% of BCBS Fee Schedule,92.64,442% of BCBS Fee Schedule,92.64,442% of BCBS Fee Schedule,92.64,442% of BCBS Fee Schedule,108.23,100% of BCBS Fee Schedule,108.23,100% of BCBS Fee Schedule,108.23,100% of BCBS Fee Schedule,108.23,100% of BCBS Fee Schedule,108.23,100% of BCBS Fee Schedule,181.65,84% of total billed charges,181.65,84% of total billed charges,181.65,84% of total billed charges,151.38,70% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.82,181.65,162.19
Outpatient Medical Services,RADIOLOGY,73600,Radiologic examination of the ankle with 2 views,320,374,269.28,Pays at 72% of billed charges with lesser of charges applied,110.43,100% OF CMS OPPS Rate,92.64,442% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,108.23,100% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,314.16,84% of total billed charges,314.16,84% of total billed charges,269.28,72% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% of CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,224.4,60% of total billed charges,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,29.26,100% OF CMS OPPS RATE,110.43,100% OF CMS OPPS Rate,261.8,70% of total billed charges,110.43,100% OF CMS OPPS Rate,132.51,120% of CMS OPPS RATE,269.28,Pays at 72% of billed charges with lesser of charges applied,269.28,Pays at 72% of billed charges with lesser of charges applied,269.28,Pays at 72% of billed charges with lesser of charges applied,269.28,Pays at 72% of billed charges with lesser of charges applied,269.28,Pays at 72% of billed charges with lesser of charges applied,269.28,Pays at 72% of billed charges with lesser of charges applied,92.64,442% of BCBS Fee Schedule,92.64,442% of BCBS Fee Schedule,92.64,442% of BCBS Fee Schedule,92.64,442% of BCBS Fee Schedule,92.64,442% of BCBS Fee Schedule,92.64,442% of BCBS Fee Schedule,92.64,442% of BCBS Fee Schedule,92.64,442% of BCBS Fee Schedule,92.64,442% of BCBS Fee Schedule,108.23,100% of BCBS Fee Schedule,108.23,100% of BCBS Fee Schedule,108.23,100% of BCBS Fee Schedule,108.23,100% of BCBS Fee Schedule,108.23,100% of BCBS Fee Schedule,314.16,84% of total billed charges,314.16,84% of total billed charges,314.16,84% of total billed charges,261.8,70% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,314.16,280.5
Outpatient Medical Services,RADIOLOGY,77076,BONE SURVEY-INFANT,320,467,336.24,Pays at 72% of billed charges with lesser of charges applied,135.85,100% OF CMS OPPS Rate,139.27,442% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,378.96,100% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,392.28,84% of total billed charges,392.28,84% of total billed charges,336.24,72% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% of CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,280.2,60% of total billed charges,91.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,91.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,88.38,100% OF CMS OPPS RATE,135.85,100% OF CMS OPPS Rate,326.9,70% of total billed charges,135.85,100% OF CMS OPPS Rate,163.02,120% of CMS OPPS RATE,336.24,Pays at 72% of billed charges with lesser of charges applied,336.24,Pays at 72% of billed charges with lesser of charges applied,336.24,Pays at 72% of billed charges with lesser of charges applied,336.24,Pays at 72% of billed charges with lesser of charges applied,336.24,Pays at 72% of billed charges with lesser of charges applied,336.24,Pays at 72% of billed charges with lesser of charges applied,139.27,442% of BCBS Fee Schedule,139.27,442% of BCBS Fee Schedule,139.27,442% of BCBS Fee Schedule,139.27,442% of BCBS Fee Schedule,139.27,442% of BCBS Fee Schedule,139.27,442% of BCBS Fee Schedule,139.27,442% of BCBS Fee Schedule,139.27,442% of BCBS Fee Schedule,139.27,442% of BCBS Fee Schedule,378.96,100% of BCBS Fee Schedule,378.96,100% of BCBS Fee Schedule,378.96,100% of BCBS Fee Schedule,378.96,100% of BCBS Fee Schedule,378.96,100% of BCBS Fee Schedule,392.28,84% of total billed charges,392.28,84% of total billed charges,392.28,84% of total billed charges,326.9,70% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,91.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,91.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,91.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,91.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,91.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,91.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,91.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,91.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,91.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,91.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,91.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,91.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,91.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,91.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,91.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,91.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,91.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,91.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,91.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,91.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,88.38,392.28,350.25
Outpatient Medical Services,RADIOLOGY,72052,C-SPINE (6+ VIEWS),320,666.75,480.06,Pays at 72% of billed charges with lesser of charges applied,135.85,100% OF CMS OPPS Rate,212.65,442% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,251.73,100% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,560.07,84% of total billed charges,560.07,84% of total billed charges,480.06,72% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% of CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,400.05,60% of total billed charges,72.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,72.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,57.13,100% OF CMS OPPS RATE,135.85,100% OF CMS OPPS Rate,466.73,70% of total billed charges,135.85,100% OF CMS OPPS Rate,163.02,120% of CMS OPPS RATE,480.06,Pays at 72% of billed charges with lesser of charges applied,480.06,Pays at 72% of billed charges with lesser of charges applied,480.06,Pays at 72% of billed charges with lesser of charges applied,480.06,Pays at 72% of billed charges with lesser of charges applied,480.06,Pays at 72% of billed charges with lesser of charges applied,480.06,Pays at 72% of billed charges with lesser of charges applied,212.65,442% of BCBS Fee Schedule,212.65,442% of BCBS Fee Schedule,212.65,442% of BCBS Fee Schedule,212.65,442% of BCBS Fee Schedule,212.65,442% of BCBS Fee Schedule,212.65,442% of BCBS Fee Schedule,212.65,442% of BCBS Fee Schedule,212.65,442% of BCBS Fee Schedule,212.65,442% of BCBS Fee Schedule,251.73,100% of BCBS Fee Schedule,251.73,100% of BCBS Fee Schedule,251.73,100% of BCBS Fee Schedule,251.73,100% of BCBS Fee Schedule,251.73,100% of BCBS Fee Schedule,560.07,84% of total billed charges,560.07,84% of total billed charges,560.07,84% of total billed charges,466.73,70% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,72.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,72.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,72.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,72.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,72.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,72.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,72.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,72.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,72.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,72.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,72.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,72.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,72.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,72.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,72.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,72.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,72.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,72.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,72.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,72.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,57.13,560.07,500.06
Outpatient Medical Services,RADIOLOGY,73070,"Radiologic examination, elbow; 2 views",320,388.5,279.72,Pays at 72% of billed charges with lesser of charges applied,110.43,100% OF CMS OPPS Rate,98.04,442% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,114.67,100% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,326.34,84% of total billed charges,326.34,84% of total billed charges,279.72,72% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% of CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,233.1,60% of total billed charges,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,25.28,100% OF CMS OPPS RATE,110.43,100% OF CMS OPPS Rate,271.95,70% of total billed charges,110.43,100% OF CMS OPPS Rate,132.51,120% of CMS OPPS RATE,279.72,Pays at 72% of billed charges with lesser of charges applied,279.72,Pays at 72% of billed charges with lesser of charges applied,279.72,Pays at 72% of billed charges with lesser of charges applied,279.72,Pays at 72% of billed charges with lesser of charges applied,279.72,Pays at 72% of billed charges with lesser of charges applied,279.72,Pays at 72% of billed charges with lesser of charges applied,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,114.67,100% of BCBS Fee Schedule,114.67,100% of BCBS Fee Schedule,114.67,100% of BCBS Fee Schedule,114.67,100% of BCBS Fee Schedule,114.67,100% of BCBS Fee Schedule,326.34,84% of total billed charges,326.34,84% of total billed charges,326.34,84% of total billed charges,271.95,70% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,25.28,326.34,291.38
Outpatient Medical Services,RADIOLOGY,70390,FL SIALOGRAM w/INJ,320,332,239.04,Pays at 72% of billed charges with lesser of charges applied,296.82,100% OF CMS OPPS Rate,332,BCBS Fee Schedule,296.82,100% OF CMS OPPS Rate,325.69,pays at 100% of bcbs fee schedule with lesser of charges applied,296.82,100% OF CMS OPPS Rate,278.88,84% of total billed charges,278.88,84% of total billed charges,239.04,72% of total billed charges,296.82,100% OF CMS OPPS Rate,296.82,100% of CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,199.2,60% of total billed charges,59.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,119.64,100% OF CMS OPPS RATE,296.82,100% OF CMS OPPS Rate,232.4,70% of total billed charges,296.82,100% OF CMS OPPS Rate,332,120% of CMS OPPS RATE,239.04,Pays at 72% of billed charges with lesser of charges applied,239.04,Pays at 72% of billed charges with lesser of charges applied,239.04,Pays at 72% of billed charges with lesser of charges applied,239.04,Pays at 72% of billed charges with lesser of charges applied,239.04,Pays at 72% of billed charges with lesser of charges applied,239.04,Pays at 72% of billed charges with lesser of charges applied,332,BCBS Fee Schedule,332,BCBS Fee Schedule,332,BCBS Fee Schedule,332,BCBS Fee Schedule,332,BCBS Fee Schedule,332,BCBS Fee Schedule,332,BCBS Fee Schedule,332,BCBS Fee Schedule,332,BCBS Fee Schedule,325.69,pays at 100% of bcbs fee schedule with lesser of charges applied,325.69,pays at 100% of bcbs fee schedule with lesser of charges applied,325.69,pays at 100% of bcbs fee schedule with lesser of charges applied,325.69,pays at 100% of bcbs fee schedule with lesser of charges applied,325.69,pays at 100% of bcbs fee schedule with lesser of charges applied,278.88,84% of total billed charges,278.88,84% of total billed charges,278.88,84% of total billed charges,232.4,70% of total billed charges,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,59.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.28,332.00,249
Outpatient Medical Services,RADIOLOGY,73650,Radiologic examination of the heel,320,374,269.28,Pays at 72% of billed charges with lesser of charges applied,110.43,100% OF CMS OPPS Rate,88.93,442% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,103.94,100% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,314.16,84% of total billed charges,314.16,84% of total billed charges,269.28,72% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% of CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,224.4,60% of total billed charges,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,24.88,100% OF CMS OPPS RATE,110.43,100% OF CMS OPPS Rate,261.8,70% of total billed charges,110.43,100% OF CMS OPPS Rate,132.51,120% of CMS OPPS RATE,269.28,Pays at 72% of billed charges with lesser of charges applied,269.28,Pays at 72% of billed charges with lesser of charges applied,269.28,Pays at 72% of billed charges with lesser of charges applied,269.28,Pays at 72% of billed charges with lesser of charges applied,269.28,Pays at 72% of billed charges with lesser of charges applied,269.28,Pays at 72% of billed charges with lesser of charges applied,88.93,442% of BCBS Fee Schedule,88.93,442% of BCBS Fee Schedule,88.93,442% of BCBS Fee Schedule,88.93,442% of BCBS Fee Schedule,88.93,442% of BCBS Fee Schedule,88.93,442% of BCBS Fee Schedule,88.93,442% of BCBS Fee Schedule,88.93,442% of BCBS Fee Schedule,88.93,442% of BCBS Fee Schedule,103.94,100% of BCBS Fee Schedule,103.94,100% of BCBS Fee Schedule,103.94,100% of BCBS Fee Schedule,103.94,100% of BCBS Fee Schedule,103.94,100% of BCBS Fee Schedule,314.16,84% of total billed charges,314.16,84% of total billed charges,314.16,84% of total billed charges,261.8,70% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.28,100% of CA Medicaid Fee Schedule with lesser of charges applied,24.88,314.16,280.5
Outpatient Medical Services,RADIOLOGY,74247,UGI W KUB AIR CONT,320,973.25,700.74,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,317.62,442% of BCBS Fee Schedule,N/A,Not Separately reimbursable,769.84,79.1% of total billed charges,N/A,Not Separately reimbursable,817.53,84% of total billed charges,817.53,84% of total billed charges,700.74,72% of total billed charges,N/A,Not Separately reimbursable,632.61,65% of total billed charges,N/A,Not Separately reimbursable,583.95,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,681.28,70% of total billed charges,973.25,100% OF CMS OPPS Rate,973.25,120% of CMS OPPS RATE,700.74,Pays at 72% of billed charges with lesser of charges applied,700.74,Pays at 72% of billed charges with lesser of charges applied,700.74,Pays at 72% of billed charges with lesser of charges applied,700.74,Pays at 72% of billed charges with lesser of charges applied,700.74,Pays at 72% of billed charges with lesser of charges applied,700.74,Pays at 72% of billed charges with lesser of charges applied,317.62,442% of BCBS Fee Schedule,317.62,442% of BCBS Fee Schedule,317.62,442% of BCBS Fee Schedule,317.62,442% of BCBS Fee Schedule,317.62,442% of BCBS Fee Schedule,317.62,442% of BCBS Fee Schedule,317.62,442% of BCBS Fee Schedule,317.62,442% of BCBS Fee Schedule,317.62,442% of BCBS Fee Schedule,769.84,79.1% of total billed charges,769.84,79.1% of total billed charges,769.84,79.1% of total billed charges,769.84,79.1% of total billed charges,769.84,79.1% of total billed charges,817.53,84% of total billed charges,817.53,84% of total billed charges,817.53,84% of total billed charges,681.28,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,317.62,973.25,729.94
Outpatient Medical Services,RADIOLOGY,73060,HUMERUS BILATERAL,320,429,308.88,Pays at 72% of billed charges with lesser of charges applied,110.43,100% OF CMS OPPS Rate,107.14,442% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,128.47,100% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,360.36,84% of total billed charges,360.36,84% of total billed charges,308.88,72% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% of CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,257.4,60% of total billed charges,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,28.86,100% OF CMS OPPS RATE,110.43,100% OF CMS OPPS Rate,300.3,70% of total billed charges,110.43,100% OF CMS OPPS Rate,132.51,120% of CMS OPPS RATE,308.88,Pays at 72% of billed charges with lesser of charges applied,308.88,Pays at 72% of billed charges with lesser of charges applied,308.88,Pays at 72% of billed charges with lesser of charges applied,308.88,Pays at 72% of billed charges with lesser of charges applied,308.88,Pays at 72% of billed charges with lesser of charges applied,308.88,Pays at 72% of billed charges with lesser of charges applied,107.14,442% of BCBS Fee Schedule,107.14,442% of BCBS Fee Schedule,107.14,442% of BCBS Fee Schedule,107.14,442% of BCBS Fee Schedule,107.14,442% of BCBS Fee Schedule,107.14,442% of BCBS Fee Schedule,107.14,442% of BCBS Fee Schedule,107.14,442% of BCBS Fee Schedule,107.14,442% of BCBS Fee Schedule,128.47,100% of BCBS Fee Schedule,128.47,100% of BCBS Fee Schedule,128.47,100% of BCBS Fee Schedule,128.47,100% of BCBS Fee Schedule,128.47,100% of BCBS Fee Schedule,360.36,84% of total billed charges,360.36,84% of total billed charges,360.36,84% of total billed charges,300.3,70% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.86,360.36,321.75
Outpatient Medical Services,RADIOLOGY,72110,"X-ray of lower and sacral spine, minimum of 4 views",320,637,458.64,Pays at 72% of billed charges with lesser of charges applied,135.85,100% OF CMS OPPS Rate,171.94,442% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,204.52,100% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,535.08,84% of total billed charges,535.08,84% of total billed charges,458.64,72% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% of CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,382.2,60% of total billed charges,62.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,62.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,46.38,100% OF CMS OPPS RATE,135.85,100% OF CMS OPPS Rate,445.9,70% of total billed charges,135.85,100% OF CMS OPPS Rate,163.02,120% of CMS OPPS RATE,458.64,Pays at 72% of billed charges with lesser of charges applied,458.64,Pays at 72% of billed charges with lesser of charges applied,458.64,Pays at 72% of billed charges with lesser of charges applied,458.64,Pays at 72% of billed charges with lesser of charges applied,458.64,Pays at 72% of billed charges with lesser of charges applied,458.64,Pays at 72% of billed charges with lesser of charges applied,171.94,442% of BCBS Fee Schedule,171.94,442% of BCBS Fee Schedule,171.94,442% of BCBS Fee Schedule,171.94,442% of BCBS Fee Schedule,171.94,442% of BCBS Fee Schedule,171.94,442% of BCBS Fee Schedule,171.94,442% of BCBS Fee Schedule,171.94,442% of BCBS Fee Schedule,171.94,442% of BCBS Fee Schedule,204.52,100% of BCBS Fee Schedule,204.52,100% of BCBS Fee Schedule,204.52,100% of BCBS Fee Schedule,204.52,100% of BCBS Fee Schedule,204.52,100% of BCBS Fee Schedule,535.08,84% of total billed charges,535.08,84% of total billed charges,535.08,84% of total billed charges,445.9,70% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,62.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,62.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,62.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,62.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,62.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,62.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,62.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,62.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,62.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,62.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,62.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,62.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,62.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,62.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,62.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,62.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,62.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,62.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,62.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,62.90,100% of CA Medicaid Fee Schedule with lesser of charges applied,46.38,535.08,477.75
Outpatient Medical Services,RADIOLOGY,70130,MASTOIDS COMP BIL,320,656.75,472.86,Pays at 72% of billed charges with lesser of charges applied,135.85,100% OF CMS OPPS Rate,148.34,442% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,177.23,100% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,551.67,84% of total billed charges,551.67,84% of total billed charges,472.86,72% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% of CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,394.05,60% of total billed charges,65.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,65.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,55.14,100% OF CMS OPPS RATE,135.85,100% OF CMS OPPS Rate,459.73,70% of total billed charges,135.85,100% OF CMS OPPS Rate,163.02,120% of CMS OPPS RATE,472.86,Pays at 72% of billed charges with lesser of charges applied,472.86,Pays at 72% of billed charges with lesser of charges applied,472.86,Pays at 72% of billed charges with lesser of charges applied,472.86,Pays at 72% of billed charges with lesser of charges applied,472.86,Pays at 72% of billed charges with lesser of charges applied,472.86,Pays at 72% of billed charges with lesser of charges applied,148.34,442% of BCBS Fee Schedule,148.34,442% of BCBS Fee Schedule,148.34,442% of BCBS Fee Schedule,148.34,442% of BCBS Fee Schedule,148.34,442% of BCBS Fee Schedule,148.34,442% of BCBS Fee Schedule,148.34,442% of BCBS Fee Schedule,148.34,442% of BCBS Fee Schedule,148.34,442% of BCBS Fee Schedule,177.23,100% of BCBS Fee Schedule,177.23,100% of BCBS Fee Schedule,177.23,100% of BCBS Fee Schedule,177.23,100% of BCBS Fee Schedule,177.23,100% of BCBS Fee Schedule,551.67,84% of total billed charges,551.67,84% of total billed charges,551.67,84% of total billed charges,459.73,70% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,65.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,65.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,65.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,65.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,65.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,65.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,65.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,65.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,65.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,65.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,65.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,65.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,65.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,65.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,65.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,65.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,65.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,65.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,65.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,65.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,55.14,551.67,492.56
Outpatient Medical Services,RADIOLOGY,73010,SCAPULA BILATERAL,320,529.5,381.24,Pays at 72% of billed charges with lesser of charges applied,135.85,100% OF CMS OPPS Rate,98.04,442% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,114.67,100% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,444.78,84% of total billed charges,444.78,84% of total billed charges,381.24,72% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% of CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,317.7,60% of total billed charges,30.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,30.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,17.71,100% OF CMS OPPS RATE,135.85,100% OF CMS OPPS Rate,370.65,70% of total billed charges,135.85,100% OF CMS OPPS Rate,163.02,120% of CMS OPPS RATE,381.24,Pays at 72% of billed charges with lesser of charges applied,381.24,Pays at 72% of billed charges with lesser of charges applied,381.24,Pays at 72% of billed charges with lesser of charges applied,381.24,Pays at 72% of billed charges with lesser of charges applied,381.24,Pays at 72% of billed charges with lesser of charges applied,381.24,Pays at 72% of billed charges with lesser of charges applied,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,114.67,100% of BCBS Fee Schedule,114.67,100% of BCBS Fee Schedule,114.67,100% of BCBS Fee Schedule,114.67,100% of BCBS Fee Schedule,114.67,100% of BCBS Fee Schedule,444.78,84% of total billed charges,444.78,84% of total billed charges,444.78,84% of total billed charges,370.65,70% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,30.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,30.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,30.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,30.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,30.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,30.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,30.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,30.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,30.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,30.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,30.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,30.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,30.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,30.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,30.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,30.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,30.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,30.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,30.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,30.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,17.71,444.78,397.13
Outpatient Medical Services,RADIOLOGY,71120,XR STERNUM MIN 2V,320,330.5,237.96,Pays at 72% of billed charges with lesser of charges applied,110.43,100% OF CMS OPPS Rate,122.12,442% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,145.64,100% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,277.62,84% of total billed charges,277.62,84% of total billed charges,237.96,72% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% of CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,198.3,60% of total billed charges,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,28.86,100% OF CMS OPPS RATE,110.43,100% OF CMS OPPS Rate,231.35,70% of total billed charges,110.43,100% OF CMS OPPS Rate,132.51,120% of CMS OPPS RATE,237.96,Pays at 72% of billed charges with lesser of charges applied,237.96,Pays at 72% of billed charges with lesser of charges applied,237.96,Pays at 72% of billed charges with lesser of charges applied,237.96,Pays at 72% of billed charges with lesser of charges applied,237.96,Pays at 72% of billed charges with lesser of charges applied,237.96,Pays at 72% of billed charges with lesser of charges applied,122.12,442% of BCBS Fee Schedule,122.12,442% of BCBS Fee Schedule,122.12,442% of BCBS Fee Schedule,122.12,442% of BCBS Fee Schedule,122.12,442% of BCBS Fee Schedule,122.12,442% of BCBS Fee Schedule,122.12,442% of BCBS Fee Schedule,122.12,442% of BCBS Fee Schedule,122.12,442% of BCBS Fee Schedule,145.64,100% of BCBS Fee Schedule,145.64,100% of BCBS Fee Schedule,145.64,100% of BCBS Fee Schedule,145.64,100% of BCBS Fee Schedule,145.64,100% of BCBS Fee Schedule,277.62,84% of total billed charges,277.62,84% of total billed charges,277.62,84% of total billed charges,231.35,70% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.86,277.62,247.88
Outpatient Medical Services,RADIOLOGY,72114,L-SPINE 6+ VIEWS,320,666.75,480.06,Pays at 72% of billed charges with lesser of charges applied,135.85,100% OF CMS OPPS Rate,222.28,442% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,264.61,100% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,560.07,84% of total billed charges,560.07,84% of total billed charges,480.06,72% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% of CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,400.05,60% of total billed charges,75.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,56.33,100% OF CMS OPPS RATE,135.85,100% OF CMS OPPS Rate,466.73,70% of total billed charges,135.85,100% OF CMS OPPS Rate,163.02,120% of CMS OPPS RATE,480.06,Pays at 72% of billed charges with lesser of charges applied,480.06,Pays at 72% of billed charges with lesser of charges applied,480.06,Pays at 72% of billed charges with lesser of charges applied,480.06,Pays at 72% of billed charges with lesser of charges applied,480.06,Pays at 72% of billed charges with lesser of charges applied,480.06,Pays at 72% of billed charges with lesser of charges applied,222.28,442% of BCBS Fee Schedule,222.28,442% of BCBS Fee Schedule,222.28,442% of BCBS Fee Schedule,222.28,442% of BCBS Fee Schedule,222.28,442% of BCBS Fee Schedule,222.28,442% of BCBS Fee Schedule,222.28,442% of BCBS Fee Schedule,222.28,442% of BCBS Fee Schedule,222.28,442% of BCBS Fee Schedule,264.61,100% of BCBS Fee Schedule,264.61,100% of BCBS Fee Schedule,264.61,100% of BCBS Fee Schedule,264.61,100% of BCBS Fee Schedule,264.61,100% of BCBS Fee Schedule,560.07,84% of total billed charges,560.07,84% of total billed charges,560.07,84% of total billed charges,466.73,70% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,75.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,56.33,560.07,500.06
Outpatient Medical Services,RADIOLOGY,70100,MANDIBLE LIMITED,320,246.5,177.48,Pays at 72% of billed charges with lesser of charges applied,110.43,100% OF CMS OPPS Rate,97.99,442% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,114.67,100% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,207.06,84% of total billed charges,207.06,84% of total billed charges,177.48,72% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% of CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,147.9,60% of total billed charges,36.00,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.00,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,35.63,100% OF CMS OPPS RATE,110.43,100% OF CMS OPPS Rate,172.55,70% of total billed charges,110.43,100% OF CMS OPPS Rate,132.51,120% of CMS OPPS RATE,177.48,Pays at 72% of billed charges with lesser of charges applied,177.48,Pays at 72% of billed charges with lesser of charges applied,177.48,Pays at 72% of billed charges with lesser of charges applied,177.48,Pays at 72% of billed charges with lesser of charges applied,177.48,Pays at 72% of billed charges with lesser of charges applied,177.48,Pays at 72% of billed charges with lesser of charges applied,97.99,442% of BCBS Fee Schedule,97.99,442% of BCBS Fee Schedule,97.99,442% of BCBS Fee Schedule,97.99,442% of BCBS Fee Schedule,97.99,442% of BCBS Fee Schedule,97.99,442% of BCBS Fee Schedule,97.99,442% of BCBS Fee Schedule,97.99,442% of BCBS Fee Schedule,97.99,442% of BCBS Fee Schedule,114.67,100% of BCBS Fee Schedule,114.67,100% of BCBS Fee Schedule,114.67,100% of BCBS Fee Schedule,114.67,100% of BCBS Fee Schedule,114.67,100% of BCBS Fee Schedule,207.06,84% of total billed charges,207.06,84% of total billed charges,207.06,84% of total billed charges,172.55,70% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,36.00,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.00,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.00,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.00,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.00,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.00,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.00,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.00,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.00,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.00,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.00,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.00,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.00,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.00,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.00,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.00,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.00,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.00,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.00,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.00,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.63,207.06,184.88
Outpatient Medical Services,RADIOLOGY,74475,PERC NEPHROSTOMY,320,434,312.48,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,434,BCBS Fee Schedule,N/A,Not Separately reimbursable,343.29,79.1% of total billed charges,N/A,Not Separately reimbursable,364.56,84% of total billed charges,364.56,84% of total billed charges,312.48,72% of total billed charges,N/A,Not Separately reimbursable,282.1,65% of total billed charges,N/A,Not Separately reimbursable,260.4,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,303.8,70% of total billed charges,434,100% OF CMS OPPS Rate,434,120% of CMS OPPS RATE,312.48,Pays at 72% of billed charges with lesser of charges applied,312.48,Pays at 72% of billed charges with lesser of charges applied,312.48,Pays at 72% of billed charges with lesser of charges applied,312.48,Pays at 72% of billed charges with lesser of charges applied,312.48,Pays at 72% of billed charges with lesser of charges applied,312.48,Pays at 72% of billed charges with lesser of charges applied,434,BCBS Fee Schedule,434,BCBS Fee Schedule,434,BCBS Fee Schedule,434,BCBS Fee Schedule,434,BCBS Fee Schedule,434,BCBS Fee Schedule,434,BCBS Fee Schedule,434,BCBS Fee Schedule,434,BCBS Fee Schedule,343.29,79.1% of total billed charges,343.29,79.1% of total billed charges,343.29,79.1% of total billed charges,343.29,79.1% of total billed charges,343.29,79.1% of total billed charges,364.56,84% of total billed charges,364.56,84% of total billed charges,364.56,84% of total billed charges,303.8,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,260.40,434.00,325.5
Outpatient Medical Services,RADIOLOGY,71100,"RIBS UNILAT, 2 V",320,380.25,273.78,Pays at 72% of billed charges with lesser of charges applied,110.43,100% OF CMS OPPS Rate,107.67,442% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,128.47,100% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,319.41,84% of total billed charges,319.41,84% of total billed charges,273.78,72% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% of CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,228.15,60% of total billed charges,38.96,100% of CA Medicaid Fee Schedule with lesser of charges applied,38.96,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,31.25,100% OF CMS OPPS RATE,110.43,100% OF CMS OPPS Rate,266.18,70% of total billed charges,110.43,100% OF CMS OPPS Rate,132.51,120% of CMS OPPS RATE,273.78,Pays at 72% of billed charges with lesser of charges applied,273.78,Pays at 72% of billed charges with lesser of charges applied,273.78,Pays at 72% of billed charges with lesser of charges applied,273.78,Pays at 72% of billed charges with lesser of charges applied,273.78,Pays at 72% of billed charges with lesser of charges applied,273.78,Pays at 72% of billed charges with lesser of charges applied,107.67,442% of BCBS Fee Schedule,107.67,442% of BCBS Fee Schedule,107.67,442% of BCBS Fee Schedule,107.67,442% of BCBS Fee Schedule,107.67,442% of BCBS Fee Schedule,107.67,442% of BCBS Fee Schedule,107.67,442% of BCBS Fee Schedule,107.67,442% of BCBS Fee Schedule,107.67,442% of BCBS Fee Schedule,128.47,100% of BCBS Fee Schedule,128.47,100% of BCBS Fee Schedule,128.47,100% of BCBS Fee Schedule,128.47,100% of BCBS Fee Schedule,128.47,100% of BCBS Fee Schedule,319.41,84% of total billed charges,319.41,84% of total billed charges,319.41,84% of total billed charges,266.18,70% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,38.96,100% of CA Medicaid Fee Schedule with lesser of charges applied,38.96,100% of CA Medicaid Fee Schedule with lesser of charges applied,38.96,100% of CA Medicaid Fee Schedule with lesser of charges applied,38.96,100% of CA Medicaid Fee Schedule with lesser of charges applied,38.96,100% of CA Medicaid Fee Schedule with lesser of charges applied,38.96,100% of CA Medicaid Fee Schedule with lesser of charges applied,38.96,100% of CA Medicaid Fee Schedule with lesser of charges applied,38.96,100% of CA Medicaid Fee Schedule with lesser of charges applied,38.96,100% of CA Medicaid Fee Schedule with lesser of charges applied,38.96,100% of CA Medicaid Fee Schedule with lesser of charges applied,38.96,100% of CA Medicaid Fee Schedule with lesser of charges applied,38.96,100% of CA Medicaid Fee Schedule with lesser of charges applied,38.96,100% of CA Medicaid Fee Schedule with lesser of charges applied,38.96,100% of CA Medicaid Fee Schedule with lesser of charges applied,38.96,100% of CA Medicaid Fee Schedule with lesser of charges applied,38.96,100% of CA Medicaid Fee Schedule with lesser of charges applied,38.96,100% of CA Medicaid Fee Schedule with lesser of charges applied,38.96,100% of CA Medicaid Fee Schedule with lesser of charges applied,38.96,100% of CA Medicaid Fee Schedule with lesser of charges applied,38.96,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.25,319.41,285.19
Outpatient Medical Services,RADIOLOGY,73552,FEMUR 2 VIEW RT,320,330.5,237.96,Pays at 72% of billed charges with lesser of charges applied,110.43,100% OF CMS OPPS Rate,173.84,442% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,136.74,100% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,277.62,84% of total billed charges,277.62,84% of total billed charges,237.96,72% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% of CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,198.3,60% of total billed charges,41.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,41.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,32.05,100% OF CMS OPPS RATE,110.43,100% OF CMS OPPS Rate,231.35,70% of total billed charges,110.43,100% OF CMS OPPS Rate,132.51,120% of CMS OPPS RATE,237.96,Pays at 72% of billed charges with lesser of charges applied,237.96,Pays at 72% of billed charges with lesser of charges applied,237.96,Pays at 72% of billed charges with lesser of charges applied,237.96,Pays at 72% of billed charges with lesser of charges applied,237.96,Pays at 72% of billed charges with lesser of charges applied,237.96,Pays at 72% of billed charges with lesser of charges applied,173.84,442% of BCBS Fee Schedule,173.84,442% of BCBS Fee Schedule,173.84,442% of BCBS Fee Schedule,173.84,442% of BCBS Fee Schedule,173.84,442% of BCBS Fee Schedule,173.84,442% of BCBS Fee Schedule,173.84,442% of BCBS Fee Schedule,173.84,442% of BCBS Fee Schedule,173.84,442% of BCBS Fee Schedule,136.74,100% of BCBS Fee Schedule,136.74,100% of BCBS Fee Schedule,136.74,100% of BCBS Fee Schedule,136.74,100% of BCBS Fee Schedule,136.74,100% of BCBS Fee Schedule,277.62,84% of total billed charges,277.62,84% of total billed charges,277.62,84% of total billed charges,231.35,70% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,41.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,41.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,41.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,41.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,41.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,41.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,41.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,41.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,41.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,41.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,41.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,41.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,41.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,41.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,41.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,41.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,41.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,41.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,41.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,41.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,32.05,277.62,247.88
Outpatient Medical Services,RADIOLOGY,70200,ORBITS COMPLETE,320,461,331.92,Pays at 72% of billed charges with lesser of charges applied,135.85,100% OF CMS OPPS Rate,148.38,442% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,177.23,100% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,387.24,84% of total billed charges,387.24,84% of total billed charges,331.92,72% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% of CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,276.6,60% of total billed charges,54.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,41.2,100% OF CMS OPPS RATE,135.85,100% OF CMS OPPS Rate,322.7,70% of total billed charges,135.85,100% OF CMS OPPS Rate,163.02,120% of CMS OPPS RATE,331.92,Pays at 72% of billed charges with lesser of charges applied,331.92,Pays at 72% of billed charges with lesser of charges applied,331.92,Pays at 72% of billed charges with lesser of charges applied,331.92,Pays at 72% of billed charges with lesser of charges applied,331.92,Pays at 72% of billed charges with lesser of charges applied,331.92,Pays at 72% of billed charges with lesser of charges applied,148.38,442% of BCBS Fee Schedule,148.38,442% of BCBS Fee Schedule,148.38,442% of BCBS Fee Schedule,148.38,442% of BCBS Fee Schedule,148.38,442% of BCBS Fee Schedule,148.38,442% of BCBS Fee Schedule,148.38,442% of BCBS Fee Schedule,148.38,442% of BCBS Fee Schedule,148.38,442% of BCBS Fee Schedule,177.23,100% of BCBS Fee Schedule,177.23,100% of BCBS Fee Schedule,177.23,100% of BCBS Fee Schedule,177.23,100% of BCBS Fee Schedule,177.23,100% of BCBS Fee Schedule,387.24,84% of total billed charges,387.24,84% of total billed charges,387.24,84% of total billed charges,322.7,70% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,54.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,41.20,387.24,345.75
Outpatient Medical Services,RADIOLOGY,72220,SACRUM + COCCYX,320,353.5,254.52,Pays at 72% of billed charges with lesser of charges applied,110.43,100% OF CMS OPPS Rate,107.14,442% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,128.47,100% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,296.94,84% of total billed charges,296.94,84% of total billed charges,254.52,72% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% of CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,212.1,60% of total billed charges,35.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,28.86,100% OF CMS OPPS RATE,110.43,100% OF CMS OPPS Rate,247.45,70% of total billed charges,110.43,100% OF CMS OPPS Rate,132.51,120% of CMS OPPS RATE,254.52,Pays at 72% of billed charges with lesser of charges applied,254.52,Pays at 72% of billed charges with lesser of charges applied,254.52,Pays at 72% of billed charges with lesser of charges applied,254.52,Pays at 72% of billed charges with lesser of charges applied,254.52,Pays at 72% of billed charges with lesser of charges applied,254.52,Pays at 72% of billed charges with lesser of charges applied,107.14,442% of BCBS Fee Schedule,107.14,442% of BCBS Fee Schedule,107.14,442% of BCBS Fee Schedule,107.14,442% of BCBS Fee Schedule,107.14,442% of BCBS Fee Schedule,107.14,442% of BCBS Fee Schedule,107.14,442% of BCBS Fee Schedule,107.14,442% of BCBS Fee Schedule,107.14,442% of BCBS Fee Schedule,128.47,100% of BCBS Fee Schedule,128.47,100% of BCBS Fee Schedule,128.47,100% of BCBS Fee Schedule,128.47,100% of BCBS Fee Schedule,128.47,100% of BCBS Fee Schedule,296.94,84% of total billed charges,296.94,84% of total billed charges,296.94,84% of total billed charges,247.45,70% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,35.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.89,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.86,296.94,265.13
Outpatient Medical Services,RADIOLOGY,70160,NASAL COMPLETE,320,338.25,243.54,Pays at 72% of billed charges with lesser of charges applied,110.43,100% OF CMS OPPS Rate,98.04,442% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,114.67,100% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,284.13,84% of total billed charges,284.13,84% of total billed charges,243.54,72% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% of CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,202.95,60% of total billed charges,35.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,35.63,100% OF CMS OPPS RATE,110.43,100% OF CMS OPPS Rate,236.78,70% of total billed charges,110.43,100% OF CMS OPPS Rate,132.51,120% of CMS OPPS RATE,243.54,Pays at 72% of billed charges with lesser of charges applied,243.54,Pays at 72% of billed charges with lesser of charges applied,243.54,Pays at 72% of billed charges with lesser of charges applied,243.54,Pays at 72% of billed charges with lesser of charges applied,243.54,Pays at 72% of billed charges with lesser of charges applied,243.54,Pays at 72% of billed charges with lesser of charges applied,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,114.67,100% of BCBS Fee Schedule,114.67,100% of BCBS Fee Schedule,114.67,100% of BCBS Fee Schedule,114.67,100% of BCBS Fee Schedule,114.67,100% of BCBS Fee Schedule,284.13,84% of total billed charges,284.13,84% of total billed charges,284.13,84% of total billed charges,236.78,70% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,35.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.56,284.13,253.69
Outpatient Medical Services,RADIOLOGY,72190,PELVIS COMP 3V,320,351.75,253.26,Pays at 72% of billed charges with lesser of charges applied,135.85,100% OF CMS OPPS Rate,125.88,442% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,149.94,100% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,295.47,84% of total billed charges,295.47,84% of total billed charges,253.26,72% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% of CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,211.05,60% of total billed charges,45.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,36.03,100% OF CMS OPPS RATE,135.85,100% OF CMS OPPS Rate,246.23,70% of total billed charges,135.85,100% OF CMS OPPS Rate,163.02,120% of CMS OPPS RATE,253.26,Pays at 72% of billed charges with lesser of charges applied,253.26,Pays at 72% of billed charges with lesser of charges applied,253.26,Pays at 72% of billed charges with lesser of charges applied,253.26,Pays at 72% of billed charges with lesser of charges applied,253.26,Pays at 72% of billed charges with lesser of charges applied,253.26,Pays at 72% of billed charges with lesser of charges applied,125.88,442% of BCBS Fee Schedule,125.88,442% of BCBS Fee Schedule,125.88,442% of BCBS Fee Schedule,125.88,442% of BCBS Fee Schedule,125.88,442% of BCBS Fee Schedule,125.88,442% of BCBS Fee Schedule,125.88,442% of BCBS Fee Schedule,125.88,442% of BCBS Fee Schedule,125.88,442% of BCBS Fee Schedule,149.94,100% of BCBS Fee Schedule,149.94,100% of BCBS Fee Schedule,149.94,100% of BCBS Fee Schedule,149.94,100% of BCBS Fee Schedule,149.94,100% of BCBS Fee Schedule,295.47,84% of total billed charges,295.47,84% of total billed charges,295.47,84% of total billed charges,246.23,70% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,45.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,36.03,295.47,263.81
Outpatient Medical Services,RADIOLOGY,70220,SINUS COMPLETE,320,553,398.16,Pays at 72% of billed charges with lesser of charges applied,110.43,100% OF CMS OPPS Rate,147.85,442% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,177.23,100% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,464.52,84% of total billed charges,464.52,84% of total billed charges,398.16,72% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% of CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,331.8,60% of total billed charges,47.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,47.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,32.44,100% OF CMS OPPS RATE,110.43,100% OF CMS OPPS Rate,387.1,70% of total billed charges,110.43,100% OF CMS OPPS Rate,132.51,120% of CMS OPPS RATE,398.16,Pays at 72% of billed charges with lesser of charges applied,398.16,Pays at 72% of billed charges with lesser of charges applied,398.16,Pays at 72% of billed charges with lesser of charges applied,398.16,Pays at 72% of billed charges with lesser of charges applied,398.16,Pays at 72% of billed charges with lesser of charges applied,398.16,Pays at 72% of billed charges with lesser of charges applied,147.85,442% of BCBS Fee Schedule,147.85,442% of BCBS Fee Schedule,147.85,442% of BCBS Fee Schedule,147.85,442% of BCBS Fee Schedule,147.85,442% of BCBS Fee Schedule,147.85,442% of BCBS Fee Schedule,147.85,442% of BCBS Fee Schedule,147.85,442% of BCBS Fee Schedule,147.85,442% of BCBS Fee Schedule,177.23,100% of BCBS Fee Schedule,177.23,100% of BCBS Fee Schedule,177.23,100% of BCBS Fee Schedule,177.23,100% of BCBS Fee Schedule,177.23,100% of BCBS Fee Schedule,464.52,84% of total billed charges,464.52,84% of total billed charges,464.52,84% of total billed charges,387.1,70% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,47.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,47.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,47.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,47.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,47.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,47.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,47.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,47.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,47.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,47.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,47.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,47.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,47.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,47.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,47.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,47.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,47.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,47.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,47.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,47.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,32.44,464.52,414.75
Outpatient Medical Services,RADIOLOGY,73562,Radiologic examination of the knee with 3 views,320,302.25,217.62,Pays at 72% of billed charges with lesser of charges applied,110.43,100% OF CMS OPPS Rate,107.1,442% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,128.47,100% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,253.89,84% of total billed charges,253.89,84% of total billed charges,217.62,72% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% of CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,181.35,60% of total billed charges,33.54,100% of CA Medicaid Fee Schedule with lesser of charges applied,33.54,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,37.62,100% OF CMS OPPS RATE,110.43,100% OF CMS OPPS Rate,211.58,70% of total billed charges,110.43,100% OF CMS OPPS Rate,132.51,120% of CMS OPPS RATE,217.62,Pays at 72% of billed charges with lesser of charges applied,217.62,Pays at 72% of billed charges with lesser of charges applied,217.62,Pays at 72% of billed charges with lesser of charges applied,217.62,Pays at 72% of billed charges with lesser of charges applied,217.62,Pays at 72% of billed charges with lesser of charges applied,217.62,Pays at 72% of billed charges with lesser of charges applied,107.1,442% of BCBS Fee Schedule,107.1,442% of BCBS Fee Schedule,107.1,442% of BCBS Fee Schedule,107.1,442% of BCBS Fee Schedule,107.1,442% of BCBS Fee Schedule,107.1,442% of BCBS Fee Schedule,107.1,442% of BCBS Fee Schedule,107.1,442% of BCBS Fee Schedule,107.1,442% of BCBS Fee Schedule,128.47,100% of BCBS Fee Schedule,128.47,100% of BCBS Fee Schedule,128.47,100% of BCBS Fee Schedule,128.47,100% of BCBS Fee Schedule,128.47,100% of BCBS Fee Schedule,253.89,84% of total billed charges,253.89,84% of total billed charges,253.89,84% of total billed charges,211.58,70% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,33.54,100% of CA Medicaid Fee Schedule with lesser of charges applied,33.54,100% of CA Medicaid Fee Schedule with lesser of charges applied,33.54,100% of CA Medicaid Fee Schedule with lesser of charges applied,33.54,100% of CA Medicaid Fee Schedule with lesser of charges applied,33.54,100% of CA Medicaid Fee Schedule with lesser of charges applied,33.54,100% of CA Medicaid Fee Schedule with lesser of charges applied,33.54,100% of CA Medicaid Fee Schedule with lesser of charges applied,33.54,100% of CA Medicaid Fee Schedule with lesser of charges applied,33.54,100% of CA Medicaid Fee Schedule with lesser of charges applied,33.54,100% of CA Medicaid Fee Schedule with lesser of charges applied,33.54,100% of CA Medicaid Fee Schedule with lesser of charges applied,33.54,100% of CA Medicaid Fee Schedule with lesser of charges applied,33.54,100% of CA Medicaid Fee Schedule with lesser of charges applied,33.54,100% of CA Medicaid Fee Schedule with lesser of charges applied,33.54,100% of CA Medicaid Fee Schedule with lesser of charges applied,33.54,100% of CA Medicaid Fee Schedule with lesser of charges applied,33.54,100% of CA Medicaid Fee Schedule with lesser of charges applied,33.54,100% of CA Medicaid Fee Schedule with lesser of charges applied,33.54,100% of CA Medicaid Fee Schedule with lesser of charges applied,33.54,100% of CA Medicaid Fee Schedule with lesser of charges applied,33.54,253.89,226.69
Outpatient Medical Services,RADIOLOGY,70110,MANDIBLE COMP,320,507.75,365.58,Pays at 72% of billed charges with lesser of charges applied,135.85,100% OF CMS OPPS Rate,116.78,442% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,139.21,100% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,426.51,84% of total billed charges,426.51,84% of total billed charges,365.58,72% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% of CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,304.65,60% of total billed charges,48.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,48.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,37.62,100% OF CMS OPPS RATE,135.85,100% OF CMS OPPS Rate,355.43,70% of total billed charges,135.85,100% OF CMS OPPS Rate,163.02,120% of CMS OPPS RATE,365.58,Pays at 72% of billed charges with lesser of charges applied,365.58,Pays at 72% of billed charges with lesser of charges applied,365.58,Pays at 72% of billed charges with lesser of charges applied,365.58,Pays at 72% of billed charges with lesser of charges applied,365.58,Pays at 72% of billed charges with lesser of charges applied,365.58,Pays at 72% of billed charges with lesser of charges applied,116.78,442% of BCBS Fee Schedule,116.78,442% of BCBS Fee Schedule,116.78,442% of BCBS Fee Schedule,116.78,442% of BCBS Fee Schedule,116.78,442% of BCBS Fee Schedule,116.78,442% of BCBS Fee Schedule,116.78,442% of BCBS Fee Schedule,116.78,442% of BCBS Fee Schedule,116.78,442% of BCBS Fee Schedule,139.21,100% of BCBS Fee Schedule,139.21,100% of BCBS Fee Schedule,139.21,100% of BCBS Fee Schedule,139.21,100% of BCBS Fee Schedule,139.21,100% of BCBS Fee Schedule,426.51,84% of total billed charges,426.51,84% of total billed charges,426.51,84% of total billed charges,355.43,70% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,48.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,48.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,48.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,48.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,48.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,48.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,48.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,48.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,48.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,48.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,48.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,48.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,48.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,48.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,48.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,48.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,48.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,48.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,48.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,48.83,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.62,426.51,380.81
Outpatient Medical Services,RADIOLOGY,70250,SKULL LIMITED,320,341.5,245.88,Pays at 72% of billed charges with lesser of charges applied,135.85,100% OF CMS OPPS Rate,116.78,442% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,139.21,100% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,286.86,84% of total billed charges,286.86,84% of total billed charges,245.88,72% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% of CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,204.9,60% of total billed charges,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,32.44,100% OF CMS OPPS RATE,135.85,100% OF CMS OPPS Rate,239.05,70% of total billed charges,135.85,100% OF CMS OPPS Rate,163.02,120% of CMS OPPS RATE,245.88,Pays at 72% of billed charges with lesser of charges applied,245.88,Pays at 72% of billed charges with lesser of charges applied,245.88,Pays at 72% of billed charges with lesser of charges applied,245.88,Pays at 72% of billed charges with lesser of charges applied,245.88,Pays at 72% of billed charges with lesser of charges applied,245.88,Pays at 72% of billed charges with lesser of charges applied,116.78,442% of BCBS Fee Schedule,116.78,442% of BCBS Fee Schedule,116.78,442% of BCBS Fee Schedule,116.78,442% of BCBS Fee Schedule,116.78,442% of BCBS Fee Schedule,116.78,442% of BCBS Fee Schedule,116.78,442% of BCBS Fee Schedule,116.78,442% of BCBS Fee Schedule,116.78,442% of BCBS Fee Schedule,139.21,100% of BCBS Fee Schedule,139.21,100% of BCBS Fee Schedule,139.21,100% of BCBS Fee Schedule,139.21,100% of BCBS Fee Schedule,139.21,100% of BCBS Fee Schedule,286.86,84% of total billed charges,286.86,84% of total billed charges,286.86,84% of total billed charges,239.05,70% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,32.44,286.86,256.13
Outpatient Medical Services,RADIOLOGY,70120,MASTOIDS LTD,320,248.5,178.92,Pays at 72% of billed charges with lesser of charges applied,135.85,100% OF CMS OPPS Rate,116.78,442% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,139.21,100% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,208.74,84% of total billed charges,208.74,84% of total billed charges,178.92,72% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% of CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,149.1,60% of total billed charges,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,35.63,100% OF CMS OPPS RATE,135.85,100% OF CMS OPPS Rate,173.95,70% of total billed charges,135.85,100% OF CMS OPPS Rate,163.02,120% of CMS OPPS RATE,178.92,Pays at 72% of billed charges with lesser of charges applied,178.92,Pays at 72% of billed charges with lesser of charges applied,178.92,Pays at 72% of billed charges with lesser of charges applied,178.92,Pays at 72% of billed charges with lesser of charges applied,178.92,Pays at 72% of billed charges with lesser of charges applied,178.92,Pays at 72% of billed charges with lesser of charges applied,116.78,442% of BCBS Fee Schedule,116.78,442% of BCBS Fee Schedule,116.78,442% of BCBS Fee Schedule,116.78,442% of BCBS Fee Schedule,116.78,442% of BCBS Fee Schedule,116.78,442% of BCBS Fee Schedule,116.78,442% of BCBS Fee Schedule,116.78,442% of BCBS Fee Schedule,116.78,442% of BCBS Fee Schedule,139.21,100% of BCBS Fee Schedule,139.21,100% of BCBS Fee Schedule,139.21,100% of BCBS Fee Schedule,139.21,100% of BCBS Fee Schedule,139.21,100% of BCBS Fee Schedule,208.74,84% of total billed charges,208.74,84% of total billed charges,208.74,84% of total billed charges,173.95,70% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,35.63,208.74,186.38
Outpatient Medical Services,RADIOLOGY,77073,BONE LENGTH,320,536,385.92,Pays at 72% of billed charges with lesser of charges applied,135.85,100% OF CMS OPPS Rate,148.38,442% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,125.72,100% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,450.24,84% of total billed charges,450.24,84% of total billed charges,385.92,72% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% of CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,321.6,60% of total billed charges,45.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,38.02,100% OF CMS OPPS RATE,135.85,100% OF CMS OPPS Rate,375.2,70% of total billed charges,135.85,100% OF CMS OPPS Rate,163.02,120% of CMS OPPS RATE,385.92,Pays at 72% of billed charges with lesser of charges applied,385.92,Pays at 72% of billed charges with lesser of charges applied,385.92,Pays at 72% of billed charges with lesser of charges applied,385.92,Pays at 72% of billed charges with lesser of charges applied,385.92,Pays at 72% of billed charges with lesser of charges applied,385.92,Pays at 72% of billed charges with lesser of charges applied,148.38,442% of BCBS Fee Schedule,148.38,442% of BCBS Fee Schedule,148.38,442% of BCBS Fee Schedule,148.38,442% of BCBS Fee Schedule,148.38,442% of BCBS Fee Schedule,148.38,442% of BCBS Fee Schedule,148.38,442% of BCBS Fee Schedule,148.38,442% of BCBS Fee Schedule,148.38,442% of BCBS Fee Schedule,125.72,100% of BCBS Fee Schedule,125.72,100% of BCBS Fee Schedule,125.72,100% of BCBS Fee Schedule,125.72,100% of BCBS Fee Schedule,125.72,100% of BCBS Fee Schedule,450.24,84% of total billed charges,450.24,84% of total billed charges,450.24,84% of total billed charges,375.2,70% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,45.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,45.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,38.02,450.24,402
Outpatient Medical Services,RADIOLOGY,74450,URETHROGRAM,320,520,374.4,Pays at 72% of billed charges with lesser of charges applied,296.82,100% OF CMS OPPS Rate,272.94,442% of BCBS Fee Schedule,296.82,100% OF CMS OPPS Rate,325.63,100% of BCBS Fee Schedule,296.82,100% OF CMS OPPS Rate,436.8,84% of total billed charges,436.8,84% of total billed charges,374.4,72% of total billed charges,296.82,100% OF CMS OPPS Rate,296.82,100% of CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,312,60% of total billed charges,59.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,N/A,Not Separately reimbursable,296.82,100% OF CMS OPPS Rate,364,70% of total billed charges,296.82,100% OF CMS OPPS Rate,356.18,120% of CMS OPPS RATE,374.4,Pays at 72% of billed charges with lesser of charges applied,374.4,Pays at 72% of billed charges with lesser of charges applied,374.4,Pays at 72% of billed charges with lesser of charges applied,374.4,Pays at 72% of billed charges with lesser of charges applied,374.4,Pays at 72% of billed charges with lesser of charges applied,374.4,Pays at 72% of billed charges with lesser of charges applied,272.94,442% of BCBS Fee Schedule,272.94,442% of BCBS Fee Schedule,272.94,442% of BCBS Fee Schedule,272.94,442% of BCBS Fee Schedule,272.94,442% of BCBS Fee Schedule,272.94,442% of BCBS Fee Schedule,272.94,442% of BCBS Fee Schedule,272.94,442% of BCBS Fee Schedule,272.94,442% of BCBS Fee Schedule,325.63,100% of BCBS Fee Schedule,325.63,100% of BCBS Fee Schedule,325.63,100% of BCBS Fee Schedule,325.63,100% of BCBS Fee Schedule,325.63,100% of BCBS Fee Schedule,436.8,84% of total billed charges,436.8,84% of total billed charges,436.8,84% of total billed charges,364,70% of total billed charges,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,59.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.56,436.80,390
Outpatient Medical Services,RADIOLOGY,74430,CYSTOGRAM,320,473.75,341.1,Pays at 72% of billed charges with lesser of charges applied,468.3,100% OF CMS OPPS Rate,197.18,442% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,236.71,100% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,397.95,84% of total billed charges,397.95,84% of total billed charges,341.1,72% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% of CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,284.25,60% of total billed charges,47.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,47.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,31.25,100% OF CMS OPPS RATE,468.3,100% OF CMS OPPS Rate,331.63,70% of total billed charges,468.3,100% OF CMS OPPS Rate,473.75,120% of CMS OPPS RATE,341.1,Pays at 72% of billed charges with lesser of charges applied,341.1,Pays at 72% of billed charges with lesser of charges applied,341.1,Pays at 72% of billed charges with lesser of charges applied,341.1,Pays at 72% of billed charges with lesser of charges applied,341.1,Pays at 72% of billed charges with lesser of charges applied,341.1,Pays at 72% of billed charges with lesser of charges applied,197.18,442% of BCBS Fee Schedule,197.18,442% of BCBS Fee Schedule,197.18,442% of BCBS Fee Schedule,197.18,442% of BCBS Fee Schedule,197.18,442% of BCBS Fee Schedule,197.18,442% of BCBS Fee Schedule,197.18,442% of BCBS Fee Schedule,197.18,442% of BCBS Fee Schedule,197.18,442% of BCBS Fee Schedule,236.71,100% of BCBS Fee Schedule,236.71,100% of BCBS Fee Schedule,236.71,100% of BCBS Fee Schedule,236.71,100% of BCBS Fee Schedule,236.71,100% of BCBS Fee Schedule,397.95,84% of total billed charges,397.95,84% of total billed charges,397.95,84% of total billed charges,331.63,70% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,47.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,47.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,47.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,47.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,47.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,47.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,47.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,47.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,47.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,47.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,47.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,47.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,47.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,47.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,47.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,47.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,47.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,47.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,47.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,47.56,100% of CA Medicaid Fee Schedule with lesser of charges applied,31.25,473.75,355.31
Outpatient Medical Services,RADIOLOGY,77072,BONE AGE,320,319.75,230.22,Pays at 72% of billed charges with lesser of charges applied,135.85,100% OF CMS OPPS Rate,98.04,442% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,76.04,100% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,268.59,84% of total billed charges,268.59,84% of total billed charges,230.22,72% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% of CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,191.85,60% of total billed charges,28.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,20.1,100% OF CMS OPPS RATE,135.85,100% OF CMS OPPS Rate,223.83,70% of total billed charges,135.85,100% OF CMS OPPS Rate,163.02,120% of CMS OPPS RATE,230.22,Pays at 72% of billed charges with lesser of charges applied,230.22,Pays at 72% of billed charges with lesser of charges applied,230.22,Pays at 72% of billed charges with lesser of charges applied,230.22,Pays at 72% of billed charges with lesser of charges applied,230.22,Pays at 72% of billed charges with lesser of charges applied,230.22,Pays at 72% of billed charges with lesser of charges applied,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,98.04,442% of BCBS Fee Schedule,76.04,100% of BCBS Fee Schedule,76.04,100% of BCBS Fee Schedule,76.04,100% of BCBS Fee Schedule,76.04,100% of BCBS Fee Schedule,76.04,100% of BCBS Fee Schedule,268.59,84% of total billed charges,268.59,84% of total billed charges,268.59,84% of total billed charges,223.83,70% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,28.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.10,268.59,239.81
Outpatient Medical Services,RADIOLOGY,73085,ELBOW ARTHROGRAM S&I BILATERAL,322,1056.5,760.68,Pays at 72% of billed charges with lesser of charges applied,468.3,100% OF CMS OPPS Rate,392.81,442% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,469.12,100% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,887.46,84% of total billed charges,887.46,84% of total billed charges,760.68,72% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% of CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,633.9,60% of total billed charges,103.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,103.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,101.33,100% OF CMS OPPS RATE,468.3,100% OF CMS OPPS Rate,739.55,70% of total billed charges,468.3,100% OF CMS OPPS Rate,561.96,120% of CMS OPPS RATE,760.68,Pays at 72% of billed charges with lesser of charges applied,760.68,Pays at 72% of billed charges with lesser of charges applied,760.68,Pays at 72% of billed charges with lesser of charges applied,760.68,Pays at 72% of billed charges with lesser of charges applied,760.68,Pays at 72% of billed charges with lesser of charges applied,760.68,Pays at 72% of billed charges with lesser of charges applied,392.81,442% of BCBS Fee Schedule,392.81,442% of BCBS Fee Schedule,392.81,442% of BCBS Fee Schedule,392.81,442% of BCBS Fee Schedule,392.81,442% of BCBS Fee Schedule,392.81,442% of BCBS Fee Schedule,392.81,442% of BCBS Fee Schedule,392.81,442% of BCBS Fee Schedule,392.81,442% of BCBS Fee Schedule,469.12,100% of BCBS Fee Schedule,469.12,100% of BCBS Fee Schedule,469.12,100% of BCBS Fee Schedule,469.12,100% of BCBS Fee Schedule,469.12,100% of BCBS Fee Schedule,887.46,84% of total billed charges,887.46,84% of total billed charges,887.46,84% of total billed charges,739.55,70% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,103.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,103.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,103.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,103.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,103.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,103.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,103.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,103.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,103.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,103.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,103.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,103.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,103.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,103.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,103.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,103.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,103.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,103.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,103.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,103.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,101.33,887.46,792.38
Outpatient Medical Services,RADIOLOGY,73040,SHOULDER ARTHROGRAM S&I BIL,322,1056.5,760.68,Pays at 72% of billed charges with lesser of charges applied,468.3,100% OF CMS OPPS Rate,392.81,442% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,469.12,100% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,887.46,84% of total billed charges,887.46,84% of total billed charges,760.68,72% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% of CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,633.9,60% of total billed charges,72.71,100% of CA Medicaid Fee Schedule with lesser of charges applied,72.71,100% of CA Medicaid Fee Schedule with lesser of charges applied,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,125.62,100% OF CMS OPPS RATE,468.3,100% OF CMS OPPS Rate,739.55,70% of total billed charges,468.3,100% OF CMS OPPS Rate,561.96,120% of CMS OPPS RATE,760.68,Pays at 72% of billed charges with lesser of charges applied,760.68,Pays at 72% of billed charges with lesser of charges applied,760.68,Pays at 72% of billed charges with lesser of charges applied,760.68,Pays at 72% of billed charges with lesser of charges applied,760.68,Pays at 72% of billed charges with lesser of charges applied,760.68,Pays at 72% of billed charges with lesser of charges applied,392.81,442% of BCBS Fee Schedule,392.81,442% of BCBS Fee Schedule,392.81,442% of BCBS Fee Schedule,392.81,442% of BCBS Fee Schedule,392.81,442% of BCBS Fee Schedule,392.81,442% of BCBS Fee Schedule,392.81,442% of BCBS Fee Schedule,392.81,442% of BCBS Fee Schedule,392.81,442% of BCBS Fee Schedule,469.12,100% of BCBS Fee Schedule,469.12,100% of BCBS Fee Schedule,469.12,100% of BCBS Fee Schedule,469.12,100% of BCBS Fee Schedule,469.12,100% of BCBS Fee Schedule,887.46,84% of total billed charges,887.46,84% of total billed charges,887.46,84% of total billed charges,739.55,70% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,72.71,100% of CA Medicaid Fee Schedule with lesser of charges applied,72.71,100% of CA Medicaid Fee Schedule with lesser of charges applied,72.71,100% of CA Medicaid Fee Schedule with lesser of charges applied,72.71,100% of CA Medicaid Fee Schedule with lesser of charges applied,72.71,100% of CA Medicaid Fee Schedule with lesser of charges applied,72.71,100% of CA Medicaid Fee Schedule with lesser of charges applied,72.71,100% of CA Medicaid Fee Schedule with lesser of charges applied,72.71,100% of CA Medicaid Fee Schedule with lesser of charges applied,72.71,100% of CA Medicaid Fee Schedule with lesser of charges applied,72.71,100% of CA Medicaid Fee Schedule with lesser of charges applied,72.71,100% of CA Medicaid Fee Schedule with lesser of charges applied,72.71,100% of CA Medicaid Fee Schedule with lesser of charges applied,72.71,100% of CA Medicaid Fee Schedule with lesser of charges applied,72.71,100% of CA Medicaid Fee Schedule with lesser of charges applied,72.71,100% of CA Medicaid Fee Schedule with lesser of charges applied,72.71,100% of CA Medicaid Fee Schedule with lesser of charges applied,72.71,100% of CA Medicaid Fee Schedule with lesser of charges applied,72.71,100% of CA Medicaid Fee Schedule with lesser of charges applied,72.71,100% of CA Medicaid Fee Schedule with lesser of charges applied,72.71,100% of CA Medicaid Fee Schedule with lesser of charges applied,72.71,887.46,792.38
Outpatient Medical Services,RADIOLOGY,73115,WRIST ARTHROGRAM S&I BIL,322,689.75,496.62,Pays at 72% of billed charges with lesser of charges applied,468.3,100% OF CMS OPPS Rate,294.99,442% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,354.45,100% of BCBS Fee Schedule,468.3,100% OF CMS OPPS Rate,579.39,84% of total billed charges,579.39,84% of total billed charges,496.62,72% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% of CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,413.85,60% of total billed charges,59.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,130,100% OF CMS OPPS RATE,468.3,100% OF CMS OPPS Rate,482.83,70% of total billed charges,468.3,100% OF CMS OPPS Rate,561.96,120% of CMS OPPS RATE,496.62,Pays at 72% of billed charges with lesser of charges applied,496.62,Pays at 72% of billed charges with lesser of charges applied,496.62,Pays at 72% of billed charges with lesser of charges applied,496.62,Pays at 72% of billed charges with lesser of charges applied,496.62,Pays at 72% of billed charges with lesser of charges applied,496.62,Pays at 72% of billed charges with lesser of charges applied,294.99,442% of BCBS Fee Schedule,294.99,442% of BCBS Fee Schedule,294.99,442% of BCBS Fee Schedule,294.99,442% of BCBS Fee Schedule,294.99,442% of BCBS Fee Schedule,294.99,442% of BCBS Fee Schedule,294.99,442% of BCBS Fee Schedule,294.99,442% of BCBS Fee Schedule,294.99,442% of BCBS Fee Schedule,354.45,100% of BCBS Fee Schedule,354.45,100% of BCBS Fee Schedule,354.45,100% of BCBS Fee Schedule,354.45,100% of BCBS Fee Schedule,354.45,100% of BCBS Fee Schedule,579.39,84% of total billed charges,579.39,84% of total billed charges,579.39,84% of total billed charges,482.83,70% of total billed charges,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,468.3,100% OF CMS OPPS Rate,59.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.01,100% of CA Medicaid Fee Schedule with lesser of charges applied,59.01,579.39,517.31
Outpatient Medical Services,RADIOLOGY,73525,HIP ARTHROGRAM S&I LT,322,457,329.04,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,392.81,442% of BCBS Fee Schedule,N/A,Not Separately reimbursable,448.32,pays at 100% of bcbs fee schedule with lesser of charges applied,N/A,Not Separately reimbursable,383.88,84% of total billed charges,383.88,84% of total billed charges,329.04,72% of total billed charges,N/A,Not Separately reimbursable,457,100% of CMS OPPS Rate,N/A,Not Separately reimbursable,274.2,60% of total billed charges,108.00,100% of CA Medicaid Fee Schedule with lesser of charges applied,108.00,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,123.23,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,319.9,70% of total billed charges,457,100% OF CMS OPPS Rate,457,120% of CMS OPPS RATE,329.04,Pays at 72% of billed charges with lesser of charges applied,329.04,Pays at 72% of billed charges with lesser of charges applied,329.04,Pays at 72% of billed charges with lesser of charges applied,329.04,Pays at 72% of billed charges with lesser of charges applied,329.04,Pays at 72% of billed charges with lesser of charges applied,329.04,Pays at 72% of billed charges with lesser of charges applied,392.81,442% of BCBS Fee Schedule,392.81,442% of BCBS Fee Schedule,392.81,442% of BCBS Fee Schedule,392.81,442% of BCBS Fee Schedule,392.81,442% of BCBS Fee Schedule,392.81,442% of BCBS Fee Schedule,392.81,442% of BCBS Fee Schedule,392.81,442% of BCBS Fee Schedule,392.81,442% of BCBS Fee Schedule,448.32,pays at 100% of bcbs fee schedule with lesser of charges applied,448.32,pays at 100% of bcbs fee schedule with lesser of charges applied,448.32,pays at 100% of bcbs fee schedule with lesser of charges applied,448.32,pays at 100% of bcbs fee schedule with lesser of charges applied,448.32,pays at 100% of bcbs fee schedule with lesser of charges applied,383.88,84% of total billed charges,383.88,84% of total billed charges,383.88,84% of total billed charges,319.9,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,108.00,100% of CA Medicaid Fee Schedule with lesser of charges applied,108.00,100% of CA Medicaid Fee Schedule with lesser of charges applied,108.00,100% of CA Medicaid Fee Schedule with lesser of charges applied,108.00,100% of CA Medicaid Fee Schedule with lesser of charges applied,108.00,100% of CA Medicaid Fee Schedule with lesser of charges applied,108.00,100% of CA Medicaid Fee Schedule with lesser of charges applied,108.00,100% of CA Medicaid Fee Schedule with lesser of charges applied,108.00,100% of CA Medicaid Fee Schedule with lesser of charges applied,108.00,100% of CA Medicaid Fee Schedule with lesser of charges applied,108.00,100% of CA Medicaid Fee Schedule with lesser of charges applied,108.00,100% of CA Medicaid Fee Schedule with lesser of charges applied,108.00,100% of CA Medicaid Fee Schedule with lesser of charges applied,108.00,100% of CA Medicaid Fee Schedule with lesser of charges applied,108.00,100% of CA Medicaid Fee Schedule with lesser of charges applied,108.00,100% of CA Medicaid Fee Schedule with lesser of charges applied,108.00,100% of CA Medicaid Fee Schedule with lesser of charges applied,108.00,100% of CA Medicaid Fee Schedule with lesser of charges applied,108.00,100% of CA Medicaid Fee Schedule with lesser of charges applied,108.00,100% of CA Medicaid Fee Schedule with lesser of charges applied,108.00,100% of CA Medicaid Fee Schedule with lesser of charges applied,108.00,457.00,342.75
Outpatient Medical Services,RADIOLOGY,77001,ANGIO VIA INDWELLING CATH (FPCA),323,338.25,243.54,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,249.38,442% of BCBS Fee Schedule,N/A,Not Separately reimbursable,331.82,pays at 100% of bcbs fee schedule with lesser of charges applied,N/A,Not Separately reimbursable,284.13,84% of total billed charges,284.13,84% of total billed charges,243.54,72% of total billed charges,N/A,Not Separately reimbursable,219.86,65% of total billed charges,N/A,Not Separately reimbursable,202.95,60% of total billed charges,91.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,91.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,98.94,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,236.78,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,243.54,Pays at 72% of billed charges with lesser of charges applied,243.54,Pays at 72% of billed charges with lesser of charges applied,243.54,Pays at 72% of billed charges with lesser of charges applied,243.54,Pays at 72% of billed charges with lesser of charges applied,243.54,Pays at 72% of billed charges with lesser of charges applied,243.54,Pays at 72% of billed charges with lesser of charges applied,249.38,442% of BCBS Fee Schedule,249.38,442% of BCBS Fee Schedule,249.38,442% of BCBS Fee Schedule,249.38,442% of BCBS Fee Schedule,249.38,442% of BCBS Fee Schedule,249.38,442% of BCBS Fee Schedule,249.38,442% of BCBS Fee Schedule,249.38,442% of BCBS Fee Schedule,249.38,442% of BCBS Fee Schedule,331.82,pays at 100% of bcbs fee schedule with lesser of charges applied,331.82,pays at 100% of bcbs fee schedule with lesser of charges applied,331.82,pays at 100% of bcbs fee schedule with lesser of charges applied,331.82,pays at 100% of bcbs fee schedule with lesser of charges applied,331.82,pays at 100% of bcbs fee schedule with lesser of charges applied,284.13,84% of total billed charges,284.13,84% of total billed charges,284.13,84% of total billed charges,236.78,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,91.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,91.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,91.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,91.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,91.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,91.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,91.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,91.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,91.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,91.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,91.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,91.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,91.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,91.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,91.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,91.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,91.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,91.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,91.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,91.17,100% of CA Medicaid Fee Schedule with lesser of charges applied,91.17,331.82,253.69
Outpatient Medical Services,RADIOLOGY,71045,Single view,324,227.5,163.8,Pays at 72% of billed charges with lesser of charges applied,110.42,100% OF CMS OPPS Rate,82.83,442% of BCBS Fee Schedule,110.42,100% OF CMS OPPS Rate,63.77,100% of BCBS Fee Schedule,110.42,100% OF CMS OPPS Rate,191.1,84% of total billed charges,191.1,84% of total billed charges,163.8,72% of total billed charges,110.42,100% OF CMS OPPS Rate,110.42,100% of CMS OPPS Rate,110.42,100% OF CMS OPPS Rate,136.5,60% of total billed charges,25.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,25.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.42,100% OF CMS OPPS Rate,110.42,100% OF CMS OPPS Rate,20.5,100% OF CMS OPPS RATE,110.42,100% OF CMS OPPS Rate,159.25,70% of total billed charges,110.42,100% OF CMS OPPS Rate,132.51,120% of CMS OPPS RATE,163.8,Pays at 72% of billed charges with lesser of charges applied,163.8,Pays at 72% of billed charges with lesser of charges applied,163.8,Pays at 72% of billed charges with lesser of charges applied,163.8,Pays at 72% of billed charges with lesser of charges applied,163.8,Pays at 72% of billed charges with lesser of charges applied,163.8,Pays at 72% of billed charges with lesser of charges applied,82.83,442% of BCBS Fee Schedule,82.83,442% of BCBS Fee Schedule,82.83,442% of BCBS Fee Schedule,82.83,442% of BCBS Fee Schedule,82.83,442% of BCBS Fee Schedule,82.83,442% of BCBS Fee Schedule,82.83,442% of BCBS Fee Schedule,82.83,442% of BCBS Fee Schedule,82.83,442% of BCBS Fee Schedule,63.77,100% of BCBS Fee Schedule,63.77,100% of BCBS Fee Schedule,63.77,100% of BCBS Fee Schedule,63.77,100% of BCBS Fee Schedule,63.77,100% of BCBS Fee Schedule,191.1,84% of total billed charges,191.1,84% of total billed charges,191.1,84% of total billed charges,159.25,70% of total billed charges,110.42,100% OF CMS OPPS Rate,110.42,100% OF CMS OPPS Rate,110.42,100% OF CMS OPPS Rate,110.42,100% OF CMS OPPS Rate,110.42,100% OF CMS OPPS Rate,110.42,100% OF CMS OPPS Rate,110.42,100% OF CMS OPPS Rate,110.42,100% OF CMS OPPS Rate,110.42,100% OF CMS OPPS Rate,110.42,100% OF CMS OPPS Rate,110.42,100% OF CMS OPPS Rate,110.42,100% OF CMS OPPS Rate,110.42,100% OF CMS OPPS Rate,110.42,100% OF CMS OPPS Rate,110.42,100% OF CMS OPPS Rate,110.42,100% OF CMS OPPS Rate,25.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,25.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,25.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,25.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,25.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,25.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,25.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,25.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,25.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,25.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,25.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,25.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,25.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,25.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,25.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,25.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,25.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,25.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,25.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,25.35,100% of CA Medicaid Fee Schedule with lesser of charges applied,20.50,191.10,170.63
Outpatient Medical Services,RADIOLOGY,71047,3 views,324,381.75,274.86,Pays at 72% of billed charges with lesser of charges applied,110.43,100% OF CMS OPPS Rate,195.19,442% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,149.62,100% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,320.67,84% of total billed charges,320.67,84% of total billed charges,274.86,72% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% of CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,229.05,60% of total billed charges,50.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,50.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,34.83,100% OF CMS OPPS RATE,110.43,100% OF CMS OPPS Rate,267.23,70% of total billed charges,110.43,100% OF CMS OPPS Rate,132.51,120% of CMS OPPS RATE,274.86,Pays at 72% of billed charges with lesser of charges applied,274.86,Pays at 72% of billed charges with lesser of charges applied,274.86,Pays at 72% of billed charges with lesser of charges applied,274.86,Pays at 72% of billed charges with lesser of charges applied,274.86,Pays at 72% of billed charges with lesser of charges applied,274.86,Pays at 72% of billed charges with lesser of charges applied,195.19,442% of BCBS Fee Schedule,195.19,442% of BCBS Fee Schedule,195.19,442% of BCBS Fee Schedule,195.19,442% of BCBS Fee Schedule,195.19,442% of BCBS Fee Schedule,195.19,442% of BCBS Fee Schedule,195.19,442% of BCBS Fee Schedule,195.19,442% of BCBS Fee Schedule,195.19,442% of BCBS Fee Schedule,149.62,100% of BCBS Fee Schedule,149.62,100% of BCBS Fee Schedule,149.62,100% of BCBS Fee Schedule,149.62,100% of BCBS Fee Schedule,149.62,100% of BCBS Fee Schedule,320.67,84% of total billed charges,320.67,84% of total billed charges,320.67,84% of total billed charges,267.23,70% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,50.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,50.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,50.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,50.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,50.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,50.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,50.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,50.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,50.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,50.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,50.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,50.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,50.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,50.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,50.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,50.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,50.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,50.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,50.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,50.59,100% of CA Medicaid Fee Schedule with lesser of charges applied,34.83,320.67,286.31
Outpatient Medical Services,RADIOLOGY,71046,"2 views, front and back",324,385.75,277.74,Pays at 72% of billed charges with lesser of charges applied,110.42,100% OF CMS OPPS Rate,153.15,442% of BCBS Fee Schedule,110.42,100% OF CMS OPPS Rate,117.43,100% of BCBS Fee Schedule,110.42,100% OF CMS OPPS Rate,324.03,84% of total billed charges,324.03,84% of total billed charges,277.74,72% of total billed charges,110.42,100% OF CMS OPPS Rate,110.42,100% of CMS OPPS Rate,110.42,100% OF CMS OPPS Rate,231.45,60% of total billed charges,39.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.42,100% OF CMS OPPS Rate,110.42,100% OF CMS OPPS Rate,27.67,100% OF CMS OPPS RATE,110.42,100% OF CMS OPPS Rate,270.03,70% of total billed charges,110.42,100% OF CMS OPPS Rate,132.51,120% of CMS OPPS RATE,277.74,Pays at 72% of billed charges with lesser of charges applied,277.74,Pays at 72% of billed charges with lesser of charges applied,277.74,Pays at 72% of billed charges with lesser of charges applied,277.74,Pays at 72% of billed charges with lesser of charges applied,277.74,Pays at 72% of billed charges with lesser of charges applied,277.74,Pays at 72% of billed charges with lesser of charges applied,153.15,442% of BCBS Fee Schedule,153.15,442% of BCBS Fee Schedule,153.15,442% of BCBS Fee Schedule,153.15,442% of BCBS Fee Schedule,153.15,442% of BCBS Fee Schedule,153.15,442% of BCBS Fee Schedule,153.15,442% of BCBS Fee Schedule,153.15,442% of BCBS Fee Schedule,153.15,442% of BCBS Fee Schedule,117.43,100% of BCBS Fee Schedule,117.43,100% of BCBS Fee Schedule,117.43,100% of BCBS Fee Schedule,117.43,100% of BCBS Fee Schedule,117.43,100% of BCBS Fee Schedule,324.03,84% of total billed charges,324.03,84% of total billed charges,324.03,84% of total billed charges,270.03,70% of total billed charges,110.42,100% OF CMS OPPS Rate,110.42,100% OF CMS OPPS Rate,110.42,100% OF CMS OPPS Rate,110.42,100% OF CMS OPPS Rate,110.42,100% OF CMS OPPS Rate,110.42,100% OF CMS OPPS Rate,110.42,100% OF CMS OPPS Rate,110.42,100% OF CMS OPPS Rate,110.42,100% OF CMS OPPS Rate,110.42,100% OF CMS OPPS Rate,110.42,100% OF CMS OPPS Rate,110.42,100% OF CMS OPPS Rate,110.42,100% OF CMS OPPS Rate,110.42,100% OF CMS OPPS Rate,110.42,100% OF CMS OPPS Rate,110.42,100% OF CMS OPPS Rate,39.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,39.42,100% of CA Medicaid Fee Schedule with lesser of charges applied,27.67,324.03,289.31
Outpatient Medical Services,RADIOLOGY,71023,CHEST 2V W FLUORO,324,385.75,277.74,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,148.87,442% of BCBS Fee Schedule,N/A,Not Separately reimbursable,305.13,79.1% of total billed charges,N/A,Not Separately reimbursable,324.03,84% of total billed charges,324.03,84% of total billed charges,277.74,72% of total billed charges,N/A,Not Separately reimbursable,250.74,65% of total billed charges,N/A,Not Separately reimbursable,231.45,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,270.03,70% of total billed charges,385.75,100% OF CMS OPPS Rate with lesser of charges applied,385.75,120% of CMS OPPS RATE,277.74,Pays at 72% of billed charges with lesser of charges applied,277.74,Pays at 72% of billed charges with lesser of charges applied,277.74,Pays at 72% of billed charges with lesser of charges applied,277.74,Pays at 72% of billed charges with lesser of charges applied,277.74,Pays at 72% of billed charges with lesser of charges applied,277.74,Pays at 72% of billed charges with lesser of charges applied,148.87,442% of BCBS Fee Schedule,148.87,442% of BCBS Fee Schedule,148.87,442% of BCBS Fee Schedule,148.87,442% of BCBS Fee Schedule,148.87,442% of BCBS Fee Schedule,148.87,442% of BCBS Fee Schedule,148.87,442% of BCBS Fee Schedule,148.87,442% of BCBS Fee Schedule,148.87,442% of BCBS Fee Schedule,305.13,79.1% of total billed charges,305.13,79.1% of total billed charges,305.13,79.1% of total billed charges,305.13,79.1% of total billed charges,305.13,79.1% of total billed charges,324.03,84% of total billed charges,324.03,84% of total billed charges,324.03,84% of total billed charges,270.03,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,148.87,385.75,289.31
Outpatient Medical Services,RADIOLOGY,71048,4 or more views,324,465.75,335.34,Pays at 72% of billed charges with lesser of charges applied,135.85,100% OF CMS OPPS Rate,200.84,442% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,153.91,100% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,391.23,84% of total billed charges,391.23,84% of total billed charges,335.34,72% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% of CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,279.45,60% of total billed charges,54.32,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.32,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,37.62,100% OF CMS OPPS RATE,135.85,100% OF CMS OPPS Rate,326.03,70% of total billed charges,135.85,100% OF CMS OPPS Rate,163.02,120% of CMS OPPS RATE,335.34,Pays at 72% of billed charges with lesser of charges applied,335.34,Pays at 72% of billed charges with lesser of charges applied,335.34,Pays at 72% of billed charges with lesser of charges applied,335.34,Pays at 72% of billed charges with lesser of charges applied,335.34,Pays at 72% of billed charges with lesser of charges applied,335.34,Pays at 72% of billed charges with lesser of charges applied,200.84,442% of BCBS Fee Schedule,200.84,442% of BCBS Fee Schedule,200.84,442% of BCBS Fee Schedule,200.84,442% of BCBS Fee Schedule,200.84,442% of BCBS Fee Schedule,200.84,442% of BCBS Fee Schedule,200.84,442% of BCBS Fee Schedule,200.84,442% of BCBS Fee Schedule,200.84,442% of BCBS Fee Schedule,153.91,100% of BCBS Fee Schedule,153.91,100% of BCBS Fee Schedule,153.91,100% of BCBS Fee Schedule,153.91,100% of BCBS Fee Schedule,153.91,100% of BCBS Fee Schedule,391.23,84% of total billed charges,391.23,84% of total billed charges,391.23,84% of total billed charges,326.03,70% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,54.32,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.32,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.32,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.32,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.32,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.32,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.32,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.32,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.32,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.32,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.32,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.32,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.32,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.32,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.32,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.32,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.32,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.32,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.32,100% of CA Medicaid Fee Schedule with lesser of charges applied,54.32,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.62,391.23,349.31
Outpatient Medical Services,SLEEP STUDY,95810,Sleep monitoring of patient (6 years or older) in sleep lab,920,3666.5,2639.88,Pays at 72% of billed charges with lesser of charges applied,1187.66,100% OF CMS OPPS Rate,1237.73,442% of BCBS Fee Schedule,1187.66,100% OF CMS OPPS Rate,3464.02,100% of BCBS Fee Schedule,1187.66,100% OF CMS OPPS Rate,3079.86,84% of total billed charges,3079.86,84% of total billed charges,2639.88,72% of total billed charges,1187.66,100% OF CMS OPPS Rate,1187.66,100% of CMS OPPS Rate,1187.66,100% OF CMS OPPS Rate,2199.9,60% of total billed charges,499.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,499.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,1187.66,100% OF CMS OPPS Rate,1187.66,100% OF CMS OPPS Rate,581.69,100% OF CMS OPPS RATE,1187.66,100% OF CMS OPPS Rate,2566.55,70% of total billed charges,1187.66,100% OF CMS OPPS Rate,1425.19,120% of CMS OPPS RATE,2639.88,Pays at 72% of billed charges with lesser of charges applied,2639.88,Pays at 72% of billed charges with lesser of charges applied,2639.88,Pays at 72% of billed charges with lesser of charges applied,2639.88,Pays at 72% of billed charges with lesser of charges applied,2639.88,Pays at 72% of billed charges with lesser of charges applied,2639.88,Pays at 72% of billed charges with lesser of charges applied,1237.73,442% of BCBS Fee Schedule,1237.73,442% of BCBS Fee Schedule,1237.73,442% of BCBS Fee Schedule,1237.73,442% of BCBS Fee Schedule,1237.73,442% of BCBS Fee Schedule,1237.73,442% of BCBS Fee Schedule,1237.73,442% of BCBS Fee Schedule,1237.73,442% of BCBS Fee Schedule,1237.73,442% of BCBS Fee Schedule,3464.02,100% of BCBS Fee Schedule,3464.02,100% of BCBS Fee Schedule,3464.02,100% of BCBS Fee Schedule,3464.02,100% of BCBS Fee Schedule,3464.02,100% of BCBS Fee Schedule,3079.86,84% of total billed charges,3079.86,84% of total billed charges,3079.86,84% of total billed charges,2566.55,70% of total billed charges,1187.66,100% OF CMS OPPS Rate,1187.66,100% OF CMS OPPS Rate,1187.66,100% OF CMS OPPS Rate,1187.66,100% OF CMS OPPS Rate,1187.66,100% OF CMS OPPS Rate,1187.66,100% OF CMS OPPS Rate,1187.66,100% OF CMS OPPS Rate,1187.66,100% OF CMS OPPS Rate,1187.66,100% OF CMS OPPS Rate,1187.66,100% OF CMS OPPS Rate,1187.66,100% OF CMS OPPS Rate,1187.66,100% OF CMS OPPS Rate,1187.66,100% OF CMS OPPS Rate,1187.66,100% OF CMS OPPS Rate,1187.66,100% OF CMS OPPS Rate,1187.66,100% OF CMS OPPS Rate,499.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,499.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,499.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,499.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,499.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,499.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,499.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,499.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,499.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,499.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,499.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,499.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,499.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,499.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,499.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,499.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,499.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,499.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,499.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,499.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,499.27,3464.02,2749.88
Outpatient Medical Services,SLEEP STUDY,94762,NOCTURNAL PULSE OXIMETRY,920,1816.75,1308.06,Pays at 72% of billed charges with lesser of charges applied,184.84,100% OF CMS OPPS Rate,232.58,442% of BCBS Fee Schedule,184.84,100% OF CMS OPPS Rate,101.21,100% of BCBS Fee Schedule,184.84,100% OF CMS OPPS Rate,1526.07,84% of total billed charges,1526.07,84% of total billed charges,1308.06,72% of total billed charges,184.84,100% OF CMS OPPS Rate,184.84,100% of CMS OPPS Rate,184.84,100% OF CMS OPPS Rate,1090.05,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,184.84,100% OF CMS OPPS Rate,184.84,100% OF CMS OPPS Rate,30.05,100% OF CMS OPPS RATE,184.84,100% OF CMS OPPS Rate,1271.73,70% of total billed charges,184.84,100% OF CMS OPPS Rate,221.81,120% of CMS OPPS RATE,1308.06,Pays at 72% of billed charges with lesser of charges applied,1308.06,Pays at 72% of billed charges with lesser of charges applied,1308.06,Pays at 72% of billed charges with lesser of charges applied,1308.06,Pays at 72% of billed charges with lesser of charges applied,1308.06,Pays at 72% of billed charges with lesser of charges applied,1308.06,Pays at 72% of billed charges with lesser of charges applied,232.58,442% of BCBS Fee Schedule,232.58,442% of BCBS Fee Schedule,232.58,442% of BCBS Fee Schedule,232.58,442% of BCBS Fee Schedule,232.58,442% of BCBS Fee Schedule,232.58,442% of BCBS Fee Schedule,232.58,442% of BCBS Fee Schedule,232.58,442% of BCBS Fee Schedule,232.58,442% of BCBS Fee Schedule,101.21,100% of BCBS Fee Schedule,101.21,100% of BCBS Fee Schedule,101.21,100% of BCBS Fee Schedule,101.21,100% of BCBS Fee Schedule,101.21,100% of BCBS Fee Schedule,1526.07,84% of total billed charges,1526.07,84% of total billed charges,1526.07,84% of total billed charges,1271.73,70% of total billed charges,184.84,100% OF CMS OPPS Rate,184.84,100% OF CMS OPPS Rate,184.84,100% OF CMS OPPS Rate,184.84,100% OF CMS OPPS Rate,184.84,100% OF CMS OPPS Rate,184.84,100% OF CMS OPPS Rate,184.84,100% OF CMS OPPS Rate,184.84,100% OF CMS OPPS Rate,184.84,100% OF CMS OPPS Rate,184.84,100% OF CMS OPPS Rate,184.84,100% OF CMS OPPS Rate,184.84,100% OF CMS OPPS Rate,184.84,100% OF CMS OPPS Rate,184.84,100% OF CMS OPPS Rate,184.84,100% OF CMS OPPS Rate,184.84,100% OF CMS OPPS Rate,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,30.05,1526.07,1362.56
Outpatient Medical Services,SPEECH THERAPY,97130,"Therapeutic intervention: cognitive function 1:1, each additional 15 minutes",440,198.5,N/A,Not Separately reimbursable,22.93,100% OF CMS OPPS Rate,N/A,Not Separately reimbursable,22.93,100% OF CMS OPPS Rate,194.73,Case rate,22.93,100% OF CMS OPPS Rate,166.74,84% of total billed charges,166.74,84% of total billed charges,142.92,72% of total billed charges,22.93,100% OF CMS OPPS Rate,22.93,100% of CMS OPPS Rate,22.93,100% OF CMS OPPS Rate,119.1,60% of total billed charges,28.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,22.93,100% OF CMS OPPS Rate,22.93,100% OF CMS OPPS Rate,22.93,100% OF CMS OPPS RATE,22.93,100% OF CMS OPPS Rate,138.95,70% of total billed charges,22.93,100% OF CMS OPPS Rate,27.52,120% of CMS OPPS RATE,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,194.73,Case rate,194.73,Case rate,194.73,Case rate,194.73,Case rate,194.73,Case rate,166.74,84% of total billed charges,166.74,84% of total billed charges,166.74,84% of total billed charges,138.95,70% of total billed charges,22.93,100% OF CMS OPPS Rate,22.93,100% OF CMS OPPS Rate,22.93,100% OF CMS OPPS Rate,22.93,100% OF CMS OPPS Rate,22.93,100% OF CMS OPPS Rate,22.93,100% OF CMS OPPS Rate,22.93,100% OF CMS OPPS Rate,22.93,100% OF CMS OPPS Rate,22.93,100% OF CMS OPPS Rate,22.93,100% OF CMS OPPS Rate,22.93,100% OF CMS OPPS Rate,22.93,100% OF CMS OPPS Rate,22.93,100% OF CMS OPPS Rate,22.93,100% OF CMS OPPS Rate,22.93,100% OF CMS OPPS Rate,22.93,100% OF CMS OPPS Rate,28.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,28.46,100% of CA Medicaid Fee Schedule with lesser of charges applied,22.93,194.73,148.88
Outpatient Medical Services,SPEECH THERAPY,V5362,Speech screening,444,198.5,142.92,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,198.5,Case rate,N/A,Not Separately reimbursable,194.73,Case rate,N/A,Not Separately reimbursable,166.74,84% of total billed charges,166.74,84% of total billed charges,142.92,72% of total billed charges,N/A,Not Separately reimbursable,129.03,65% of total billed charges,N/A,Not Separately reimbursable,119.1,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,138.95,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,142.92,Pays at 72% of billed charges with lesser of charges applied,142.92,Pays at 72% of billed charges with lesser of charges applied,142.92,Pays at 72% of billed charges with lesser of charges applied,142.92,Pays at 72% of billed charges with lesser of charges applied,142.92,Pays at 72% of billed charges with lesser of charges applied,142.92,Pays at 72% of billed charges with lesser of charges applied,198.5,Case rate,198.5,Case rate,198.5,Case rate,198.5,Case rate,198.5,Case rate,198.5,Case rate,198.5,Case rate,198.5,Case rate,198.5,Case rate,194.73,Case rate,194.73,Case rate,194.73,Case rate,194.73,Case rate,194.73,Case rate,166.74,84% of total billed charges,166.74,84% of total billed charges,166.74,84% of total billed charges,138.95,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,119.10,198.50,148.88
Outpatient Medical Services,SPEECH THERAPY,97129,"Therapeutic intervention: cognitive function 1:1, first 15 minutes",440,308,N/A,Not Separately reimbursable,23.63,100% OF CMS OPPS Rate,N/A,Not Separately reimbursable,23.63,100% OF CMS OPPS Rate,302.15,Case rate,23.63,100% OF CMS OPPS Rate,258.72,84% of total billed charges,258.72,84% of total billed charges,221.76,72% of total billed charges,23.63,100% OF CMS OPPS Rate,23.63,100% of CMS OPPS Rate,23.63,100% OF CMS OPPS Rate,184.8,60% of total billed charges,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,23.63,100% OF CMS OPPS Rate,23.63,100% OF CMS OPPS Rate,23.63,100% OF CMS OPPS RATE,23.63,100% OF CMS OPPS Rate,215.6,70% of total billed charges,23.63,100% OF CMS OPPS Rate,28.36,120% of CMS OPPS RATE,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,302.15,Case rate,302.15,Case rate,302.15,Case rate,302.15,Case rate,302.15,Case rate,258.72,84% of total billed charges,258.72,84% of total billed charges,258.72,84% of total billed charges,215.6,70% of total billed charges,23.63,100% OF CMS OPPS Rate,23.63,100% OF CMS OPPS Rate,23.63,100% OF CMS OPPS Rate,23.63,100% OF CMS OPPS Rate,23.63,100% OF CMS OPPS Rate,23.63,100% OF CMS OPPS Rate,23.63,100% OF CMS OPPS Rate,23.63,100% OF CMS OPPS Rate,23.63,100% OF CMS OPPS Rate,23.63,100% OF CMS OPPS Rate,23.63,100% OF CMS OPPS Rate,23.63,100% OF CMS OPPS Rate,23.63,100% OF CMS OPPS Rate,23.63,100% OF CMS OPPS Rate,23.63,100% OF CMS OPPS Rate,23.63,100% OF CMS OPPS Rate,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,29.81,100% of CA Medicaid Fee Schedule with lesser of charges applied,23.63,302.15,231
Outpatient Medical Services,SPEECH THERAPY,92507,Therapy for speech or hearing,441,329.5,237.24,Pays at 72% of billed charges with lesser of charges applied,83.63,100% OF CMS OPPS Rate,329.5,Case rate,83.63,100% OF CMS OPPS Rate,323.24,Case rate,83.63,100% OF CMS OPPS Rate,276.78,84% of total billed charges,276.78,84% of total billed charges,237.24,72% of total billed charges,83.63,100% OF CMS OPPS Rate,83.63,100% of CMS OPPS Rate,83.63,100% OF CMS OPPS Rate,197.7,60% of total billed charges,42.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,42.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,83.63,100% OF CMS OPPS Rate,83.63,100% OF CMS OPPS Rate,83.63,100% OF CMS OPPS RATE,83.63,100% OF CMS OPPS Rate,230.65,70% of total billed charges,83.63,100% OF CMS OPPS Rate,100.36,120% of CMS OPPS RATE,237.24,Pays at 72% of billed charges with lesser of charges applied,237.24,Pays at 72% of billed charges with lesser of charges applied,237.24,Pays at 72% of billed charges with lesser of charges applied,237.24,Pays at 72% of billed charges with lesser of charges applied,237.24,Pays at 72% of billed charges with lesser of charges applied,237.24,Pays at 72% of billed charges with lesser of charges applied,329.5,Case rate,329.5,Case rate,329.5,Case rate,329.5,Case rate,329.5,Case rate,329.5,Case rate,329.5,Case rate,329.5,Case rate,329.5,Case rate,323.24,Case rate,323.24,Case rate,323.24,Case rate,323.24,Case rate,323.24,Case rate,276.78,84% of total billed charges,276.78,84% of total billed charges,276.78,84% of total billed charges,230.65,70% of total billed charges,83.63,100% OF CMS OPPS Rate,83.63,100% OF CMS OPPS Rate,83.63,100% OF CMS OPPS Rate,83.63,100% OF CMS OPPS Rate,83.63,100% OF CMS OPPS Rate,83.63,100% OF CMS OPPS Rate,83.63,100% OF CMS OPPS Rate,83.63,100% OF CMS OPPS Rate,83.63,100% OF CMS OPPS Rate,83.63,100% OF CMS OPPS Rate,83.63,100% OF CMS OPPS Rate,83.63,100% OF CMS OPPS Rate,83.63,100% OF CMS OPPS Rate,83.63,100% OF CMS OPPS Rate,83.63,100% OF CMS OPPS Rate,83.63,100% OF CMS OPPS Rate,42.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,42.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,42.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,42.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,42.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,42.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,42.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,42.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,42.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,42.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,42.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,42.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,42.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,42.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,42.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,42.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,42.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,42.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,42.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,42.63,100% of CA Medicaid Fee Schedule with lesser of charges applied,42.63,329.50,247.13
Outpatient Medical Services,SPEECH THERAPY,92526,Treatment of swallowing and/or oral function for feeding,441,329.5,237.24,Pays at 72% of billed charges with lesser of charges applied,93.39,100% OF CMS OPPS Rate,329.5,Case rate,93.39,100% OF CMS OPPS Rate,323.24,Case rate,93.39,100% OF CMS OPPS Rate,276.78,84% of total billed charges,276.78,84% of total billed charges,237.24,72% of total billed charges,93.39,100% OF CMS OPPS Rate,93.39,100% of CMS OPPS Rate,93.39,100% OF CMS OPPS Rate,197.7,60% of total billed charges,48.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,48.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,93.39,100% OF CMS OPPS Rate,93.39,100% OF CMS OPPS Rate,93.39,100% OF CMS OPPS RATE,93.39,100% OF CMS OPPS Rate,230.65,70% of total billed charges,93.39,100% OF CMS OPPS Rate,112.07,120% of CMS OPPS RATE,237.24,Pays at 72% of billed charges with lesser of charges applied,237.24,Pays at 72% of billed charges with lesser of charges applied,237.24,Pays at 72% of billed charges with lesser of charges applied,237.24,Pays at 72% of billed charges with lesser of charges applied,237.24,Pays at 72% of billed charges with lesser of charges applied,237.24,Pays at 72% of billed charges with lesser of charges applied,329.5,Case rate,329.5,Case rate,329.5,Case rate,329.5,Case rate,329.5,Case rate,329.5,Case rate,329.5,Case rate,329.5,Case rate,329.5,Case rate,323.24,Case rate,323.24,Case rate,323.24,Case rate,323.24,Case rate,323.24,Case rate,276.78,84% of total billed charges,276.78,84% of total billed charges,276.78,84% of total billed charges,230.65,70% of total billed charges,93.39,100% OF CMS OPPS Rate,93.39,100% OF CMS OPPS Rate,93.39,100% OF CMS OPPS Rate,93.39,100% OF CMS OPPS Rate,93.39,100% OF CMS OPPS Rate,93.39,100% OF CMS OPPS Rate,93.39,100% OF CMS OPPS Rate,93.39,100% OF CMS OPPS Rate,93.39,100% OF CMS OPPS Rate,93.39,100% OF CMS OPPS Rate,93.39,100% OF CMS OPPS Rate,93.39,100% OF CMS OPPS Rate,93.39,100% OF CMS OPPS Rate,93.39,100% OF CMS OPPS Rate,93.39,100% OF CMS OPPS Rate,93.39,100% OF CMS OPPS Rate,48.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,48.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,48.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,48.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,48.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,48.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,48.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,48.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,48.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,48.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,48.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,48.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,48.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,48.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,48.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,48.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,48.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,48.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,48.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,48.51,100% of CA Medicaid Fee Schedule with lesser of charges applied,48.51,329.50,247.13
Outpatient Medical Services,SPEECH THERAPY,92609,"Therapy for AAC speech device, programming & modification",441,429.75,309.42,Pays at 72% of billed charges with lesser of charges applied,114.51,100% OF CMS OPPS Rate,420,Case rate,114.51,100% OF CMS OPPS Rate,421.58,Case rate,114.51,100% OF CMS OPPS Rate,360.99,84% of total billed charges,360.99,84% of total billed charges,309.42,72% of total billed charges,114.51,100% OF CMS OPPS Rate,114.51,100% of CMS OPPS Rate,114.51,100% OF CMS OPPS Rate,257.85,60% of total billed charges,74.52,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.52,100% of CA Medicaid Fee Schedule with lesser of charges applied,114.51,100% OF CMS OPPS Rate,114.51,100% OF CMS OPPS Rate,114.51,100% OF CMS OPPS RATE,114.51,100% OF CMS OPPS Rate,300.83,70% of total billed charges,114.51,100% OF CMS OPPS Rate,137.41,120% of CMS OPPS RATE,309.42,Pays at 72% of billed charges with lesser of charges applied,309.42,Pays at 72% of billed charges with lesser of charges applied,309.42,Pays at 72% of billed charges with lesser of charges applied,309.42,Pays at 72% of billed charges with lesser of charges applied,309.42,Pays at 72% of billed charges with lesser of charges applied,309.42,Pays at 72% of billed charges with lesser of charges applied,420,Case rate,420,Case rate,420,Case rate,420,Case rate,420,Case rate,420,Case rate,420,Case rate,420,Case rate,420,Case rate,421.58,Case rate,421.58,Case rate,421.58,Case rate,421.58,Case rate,421.58,Case rate,360.99,84% of total billed charges,360.99,84% of total billed charges,360.99,84% of total billed charges,300.83,70% of total billed charges,114.51,100% OF CMS OPPS Rate,114.51,100% OF CMS OPPS Rate,114.51,100% OF CMS OPPS Rate,114.51,100% OF CMS OPPS Rate,114.51,100% OF CMS OPPS Rate,114.51,100% OF CMS OPPS Rate,114.51,100% OF CMS OPPS Rate,114.51,100% OF CMS OPPS Rate,114.51,100% OF CMS OPPS Rate,114.51,100% OF CMS OPPS Rate,114.51,100% OF CMS OPPS Rate,114.51,100% OF CMS OPPS Rate,114.51,100% OF CMS OPPS Rate,114.51,100% OF CMS OPPS Rate,114.51,100% OF CMS OPPS Rate,114.51,100% OF CMS OPPS Rate,74.52,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.52,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.52,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.52,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.52,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.52,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.52,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.52,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.52,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.52,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.52,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.52,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.52,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.52,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.52,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.52,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.52,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.52,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.52,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.52,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.52,421.58,322.31
Outpatient Medical Services,SPEECH THERAPY,92607,"Evaluation for speech generating AAC, first hour",441,472.75,340.38,Pays at 72% of billed charges with lesser of charges applied,137.09,100% OF CMS OPPS Rate,420,Case rate,137.09,100% OF CMS OPPS Rate,463.77,Case rate,137.09,100% OF CMS OPPS Rate,397.11,84% of total billed charges,397.11,84% of total billed charges,340.38,72% of total billed charges,137.09,100% OF CMS OPPS Rate,137.09,100% of CMS OPPS Rate,137.09,100% OF CMS OPPS Rate,283.65,60% of total billed charges,137.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,137.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,137.09,100% OF CMS OPPS Rate,137.09,100% OF CMS OPPS Rate,137.09,100% OF CMS OPPS RATE,137.09,100% OF CMS OPPS Rate,330.93,70% of total billed charges,137.09,100% OF CMS OPPS Rate,164.51,120% of CMS OPPS RATE,340.38,Pays at 72% of billed charges with lesser of charges applied,340.38,Pays at 72% of billed charges with lesser of charges applied,340.38,Pays at 72% of billed charges with lesser of charges applied,340.38,Pays at 72% of billed charges with lesser of charges applied,340.38,Pays at 72% of billed charges with lesser of charges applied,340.38,Pays at 72% of billed charges with lesser of charges applied,420,Case rate,420,Case rate,420,Case rate,420,Case rate,420,Case rate,420,Case rate,420,Case rate,420,Case rate,420,Case rate,463.77,Case rate,463.77,Case rate,463.77,Case rate,463.77,Case rate,463.77,Case rate,397.11,84% of total billed charges,397.11,84% of total billed charges,397.11,84% of total billed charges,330.93,70% of total billed charges,137.09,100% OF CMS OPPS Rate,137.09,100% OF CMS OPPS Rate,137.09,100% OF CMS OPPS Rate,137.09,100% OF CMS OPPS Rate,137.09,100% OF CMS OPPS Rate,137.09,100% OF CMS OPPS Rate,137.09,100% OF CMS OPPS Rate,137.09,100% OF CMS OPPS Rate,137.09,100% OF CMS OPPS Rate,137.09,100% OF CMS OPPS Rate,137.09,100% OF CMS OPPS Rate,137.09,100% OF CMS OPPS Rate,137.09,100% OF CMS OPPS Rate,137.09,100% OF CMS OPPS Rate,137.09,100% OF CMS OPPS Rate,137.09,100% OF CMS OPPS Rate,137.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,137.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,137.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,137.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,137.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,137.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,137.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,137.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,137.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,137.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,137.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,137.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,137.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,137.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,137.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,137.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,137.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,137.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,137.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,137.66,100% of CA Medicaid Fee Schedule with lesser of charges applied,137.09,463.77,354.56
Outpatient Medical Services,SPEECH THERAPY,92524,Behavioral & qualitative analysis; voice + resonance,444,505.5,363.96,Pays at 72% of billed charges with lesser of charges applied,119.42,100% OF CMS OPPS Rate,420,Case rate,119.42,100% OF CMS OPPS Rate,495.9,Case rate,119.42,100% OF CMS OPPS Rate,424.62,84% of total billed charges,424.62,84% of total billed charges,363.96,72% of total billed charges,119.42,100% OF CMS OPPS Rate,119.42,100% of CMS OPPS Rate,119.42,100% OF CMS OPPS Rate,303.3,60% of total billed charges,77.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,77.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,119.42,100% OF CMS OPPS Rate,119.42,100% OF CMS OPPS Rate,119.42,100% OF CMS OPPS RATE,119.42,100% OF CMS OPPS Rate,353.85,70% of total billed charges,119.42,100% OF CMS OPPS Rate,143.3,120% of CMS OPPS RATE,363.96,Pays at 72% of billed charges with lesser of charges applied,363.96,Pays at 72% of billed charges with lesser of charges applied,363.96,Pays at 72% of billed charges with lesser of charges applied,363.96,Pays at 72% of billed charges with lesser of charges applied,363.96,Pays at 72% of billed charges with lesser of charges applied,363.96,Pays at 72% of billed charges with lesser of charges applied,420,Case rate,420,Case rate,420,Case rate,420,Case rate,420,Case rate,420,Case rate,420,Case rate,420,Case rate,420,Case rate,495.9,Case rate,495.9,Case rate,495.9,Case rate,495.9,Case rate,495.9,Case rate,424.62,84% of total billed charges,424.62,84% of total billed charges,424.62,84% of total billed charges,353.85,70% of total billed charges,119.42,100% OF CMS OPPS Rate,119.42,100% OF CMS OPPS Rate,119.42,100% OF CMS OPPS Rate,119.42,100% OF CMS OPPS Rate,119.42,100% OF CMS OPPS Rate,119.42,100% OF CMS OPPS Rate,119.42,100% OF CMS OPPS Rate,119.42,100% OF CMS OPPS Rate,119.42,100% OF CMS OPPS Rate,119.42,100% OF CMS OPPS Rate,119.42,100% OF CMS OPPS Rate,119.42,100% OF CMS OPPS Rate,119.42,100% OF CMS OPPS Rate,119.42,100% OF CMS OPPS Rate,119.42,100% OF CMS OPPS Rate,119.42,100% OF CMS OPPS Rate,77.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,77.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,77.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,77.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,77.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,77.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,77.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,77.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,77.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,77.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,77.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,77.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,77.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,77.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,77.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,77.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,77.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,77.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,77.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,77.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,77.23,495.90,379.13
Outpatient Medical Services,SPEECH THERAPY,92608,"Eval for speech generating AAC, additional 30 minutes",444,505.5,363.96,Pays at 72% of billed charges with lesser of charges applied,53.91,100% OF CMS OPPS Rate,420,Case rate,53.91,100% OF CMS OPPS Rate,495.9,Case rate,53.91,100% OF CMS OPPS Rate,424.62,84% of total billed charges,424.62,84% of total billed charges,363.96,72% of total billed charges,53.91,100% OF CMS OPPS Rate,53.91,100% of CMS OPPS Rate,53.91,100% OF CMS OPPS Rate,303.3,60% of total billed charges,26.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,26.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,53.91,100% OF CMS OPPS Rate,53.91,100% OF CMS OPPS Rate,53.91,100% OF CMS OPPS RATE,53.91,100% OF CMS OPPS Rate,353.85,70% of total billed charges,53.91,100% OF CMS OPPS Rate,64.69,120% of CMS OPPS RATE,363.96,Pays at 72% of billed charges with lesser of charges applied,363.96,Pays at 72% of billed charges with lesser of charges applied,363.96,Pays at 72% of billed charges with lesser of charges applied,363.96,Pays at 72% of billed charges with lesser of charges applied,363.96,Pays at 72% of billed charges with lesser of charges applied,363.96,Pays at 72% of billed charges with lesser of charges applied,420,Case rate,420,Case rate,420,Case rate,420,Case rate,420,Case rate,420,Case rate,420,Case rate,420,Case rate,420,Case rate,495.9,Case rate,495.9,Case rate,495.9,Case rate,495.9,Case rate,495.9,Case rate,424.62,84% of total billed charges,424.62,84% of total billed charges,424.62,84% of total billed charges,353.85,70% of total billed charges,53.91,100% OF CMS OPPS Rate,53.91,100% OF CMS OPPS Rate,53.91,100% OF CMS OPPS Rate,53.91,100% OF CMS OPPS Rate,53.91,100% OF CMS OPPS Rate,53.91,100% OF CMS OPPS Rate,53.91,100% OF CMS OPPS Rate,53.91,100% OF CMS OPPS Rate,53.91,100% OF CMS OPPS Rate,53.91,100% OF CMS OPPS Rate,53.91,100% OF CMS OPPS Rate,53.91,100% OF CMS OPPS Rate,53.91,100% OF CMS OPPS Rate,53.91,100% OF CMS OPPS Rate,53.91,100% OF CMS OPPS Rate,53.91,100% OF CMS OPPS Rate,26.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,26.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,26.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,26.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,26.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,26.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,26.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,26.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,26.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,26.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,26.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,26.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,26.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,26.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,26.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,26.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,26.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,26.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,26.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,26.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,26.97,495.90,379.13
Outpatient Medical Services,SPEECH THERAPY,92521,"Evaluation of speech fluency (stuttering, cluttering)",444,505.5,363.96,Pays at 72% of billed charges with lesser of charges applied,145.53,100% OF CMS OPPS Rate,420,Case rate,145.53,100% OF CMS OPPS Rate,495.9,Case rate,145.53,100% OF CMS OPPS Rate,424.62,84% of total billed charges,424.62,84% of total billed charges,363.96,72% of total billed charges,145.53,100% OF CMS OPPS Rate,145.53,100% of CMS OPPS Rate,145.53,100% OF CMS OPPS Rate,303.3,60% of total billed charges,107.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,107.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,145.53,100% OF CMS OPPS Rate,145.53,100% OF CMS OPPS Rate,145.53,100% OF CMS OPPS RATE,145.53,100% OF CMS OPPS Rate,353.85,70% of total billed charges,145.53,100% OF CMS OPPS Rate,174.64,120% of CMS OPPS RATE,363.96,Pays at 72% of billed charges with lesser of charges applied,363.96,Pays at 72% of billed charges with lesser of charges applied,363.96,Pays at 72% of billed charges with lesser of charges applied,363.96,Pays at 72% of billed charges with lesser of charges applied,363.96,Pays at 72% of billed charges with lesser of charges applied,363.96,Pays at 72% of billed charges with lesser of charges applied,420,Case rate,420,Case rate,420,Case rate,420,Case rate,420,Case rate,420,Case rate,420,Case rate,420,Case rate,420,Case rate,495.9,Case rate,495.9,Case rate,495.9,Case rate,495.9,Case rate,495.9,Case rate,424.62,84% of total billed charges,424.62,84% of total billed charges,424.62,84% of total billed charges,353.85,70% of total billed charges,145.53,100% OF CMS OPPS Rate,145.53,100% OF CMS OPPS Rate,145.53,100% OF CMS OPPS Rate,145.53,100% OF CMS OPPS Rate,145.53,100% OF CMS OPPS Rate,145.53,100% OF CMS OPPS Rate,145.53,100% OF CMS OPPS Rate,145.53,100% OF CMS OPPS Rate,145.53,100% OF CMS OPPS Rate,145.53,100% OF CMS OPPS Rate,145.53,100% OF CMS OPPS Rate,145.53,100% OF CMS OPPS Rate,145.53,100% OF CMS OPPS Rate,145.53,100% OF CMS OPPS Rate,145.53,100% OF CMS OPPS Rate,145.53,100% OF CMS OPPS Rate,107.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,107.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,107.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,107.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,107.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,107.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,107.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,107.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,107.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,107.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,107.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,107.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,107.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,107.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,107.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,107.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,107.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,107.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,107.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,107.55,100% of CA Medicaid Fee Schedule with lesser of charges applied,107.55,495.90,379.13
Outpatient Medical Services,SPEECH THERAPY,92523,Evaluation of speech sound production with evaluation of language comprehension,444,505.5,363.96,Pays at 72% of billed charges with lesser of charges applied,249.6,100% OF CMS OPPS Rate,420,Case rate,249.6,100% OF CMS OPPS Rate,495.9,Case rate,249.6,100% OF CMS OPPS Rate,424.62,84% of total billed charges,424.62,84% of total billed charges,363.96,72% of total billed charges,249.6,100% OF CMS OPPS Rate,249.6,100% of CMS OPPS Rate,249.6,100% OF CMS OPPS Rate,303.3,60% of total billed charges,187.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,187.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,249.6,100% OF CMS OPPS Rate,249.6,100% OF CMS OPPS Rate,249.6,100% OF CMS OPPS RATE,249.6,100% OF CMS OPPS Rate,353.85,70% of total billed charges,249.6,100% OF CMS OPPS Rate,299.52,120% of CMS OPPS RATE,363.96,Pays at 72% of billed charges with lesser of charges applied,363.96,Pays at 72% of billed charges with lesser of charges applied,363.96,Pays at 72% of billed charges with lesser of charges applied,363.96,Pays at 72% of billed charges with lesser of charges applied,363.96,Pays at 72% of billed charges with lesser of charges applied,363.96,Pays at 72% of billed charges with lesser of charges applied,420,Case rate,420,Case rate,420,Case rate,420,Case rate,420,Case rate,420,Case rate,420,Case rate,420,Case rate,420,Case rate,495.9,Case rate,495.9,Case rate,495.9,Case rate,495.9,Case rate,495.9,Case rate,424.62,84% of total billed charges,424.62,84% of total billed charges,424.62,84% of total billed charges,353.85,70% of total billed charges,249.6,100% OF CMS OPPS Rate,249.6,100% OF CMS OPPS Rate,249.6,100% OF CMS OPPS Rate,249.6,100% OF CMS OPPS Rate,249.6,100% OF CMS OPPS Rate,249.6,100% OF CMS OPPS Rate,249.6,100% OF CMS OPPS Rate,249.6,100% OF CMS OPPS Rate,249.6,100% OF CMS OPPS Rate,249.6,100% OF CMS OPPS Rate,249.6,100% OF CMS OPPS Rate,249.6,100% OF CMS OPPS Rate,249.6,100% OF CMS OPPS Rate,249.6,100% OF CMS OPPS Rate,249.6,100% OF CMS OPPS Rate,249.6,100% OF CMS OPPS Rate,187.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,187.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,187.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,187.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,187.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,187.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,187.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,187.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,187.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,187.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,187.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,187.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,187.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,187.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,187.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,187.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,187.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,187.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,187.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,187.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,187.30,495.90,379.13
Outpatient Medical Services,SPEECH THERAPY,96105,"Assessment of aphasia, per hour, eval + report",444,505.5,363.96,Pays at 72% of billed charges with lesser of charges applied,104.91,100% OF CMS OPPS Rate,505.5,Case rate,104.91,100% OF CMS OPPS Rate,495.9,Case rate,104.91,100% OF CMS OPPS Rate,424.62,84% of total billed charges,424.62,84% of total billed charges,363.96,72% of total billed charges,104.91,100% OF CMS OPPS Rate,104.91,100% of CMS OPPS Rate,104.91,100% OF CMS OPPS Rate,303.3,60% of total billed charges,73.44,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.44,100% of CA Medicaid Fee Schedule with lesser of charges applied,104.91,100% OF CMS OPPS Rate,104.91,100% OF CMS OPPS Rate,104.91,100% OF CMS OPPS RATE,104.91,100% OF CMS OPPS Rate,353.85,70% of total billed charges,104.91,100% OF CMS OPPS Rate,125.89,120% of CMS OPPS RATE,363.96,Pays at 72% of billed charges with lesser of charges applied,363.96,Pays at 72% of billed charges with lesser of charges applied,363.96,Pays at 72% of billed charges with lesser of charges applied,363.96,Pays at 72% of billed charges with lesser of charges applied,363.96,Pays at 72% of billed charges with lesser of charges applied,363.96,Pays at 72% of billed charges with lesser of charges applied,505.5,Case rate,505.5,Case rate,505.5,Case rate,505.5,Case rate,505.5,Case rate,505.5,Case rate,505.5,Case rate,505.5,Case rate,505.5,Case rate,495.9,Case rate,495.9,Case rate,495.9,Case rate,495.9,Case rate,495.9,Case rate,424.62,84% of total billed charges,424.62,84% of total billed charges,424.62,84% of total billed charges,353.85,70% of total billed charges,104.91,100% OF CMS OPPS Rate,104.91,100% OF CMS OPPS Rate,104.91,100% OF CMS OPPS Rate,104.91,100% OF CMS OPPS Rate,104.91,100% OF CMS OPPS Rate,104.91,100% OF CMS OPPS Rate,104.91,100% OF CMS OPPS Rate,104.91,100% OF CMS OPPS Rate,104.91,100% OF CMS OPPS Rate,104.91,100% OF CMS OPPS Rate,104.91,100% OF CMS OPPS Rate,104.91,100% OF CMS OPPS Rate,104.91,100% OF CMS OPPS Rate,104.91,100% OF CMS OPPS Rate,104.91,100% OF CMS OPPS Rate,104.91,100% OF CMS OPPS Rate,73.44,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.44,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.44,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.44,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.44,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.44,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.44,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.44,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.44,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.44,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.44,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.44,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.44,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.44,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.44,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.44,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.44,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.44,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.44,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.44,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.44,505.50,379.13
Outpatient Medical Services,SPEECH THERAPY,92610,Evaluation of oral and pharyngeal swallowing,444,505.5,363.96,Pays at 72% of billed charges with lesser of charges applied,75.66,100% OF CMS OPPS Rate,420,Case rate,75.66,100% OF CMS OPPS Rate,495.9,Case rate,75.66,100% OF CMS OPPS Rate,424.62,84% of total billed charges,424.62,84% of total billed charges,363.96,72% of total billed charges,75.66,100% OF CMS OPPS Rate,75.66,100% of CMS OPPS Rate,75.66,100% OF CMS OPPS Rate,303.3,60% of total billed charges,69.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,69.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.66,100% OF CMS OPPS Rate,75.66,100% OF CMS OPPS Rate,75.66,100% OF CMS OPPS RATE,75.66,100% OF CMS OPPS Rate,353.85,70% of total billed charges,75.66,100% OF CMS OPPS Rate,90.79,120% of CMS OPPS RATE,363.96,Pays at 72% of billed charges with lesser of charges applied,363.96,Pays at 72% of billed charges with lesser of charges applied,363.96,Pays at 72% of billed charges with lesser of charges applied,363.96,Pays at 72% of billed charges with lesser of charges applied,363.96,Pays at 72% of billed charges with lesser of charges applied,363.96,Pays at 72% of billed charges with lesser of charges applied,420,Case rate,420,Case rate,420,Case rate,420,Case rate,420,Case rate,420,Case rate,420,Case rate,420,Case rate,420,Case rate,495.9,Case rate,495.9,Case rate,495.9,Case rate,495.9,Case rate,495.9,Case rate,424.62,84% of total billed charges,424.62,84% of total billed charges,424.62,84% of total billed charges,353.85,70% of total billed charges,75.66,100% OF CMS OPPS Rate,75.66,100% OF CMS OPPS Rate,75.66,100% OF CMS OPPS Rate,75.66,100% OF CMS OPPS Rate,75.66,100% OF CMS OPPS Rate,75.66,100% OF CMS OPPS Rate,75.66,100% OF CMS OPPS Rate,75.66,100% OF CMS OPPS Rate,75.66,100% OF CMS OPPS Rate,75.66,100% OF CMS OPPS Rate,75.66,100% OF CMS OPPS Rate,75.66,100% OF CMS OPPS Rate,75.66,100% OF CMS OPPS Rate,75.66,100% OF CMS OPPS Rate,75.66,100% OF CMS OPPS Rate,75.66,100% OF CMS OPPS Rate,69.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,69.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,69.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,69.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,69.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,69.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,69.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,69.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,69.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,69.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,69.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,69.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,69.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,69.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,69.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,69.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,69.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,69.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,69.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,69.97,100% of CA Medicaid Fee Schedule with lesser of charges applied,69.97,495.90,379.13
Outpatient Medical Services,SPEECH THERAPY,92522,Evaluation of speech sound production,444,505.5,363.96,Pays at 72% of billed charges with lesser of charges applied,121.01,100% OF CMS OPPS Rate,420,Case rate,121.01,100% OF CMS OPPS Rate,495.9,Case rate,121.01,100% OF CMS OPPS Rate,424.62,84% of total billed charges,424.62,84% of total billed charges,363.96,72% of total billed charges,121.01,100% OF CMS OPPS Rate,121.01,100% of CMS OPPS Rate,121.01,100% OF CMS OPPS Rate,303.3,60% of total billed charges,77.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,77.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,121.01,100% OF CMS OPPS Rate,121.01,100% OF CMS OPPS Rate,121.01,100% OF CMS OPPS RATE,121.01,100% OF CMS OPPS Rate,353.85,70% of total billed charges,121.01,100% OF CMS OPPS Rate,145.21,120% of CMS OPPS RATE,363.96,Pays at 72% of billed charges with lesser of charges applied,363.96,Pays at 72% of billed charges with lesser of charges applied,363.96,Pays at 72% of billed charges with lesser of charges applied,363.96,Pays at 72% of billed charges with lesser of charges applied,363.96,Pays at 72% of billed charges with lesser of charges applied,363.96,Pays at 72% of billed charges with lesser of charges applied,420,Case rate,420,Case rate,420,Case rate,420,Case rate,420,Case rate,420,Case rate,420,Case rate,420,Case rate,420,Case rate,495.9,Case rate,495.9,Case rate,495.9,Case rate,495.9,Case rate,495.9,Case rate,424.62,84% of total billed charges,424.62,84% of total billed charges,424.62,84% of total billed charges,353.85,70% of total billed charges,121.01,100% OF CMS OPPS Rate,121.01,100% OF CMS OPPS Rate,121.01,100% OF CMS OPPS Rate,121.01,100% OF CMS OPPS Rate,121.01,100% OF CMS OPPS Rate,121.01,100% OF CMS OPPS Rate,121.01,100% OF CMS OPPS Rate,121.01,100% OF CMS OPPS Rate,121.01,100% OF CMS OPPS Rate,121.01,100% OF CMS OPPS Rate,121.01,100% OF CMS OPPS Rate,121.01,100% OF CMS OPPS Rate,121.01,100% OF CMS OPPS Rate,121.01,100% OF CMS OPPS Rate,121.01,100% OF CMS OPPS Rate,121.01,100% OF CMS OPPS Rate,77.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,77.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,77.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,77.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,77.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,77.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,77.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,77.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,77.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,77.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,77.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,77.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,77.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,77.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,77.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,77.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,77.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,77.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,77.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,77.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,77.23,495.90,379.13
Outpatient Medical Services,SPEECH THERAPY,92611,Modified Barium Swallow with recording,444,585,421.2,Pays at 72% of billed charges with lesser of charges applied,100.54,100% OF CMS OPPS Rate,420,Case rate,100.54,100% OF CMS OPPS Rate,537,Case rate,100.54,100% OF CMS OPPS Rate,491.4,84% of total billed charges,491.4,84% of total billed charges,421.2,72% of total billed charges,100.54,100% OF CMS OPPS Rate,100.54,100% of CMS OPPS Rate,100.54,100% OF CMS OPPS Rate,351,60% of total billed charges,57.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,57.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,100.54,100% OF CMS OPPS Rate,100.54,100% OF CMS OPPS Rate,100.54,100% OF CMS OPPS RATE,100.54,100% OF CMS OPPS Rate,409.5,70% of total billed charges,100.54,100% OF CMS OPPS Rate,120.65,120% of CMS OPPS RATE,421.2,Pays at 72% of billed charges with lesser of charges applied,421.2,Pays at 72% of billed charges with lesser of charges applied,421.2,Pays at 72% of billed charges with lesser of charges applied,421.2,Pays at 72% of billed charges with lesser of charges applied,421.2,Pays at 72% of billed charges with lesser of charges applied,421.2,Pays at 72% of billed charges with lesser of charges applied,420,Case rate,420,Case rate,420,Case rate,420,Case rate,420,Case rate,420,Case rate,420,Case rate,420,Case rate,420,Case rate,537,Case rate,537,Case rate,537,Case rate,537,Case rate,537,Case rate,491.4,84% of total billed charges,491.4,84% of total billed charges,491.4,84% of total billed charges,409.5,70% of total billed charges,100.54,100% OF CMS OPPS Rate,100.54,100% OF CMS OPPS Rate,100.54,100% OF CMS OPPS Rate,100.54,100% OF CMS OPPS Rate,100.54,100% OF CMS OPPS Rate,100.54,100% OF CMS OPPS Rate,100.54,100% OF CMS OPPS Rate,100.54,100% OF CMS OPPS Rate,100.54,100% OF CMS OPPS Rate,100.54,100% OF CMS OPPS Rate,100.54,100% OF CMS OPPS Rate,100.54,100% OF CMS OPPS Rate,100.54,100% OF CMS OPPS Rate,100.54,100% OF CMS OPPS Rate,100.54,100% OF CMS OPPS Rate,100.54,100% OF CMS OPPS Rate,57.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,57.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,57.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,57.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,57.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,57.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,57.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,57.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,57.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,57.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,57.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,57.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,57.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,57.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,57.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,57.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,57.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,57.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,57.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,57.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,57.30,537.00,438.75
Outpatient Medical Services,ULTRASOUND,76812,"OB COMPLETE WITH DETAILED FETAL EXAM, ADDITIONAL GESTATI",402,688,495.36,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,242.97,442% of BCBS Fee Schedule,N/A,Not Separately reimbursable,290.47,100% of BCBS Fee Schedule,N/A,Not Separately reimbursable,577.92,84% of total billed charges,577.92,84% of total billed charges,495.36,72% of total billed charges,N/A,Not Separately reimbursable,447.2,65% of total billed charges,N/A,Not Separately reimbursable,412.8,60% of total billed charges,170.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,170.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,128.6,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,481.6,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,495.36,Pays at 72% of billed charges with lesser of charges applied,495.36,Pays at 72% of billed charges with lesser of charges applied,495.36,Pays at 72% of billed charges with lesser of charges applied,495.36,Pays at 72% of billed charges with lesser of charges applied,495.36,Pays at 72% of billed charges with lesser of charges applied,495.36,Pays at 72% of billed charges with lesser of charges applied,242.97,442% of BCBS Fee Schedule,242.97,442% of BCBS Fee Schedule,242.97,442% of BCBS Fee Schedule,242.97,442% of BCBS Fee Schedule,242.97,442% of BCBS Fee Schedule,242.97,442% of BCBS Fee Schedule,242.97,442% of BCBS Fee Schedule,242.97,442% of BCBS Fee Schedule,242.97,442% of BCBS Fee Schedule,290.47,100% of BCBS Fee Schedule,290.47,100% of BCBS Fee Schedule,290.47,100% of BCBS Fee Schedule,290.47,100% of BCBS Fee Schedule,290.47,100% of BCBS Fee Schedule,577.92,84% of total billed charges,577.92,84% of total billed charges,577.92,84% of total billed charges,481.6,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,170.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,170.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,170.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,170.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,170.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,170.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,170.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,170.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,170.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,170.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,170.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,170.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,170.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,170.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,170.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,170.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,170.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,170.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,170.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,170.95,100% of CA Medicaid Fee Schedule with lesser of charges applied,128.60,577.92,516
Outpatient Medical Services,ULTRASOUND,76831,A diagnostic procedure that allows a provider to see the uterus,402,568,408.96,Pays at 72% of billed charges with lesser of charges applied,296.82,100% OF CMS OPPS Rate,286.95,442% of BCBS Fee Schedule,296.82,100% OF CMS OPPS Rate,341.58,100% of BCBS Fee Schedule,296.82,100% OF CMS OPPS Rate,477.12,84% of total billed charges,477.12,84% of total billed charges,408.96,72% of total billed charges,296.82,100% OF CMS OPPS Rate,296.82,100% of CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,340.8,60% of total billed charges,108.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,108.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,98.54,100% OF CMS OPPS RATE,296.82,100% OF CMS OPPS Rate,397.6,70% of total billed charges,296.82,100% OF CMS OPPS Rate,356.18,120% of CMS OPPS RATE,408.96,Pays at 72% of billed charges with lesser of charges applied,408.96,Pays at 72% of billed charges with lesser of charges applied,408.96,Pays at 72% of billed charges with lesser of charges applied,408.96,Pays at 72% of billed charges with lesser of charges applied,408.96,Pays at 72% of billed charges with lesser of charges applied,408.96,Pays at 72% of billed charges with lesser of charges applied,286.95,442% of BCBS Fee Schedule,286.95,442% of BCBS Fee Schedule,286.95,442% of BCBS Fee Schedule,286.95,442% of BCBS Fee Schedule,286.95,442% of BCBS Fee Schedule,286.95,442% of BCBS Fee Schedule,286.95,442% of BCBS Fee Schedule,286.95,442% of BCBS Fee Schedule,286.95,442% of BCBS Fee Schedule,341.58,100% of BCBS Fee Schedule,341.58,100% of BCBS Fee Schedule,341.58,100% of BCBS Fee Schedule,341.58,100% of BCBS Fee Schedule,341.58,100% of BCBS Fee Schedule,477.12,84% of total billed charges,477.12,84% of total billed charges,477.12,84% of total billed charges,397.6,70% of total billed charges,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,108.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,108.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,108.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,108.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,108.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,108.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,108.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,108.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,108.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,108.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,108.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,108.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,108.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,108.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,108.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,108.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,108.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,108.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,108.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,108.33,100% of CA Medicaid Fee Schedule with lesser of charges applied,98.54,477.12,426
Outpatient Medical Services,ULTRASOUND,76536,Ultrasound of head and neck,402,229.5,165.24,Pays at 72% of billed charges with lesser of charges applied,135.85,100% OF CMS OPPS Rate,229.5,BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,225.14,pays at 100% of bcbs fee schedule with lesser of charges applied,135.85,100% OF CMS OPPS Rate,192.78,84% of total billed charges,192.78,84% of total billed charges,165.24,72% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% of CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,137.7,60% of total billed charges,85.69,100% of CA Medicaid Fee Schedule with lesser of charges applied,85.69,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,100.93,100% OF CMS OPPS RATE,135.85,100% OF CMS OPPS Rate,160.65,70% of total billed charges,135.85,100% OF CMS OPPS Rate,163.02,120% of CMS OPPS RATE,165.24,Pays at 72% of billed charges with lesser of charges applied,165.24,Pays at 72% of billed charges with lesser of charges applied,165.24,Pays at 72% of billed charges with lesser of charges applied,165.24,Pays at 72% of billed charges with lesser of charges applied,165.24,Pays at 72% of billed charges with lesser of charges applied,165.24,Pays at 72% of billed charges with lesser of charges applied,229.5,BCBS Fee Schedule,229.5,BCBS Fee Schedule,229.5,BCBS Fee Schedule,229.5,BCBS Fee Schedule,229.5,BCBS Fee Schedule,229.5,BCBS Fee Schedule,229.5,BCBS Fee Schedule,229.5,BCBS Fee Schedule,229.5,BCBS Fee Schedule,225.14,pays at 100% of bcbs fee schedule with lesser of charges applied,225.14,pays at 100% of bcbs fee schedule with lesser of charges applied,225.14,pays at 100% of bcbs fee schedule with lesser of charges applied,225.14,pays at 100% of bcbs fee schedule with lesser of charges applied,225.14,pays at 100% of bcbs fee schedule with lesser of charges applied,192.78,84% of total billed charges,192.78,84% of total billed charges,192.78,84% of total billed charges,160.65,70% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,85.69,100% of CA Medicaid Fee Schedule with lesser of charges applied,85.69,100% of CA Medicaid Fee Schedule with lesser of charges applied,85.69,100% of CA Medicaid Fee Schedule with lesser of charges applied,85.69,100% of CA Medicaid Fee Schedule with lesser of charges applied,85.69,100% of CA Medicaid Fee Schedule with lesser of charges applied,85.69,100% of CA Medicaid Fee Schedule with lesser of charges applied,85.69,100% of CA Medicaid Fee Schedule with lesser of charges applied,85.69,100% of CA Medicaid Fee Schedule with lesser of charges applied,85.69,100% of CA Medicaid Fee Schedule with lesser of charges applied,85.69,100% of CA Medicaid Fee Schedule with lesser of charges applied,85.69,100% of CA Medicaid Fee Schedule with lesser of charges applied,85.69,100% of CA Medicaid Fee Schedule with lesser of charges applied,85.69,100% of CA Medicaid Fee Schedule with lesser of charges applied,85.69,100% of CA Medicaid Fee Schedule with lesser of charges applied,85.69,100% of CA Medicaid Fee Schedule with lesser of charges applied,85.69,100% of CA Medicaid Fee Schedule with lesser of charges applied,85.69,100% of CA Medicaid Fee Schedule with lesser of charges applied,85.69,100% of CA Medicaid Fee Schedule with lesser of charges applied,85.69,100% of CA Medicaid Fee Schedule with lesser of charges applied,85.69,100% of CA Medicaid Fee Schedule with lesser of charges applied,85.69,229.50,172.13
Outpatient Medical Services,ULTRASOUND,76604,US CHEST B-SCAN &/OR REAL TIME WITH IMAGE DOC LIMITED,402,802.75,577.98,Pays at 72% of billed charges with lesser of charges applied,135.85,100% OF CMS OPPS Rate,245.31,442% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,291.9,100% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,674.31,84% of total billed charges,674.31,84% of total billed charges,577.98,72% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% of CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,481.65,60% of total billed charges,76.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,76.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,34.83,100% OF CMS OPPS RATE,135.85,100% OF CMS OPPS Rate,561.93,70% of total billed charges,135.85,100% OF CMS OPPS Rate,163.02,120% of CMS OPPS RATE,577.98,Pays at 72% of billed charges with lesser of charges applied,577.98,Pays at 72% of billed charges with lesser of charges applied,577.98,Pays at 72% of billed charges with lesser of charges applied,577.98,Pays at 72% of billed charges with lesser of charges applied,577.98,Pays at 72% of billed charges with lesser of charges applied,577.98,Pays at 72% of billed charges with lesser of charges applied,245.31,442% of BCBS Fee Schedule,245.31,442% of BCBS Fee Schedule,245.31,442% of BCBS Fee Schedule,245.31,442% of BCBS Fee Schedule,245.31,442% of BCBS Fee Schedule,245.31,442% of BCBS Fee Schedule,245.31,442% of BCBS Fee Schedule,245.31,442% of BCBS Fee Schedule,245.31,442% of BCBS Fee Schedule,291.9,100% of BCBS Fee Schedule,291.9,100% of BCBS Fee Schedule,291.9,100% of BCBS Fee Schedule,291.9,100% of BCBS Fee Schedule,291.9,100% of BCBS Fee Schedule,674.31,84% of total billed charges,674.31,84% of total billed charges,674.31,84% of total billed charges,561.93,70% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,76.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,76.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,76.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,76.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,76.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,76.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,76.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,76.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,76.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,76.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,76.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,76.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,76.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,76.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,76.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,76.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,76.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,76.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,76.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,76.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,34.83,674.31,602.06
Outpatient Medical Services,ULTRASOUND,20611,"US ASPIR OR INJ OF SHOULDER, HIP OR KNEE W/US GUIDE",402,1009.25,726.66,Pays at 72% of billed charges with lesser of charges applied,345.59,100% OF CMS OPPS Rate,1009.25,100% of ASC Tier Grouping Fee Schedule,345.59,100% OF CMS OPPS Rate,798.32,79.1% of total billed charges,345.59,100% OF CMS OPPS Rate,847.77,84% of total billed charges,847.77,84% of total billed charges,726.66,72% of total billed charges,345.59,100% OF CMS OPPS Rate,345.59,100% of CMS OPPS Rate,345.59,100% OF CMS OPPS Rate,605.55,60% of total billed charges,75.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,345.59,100% OF CMS OPPS Rate,345.59,100% OF CMS OPPS Rate,62.07,100% OF CMS OPPS RATE,345.59,100% OF CMS OPPS Rate,706.48,70% of total billed charges,345.59,100% OF CMS OPPS Rate,414.69,120% of CMS OPPS RATE,726.66,Pays at 72% of billed charges with lesser of charges applied,726.66,Pays at 72% of billed charges with lesser of charges applied,726.66,Pays at 72% of billed charges with lesser of charges applied,726.66,Pays at 72% of billed charges with lesser of charges applied,726.66,Pays at 72% of billed charges with lesser of charges applied,726.66,Pays at 72% of billed charges with lesser of charges applied,1009.25,100% of ASC Tier Grouping Fee Schedule,1009.25,100% of ASC Tier Grouping Fee Schedule,1009.25,100% of ASC Tier Grouping Fee Schedule,1009.25,100% of ASC Tier Grouping Fee Schedule,1009.25,100% of ASC Tier Grouping Fee Schedule,1009.25,100% of ASC Tier Grouping Fee Schedule,1009.25,100% of ASC Tier Grouping Fee Schedule,1009.25,100% of ASC Tier Grouping Fee Schedule,1009.25,100% of ASC Tier Grouping Fee Schedule,798.32,79.1% of total billed charges,798.32,79.1% of total billed charges,798.32,79.1% of total billed charges,798.32,79.1% of total billed charges,798.32,79.1% of total billed charges,847.77,84% of total billed charges,847.77,84% of total billed charges,847.77,84% of total billed charges,706.48,70% of total billed charges,345.59,100% OF CMS OPPS Rate,345.59,100% OF CMS OPPS Rate,345.59,100% OF CMS OPPS Rate,345.59,100% OF CMS OPPS Rate,345.59,100% OF CMS OPPS Rate,345.59,100% OF CMS OPPS Rate,345.59,100% OF CMS OPPS Rate,345.59,100% OF CMS OPPS Rate,345.59,100% OF CMS OPPS Rate,345.59,100% OF CMS OPPS Rate,345.59,100% OF CMS OPPS Rate,345.59,100% OF CMS OPPS Rate,345.59,100% OF CMS OPPS Rate,345.59,100% OF CMS OPPS Rate,345.59,100% OF CMS OPPS Rate,345.59,100% OF CMS OPPS Rate,75.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,75.84,100% of CA Medicaid Fee Schedule with lesser of charges applied,62.07,1009.25,756.94
Outpatient Medical Services,ULTRASOUND,19083,BIOPSY US GUIDED BREAST-VAC w/CLIP and SPECIMEN-LT,402,3576.25,2574.9,Pays at 72% of billed charges with lesser of charges applied,1906.04,100% OF CMS OPPS Rate,3576.25,100% of ASC Tier Grouping Fee Schedule,1906.04,100% OF CMS OPPS Rate,2828.81,79.1% of total billed charges,1906.04,100% OF CMS OPPS Rate,3004.05,84% of total billed charges,3004.05,84% of total billed charges,2574.9,72% of total billed charges,1906.04,100% OF CMS OPPS Rate,1906.04,100% of CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,2145.75,60% of total billed charges,880.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,880.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,158.98,100% OF CMS OPPS RATE,1906.04,100% OF CMS OPPS Rate,2503.38,70% of total billed charges,1906.04,100% OF CMS OPPS Rate,2287.25,120% of CMS OPPS RATE,2574.9,Pays at 72% of billed charges with lesser of charges applied,2574.9,Pays at 72% of billed charges with lesser of charges applied,2574.9,Pays at 72% of billed charges with lesser of charges applied,2574.9,Pays at 72% of billed charges with lesser of charges applied,2574.9,Pays at 72% of billed charges with lesser of charges applied,2574.9,Pays at 72% of billed charges with lesser of charges applied,3576.25,100% of ASC Tier Grouping Fee Schedule,3576.25,100% of ASC Tier Grouping Fee Schedule,3576.25,100% of ASC Tier Grouping Fee Schedule,3576.25,100% of ASC Tier Grouping Fee Schedule,3576.25,100% of ASC Tier Grouping Fee Schedule,3576.25,100% of ASC Tier Grouping Fee Schedule,3576.25,100% of ASC Tier Grouping Fee Schedule,3576.25,100% of ASC Tier Grouping Fee Schedule,3576.25,100% of ASC Tier Grouping Fee Schedule,2828.81,79.1% of total billed charges,2828.81,79.1% of total billed charges,2828.81,79.1% of total billed charges,2828.81,79.1% of total billed charges,2828.81,79.1% of total billed charges,3004.05,84% of total billed charges,3004.05,84% of total billed charges,3004.05,84% of total billed charges,2503.38,70% of total billed charges,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,1906.04,100% OF CMS OPPS Rate,880.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,880.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,880.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,880.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,880.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,880.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,880.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,880.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,880.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,880.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,880.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,880.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,880.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,880.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,880.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,880.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,880.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,880.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,880.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,880.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,158.98,3576.25,2682.19
Outpatient Medical Services,ULTRASOUND,10006,"US ASPIRATION, 2ND OR MORE LESIONS W/US GUIDANCE",402,1399.25,1007.46,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,1399.25,100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,1106.81,79.1% of total billed charges,N/A,Not Separately reimbursable,1175.37,84% of total billed charges,1175.37,84% of total billed charges,1007.46,72% of total billed charges,N/A,Not Separately reimbursable,909.51,65% of total billed charges,N/A,Not Separately reimbursable,839.55,60% of total billed charges,74.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,52.03,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,979.48,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,1007.46,Pays at 72% of billed charges with lesser of charges applied,1007.46,Pays at 72% of billed charges with lesser of charges applied,1007.46,Pays at 72% of billed charges with lesser of charges applied,1007.46,Pays at 72% of billed charges with lesser of charges applied,1007.46,Pays at 72% of billed charges with lesser of charges applied,1007.46,Pays at 72% of billed charges with lesser of charges applied,1399.25,100% of ASC Tier Grouping Fee Schedule,1399.25,100% of ASC Tier Grouping Fee Schedule,1399.25,100% of ASC Tier Grouping Fee Schedule,1399.25,100% of ASC Tier Grouping Fee Schedule,1399.25,100% of ASC Tier Grouping Fee Schedule,1399.25,100% of ASC Tier Grouping Fee Schedule,1399.25,100% of ASC Tier Grouping Fee Schedule,1399.25,100% of ASC Tier Grouping Fee Schedule,1399.25,100% of ASC Tier Grouping Fee Schedule,1106.81,79.1% of total billed charges,1106.81,79.1% of total billed charges,1106.81,79.1% of total billed charges,1106.81,79.1% of total billed charges,1106.81,79.1% of total billed charges,1175.37,84% of total billed charges,1175.37,84% of total billed charges,1175.37,84% of total billed charges,979.48,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,74.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.23,100% of CA Medicaid Fee Schedule with lesser of charges applied,52.03,1399.25,1049.44
Outpatient Medical Services,ULTRASOUND,76645,US BREAST(S)B-SCAN &/OR REAL TIME WITH IMAGE DOC,402,802.75,577.98,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,199.25,442% of BCBS Fee Schedule,N/A,Not Separately reimbursable,634.98,79.1% of total billed charges,N/A,Not Separately reimbursable,674.31,84% of total billed charges,674.31,84% of total billed charges,577.98,72% of total billed charges,N/A,Not Separately reimbursable,521.79,65% of total billed charges,N/A,Not Separately reimbursable,481.65,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,561.93,70% of total billed charges,802.75,100% OF CMS OPPS Rate with lesser of charges applied,802.75,120% of CMS OPPS RATE,577.98,Pays at 72% of billed charges with lesser of charges applied,577.98,Pays at 72% of billed charges with lesser of charges applied,577.98,Pays at 72% of billed charges with lesser of charges applied,577.98,Pays at 72% of billed charges with lesser of charges applied,577.98,Pays at 72% of billed charges with lesser of charges applied,577.98,Pays at 72% of billed charges with lesser of charges applied,199.25,442% of BCBS Fee Schedule,199.25,442% of BCBS Fee Schedule,199.25,442% of BCBS Fee Schedule,199.25,442% of BCBS Fee Schedule,199.25,442% of BCBS Fee Schedule,199.25,442% of BCBS Fee Schedule,199.25,442% of BCBS Fee Schedule,199.25,442% of BCBS Fee Schedule,199.25,442% of BCBS Fee Schedule,634.98,79.1% of total billed charges,634.98,79.1% of total billed charges,634.98,79.1% of total billed charges,634.98,79.1% of total billed charges,634.98,79.1% of total billed charges,674.31,84% of total billed charges,674.31,84% of total billed charges,674.31,84% of total billed charges,561.93,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,199.25,802.75,602.06
Outpatient Medical Services,ULTRASOUND,19285,"MG WIRE, w/ CLIP PLCMNT-US GUIDED BREAST-RT",402,980.5,705.96,Pays at 72% of billed charges with lesser of charges applied,824.89,100% OF CMS OPPS Rate,980.5,100% of ASC Tier Grouping Fee Schedule,824.89,100% OF CMS OPPS Rate,775.58,79.1% of total billed charges,824.89,100% OF CMS OPPS Rate,823.62,84% of total billed charges,823.62,84% of total billed charges,705.96,72% of total billed charges,824.89,100% OF CMS OPPS Rate,824.89,100% of CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,588.3,60% of total billed charges,683.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,683.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,87.61,100% OF CMS OPPS RATE,824.89,100% OF CMS OPPS Rate,686.35,70% of total billed charges,824.89,100% OF CMS OPPS Rate,980.5,120% of CMS OPPS RATE,705.96,Pays at 72% of billed charges with lesser of charges applied,705.96,Pays at 72% of billed charges with lesser of charges applied,705.96,Pays at 72% of billed charges with lesser of charges applied,705.96,Pays at 72% of billed charges with lesser of charges applied,705.96,Pays at 72% of billed charges with lesser of charges applied,705.96,Pays at 72% of billed charges with lesser of charges applied,980.5,100% of ASC Tier Grouping Fee Schedule,980.5,100% of ASC Tier Grouping Fee Schedule,980.5,100% of ASC Tier Grouping Fee Schedule,980.5,100% of ASC Tier Grouping Fee Schedule,980.5,100% of ASC Tier Grouping Fee Schedule,980.5,100% of ASC Tier Grouping Fee Schedule,980.5,100% of ASC Tier Grouping Fee Schedule,980.5,100% of ASC Tier Grouping Fee Schedule,980.5,100% of ASC Tier Grouping Fee Schedule,775.58,79.1% of total billed charges,775.58,79.1% of total billed charges,775.58,79.1% of total billed charges,775.58,79.1% of total billed charges,775.58,79.1% of total billed charges,823.62,84% of total billed charges,823.62,84% of total billed charges,823.62,84% of total billed charges,686.35,70% of total billed charges,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,683.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,683.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,683.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,683.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,683.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,683.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,683.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,683.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,683.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,683.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,683.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,683.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,683.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,683.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,683.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,683.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,683.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,683.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,683.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,683.02,100% of CA Medicaid Fee Schedule with lesser of charges applied,87.61,980.50,735.38
Outpatient Medical Services,ULTRASOUND,0126T,US-COMMON CARTOTID INTIMA-MEDIA THICKNESS,402,319.75,230.22,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,319.75,100% of ASC Tier Grouping Fee Schedule,N/A,Not Separately reimbursable,252.92,79.1% of total billed charges,N/A,Not Separately reimbursable,268.59,84% of total billed charges,268.59,84% of total billed charges,230.22,72% of total billed charges,N/A,Not Separately reimbursable,207.84,65% of total billed charges,N/A,Not Separately reimbursable,191.85,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,223.83,70% of total billed charges,319.75,100% OF CMS OPPS Rate with lesser of charges applied,319.75,120% of CMS OPPS RATE,230.22,Pays at 72% of billed charges with lesser of charges applied,230.22,Pays at 72% of billed charges with lesser of charges applied,230.22,Pays at 72% of billed charges with lesser of charges applied,230.22,Pays at 72% of billed charges with lesser of charges applied,230.22,Pays at 72% of billed charges with lesser of charges applied,230.22,Pays at 72% of billed charges with lesser of charges applied,319.75,100% of ASC Tier Grouping Fee Schedule,319.75,100% of ASC Tier Grouping Fee Schedule,319.75,100% of ASC Tier Grouping Fee Schedule,319.75,100% of ASC Tier Grouping Fee Schedule,319.75,100% of ASC Tier Grouping Fee Schedule,319.75,100% of ASC Tier Grouping Fee Schedule,319.75,100% of ASC Tier Grouping Fee Schedule,319.75,100% of ASC Tier Grouping Fee Schedule,319.75,100% of ASC Tier Grouping Fee Schedule,252.92,79.1% of total billed charges,252.92,79.1% of total billed charges,252.92,79.1% of total billed charges,252.92,79.1% of total billed charges,252.92,79.1% of total billed charges,268.59,84% of total billed charges,268.59,84% of total billed charges,268.59,84% of total billed charges,223.83,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,191.85,319.75,239.81
Outpatient Medical Services,ULTRASOUND,10005,"Fine needle aspiration biopsy, including ultrasound guidance; first lesion",402,2066,1487.52,Pays at 72% of billed charges with lesser of charges applied,824.89,100% OF CMS OPPS Rate,2066,100% of ASC Tier Grouping Fee Schedule,824.89,100% OF CMS OPPS Rate,1634.21,79.1% of total billed charges,824.89,100% OF CMS OPPS Rate,1735.44,84% of total billed charges,1735.44,84% of total billed charges,1487.52,72% of total billed charges,824.89,100% OF CMS OPPS Rate,824.89,100% of CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,1239.6,60% of total billed charges,160.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,160.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,76.24,100% OF CMS OPPS RATE,824.89,100% OF CMS OPPS Rate,1446.2,70% of total billed charges,824.89,100% OF CMS OPPS Rate,989.86,120% of CMS OPPS RATE,1487.52,Pays at 72% of billed charges with lesser of charges applied,1487.52,Pays at 72% of billed charges with lesser of charges applied,1487.52,Pays at 72% of billed charges with lesser of charges applied,1487.52,Pays at 72% of billed charges with lesser of charges applied,1487.52,Pays at 72% of billed charges with lesser of charges applied,1487.52,Pays at 72% of billed charges with lesser of charges applied,2066,100% of ASC Tier Grouping Fee Schedule,2066,100% of ASC Tier Grouping Fee Schedule,2066,100% of ASC Tier Grouping Fee Schedule,2066,100% of ASC Tier Grouping Fee Schedule,2066,100% of ASC Tier Grouping Fee Schedule,2066,100% of ASC Tier Grouping Fee Schedule,2066,100% of ASC Tier Grouping Fee Schedule,2066,100% of ASC Tier Grouping Fee Schedule,2066,100% of ASC Tier Grouping Fee Schedule,1634.21,79.1% of total billed charges,1634.21,79.1% of total billed charges,1634.21,79.1% of total billed charges,1634.21,79.1% of total billed charges,1634.21,79.1% of total billed charges,1735.44,84% of total billed charges,1735.44,84% of total billed charges,1735.44,84% of total billed charges,1446.2,70% of total billed charges,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,824.89,100% OF CMS OPPS Rate,160.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,160.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,160.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,160.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,160.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,160.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,160.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,160.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,160.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,160.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,160.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,160.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,160.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,160.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,160.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,160.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,160.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,160.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,160.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,160.21,100% of CA Medicaid Fee Schedule with lesser of charges applied,76.24,2066.00,1549.5
Outpatient Medical Services,ULTRASOUND,76882,"Diagnostic ultrasound of an extremity excluding the bone, joints or vessels",402,409.5,294.84,Pays at 72% of billed charges with lesser of charges applied,135.85,100% OF CMS OPPS Rate,52.73,442% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,63.77,100% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,343.98,84% of total billed charges,343.98,84% of total billed charges,294.84,72% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% of CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,245.7,60% of total billed charges,37.65,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.65,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,10.94,100% OF CMS OPPS RATE,135.85,100% OF CMS OPPS Rate,286.65,70% of total billed charges,135.85,100% OF CMS OPPS Rate,163.02,120% of CMS OPPS RATE,294.84,Pays at 72% of billed charges with lesser of charges applied,294.84,Pays at 72% of billed charges with lesser of charges applied,294.84,Pays at 72% of billed charges with lesser of charges applied,294.84,Pays at 72% of billed charges with lesser of charges applied,294.84,Pays at 72% of billed charges with lesser of charges applied,294.84,Pays at 72% of billed charges with lesser of charges applied,52.73,442% of BCBS Fee Schedule,52.73,442% of BCBS Fee Schedule,52.73,442% of BCBS Fee Schedule,52.73,442% of BCBS Fee Schedule,52.73,442% of BCBS Fee Schedule,52.73,442% of BCBS Fee Schedule,52.73,442% of BCBS Fee Schedule,52.73,442% of BCBS Fee Schedule,52.73,442% of BCBS Fee Schedule,63.77,100% of BCBS Fee Schedule,63.77,100% of BCBS Fee Schedule,63.77,100% of BCBS Fee Schedule,63.77,100% of BCBS Fee Schedule,63.77,100% of BCBS Fee Schedule,343.98,84% of total billed charges,343.98,84% of total billed charges,343.98,84% of total billed charges,286.65,70% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,37.65,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.65,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.65,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.65,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.65,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.65,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.65,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.65,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.65,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.65,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.65,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.65,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.65,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.65,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.65,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.65,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.65,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.65,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.65,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.65,100% of CA Medicaid Fee Schedule with lesser of charges applied,10.94,343.98,307.13
Outpatient Medical Services,ULTRASOUND,76705,A diagnostic procedure that allows a provider to see the organs and other structures in the abdomen,402,442.5,318.6,Pays at 72% of billed charges with lesser of charges applied,135.84,100% OF CMS OPPS Rate,267.28,442% of BCBS Fee Schedule,135.84,100% OF CMS OPPS Rate,319.19,100% of BCBS Fee Schedule,135.84,100% OF CMS OPPS Rate,371.7,84% of total billed charges,371.7,84% of total billed charges,318.6,72% of total billed charges,135.84,100% OF CMS OPPS Rate,135.84,100% of CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,265.5,60% of total billed charges,87.13,100% of CA Medicaid Fee Schedule with lesser of charges applied,87.13,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,71.86,100% OF CMS OPPS RATE,135.84,100% OF CMS OPPS Rate,309.75,70% of total billed charges,135.84,100% OF CMS OPPS Rate,163.01,120% of CMS OPPS RATE,318.6,Pays at 72% of billed charges with lesser of charges applied,318.6,Pays at 72% of billed charges with lesser of charges applied,318.6,Pays at 72% of billed charges with lesser of charges applied,318.6,Pays at 72% of billed charges with lesser of charges applied,318.6,Pays at 72% of billed charges with lesser of charges applied,318.6,Pays at 72% of billed charges with lesser of charges applied,267.28,442% of BCBS Fee Schedule,267.28,442% of BCBS Fee Schedule,267.28,442% of BCBS Fee Schedule,267.28,442% of BCBS Fee Schedule,267.28,442% of BCBS Fee Schedule,267.28,442% of BCBS Fee Schedule,267.28,442% of BCBS Fee Schedule,267.28,442% of BCBS Fee Schedule,267.28,442% of BCBS Fee Schedule,319.19,100% of BCBS Fee Schedule,319.19,100% of BCBS Fee Schedule,319.19,100% of BCBS Fee Schedule,319.19,100% of BCBS Fee Schedule,319.19,100% of BCBS Fee Schedule,371.7,84% of total billed charges,371.7,84% of total billed charges,371.7,84% of total billed charges,309.75,70% of total billed charges,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,87.13,100% of CA Medicaid Fee Schedule with lesser of charges applied,87.13,100% of CA Medicaid Fee Schedule with lesser of charges applied,87.13,100% of CA Medicaid Fee Schedule with lesser of charges applied,87.13,100% of CA Medicaid Fee Schedule with lesser of charges applied,87.13,100% of CA Medicaid Fee Schedule with lesser of charges applied,87.13,100% of CA Medicaid Fee Schedule with lesser of charges applied,87.13,100% of CA Medicaid Fee Schedule with lesser of charges applied,87.13,100% of CA Medicaid Fee Schedule with lesser of charges applied,87.13,100% of CA Medicaid Fee Schedule with lesser of charges applied,87.13,100% of CA Medicaid Fee Schedule with lesser of charges applied,87.13,100% of CA Medicaid Fee Schedule with lesser of charges applied,87.13,100% of CA Medicaid Fee Schedule with lesser of charges applied,87.13,100% of CA Medicaid Fee Schedule with lesser of charges applied,87.13,100% of CA Medicaid Fee Schedule with lesser of charges applied,87.13,100% of CA Medicaid Fee Schedule with lesser of charges applied,87.13,100% of CA Medicaid Fee Schedule with lesser of charges applied,87.13,100% of CA Medicaid Fee Schedule with lesser of charges applied,87.13,100% of CA Medicaid Fee Schedule with lesser of charges applied,87.13,100% of CA Medicaid Fee Schedule with lesser of charges applied,87.13,100% of CA Medicaid Fee Schedule with lesser of charges applied,71.86,371.70,331.88
Outpatient Medical Services,ULTRASOUND,76810,"US OP COMP, MULT GEST, AFTER 1ST TRI",402,516,371.52,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,509.89,442% of BCBS Fee Schedule,N/A,Not Separately reimbursable,261.28,100% of BCBS Fee Schedule,N/A,Not Separately reimbursable,433.44,84% of total billed charges,433.44,84% of total billed charges,371.52,72% of total billed charges,N/A,Not Separately reimbursable,335.4,65% of total billed charges,N/A,Not Separately reimbursable,309.6,60% of total billed charges,115.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,115.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,49.56,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,361.2,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,371.52,Pays at 72% of billed charges with lesser of charges applied,371.52,Pays at 72% of billed charges with lesser of charges applied,371.52,Pays at 72% of billed charges with lesser of charges applied,371.52,Pays at 72% of billed charges with lesser of charges applied,371.52,Pays at 72% of billed charges with lesser of charges applied,371.52,Pays at 72% of billed charges with lesser of charges applied,509.89,442% of BCBS Fee Schedule,509.89,442% of BCBS Fee Schedule,509.89,442% of BCBS Fee Schedule,509.89,442% of BCBS Fee Schedule,509.89,442% of BCBS Fee Schedule,509.89,442% of BCBS Fee Schedule,509.89,442% of BCBS Fee Schedule,509.89,442% of BCBS Fee Schedule,509.89,442% of BCBS Fee Schedule,261.28,100% of BCBS Fee Schedule,261.28,100% of BCBS Fee Schedule,261.28,100% of BCBS Fee Schedule,261.28,100% of BCBS Fee Schedule,261.28,100% of BCBS Fee Schedule,433.44,84% of total billed charges,433.44,84% of total billed charges,433.44,84% of total billed charges,361.2,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,115.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,115.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,115.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,115.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,115.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,115.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,115.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,115.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,115.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,115.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,115.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,115.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,115.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,115.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,115.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,115.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,115.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,115.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,115.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,115.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,49.56,509.89,387
Outpatient Medical Services,ULTRASOUND,76776,US TRANSPLANTED KIDNEY(+/-DUPLEX),402,626.5,451.08,Pays at 72% of billed charges with lesser of charges applied,135.84,100% OF CMS OPPS Rate,351.88,442% of BCBS Fee Schedule,135.84,100% OF CMS OPPS Rate,614.6,pays at 100% of bcbs fee schedule with lesser of charges applied,135.84,100% OF CMS OPPS Rate,526.26,84% of total billed charges,526.26,84% of total billed charges,451.08,72% of total billed charges,135.84,100% OF CMS OPPS Rate,135.84,100% of CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,375.9,60% of total billed charges,158.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,158.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,134.57,100% OF CMS OPPS RATE,135.84,100% OF CMS OPPS Rate,438.55,70% of total billed charges,135.84,100% OF CMS OPPS Rate,163.01,120% of CMS OPPS RATE,451.08,Pays at 72% of billed charges with lesser of charges applied,451.08,Pays at 72% of billed charges with lesser of charges applied,451.08,Pays at 72% of billed charges with lesser of charges applied,451.08,Pays at 72% of billed charges with lesser of charges applied,451.08,Pays at 72% of billed charges with lesser of charges applied,451.08,Pays at 72% of billed charges with lesser of charges applied,351.88,442% of BCBS Fee Schedule,351.88,442% of BCBS Fee Schedule,351.88,442% of BCBS Fee Schedule,351.88,442% of BCBS Fee Schedule,351.88,442% of BCBS Fee Schedule,351.88,442% of BCBS Fee Schedule,351.88,442% of BCBS Fee Schedule,351.88,442% of BCBS Fee Schedule,351.88,442% of BCBS Fee Schedule,614.6,pays at 100% of bcbs fee schedule with lesser of charges applied,614.6,pays at 100% of bcbs fee schedule with lesser of charges applied,614.6,pays at 100% of bcbs fee schedule with lesser of charges applied,614.6,pays at 100% of bcbs fee schedule with lesser of charges applied,614.6,pays at 100% of bcbs fee schedule with lesser of charges applied,526.26,84% of total billed charges,526.26,84% of total billed charges,526.26,84% of total billed charges,438.55,70% of total billed charges,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,158.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,158.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,158.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,158.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,158.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,158.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,158.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,158.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,158.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,158.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,158.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,158.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,158.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,158.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,158.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,158.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,158.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,158.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,158.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,158.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,134.57,614.60,469.88
Outpatient Medical Services,ULTRASOUND,38482,HEAD AND TRUNK VASCULAR SYSTEM,402,415.26,298.99,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,339.27,81.7% of total Billed charges,N/A,Not Separately reimbursable,328.47,79.1% of total billed charges,N/A,Not Separately reimbursable,348.82,84% of total billed charges,348.82,84% of total billed charges,298.99,72% of total billed charges,N/A,Not Separately reimbursable,269.92,65% of total billed charges,N/A,Not Separately reimbursable,249.16,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,290.68,70% of total billed charges,415.26,100% OF CMS OPPS Rate,415.26,120% of CMS OPPS RATE,298.99,Pays at 72% of billed charges with lesser of charges applied,298.99,Pays at 72% of billed charges with lesser of charges applied,298.99,Pays at 72% of billed charges with lesser of charges applied,298.99,Pays at 72% of billed charges with lesser of charges applied,298.99,Pays at 72% of billed charges with lesser of charges applied,298.99,Pays at 72% of billed charges with lesser of charges applied,339.27,81.7% of total Billed charges,339.27,81.7% of total Billed charges,339.27,81.7% of total Billed charges,339.27,81.7% of total Billed charges,339.27,81.7% of total Billed charges,339.27,81.7% of total Billed charges,339.27,81.7% of total Billed charges,339.27,81.7% of total Billed charges,339.27,81.7% of total Billed charges,328.47,79.1% of total billed charges,328.47,79.1% of total billed charges,328.47,79.1% of total billed charges,328.47,79.1% of total billed charges,328.47,79.1% of total billed charges,348.82,84% of total billed charges,348.82,84% of total billed charges,348.82,84% of total billed charges,290.68,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,249.16,415.26,311.45
Outpatient Medical Services,ULTRASOUND,76641,ULTRASOUND BREAST COMP BILATER,402,1282.5,923.4,Pays at 72% of billed charges with lesser of charges applied,135.85,100% OF CMS OPPS Rate,465.69,442% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,428.62,100% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,1077.3,84% of total billed charges,1077.3,84% of total billed charges,923.4,72% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% of CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,769.5,60% of total billed charges,138.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,138.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,82.22,100% OF CMS OPPS RATE,135.85,100% OF CMS OPPS Rate,897.75,70% of total billed charges,135.85,100% OF CMS OPPS Rate,163.02,120% of CMS OPPS RATE,923.4,Pays at 72% of billed charges with lesser of charges applied,923.4,Pays at 72% of billed charges with lesser of charges applied,923.4,Pays at 72% of billed charges with lesser of charges applied,923.4,Pays at 72% of billed charges with lesser of charges applied,923.4,Pays at 72% of billed charges with lesser of charges applied,923.4,Pays at 72% of billed charges with lesser of charges applied,465.69,442% of BCBS Fee Schedule,465.69,442% of BCBS Fee Schedule,465.69,442% of BCBS Fee Schedule,465.69,442% of BCBS Fee Schedule,465.69,442% of BCBS Fee Schedule,465.69,442% of BCBS Fee Schedule,465.69,442% of BCBS Fee Schedule,465.69,442% of BCBS Fee Schedule,465.69,442% of BCBS Fee Schedule,428.62,100% of BCBS Fee Schedule,428.62,100% of BCBS Fee Schedule,428.62,100% of BCBS Fee Schedule,428.62,100% of BCBS Fee Schedule,428.62,100% of BCBS Fee Schedule,1077.3,84% of total billed charges,1077.3,84% of total billed charges,1077.3,84% of total billed charges,897.75,70% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,138.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,138.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,138.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,138.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,138.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,138.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,138.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,138.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,138.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,138.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,138.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,138.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,138.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,138.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,138.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,138.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,138.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,138.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,138.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,138.03,100% of CA Medicaid Fee Schedule with lesser of charges applied,82.22,1077.30,961.88
Outpatient Medical Services,ULTRASOUND,76802,OBUS1ST TRIMESTER ECH ADDT FET,402,613.25,441.54,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,145.59,442% of BCBS Fee Schedule,N/A,Not Separately reimbursable,245.92,100% of BCBS Fee Schedule,N/A,Not Separately reimbursable,515.13,84% of total billed charges,515.13,84% of total billed charges,441.54,72% of total billed charges,N/A,Not Separately reimbursable,398.61,65% of total billed charges,N/A,Not Separately reimbursable,367.95,60% of total billed charges,79.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,79.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,25.48,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,429.28,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,441.54,Pays at 72% of billed charges with lesser of charges applied,441.54,Pays at 72% of billed charges with lesser of charges applied,441.54,Pays at 72% of billed charges with lesser of charges applied,441.54,Pays at 72% of billed charges with lesser of charges applied,441.54,Pays at 72% of billed charges with lesser of charges applied,441.54,Pays at 72% of billed charges with lesser of charges applied,145.59,442% of BCBS Fee Schedule,145.59,442% of BCBS Fee Schedule,145.59,442% of BCBS Fee Schedule,145.59,442% of BCBS Fee Schedule,145.59,442% of BCBS Fee Schedule,145.59,442% of BCBS Fee Schedule,145.59,442% of BCBS Fee Schedule,145.59,442% of BCBS Fee Schedule,145.59,442% of BCBS Fee Schedule,245.92,100% of BCBS Fee Schedule,245.92,100% of BCBS Fee Schedule,245.92,100% of BCBS Fee Schedule,245.92,100% of BCBS Fee Schedule,245.92,100% of BCBS Fee Schedule,515.13,84% of total billed charges,515.13,84% of total billed charges,515.13,84% of total billed charges,429.28,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,79.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,79.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,79.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,79.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,79.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,79.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,79.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,79.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,79.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,79.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,79.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,79.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,79.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,79.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,79.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,79.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,79.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,79.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,79.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,79.06,100% of CA Medicaid Fee Schedule with lesser of charges applied,25.48,515.13,459.94
Outpatient Medical Services,ULTRASOUND,76801,Abdominal ultrasound of pregnant uterus (less than 14 weeks) single or first fetus,402,251.25,180.9,Pays at 72% of billed charges with lesser of charges applied,135.84,100% OF CMS OPPS Rate,206.1,442% of BCBS Fee Schedule,135.84,100% OF CMS OPPS Rate,246.48,pays at 100% of bcbs fee schedule with lesser of charges applied,135.84,100% OF CMS OPPS Rate,211.05,84% of total billed charges,211.05,84% of total billed charges,180.9,72% of total billed charges,135.84,100% OF CMS OPPS Rate,135.84,100% of CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,150.75,60% of total billed charges,112.49,100% of CA Medicaid Fee Schedule with lesser of charges applied,112.49,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,85,100% OF CMS OPPS RATE,135.84,100% OF CMS OPPS Rate,175.88,70% of total billed charges,135.84,100% OF CMS OPPS Rate,163.01,120% of CMS OPPS RATE,180.9,Pays at 72% of billed charges with lesser of charges applied,180.9,Pays at 72% of billed charges with lesser of charges applied,180.9,Pays at 72% of billed charges with lesser of charges applied,180.9,Pays at 72% of billed charges with lesser of charges applied,180.9,Pays at 72% of billed charges with lesser of charges applied,180.9,Pays at 72% of billed charges with lesser of charges applied,206.1,442% of BCBS Fee Schedule,206.1,442% of BCBS Fee Schedule,206.1,442% of BCBS Fee Schedule,206.1,442% of BCBS Fee Schedule,206.1,442% of BCBS Fee Schedule,206.1,442% of BCBS Fee Schedule,206.1,442% of BCBS Fee Schedule,206.1,442% of BCBS Fee Schedule,206.1,442% of BCBS Fee Schedule,246.48,pays at 100% of bcbs fee schedule with lesser of charges applied,246.48,pays at 100% of bcbs fee schedule with lesser of charges applied,246.48,pays at 100% of bcbs fee schedule with lesser of charges applied,246.48,pays at 100% of bcbs fee schedule with lesser of charges applied,246.48,pays at 100% of bcbs fee schedule with lesser of charges applied,211.05,84% of total billed charges,211.05,84% of total billed charges,211.05,84% of total billed charges,175.88,70% of total billed charges,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,112.49,100% of CA Medicaid Fee Schedule with lesser of charges applied,112.49,100% of CA Medicaid Fee Schedule with lesser of charges applied,112.49,100% of CA Medicaid Fee Schedule with lesser of charges applied,112.49,100% of CA Medicaid Fee Schedule with lesser of charges applied,112.49,100% of CA Medicaid Fee Schedule with lesser of charges applied,112.49,100% of CA Medicaid Fee Schedule with lesser of charges applied,112.49,100% of CA Medicaid Fee Schedule with lesser of charges applied,112.49,100% of CA Medicaid Fee Schedule with lesser of charges applied,112.49,100% of CA Medicaid Fee Schedule with lesser of charges applied,112.49,100% of CA Medicaid Fee Schedule with lesser of charges applied,112.49,100% of CA Medicaid Fee Schedule with lesser of charges applied,112.49,100% of CA Medicaid Fee Schedule with lesser of charges applied,112.49,100% of CA Medicaid Fee Schedule with lesser of charges applied,112.49,100% of CA Medicaid Fee Schedule with lesser of charges applied,112.49,100% of CA Medicaid Fee Schedule with lesser of charges applied,112.49,100% of CA Medicaid Fee Schedule with lesser of charges applied,112.49,100% of CA Medicaid Fee Schedule with lesser of charges applied,112.49,100% of CA Medicaid Fee Schedule with lesser of charges applied,112.49,100% of CA Medicaid Fee Schedule with lesser of charges applied,112.49,100% of CA Medicaid Fee Schedule with lesser of charges applied,85.00,246.48,188.44
Outpatient Medical Services,ULTRASOUND,93880,Study of vessels on both sides of the head and neck,402,851.5,613.08,Pays at 72% of billed charges with lesser of charges applied,296.82,100% OF CMS OPPS Rate,851.5,BCBS Fee Schedule,296.82,100% OF CMS OPPS Rate,835.32,pays at 100% of bcbs fee schedule with lesser of charges applied,296.82,100% OF CMS OPPS Rate,715.26,84% of total billed charges,715.26,84% of total billed charges,613.08,72% of total billed charges,296.82,100% OF CMS OPPS Rate,296.82,100% of CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,510.9,60% of total billed charges,224.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,224.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,182.35,100% OF CMS OPPS RATE,296.82,100% OF CMS OPPS Rate,596.05,70% of total billed charges,296.82,100% OF CMS OPPS Rate,356.18,120% of CMS OPPS RATE,613.08,Pays at 72% of billed charges with lesser of charges applied,613.08,Pays at 72% of billed charges with lesser of charges applied,613.08,Pays at 72% of billed charges with lesser of charges applied,613.08,Pays at 72% of billed charges with lesser of charges applied,613.08,Pays at 72% of billed charges with lesser of charges applied,613.08,Pays at 72% of billed charges with lesser of charges applied,851.5,BCBS Fee Schedule,851.5,BCBS Fee Schedule,851.5,BCBS Fee Schedule,851.5,BCBS Fee Schedule,851.5,BCBS Fee Schedule,851.5,BCBS Fee Schedule,851.5,BCBS Fee Schedule,851.5,BCBS Fee Schedule,851.5,BCBS Fee Schedule,835.32,pays at 100% of bcbs fee schedule with lesser of charges applied,835.32,pays at 100% of bcbs fee schedule with lesser of charges applied,835.32,pays at 100% of bcbs fee schedule with lesser of charges applied,835.32,pays at 100% of bcbs fee schedule with lesser of charges applied,835.32,pays at 100% of bcbs fee schedule with lesser of charges applied,715.26,84% of total billed charges,715.26,84% of total billed charges,715.26,84% of total billed charges,596.05,70% of total billed charges,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,224.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,224.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,224.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,224.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,224.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,224.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,224.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,224.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,224.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,224.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,224.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,224.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,224.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,224.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,224.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,224.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,224.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,224.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,224.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,224.68,100% of CA Medicaid Fee Schedule with lesser of charges applied,182.35,851.50,638.63
Outpatient Medical Services,ULTRASOUND,76870,Ultrasound of the scrotum,402,214.25,154.26,Pays at 72% of billed charges with lesser of charges applied,135.85,100% OF CMS OPPS Rate,214.25,BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,210.18,pays at 100% of bcbs fee schedule with lesser of charges applied,135.85,100% OF CMS OPPS Rate,179.97,84% of total billed charges,179.97,84% of total billed charges,154.26,72% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% of CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,128.55,60% of total billed charges,85.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,85.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,84.6,100% OF CMS OPPS RATE,135.85,100% OF CMS OPPS Rate,149.98,70% of total billed charges,135.85,100% OF CMS OPPS Rate,163.02,120% of CMS OPPS RATE,154.26,Pays at 72% of billed charges with lesser of charges applied,154.26,Pays at 72% of billed charges with lesser of charges applied,154.26,Pays at 72% of billed charges with lesser of charges applied,154.26,Pays at 72% of billed charges with lesser of charges applied,154.26,Pays at 72% of billed charges with lesser of charges applied,154.26,Pays at 72% of billed charges with lesser of charges applied,214.25,BCBS Fee Schedule,214.25,BCBS Fee Schedule,214.25,BCBS Fee Schedule,214.25,BCBS Fee Schedule,214.25,BCBS Fee Schedule,214.25,BCBS Fee Schedule,214.25,BCBS Fee Schedule,214.25,BCBS Fee Schedule,214.25,BCBS Fee Schedule,210.18,pays at 100% of bcbs fee schedule with lesser of charges applied,210.18,pays at 100% of bcbs fee schedule with lesser of charges applied,210.18,pays at 100% of bcbs fee schedule with lesser of charges applied,210.18,pays at 100% of bcbs fee schedule with lesser of charges applied,210.18,pays at 100% of bcbs fee schedule with lesser of charges applied,179.97,84% of total billed charges,179.97,84% of total billed charges,179.97,84% of total billed charges,149.98,70% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,85.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,85.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,85.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,85.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,85.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,85.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,85.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,85.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,85.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,85.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,85.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,85.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,85.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,85.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,85.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,85.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,85.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,85.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,85.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,85.75,100% of CA Medicaid Fee Schedule with lesser of charges applied,84.60,214.25,160.69
Outpatient Medical Services,ULTRASOUND,76815,Ultrasound of fetus with limited views,402,229.5,165.24,Pays at 72% of billed charges with lesser of charges applied,135.85,100% OF CMS OPPS Rate,229.5,BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,225.14,pays at 100% of bcbs fee schedule with lesser of charges applied,135.85,100% OF CMS OPPS Rate,192.78,84% of total billed charges,192.78,84% of total billed charges,165.24,72% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% of CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,137.7,60% of total billed charges,90.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,90.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,60.32,100% OF CMS OPPS RATE,135.85,100% OF CMS OPPS Rate,160.65,70% of total billed charges,135.85,100% OF CMS OPPS Rate,163.02,120% of CMS OPPS RATE,165.24,Pays at 72% of billed charges with lesser of charges applied,165.24,Pays at 72% of billed charges with lesser of charges applied,165.24,Pays at 72% of billed charges with lesser of charges applied,165.24,Pays at 72% of billed charges with lesser of charges applied,165.24,Pays at 72% of billed charges with lesser of charges applied,165.24,Pays at 72% of billed charges with lesser of charges applied,229.5,BCBS Fee Schedule,229.5,BCBS Fee Schedule,229.5,BCBS Fee Schedule,229.5,BCBS Fee Schedule,229.5,BCBS Fee Schedule,229.5,BCBS Fee Schedule,229.5,BCBS Fee Schedule,229.5,BCBS Fee Schedule,229.5,BCBS Fee Schedule,225.14,pays at 100% of bcbs fee schedule with lesser of charges applied,225.14,pays at 100% of bcbs fee schedule with lesser of charges applied,225.14,pays at 100% of bcbs fee schedule with lesser of charges applied,225.14,pays at 100% of bcbs fee schedule with lesser of charges applied,225.14,pays at 100% of bcbs fee schedule with lesser of charges applied,192.78,84% of total billed charges,192.78,84% of total billed charges,192.78,84% of total billed charges,160.65,70% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,90.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,90.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,90.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,90.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,90.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,90.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,90.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,90.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,90.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,90.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,90.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,90.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,90.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,90.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,90.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,90.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,90.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,90.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,90.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,90.30,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.32,229.50,172.13
Outpatient Medical Services,ULTRASOUND,76811,Ultrasound of single fetus,402,861.75,620.46,Pays at 72% of billed charges with lesser of charges applied,296.82,100% OF CMS OPPS Rate,699.07,442% of BCBS Fee Schedule,296.82,100% OF CMS OPPS Rate,825.79,100% of BCBS Fee Schedule,296.82,100% OF CMS OPPS Rate,723.87,84% of total billed charges,723.87,84% of total billed charges,620.46,72% of total billed charges,296.82,100% OF CMS OPPS Rate,296.82,100% of CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,517.05,60% of total billed charges,227.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,227.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,102.31,100% OF CMS OPPS RATE,296.82,100% OF CMS OPPS Rate,603.23,70% of total billed charges,296.82,100% OF CMS OPPS Rate,356.18,120% of CMS OPPS RATE,620.46,Pays at 72% of billed charges with lesser of charges applied,620.46,Pays at 72% of billed charges with lesser of charges applied,620.46,Pays at 72% of billed charges with lesser of charges applied,620.46,Pays at 72% of billed charges with lesser of charges applied,620.46,Pays at 72% of billed charges with lesser of charges applied,620.46,Pays at 72% of billed charges with lesser of charges applied,699.07,442% of BCBS Fee Schedule,699.07,442% of BCBS Fee Schedule,699.07,442% of BCBS Fee Schedule,699.07,442% of BCBS Fee Schedule,699.07,442% of BCBS Fee Schedule,699.07,442% of BCBS Fee Schedule,699.07,442% of BCBS Fee Schedule,699.07,442% of BCBS Fee Schedule,699.07,442% of BCBS Fee Schedule,825.79,100% of BCBS Fee Schedule,825.79,100% of BCBS Fee Schedule,825.79,100% of BCBS Fee Schedule,825.79,100% of BCBS Fee Schedule,825.79,100% of BCBS Fee Schedule,723.87,84% of total billed charges,723.87,84% of total billed charges,723.87,84% of total billed charges,603.23,70% of total billed charges,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,296.82,100% OF CMS OPPS Rate,227.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,227.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,227.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,227.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,227.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,227.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,227.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,227.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,227.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,227.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,227.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,227.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,227.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,227.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,227.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,227.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,227.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,227.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,227.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,227.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,102.31,825.79,646.31
Outpatient Medical Services,ULTRASOUND,76529,US ORBIT FOR FB LOCALIZATION,402,214.25,154.26,Pays at 72% of billed charges with lesser of charges applied,110.43,100% OF CMS OPPS Rate,214.25,BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,123.89,100% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,179.97,84% of total billed charges,179.97,84% of total billed charges,154.26,72% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% of CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,128.55,60% of total billed charges,84.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,84.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,64.3,100% OF CMS OPPS RATE,110.43,100% OF CMS OPPS Rate,149.98,70% of total billed charges,110.43,100% OF CMS OPPS Rate,132.51,120% of CMS OPPS RATE,154.26,Pays at 72% of billed charges with lesser of charges applied,154.26,Pays at 72% of billed charges with lesser of charges applied,154.26,Pays at 72% of billed charges with lesser of charges applied,154.26,Pays at 72% of billed charges with lesser of charges applied,154.26,Pays at 72% of billed charges with lesser of charges applied,154.26,Pays at 72% of billed charges with lesser of charges applied,214.25,BCBS Fee Schedule,214.25,BCBS Fee Schedule,214.25,BCBS Fee Schedule,214.25,BCBS Fee Schedule,214.25,BCBS Fee Schedule,214.25,BCBS Fee Schedule,214.25,BCBS Fee Schedule,214.25,BCBS Fee Schedule,214.25,BCBS Fee Schedule,123.89,100% of BCBS Fee Schedule,123.89,100% of BCBS Fee Schedule,123.89,100% of BCBS Fee Schedule,123.89,100% of BCBS Fee Schedule,123.89,100% of BCBS Fee Schedule,179.97,84% of total billed charges,179.97,84% of total billed charges,179.97,84% of total billed charges,149.98,70% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,84.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,84.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,84.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,84.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,84.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,84.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,84.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,84.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,84.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,84.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,84.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,84.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,84.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,84.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,84.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,84.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,84.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,84.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,84.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,84.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,64.30,214.25,160.69
Outpatient Medical Services,ULTRASOUND,76942,ULTRASOUND GUIDED BX ASP LT,402,666.75,480.06,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,285.75,442% of BCBS Fee Schedule,N/A,Not Separately reimbursable,560.48,100% of BCBS Fee Schedule,N/A,Not Separately reimbursable,560.07,84% of total billed charges,560.07,84% of total billed charges,480.06,72% of total billed charges,N/A,Not Separately reimbursable,433.39,65% of total billed charges,N/A,Not Separately reimbursable,400.05,60% of total billed charges,72.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,72.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,33.24,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,466.73,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,480.06,Pays at 72% of billed charges with lesser of charges applied,480.06,Pays at 72% of billed charges with lesser of charges applied,480.06,Pays at 72% of billed charges with lesser of charges applied,480.06,Pays at 72% of billed charges with lesser of charges applied,480.06,Pays at 72% of billed charges with lesser of charges applied,480.06,Pays at 72% of billed charges with lesser of charges applied,285.75,442% of BCBS Fee Schedule,285.75,442% of BCBS Fee Schedule,285.75,442% of BCBS Fee Schedule,285.75,442% of BCBS Fee Schedule,285.75,442% of BCBS Fee Schedule,285.75,442% of BCBS Fee Schedule,285.75,442% of BCBS Fee Schedule,285.75,442% of BCBS Fee Schedule,285.75,442% of BCBS Fee Schedule,560.48,100% of BCBS Fee Schedule,560.48,100% of BCBS Fee Schedule,560.48,100% of BCBS Fee Schedule,560.48,100% of BCBS Fee Schedule,560.48,100% of BCBS Fee Schedule,560.07,84% of total billed charges,560.07,84% of total billed charges,560.07,84% of total billed charges,466.73,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,72.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,72.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,72.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,72.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,72.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,72.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,72.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,72.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,72.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,72.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,72.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,72.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,72.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,72.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,72.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,72.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,72.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,72.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,72.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,72.61,100% of CA Medicaid Fee Schedule with lesser of charges applied,33.24,560.48,500.06
Outpatient Medical Services,ULTRASOUND,76770,Ultrasound of back wall of the abdomen with all areas viewed,402,802.75,577.98,Pays at 72% of billed charges with lesser of charges applied,135.84,100% OF CMS OPPS Rate,371.19,442% of BCBS Fee Schedule,135.84,100% OF CMS OPPS Rate,441.83,100% of BCBS Fee Schedule,135.84,100% OF CMS OPPS Rate,674.31,84% of total billed charges,674.31,84% of total billed charges,577.98,72% of total billed charges,135.84,100% OF CMS OPPS Rate,135.84,100% of CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,481.65,60% of total billed charges,115.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,115.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,88.59,100% OF CMS OPPS RATE,135.84,100% OF CMS OPPS Rate,561.93,70% of total billed charges,135.84,100% OF CMS OPPS Rate,163.01,120% of CMS OPPS RATE,577.98,Pays at 72% of billed charges with lesser of charges applied,577.98,Pays at 72% of billed charges with lesser of charges applied,577.98,Pays at 72% of billed charges with lesser of charges applied,577.98,Pays at 72% of billed charges with lesser of charges applied,577.98,Pays at 72% of billed charges with lesser of charges applied,577.98,Pays at 72% of billed charges with lesser of charges applied,371.19,442% of BCBS Fee Schedule,371.19,442% of BCBS Fee Schedule,371.19,442% of BCBS Fee Schedule,371.19,442% of BCBS Fee Schedule,371.19,442% of BCBS Fee Schedule,371.19,442% of BCBS Fee Schedule,371.19,442% of BCBS Fee Schedule,371.19,442% of BCBS Fee Schedule,371.19,442% of BCBS Fee Schedule,441.83,100% of BCBS Fee Schedule,441.83,100% of BCBS Fee Schedule,441.83,100% of BCBS Fee Schedule,441.83,100% of BCBS Fee Schedule,441.83,100% of BCBS Fee Schedule,674.31,84% of total billed charges,674.31,84% of total billed charges,674.31,84% of total billed charges,561.93,70% of total billed charges,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,115.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,115.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,115.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,115.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,115.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,115.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,115.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,115.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,115.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,115.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,115.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,115.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,115.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,115.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,115.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,115.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,115.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,115.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,115.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,115.78,100% of CA Medicaid Fee Schedule with lesser of charges applied,88.59,674.31,602.06
Outpatient Medical Services,ULTRASOUND,76775,Ultrasound of back wall of the abdomen with limited areas viewed,402,434,312.48,Pays at 72% of billed charges with lesser of charges applied,135.85,100% OF CMS OPPS Rate,267.23,442% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,319.19,100% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,364.56,84% of total billed charges,364.56,84% of total billed charges,312.48,72% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% of CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,260.4,60% of total billed charges,73.70,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.70,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,37.62,100% OF CMS OPPS RATE,135.85,100% OF CMS OPPS Rate,303.8,70% of total billed charges,135.85,100% OF CMS OPPS Rate,163.02,120% of CMS OPPS RATE,312.48,Pays at 72% of billed charges with lesser of charges applied,312.48,Pays at 72% of billed charges with lesser of charges applied,312.48,Pays at 72% of billed charges with lesser of charges applied,312.48,Pays at 72% of billed charges with lesser of charges applied,312.48,Pays at 72% of billed charges with lesser of charges applied,312.48,Pays at 72% of billed charges with lesser of charges applied,267.23,442% of BCBS Fee Schedule,267.23,442% of BCBS Fee Schedule,267.23,442% of BCBS Fee Schedule,267.23,442% of BCBS Fee Schedule,267.23,442% of BCBS Fee Schedule,267.23,442% of BCBS Fee Schedule,267.23,442% of BCBS Fee Schedule,267.23,442% of BCBS Fee Schedule,267.23,442% of BCBS Fee Schedule,319.19,100% of BCBS Fee Schedule,319.19,100% of BCBS Fee Schedule,319.19,100% of BCBS Fee Schedule,319.19,100% of BCBS Fee Schedule,319.19,100% of BCBS Fee Schedule,364.56,84% of total billed charges,364.56,84% of total billed charges,364.56,84% of total billed charges,303.8,70% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,73.70,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.70,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.70,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.70,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.70,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.70,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.70,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.70,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.70,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.70,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.70,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.70,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.70,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.70,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.70,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.70,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.70,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.70,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.70,100% of CA Medicaid Fee Schedule with lesser of charges applied,73.70,100% of CA Medicaid Fee Schedule with lesser of charges applied,37.62,364.56,325.5
Outpatient Medical Services,ULTRASOUND,76642,Limited ultrasound of the breast,402,229.5,165.24,Pays at 72% of billed charges with lesser of charges applied,110.43,100% OF CMS OPPS Rate,229.5,BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,225.14,pays at 100% of bcbs fee schedule with lesser of charges applied,110.43,100% OF CMS OPPS Rate,192.78,84% of total billed charges,192.78,84% of total billed charges,165.24,72% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% of CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,137.7,60% of total billed charges,112.54,100% of CA Medicaid Fee Schedule with lesser of charges applied,112.54,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,63.1,100% OF CMS OPPS RATE,110.43,100% OF CMS OPPS Rate,160.65,70% of total billed charges,110.43,100% OF CMS OPPS Rate,132.51,120% of CMS OPPS RATE,165.24,Pays at 72% of billed charges with lesser of charges applied,165.24,Pays at 72% of billed charges with lesser of charges applied,165.24,Pays at 72% of billed charges with lesser of charges applied,165.24,Pays at 72% of billed charges with lesser of charges applied,165.24,Pays at 72% of billed charges with lesser of charges applied,165.24,Pays at 72% of billed charges with lesser of charges applied,229.5,BCBS Fee Schedule,229.5,BCBS Fee Schedule,229.5,BCBS Fee Schedule,229.5,BCBS Fee Schedule,229.5,BCBS Fee Schedule,229.5,BCBS Fee Schedule,229.5,BCBS Fee Schedule,229.5,BCBS Fee Schedule,229.5,BCBS Fee Schedule,225.14,pays at 100% of bcbs fee schedule with lesser of charges applied,225.14,pays at 100% of bcbs fee schedule with lesser of charges applied,225.14,pays at 100% of bcbs fee schedule with lesser of charges applied,225.14,pays at 100% of bcbs fee schedule with lesser of charges applied,225.14,pays at 100% of bcbs fee schedule with lesser of charges applied,192.78,84% of total billed charges,192.78,84% of total billed charges,192.78,84% of total billed charges,160.65,70% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,112.54,100% of CA Medicaid Fee Schedule with lesser of charges applied,112.54,100% of CA Medicaid Fee Schedule with lesser of charges applied,112.54,100% of CA Medicaid Fee Schedule with lesser of charges applied,112.54,100% of CA Medicaid Fee Schedule with lesser of charges applied,112.54,100% of CA Medicaid Fee Schedule with lesser of charges applied,112.54,100% of CA Medicaid Fee Schedule with lesser of charges applied,112.54,100% of CA Medicaid Fee Schedule with lesser of charges applied,112.54,100% of CA Medicaid Fee Schedule with lesser of charges applied,112.54,100% of CA Medicaid Fee Schedule with lesser of charges applied,112.54,100% of CA Medicaid Fee Schedule with lesser of charges applied,112.54,100% of CA Medicaid Fee Schedule with lesser of charges applied,112.54,100% of CA Medicaid Fee Schedule with lesser of charges applied,112.54,100% of CA Medicaid Fee Schedule with lesser of charges applied,112.54,100% of CA Medicaid Fee Schedule with lesser of charges applied,112.54,100% of CA Medicaid Fee Schedule with lesser of charges applied,112.54,100% of CA Medicaid Fee Schedule with lesser of charges applied,112.54,100% of CA Medicaid Fee Schedule with lesser of charges applied,112.54,100% of CA Medicaid Fee Schedule with lesser of charges applied,112.54,100% of CA Medicaid Fee Schedule with lesser of charges applied,112.54,100% of CA Medicaid Fee Schedule with lesser of charges applied,63.10,229.50,172.13
Outpatient Medical Services,ULTRASOUND,76857,Limited ultrasound of the pelvis,402,434,312.48,Pays at 72% of billed charges with lesser of charges applied,135.84,100% OF CMS OPPS Rate,198.15,442% of BCBS Fee Schedule,135.84,100% OF CMS OPPS Rate,346.16,100% of BCBS Fee Schedule,135.84,100% OF CMS OPPS Rate,364.56,84% of total billed charges,364.56,84% of total billed charges,312.48,72% of total billed charges,135.84,100% OF CMS OPPS Rate,135.84,100% of CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,260.4,60% of total billed charges,60.49,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.49,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,30.05,100% OF CMS OPPS RATE,135.84,100% OF CMS OPPS Rate,303.8,70% of total billed charges,135.84,100% OF CMS OPPS Rate,163.01,120% of CMS OPPS RATE,312.48,Pays at 72% of billed charges with lesser of charges applied,312.48,Pays at 72% of billed charges with lesser of charges applied,312.48,Pays at 72% of billed charges with lesser of charges applied,312.48,Pays at 72% of billed charges with lesser of charges applied,312.48,Pays at 72% of billed charges with lesser of charges applied,312.48,Pays at 72% of billed charges with lesser of charges applied,198.15,442% of BCBS Fee Schedule,198.15,442% of BCBS Fee Schedule,198.15,442% of BCBS Fee Schedule,198.15,442% of BCBS Fee Schedule,198.15,442% of BCBS Fee Schedule,198.15,442% of BCBS Fee Schedule,198.15,442% of BCBS Fee Schedule,198.15,442% of BCBS Fee Schedule,198.15,442% of BCBS Fee Schedule,346.16,100% of BCBS Fee Schedule,346.16,100% of BCBS Fee Schedule,346.16,100% of BCBS Fee Schedule,346.16,100% of BCBS Fee Schedule,346.16,100% of BCBS Fee Schedule,364.56,84% of total billed charges,364.56,84% of total billed charges,364.56,84% of total billed charges,303.8,70% of total billed charges,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,60.49,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.49,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.49,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.49,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.49,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.49,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.49,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.49,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.49,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.49,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.49,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.49,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.49,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.49,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.49,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.49,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.49,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.49,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.49,100% of CA Medicaid Fee Schedule with lesser of charges applied,60.49,100% of CA Medicaid Fee Schedule with lesser of charges applied,30.05,364.56,325.5
Outpatient Medical Services,ULTRASOUND,76825,"ECHOCARDIOGRAPHY, FETAL",402,802.75,577.98,Pays at 72% of billed charges with lesser of charges applied,639.51,100% OF CMS OPPS Rate,360.98,442% of BCBS Fee Schedule,639.51,100% OF CMS OPPS Rate,441.83,100% of BCBS Fee Schedule,639.51,100% OF CMS OPPS Rate,674.31,84% of total billed charges,674.31,84% of total billed charges,577.98,72% of total billed charges,639.51,100% OF CMS OPPS Rate,639.51,100% of CMS OPPS Rate,639.51,100% OF CMS OPPS Rate,481.65,60% of total billed charges,116.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,639.51,100% OF CMS OPPS Rate,639.51,100% OF CMS OPPS Rate,219.38,100% OF CMS OPPS RATE,639.51,100% OF CMS OPPS Rate,561.93,70% of total billed charges,639.51,100% OF CMS OPPS Rate,767.41,120% of CMS OPPS RATE,577.98,Pays at 72% of billed charges with lesser of charges applied,577.98,Pays at 72% of billed charges with lesser of charges applied,577.98,Pays at 72% of billed charges with lesser of charges applied,577.98,Pays at 72% of billed charges with lesser of charges applied,577.98,Pays at 72% of billed charges with lesser of charges applied,577.98,Pays at 72% of billed charges with lesser of charges applied,360.98,442% of BCBS Fee Schedule,360.98,442% of BCBS Fee Schedule,360.98,442% of BCBS Fee Schedule,360.98,442% of BCBS Fee Schedule,360.98,442% of BCBS Fee Schedule,360.98,442% of BCBS Fee Schedule,360.98,442% of BCBS Fee Schedule,360.98,442% of BCBS Fee Schedule,360.98,442% of BCBS Fee Schedule,441.83,100% of BCBS Fee Schedule,441.83,100% of BCBS Fee Schedule,441.83,100% of BCBS Fee Schedule,441.83,100% of BCBS Fee Schedule,441.83,100% of BCBS Fee Schedule,674.31,84% of total billed charges,674.31,84% of total billed charges,674.31,84% of total billed charges,561.93,70% of total billed charges,639.51,100% OF CMS OPPS Rate,639.51,100% OF CMS OPPS Rate,639.51,100% OF CMS OPPS Rate,639.51,100% OF CMS OPPS Rate,639.51,100% OF CMS OPPS Rate,639.51,100% OF CMS OPPS Rate,639.51,100% OF CMS OPPS Rate,639.51,100% OF CMS OPPS Rate,639.51,100% OF CMS OPPS Rate,639.51,100% OF CMS OPPS Rate,639.51,100% OF CMS OPPS Rate,639.51,100% OF CMS OPPS Rate,639.51,100% OF CMS OPPS Rate,639.51,100% OF CMS OPPS Rate,639.51,100% OF CMS OPPS Rate,639.51,100% OF CMS OPPS Rate,116.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.87,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.87,767.41,602.06
Outpatient Medical Services,ULTRASOUND,76885,"US INFANT HIPS, DYNAMIC",402,454,326.88,Pays at 72% of billed charges with lesser of charges applied,110.43,100% OF CMS OPPS Rate,286.99,442% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,341.58,100% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,381.36,84% of total billed charges,381.36,84% of total billed charges,326.88,72% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% of CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,272.4,60% of total billed charges,109.14,100% of CA Medicaid Fee Schedule with lesser of charges applied,109.14,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,121.83,100% OF CMS OPPS RATE,110.43,100% OF CMS OPPS Rate,317.8,70% of total billed charges,110.43,100% OF CMS OPPS Rate,132.51,120% of CMS OPPS RATE,326.88,Pays at 72% of billed charges with lesser of charges applied,326.88,Pays at 72% of billed charges with lesser of charges applied,326.88,Pays at 72% of billed charges with lesser of charges applied,326.88,Pays at 72% of billed charges with lesser of charges applied,326.88,Pays at 72% of billed charges with lesser of charges applied,326.88,Pays at 72% of billed charges with lesser of charges applied,286.99,442% of BCBS Fee Schedule,286.99,442% of BCBS Fee Schedule,286.99,442% of BCBS Fee Schedule,286.99,442% of BCBS Fee Schedule,286.99,442% of BCBS Fee Schedule,286.99,442% of BCBS Fee Schedule,286.99,442% of BCBS Fee Schedule,286.99,442% of BCBS Fee Schedule,286.99,442% of BCBS Fee Schedule,341.58,100% of BCBS Fee Schedule,341.58,100% of BCBS Fee Schedule,341.58,100% of BCBS Fee Schedule,341.58,100% of BCBS Fee Schedule,341.58,100% of BCBS Fee Schedule,381.36,84% of total billed charges,381.36,84% of total billed charges,381.36,84% of total billed charges,317.8,70% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,109.14,100% of CA Medicaid Fee Schedule with lesser of charges applied,109.14,100% of CA Medicaid Fee Schedule with lesser of charges applied,109.14,100% of CA Medicaid Fee Schedule with lesser of charges applied,109.14,100% of CA Medicaid Fee Schedule with lesser of charges applied,109.14,100% of CA Medicaid Fee Schedule with lesser of charges applied,109.14,100% of CA Medicaid Fee Schedule with lesser of charges applied,109.14,100% of CA Medicaid Fee Schedule with lesser of charges applied,109.14,100% of CA Medicaid Fee Schedule with lesser of charges applied,109.14,100% of CA Medicaid Fee Schedule with lesser of charges applied,109.14,100% of CA Medicaid Fee Schedule with lesser of charges applied,109.14,100% of CA Medicaid Fee Schedule with lesser of charges applied,109.14,100% of CA Medicaid Fee Schedule with lesser of charges applied,109.14,100% of CA Medicaid Fee Schedule with lesser of charges applied,109.14,100% of CA Medicaid Fee Schedule with lesser of charges applied,109.14,100% of CA Medicaid Fee Schedule with lesser of charges applied,109.14,100% of CA Medicaid Fee Schedule with lesser of charges applied,109.14,100% of CA Medicaid Fee Schedule with lesser of charges applied,109.14,100% of CA Medicaid Fee Schedule with lesser of charges applied,109.14,100% of CA Medicaid Fee Schedule with lesser of charges applied,109.14,100% of CA Medicaid Fee Schedule with lesser of charges applied,109.14,381.36,340.5
Outpatient Medical Services,ULTRASOUND,76886,"US INFANT HIPS, LIMITED",402,418.5,301.32,Pays at 72% of billed charges with lesser of charges applied,110.43,100% OF CMS OPPS Rate,266.75,442% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,319.19,100% of BCBS Fee Schedule,110.43,100% OF CMS OPPS Rate,351.54,84% of total billed charges,351.54,84% of total billed charges,301.32,72% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% of CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,251.1,60% of total billed charges,97.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,85.4,100% OF CMS OPPS RATE,110.43,100% OF CMS OPPS Rate,292.95,70% of total billed charges,110.43,100% OF CMS OPPS Rate,132.51,120% of CMS OPPS RATE,301.32,Pays at 72% of billed charges with lesser of charges applied,301.32,Pays at 72% of billed charges with lesser of charges applied,301.32,Pays at 72% of billed charges with lesser of charges applied,301.32,Pays at 72% of billed charges with lesser of charges applied,301.32,Pays at 72% of billed charges with lesser of charges applied,301.32,Pays at 72% of billed charges with lesser of charges applied,266.75,442% of BCBS Fee Schedule,266.75,442% of BCBS Fee Schedule,266.75,442% of BCBS Fee Schedule,266.75,442% of BCBS Fee Schedule,266.75,442% of BCBS Fee Schedule,266.75,442% of BCBS Fee Schedule,266.75,442% of BCBS Fee Schedule,266.75,442% of BCBS Fee Schedule,266.75,442% of BCBS Fee Schedule,319.19,100% of BCBS Fee Schedule,319.19,100% of BCBS Fee Schedule,319.19,100% of BCBS Fee Schedule,319.19,100% of BCBS Fee Schedule,319.19,100% of BCBS Fee Schedule,351.54,84% of total billed charges,351.54,84% of total billed charges,351.54,84% of total billed charges,292.95,70% of total billed charges,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,110.43,100% OF CMS OPPS Rate,97.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.27,100% of CA Medicaid Fee Schedule with lesser of charges applied,85.40,351.54,313.88
Outpatient Medical Services,ULTRASOUND,76830,Ultrasound of the pelvis through vagina,402,229.5,165.24,Pays at 72% of billed charges with lesser of charges applied,135.84,100% OF CMS OPPS Rate,229.5,BCBS Fee Schedule,135.84,100% OF CMS OPPS Rate,225.14,pays at 100% of bcbs fee schedule with lesser of charges applied,135.84,100% OF CMS OPPS Rate,192.78,84% of total billed charges,192.78,84% of total billed charges,165.24,72% of total billed charges,135.84,100% OF CMS OPPS Rate,135.84,100% of CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,137.7,60% of total billed charges,97.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,104.11,100% OF CMS OPPS RATE,135.84,100% OF CMS OPPS Rate,160.65,70% of total billed charges,135.84,100% OF CMS OPPS Rate,163.01,120% of CMS OPPS RATE,165.24,Pays at 72% of billed charges with lesser of charges applied,165.24,Pays at 72% of billed charges with lesser of charges applied,165.24,Pays at 72% of billed charges with lesser of charges applied,165.24,Pays at 72% of billed charges with lesser of charges applied,165.24,Pays at 72% of billed charges with lesser of charges applied,165.24,Pays at 72% of billed charges with lesser of charges applied,229.5,BCBS Fee Schedule,229.5,BCBS Fee Schedule,229.5,BCBS Fee Schedule,229.5,BCBS Fee Schedule,229.5,BCBS Fee Schedule,229.5,BCBS Fee Schedule,229.5,BCBS Fee Schedule,229.5,BCBS Fee Schedule,229.5,BCBS Fee Schedule,225.14,pays at 100% of bcbs fee schedule with lesser of charges applied,225.14,pays at 100% of bcbs fee schedule with lesser of charges applied,225.14,pays at 100% of bcbs fee schedule with lesser of charges applied,225.14,pays at 100% of bcbs fee schedule with lesser of charges applied,225.14,pays at 100% of bcbs fee schedule with lesser of charges applied,192.78,84% of total billed charges,192.78,84% of total billed charges,192.78,84% of total billed charges,160.65,70% of total billed charges,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,97.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.04,229.50,172.13
Outpatient Medical Services,ULTRASOUND,76700,Ultrasound of abdomen with all areas scanned,402,802.75,577.98,Pays at 72% of billed charges with lesser of charges applied,135.84,100% OF CMS OPPS Rate,371.19,442% of BCBS Fee Schedule,135.84,100% OF CMS OPPS Rate,441.83,100% of BCBS Fee Schedule,135.84,100% OF CMS OPPS Rate,674.31,84% of total billed charges,674.31,84% of total billed charges,577.98,72% of total billed charges,135.84,100% OF CMS OPPS Rate,135.84,100% of CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,481.65,60% of total billed charges,119.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,119.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,94.16,100% OF CMS OPPS RATE,135.84,100% OF CMS OPPS Rate,561.93,70% of total billed charges,135.84,100% OF CMS OPPS Rate,163.01,120% of CMS OPPS RATE,577.98,Pays at 72% of billed charges with lesser of charges applied,577.98,Pays at 72% of billed charges with lesser of charges applied,577.98,Pays at 72% of billed charges with lesser of charges applied,577.98,Pays at 72% of billed charges with lesser of charges applied,577.98,Pays at 72% of billed charges with lesser of charges applied,577.98,Pays at 72% of billed charges with lesser of charges applied,371.19,442% of BCBS Fee Schedule,371.19,442% of BCBS Fee Schedule,371.19,442% of BCBS Fee Schedule,371.19,442% of BCBS Fee Schedule,371.19,442% of BCBS Fee Schedule,371.19,442% of BCBS Fee Schedule,371.19,442% of BCBS Fee Schedule,371.19,442% of BCBS Fee Schedule,371.19,442% of BCBS Fee Schedule,441.83,100% of BCBS Fee Schedule,441.83,100% of BCBS Fee Schedule,441.83,100% of BCBS Fee Schedule,441.83,100% of BCBS Fee Schedule,441.83,100% of BCBS Fee Schedule,674.31,84% of total billed charges,674.31,84% of total billed charges,674.31,84% of total billed charges,561.93,70% of total billed charges,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,119.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,119.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,119.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,119.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,119.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,119.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,119.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,119.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,119.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,119.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,119.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,119.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,119.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,119.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,119.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,119.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,119.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,119.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,119.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,119.34,100% of CA Medicaid Fee Schedule with lesser of charges applied,94.16,674.31,602.06
Outpatient Medical Services,ULTRASOUND,76506,US ECHOENCEPHALOGRAPHY,402,802.75,577.98,Pays at 72% of billed charges with lesser of charges applied,135.85,100% OF CMS OPPS Rate,230.33,442% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,319.19,100% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,674.31,84% of total billed charges,674.31,84% of total billed charges,577.98,72% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% of CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,481.65,60% of total billed charges,89.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,89.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,99.73,100% OF CMS OPPS RATE,135.85,100% OF CMS OPPS Rate,561.93,70% of total billed charges,135.85,100% OF CMS OPPS Rate,163.02,120% of CMS OPPS RATE,577.98,Pays at 72% of billed charges with lesser of charges applied,577.98,Pays at 72% of billed charges with lesser of charges applied,577.98,Pays at 72% of billed charges with lesser of charges applied,577.98,Pays at 72% of billed charges with lesser of charges applied,577.98,Pays at 72% of billed charges with lesser of charges applied,577.98,Pays at 72% of billed charges with lesser of charges applied,230.33,442% of BCBS Fee Schedule,230.33,442% of BCBS Fee Schedule,230.33,442% of BCBS Fee Schedule,230.33,442% of BCBS Fee Schedule,230.33,442% of BCBS Fee Schedule,230.33,442% of BCBS Fee Schedule,230.33,442% of BCBS Fee Schedule,230.33,442% of BCBS Fee Schedule,230.33,442% of BCBS Fee Schedule,319.19,100% of BCBS Fee Schedule,319.19,100% of BCBS Fee Schedule,319.19,100% of BCBS Fee Schedule,319.19,100% of BCBS Fee Schedule,319.19,100% of BCBS Fee Schedule,674.31,84% of total billed charges,674.31,84% of total billed charges,674.31,84% of total billed charges,561.93,70% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,89.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,89.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,89.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,89.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,89.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,89.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,89.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,89.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,89.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,89.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,89.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,89.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,89.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,89.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,89.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,89.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,89.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,89.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,89.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,89.26,100% of CA Medicaid Fee Schedule with lesser of charges applied,89.26,674.31,602.06
Outpatient Medical Services,ULTRASOUND,93882,"US-CAROTIDS,RIGHT SIDE",402,851.5,613.08,Pays at 72% of billed charges with lesser of charges applied,135.84,100% OF CMS OPPS Rate,595.82,442% of BCBS Fee Schedule,135.84,100% OF CMS OPPS Rate,649.74,100% of BCBS Fee Schedule,135.84,100% OF CMS OPPS Rate,715.26,84% of total billed charges,715.26,84% of total billed charges,613.08,72% of total billed charges,135.84,100% OF CMS OPPS Rate,135.84,100% of CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,510.9,60% of total billed charges,109.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,109.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,119.44,100% OF CMS OPPS RATE,135.84,100% OF CMS OPPS Rate,596.05,70% of total billed charges,135.84,100% OF CMS OPPS Rate,163.01,120% of CMS OPPS RATE,613.08,Pays at 72% of billed charges with lesser of charges applied,613.08,Pays at 72% of billed charges with lesser of charges applied,613.08,Pays at 72% of billed charges with lesser of charges applied,613.08,Pays at 72% of billed charges with lesser of charges applied,613.08,Pays at 72% of billed charges with lesser of charges applied,613.08,Pays at 72% of billed charges with lesser of charges applied,595.82,442% of BCBS Fee Schedule,595.82,442% of BCBS Fee Schedule,595.82,442% of BCBS Fee Schedule,595.82,442% of BCBS Fee Schedule,595.82,442% of BCBS Fee Schedule,595.82,442% of BCBS Fee Schedule,595.82,442% of BCBS Fee Schedule,595.82,442% of BCBS Fee Schedule,595.82,442% of BCBS Fee Schedule,649.74,100% of BCBS Fee Schedule,649.74,100% of BCBS Fee Schedule,649.74,100% of BCBS Fee Schedule,649.74,100% of BCBS Fee Schedule,649.74,100% of BCBS Fee Schedule,715.26,84% of total billed charges,715.26,84% of total billed charges,715.26,84% of total billed charges,596.05,70% of total billed charges,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,109.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,109.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,109.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,109.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,109.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,109.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,109.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,109.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,109.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,109.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,109.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,109.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,109.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,109.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,109.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,109.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,109.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,109.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,109.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,109.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,109.36,715.26,638.63
Outpatient Medical Services,ULTRASOUND,76930,US GUIDE (PERICARDIO),402,626.5,451.08,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,286.95,442% of BCBS Fee Schedule,N/A,Not Separately reimbursable,495.56,79.1% of total billed charges,N/A,Not Separately reimbursable,526.26,84% of total billed charges,526.26,84% of total billed charges,451.08,72% of total billed charges,N/A,Not Separately reimbursable,407.23,65% of total billed charges,N/A,Not Separately reimbursable,375.9,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,438.55,70% of total billed charges,626.5,100% OF CMS OPPS Rate with lesser of charges applied,626.5,120% of CMS OPPS RATE,451.08,Pays at 72% of billed charges with lesser of charges applied,451.08,Pays at 72% of billed charges with lesser of charges applied,451.08,Pays at 72% of billed charges with lesser of charges applied,451.08,Pays at 72% of billed charges with lesser of charges applied,451.08,Pays at 72% of billed charges with lesser of charges applied,451.08,Pays at 72% of billed charges with lesser of charges applied,286.95,442% of BCBS Fee Schedule,286.95,442% of BCBS Fee Schedule,286.95,442% of BCBS Fee Schedule,286.95,442% of BCBS Fee Schedule,286.95,442% of BCBS Fee Schedule,286.95,442% of BCBS Fee Schedule,286.95,442% of BCBS Fee Schedule,286.95,442% of BCBS Fee Schedule,286.95,442% of BCBS Fee Schedule,495.56,79.1% of total billed charges,495.56,79.1% of total billed charges,495.56,79.1% of total billed charges,495.56,79.1% of total billed charges,495.56,79.1% of total billed charges,526.26,84% of total billed charges,526.26,84% of total billed charges,526.26,84% of total billed charges,438.55,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,286.95,626.50,469.88
Outpatient Medical Services,ULTRASOUND,76946,US GUIDE (AMINOCENT),402,666.75,480.06,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,285.75,442% of BCBS Fee Schedule,N/A,Not Separately reimbursable,341.58,100% of BCBS Fee Schedule,N/A,Not Separately reimbursable,560.07,84% of total billed charges,560.07,84% of total billed charges,480.06,72% of total billed charges,N/A,Not Separately reimbursable,433.39,65% of total billed charges,N/A,Not Separately reimbursable,400.05,60% of total billed charges,41.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,41.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,17.31,100% OF CMS OPPS RATE,N/A,Not Separately reimbursable,466.73,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,480.06,Pays at 72% of billed charges with lesser of charges applied,480.06,Pays at 72% of billed charges with lesser of charges applied,480.06,Pays at 72% of billed charges with lesser of charges applied,480.06,Pays at 72% of billed charges with lesser of charges applied,480.06,Pays at 72% of billed charges with lesser of charges applied,480.06,Pays at 72% of billed charges with lesser of charges applied,285.75,442% of BCBS Fee Schedule,285.75,442% of BCBS Fee Schedule,285.75,442% of BCBS Fee Schedule,285.75,442% of BCBS Fee Schedule,285.75,442% of BCBS Fee Schedule,285.75,442% of BCBS Fee Schedule,285.75,442% of BCBS Fee Schedule,285.75,442% of BCBS Fee Schedule,285.75,442% of BCBS Fee Schedule,341.58,100% of BCBS Fee Schedule,341.58,100% of BCBS Fee Schedule,341.58,100% of BCBS Fee Schedule,341.58,100% of BCBS Fee Schedule,341.58,100% of BCBS Fee Schedule,560.07,84% of total billed charges,560.07,84% of total billed charges,560.07,84% of total billed charges,466.73,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,41.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,41.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,41.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,41.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,41.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,41.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,41.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,41.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,41.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,41.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,41.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,41.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,41.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,41.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,41.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,41.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,41.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,41.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,41.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,41.10,100% of CA Medicaid Fee Schedule with lesser of charges applied,17.31,560.07,500.06
Outpatient Medical Services,ULTRASOUND,76816,US OB F/U OR REPEAT,402,516,371.52,Pays at 72% of billed charges with lesser of charges applied,135.85,100% OF CMS OPPS Rate,180.47,442% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,249.59,100% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,433.44,84% of total billed charges,433.44,84% of total billed charges,371.52,72% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% of CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,309.6,60% of total billed charges,74.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,83.01,100% OF CMS OPPS RATE,135.85,100% OF CMS OPPS Rate,361.2,70% of total billed charges,135.85,100% OF CMS OPPS Rate,163.02,120% of CMS OPPS RATE,371.52,Pays at 72% of billed charges with lesser of charges applied,371.52,Pays at 72% of billed charges with lesser of charges applied,371.52,Pays at 72% of billed charges with lesser of charges applied,371.52,Pays at 72% of billed charges with lesser of charges applied,371.52,Pays at 72% of billed charges with lesser of charges applied,371.52,Pays at 72% of billed charges with lesser of charges applied,180.47,442% of BCBS Fee Schedule,180.47,442% of BCBS Fee Schedule,180.47,442% of BCBS Fee Schedule,180.47,442% of BCBS Fee Schedule,180.47,442% of BCBS Fee Schedule,180.47,442% of BCBS Fee Schedule,180.47,442% of BCBS Fee Schedule,180.47,442% of BCBS Fee Schedule,180.47,442% of BCBS Fee Schedule,249.59,100% of BCBS Fee Schedule,249.59,100% of BCBS Fee Schedule,249.59,100% of BCBS Fee Schedule,249.59,100% of BCBS Fee Schedule,249.59,100% of BCBS Fee Schedule,433.44,84% of total billed charges,433.44,84% of total billed charges,433.44,84% of total billed charges,361.2,70% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,74.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.36,100% of CA Medicaid Fee Schedule with lesser of charges applied,74.36,433.44,387
Outpatient Medical Services,ULTRASOUND,76817,Transvaginal ultrasound of uterus,402,229.5,165.24,Pays at 72% of billed charges with lesser of charges applied,135.85,100% OF CMS OPPS Rate,229.5,BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,225.14,pays at 100% of bcbs fee schedule with lesser of charges applied,135.85,100% OF CMS OPPS Rate,192.78,84% of total billed charges,192.78,84% of total billed charges,165.24,72% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% of CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,137.7,60% of total billed charges,117.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,117.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,68.28,100% OF CMS OPPS RATE,135.85,100% OF CMS OPPS Rate,160.65,70% of total billed charges,135.85,100% OF CMS OPPS Rate,163.02,120% of CMS OPPS RATE,165.24,Pays at 72% of billed charges with lesser of charges applied,165.24,Pays at 72% of billed charges with lesser of charges applied,165.24,Pays at 72% of billed charges with lesser of charges applied,165.24,Pays at 72% of billed charges with lesser of charges applied,165.24,Pays at 72% of billed charges with lesser of charges applied,165.24,Pays at 72% of billed charges with lesser of charges applied,229.5,BCBS Fee Schedule,229.5,BCBS Fee Schedule,229.5,BCBS Fee Schedule,229.5,BCBS Fee Schedule,229.5,BCBS Fee Schedule,229.5,BCBS Fee Schedule,229.5,BCBS Fee Schedule,229.5,BCBS Fee Schedule,229.5,BCBS Fee Schedule,225.14,pays at 100% of bcbs fee schedule with lesser of charges applied,225.14,pays at 100% of bcbs fee schedule with lesser of charges applied,225.14,pays at 100% of bcbs fee schedule with lesser of charges applied,225.14,pays at 100% of bcbs fee schedule with lesser of charges applied,225.14,pays at 100% of bcbs fee schedule with lesser of charges applied,192.78,84% of total billed charges,192.78,84% of total billed charges,192.78,84% of total billed charges,160.65,70% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,117.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,117.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,117.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,117.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,117.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,117.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,117.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,117.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,117.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,117.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,117.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,117.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,117.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,117.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,117.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,117.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,117.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,117.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,117.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,117.86,100% of CA Medicaid Fee Schedule with lesser of charges applied,68.28,229.50,172.13
Outpatient Medical Services,ULTRASOUND,76856,Complete ultrasound of the pelvis,402,802.75,577.98,Pays at 72% of billed charges with lesser of charges applied,135.84,100% OF CMS OPPS Rate,288.14,442% of BCBS Fee Schedule,135.84,100% OF CMS OPPS Rate,341.58,100% of BCBS Fee Schedule,135.84,100% OF CMS OPPS Rate,674.31,84% of total billed charges,674.31,84% of total billed charges,577.98,72% of total billed charges,135.84,100% OF CMS OPPS Rate,135.84,100% of CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,481.65,60% of total billed charges,97.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,87.39,100% OF CMS OPPS RATE,135.84,100% OF CMS OPPS Rate,561.93,70% of total billed charges,135.84,100% OF CMS OPPS Rate,163.01,120% of CMS OPPS RATE,577.98,Pays at 72% of billed charges with lesser of charges applied,577.98,Pays at 72% of billed charges with lesser of charges applied,577.98,Pays at 72% of billed charges with lesser of charges applied,577.98,Pays at 72% of billed charges with lesser of charges applied,577.98,Pays at 72% of billed charges with lesser of charges applied,577.98,Pays at 72% of billed charges with lesser of charges applied,288.14,442% of BCBS Fee Schedule,288.14,442% of BCBS Fee Schedule,288.14,442% of BCBS Fee Schedule,288.14,442% of BCBS Fee Schedule,288.14,442% of BCBS Fee Schedule,288.14,442% of BCBS Fee Schedule,288.14,442% of BCBS Fee Schedule,288.14,442% of BCBS Fee Schedule,288.14,442% of BCBS Fee Schedule,341.58,100% of BCBS Fee Schedule,341.58,100% of BCBS Fee Schedule,341.58,100% of BCBS Fee Schedule,341.58,100% of BCBS Fee Schedule,341.58,100% of BCBS Fee Schedule,674.31,84% of total billed charges,674.31,84% of total billed charges,674.31,84% of total billed charges,561.93,70% of total billed charges,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,97.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,87.39,674.31,602.06
Outpatient Medical Services,ULTRASOUND,76998,US INTRAOPERATIVE,402,626.5,451.08,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,426.31,442% of BCBS Fee Schedule,N/A,Not Separately reimbursable,495.56,79.1% of total billed charges,N/A,Not Separately reimbursable,526.26,84% of total billed charges,526.26,84% of total billed charges,451.08,72% of total billed charges,N/A,Not Separately reimbursable,407.23,65% of total billed charges,N/A,Not Separately reimbursable,375.9,60% of total billed charges,167.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,167.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,438.55,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,451.08,Pays at 72% of billed charges with lesser of charges applied,451.08,Pays at 72% of billed charges with lesser of charges applied,451.08,Pays at 72% of billed charges with lesser of charges applied,451.08,Pays at 72% of billed charges with lesser of charges applied,451.08,Pays at 72% of billed charges with lesser of charges applied,451.08,Pays at 72% of billed charges with lesser of charges applied,426.31,442% of BCBS Fee Schedule,426.31,442% of BCBS Fee Schedule,426.31,442% of BCBS Fee Schedule,426.31,442% of BCBS Fee Schedule,426.31,442% of BCBS Fee Schedule,426.31,442% of BCBS Fee Schedule,426.31,442% of BCBS Fee Schedule,426.31,442% of BCBS Fee Schedule,426.31,442% of BCBS Fee Schedule,495.56,79.1% of total billed charges,495.56,79.1% of total billed charges,495.56,79.1% of total billed charges,495.56,79.1% of total billed charges,495.56,79.1% of total billed charges,526.26,84% of total billed charges,526.26,84% of total billed charges,526.26,84% of total billed charges,438.55,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,167.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,167.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,167.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,167.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,167.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,167.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,167.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,167.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,167.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,167.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,167.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,167.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,167.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,167.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,167.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,167.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,167.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,167.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,167.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,167.18,100% of CA Medicaid Fee Schedule with lesser of charges applied,167.18,526.26,469.88
Outpatient Medical Services,ULTRASOUND,76819,Fetal biophysical profile without non-stress test,402,285.5,205.56,Pays at 72% of billed charges with lesser of charges applied,135.84,100% OF CMS OPPS Rate,285.5,BCBS Fee Schedule,135.84,100% OF CMS OPPS Rate,280.08,pays at 100% of bcbs fee schedule with lesser of charges applied,135.84,100% OF CMS OPPS Rate,239.82,84% of total billed charges,239.82,84% of total billed charges,205.56,72% of total billed charges,135.84,100% OF CMS OPPS Rate,135.84,100% of CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,171.3,60% of total billed charges,110.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,57.13,100% OF CMS OPPS RATE,135.84,100% OF CMS OPPS Rate,199.85,70% of total billed charges,135.84,100% OF CMS OPPS Rate,163.01,120% of CMS OPPS RATE,205.56,Pays at 72% of billed charges with lesser of charges applied,205.56,Pays at 72% of billed charges with lesser of charges applied,205.56,Pays at 72% of billed charges with lesser of charges applied,205.56,Pays at 72% of billed charges with lesser of charges applied,205.56,Pays at 72% of billed charges with lesser of charges applied,205.56,Pays at 72% of billed charges with lesser of charges applied,285.5,BCBS Fee Schedule,285.5,BCBS Fee Schedule,285.5,BCBS Fee Schedule,285.5,BCBS Fee Schedule,285.5,BCBS Fee Schedule,285.5,BCBS Fee Schedule,285.5,BCBS Fee Schedule,285.5,BCBS Fee Schedule,285.5,BCBS Fee Schedule,280.08,pays at 100% of bcbs fee schedule with lesser of charges applied,280.08,pays at 100% of bcbs fee schedule with lesser of charges applied,280.08,pays at 100% of bcbs fee schedule with lesser of charges applied,280.08,pays at 100% of bcbs fee schedule with lesser of charges applied,280.08,pays at 100% of bcbs fee schedule with lesser of charges applied,239.82,84% of total billed charges,239.82,84% of total billed charges,239.82,84% of total billed charges,199.85,70% of total billed charges,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,110.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,110.31,100% of CA Medicaid Fee Schedule with lesser of charges applied,57.13,285.50,214.13
Outpatient Medical Services,ULTRASOUND,76800,US SPINAL CANAL,402,626.5,451.08,Pays at 72% of billed charges with lesser of charges applied,135.85,100% OF CMS OPPS Rate,270.5,442% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,319.19,100% of BCBS Fee Schedule,135.85,100% OF CMS OPPS Rate,526.26,84% of total billed charges,526.26,84% of total billed charges,451.08,72% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% of CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,375.9,60% of total billed charges,116.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,115.26,100% OF CMS OPPS RATE,135.85,100% OF CMS OPPS Rate,438.55,70% of total billed charges,135.85,100% OF CMS OPPS Rate,163.02,120% of CMS OPPS RATE,451.08,Pays at 72% of billed charges with lesser of charges applied,451.08,Pays at 72% of billed charges with lesser of charges applied,451.08,Pays at 72% of billed charges with lesser of charges applied,451.08,Pays at 72% of billed charges with lesser of charges applied,451.08,Pays at 72% of billed charges with lesser of charges applied,451.08,Pays at 72% of billed charges with lesser of charges applied,270.5,442% of BCBS Fee Schedule,270.5,442% of BCBS Fee Schedule,270.5,442% of BCBS Fee Schedule,270.5,442% of BCBS Fee Schedule,270.5,442% of BCBS Fee Schedule,270.5,442% of BCBS Fee Schedule,270.5,442% of BCBS Fee Schedule,270.5,442% of BCBS Fee Schedule,270.5,442% of BCBS Fee Schedule,319.19,100% of BCBS Fee Schedule,319.19,100% of BCBS Fee Schedule,319.19,100% of BCBS Fee Schedule,319.19,100% of BCBS Fee Schedule,319.19,100% of BCBS Fee Schedule,526.26,84% of total billed charges,526.26,84% of total billed charges,526.26,84% of total billed charges,438.55,70% of total billed charges,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,135.85,100% OF CMS OPPS Rate,116.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,116.16,100% of CA Medicaid Fee Schedule with lesser of charges applied,115.26,526.26,469.88
Outpatient Medical Services,ULTRASOUND,76805,Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus,402,688,495.36,Pays at 72% of billed charges with lesser of charges applied,135.84,100% OF CMS OPPS Rate,385.07,442% of BCBS Fee Schedule,135.84,100% OF CMS OPPS Rate,469.12,100% of BCBS Fee Schedule,135.84,100% OF CMS OPPS Rate,577.92,84% of total billed charges,577.92,84% of total billed charges,495.36,72% of total billed charges,135.84,100% OF CMS OPPS Rate,135.84,100% of CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,412.8,60% of total billed charges,135.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,105.9,100% OF CMS OPPS RATE,135.84,100% OF CMS OPPS Rate,481.6,70% of total billed charges,135.84,100% OF CMS OPPS Rate,163.01,120% of CMS OPPS RATE,495.36,Pays at 72% of billed charges with lesser of charges applied,495.36,Pays at 72% of billed charges with lesser of charges applied,495.36,Pays at 72% of billed charges with lesser of charges applied,495.36,Pays at 72% of billed charges with lesser of charges applied,495.36,Pays at 72% of billed charges with lesser of charges applied,495.36,Pays at 72% of billed charges with lesser of charges applied,385.07,442% of BCBS Fee Schedule,385.07,442% of BCBS Fee Schedule,385.07,442% of BCBS Fee Schedule,385.07,442% of BCBS Fee Schedule,385.07,442% of BCBS Fee Schedule,385.07,442% of BCBS Fee Schedule,385.07,442% of BCBS Fee Schedule,385.07,442% of BCBS Fee Schedule,385.07,442% of BCBS Fee Schedule,469.12,100% of BCBS Fee Schedule,469.12,100% of BCBS Fee Schedule,469.12,100% of BCBS Fee Schedule,469.12,100% of BCBS Fee Schedule,469.12,100% of BCBS Fee Schedule,577.92,84% of total billed charges,577.92,84% of total billed charges,577.92,84% of total billed charges,481.6,70% of total billed charges,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.29,100% of CA Medicaid Fee Schedule with lesser of charges applied,105.90,577.92,516
Outpatient Medical Services,ULTRASOUND,76970,US F/U STUDY,402,285.5,205.56,Pays at 72% of billed charges with lesser of charges applied,N/A,Not Separately reimbursable,196.56,442% of BCBS Fee Schedule,N/A,Not Separately reimbursable,225.83,79.1% of total billed charges,N/A,Not Separately reimbursable,239.82,84% of total billed charges,239.82,84% of total billed charges,205.56,72% of total billed charges,N/A,Not Separately reimbursable,185.58,65% of total billed charges,N/A,Not Separately reimbursable,171.3,60% of total billed charges,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,199.85,70% of total billed charges,285.5,100% OF CMS OPPS Rate with lesser of charges applied,285.5,120% of CMS OPPS RATE,205.56,Pays at 72% of billed charges with lesser of charges applied,205.56,Pays at 72% of billed charges with lesser of charges applied,205.56,Pays at 72% of billed charges with lesser of charges applied,205.56,Pays at 72% of billed charges with lesser of charges applied,205.56,Pays at 72% of billed charges with lesser of charges applied,205.56,Pays at 72% of billed charges with lesser of charges applied,196.56,442% of BCBS Fee Schedule,196.56,442% of BCBS Fee Schedule,196.56,442% of BCBS Fee Schedule,196.56,442% of BCBS Fee Schedule,196.56,442% of BCBS Fee Schedule,196.56,442% of BCBS Fee Schedule,196.56,442% of BCBS Fee Schedule,196.56,442% of BCBS Fee Schedule,196.56,442% of BCBS Fee Schedule,225.83,79.1% of total billed charges,225.83,79.1% of total billed charges,225.83,79.1% of total billed charges,225.83,79.1% of total billed charges,225.83,79.1% of total billed charges,239.82,84% of total billed charges,239.82,84% of total billed charges,239.82,84% of total billed charges,199.85,70% of total billed charges,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not Separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,N/A,Not separately reimbursable,171.30,285.50,214.13
Outpatient Medical Services,ULTRASOUND,76872,Transrectal ultrasound,402,600,432,Pays at 72% of billed charges with lesser of charges applied,135.84,100% OF CMS OPPS Rate,256.01,442% of BCBS Fee Schedule,135.84,100% OF CMS OPPS Rate,414.54,100% of BCBS Fee Schedule,135.84,100% OF CMS OPPS Rate,504,84% of total billed charges,504,84% of total billed charges,432,72% of total billed charges,135.84,100% OF CMS OPPS Rate,135.84,100% of CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,360,60% of total billed charges,97.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,159.28,100% OF CMS OPPS RATE,135.84,100% OF CMS OPPS Rate,420,70% of total billed charges,135.84,100% OF CMS OPPS Rate,163.01,120% of CMS OPPS RATE,432,Pays at 72% of billed charges with lesser of charges applied,432,Pays at 72% of billed charges with lesser of charges applied,432,Pays at 72% of billed charges with lesser of charges applied,432,Pays at 72% of billed charges with lesser of charges applied,432,Pays at 72% of billed charges with lesser of charges applied,432,Pays at 72% of billed charges with lesser of charges applied,256.01,442% of BCBS Fee Schedule,256.01,442% of BCBS Fee Schedule,256.01,442% of BCBS Fee Schedule,256.01,442% of BCBS Fee Schedule,256.01,442% of BCBS Fee Schedule,256.01,442% of BCBS Fee Schedule,256.01,442% of BCBS Fee Schedule,256.01,442% of BCBS Fee Schedule,256.01,442% of BCBS Fee Schedule,414.54,100% of BCBS Fee Schedule,414.54,100% of BCBS Fee Schedule,414.54,100% of BCBS Fee Schedule,414.54,100% of BCBS Fee Schedule,414.54,100% of BCBS Fee Schedule,504,84% of total billed charges,504,84% of total billed charges,504,84% of total billed charges,420,70% of total billed charges,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,135.84,100% OF CMS OPPS Rate,97.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.04,100% of CA Medicaid Fee Schedule with lesser of charges applied,97.04,504.00,450
Outpatient Medical Services,LAB,81000,Manual urinalysis test with examination using microscope,300,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,OUTPATIENT SERVICES,29826,Shaving of shoulder bone using an endoscope,360,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,OUTPATIENT SERVICES,29881,Removal of one knee cartilage using an endoscope,360,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,OUTPATIENT SERVICES,42820,Removal of tonsils and adenoid glands patient younger than age 12,360,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,OUTPATIENT SERVICES,45380,Biopsy of large bowel using an endoscope,360,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,OUTPATIENT SERVICES,45391,Ultrasound examination of lower large bowel using an endoscope,360,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,OUTPATIENT SERVICES,47562,Removal of gallbladder using an endoscope,360,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,OUTPATIENT SERVICES,49505,Repair of groin hernia patient age 5 or older,360,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,OUTPATIENT SERVICES,55700,Biopsy of prostate gland,360,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,OUTPATIENT SERVICES,55866,Surgical removal of prostate and surrounding lymph nodes using an endoscope,360,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,OUTPATIENT SERVICES,59400,"Routine obstetric care for vaginal delivery, including pre-and post-delivery care",720,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,OUTPATIENT SERVICES,59510,"Routine obstetric care for cesarean delivery, including pre-and post-delivery care",720,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,OUTPATIENT SERVICES,59610,Routine obstetric care for vaginal delivery after prior cesarean delivery including pre-and post-delivery care,720,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,OUTPATIENT SERVICES,62323,Injection of substance into spinal canal of lower back or sacrum using imaging guidanc,360,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,OUTPATIENT SERVICES,62322,Injection of substance into spinal canal of lower back or sacrum using imaging guidanc,360,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,OUTPATIENT SERVICES,64483,Injections of anesthetic and/or steroid drug into lower or sacral spine nerve root using imaging guidance,360,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,OUTPATIENT SERVICES,66821,Removal of recurring cataract in lens capsule using laser,360,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,OUTPATIENT SERVICES,66984,Removal of cataract with insertion of lens,360,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,ECCG,93000,"Electrocardiogram, routine, with interpretation and report",730,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,CARDIOLOGY,93452,Insertion of catheter into left heart for diagnosis,480,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Inpatient Medical Services,INPATIENT PROCEDURES,216,Cardiac valve and other major cardiothoracic procedures with cardiac catheterization with major complications or comorbidities,100,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Inpatient Medical Services,INPATIENT PROCEDURES,460,Spinal fusion except cervical without major comorbid conditions or complications,100,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Inpatient Medical Services,INPATIENT PROCEDURES,470,Major joint replacement or reattachment of lower extremity without major comorbid conditions or complications,100,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Inpatient Medical Services,INPATIENT PROCEDURES,473,Cervical spinal fusion without comorbid conditions or major comorbid conditions or complications,100,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Inpatient Medical Services,INPATIENT PROCEDURES,743,Uterine and adnexa procedures for non-malignancy without comorbid conditions or major comorbid conditions or complications,100,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A