hospital_name,last_updated_on,version,hospital_location,hospital_address,license_number|CO,"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.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Rio Grande Hospital,2024-04-01,2.0.0,"310 Country Road 14 Del Norte, CO 81132",Rio Grande Hospital,841276376,TRUE,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SERVICE DESCRIPTION,CATEGORY,BILLING MSDRG | CPT | HCPCS,ITEM/SERVICE DESCRIPTION,BILLING REVENUE CODE,GROSS CHARGES,AETNA PLAN,REIMBURSEMENT METHOD,AETNA MEDICAL RENTAL COFINITY PLAN,REIMBURSEMENT METHOD,AETNA MEDICARE PLAN,REIMBURSEMENT METHOD,APOSTROPHE PLAN,REIMBURSEMENT METHOD,BLUE CROSS PLAN,REIMBURSEMENT METHOD,BLUE CROSS MEDICARE PLAN,REIMBURSEMENT METHOD,CIGNA PLAN,REIMBURSEMENT METHOD,COFINITY PLAN,REIMBURSEMENT METHOD,HUMANA CHOICECARE PLAN,REIMBURSEMENT METHOD,HUMANA MEDICARE PFFS PLAN,REIMBURSEMENT METHOD,HUMANA MEDICARE PPO PLAN,REIMBURSEMENT METHOD,MEDICARE PLAN,REIMBURSEMENT METHOD,SLVHMO FRIDAY PLAN,REIMBURSEMENT METHOD,UHC PLAN,REIMBURSEMENT METHOD,De-Identified Minimum Negotiated Rate,De-Identified Maximum Negotiated Rate,DISCOUNTED CASH PRICE
Outpatient Medical Services,Emergency Services,10061,Incision & Drainage multi/complex-Fac,450,$421.23 ,$379.11 ,90% of total billed charges for outpatient setting,$391.74 ,93% of total billed charges for outpatient setting,$160.07 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$160.07 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$358.05 ,85% of total billed charges for outpatient setting,$160.07 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$342.88 ,81.4% of total billed charges for outpatient setting,$379.11 ,90% of total billed charges for outpatient setting,$379.11 ,90% of total billed charges for outpatient setting,$160.07 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$160.07 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$160.07 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$315.92 ,75% of total billed charges for outpatient setting,$358.05 ,85% of total billed charges for outpatient setting,$160.07 ,$391.74 ,$315.92 
Clinic Medical Services,Creede family practice clinic,11042,Debridement - Skin 20 Sq cm or<,521,$498.54 ,$448.69 ,90% of total billed charges for outpatient setting,$463.64 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$423.76 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$405.81 ,81.4% of total billed charges for outpatient setting,$448.69 ,90% of total billed charges for outpatient setting,$448.69 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$373.91 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$185.84 ,$463.64 ,$373.91 
Clinic Medical Services,Monte Vista Medical Clinic,11042,Debridement - Skin 20 Sq cm or<,521,$498.54 ,$448.69 ,90% of total billed charges for outpatient setting,$463.64 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$423.76 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$405.81 ,81.4% of total billed charges for outpatient setting,$448.69 ,90% of total billed charges for outpatient setting,$448.69 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$373.91 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$185.84 ,$463.64 ,$373.91 
Clinic Medical Services,Rio Grande Hospital Clinic,11042,Debridement - Skin 20 Sq cm or<,521,$498.54 ,$448.69 ,90% of total billed charges for outpatient setting,$463.64 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$423.76 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$405.81 ,81.4% of total billed charges for outpatient setting,$448.69 ,90% of total billed charges for outpatient setting,$448.69 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$373.91 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$185.84 ,$463.64 ,$373.91 
Clinic Medical Services,South Fork Clinic,11042,Debridement - Skin 20 Sq cm or<,521,$498.54 ,$448.69 ,90% of total billed charges for outpatient setting,$463.64 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$423.76 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$405.81 ,81.4% of total billed charges for outpatient setting,$448.69 ,90% of total billed charges for outpatient setting,$448.69 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$373.91 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$185.84 ,$463.64 ,$373.91 
Outpatient Medical Services,Wound Care,11042,Wound Care Debridement sq tissue 20 cm2/< FAC,761,$389.67 ,$350.70 ,90% of total billed charges for outpatient setting,$362.39 ,93% of total billed charges for outpatient setting,$148.07 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$148.07 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,,Not seperately reimbursable per contract terms,$148.07 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$317.19 ,81.4% of total billed charges for outpatient setting,$350.70 ,90% of total billed charges for outpatient setting,$350.70 ,90% of total billed charges for outpatient setting,$148.07 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$148.07 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$148.07 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$292.25 ,75% of total billed charges for outpatient setting,$331.22 ,85% of total billed charges for outpatient setting,$148.07 ,$362.39 ,$292.25 
Outpatient Medical Services,Wound Care,11042,Wound Care Debridement sq tissue 20 cm2/< PRO,982,$324.73 ,$67.16 ,130% of 2011 CMS RBRVS fee schedule,$67.16 ,130% of 2011 CMS RBRVS fee schedule,$60.41 ,100% of CMS RBRVS fee schedule for physician setting,$60.41 ,100% of CMS RBRVS fee schedule for physician setting,$75.54 ,119% CMS RBRVS fee schedule for physician setting,$60.41 ,100% of CMS RBRVS fee schedule for physician setting,$60.41 ,100% of CMS RBRVS fee schedule for physician setting,$292.26 ,90% of total billed charges for physician setting,$60.41 ,100% of CMS RBRVS fee schedule for physician setting,$60.41 ,100% of CMS RBRVS fee schedule for physician setting,$60.41 ,100% of CMS RBRVS fee schedule for physician setting,$60.41 ,100% of CMS RBRVS fee schedule for physician setting,$86.23 ,100% of SLVHMO physician fee schedule,$60.41 ,100% of CMS RBRVS fee schedule for physician setting,$60.41 ,$292.26 ,$243.55 
Outpatient Medical Services,Wound Care,11043,Wound Care Debridement sq tissue 20 cm2/< FAC,761,$487.09 ,$438.38 ,90% of total billed charges for outpatient setting,$452.99 ,93% of total billed charges for outpatient setting,$185.09 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$185.09 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,,Not seperately reimbursable per contract terms,$185.09 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$396.49 ,81.4% of total billed charges for outpatient setting,$438.38 ,90% of total billed charges for outpatient setting,$438.38 ,90% of total billed charges for outpatient setting,$185.09 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$185.09 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$185.09 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$365.32 ,75% of total billed charges for outpatient setting,$414.03 ,85% of total billed charges for outpatient setting,$185.09 ,$452.99 ,$365.32 
Outpatient Medical Services,Wound Care,11043,Wound Care Debridement sq tissue 20 cm2/< PRO,982,$438.39 ,$159.47 ,130% of 2011 CMS RBRVS fee schedule,$159.47 ,130% of 2011 CMS RBRVS fee schedule,$154.34 ,100% of CMS RBRVS fee schedule for physician setting,$154.34 ,100% of CMS RBRVS fee schedule for physician setting,$192.16 ,119% CMS RBRVS fee schedule for physician setting,$154.34 ,100% of CMS RBRVS fee schedule for physician setting,$154.34 ,100% of CMS RBRVS fee schedule for physician setting,$394.55 ,90% of total billed charges for physician setting,$154.34 ,100% of CMS RBRVS fee schedule for physician setting,$154.34 ,100% of CMS RBRVS fee schedule for physician setting,$154.34 ,100% of CMS RBRVS fee schedule for physician setting,$154.34 ,100% of CMS RBRVS fee schedule for physician setting,$215.58 ,100% of SLVHMO physician fee schedule,$154.34 ,100% of CMS RBRVS fee schedule for physician setting,$154.34 ,$394.55 ,$328.79 
Outpatient Medical Services,Emergency Services,12001,"Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities",450,$270.30 ,$243.27 ,90% of total billed charges for outpatient setting,$251.38 ,93% of total billed charges for outpatient setting,$102.71 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$102.71 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$229.76 ,85% of total billed charges for outpatient setting,$102.71 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$220.02 ,81.4% of total billed charges for outpatient setting,$243.27 ,90% of total billed charges for outpatient setting,$243.27 ,90% of total billed charges for outpatient setting,$102.71 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$102.71 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$102.71 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$202.73 ,75% of total billed charges for outpatient setting,$229.76 ,85% of total billed charges for outpatient setting,$102.71 ,$251.38 ,$202.73 
Outpatient Medical Services,Emergency Services,12001,"Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities",981,$158.79 ,$59.58 ,130% of 2011 CMS RBRVS fee schedule,$59.58 ,130% of 2011 CMS RBRVS fee schedule,$44.94 ,100% of CMS RBRVS fee schedule for physician setting,$44.94 ,100% of CMS RBRVS fee schedule for physician setting,$55.66 ,119% CMS RBRVS fee schedule for physician setting,$44.94 ,100% of CMS RBRVS fee schedule for physician setting,$44.94 ,100% of CMS RBRVS fee schedule for physician setting,$142.91 ,90% of total billed charges for physician setting,$44.94 ,100% of CMS RBRVS fee schedule for physician setting,$44.94 ,100% of CMS RBRVS fee schedule for physician setting,$44.94 ,100% of CMS RBRVS fee schedule for physician setting,$44.94 ,100% of CMS RBRVS fee schedule for physician setting,$71.86 ,100% of SLVHMO physician fee schedule,$44.94 ,100% of CMS RBRVS fee schedule for physician setting,$44.94 ,$142.91 ,$119.09 
Outpatient Medical Services,Emergency Services,12011,"Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes",450,$270.30 ,$243.27 ,90% of total billed charges for outpatient setting,$251.38 ,93% of total billed charges for outpatient setting,$102.71 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$102.71 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$229.76 ,85% of total billed charges for outpatient setting,$102.71 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$220.02 ,81.4% of total billed charges for outpatient setting,$243.27 ,90% of total billed charges for outpatient setting,$243.27 ,90% of total billed charges for outpatient setting,$102.71 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$102.71 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$102.71 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$202.73 ,75% of total billed charges for outpatient setting,$229.76 ,85% of total billed charges for outpatient setting,$102.71 ,$251.38 ,$202.73 
Clinic Medical Services,Creede family practice clinic,17000,Destruction of pre-cancerous lesion,521,$155.43 ,$139.89 ,90% of total billed charges for outpatient setting,$144.55 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$132.12 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$126.52 ,81.4% of total billed charges for outpatient setting,$139.89 ,90% of total billed charges for outpatient setting,$139.89 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$116.57 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$116.57 ,$185.84 ,$116.57 
Clinic Medical Services,Monte Vista Medical Clinic,17000,Destruction of pre-cancerous lesion,521,$155.43 ,$139.89 ,90% of total billed charges for outpatient setting,$144.55 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$132.12 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$126.52 ,81.4% of total billed charges for outpatient setting,$139.89 ,90% of total billed charges for outpatient setting,$139.89 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$116.57 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$116.57 ,$185.84 ,$116.57 
Clinic Medical Services,Rio Grande Hospital Clinic,17000,Destruction of pre-cancerous lesion,521,$155.43 ,$139.89 ,90% of total billed charges for outpatient setting,$144.55 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$132.12 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$126.52 ,81.4% of total billed charges for outpatient setting,$139.89 ,90% of total billed charges for outpatient setting,$139.89 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$116.57 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$116.57 ,$185.84 ,$116.57 
Clinic Medical Services,South Fork Clinic,17000,Destruction of pre-cancerous lesion,521,$155.43 ,$139.89 ,90% of total billed charges for outpatient setting,$144.55 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$132.12 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$126.52 ,81.4% of total billed charges for outpatient setting,$139.89 ,90% of total billed charges for outpatient setting,$139.89 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$116.57 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$116.57 ,$185.84 ,$116.57 
Clinic Medical Services,Creede family practice clinic,20552,Therapeutic Inj Trigger Point(s);1or,521,$167.81 ,$151.03 ,90% of total billed charges for outpatient setting,$156.06 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$142.64 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$136.60 ,81.4% of total billed charges for outpatient setting,$151.03 ,90% of total billed charges for outpatient setting,$151.03 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$125.86 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$125.86 ,$185.84 ,$125.86 
Clinic Medical Services,Monte Vista Medical Clinic,20552,Therapeutic Inj Trigger Point(s);1or,521,$167.81 ,$151.03 ,90% of total billed charges for outpatient setting,$156.06 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$142.64 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$136.60 ,81.4% of total billed charges for outpatient setting,$151.03 ,90% of total billed charges for outpatient setting,$151.03 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$125.86 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$125.86 ,$185.84 ,$125.86 
Clinic Medical Services,Rio Grande Hospital Clinic,20552,Therapeutic Inj Trigger Point(s);1or,521,$167.81 ,$151.03 ,90% of total billed charges for outpatient setting,$156.06 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$142.64 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$136.60 ,81.4% of total billed charges for outpatient setting,$151.03 ,90% of total billed charges for outpatient setting,$151.03 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$125.86 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$125.86 ,$185.84 ,$125.86 
Clinic Medical Services,South Fork Clinic,20552,Therapeutic Inj Trigger Point(s);1or,521,$167.81 ,$151.03 ,90% of total billed charges for outpatient setting,$156.06 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$142.64 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$136.60 ,81.4% of total billed charges for outpatient setting,$151.03 ,90% of total billed charges for outpatient setting,$151.03 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$125.86 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$125.86 ,$185.84 ,$125.86 
Clinic Medical Services,Creede family practice clinic,20610,Draining or injecting medication into a major joint/bursa without ultrasound,521,$257.92 ,$232.13 ,90% of total billed charges for outpatient setting,$239.87 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$219.23 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$209.95 ,81.4% of total billed charges for outpatient setting,$232.13 ,90% of total billed charges for outpatient setting,$232.13 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$193.44 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$185.84 ,$239.87 ,$193.44 
Clinic Medical Services,Monte Vista Medical Clinic,20610,Draining or injecting medication into a major joint/bursa without ultrasound,521,$257.92 ,$232.13 ,90% of total billed charges for outpatient setting,$239.87 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$219.23 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$209.95 ,81.4% of total billed charges for outpatient setting,$232.13 ,90% of total billed charges for outpatient setting,$232.13 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$193.44 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$185.84 ,$239.87 ,$193.44 
Clinic Medical Services,Rio Grande Hospital Clinic,20610,Draining or injecting medication into a major joint/bursa without ultrasound,521,$257.92 ,$232.13 ,90% of total billed charges for outpatient setting,$239.87 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$219.23 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$209.95 ,81.4% of total billed charges for outpatient setting,$232.13 ,90% of total billed charges for outpatient setting,$232.13 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$193.44 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$185.84 ,$239.87 ,$193.44 
Clinic Medical Services,South Fork Clinic,20610,Draining or injecting medication into a major joint/bursa without ultrasound,521,$257.92 ,$232.13 ,90% of total billed charges for outpatient setting,$239.87 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$219.23 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$209.95 ,81.4% of total billed charges for outpatient setting,$232.13 ,90% of total billed charges for outpatient setting,$232.13 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$193.44 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$185.84 ,$239.87 ,$193.44 
Outpatient Medical Services,Emergency Services,25500,FRX-radial shaft-clsd-w/o manip-,981,$636.72 ,$321.26 ,130% of 2011 CMS RBRVS fee schedule,$321.26 ,130% of 2011 CMS RBRVS fee schedule,$274.35 ,100% of CMS RBRVS fee schedule for physician setting,$274.35 ,100% of CMS RBRVS fee schedule for physician setting,$315.31 ,119% CMS RBRVS fee schedule for physician setting,$274.35 ,100% of CMS RBRVS fee schedule for physician setting,$274.35 ,100% of CMS RBRVS fee schedule for physician setting,$573.05 ,90% of total billed charges for physician setting,$274.35 ,100% of CMS RBRVS fee schedule for physician setting,$274.35 ,100% of CMS RBRVS fee schedule for physician setting,$274.35 ,100% of CMS RBRVS fee schedule for physician setting,$274.35 ,100% of CMS RBRVS fee schedule for physician setting,$93.42 ,100% of SLVHMO physician fee schedule,$274.35 ,100% of CMS RBRVS fee schedule for physician setting,$93.42 ,$573.05 ,$477.54 
Clinic Medical Services,Surgery Physician,26055,Tendon sheath repair,975,"$1,203.45 ",$405.68 ,130% of 2011 CMS RBRVS fee schedule,$405.68 ,130% of 2011 CMS RBRVS fee schedule,$305.53 ,100% of CMS RBRVS fee schedule for physician setting,$305.53 ,100% of CMS RBRVS fee schedule for physician setting,$361.18 ,119% CMS RBRVS fee schedule for physician setting,$305.53 ,100% of CMS RBRVS fee schedule for physician setting,$305.53 ,100% of CMS RBRVS fee schedule for physician setting,"$1,083.11 ",90% of total billed charges for physician setting,$305.53 ,100% of CMS RBRVS fee schedule for physician setting,$305.53 ,100% of CMS RBRVS fee schedule for physician setting,$305.53 ,100% of CMS RBRVS fee schedule for physician setting,$305.53 ,100% of CMS RBRVS fee schedule for physician setting,$359.30 ,100% of SLVHMO physician fee schedule,$305.53 ,100% of CMS RBRVS fee schedule for physician setting,$305.53 ,"$1,083.11 ",$902.59 
Outpatient Medical Services,Surgical Hospital,26055,Tendon sheath repair,360,"$2,097.12 ","$1,887.41 ",90% of total billed charges for outpatient setting,"$1,950.32 ",93% of total billed charges for outpatient setting,$796.91 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$796.91 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,782.55 ",85% of total billed charges for outpatient setting,$796.91 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,707.06 ",81.4% of total billed charges for outpatient setting,"$1,887.41 ",90% of total billed charges for outpatient setting,"$1,887.41 ",90% of total billed charges for outpatient setting,$796.91 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$796.91 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$796.91 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,572.84 ",75% of total billed charges for outpatient setting,"$1,782.55 ",85% of total billed charges for outpatient setting,$796.91 ,"$1,950.32 ","$1,572.84 "
Outpatient Medical Services,Surgical Hospital,27446,Repair of knee joint,360,"$4,329.73 ","$3,896.76 ",90% of total billed charges for outpatient setting,"$4,026.65 ",93% of total billed charges for outpatient setting,"$1,645.30 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,645.30 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$3,680.27 ",85% of total billed charges for outpatient setting,"$1,645.30 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$3,524.40 ",81.4% of total billed charges for outpatient setting,"$3,896.76 ",90% of total billed charges for outpatient setting,"$3,896.76 ",90% of total billed charges for outpatient setting,"$1,645.30 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,645.30 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,645.30 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$3,247.30 ",75% of total billed charges for outpatient setting,"$3,680.27 ",85% of total billed charges for outpatient setting,"$1,645.30 ","$4,026.65 ","$3,247.30 "
Outpatient Medical Services,Surgical Hospital,27447,Total Knee replacement,360,"$7,035.81 ","$6,332.23 ",90% of total billed charges for outpatient setting,"$6,543.30 ",93% of total billed charges for outpatient setting,"$2,673.61 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,673.61 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$5,980.44 ",85% of total billed charges for outpatient setting,"$2,673.61 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$5,727.15 ",81.4% of total billed charges for outpatient setting,"$6,332.23 ",90% of total billed charges for outpatient setting,"$6,332.23 ",90% of total billed charges for outpatient setting,"$2,673.61 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,673.61 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,673.61 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$5,276.86 ",75% of total billed charges for outpatient setting,"$5,980.44 ",85% of total billed charges for outpatient setting,"$2,673.61 ","$6,543.30 ","$5,276.86 "
Clinic Medical Services,Surgery Physician,29881,Surgery to remove of all or part of a torn meniscus in one compartment,975,"$1,269.70 ",$857.38 ,130% of 2011 CMS RBRVS fee schedule,$857.38 ,130% of 2011 CMS RBRVS fee schedule,$558.66 ,100% of CMS RBRVS fee schedule for physician setting,$558.66 ,100% of CMS RBRVS fee schedule for physician setting,$674.63 ,119% CMS RBRVS fee schedule for physician setting,$558.66 ,100% of CMS RBRVS fee schedule for physician setting,$558.66 ,100% of CMS RBRVS fee schedule for physician setting,"$1,142.73 ",90% of total billed charges for physician setting,$558.66 ,100% of CMS RBRVS fee schedule for physician setting,$558.66 ,100% of CMS RBRVS fee schedule for physician setting,$558.66 ,100% of CMS RBRVS fee schedule for physician setting,$558.66 ,100% of CMS RBRVS fee schedule for physician setting,"$1,006.04 ",100% of SLVHMO physician fee schedule,$558.66 ,100% of CMS RBRVS fee schedule for physician setting,$558.66 ,"$1,142.73 ",$952.28 
Outpatient Medical Services,Surgical Hospital,29881,Surgery to remove of all or part of a torn meniscus in one compartment,360,"$7,176.53 ","$6,458.88 ",90% of total billed charges for outpatient setting,"$6,674.17 ",93% of total billed charges for outpatient setting,"$2,727.08 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,727.08 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$6,100.05 ",85% of total billed charges for outpatient setting,"$2,727.08 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$5,841.70 ",81.4% of total billed charges for outpatient setting,"$6,458.88 ",90% of total billed charges for outpatient setting,"$6,458.88 ",90% of total billed charges for outpatient setting,"$2,727.08 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,727.08 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,727.08 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$5,382.40 ",75% of total billed charges for outpatient setting,"$6,100.05 ",85% of total billed charges for outpatient setting,"$2,727.08 ","$6,674.17 ","$5,382.40 "
Clinic Medical Services,Surgery Physician,43235,"Diagnostic examination of esophagus, stomach, and/or upper small bowel using an endoscope",975,$433.91 ,$193.80 ,130% of 2011 CMS RBRVS fee schedule,$193.80 ,130% of 2011 CMS RBRVS fee schedule,$122.67 ,100% of CMS RBRVS fee schedule for physician setting,$122.67 ,100% of CMS RBRVS fee schedule for physician setting,$152.65 ,119% CMS RBRVS fee schedule for physician setting,$122.67 ,100% of CMS RBRVS fee schedule for physician setting,$122.67 ,100% of CMS RBRVS fee schedule for physician setting,$390.52 ,90% of total billed charges for physician setting,$122.67 ,100% of CMS RBRVS fee schedule for physician setting,$122.67 ,100% of CMS RBRVS fee schedule for physician setting,$122.67 ,100% of CMS RBRVS fee schedule for physician setting,$122.67 ,100% of CMS RBRVS fee schedule for physician setting,$301.81 ,100% of SLVHMO physician fee schedule,$122.67 ,100% of CMS RBRVS fee schedule for physician setting,$122.67 ,$390.52 ,$325.43 
Outpatient Medical Services,Surgical Hospital,43235,"Diagnostic examination of esophagus, stomach, and/or upper small bowel using an endoscope",360,"$1,821.73 ","$1,639.56 ",90% of total billed charges for outpatient setting,"$1,694.21 ",93% of total billed charges for outpatient setting,$692.26 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$692.26 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,548.47 ",85% of total billed charges for outpatient setting,$692.26 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,482.89 ",81.4% of total billed charges for outpatient setting,"$1,639.56 ",90% of total billed charges for outpatient setting,"$1,639.56 ",90% of total billed charges for outpatient setting,$692.26 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$692.26 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$692.26 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,366.30 ",75% of total billed charges for outpatient setting,"$1,548.47 ",85% of total billed charges for outpatient setting,$692.26 ,"$1,694.21 ","$1,366.30 "
Clinic Medical Services,Surgery Physician,45378,Diagnostic examination of large bowel using an endoscope,975,$341.26 ,$289.68 ,130% of 2011 CMS RBRVS fee schedule,$289.68 ,130% of 2011 CMS RBRVS fee schedule,$184.27 ,100% of CMS RBRVS fee schedule for physician setting,$184.27 ,100% of CMS RBRVS fee schedule for physician setting,$230.47 ,119% CMS RBRVS fee schedule for physician setting,$184.27 ,100% of CMS RBRVS fee schedule for physician setting,$184.27 ,100% of CMS RBRVS fee schedule for physician setting,$307.13 ,90% of total billed charges for physician setting,$184.27 ,100% of CMS RBRVS fee schedule for physician setting,$184.27 ,100% of CMS RBRVS fee schedule for physician setting,$184.27 ,100% of CMS RBRVS fee schedule for physician setting,$184.27 ,100% of CMS RBRVS fee schedule for physician setting,$467.09 ,100% of SLVHMO physician fee schedule,$184.27 ,100% of CMS RBRVS fee schedule for physician setting,$184.27 ,$467.09 ,$255.95 
Outpatient Medical Services,Surgical Hospital,45378,Diagnostic examination of large bowel using an endoscope,360,"$1,674.76 ","$1,507.28 ",90% of total billed charges for outpatient setting,"$1,557.53 ",93% of total billed charges for outpatient setting,$636.41 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$636.41 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,423.55 ",85% of total billed charges for outpatient setting,$636.41 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,363.25 ",81.4% of total billed charges for outpatient setting,"$1,507.28 ",90% of total billed charges for outpatient setting,"$1,507.28 ",90% of total billed charges for outpatient setting,$636.41 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$636.41 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$636.41 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,256.07 ",75% of total billed charges for outpatient setting,"$1,423.55 ",85% of total billed charges for outpatient setting,$636.41 ,"$1,557.53 ","$1,256.07 "
Clinic Medical Services,Surgery Physician,45380,Biopsy of large bowel using an endoscope,975,"$1,137.54 ",$346.55 ,130% of 2011 CMS RBRVS fee schedule,$346.55 ,130% of 2011 CMS RBRVS fee schedule,$200.37 ,100% of CMS RBRVS fee schedule for physician setting,$200.37 ,100% of CMS RBRVS fee schedule for physician setting,$249.57 ,119% CMS RBRVS fee schedule for physician setting,$200.37 ,100% of CMS RBRVS fee schedule for physician setting,$200.37 ,100% of CMS RBRVS fee schedule for physician setting,"$1,023.79 ",90% of total billed charges for physician setting,$200.37 ,100% of CMS RBRVS fee schedule for physician setting,$200.37 ,100% of CMS RBRVS fee schedule for physician setting,$200.37 ,100% of CMS RBRVS fee schedule for physician setting,$200.37 ,100% of CMS RBRVS fee schedule for physician setting,$488.65 ,100% of SLVHMO physician fee schedule,$200.37 ,100% of CMS RBRVS fee schedule for physician setting,$200.37 ,"$1,023.79 ",$853.16 
Outpatient Medical Services,Surgical Hospital,45380,Biopsy of large bowel using an endoscope,360,"$2,190.60 ","$1,971.54 ",90% of total billed charges for outpatient setting,"$2,037.26 ",93% of total billed charges for outpatient setting,$832.43 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$832.43 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,862.01 ",85% of total billed charges for outpatient setting,$832.43 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,783.15 ",81.4% of total billed charges for outpatient setting,"$1,971.54 ",90% of total billed charges for outpatient setting,"$1,971.54 ",90% of total billed charges for outpatient setting,$832.43 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$832.43 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$832.43 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,642.95 ",75% of total billed charges for outpatient setting,"$1,862.01 ",85% of total billed charges for outpatient setting,$832.43 ,"$2,037.26 ","$1,642.95 "
Clinic Medical Services,Surgery Physician,45385,Removal of polyps or growths of large bowel using an endoscope,975,$751.23 ,$411.16 ,130% of 2011 CMS RBRVS fee schedule,$411.16 ,130% of 2011 CMS RBRVS fee schedule,$253.39 ,100% of CMS RBRVS fee schedule for physician setting,$253.39 ,100% of CMS RBRVS fee schedule for physician setting,$316.73 ,119% CMS RBRVS fee schedule for physician setting,$253.39 ,100% of CMS RBRVS fee schedule for physician setting,$253.39 ,100% of CMS RBRVS fee schedule for physician setting,$676.11 ,90% of total billed charges for physician setting,$253.39 ,100% of CMS RBRVS fee schedule for physician setting,$253.39 ,100% of CMS RBRVS fee schedule for physician setting,$253.39 ,100% of CMS RBRVS fee schedule for physician setting,$253.39 ,100% of CMS RBRVS fee schedule for physician setting,$531.76 ,100% of SLVHMO physician fee schedule,$253.39 ,100% of CMS RBRVS fee schedule for physician setting,$253.39 ,$676.11 ,$563.42 
Outpatient Medical Services,Surgical Hospital,45385,Removal of polyps or growths of large bowel using an endoscope,360,"$2,190.60 ","$1,971.54 ",90% of total billed charges for outpatient setting,"$2,037.26 ",93% of total billed charges for outpatient setting,$832.43 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$832.43 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,862.01 ",85% of total billed charges for outpatient setting,$832.43 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,783.15 ",81.4% of total billed charges for outpatient setting,"$1,971.54 ",90% of total billed charges for outpatient setting,"$1,971.54 ",90% of total billed charges for outpatient setting,$832.43 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$832.43 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$832.43 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,642.95 ",75% of total billed charges for outpatient setting,"$1,862.01 ",85% of total billed charges for outpatient setting,$832.43 ,"$2,037.26 ","$1,642.95 "
Outpatient Medical Services,Emergency Services,49083,Abominal Paracentesis facility,981,$295.09 ,$236.07 ,80% of total billed charges for physician setting,$236.07 ,80% of total billed charges for physician setting,$106.33 ,100% of CMS RBRVS fee schedule for physician setting,$106.33 ,100% of CMS RBRVS fee schedule for physician setting,$134.14 ,119% CMS RBRVS fee schedule for physician setting,$106.33 ,100% of CMS RBRVS fee schedule for physician setting,$106.33 ,100% of CMS RBRVS fee schedule for physician setting,$265.58 ,90% of total billed charges for physician setting,$106.33 ,100% of CMS RBRVS fee schedule for physician setting,$106.33 ,100% of CMS RBRVS fee schedule for physician setting,$106.33 ,100% of CMS RBRVS fee schedule for physician setting,$106.33 ,100% of CMS RBRVS fee schedule for physician setting,,Not seperately reimbursable per contract terms,$106.33 ,100% of CMS RBRVS fee schedule for physician setting,$106.33 ,$265.58 ,$221.32 
Outpatient Medical Services,Emergency Services,51702,Insertion of Foley urinary catheter-Fac,450,$198.23 ,$178.41 ,90% of total billed charges for outpatient setting,$184.35 ,93% of total billed charges for outpatient setting,$75.33 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$75.33 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$168.50 ,85% of total billed charges for outpatient setting,$75.33 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$161.36 ,81.4% of total billed charges for outpatient setting,$178.41 ,90% of total billed charges for outpatient setting,$178.41 ,90% of total billed charges for outpatient setting,$75.33 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$75.33 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$75.33 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$148.67 ,75% of total billed charges for outpatient setting,$168.50 ,85% of total billed charges for outpatient setting,$75.33 ,$184.35 ,$148.67 
Clinic Medical Services,Surgery Physician,64721,Release of the transverse carpal ligament,975,"$1,026.04 ",$561.65 ,130% of 2011 CMS RBRVS fee schedule,$561.65 ,130% of 2011 CMS RBRVS fee schedule,$453.78 ,100% of CMS RBRVS fee schedule for physician setting,$453.78 ,100% of CMS RBRVS fee schedule for physician setting,$536.45 ,119% CMS RBRVS fee schedule for physician setting,$453.78 ,100% of CMS RBRVS fee schedule for physician setting,$453.78 ,100% of CMS RBRVS fee schedule for physician setting,$923.44 ,90% of total billed charges for physician setting,$453.78 ,100% of CMS RBRVS fee schedule for physician setting,$453.78 ,100% of CMS RBRVS fee schedule for physician setting,$453.78 ,100% of CMS RBRVS fee schedule for physician setting,$453.78 ,100% of CMS RBRVS fee schedule for physician setting,$574.88 ,100% of SLVHMO physician fee schedule,$453.78 ,100% of CMS RBRVS fee schedule for physician setting,$453.78 ,$923.44 ,$769.53 
Outpatient Medical Services,Surgical Hospital,64721,Release of the transverse carpal ligament,360,"$3,057.83 ","$2,752.05 ",90% of total billed charges for outpatient setting,"$2,843.78 ",93% of total billed charges for outpatient setting,"$1,161.98 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,161.98 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,599.16 ",85% of total billed charges for outpatient setting,"$1,161.98 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,489.07 ",81.4% of total billed charges for outpatient setting,"$2,752.05 ",90% of total billed charges for outpatient setting,"$2,752.05 ",90% of total billed charges for outpatient setting,"$1,161.98 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,161.98 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,161.98 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,293.37 ",75% of total billed charges for outpatient setting,"$2,599.16 ",85% of total billed charges for outpatient setting,"$1,161.98 ","$2,843.78 ","$2,293.37 "
Outpatient Medical Services,Surgical Hospital,66821,Removal of recurring cataract in lens capsule using laser,360,$845.84 ,$761.26 ,90% of total billed charges for outpatient setting,$786.63 ,93% of total billed charges for outpatient setting,$321.42 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$321.42 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$718.96 ,85% of total billed charges for outpatient setting,$321.42 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$688.51 ,81.4% of total billed charges for outpatient setting,$761.26 ,90% of total billed charges for outpatient setting,$761.26 ,90% of total billed charges for outpatient setting,$321.42 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$321.42 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$321.42 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$634.38 ,75% of total billed charges for outpatient setting,$718.96 ,85% of total billed charges for outpatient setting,$321.42 ,$786.63 ,$634.38 
Outpatient Medical Services,Surgical Hospital,66984,Removal of cataract with insertion of lens,360,"$3,589.43 ","$3,230.49 ",90% of total billed charges for outpatient setting,"$3,338.17 ",93% of total billed charges for outpatient setting,"$1,363.98 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,363.98 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$3,051.02 ",85% of total billed charges for outpatient setting,"$1,363.98 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,921.80 ",81.4% of total billed charges for outpatient setting,"$3,230.49 ",90% of total billed charges for outpatient setting,"$3,230.49 ",90% of total billed charges for outpatient setting,"$1,363.98 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,363.98 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,363.98 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,692.07 ",75% of total billed charges for outpatient setting,"$3,051.02 ",85% of total billed charges for outpatient setting,"$1,363.98 ","$3,338.17 ","$2,692.07 "
Clinic Medical Services,Creede family practice clinic,69209,Remove impacted Cerumen w/o instru,521,$55.75 ,$50.18 ,90% of total billed charges for outpatient setting,$51.85 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$47.39 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$45.38 ,81.4% of total billed charges for outpatient setting,$50.18 ,90% of total billed charges for outpatient setting,$50.18 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$41.81 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$41.81 ,$185.84 ,$41.81 
Clinic Medical Services,Monte Vista Medical Clinic,69209,Remove impacted Cerumen w/o instru,521,$55.75 ,$50.18 ,90% of total billed charges for outpatient setting,$51.85 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$47.39 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$45.38 ,81.4% of total billed charges for outpatient setting,$50.18 ,90% of total billed charges for outpatient setting,$50.18 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$41.81 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$41.81 ,$185.84 ,$41.81 
Clinic Medical Services,Rio Grande Hospital Clinic,69209,Remove impacted Cerumen w/o instru,521,$55.75 ,$50.18 ,90% of total billed charges for outpatient setting,$51.85 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$47.39 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$45.38 ,81.4% of total billed charges for outpatient setting,$50.18 ,90% of total billed charges for outpatient setting,$50.18 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$41.81 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$41.81 ,$185.84 ,$41.81 
Clinic Medical Services,South Fork Clinic,69209,Remove impacted Cerumen w/o instru,521,$55.75 ,$50.18 ,90% of total billed charges for outpatient setting,$51.85 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$47.39 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$45.38 ,81.4% of total billed charges for outpatient setting,$50.18 ,90% of total billed charges for outpatient setting,$50.18 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$41.81 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$41.81 ,$185.84 ,$41.81 
Outpatient Medical Services,MRI,70336,MRI Temporomandibular Jts,610,"$2,016.04 ","$1,814.44 ",90% of total billed charges for outpatient setting,"$1,874.92 ",93% of total billed charges for outpatient setting,$766.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$766.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,713.63 ",85% of total billed charges for outpatient setting,$766.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,641.06 ",81.4% of total billed charges for outpatient setting,"$1,814.44 ",90% of total billed charges for outpatient setting,"$1,814.44 ",90% of total billed charges for outpatient setting,$766.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$766.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$766.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,512.03 ",75% of total billed charges for outpatient setting,"$1,613.00 ",100% UHC case rate for outpatient setting,$766.10 ,"$1,874.92 ","$1,512.03 "
Outpatient Medical Services,CT Scan,70450,CT scan head or brain without dye,350,"$1,281.70 ","$1,153.53 ",90% of total billed charges for outpatient setting,"$1,191.98 ",93% of total billed charges for outpatient setting,$487.05 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$487.05 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$500.00 ,100% of CT case rate,$487.05 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,043.30 ",81.4% of total billed charges for outpatient setting,"$1,153.53 ",90% of total billed charges for outpatient setting,"$1,153.53 ",90% of total billed charges for outpatient setting,$487.05 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$487.05 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$487.05 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$961.28 ,75% of total billed charges for outpatient setting,"$1,209.00 ",100% UHC case rate for outpatient setting,$487.05 ,"$1,209.00 ",$961.28 
Outpatient Medical Services,CT Scan,70460,CT Head w/ contrast,350,"$1,430.38 ","$1,287.34 ",90% of total billed charges for outpatient setting,"$1,330.25 ",93% of total billed charges for outpatient setting,$543.54 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$543.54 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$500.00 ,100% of CT case rate,$543.54 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,164.33 ",81.4% of total billed charges for outpatient setting,"$1,287.34 ",90% of total billed charges for outpatient setting,"$1,287.34 ",90% of total billed charges for outpatient setting,$543.54 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$543.54 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$543.54 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,072.79 ",75% of total billed charges for outpatient setting,"$1,209.00 ",100% UHC case rate for outpatient setting,$500.00 ,"$1,330.25 ","$1,072.79 "
Outpatient Medical Services,CT Scan,70470,"CT Head w, w/o",350,"$1,717.57 ","$1,545.81 ",90% of total billed charges for outpatient setting,"$1,597.34 ",93% of total billed charges for outpatient setting,$652.68 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$652.68 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$500.00 ,100% of CT case rate,$652.68 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,398.10 ",81.4% of total billed charges for outpatient setting,"$1,545.81 ",90% of total billed charges for outpatient setting,"$1,545.81 ",90% of total billed charges for outpatient setting,$652.68 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$652.68 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$652.68 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,288.18 ",75% of total billed charges for outpatient setting,"$1,209.00 ",100% UHC case rate for outpatient setting,$500.00 ,"$1,597.34 ","$1,288.18 "
Outpatient Medical Services,CT Scan,70480,CT IAC/MID/INNER EAR WO,350,"$1,229.89 ","$1,106.90 ",90% of total billed charges for outpatient setting,"$1,143.80 ",93% of total billed charges for outpatient setting,$467.36 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$467.36 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$500.00 ,100% of CT case rate,$467.36 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,001.13 ",81.4% of total billed charges for outpatient setting,"$1,106.90 ",90% of total billed charges for outpatient setting,"$1,106.90 ",90% of total billed charges for outpatient setting,$467.36 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$467.36 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$467.36 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$922.42 ,75% of total billed charges for outpatient setting,"$1,209.00 ",100% UHC case rate for outpatient setting,$467.36 ,"$1,209.00 ",$922.42 
Outpatient Medical Services,CT Scan,70481,CT ORBIT/SELLA/OUTER-M,350,"$1,556.51 ","$1,400.86 ",90% of total billed charges for outpatient setting,"$1,447.55 ",93% of total billed charges for outpatient setting,$591.47 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$591.47 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$500.00 ,100% of CT case rate,$591.47 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,267.00 ",81.4% of total billed charges for outpatient setting,"$1,400.86 ",90% of total billed charges for outpatient setting,"$1,400.86 ",90% of total billed charges for outpatient setting,$591.47 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$591.47 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$591.47 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,167.38 ",75% of total billed charges for outpatient setting,"$1,209.00 ",100% UHC case rate for outpatient setting,$500.00 ,"$1,447.55 ","$1,167.38 "
Outpatient Medical Services,CT Scan,70482,"CT IAC/mid-inner ear, w/wo",350,"$1,457.41 ","$1,311.67 ",90% of total billed charges for outpatient setting,"$1,355.39 ",93% of total billed charges for outpatient setting,$553.82 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$553.82 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$500.00 ,100% of CT case rate,$553.82 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,186.33 ",81.4% of total billed charges for outpatient setting,"$1,311.67 ",90% of total billed charges for outpatient setting,"$1,311.67 ",90% of total billed charges for outpatient setting,$553.82 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$553.82 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$553.82 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,093.06 ",75% of total billed charges for outpatient setting,"$1,209.00 ",100% UHC case rate for outpatient setting,$500.00 ,"$1,355.39 ","$1,093.06 "
Outpatient Medical Services,CT Scan,70486,CT Scan of the face and jaw without dye,350,"$1,340.26 ","$1,206.23 ",90% of total billed charges for outpatient setting,"$1,246.44 ",93% of total billed charges for outpatient setting,$509.30 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$509.30 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$500.00 ,100% of CT case rate,$509.30 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,090.97 ",81.4% of total billed charges for outpatient setting,"$1,206.23 ",90% of total billed charges for outpatient setting,"$1,206.23 ",90% of total billed charges for outpatient setting,$509.30 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$509.30 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$509.30 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,005.20 ",75% of total billed charges for outpatient setting,"$1,209.00 ",100% UHC case rate for outpatient setting,$500.00 ,"$1,246.44 ","$1,005.20 "
Outpatient Medical Services,CT Scan,70486,CT Scan of the face and jaw without dye,350,"$1,340.26 ","$1,206.23 ",90% of total billed charges for outpatient setting,"$1,246.44 ",93% of total billed charges for outpatient setting,$509.30 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$509.30 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$500.00 ,100% of CT case rate,$509.30 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,090.97 ",81.4% of total billed charges for outpatient setting,"$1,206.23 ",90% of total billed charges for outpatient setting,"$1,206.23 ",90% of total billed charges for outpatient setting,$509.30 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$509.30 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$509.30 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,005.20 ",75% of total billed charges for outpatient setting,"$1,209.00 ",100% UHC case rate for outpatient setting,$500.00 ,"$1,246.44 ","$1,005.20 "
Outpatient Medical Services,CT Scan,70487,CT Max/Fac w/ contrast,350,"$1,512.59 ","$1,361.33 ",90% of total billed charges for outpatient setting,"$1,406.71 ",93% of total billed charges for outpatient setting,$574.78 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$574.78 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$500.00 ,100% of CT case rate,$574.78 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,231.25 ",81.4% of total billed charges for outpatient setting,"$1,361.33 ",90% of total billed charges for outpatient setting,"$1,361.33 ",90% of total billed charges for outpatient setting,$574.78 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$574.78 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$574.78 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,134.44 ",75% of total billed charges for outpatient setting,"$1,209.00 ",100% UHC case rate for outpatient setting,$500.00 ,"$1,406.71 ","$1,134.44 "
Outpatient Medical Services,CT Scan,70488,"CT Max/Fac w, w/o contrast",350,"$1,814.44 ","$1,633.00 ",90% of total billed charges for outpatient setting,"$1,687.43 ",93% of total billed charges for outpatient setting,$689.49 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$689.49 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$500.00 ,100% of CT case rate,$689.49 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,476.95 ",81.4% of total billed charges for outpatient setting,"$1,633.00 ",90% of total billed charges for outpatient setting,"$1,633.00 ",90% of total billed charges for outpatient setting,$689.49 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$689.49 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$689.49 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,360.83 ",75% of total billed charges for outpatient setting,"$1,209.00 ",100% UHC case rate for outpatient setting,$500.00 ,"$1,687.43 ","$1,360.83 "
Outpatient Medical Services,CT Scan,70490,CT Soft Tissue Neck w/o contrast,350,"$1,354.91 ","$1,219.42 ",90% of total billed charges for outpatient setting,"$1,260.07 ",93% of total billed charges for outpatient setting,$514.87 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$514.87 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$500.00 ,100% of CT case rate,$514.87 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,102.90 ",81.4% of total billed charges for outpatient setting,"$1,219.42 ",90% of total billed charges for outpatient setting,"$1,219.42 ",90% of total billed charges for outpatient setting,$514.87 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$514.87 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$514.87 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,016.18 ",75% of total billed charges for outpatient setting,"$1,209.00 ",100% UHC case rate for outpatient setting,$500.00 ,"$1,260.07 ","$1,016.18 "
Outpatient Medical Services,CT Scan,70492,CT Soft Tissue Neck w/wo contrast,350,"$1,863.99 ","$1,677.59 ",90% of total billed charges for outpatient setting,"$1,733.51 ",93% of total billed charges for outpatient setting,$708.32 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$708.32 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$500.00 ,100% of CT case rate,$708.32 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,517.29 ",81.4% of total billed charges for outpatient setting,"$1,677.59 ",90% of total billed charges for outpatient setting,"$1,677.59 ",90% of total billed charges for outpatient setting,$708.32 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$708.32 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$708.32 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,397.99 ",75% of total billed charges for outpatient setting,"$1,209.00 ",100% UHC case rate for outpatient setting,$500.00 ,"$1,733.51 ","$1,397.99 "
Outpatient Medical Services,CT Scan,70496,CT Angio of the Brain (COW),350,"$1,776.13 ","$1,598.52 ",90% of total billed charges for outpatient setting,"$1,651.80 ",93% of total billed charges for outpatient setting,$674.93 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$674.93 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$500.00 ,100% of CT case rate,$674.93 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,445.77 ",81.4% of total billed charges for outpatient setting,"$1,598.52 ",90% of total billed charges for outpatient setting,"$1,598.52 ",90% of total billed charges for outpatient setting,$674.93 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$674.93 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$674.93 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,332.10 ",75% of total billed charges for outpatient setting,"$1,209.00 ",100% UHC case rate for outpatient setting,$500.00 ,"$1,651.80 ","$1,332.10 "
Outpatient Medical Services,CT Scan,70498,CT Angio of Carotids,350,"$1,898.90 ","$1,709.01 ",90% of total billed charges for outpatient setting,"$1,765.98 ",93% of total billed charges for outpatient setting,$721.58 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$721.58 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$500.00 ,100% of CT case rate,$721.58 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,545.70 ",81.4% of total billed charges for outpatient setting,"$1,709.01 ",90% of total billed charges for outpatient setting,"$1,709.01 ",90% of total billed charges for outpatient setting,$721.58 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$721.58 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$721.58 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,424.18 ",75% of total billed charges for outpatient setting,"$1,209.00 ",100% UHC case rate for outpatient setting,$500.00 ,"$1,765.98 ","$1,424.18 "
Outpatient Medical Services,MRI,70540,"MRI Face, Neck or Orbits w/o contrast",610,"$2,555.52 ","$2,299.97 ",90% of total billed charges for outpatient setting,"$2,376.63 ",93% of total billed charges for outpatient setting,$971.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$971.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,172.19 ",85% of total billed charges for outpatient setting,$971.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,080.19 ",81.4% of total billed charges for outpatient setting,"$2,299.97 ",90% of total billed charges for outpatient setting,"$2,299.97 ",90% of total billed charges for outpatient setting,$971.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$971.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$971.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,916.64 ",75% of total billed charges for outpatient setting,"$1,613.00 ",100% UHC case rate for outpatient setting,$971.10 ,"$2,376.63 ","$1,916.64 "
Outpatient Medical Services,MRI,70542,"MRI Face, Neck or Orbits w/ contrast",610,"$2,842.70 ","$2,558.43 ",90% of total billed charges for outpatient setting,"$2,643.71 ",93% of total billed charges for outpatient setting,"$1,080.23 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,080.23 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,416.30 ",85% of total billed charges for outpatient setting,"$1,080.23 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,313.96 ",81.4% of total billed charges for outpatient setting,"$2,558.43 ",90% of total billed charges for outpatient setting,"$2,558.43 ",90% of total billed charges for outpatient setting,"$1,080.23 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,080.23 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,080.23 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,132.03 ",75% of total billed charges for outpatient setting,"$1,613.00 ",100% UHC case rate for outpatient setting,"$1,080.23 ","$2,643.71 ","$2,132.03 "
Outpatient Medical Services,MRI,70543,"MRI Face, Neck or Orbits w, w/o contrast",610,"$4,412.73 ","$3,971.46 ",90% of total billed charges for outpatient setting,"$4,103.84 ",93% of total billed charges for outpatient setting,"$1,676.84 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,676.84 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$3,750.82 ",85% of total billed charges for outpatient setting,"$1,676.84 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$3,591.96 ",81.4% of total billed charges for outpatient setting,"$3,971.46 ",90% of total billed charges for outpatient setting,"$3,971.46 ",90% of total billed charges for outpatient setting,"$1,676.84 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,676.84 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,676.84 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$3,309.55 ",75% of total billed charges for outpatient setting,"$1,613.00 ",100% UHC case rate for outpatient setting,"$1,613.00 ","$4,103.84 ","$3,309.55 "
Outpatient Medical Services,MRI,70544,MRI MRA Head w/o contrast,610,"$2,901.29 ","$2,611.16 ",90% of total billed charges for outpatient setting,"$2,698.20 ",93% of total billed charges for outpatient setting,"$1,102.49 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,102.49 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,466.10 ",85% of total billed charges for outpatient setting,"$1,102.49 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,361.65 ",81.4% of total billed charges for outpatient setting,"$2,611.16 ",90% of total billed charges for outpatient setting,"$2,611.16 ",90% of total billed charges for outpatient setting,"$1,102.49 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,102.49 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,102.49 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,175.97 ",75% of total billed charges for outpatient setting,"$1,613.00 ",100% UHC case rate for outpatient setting,"$1,102.49 ","$2,698.20 ","$2,175.97 "
Outpatient Medical Services,MRI,70545,MRI MRA Head w/wo contrast,610,"$3,381.08 ","$3,042.97 ",90% of total billed charges for outpatient setting,"$3,144.40 ",93% of total billed charges for outpatient setting,"$1,284.81 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,284.81 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,873.92 ",85% of total billed charges for outpatient setting,"$1,284.81 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,752.20 ",81.4% of total billed charges for outpatient setting,"$3,042.97 ",90% of total billed charges for outpatient setting,"$3,042.97 ",90% of total billed charges for outpatient setting,"$1,284.81 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,284.81 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,284.81 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,535.81 ",75% of total billed charges for outpatient setting,"$1,613.00 ",100% UHC case rate for outpatient setting,"$1,284.81 ","$3,144.40 ","$2,535.81 "
Outpatient Medical Services,MRI,70547,MRI MRA Neck w/o contrast,610,"$2,584.79 ","$2,326.31 ",90% of total billed charges for outpatient setting,"$2,403.85 ",93% of total billed charges for outpatient setting,$982.22 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$982.22 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,197.07 ",85% of total billed charges for outpatient setting,$982.22 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,104.02 ",81.4% of total billed charges for outpatient setting,"$2,326.31 ",90% of total billed charges for outpatient setting,"$2,326.31 ",90% of total billed charges for outpatient setting,$982.22 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$982.22 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$982.22 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,938.59 ",75% of total billed charges for outpatient setting,"$1,613.00 ",100% UHC case rate for outpatient setting,$982.22 ,"$2,403.85 ","$1,938.59 "
Outpatient Medical Services,MRI,70548,MRI MRA Neck w/contrast,610,"$3,153.56 ","$2,838.20 ",90% of total billed charges for outpatient setting,"$2,932.81 ",93% of total billed charges for outpatient setting,"$1,198.35 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,198.35 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,680.53 ",85% of total billed charges for outpatient setting,"$1,198.35 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,567.00 ",81.4% of total billed charges for outpatient setting,"$2,838.20 ",90% of total billed charges for outpatient setting,"$2,838.20 ",90% of total billed charges for outpatient setting,"$1,198.35 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,198.35 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,198.35 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,365.17 ",75% of total billed charges for outpatient setting,"$1,613.00 ",100% UHC case rate for outpatient setting,"$1,198.35 ","$2,932.81 ","$2,365.17 "
Outpatient Medical Services,MRI,70549,MRI MRA Neck w/wo contrast,610,"$3,953.20 ","$3,557.88 ",90% of total billed charges for outpatient setting,"$3,676.48 ",93% of total billed charges for outpatient setting,"$1,502.22 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,502.22 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$3,360.22 ",85% of total billed charges for outpatient setting,"$1,502.22 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$3,217.90 ",81.4% of total billed charges for outpatient setting,"$3,557.88 ",90% of total billed charges for outpatient setting,"$3,557.88 ",90% of total billed charges for outpatient setting,"$1,502.22 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,502.22 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,502.22 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,964.90 ",75% of total billed charges for outpatient setting,"$1,613.00 ",100% UHC case rate for outpatient setting,"$1,502.22 ","$3,676.48 ","$2,964.90 "
Outpatient Medical Services,MRI,70551,MRI of brain stem without dye,610,"$3,026.31 ","$2,723.68 ",90% of total billed charges for outpatient setting,"$2,814.47 ",93% of total billed charges for outpatient setting,"$1,150.00 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,150.00 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,572.36 ",85% of total billed charges for outpatient setting,"$1,150.00 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,463.42 ",81.4% of total billed charges for outpatient setting,"$2,723.68 ",90% of total billed charges for outpatient setting,"$2,723.68 ",90% of total billed charges for outpatient setting,"$1,150.00 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,150.00 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,150.00 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,269.73 ",75% of total billed charges for outpatient setting,"$1,613.00 ",100% UHC case rate for outpatient setting,"$1,150.00 ","$2,814.47 ","$2,269.73 "
Outpatient Medical Services,MRI,70552,MRI Brain w/ contrast,610,"$3,394.59 ","$3,055.13 ",90% of total billed charges for outpatient setting,"$3,156.97 ",93% of total billed charges for outpatient setting,"$1,289.94 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,289.94 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,885.40 ",85% of total billed charges for outpatient setting,"$1,289.94 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,763.20 ",81.4% of total billed charges for outpatient setting,"$3,055.13 ",90% of total billed charges for outpatient setting,"$3,055.13 ",90% of total billed charges for outpatient setting,"$1,289.94 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,289.94 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,289.94 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,545.94 ",75% of total billed charges for outpatient setting,"$1,613.00 ",100% UHC case rate for outpatient setting,"$1,289.94 ","$3,156.97 ","$2,545.94 "
Outpatient Medical Services,MRI,70553,MRI scan of brain before and after contrast,610,"$4,479.20 ","$4,031.28 ",90% of total billed charges for outpatient setting,"$4,165.66 ",93% of total billed charges for outpatient setting,"$1,702.10 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,702.10 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$3,807.32 ",85% of total billed charges for outpatient setting,"$1,702.10 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$3,646.07 ",81.4% of total billed charges for outpatient setting,"$4,031.28 ",90% of total billed charges for outpatient setting,"$4,031.28 ",90% of total billed charges for outpatient setting,"$1,702.10 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,702.10 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,702.10 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$3,359.40 ",75% of total billed charges for outpatient setting,"$1,613.00 ",100% UHC case rate for outpatient setting,"$1,613.00 ","$4,165.66 ","$3,359.40 "
Outpatient Medical Services,Radiology,71045,Single view,320,$132.42 ,$119.18 ,90% of total billed charges for outpatient setting,$123.15 ,93% of total billed charges for outpatient setting,$50.32 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$50.32 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$112.56 ,85% of total billed charges for outpatient setting,$50.32 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$107.79 ,81.4% of total billed charges for outpatient setting,$119.18 ,90% of total billed charges for outpatient setting,$119.18 ,90% of total billed charges for outpatient setting,$50.32 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$50.32 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$50.32 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$99.32 ,75% of total billed charges for outpatient setting,$112.56 ,85% of total billed charges for outpatient setting,$50.32 ,$123.15 ,$99.32 
Outpatient Medical Services,Radiology,71046,"2 views, front and back",320,$140.72 ,$126.65 ,90% of total billed charges for outpatient setting,$130.87 ,93% of total billed charges for outpatient setting,$53.47 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$53.47 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$119.61 ,85% of total billed charges for outpatient setting,$53.47 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$114.55 ,81.4% of total billed charges for outpatient setting,$126.65 ,90% of total billed charges for outpatient setting,$126.65 ,90% of total billed charges for outpatient setting,$53.47 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$53.47 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$53.47 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$105.54 ,75% of total billed charges for outpatient setting,$119.61 ,85% of total billed charges for outpatient setting,$53.47 ,$130.87 ,$105.54 
Outpatient Medical Services,CT Scan,71250,CT scan of the thorax without dye,350,"$1,840.32 ","$1,656.29 ",90% of total billed charges for outpatient setting,"$1,711.50 ",93% of total billed charges for outpatient setting,$699.32 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$699.32 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$500.00 ,100% of CT case rate,$699.32 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,498.02 ",81.4% of total billed charges for outpatient setting,"$1,656.29 ",90% of total billed charges for outpatient setting,"$1,656.29 ",90% of total billed charges for outpatient setting,$699.32 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$699.32 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$699.32 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,380.24 ",75% of total billed charges for outpatient setting,"$1,209.00 ",100% UHC case rate for outpatient setting,$500.00 ,"$1,711.50 ","$1,380.24 "
Outpatient Medical Services,CT Scan,71260,CT scan of the thorax with dye,350,"$2,112.89 ","$1,901.60 ",90% of total billed charges for outpatient setting,"$1,964.99 ",93% of total billed charges for outpatient setting,$802.90 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$802.90 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$500.00 ,100% of CT case rate,$802.90 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,719.89 ",81.4% of total billed charges for outpatient setting,"$1,901.60 ",90% of total billed charges for outpatient setting,"$1,901.60 ",90% of total billed charges for outpatient setting,$802.90 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$802.90 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$802.90 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,584.67 ",75% of total billed charges for outpatient setting,"$1,209.00 ",100% UHC case rate for outpatient setting,$500.00 ,"$1,964.99 ","$1,584.67 "
Outpatient Medical Services,CT Scan,71270,"CT Thorax w, w/o contrast",350,"$2,540.88 ","$2,286.79 ",90% of total billed charges for outpatient setting,"$2,363.02 ",93% of total billed charges for outpatient setting,$965.53 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$965.53 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$500.00 ,100% of CT case rate,$965.53 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,068.28 ",81.4% of total billed charges for outpatient setting,"$2,286.79 ",90% of total billed charges for outpatient setting,"$2,286.79 ",90% of total billed charges for outpatient setting,$965.53 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$965.53 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$965.53 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,905.66 ",75% of total billed charges for outpatient setting,"$1,209.00 ",100% UHC case rate for outpatient setting,$500.00 ,"$2,363.02 ","$1,905.66 "
Outpatient Medical Services,CT Scan,71275,Diagnostic Radiology (Diagnostic Imaging) Procedures of the Chest,350,"$2,368.55 ","$2,131.70 ",90% of total billed charges for outpatient setting,"$2,202.75 ",93% of total billed charges for outpatient setting,$900.05 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$900.05 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$500.00 ,100% of CT case rate,$900.05 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,928.00 ",81.4% of total billed charges for outpatient setting,"$2,131.70 ",90% of total billed charges for outpatient setting,"$2,131.70 ",90% of total billed charges for outpatient setting,$900.05 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$900.05 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$900.05 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,776.41 ",75% of total billed charges for outpatient setting,"$1,209.00 ",100% UHC case rate for outpatient setting,$500.00 ,"$2,202.75 ","$1,776.41 "
Outpatient Medical Services,CT Scan,71275,Diagnostic Radiology (Diagnostic Imaging) Procedures of the Chest,350,"$2,368.55 ","$2,131.70 ",90% of total billed charges for outpatient setting,"$2,202.75 ",93% of total billed charges for outpatient setting,$900.05 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$900.05 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$500.00 ,100% of CT case rate,$900.05 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,928.00 ",81.4% of total billed charges for outpatient setting,"$2,131.70 ",90% of total billed charges for outpatient setting,"$2,131.70 ",90% of total billed charges for outpatient setting,$900.05 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$900.05 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$900.05 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,776.41 ",75% of total billed charges for outpatient setting,"$1,209.00 ",100% UHC case rate for outpatient setting,$500.00 ,"$2,202.75 ","$1,776.41 "
Outpatient Medical Services,MRI,71550,MRI Chest w/o contrast,610,"$2,449.64 ","$2,204.68 ",90% of total billed charges for outpatient setting,"$2,278.17 ",93% of total billed charges for outpatient setting,$930.86 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$930.86 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,082.19 ",85% of total billed charges for outpatient setting,$930.86 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,994.01 ",81.4% of total billed charges for outpatient setting,"$2,204.68 ",90% of total billed charges for outpatient setting,"$2,204.68 ",90% of total billed charges for outpatient setting,$930.86 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$930.86 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$930.86 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,837.23 ",75% of total billed charges for outpatient setting,"$1,613.00 ",100% UHC case rate for outpatient setting,$930.86 ,"$2,278.17 ","$1,837.23 "
Outpatient Medical Services,MRI,71551,MRI Chest w/ contrast,610,"$2,733.48 ","$2,460.13 ",90% of total billed charges for outpatient setting,"$2,542.14 ",93% of total billed charges for outpatient setting,"$1,038.72 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,038.72 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,323.46 ",85% of total billed charges for outpatient setting,"$1,038.72 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,225.05 ",81.4% of total billed charges for outpatient setting,"$2,460.13 ",90% of total billed charges for outpatient setting,"$2,460.13 ",90% of total billed charges for outpatient setting,"$1,038.72 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,038.72 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,038.72 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,050.11 ",75% of total billed charges for outpatient setting,"$1,613.00 ",100% UHC case rate for outpatient setting,"$1,038.72 ","$2,542.14 ","$2,050.11 "
Outpatient Medical Services,MRI,71552,"MRI Chest w, w/o contrast",610,"$4,393.59 ","$3,954.23 ",90% of total billed charges for outpatient setting,"$4,086.04 ",93% of total billed charges for outpatient setting,"$1,669.56 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,669.56 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$3,734.55 ",85% of total billed charges for outpatient setting,"$1,669.56 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$3,576.38 ",81.4% of total billed charges for outpatient setting,"$3,954.23 ",90% of total billed charges for outpatient setting,"$3,954.23 ",90% of total billed charges for outpatient setting,"$1,669.56 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,669.56 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,669.56 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$3,295.19 ",75% of total billed charges for outpatient setting,"$1,613.00 ",100% UHC case rate for outpatient setting,"$1,613.00 ","$4,086.04 ","$3,295.19 "
Outpatient Medical Services,Radiology,72040,"Radiologic examination of the neck/spine, 2-3 views",320,$238.77 ,$214.89 ,90% of total billed charges for outpatient setting,$222.06 ,93% of total billed charges for outpatient setting,$90.73 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$90.73 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$202.95 ,85% of total billed charges for outpatient setting,$90.73 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$194.36 ,81.4% of total billed charges for outpatient setting,$214.89 ,90% of total billed charges for outpatient setting,$214.89 ,90% of total billed charges for outpatient setting,$90.73 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$90.73 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$90.73 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$179.08 ,75% of total billed charges for outpatient setting,$202.95 ,85% of total billed charges for outpatient setting,$90.73 ,$222.06 ,$179.08 
Outpatient Medical Services,Radiology,72050,"Radiologic examination of the neck/spine, 4-5 views",320,$313.11 ,$281.80 ,90% of total billed charges for outpatient setting,$291.19 ,93% of total billed charges for outpatient setting,$118.98 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$118.98 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$266.14 ,85% of total billed charges for outpatient setting,$118.98 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$254.87 ,81.4% of total billed charges for outpatient setting,$281.80 ,90% of total billed charges for outpatient setting,$281.80 ,90% of total billed charges for outpatient setting,$118.98 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$118.98 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$118.98 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$234.83 ,75% of total billed charges for outpatient setting,$266.14 ,85% of total billed charges for outpatient setting,$118.98 ,$291.19 ,$234.83 
Outpatient Medical Services,Radiology,72100,X-ray of the lower spine 2-3 views,320,$265.79 ,$239.21 ,90% of total billed charges for outpatient setting,$247.18 ,93% of total billed charges for outpatient setting,$101.00 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$101.00 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$225.92 ,85% of total billed charges for outpatient setting,$101.00 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$216.35 ,81.4% of total billed charges for outpatient setting,$239.21 ,90% of total billed charges for outpatient setting,$239.21 ,90% of total billed charges for outpatient setting,$101.00 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$101.00 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$101.00 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$199.34 ,75% of total billed charges for outpatient setting,$225.92 ,85% of total billed charges for outpatient setting,$101.00 ,$247.18 ,$199.34 
Outpatient Medical Services,Radiology,72110,"X-ray of lower and sacral spine, minimum of 4 views",320,$353.65 ,$318.29 ,90% of total billed charges for outpatient setting,$328.89 ,93% of total billed charges for outpatient setting,$134.39 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$134.39 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$300.60 ,85% of total billed charges for outpatient setting,$134.39 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$287.87 ,81.4% of total billed charges for outpatient setting,$318.29 ,90% of total billed charges for outpatient setting,$318.29 ,90% of total billed charges for outpatient setting,$134.39 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$134.39 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$134.39 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$265.24 ,75% of total billed charges for outpatient setting,$300.60 ,85% of total billed charges for outpatient setting,$134.39 ,$328.89 ,$265.24 
Outpatient Medical Services,Radiology,72114,Lumbar-Spine 7V (Flex & Ext),320,$417.85 ,$376.07 ,90% of total billed charges for outpatient setting,$388.60 ,93% of total billed charges for outpatient setting,$158.78 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$158.78 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$355.17 ,85% of total billed charges for outpatient setting,$158.78 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$340.13 ,81.4% of total billed charges for outpatient setting,$376.07 ,90% of total billed charges for outpatient setting,$376.07 ,90% of total billed charges for outpatient setting,$158.78 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$158.78 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$158.78 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$313.39 ,75% of total billed charges for outpatient setting,$355.17 ,85% of total billed charges for outpatient setting,$158.78 ,$388.60 ,$313.39 
Outpatient Medical Services,CT Scan,72125,CT C-Spine w/o contrast,350,"$1,331.26 ","$1,198.13 ",90% of total billed charges for outpatient setting,"$1,238.07 ",93% of total billed charges for outpatient setting,$505.88 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$505.88 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$500.00 ,100% of CT case rate,$505.88 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,083.65 ",81.4% of total billed charges for outpatient setting,"$1,198.13 ",90% of total billed charges for outpatient setting,"$1,198.13 ",90% of total billed charges for outpatient setting,$505.88 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$505.88 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$505.88 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$998.45 ,75% of total billed charges for outpatient setting,"$1,209.00 ",100% UHC case rate for outpatient setting,$500.00 ,"$1,238.07 ",$998.45 
Outpatient Medical Services,CT Scan,72128,CT T-Spine w/o contrast,350,"$1,331.26 ","$1,198.13 ",90% of total billed charges for outpatient setting,"$1,238.07 ",93% of total billed charges for outpatient setting,$505.88 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$505.88 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$500.00 ,100% of CT case rate,$505.88 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,083.65 ",81.4% of total billed charges for outpatient setting,"$1,198.13 ",90% of total billed charges for outpatient setting,"$1,198.13 ",90% of total billed charges for outpatient setting,$505.88 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$505.88 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$505.88 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$998.45 ,75% of total billed charges for outpatient setting,"$1,209.00 ",100% UHC case rate for outpatient setting,$500.00 ,"$1,238.07 ",$998.45 
Outpatient Medical Services,CT Scan,72131,CT scan of lower spine without dye,350,"$1,331.26 ","$1,198.13 ",90% of total billed charges for outpatient setting,"$1,238.07 ",93% of total billed charges for outpatient setting,$505.88 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$505.88 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$500.00 ,100% of CT case rate,$505.88 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,083.65 ",81.4% of total billed charges for outpatient setting,"$1,198.13 ",90% of total billed charges for outpatient setting,"$1,198.13 ",90% of total billed charges for outpatient setting,$505.88 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$505.88 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$505.88 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$998.45 ,75% of total billed charges for outpatient setting,"$1,209.00 ",100% UHC case rate for outpatient setting,$500.00 ,"$1,238.07 ",$998.45 
Outpatient Medical Services,MRI,72141,MRI of the neck or spine without dye,610,"$2,588.17 ","$2,329.35 ",90% of total billed charges for outpatient setting,"$2,407.00 ",93% of total billed charges for outpatient setting,$983.50 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$983.50 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,199.94 ",85% of total billed charges for outpatient setting,$983.50 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,106.77 ",81.4% of total billed charges for outpatient setting,"$2,329.35 ",90% of total billed charges for outpatient setting,"$2,329.35 ",90% of total billed charges for outpatient setting,$983.50 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$983.50 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$983.50 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,941.13 ",75% of total billed charges for outpatient setting,"$1,613.00 ",100% UHC case rate for outpatient setting,$983.50 ,"$2,407.00 ","$1,941.13 "
Outpatient Medical Services,MRI,72142,MRI C-Spine w/ contrast,610,"$3,007.14 ","$2,706.43 ",90% of total billed charges for outpatient setting,"$2,796.64 ",93% of total billed charges for outpatient setting,"$1,142.71 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,142.71 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,556.07 ",85% of total billed charges for outpatient setting,"$1,142.71 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,447.81 ",81.4% of total billed charges for outpatient setting,"$2,706.43 ",90% of total billed charges for outpatient setting,"$2,706.43 ",90% of total billed charges for outpatient setting,"$1,142.71 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,142.71 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,142.71 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,255.36 ",75% of total billed charges for outpatient setting,"$1,613.00 ",100% UHC case rate for outpatient setting,"$1,142.71 ","$2,796.64 ","$2,255.36 "
Outpatient Medical Services,MRI,72146,MRI of chest and spine without dye,610,"$2,578.04 ","$2,320.24 ",90% of total billed charges for outpatient setting,"$2,397.58 ",93% of total billed charges for outpatient setting,$979.66 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$979.66 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,191.33 ",85% of total billed charges for outpatient setting,$979.66 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,098.52 ",81.4% of total billed charges for outpatient setting,"$2,320.24 ",90% of total billed charges for outpatient setting,"$2,320.24 ",90% of total billed charges for outpatient setting,$979.66 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$979.66 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$979.66 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,933.53 ",75% of total billed charges for outpatient setting,"$1,613.00 ",100% UHC case rate for outpatient setting,$979.66 ,"$2,397.58 ","$1,933.53 "
Outpatient Medical Services,MRI,72147,MRI T-Spine w/ contrast,610,"$3,098.38 ","$2,788.54 ",90% of total billed charges for outpatient setting,"$2,881.49 ",93% of total billed charges for outpatient setting,"$1,177.38 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,177.38 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,633.62 ",85% of total billed charges for outpatient setting,"$1,177.38 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,522.08 ",81.4% of total billed charges for outpatient setting,"$2,788.54 ",90% of total billed charges for outpatient setting,"$2,788.54 ",90% of total billed charges for outpatient setting,"$1,177.38 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,177.38 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,177.38 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,323.79 ",75% of total billed charges for outpatient setting,"$1,613.00 ",100% UHC case rate for outpatient setting,"$1,177.38 ","$2,881.49 ","$2,323.79 "
Outpatient Medical Services,MRI,72148,MRI scan of lower spinal canal,610,"$2,578.04 ","$2,320.24 ",90% of total billed charges for outpatient setting,"$2,397.58 ",93% of total billed charges for outpatient setting,$979.66 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$979.66 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,191.33 ",85% of total billed charges for outpatient setting,$979.66 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,098.52 ",81.4% of total billed charges for outpatient setting,"$2,320.24 ",90% of total billed charges for outpatient setting,"$2,320.24 ",90% of total billed charges for outpatient setting,$979.66 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$979.66 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$979.66 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,933.53 ",75% of total billed charges for outpatient setting,"$1,613.00 ",100% UHC case rate for outpatient setting,$979.66 ,"$2,397.58 ","$1,933.53 "
Outpatient Medical Services,MRI,72149,MRI L-Spine w/ contrast,610,"$3,076.97 ","$2,769.27 ",90% of total billed charges for outpatient setting,"$2,861.58 ",93% of total billed charges for outpatient setting,"$1,169.25 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,169.25 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,615.42 ",85% of total billed charges for outpatient setting,"$1,169.25 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,504.65 ",81.4% of total billed charges for outpatient setting,"$2,769.27 ",90% of total billed charges for outpatient setting,"$2,769.27 ",90% of total billed charges for outpatient setting,"$1,169.25 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,169.25 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,169.25 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,307.73 ",75% of total billed charges for outpatient setting,"$1,613.00 ",100% UHC case rate for outpatient setting,"$1,169.25 ","$2,861.58 ","$2,307.73 "
Outpatient Medical Services,MRI,72156,MRI of neck/spine with and without dye,610,"$4,479.20 ","$4,031.28 ",90% of total billed charges for outpatient setting,"$4,165.66 ",93% of total billed charges for outpatient setting,"$1,702.10 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,702.10 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$3,807.32 ",85% of total billed charges for outpatient setting,"$1,702.10 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$3,646.07 ",81.4% of total billed charges for outpatient setting,"$4,031.28 ",90% of total billed charges for outpatient setting,"$4,031.28 ",90% of total billed charges for outpatient setting,"$1,702.10 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,702.10 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,702.10 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$3,359.40 ",75% of total billed charges for outpatient setting,"$1,613.00 ",100% UHC case rate for outpatient setting,"$1,613.00 ","$4,165.66 ","$3,359.40 "
Outpatient Medical Services,MRI,72157,MRI of chest and spine with and without dye,610,"$4,479.20 ","$4,031.28 ",90% of total billed charges for outpatient setting,"$4,165.66 ",93% of total billed charges for outpatient setting,"$1,702.10 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,702.10 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$3,807.32 ",85% of total billed charges for outpatient setting,"$1,702.10 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$3,646.07 ",81.4% of total billed charges for outpatient setting,"$4,031.28 ",90% of total billed charges for outpatient setting,"$4,031.28 ",90% of total billed charges for outpatient setting,"$1,702.10 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,702.10 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,702.10 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$3,359.40 ",75% of total billed charges for outpatient setting,"$1,613.00 ",100% UHC case rate for outpatient setting,"$1,613.00 ","$4,165.66 ","$3,359.40 "
Outpatient Medical Services,MRI,72158,MRI of lower back with and without dye,610,"$4,479.20 ","$4,031.28 ",90% of total billed charges for outpatient setting,"$4,165.66 ",93% of total billed charges for outpatient setting,"$1,702.10 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,702.10 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$3,807.32 ",85% of total billed charges for outpatient setting,"$1,702.10 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$3,646.07 ",81.4% of total billed charges for outpatient setting,"$4,031.28 ",90% of total billed charges for outpatient setting,"$4,031.28 ",90% of total billed charges for outpatient setting,"$1,702.10 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,702.10 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,702.10 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$3,359.40 ",75% of total billed charges for outpatient setting,"$1,613.00 ",100% UHC case rate for outpatient setting,"$1,613.00 ","$4,165.66 ","$3,359.40 "
Outpatient Medical Services,Radiology,72170,Radiologic examination of the pelvis,320,$217.38 ,$195.64 ,90% of total billed charges for outpatient setting,$202.16 ,93% of total billed charges for outpatient setting,$82.60 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$82.60 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$184.77 ,85% of total billed charges for outpatient setting,$82.60 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$176.95 ,81.4% of total billed charges for outpatient setting,$195.64 ,90% of total billed charges for outpatient setting,$195.64 ,90% of total billed charges for outpatient setting,$82.60 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$82.60 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$82.60 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$163.04 ,75% of total billed charges for outpatient setting,$184.77 ,85% of total billed charges for outpatient setting,$82.60 ,$202.16 ,$163.04 
Outpatient Medical Services,CT Scan,72191,CT Angio PEL - AAA Protocol,350,"$1,472.04 ","$1,324.84 ",90% of total billed charges for outpatient setting,"$1,369.00 ",93% of total billed charges for outpatient setting,$559.38 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$559.38 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$500.00 ,100% of CT case rate,$559.38 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,198.24 ",81.4% of total billed charges for outpatient setting,"$1,324.84 ",90% of total billed charges for outpatient setting,"$1,324.84 ",90% of total billed charges for outpatient setting,$559.38 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$559.38 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$559.38 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,104.03 ",75% of total billed charges for outpatient setting,"$1,209.00 ",100% UHC case rate for outpatient setting,$500.00 ,"$1,369.00 ","$1,104.03 "
Outpatient Medical Services,CT Scan,72192,CT of pelvis without dye,350,"$1,117.27 ","$1,005.54 ",90% of total billed charges for outpatient setting,"$1,039.06 ",93% of total billed charges for outpatient setting,$424.56 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$424.56 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$500.00 ,100% of CT case rate,$424.56 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$909.46 ,81.4% of total billed charges for outpatient setting,"$1,005.54 ",90% of total billed charges for outpatient setting,"$1,005.54 ",90% of total billed charges for outpatient setting,$424.56 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$424.56 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$424.56 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$837.95 ,75% of total billed charges for outpatient setting,"$1,209.00 ",100% UHC case rate for outpatient setting,$424.56 ,"$1,209.00 ",$837.95 
Outpatient Medical Services,CT Scan,72193,"CT scan, pelvis, with contrast",350,"$1,281.70 ","$1,153.53 ",90% of total billed charges for outpatient setting,"$1,191.98 ",93% of total billed charges for outpatient setting,$487.05 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$487.05 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$500.00 ,100% of CT case rate,$487.05 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,043.30 ",81.4% of total billed charges for outpatient setting,"$1,153.53 ",90% of total billed charges for outpatient setting,"$1,153.53 ",90% of total billed charges for outpatient setting,$487.05 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$487.05 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$487.05 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$961.28 ,75% of total billed charges for outpatient setting,"$1,209.00 ",100% UHC case rate for outpatient setting,$487.05 ,"$1,209.00 ",$961.28 
Outpatient Medical Services,MRI,72195,MRI of pelvis without dye,610,"$2,565.66 ","$2,309.09 ",90% of total billed charges for outpatient setting,"$2,386.06 ",93% of total billed charges for outpatient setting,$974.95 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$974.95 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,180.81 ",85% of total billed charges for outpatient setting,$974.95 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,088.45 ",81.4% of total billed charges for outpatient setting,"$2,309.09 ",90% of total billed charges for outpatient setting,"$2,309.09 ",90% of total billed charges for outpatient setting,$974.95 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$974.95 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$974.95 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,924.25 ",75% of total billed charges for outpatient setting,"$1,613.00 ",100% UHC case rate for outpatient setting,$974.95 ,"$2,386.06 ","$1,924.25 "
Outpatient Medical Services,MRI,72196,MRI Pelvis w/ contrast,610,"$2,960.97 ","$2,664.87 ",90% of total billed charges for outpatient setting,"$2,753.70 ",93% of total billed charges for outpatient setting,"$1,125.17 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,125.17 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,516.82 ",85% of total billed charges for outpatient setting,"$1,125.17 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,410.23 ",81.4% of total billed charges for outpatient setting,"$2,664.87 ",90% of total billed charges for outpatient setting,"$2,664.87 ",90% of total billed charges for outpatient setting,"$1,125.17 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,125.17 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,125.17 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,220.73 ",75% of total billed charges for outpatient setting,"$1,613.00 ",100% UHC case rate for outpatient setting,"$1,125.17 ","$2,753.70 ","$2,220.73 "
Outpatient Medical Services,MRI,72197,MRI of pelvis before and after dye,610,"$4,424.00 ","$3,981.60 ",90% of total billed charges for outpatient setting,"$4,114.32 ",93% of total billed charges for outpatient setting,"$1,681.12 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,681.12 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$3,760.40 ",85% of total billed charges for outpatient setting,"$1,681.12 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$3,601.14 ",81.4% of total billed charges for outpatient setting,"$3,981.60 ",90% of total billed charges for outpatient setting,"$3,981.60 ",90% of total billed charges for outpatient setting,"$1,681.12 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,681.12 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,681.12 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$3,318.00 ",75% of total billed charges for outpatient setting,"$1,613.00 ",100% UHC case rate for outpatient setting,"$1,613.00 ","$4,114.32 ","$3,318.00 "
Outpatient Medical Services,Radiology,73030,Radiologic examination of the shoulder,320,$197.09 ,$177.38 ,90% of total billed charges for outpatient setting,$183.29 ,93% of total billed charges for outpatient setting,$74.89 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$74.89 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$167.53 ,85% of total billed charges for outpatient setting,$74.89 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$160.43 ,81.4% of total billed charges for outpatient setting,$177.38 ,90% of total billed charges for outpatient setting,$177.38 ,90% of total billed charges for outpatient setting,$74.89 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$74.89 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$74.89 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$147.82 ,75% of total billed charges for outpatient setting,$167.53 ,85% of total billed charges for outpatient setting,$74.89 ,$183.29 ,$147.82 
Outpatient Medical Services,Radiology,73030,Radiologic examination of the shoulder,320,$197.09 ,$177.38 ,90% of total billed charges for outpatient setting,$183.29 ,93% of total billed charges for outpatient setting,$74.89 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$74.89 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$167.53 ,85% of total billed charges for outpatient setting,$74.89 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$160.43 ,81.4% of total billed charges for outpatient setting,$177.38 ,90% of total billed charges for outpatient setting,$177.38 ,90% of total billed charges for outpatient setting,$74.89 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$74.89 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$74.89 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$147.82 ,75% of total billed charges for outpatient setting,$167.53 ,85% of total billed charges for outpatient setting,$74.89 ,$183.29 ,$147.82 
Outpatient Medical Services,Radiology,73060,Humerus L/R,320,$221.88 ,$199.69 ,90% of total billed charges for outpatient setting,$206.35 ,93% of total billed charges for outpatient setting,$84.31 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$84.31 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$188.60 ,85% of total billed charges for outpatient setting,$84.31 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$180.61 ,81.4% of total billed charges for outpatient setting,$199.69 ,90% of total billed charges for outpatient setting,$199.69 ,90% of total billed charges for outpatient setting,$84.31 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$84.31 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$84.31 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$166.41 ,75% of total billed charges for outpatient setting,$188.60 ,85% of total billed charges for outpatient setting,$84.31 ,$206.35 ,$166.41 
Outpatient Medical Services,Radiology,73080,"Radiologic examination, elbow; 3 or more views",320,$197.09 ,$177.38 ,90% of total billed charges for outpatient setting,$183.29 ,93% of total billed charges for outpatient setting,$74.89 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$74.89 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$167.53 ,85% of total billed charges for outpatient setting,$74.89 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$160.43 ,81.4% of total billed charges for outpatient setting,$177.38 ,90% of total billed charges for outpatient setting,$177.38 ,90% of total billed charges for outpatient setting,$74.89 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$74.89 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$74.89 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$147.82 ,75% of total billed charges for outpatient setting,$167.53 ,85% of total billed charges for outpatient setting,$74.89 ,$183.29 ,$147.82 
Outpatient Medical Services,Radiology,73090,Radiologic examination of the forearm,320,$199.35 ,$179.42 ,90% of total billed charges for outpatient setting,$185.40 ,93% of total billed charges for outpatient setting,$75.75 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$75.75 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$169.45 ,85% of total billed charges for outpatient setting,$75.75 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$162.27 ,81.4% of total billed charges for outpatient setting,$179.42 ,90% of total billed charges for outpatient setting,$179.42 ,90% of total billed charges for outpatient setting,$75.75 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$75.75 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$75.75 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$149.51 ,75% of total billed charges for outpatient setting,$169.45 ,85% of total billed charges for outpatient setting,$75.75 ,$185.40 ,$149.51 
Outpatient Medical Services,Radiology,73110,Up to 3 views,320,$207.23 ,$186.51 ,90% of total billed charges for outpatient setting,$192.72 ,93% of total billed charges for outpatient setting,$78.75 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$78.75 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$176.15 ,85% of total billed charges for outpatient setting,$78.75 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$168.69 ,81.4% of total billed charges for outpatient setting,$186.51 ,90% of total billed charges for outpatient setting,$186.51 ,90% of total billed charges for outpatient setting,$78.75 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$78.75 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$78.75 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$155.42 ,75% of total billed charges for outpatient setting,$176.15 ,85% of total billed charges for outpatient setting,$78.75 ,$192.72 ,$155.42 
Outpatient Medical Services,Radiology,73110,Up to 3 views,320,$207.23 ,$186.51 ,90% of total billed charges for outpatient setting,$192.72 ,93% of total billed charges for outpatient setting,$78.75 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$78.75 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$176.15 ,85% of total billed charges for outpatient setting,$78.75 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$168.69 ,81.4% of total billed charges for outpatient setting,$186.51 ,90% of total billed charges for outpatient setting,$186.51 ,90% of total billed charges for outpatient setting,$78.75 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$78.75 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$78.75 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$155.42 ,75% of total billed charges for outpatient setting,$176.15 ,85% of total billed charges for outpatient setting,$78.75 ,$192.72 ,$155.42 
Outpatient Medical Services,Radiology,73120,X-ray of the hand with 2 views,320,$159.93 ,$143.94 ,90% of total billed charges for outpatient setting,$148.73 ,93% of total billed charges for outpatient setting,$60.77 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$60.77 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$135.94 ,85% of total billed charges for outpatient setting,$60.77 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$130.18 ,81.4% of total billed charges for outpatient setting,$143.94 ,90% of total billed charges for outpatient setting,$143.94 ,90% of total billed charges for outpatient setting,$60.77 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$60.77 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$60.77 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$119.95 ,75% of total billed charges for outpatient setting,$135.94 ,85% of total billed charges for outpatient setting,$60.77 ,$148.73 ,$119.95 
Outpatient Medical Services,Radiology,73130,X-ray of the hand with 3 or more views,320,$197.09 ,$177.38 ,90% of total billed charges for outpatient setting,$183.29 ,93% of total billed charges for outpatient setting,$74.89 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$74.89 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$167.53 ,85% of total billed charges for outpatient setting,$74.89 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$160.43 ,81.4% of total billed charges for outpatient setting,$177.38 ,90% of total billed charges for outpatient setting,$177.38 ,90% of total billed charges for outpatient setting,$74.89 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$74.89 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$74.89 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$147.82 ,75% of total billed charges for outpatient setting,$167.53 ,85% of total billed charges for outpatient setting,$74.89 ,$183.29 ,$147.82 
Outpatient Medical Services,Radiology,73140,Radiologic examination of the finger(s),320,$197.09 ,$177.38 ,90% of total billed charges for outpatient setting,$183.29 ,93% of total billed charges for outpatient setting,$74.89 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$74.89 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$167.53 ,85% of total billed charges for outpatient setting,$74.89 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$160.43 ,81.4% of total billed charges for outpatient setting,$177.38 ,90% of total billed charges for outpatient setting,$177.38 ,90% of total billed charges for outpatient setting,$74.89 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$74.89 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$74.89 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$147.82 ,75% of total billed charges for outpatient setting,$167.53 ,85% of total billed charges for outpatient setting,$74.89 ,$183.29 ,$147.82 
Outpatient Medical Services,CT Scan,73200,"CT Upper Ext, w/o contrast",350,$953.96 ,$858.56 ,90% of total billed charges for outpatient setting,$887.18 ,93% of total billed charges for outpatient setting,$362.50 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$362.50 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$500.00 ,100% of CT case rate,$362.50 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$776.52 ,81.4% of total billed charges for outpatient setting,$858.56 ,90% of total billed charges for outpatient setting,$858.56 ,90% of total billed charges for outpatient setting,$362.50 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$362.50 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$362.50 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$715.47 ,75% of total billed charges for outpatient setting,"$1,209.00 ",100% UHC case rate for outpatient setting,$362.50 ,"$1,209.00 ",$715.47 
Outpatient Medical Services,CT Scan,73201,"CT Upper Ext, w/ contrast",350,"$1,096.99 ",$987.29 ,90% of total billed charges for outpatient setting,"$1,020.20 ",93% of total billed charges for outpatient setting,$416.86 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$416.86 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$500.00 ,100% of CT case rate,$416.86 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$892.95 ,81.4% of total billed charges for outpatient setting,$987.29 ,90% of total billed charges for outpatient setting,$987.29 ,90% of total billed charges for outpatient setting,$416.86 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$416.86 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$416.86 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$822.74 ,75% of total billed charges for outpatient setting,"$1,209.00 ",100% UHC case rate for outpatient setting,$416.86 ,"$1,209.00 ",$822.74 
Outpatient Medical Services,CT Scan,73206,CT Angio Upper Extremitiy w/ cont,350,"$1,495.69 ","$1,346.12 ",90% of total billed charges for outpatient setting,"$1,390.99 ",93% of total billed charges for outpatient setting,$568.36 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$568.36 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$500.00 ,100% of CT case rate,$568.36 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,217.49 ",81.4% of total billed charges for outpatient setting,"$1,346.12 ",90% of total billed charges for outpatient setting,"$1,346.12 ",90% of total billed charges for outpatient setting,$568.36 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$568.36 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$568.36 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,121.77 ",75% of total billed charges for outpatient setting,"$1,209.00 ",100% UHC case rate for outpatient setting,$500.00 ,"$1,390.99 ","$1,121.77 "
Outpatient Medical Services,MRI,73218,MRI Bi-lateral Upper Extem Other Than JT,610,"$1,858.35 ","$1,672.52 ",90% of total billed charges for outpatient setting,"$1,728.27 ",93% of total billed charges for outpatient setting,$706.17 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$706.17 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,579.60 ",85% of total billed charges for outpatient setting,$706.17 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,512.70 ",81.4% of total billed charges for outpatient setting,"$1,672.52 ",90% of total billed charges for outpatient setting,"$1,672.52 ",90% of total billed charges for outpatient setting,$706.17 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$706.17 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$706.17 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,393.76 ",75% of total billed charges for outpatient setting,"$1,613.00 ",100% UHC case rate for outpatient setting,$706.17 ,"$1,728.27 ","$1,393.76 "
Outpatient Medical Services,MRI,73218,MRI Upper Extrem Other Than JT,610,"$1,858.35 ","$1,672.52 ",90% of total billed charges for outpatient setting,"$1,728.27 ",93% of total billed charges for outpatient setting,$706.17 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$706.17 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,579.60 ",85% of total billed charges for outpatient setting,$706.17 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,512.70 ",81.4% of total billed charges for outpatient setting,"$1,672.52 ",90% of total billed charges for outpatient setting,"$1,672.52 ",90% of total billed charges for outpatient setting,$706.17 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$706.17 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$706.17 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,393.76 ",75% of total billed charges for outpatient setting,"$1,613.00 ",100% UHC case rate for outpatient setting,$706.17 ,"$1,728.27 ","$1,393.76 "
Outpatient Medical Services,MRI,73220,MRI Upper Ext; w/wo contrast,610,"$3,227.89 ","$2,905.10 ",90% of total billed charges for outpatient setting,"$3,001.94 ",93% of total billed charges for outpatient setting,"$1,226.60 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,226.60 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,743.71 ",85% of total billed charges for outpatient setting,"$1,226.60 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,627.50 ",81.4% of total billed charges for outpatient setting,"$2,905.10 ",90% of total billed charges for outpatient setting,"$2,905.10 ",90% of total billed charges for outpatient setting,"$1,226.60 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,226.60 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,226.60 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,420.92 ",75% of total billed charges for outpatient setting,"$1,613.00 ",100% UHC case rate for outpatient setting,"$1,226.60 ","$3,001.94 ","$2,420.92 "
Outpatient Medical Services,MRI,73221,MRI of upper extremity without dye,610,"$1,858.35 ","$1,672.52 ",90% of total billed charges for outpatient setting,"$1,728.27 ",93% of total billed charges for outpatient setting,$706.17 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$706.17 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,579.60 ",85% of total billed charges for outpatient setting,$706.17 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,512.70 ",81.4% of total billed charges for outpatient setting,"$1,672.52 ",90% of total billed charges for outpatient setting,"$1,672.52 ",90% of total billed charges for outpatient setting,$706.17 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$706.17 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$706.17 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,393.76 ",75% of total billed charges for outpatient setting,"$1,613.00 ",100% UHC case rate for outpatient setting,$706.17 ,"$1,728.27 ","$1,393.76 "
Outpatient Medical Services,MRI,73221,MRI of upper extremity without dye,610,"$1,858.35 ","$1,672.52 ",90% of total billed charges for outpatient setting,"$1,728.27 ",93% of total billed charges for outpatient setting,$706.17 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$706.17 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,579.60 ",85% of total billed charges for outpatient setting,$706.17 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,512.70 ",81.4% of total billed charges for outpatient setting,"$1,672.52 ",90% of total billed charges for outpatient setting,"$1,672.52 ",90% of total billed charges for outpatient setting,$706.17 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$706.17 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$706.17 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,393.76 ",75% of total billed charges for outpatient setting,"$1,613.00 ",100% UHC case rate for outpatient setting,$706.17 ,"$1,728.27 ","$1,393.76 "
Outpatient Medical Services,MRI,73222,"MRI Upper Extrem jt. (Shoulder, Elbow, Wrist w/cont)",610,"$1,858.16 ","$1,672.34 ",90% of total billed charges for outpatient setting,"$1,728.09 ",93% of total billed charges for outpatient setting,$706.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$706.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,579.44 ",85% of total billed charges for outpatient setting,$706.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,512.54 ",81.4% of total billed charges for outpatient setting,"$1,672.34 ",90% of total billed charges for outpatient setting,"$1,672.34 ",90% of total billed charges for outpatient setting,$706.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$706.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$706.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,393.62 ",75% of total billed charges for outpatient setting,"$1,613.00 ",100% UHC case rate for outpatient setting,$706.10 ,"$1,728.09 ","$1,393.62 "
Outpatient Medical Services,MRI,73223,"MRI Upper Extrem jt (Shoulder, Elbow, Wrist w/wo cont)",610,"$1,987.34 ","$1,788.61 ",90% of total billed charges for outpatient setting,"$1,848.23 ",93% of total billed charges for outpatient setting,$755.19 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$755.19 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,689.24 ",85% of total billed charges for outpatient setting,$755.19 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,617.69 ",81.4% of total billed charges for outpatient setting,"$1,788.61 ",90% of total billed charges for outpatient setting,"$1,788.61 ",90% of total billed charges for outpatient setting,$755.19 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$755.19 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$755.19 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,490.51 ",75% of total billed charges for outpatient setting,"$1,613.00 ",100% UHC case rate for outpatient setting,$755.19 ,"$1,848.23 ","$1,490.51 "
Outpatient Medical Services,Radiology,73502,Hip Unilat 2 V w pelvis,320,$243.29 ,$218.96 ,90% of total billed charges for outpatient setting,$226.26 ,93% of total billed charges for outpatient setting,$92.45 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$92.45 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$206.80 ,85% of total billed charges for outpatient setting,$92.45 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$198.04 ,81.4% of total billed charges for outpatient setting,$218.96 ,90% of total billed charges for outpatient setting,$218.96 ,90% of total billed charges for outpatient setting,$92.45 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$92.45 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$92.45 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$182.47 ,75% of total billed charges for outpatient setting,$206.80 ,85% of total billed charges for outpatient setting,$92.45 ,$226.26 ,$182.47 
Outpatient Medical Services,Radiology,73521,Hip Bilat w pelvis  2 views,320,$327.76 ,$294.98 ,90% of total billed charges for outpatient setting,$304.82 ,93% of total billed charges for outpatient setting,$124.55 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$124.55 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$278.60 ,85% of total billed charges for outpatient setting,$124.55 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$266.80 ,81.4% of total billed charges for outpatient setting,$294.98 ,90% of total billed charges for outpatient setting,$294.98 ,90% of total billed charges for outpatient setting,$124.55 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$124.55 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$124.55 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$245.82 ,75% of total billed charges for outpatient setting,$278.60 ,85% of total billed charges for outpatient setting,$124.55 ,$304.82 ,$245.82 
Outpatient Medical Services,Radiology,73560,Radiologic examination of the knee with 1 or 2 views,320,$197.09 ,$177.38 ,90% of total billed charges for outpatient setting,$183.29 ,93% of total billed charges for outpatient setting,$74.89 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$74.89 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$167.53 ,85% of total billed charges for outpatient setting,$74.89 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$160.43 ,81.4% of total billed charges for outpatient setting,$177.38 ,90% of total billed charges for outpatient setting,$177.38 ,90% of total billed charges for outpatient setting,$74.89 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$74.89 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$74.89 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$147.82 ,75% of total billed charges for outpatient setting,$167.53 ,85% of total billed charges for outpatient setting,$74.89 ,$183.29 ,$147.82 
Outpatient Medical Services,Radiology,73564,Radiologic examination of the knee with 4 or more views,320,$254.53 ,$229.08 ,90% of total billed charges for outpatient setting,$236.71 ,93% of total billed charges for outpatient setting,$96.72 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$96.72 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$216.35 ,85% of total billed charges for outpatient setting,$96.72 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$207.19 ,81.4% of total billed charges for outpatient setting,$229.08 ,90% of total billed charges for outpatient setting,$229.08 ,90% of total billed charges for outpatient setting,$96.72 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$96.72 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$96.72 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$190.90 ,75% of total billed charges for outpatient setting,$216.35 ,85% of total billed charges for outpatient setting,$96.72 ,$236.71 ,$190.90 
Outpatient Medical Services,Radiology,73564,Radiologic examination of the knee with 4 or more views,320,$254.53 ,$229.08 ,90% of total billed charges for outpatient setting,$236.71 ,93% of total billed charges for outpatient setting,$96.72 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$96.72 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$216.35 ,85% of total billed charges for outpatient setting,$96.72 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$207.19 ,81.4% of total billed charges for outpatient setting,$229.08 ,90% of total billed charges for outpatient setting,$229.08 ,90% of total billed charges for outpatient setting,$96.72 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$96.72 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$96.72 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$190.90 ,75% of total billed charges for outpatient setting,$216.35 ,85% of total billed charges for outpatient setting,$96.72 ,$236.71 ,$190.90 
Outpatient Medical Services,Radiology,73590,Radiologic examination of the lower leg,320,$217.38 ,$195.64 ,90% of total billed charges for outpatient setting,$202.16 ,93% of total billed charges for outpatient setting,$82.60 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$82.60 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$184.77 ,85% of total billed charges for outpatient setting,$82.60 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$176.95 ,81.4% of total billed charges for outpatient setting,$195.64 ,90% of total billed charges for outpatient setting,$195.64 ,90% of total billed charges for outpatient setting,$82.60 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$82.60 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$82.60 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$163.04 ,75% of total billed charges for outpatient setting,$184.77 ,85% of total billed charges for outpatient setting,$82.60 ,$202.16 ,$163.04 
Outpatient Medical Services,Radiology,73600,Radiologic examination of the ankle with 2 views,320,$145.28 ,$130.75 ,90% of total billed charges for outpatient setting,$135.11 ,93% of total billed charges for outpatient setting,$55.21 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$55.21 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$123.49 ,85% of total billed charges for outpatient setting,$55.21 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$118.26 ,81.4% of total billed charges for outpatient setting,$130.75 ,90% of total billed charges for outpatient setting,$130.75 ,90% of total billed charges for outpatient setting,$55.21 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$55.21 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$55.21 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$108.96 ,75% of total billed charges for outpatient setting,$123.49 ,85% of total billed charges for outpatient setting,$55.21 ,$135.11 ,$108.96 
Outpatient Medical Services,Radiology,73610,Radiologic examination of the ankle with 3 views,320,$218.50 ,$196.65 ,90% of total billed charges for outpatient setting,$203.21 ,93% of total billed charges for outpatient setting,$83.03 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$83.03 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$185.73 ,85% of total billed charges for outpatient setting,$83.03 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$177.86 ,81.4% of total billed charges for outpatient setting,$196.65 ,90% of total billed charges for outpatient setting,$196.65 ,90% of total billed charges for outpatient setting,$83.03 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$83.03 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$83.03 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$163.88 ,75% of total billed charges for outpatient setting,$185.73 ,85% of total billed charges for outpatient setting,$83.03 ,$203.21 ,$163.88 
Outpatient Medical Services,Radiology,73620,"Radiologic examination, foot; 2 views",320,$185.83 ,$167.25 ,90% of total billed charges for outpatient setting,$172.82 ,93% of total billed charges for outpatient setting,$70.62 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$70.62 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$157.96 ,85% of total billed charges for outpatient setting,$70.62 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$151.27 ,81.4% of total billed charges for outpatient setting,$167.25 ,90% of total billed charges for outpatient setting,$167.25 ,90% of total billed charges for outpatient setting,$70.62 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$70.62 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$70.62 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$139.37 ,75% of total billed charges for outpatient setting,$157.96 ,85% of total billed charges for outpatient setting,$70.62 ,$172.82 ,$139.37 
Outpatient Medical Services,Radiology,73630,Radiologic examination of the foot with 3 or more views,320,$216.26 ,$194.63 ,90% of total billed charges for outpatient setting,$201.12 ,93% of total billed charges for outpatient setting,$82.18 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$82.18 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$183.82 ,85% of total billed charges for outpatient setting,$82.18 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$176.04 ,81.4% of total billed charges for outpatient setting,$194.63 ,90% of total billed charges for outpatient setting,$194.63 ,90% of total billed charges for outpatient setting,$82.18 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$82.18 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$82.18 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$162.20 ,75% of total billed charges for outpatient setting,$183.82 ,85% of total billed charges for outpatient setting,$82.18 ,$201.12 ,$162.20 
Outpatient Medical Services,CT Scan,73700,CT scan of leg without dye,350,$679.15 ,$611.24 ,90% of total billed charges for outpatient setting,$631.61 ,93% of total billed charges for outpatient setting,$258.08 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$258.08 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$500.00 ,100% of CT case rate,$258.08 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$552.83 ,81.4% of total billed charges for outpatient setting,$611.24 ,90% of total billed charges for outpatient setting,$611.24 ,90% of total billed charges for outpatient setting,$258.08 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$258.08 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$258.08 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$509.36 ,75% of total billed charges for outpatient setting,"$1,209.00 ",100% UHC case rate for outpatient setting,$258.08 ,"$1,209.00 ",$509.36 
Outpatient Medical Services,CT Scan,73701,"CT Lower Ext, w/ contrast",350,"$1,093.61 ",$984.25 ,90% of total billed charges for outpatient setting,"$1,017.06 ",93% of total billed charges for outpatient setting,$415.57 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$415.57 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$500.00 ,100% of CT case rate,$415.57 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$890.20 ,81.4% of total billed charges for outpatient setting,$984.25 ,90% of total billed charges for outpatient setting,$984.25 ,90% of total billed charges for outpatient setting,$415.57 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$415.57 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$415.57 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$820.21 ,75% of total billed charges for outpatient setting,"$1,209.00 ",100% UHC case rate for outpatient setting,$415.57 ,"$1,209.00 ",$820.21 
Outpatient Medical Services,CT Scan,73706,CT Angio Lower Extrem w/ cont,350,"$1,189.35 ","$1,070.42 ",90% of total billed charges for outpatient setting,"$1,106.10 ",93% of total billed charges for outpatient setting,$451.95 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$451.95 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$500.00 ,100% of CT case rate,$451.95 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$968.13 ,81.4% of total billed charges for outpatient setting,"$1,070.42 ",90% of total billed charges for outpatient setting,"$1,070.42 ",90% of total billed charges for outpatient setting,$451.95 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$451.95 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$451.95 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$892.01 ,75% of total billed charges for outpatient setting,"$1,209.00 ",100% UHC case rate for outpatient setting,$451.95 ,"$1,209.00 ",$892.01 
Outpatient Medical Services,MRI,73718,MRI of leg without dye,610,"$2,540.88 ","$2,286.79 ",90% of total billed charges for outpatient setting,"$2,363.02 ",93% of total billed charges for outpatient setting,$965.53 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$965.53 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,159.75 ",85% of total billed charges for outpatient setting,$965.53 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,068.28 ",81.4% of total billed charges for outpatient setting,"$2,286.79 ",90% of total billed charges for outpatient setting,"$2,286.79 ",90% of total billed charges for outpatient setting,$965.53 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$965.53 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$965.53 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,905.66 ",75% of total billed charges for outpatient setting,"$1,613.00 ",100% UHC case rate for outpatient setting,$965.53 ,"$2,363.02 ","$1,905.66 "
Outpatient Medical Services,MRI,73718,MRI of leg without dye,610,"$2,540.88 ","$2,286.79 ",90% of total billed charges for outpatient setting,"$2,363.02 ",93% of total billed charges for outpatient setting,$965.53 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$965.53 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,159.75 ",85% of total billed charges for outpatient setting,$965.53 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,068.28 ",81.4% of total billed charges for outpatient setting,"$2,286.79 ",90% of total billed charges for outpatient setting,"$2,286.79 ",90% of total billed charges for outpatient setting,$965.53 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$965.53 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$965.53 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,905.66 ",75% of total billed charges for outpatient setting,"$1,613.00 ",100% UHC case rate for outpatient setting,$965.53 ,"$2,363.02 ","$1,905.66 "
Outpatient Medical Services,MRI,73720,MRI Lower Ext; Other/Than Jt. w/wo contrast,610,"$4,124.42 ","$3,711.98 ",90% of total billed charges for outpatient setting,"$3,835.71 ",93% of total billed charges for outpatient setting,"$1,567.28 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,567.28 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$3,505.76 ",85% of total billed charges for outpatient setting,"$1,567.28 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$3,357.28 ",81.4% of total billed charges for outpatient setting,"$3,711.98 ",90% of total billed charges for outpatient setting,"$3,711.98 ",90% of total billed charges for outpatient setting,"$1,567.28 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,567.28 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,567.28 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$3,093.32 ",75% of total billed charges for outpatient setting,"$1,613.00 ",100% UHC case rate for outpatient setting,"$1,567.28 ","$3,835.71 ","$3,093.32 "
Outpatient Medical Services,MRI,73721,MRI of lower extremity joint (knee/ankle) without dye,610,"$2,958.72 ","$2,662.85 ",90% of total billed charges for outpatient setting,"$2,751.61 ",93% of total billed charges for outpatient setting,"$1,124.31 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,124.31 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,514.91 ",85% of total billed charges for outpatient setting,"$1,124.31 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,408.40 ",81.4% of total billed charges for outpatient setting,"$2,662.85 ",90% of total billed charges for outpatient setting,"$2,662.85 ",90% of total billed charges for outpatient setting,"$1,124.31 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,124.31 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,124.31 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,219.04 ",75% of total billed charges for outpatient setting,"$1,613.00 ",100% UHC case rate for outpatient setting,"$1,124.31 ","$2,751.61 ","$2,219.04 "
Outpatient Medical Services,MRI,73721,MRI of lower extremity joint (knee/ankle) without dye,610,"$2,958.72 ","$2,662.85 ",90% of total billed charges for outpatient setting,"$2,751.61 ",93% of total billed charges for outpatient setting,"$1,124.31 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,124.31 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,514.91 ",85% of total billed charges for outpatient setting,"$1,124.31 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,408.40 ",81.4% of total billed charges for outpatient setting,"$2,662.85 ",90% of total billed charges for outpatient setting,"$2,662.85 ",90% of total billed charges for outpatient setting,"$1,124.31 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,124.31 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,124.31 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,219.04 ",75% of total billed charges for outpatient setting,"$1,613.00 ",100% UHC case rate for outpatient setting,"$1,124.31 ","$2,751.61 ","$2,219.04 "
Outpatient Medical Services,MRI,73722,MRI of lower extremity joint (knee/ankle) with dye,610,"$2,981.02 ","$2,682.92 ",90% of total billed charges for outpatient setting,"$2,772.35 ",93% of total billed charges for outpatient setting,"$1,132.79 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,132.79 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,533.87 ",85% of total billed charges for outpatient setting,"$1,132.79 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,426.55 ",81.4% of total billed charges for outpatient setting,"$2,682.92 ",90% of total billed charges for outpatient setting,"$2,682.92 ",90% of total billed charges for outpatient setting,"$1,132.79 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,132.79 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,132.79 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,235.77 ",75% of total billed charges for outpatient setting,"$1,613.00 ",100% UHC case rate for outpatient setting,"$1,132.79 ","$2,772.35 ","$2,235.77 "
Outpatient Medical Services,MRI,73723,MRI of lower extremity joint (knee/ankle) with and without dye,610,"$3,091.43 ","$2,782.29 ",90% of total billed charges for outpatient setting,"$2,875.03 ",93% of total billed charges for outpatient setting,"$1,174.74 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,174.74 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,627.72 ",85% of total billed charges for outpatient setting,"$1,174.74 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,516.42 ",81.4% of total billed charges for outpatient setting,"$2,782.29 ",90% of total billed charges for outpatient setting,"$2,782.29 ",90% of total billed charges for outpatient setting,"$1,174.74 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,174.74 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,174.74 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,318.57 ",75% of total billed charges for outpatient setting,"$1,613.00 ",100% UHC case rate for outpatient setting,"$1,174.74 ","$2,875.03 ","$2,318.57 "
Outpatient Medical Services,Radiology,74018,Abdomen 1 V(KUB or Upright),320,$191.47 ,$172.32 ,90% of total billed charges for outpatient setting,$178.07 ,93% of total billed charges for outpatient setting,$72.76 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$72.76 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$162.75 ,85% of total billed charges for outpatient setting,$72.76 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$155.86 ,81.4% of total billed charges for outpatient setting,$172.32 ,90% of total billed charges for outpatient setting,$172.32 ,90% of total billed charges for outpatient setting,$72.76 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$72.76 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$72.76 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$143.60 ,75% of total billed charges for outpatient setting,$162.75 ,85% of total billed charges for outpatient setting,$72.76 ,$178.07 ,$143.60 
Outpatient Medical Services,Radiology,74019,Abdomen 2 V,320,$245.53 ,$220.98 ,90% of total billed charges for outpatient setting,$228.34 ,93% of total billed charges for outpatient setting,$93.30 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$93.30 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$208.70 ,85% of total billed charges for outpatient setting,$93.30 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$199.86 ,81.4% of total billed charges for outpatient setting,$220.98 ,90% of total billed charges for outpatient setting,$220.98 ,90% of total billed charges for outpatient setting,$93.30 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$93.30 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$93.30 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$184.15 ,75% of total billed charges for outpatient setting,$208.70 ,85% of total billed charges for outpatient setting,$93.30 ,$228.34 ,$184.15 
Outpatient Medical Services,Radiology,74022,Serial radiologic examination of the abdomen,320,$331.13 ,$298.02 ,90% of total billed charges for outpatient setting,$307.95 ,93% of total billed charges for outpatient setting,$125.83 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$125.83 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$281.46 ,85% of total billed charges for outpatient setting,$125.83 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$269.54 ,81.4% of total billed charges for outpatient setting,$298.02 ,90% of total billed charges for outpatient setting,$298.02 ,90% of total billed charges for outpatient setting,$125.83 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$125.83 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$125.83 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$248.35 ,75% of total billed charges for outpatient setting,$281.46 ,85% of total billed charges for outpatient setting,$125.83 ,$307.95 ,$248.35 
Outpatient Medical Services,CT Scan,74150,CT of abdomen without dye,350,"$1,419.12 ","$1,277.21 ",90% of total billed charges for outpatient setting,"$1,319.78 ",93% of total billed charges for outpatient setting,$539.27 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$539.27 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$500.00 ,100% of CT case rate,$539.27 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,155.16 ",81.4% of total billed charges for outpatient setting,"$1,277.21 ",90% of total billed charges for outpatient setting,"$1,277.21 ",90% of total billed charges for outpatient setting,$539.27 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$539.27 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$539.27 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,064.34 ",75% of total billed charges for outpatient setting,"$1,209.00 ",100% UHC case rate for outpatient setting,$500.00 ,"$1,319.78 ","$1,064.34 "
Outpatient Medical Services,CT Scan,74160,CT of abdomen with dye,350,"$1,634.23 ","$1,470.81 ",90% of total billed charges for outpatient setting,"$1,519.83 ",93% of total billed charges for outpatient setting,$621.01 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$621.01 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$500.00 ,100% of CT case rate,$621.01 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,330.26 ",81.4% of total billed charges for outpatient setting,"$1,470.81 ",90% of total billed charges for outpatient setting,"$1,470.81 ",90% of total billed charges for outpatient setting,$621.01 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$621.01 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$621.01 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,225.67 ",75% of total billed charges for outpatient setting,"$1,209.00 ",100% UHC case rate for outpatient setting,$500.00 ,"$1,519.83 ","$1,225.67 "
Outpatient Medical Services,CT Scan,74170,CT of abdomen with and without dye,350,"$2,964.34 ","$2,667.91 ",90% of total billed charges for outpatient setting,"$2,756.84 ",93% of total billed charges for outpatient setting,"$1,126.45 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,126.45 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$500.00 ,100% of CT case rate,"$1,126.45 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,412.97 ",81.4% of total billed charges for outpatient setting,"$2,667.91 ",90% of total billed charges for outpatient setting,"$2,667.91 ",90% of total billed charges for outpatient setting,"$1,126.45 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,126.45 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,126.45 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,223.26 ",75% of total billed charges for outpatient setting,"$1,209.00 ",100% UHC case rate for outpatient setting,$500.00 ,"$2,756.84 ","$2,223.26 "
Outpatient Medical Services,CT Scan,74175,CT Angio ABD  - AAA Protocol,350,"$1,977.74 ","$1,779.97 ",90% of total billed charges for outpatient setting,"$1,839.30 ",93% of total billed charges for outpatient setting,$751.54 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$751.54 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$500.00 ,100% of CT case rate,$751.54 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,609.88 ",81.4% of total billed charges for outpatient setting,"$1,779.97 ",90% of total billed charges for outpatient setting,"$1,779.97 ",90% of total billed charges for outpatient setting,$751.54 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$751.54 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$751.54 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,483.31 ",75% of total billed charges for outpatient setting,"$1,209.00 ",100% UHC case rate for outpatient setting,$500.00 ,"$1,839.30 ","$1,483.31 "
Outpatient Medical Services,CT Scan,74176,CT of abdomen and pelvis without dye,350,"$2,460.91 ","$2,214.82 ",90% of total billed charges for outpatient setting,"$2,288.65 ",93% of total billed charges for outpatient setting,$935.15 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$935.15 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$500.00 ,100% of CT case rate,$935.15 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,003.18 ",81.4% of total billed charges for outpatient setting,"$2,214.82 ",90% of total billed charges for outpatient setting,"$2,214.82 ",90% of total billed charges for outpatient setting,$935.15 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$935.15 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$935.15 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,845.68 ",75% of total billed charges for outpatient setting,"$1,209.00 ",100% UHC case rate for outpatient setting,$500.00 ,"$2,288.65 ","$1,845.68 "
Outpatient Medical Services,CT Scan,74177,CT scan of abdomen and pelvis with contrast,350,"$2,695.17 ","$2,425.65 ",90% of total billed charges for outpatient setting,"$2,506.51 ",93% of total billed charges for outpatient setting,"$1,024.16 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,024.16 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$500.00 ,100% of CT case rate,"$1,024.16 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,193.87 ",81.4% of total billed charges for outpatient setting,"$2,425.65 ",90% of total billed charges for outpatient setting,"$2,425.65 ",90% of total billed charges for outpatient setting,"$1,024.16 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,024.16 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,024.16 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,021.38 ",75% of total billed charges for outpatient setting,"$1,209.00 ",100% UHC case rate for outpatient setting,$500.00 ,"$2,506.51 ","$2,021.38 "
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 ",350,"$3,516.23 ","$3,164.61 ",90% of total billed charges for outpatient setting,"$3,270.09 ",93% of total billed charges for outpatient setting,"$1,336.17 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,336.17 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$500.00 ,100% of CT case rate,"$1,336.17 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,862.21 ",81.4% of total billed charges for outpatient setting,"$3,164.61 ",90% of total billed charges for outpatient setting,"$3,164.61 ",90% of total billed charges for outpatient setting,"$1,336.17 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,336.17 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,336.17 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,637.17 ",75% of total billed charges for outpatient setting,"$1,209.00 ",100% UHC case rate for outpatient setting,$500.00 ,"$3,270.09 ","$2,637.17 "
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 ",350,"$3,516.23 ","$3,164.61 ",90% of total billed charges for outpatient setting,"$3,270.09 ",93% of total billed charges for outpatient setting,"$1,336.17 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,336.17 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$500.00 ,100% of CT case rate,"$1,336.17 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,862.21 ",81.4% of total billed charges for outpatient setting,"$3,164.61 ",90% of total billed charges for outpatient setting,"$3,164.61 ",90% of total billed charges for outpatient setting,"$1,336.17 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,336.17 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,336.17 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,637.17 ",75% of total billed charges for outpatient setting,"$1,209.00 ",100% UHC case rate for outpatient setting,$500.00 ,"$3,270.09 ","$2,637.17 "
Outpatient Medical Services,MRI,74181,MRI of abdomen without dye,610,"$3,099.50 ","$2,789.55 ",90% of total billed charges for outpatient setting,"$2,882.54 ",93% of total billed charges for outpatient setting,"$1,177.81 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,177.81 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,634.58 ",85% of total billed charges for outpatient setting,"$1,177.81 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,522.99 ",81.4% of total billed charges for outpatient setting,"$2,789.55 ",90% of total billed charges for outpatient setting,"$2,789.55 ",90% of total billed charges for outpatient setting,"$1,177.81 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,177.81 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,177.81 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,324.63 ",75% of total billed charges for outpatient setting,"$1,613.00 ",100% UHC case rate for outpatient setting,"$1,177.81 ","$2,882.54 ","$2,324.63 "
Outpatient Medical Services,MRI,74182,MRI Abd w/ contrast,610,"$3,327.02 ","$2,994.32 ",90% of total billed charges for outpatient setting,"$3,094.13 ",93% of total billed charges for outpatient setting,"$1,264.27 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,264.27 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,827.97 ",85% of total billed charges for outpatient setting,"$1,264.27 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,708.19 ",81.4% of total billed charges for outpatient setting,"$2,994.32 ",90% of total billed charges for outpatient setting,"$2,994.32 ",90% of total billed charges for outpatient setting,"$1,264.27 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,264.27 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,264.27 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,495.27 ",75% of total billed charges for outpatient setting,"$1,613.00 ",100% UHC case rate for outpatient setting,"$1,264.27 ","$3,094.13 ","$2,495.27 "
Outpatient Medical Services,MRI,74183,MRI of abdomen without and with dye,610,"$4,132.31 ","$3,719.08 ",90% of total billed charges for outpatient setting,"$3,843.05 ",93% of total billed charges for outpatient setting,"$1,570.28 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,570.28 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$3,512.46 ",85% of total billed charges for outpatient setting,"$1,570.28 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$3,363.70 ",81.4% of total billed charges for outpatient setting,"$3,719.08 ",90% of total billed charges for outpatient setting,"$3,719.08 ",90% of total billed charges for outpatient setting,"$1,570.28 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,570.28 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,570.28 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$3,099.23 ",75% of total billed charges for outpatient setting,"$1,613.00 ",100% UHC case rate for outpatient setting,"$1,570.28 ","$3,843.05 ","$3,099.23 "
Outpatient Medical Services,CT Scan,75571,CT Heart (Calcium Scores),350,$104.04 ,$93.64 ,90% of total billed charges for outpatient setting,$96.76 ,93% of total billed charges for outpatient setting,$39.54 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$39.54 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$500.00 ,100% of CT case rate,$39.54 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$84.69 ,81.4% of total billed charges for outpatient setting,$93.64 ,90% of total billed charges for outpatient setting,$93.64 ,90% of total billed charges for outpatient setting,$39.54 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$39.54 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$39.54 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$78.03 ,75% of total billed charges for outpatient setting,"$1,209.00 ",100% UHC case rate for outpatient setting,$39.54 ,"$1,209.00 ",$78.03 
Outpatient Medical Services,Ultrasound,76536,Ultrasound of head and neck,402,$549.64 ,$494.68 ,90% of total billed charges for outpatient setting,$511.17 ,93% of total billed charges for outpatient setting,$208.86 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$208.86 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$467.19 ,85% of total billed charges for outpatient setting,$208.86 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$447.41 ,81.4% of total billed charges for outpatient setting,$494.68 ,90% of total billed charges for outpatient setting,$494.68 ,90% of total billed charges for outpatient setting,$208.86 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$208.86 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$208.86 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$412.23 ,75% of total billed charges for outpatient setting,$467.19 ,85% of total billed charges for outpatient setting,$208.86 ,$511.17 ,$412.23 
Outpatient Medical Services,Ultrasound,76604,"US Chest, lim, nonvas",402,$296.21 ,$266.59 ,90% of total billed charges for outpatient setting,$275.48 ,93% of total billed charges for outpatient setting,$112.56 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$112.56 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$251.78 ,85% of total billed charges for outpatient setting,$112.56 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$241.11 ,81.4% of total billed charges for outpatient setting,$266.59 ,90% of total billed charges for outpatient setting,$266.59 ,90% of total billed charges for outpatient setting,$112.56 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$112.56 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$112.56 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$222.16 ,75% of total billed charges for outpatient setting,$251.78 ,85% of total billed charges for outpatient setting,$112.56 ,$275.48 ,$222.16 
Outpatient Medical Services,Ultrasound,76641,US Breast Soft Tissue,402,$453.89 ,$408.50 ,90% of total billed charges for outpatient setting,$422.12 ,93% of total billed charges for outpatient setting,$172.48 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$172.48 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$385.81 ,85% of total billed charges for outpatient setting,$172.48 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$369.47 ,81.4% of total billed charges for outpatient setting,$408.50 ,90% of total billed charges for outpatient setting,$408.50 ,90% of total billed charges for outpatient setting,$172.48 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$172.48 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$172.48 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$340.42 ,75% of total billed charges for outpatient setting,$385.81 ,85% of total billed charges for outpatient setting,$172.48 ,$422.12 ,$340.42 
Outpatient Medical Services,Ultrasound,76700,Ultrasound of abdomen with all areas scanned,402,$950.56 ,$855.50 ,90% of total billed charges for outpatient setting,$884.02 ,93% of total billed charges for outpatient setting,$361.21 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$361.21 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$807.98 ,85% of total billed charges for outpatient setting,$361.21 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$773.76 ,81.4% of total billed charges for outpatient setting,$855.50 ,90% of total billed charges for outpatient setting,$855.50 ,90% of total billed charges for outpatient setting,$361.21 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$361.21 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$361.21 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$712.92 ,75% of total billed charges for outpatient setting,$807.98 ,85% of total billed charges for outpatient setting,$361.21 ,$884.02 ,$712.92 
Outpatient Medical Services,Ultrasound,76705,A diagnostic procedure that allows a provider to see the organs and other structures in the abdomen,402,$449.38 ,$404.44 ,90% of total billed charges for outpatient setting,$417.92 ,93% of total billed charges for outpatient setting,$170.76 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$170.76 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$381.97 ,85% of total billed charges for outpatient setting,$170.76 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$365.80 ,81.4% of total billed charges for outpatient setting,$404.44 ,90% of total billed charges for outpatient setting,$404.44 ,90% of total billed charges for outpatient setting,$170.76 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$170.76 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$170.76 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$337.04 ,75% of total billed charges for outpatient setting,$381.97 ,85% of total billed charges for outpatient setting,$170.76 ,$417.92 ,$337.04 
Outpatient Medical Services,Ultrasound,76770,Ultrasound of back wall of the abdomen with all areas viewed,402,$549.64 ,$494.68 ,90% of total billed charges for outpatient setting,$511.17 ,93% of total billed charges for outpatient setting,$208.86 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$208.86 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$467.19 ,85% of total billed charges for outpatient setting,$208.86 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$447.41 ,81.4% of total billed charges for outpatient setting,$494.68 ,90% of total billed charges for outpatient setting,$494.68 ,90% of total billed charges for outpatient setting,$208.86 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$208.86 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$208.86 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$412.23 ,75% of total billed charges for outpatient setting,$467.19 ,85% of total billed charges for outpatient setting,$208.86 ,$511.17 ,$412.23 
Outpatient Medical Services,Ultrasound,76801,Abdominal ultrasound of pregnant uterus (less than 14 weeks) single or first fetus,402,$505.69 ,$455.12 ,90% of total billed charges for outpatient setting,$470.29 ,93% of total billed charges for outpatient setting,$192.16 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$192.16 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$429.84 ,85% of total billed charges for outpatient setting,$192.16 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$411.63 ,81.4% of total billed charges for outpatient setting,$455.12 ,90% of total billed charges for outpatient setting,$455.12 ,90% of total billed charges for outpatient setting,$192.16 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$192.16 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$192.16 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$379.27 ,75% of total billed charges for outpatient setting,$429.84 ,85% of total billed charges for outpatient setting,$192.16 ,$470.29 ,$379.27 
Outpatient Medical Services,Ultrasound,76811,Ultrasound of single fetus,402,$515.83 ,$464.25 ,90% of total billed charges for outpatient setting,$479.72 ,93% of total billed charges for outpatient setting,$196.02 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$196.02 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$438.46 ,85% of total billed charges for outpatient setting,$196.02 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$419.89 ,81.4% of total billed charges for outpatient setting,$464.25 ,90% of total billed charges for outpatient setting,$464.25 ,90% of total billed charges for outpatient setting,$196.02 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$196.02 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$196.02 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$386.87 ,75% of total billed charges for outpatient setting,$438.46 ,85% of total billed charges for outpatient setting,$196.02 ,$479.72 ,$386.87 
Outpatient Medical Services,Ultrasound,76812,US OB Complete (Twin) Add,402,$394.20 ,$354.78 ,90% of total billed charges for outpatient setting,$366.61 ,93% of total billed charges for outpatient setting,$149.80 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$149.80 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$335.07 ,85% of total billed charges for outpatient setting,$149.80 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$320.88 ,81.4% of total billed charges for outpatient setting,$354.78 ,90% of total billed charges for outpatient setting,$354.78 ,90% of total billed charges for outpatient setting,$149.80 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$149.80 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$149.80 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$295.65 ,75% of total billed charges for outpatient setting,$335.07 ,85% of total billed charges for outpatient setting,$149.80 ,$366.61 ,$295.65 
Outpatient Medical Services,Ultrasound,76815,Ultrasound of fetus with limited views,402,$366.04 ,$329.44 ,90% of total billed charges for outpatient setting,$340.42 ,93% of total billed charges for outpatient setting,$139.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$139.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$311.13 ,85% of total billed charges for outpatient setting,$139.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$297.96 ,81.4% of total billed charges for outpatient setting,$329.44 ,90% of total billed charges for outpatient setting,$329.44 ,90% of total billed charges for outpatient setting,$139.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$139.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$139.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$274.53 ,75% of total billed charges for outpatient setting,$311.13 ,85% of total billed charges for outpatient setting,$139.10 ,$340.42 ,$274.53 
Outpatient Medical Services,Ultrasound,76816,US OB Follow-up,402,$407.71 ,$366.94 ,90% of total billed charges for outpatient setting,$379.17 ,93% of total billed charges for outpatient setting,$154.93 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$154.93 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$346.55 ,85% of total billed charges for outpatient setting,$154.93 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$331.88 ,81.4% of total billed charges for outpatient setting,$366.94 ,90% of total billed charges for outpatient setting,$366.94 ,90% of total billed charges for outpatient setting,$154.93 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$154.93 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$154.93 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$305.78 ,75% of total billed charges for outpatient setting,$346.55 ,85% of total billed charges for outpatient setting,$154.93 ,$379.17 ,$305.78 
Outpatient Medical Services,Ultrasound,76817,Transvaginal ultrasound of uterus,402,$430.24 ,$387.22 ,90% of total billed charges for outpatient setting,$400.12 ,93% of total billed charges for outpatient setting,$163.49 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$163.49 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$365.70 ,85% of total billed charges for outpatient setting,$163.49 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$350.22 ,81.4% of total billed charges for outpatient setting,$387.22 ,90% of total billed charges for outpatient setting,$387.22 ,90% of total billed charges for outpatient setting,$163.49 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$163.49 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$163.49 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$322.68 ,75% of total billed charges for outpatient setting,$365.70 ,85% of total billed charges for outpatient setting,$163.49 ,$400.12 ,$322.68 
Outpatient Medical Services,Ultrasound,76830,Ultrasound of the pelvis through vagina,402,$280.44 ,$252.40 ,90% of total billed charges for outpatient setting,$260.81 ,93% of total billed charges for outpatient setting,$106.57 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$106.57 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$238.37 ,85% of total billed charges for outpatient setting,$106.57 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$228.28 ,81.4% of total billed charges for outpatient setting,$252.40 ,90% of total billed charges for outpatient setting,$252.40 ,90% of total billed charges for outpatient setting,$106.57 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$106.57 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$106.57 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$210.33 ,75% of total billed charges for outpatient setting,$238.37 ,85% of total billed charges for outpatient setting,$106.57 ,$260.81 ,$210.33 
Outpatient Medical Services,Ultrasound,76856,Complete ultrasound of the pelvis,402,$520.34 ,$468.31 ,90% of total billed charges for outpatient setting,$483.92 ,93% of total billed charges for outpatient setting,$197.73 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$197.73 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$442.29 ,85% of total billed charges for outpatient setting,$197.73 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$423.56 ,81.4% of total billed charges for outpatient setting,$468.31 ,90% of total billed charges for outpatient setting,$468.31 ,90% of total billed charges for outpatient setting,$197.73 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$197.73 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$197.73 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$390.26 ,75% of total billed charges for outpatient setting,$442.29 ,85% of total billed charges for outpatient setting,$197.73 ,$483.92 ,$390.26 
Outpatient Medical Services,Ultrasound,76857,Limited ultrasound of the pelvis,402,$398.70 ,$358.83 ,90% of total billed charges for outpatient setting,$370.79 ,93% of total billed charges for outpatient setting,$151.51 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$151.51 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$338.90 ,85% of total billed charges for outpatient setting,$151.51 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$324.54 ,81.4% of total billed charges for outpatient setting,$358.83 ,90% of total billed charges for outpatient setting,$358.83 ,90% of total billed charges for outpatient setting,$151.51 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$151.51 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$151.51 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$299.03 ,75% of total billed charges for outpatient setting,$338.90 ,85% of total billed charges for outpatient setting,$151.51 ,$370.79 ,$299.03 
Outpatient Medical Services,Ultrasound,76870,Ultrasound of the scrotum,402,$555.25 ,$499.73 ,90% of total billed charges for outpatient setting,$516.38 ,93% of total billed charges for outpatient setting,$211.00 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$211.00 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$471.96 ,85% of total billed charges for outpatient setting,$211.00 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$451.97 ,81.4% of total billed charges for outpatient setting,$499.73 ,90% of total billed charges for outpatient setting,$499.73 ,90% of total billed charges for outpatient setting,$211.00 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$211.00 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$211.00 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$416.44 ,75% of total billed charges for outpatient setting,$471.96 ,85% of total billed charges for outpatient setting,$211.00 ,$516.38 ,$416.44 
Outpatient Medical Services,Ultrasound,76873,US Prostate Volume  Transrectal,402,$568.76 ,$511.88 ,90% of total billed charges for outpatient setting,$528.95 ,93% of total billed charges for outpatient setting,$216.13 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$216.13 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$483.45 ,85% of total billed charges for outpatient setting,$216.13 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$462.97 ,81.4% of total billed charges for outpatient setting,$511.88 ,90% of total billed charges for outpatient setting,$511.88 ,90% of total billed charges for outpatient setting,$216.13 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$216.13 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$216.13 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$426.57 ,75% of total billed charges for outpatient setting,$483.45 ,85% of total billed charges for outpatient setting,$216.13 ,$528.95 ,$426.57 
Outpatient Medical Services,Ultrasound,76882,"Diagnostic ultrasound of an extremity excluding the bone, joints or vessels",402,$435.87 ,$392.28 ,90% of total billed charges for outpatient setting,$405.36 ,93% of total billed charges for outpatient setting,$165.63 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$165.63 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$370.49 ,85% of total billed charges for outpatient setting,$165.63 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$354.80 ,81.4% of total billed charges for outpatient setting,$392.28 ,90% of total billed charges for outpatient setting,$392.28 ,90% of total billed charges for outpatient setting,$165.63 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$165.63 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$165.63 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$326.90 ,75% of total billed charges for outpatient setting,$370.49 ,85% of total billed charges for outpatient setting,$165.63 ,$405.36 ,$326.90 
Outpatient Medical Services,Ultrasound,76942,US GUIDANCE AND NEEDLE PLACEMENT,402,$224.12 ,$201.71 ,90% of total billed charges for outpatient setting,$208.43 ,93% of total billed charges for outpatient setting,$85.17 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$85.17 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$190.50 ,85% of total billed charges for outpatient setting,$85.17 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$182.43 ,81.4% of total billed charges for outpatient setting,$201.71 ,90% of total billed charges for outpatient setting,$201.71 ,90% of total billed charges for outpatient setting,$85.17 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$85.17 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$85.17 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$168.09 ,75% of total billed charges for outpatient setting,$190.50 ,85% of total billed charges for outpatient setting,$85.17 ,$208.43 ,$168.09 
Outpatient Medical Services,Laboratory,80048,Basic metabolic panel,300,$93.48 ,$84.13 ,90% of total billed charges for outpatient setting,$86.94 ,93% of total billed charges for outpatient setting,$35.52 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$35.52 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$79.46 ,85% of total billed charges for outpatient setting,$35.52 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$76.09 ,81.4% of total billed charges for outpatient setting,$84.13 ,90% of total billed charges for outpatient setting,$84.13 ,90% of total billed charges for outpatient setting,$35.52 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$35.52 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$35.52 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$70.11 ,75% of total billed charges for outpatient setting,$79.46 ,85% of total billed charges for outpatient setting,$35.52 ,$86.94 ,$70.11 
Outpatient Medical Services,Laboratory,80053,"Blood test, comprehensive group of blood chemicals",300,$188.11 ,$169.30 ,90% of total billed charges for outpatient setting,$174.94 ,93% of total billed charges for outpatient setting,$71.48 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$71.48 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$159.89 ,85% of total billed charges for outpatient setting,$71.48 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$153.12 ,81.4% of total billed charges for outpatient setting,$169.30 ,90% of total billed charges for outpatient setting,$169.30 ,90% of total billed charges for outpatient setting,$71.48 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$71.48 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$71.48 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$141.08 ,75% of total billed charges for outpatient setting,$159.89 ,85% of total billed charges for outpatient setting,$71.48 ,$174.94 ,$141.08 
Outpatient Medical Services,Laboratory,80055,Obstetric blood test panel,300,$193.72 ,$174.35 ,90% of total billed charges for outpatient setting,$180.16 ,93% of total billed charges for outpatient setting,$73.61 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$73.61 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$164.66 ,85% of total billed charges for outpatient setting,$73.61 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$157.69 ,81.4% of total billed charges for outpatient setting,$174.35 ,90% of total billed charges for outpatient setting,$174.35 ,90% of total billed charges for outpatient setting,$73.61 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$73.61 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$73.61 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$145.29 ,75% of total billed charges for outpatient setting,$164.66 ,85% of total billed charges for outpatient setting,$73.61 ,$180.16 ,$145.29 
Outpatient Medical Services,Laboratory,80061,"Blood test, lipids (cholesterol and triglycerides)",300,$103.61 ,$93.25 ,90% of total billed charges for outpatient setting,$96.36 ,93% of total billed charges for outpatient setting,$39.37 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$39.37 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$88.07 ,85% of total billed charges for outpatient setting,$39.37 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$84.34 ,81.4% of total billed charges for outpatient setting,$93.25 ,90% of total billed charges for outpatient setting,$93.25 ,90% of total billed charges for outpatient setting,$39.37 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$39.37 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$39.37 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$77.71 ,75% of total billed charges for outpatient setting,$88.07 ,85% of total billed charges for outpatient setting,$39.37 ,$96.36 ,$77.71 
Outpatient Medical Services,Laboratory,80069,Kidney function panel test,300,$68.70 ,$61.83 ,90% of total billed charges for outpatient setting,$63.89 ,93% of total billed charges for outpatient setting,$26.11 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$26.11 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$58.40 ,85% of total billed charges for outpatient setting,$26.11 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$55.92 ,81.4% of total billed charges for outpatient setting,$61.83 ,90% of total billed charges for outpatient setting,$61.83 ,90% of total billed charges for outpatient setting,$26.11 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$26.11 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$26.11 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$51.53 ,75% of total billed charges for outpatient setting,$58.40 ,85% of total billed charges for outpatient setting,$26.11 ,$63.89 ,$51.53 
Outpatient Medical Services,Laboratory,80074,Acute hepatitis panel,300,$546.41 ,$491.77 ,90% of total billed charges for outpatient setting,$508.16 ,93% of total billed charges for outpatient setting,$207.64 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$207.64 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$464.45 ,85% of total billed charges for outpatient setting,$207.64 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$444.78 ,81.4% of total billed charges for outpatient setting,$491.77 ,90% of total billed charges for outpatient setting,$491.77 ,90% of total billed charges for outpatient setting,$207.64 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$207.64 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$207.64 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$409.81 ,75% of total billed charges for outpatient setting,$464.45 ,85% of total billed charges for outpatient setting,$207.64 ,$508.16 ,$409.81 
Outpatient Medical Services,Laboratory,80076,Liver function blood test panel,300,$123.88 ,$111.49 ,90% of total billed charges for outpatient setting,$115.21 ,93% of total billed charges for outpatient setting,$47.07 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$47.07 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$105.30 ,85% of total billed charges for outpatient setting,$47.07 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$100.84 ,81.4% of total billed charges for outpatient setting,$111.49 ,90% of total billed charges for outpatient setting,$111.49 ,90% of total billed charges for outpatient setting,$47.07 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$47.07 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$47.07 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$92.91 ,75% of total billed charges for outpatient setting,$105.30 ,85% of total billed charges for outpatient setting,$47.07 ,$115.21 ,$92.91 
Outpatient Medical Services,Laboratory,80164,Valproic Acid (DEPAKOTE),300,$51.82 ,$46.64 ,90% of total billed charges for outpatient setting,$48.19 ,93% of total billed charges for outpatient setting,$19.69 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$19.69 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$44.05 ,85% of total billed charges for outpatient setting,$19.69 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$42.18 ,81.4% of total billed charges for outpatient setting,$46.64 ,90% of total billed charges for outpatient setting,$46.64 ,90% of total billed charges for outpatient setting,$19.69 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$19.69 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$19.69 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$38.87 ,75% of total billed charges for outpatient setting,$44.05 ,85% of total billed charges for outpatient setting,$19.69 ,$48.19 ,$38.87 
Outpatient Medical Services,Laboratory,80202,Vancomycin,300,$116.00 ,$104.40 ,90% of total billed charges for outpatient setting,$107.88 ,93% of total billed charges for outpatient setting,$44.08 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$44.08 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$98.60 ,85% of total billed charges for outpatient setting,$44.08 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$94.42 ,81.4% of total billed charges for outpatient setting,$104.40 ,90% of total billed charges for outpatient setting,$104.40 ,90% of total billed charges for outpatient setting,$44.08 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$44.08 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$44.08 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$87.00 ,75% of total billed charges for outpatient setting,$98.60 ,85% of total billed charges for outpatient setting,$44.08 ,$107.88 ,$87.00 
Outpatient Medical Services,Laboratory,80305,Clinic drug testing,300,$250.03 ,$225.03 ,90% of total billed charges for outpatient setting,$232.53 ,93% of total billed charges for outpatient setting,$95.01 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$95.01 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$212.53 ,85% of total billed charges for outpatient setting,$95.01 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$203.52 ,81.4% of total billed charges for outpatient setting,$225.03 ,90% of total billed charges for outpatient setting,$225.03 ,90% of total billed charges for outpatient setting,$95.01 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$95.01 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$95.01 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$187.52 ,75% of total billed charges for outpatient setting,$212.53 ,85% of total billed charges for outpatient setting,$95.01 ,$232.53 ,$187.52 
Outpatient Medical Services,Laboratory,80305,Urine Drug Screen Panel,300,$250.03 ,$225.03 ,90% of total billed charges for outpatient setting,$232.53 ,93% of total billed charges for outpatient setting,$95.01 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$95.01 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$212.53 ,85% of total billed charges for outpatient setting,$95.01 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$203.52 ,81.4% of total billed charges for outpatient setting,$225.03 ,90% of total billed charges for outpatient setting,$225.03 ,90% of total billed charges for outpatient setting,$95.01 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$95.01 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$95.01 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$187.52 ,75% of total billed charges for outpatient setting,$212.53 ,85% of total billed charges for outpatient setting,$95.01 ,$232.53 ,$187.52 
Outpatient Medical Services,Laboratory,80320,Blood Alcohol,300,$117.13 ,$105.42 ,90% of total billed charges for outpatient setting,$108.93 ,93% of total billed charges for outpatient setting,$44.51 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$44.51 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$99.56 ,85% of total billed charges for outpatient setting,$44.51 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$95.34 ,81.4% of total billed charges for outpatient setting,$105.42 ,90% of total billed charges for outpatient setting,$105.42 ,90% of total billed charges for outpatient setting,$44.51 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$44.51 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$44.51 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$87.85 ,75% of total billed charges for outpatient setting,$99.56 ,85% of total billed charges for outpatient setting,$44.51 ,$108.93 ,$87.85 
Outpatient Medical Services,Laboratory,80329,Salicylate,300,$129.52 ,$116.57 ,90% of total billed charges for outpatient setting,$120.45 ,93% of total billed charges for outpatient setting,$49.22 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$49.22 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$110.09 ,85% of total billed charges for outpatient setting,$49.22 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$105.43 ,81.4% of total billed charges for outpatient setting,$116.57 ,90% of total billed charges for outpatient setting,$116.57 ,90% of total billed charges for outpatient setting,$49.22 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$49.22 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$49.22 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$97.14 ,75% of total billed charges for outpatient setting,$110.09 ,85% of total billed charges for outpatient setting,$49.22 ,$120.45 ,$97.14 
Outpatient Medical Services,Laboratory,81001,Manual urinalysis test with examination with or without using microscope,300,$63.08 ,$56.77 ,90% of total billed charges for outpatient setting,$58.66 ,93% of total billed charges for outpatient setting,$23.97 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$23.97 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$53.62 ,85% of total billed charges for outpatient setting,$23.97 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$51.35 ,81.4% of total billed charges for outpatient setting,$56.77 ,90% of total billed charges for outpatient setting,$56.77 ,90% of total billed charges for outpatient setting,$23.97 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$23.97 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$23.97 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$47.31 ,75% of total billed charges for outpatient setting,$53.62 ,85% of total billed charges for outpatient setting,$23.97 ,$58.66 ,$47.31 
Outpatient Medical Services,Laboratory,81025,Urine pregnancy test,300,$77.30 ,$69.57 ,90% of total billed charges for outpatient setting,$71.89 ,93% of total billed charges for outpatient setting,$29.37 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$29.37 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$65.71 ,85% of total billed charges for outpatient setting,$29.37 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$62.92 ,81.4% of total billed charges for outpatient setting,$69.57 ,90% of total billed charges for outpatient setting,$69.57 ,90% of total billed charges for outpatient setting,$29.37 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$29.37 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$29.37 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$57.98 ,75% of total billed charges for outpatient setting,$65.71 ,85% of total billed charges for outpatient setting,$29.37 ,$71.89 ,$57.98 
Outpatient Medical Services,Laboratory,82140,Ammonia,300,$154.31 ,$138.88 ,90% of total billed charges for outpatient setting,$143.51 ,93% of total billed charges for outpatient setting,$58.64 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$58.64 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$131.16 ,85% of total billed charges for outpatient setting,$58.64 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$125.61 ,81.4% of total billed charges for outpatient setting,$138.88 ,90% of total billed charges for outpatient setting,$138.88 ,90% of total billed charges for outpatient setting,$58.64 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$58.64 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$58.64 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$115.73 ,75% of total billed charges for outpatient setting,$131.16 ,85% of total billed charges for outpatient setting,$58.64 ,$143.51 ,$115.73 
Outpatient Medical Services,Laboratory,82248,Measurement of direct bilirubin,300,$36.04 ,$32.44 ,90% of total billed charges for outpatient setting,$33.52 ,93% of total billed charges for outpatient setting,$13.70 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$13.70 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$30.63 ,85% of total billed charges for outpatient setting,$13.70 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$29.34 ,81.4% of total billed charges for outpatient setting,$32.44 ,90% of total billed charges for outpatient setting,$32.44 ,90% of total billed charges for outpatient setting,$13.70 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$13.70 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$13.70 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$27.03 ,75% of total billed charges for outpatient setting,$30.63 ,85% of total billed charges for outpatient setting,$13.70 ,$33.52 ,$27.03 
Outpatient Medical Services,Laboratory,82274,Fecal Occult blood test,300,$57.44 ,$51.70 ,90% of total billed charges for outpatient setting,$53.42 ,93% of total billed charges for outpatient setting,$21.83 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$21.83 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$48.82 ,85% of total billed charges for outpatient setting,$21.83 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$46.76 ,81.4% of total billed charges for outpatient setting,$51.70 ,90% of total billed charges for outpatient setting,$51.70 ,90% of total billed charges for outpatient setting,$21.83 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$21.83 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$21.83 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$43.08 ,75% of total billed charges for outpatient setting,$48.82 ,85% of total billed charges for outpatient setting,$21.83 ,$53.42 ,$43.08 
Outpatient Medical Services,Laboratory,82306,Blood test to monitor vitamin D levels,300,$355.91 ,$320.32 ,90% of total billed charges for outpatient setting,$331.00 ,93% of total billed charges for outpatient setting,$135.25 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$135.25 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$302.52 ,85% of total billed charges for outpatient setting,$135.25 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$289.71 ,81.4% of total billed charges for outpatient setting,$320.32 ,90% of total billed charges for outpatient setting,$320.32 ,90% of total billed charges for outpatient setting,$135.25 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$135.25 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$135.25 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$266.93 ,75% of total billed charges for outpatient setting,$302.52 ,85% of total billed charges for outpatient setting,$135.25 ,$331.00 ,$266.93 
Outpatient Medical Services,Laboratory,82550,CPK,300,$36.04 ,$32.44 ,90% of total billed charges for outpatient setting,$33.52 ,93% of total billed charges for outpatient setting,$13.70 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$13.70 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$30.63 ,85% of total billed charges for outpatient setting,$13.70 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$29.34 ,81.4% of total billed charges for outpatient setting,$32.44 ,90% of total billed charges for outpatient setting,$32.44 ,90% of total billed charges for outpatient setting,$13.70 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$13.70 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$13.70 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$27.03 ,75% of total billed charges for outpatient setting,$30.63 ,85% of total billed charges for outpatient setting,$13.70 ,$33.52 ,$27.03 
Outpatient Medical Services,Laboratory,82565,Creatinine,300,$29.27 ,$26.34 ,90% of total billed charges for outpatient setting,$27.22 ,93% of total billed charges for outpatient setting,$11.12 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$11.12 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$24.88 ,85% of total billed charges for outpatient setting,$11.12 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$23.83 ,81.4% of total billed charges for outpatient setting,$26.34 ,90% of total billed charges for outpatient setting,$26.34 ,90% of total billed charges for outpatient setting,$11.12 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$11.12 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$11.12 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$21.95 ,75% of total billed charges for outpatient setting,$24.88 ,85% of total billed charges for outpatient setting,$11.12 ,$27.22 ,$21.95 
Outpatient Medical Services,Laboratory,82570,Test to measure creatinine in the urine,300,$54.06 ,$48.65 ,90% of total billed charges for outpatient setting,$50.28 ,93% of total billed charges for outpatient setting,$20.54 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$20.54 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$45.95 ,85% of total billed charges for outpatient setting,$20.54 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$44.00 ,81.4% of total billed charges for outpatient setting,$48.65 ,90% of total billed charges for outpatient setting,$48.65 ,90% of total billed charges for outpatient setting,$20.54 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$20.54 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$20.54 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$40.55 ,75% of total billed charges for outpatient setting,$45.95 ,85% of total billed charges for outpatient setting,$20.54 ,$50.28 ,$40.55 
Outpatient Medical Services,Laboratory,82607,Blood test to measure B-12,300,$63.08 ,$56.77 ,90% of total billed charges for outpatient setting,$58.66 ,93% of total billed charges for outpatient setting,$23.97 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$23.97 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$53.62 ,85% of total billed charges for outpatient setting,$23.97 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$51.35 ,81.4% of total billed charges for outpatient setting,$56.77 ,90% of total billed charges for outpatient setting,$56.77 ,90% of total billed charges for outpatient setting,$23.97 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$23.97 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$23.97 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$47.31 ,75% of total billed charges for outpatient setting,$53.62 ,85% of total billed charges for outpatient setting,$23.97 ,$58.66 ,$47.31 
Outpatient Medical Services,Laboratory,82728,Test to determine level of iron in the blood,300,$113.75 ,$102.38 ,90% of total billed charges for outpatient setting,$105.79 ,93% of total billed charges for outpatient setting,$43.23 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$43.23 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$96.69 ,85% of total billed charges for outpatient setting,$43.23 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$92.59 ,81.4% of total billed charges for outpatient setting,$102.38 ,90% of total billed charges for outpatient setting,$102.38 ,90% of total billed charges for outpatient setting,$43.23 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$43.23 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$43.23 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$85.31 ,75% of total billed charges for outpatient setting,$96.69 ,85% of total billed charges for outpatient setting,$43.23 ,$105.79 ,$85.31 
Outpatient Medical Services,Laboratory,82746,"Folate, Serum",300,$140.78 ,$126.70 ,90% of total billed charges for outpatient setting,$130.93 ,93% of total billed charges for outpatient setting,$53.50 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$53.50 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$119.66 ,85% of total billed charges for outpatient setting,$53.50 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$114.59 ,81.4% of total billed charges for outpatient setting,$126.70 ,90% of total billed charges for outpatient setting,$126.70 ,90% of total billed charges for outpatient setting,$53.50 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$53.50 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$53.50 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$105.59 ,75% of total billed charges for outpatient setting,$119.66 ,85% of total billed charges for outpatient setting,$53.50 ,$130.93 ,$105.59 
Outpatient Medical Services,Laboratory,82803,Test to measure arterial blood gases,300,$107.01 ,$96.31 ,90% of total billed charges for outpatient setting,$99.52 ,93% of total billed charges for outpatient setting,$40.66 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$40.66 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$90.96 ,85% of total billed charges for outpatient setting,$40.66 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$87.11 ,81.4% of total billed charges for outpatient setting,$96.31 ,90% of total billed charges for outpatient setting,$96.31 ,90% of total billed charges for outpatient setting,$40.66 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$40.66 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$40.66 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$80.26 ,75% of total billed charges for outpatient setting,$90.96 ,85% of total billed charges for outpatient setting,$40.66 ,$99.52 ,$80.26 
Outpatient Medical Services,Laboratory,82805,Arterial Blood Gas,300,$322.12 ,$289.91 ,90% of total billed charges for outpatient setting,$299.57 ,93% of total billed charges for outpatient setting,$122.41 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$122.41 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$273.80 ,85% of total billed charges for outpatient setting,$122.41 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$262.21 ,81.4% of total billed charges for outpatient setting,$289.91 ,90% of total billed charges for outpatient setting,$289.91 ,90% of total billed charges for outpatient setting,$122.41 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$122.41 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$122.41 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$241.59 ,75% of total billed charges for outpatient setting,$273.80 ,85% of total billed charges for outpatient setting,$122.41 ,$299.57 ,$241.59 
Outpatient Medical Services,Laboratory,82962,"Glucose, Whole Blood",300,$23.65 ,$21.29 ,90% of total billed charges for outpatient setting,$21.99 ,93% of total billed charges for outpatient setting,$8.99 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$8.99 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$20.10 ,85% of total billed charges for outpatient setting,$8.99 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$19.25 ,81.4% of total billed charges for outpatient setting,$21.29 ,90% of total billed charges for outpatient setting,$21.29 ,90% of total billed charges for outpatient setting,$8.99 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$8.99 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$8.99 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$17.74 ,75% of total billed charges for outpatient setting,$20.10 ,85% of total billed charges for outpatient setting,$8.99 ,$21.99 ,$17.74 
Outpatient Medical Services,Laboratory,83001,Test of hormone in the blood,300,$74.34 ,$66.91 ,90% of total billed charges for outpatient setting,$69.14 ,93% of total billed charges for outpatient setting,$28.25 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$28.25 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$63.19 ,85% of total billed charges for outpatient setting,$28.25 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$60.51 ,81.4% of total billed charges for outpatient setting,$66.91 ,90% of total billed charges for outpatient setting,$66.91 ,90% of total billed charges for outpatient setting,$28.25 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$28.25 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$28.25 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$55.76 ,75% of total billed charges for outpatient setting,$63.19 ,85% of total billed charges for outpatient setting,$28.25 ,$69.14 ,$55.76 
Outpatient Medical Services,Laboratory,83036,Blood test to measure average blood glucose levels for past 2-3 months,300,$74.34 ,$66.91 ,90% of total billed charges for outpatient setting,$69.14 ,93% of total billed charges for outpatient setting,$28.25 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$28.25 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$63.19 ,85% of total billed charges for outpatient setting,$28.25 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$60.51 ,81.4% of total billed charges for outpatient setting,$66.91 ,90% of total billed charges for outpatient setting,$66.91 ,90% of total billed charges for outpatient setting,$28.25 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$28.25 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$28.25 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$55.76 ,75% of total billed charges for outpatient setting,$63.19 ,85% of total billed charges for outpatient setting,$28.25 ,$69.14 ,$55.76 
Outpatient Medical Services,Laboratory,83037,Clinic Hemoglobin A1C whole blood,300,$81.18 ,$73.06 ,90% of total billed charges for outpatient setting,$75.50 ,93% of total billed charges for outpatient setting,$30.85 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$30.85 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$69.00 ,85% of total billed charges for outpatient setting,$30.85 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$66.08 ,81.4% of total billed charges for outpatient setting,$73.06 ,90% of total billed charges for outpatient setting,$73.06 ,90% of total billed charges for outpatient setting,$30.85 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$30.85 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$30.85 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$60.89 ,75% of total billed charges for outpatient setting,$69.00 ,85% of total billed charges for outpatient setting,$30.85 ,$75.50 ,$60.89 
Outpatient Medical Services,Laboratory,83540,Blood test to measure the amount of iron that is in transit in the body,300,$87.86 ,$79.07 ,90% of total billed charges for outpatient setting,$81.71 ,93% of total billed charges for outpatient setting,$33.39 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$33.39 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$74.68 ,85% of total billed charges for outpatient setting,$33.39 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$71.52 ,81.4% of total billed charges for outpatient setting,$79.07 ,90% of total billed charges for outpatient setting,$79.07 ,90% of total billed charges for outpatient setting,$33.39 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$33.39 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$33.39 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$65.90 ,75% of total billed charges for outpatient setting,$74.68 ,85% of total billed charges for outpatient setting,$33.39 ,$81.71 ,$65.90 
Outpatient Medical Services,Laboratory,83615,LDH,300,$31.53 ,$28.38 ,90% of total billed charges for outpatient setting,$29.32 ,93% of total billed charges for outpatient setting,$11.98 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$11.98 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$26.80 ,85% of total billed charges for outpatient setting,$11.98 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$25.67 ,81.4% of total billed charges for outpatient setting,$28.38 ,90% of total billed charges for outpatient setting,$28.38 ,90% of total billed charges for outpatient setting,$11.98 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$11.98 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$11.98 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$23.65 ,75% of total billed charges for outpatient setting,$26.80 ,85% of total billed charges for outpatient setting,$11.98 ,$29.32 ,$23.65 
Outpatient Medical Services,Laboratory,83690,Lipase,300,$95.73 ,$86.16 ,90% of total billed charges for outpatient setting,$89.03 ,93% of total billed charges for outpatient setting,$36.38 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$36.38 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$81.37 ,85% of total billed charges for outpatient setting,$36.38 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$77.92 ,81.4% of total billed charges for outpatient setting,$86.16 ,90% of total billed charges for outpatient setting,$86.16 ,90% of total billed charges for outpatient setting,$36.38 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$36.38 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$36.38 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$71.80 ,75% of total billed charges for outpatient setting,$81.37 ,85% of total billed charges for outpatient setting,$36.38 ,$89.03 ,$71.80 
Outpatient Medical Services,Laboratory,83735,Magnesium,300,$36.04 ,$32.44 ,90% of total billed charges for outpatient setting,$33.52 ,93% of total billed charges for outpatient setting,$13.70 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$13.70 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$30.63 ,85% of total billed charges for outpatient setting,$13.70 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$29.34 ,81.4% of total billed charges for outpatient setting,$32.44 ,90% of total billed charges for outpatient setting,$32.44 ,90% of total billed charges for outpatient setting,$13.70 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$13.70 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$13.70 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$27.03 ,75% of total billed charges for outpatient setting,$30.63 ,85% of total billed charges for outpatient setting,$13.70 ,$33.52 ,$27.03 
Outpatient Medical Services,Laboratory,83880,Blood test used to diagnose heart failure,300,$197.09 ,$177.38 ,90% of total billed charges for outpatient setting,$183.29 ,93% of total billed charges for outpatient setting,$74.89 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$74.89 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$167.53 ,85% of total billed charges for outpatient setting,$74.89 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$160.43 ,81.4% of total billed charges for outpatient setting,$177.38 ,90% of total billed charges for outpatient setting,$177.38 ,90% of total billed charges for outpatient setting,$74.89 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$74.89 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$74.89 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$147.82 ,75% of total billed charges for outpatient setting,$167.53 ,85% of total billed charges for outpatient setting,$74.89 ,$183.29 ,$147.82 
Outpatient Medical Services,Laboratory,84100,Phosphorus,300,$36.04 ,$32.44 ,90% of total billed charges for outpatient setting,$33.52 ,93% of total billed charges for outpatient setting,$13.70 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$13.70 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$30.63 ,85% of total billed charges for outpatient setting,$13.70 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$29.34 ,81.4% of total billed charges for outpatient setting,$32.44 ,90% of total billed charges for outpatient setting,$32.44 ,90% of total billed charges for outpatient setting,$13.70 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$13.70 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$13.70 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$27.03 ,75% of total billed charges for outpatient setting,$30.63 ,85% of total billed charges for outpatient setting,$13.70 ,$33.52 ,$27.03 
Outpatient Medical Services,Laboratory,84153,PSA (prostate specific antigen),300,$104.74 ,$94.27 ,90% of total billed charges for outpatient setting,$97.41 ,93% of total billed charges for outpatient setting,$39.80 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$39.80 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$89.03 ,85% of total billed charges for outpatient setting,$39.80 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$85.26 ,81.4% of total billed charges for outpatient setting,$94.27 ,90% of total billed charges for outpatient setting,$94.27 ,90% of total billed charges for outpatient setting,$39.80 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$39.80 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$39.80 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$78.56 ,75% of total billed charges for outpatient setting,$89.03 ,85% of total billed charges for outpatient setting,$39.80 ,$97.41 ,$78.56 
Outpatient Medical Services,Laboratory,84439,Blood test to evaluate thyroid function,300,$97.99 ,$88.19 ,90% of total billed charges for outpatient setting,$91.13 ,93% of total billed charges for outpatient setting,$37.24 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$37.24 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$83.29 ,85% of total billed charges for outpatient setting,$37.24 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$79.76 ,81.4% of total billed charges for outpatient setting,$88.19 ,90% of total billed charges for outpatient setting,$88.19 ,90% of total billed charges for outpatient setting,$37.24 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$37.24 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$37.24 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$73.49 ,75% of total billed charges for outpatient setting,$83.29 ,85% of total billed charges for outpatient setting,$37.24 ,$91.13 ,$73.49 
Outpatient Medical Services,Laboratory,84443,"Blood test, thyroid stimulating hormone (TSH)",300,$96.86 ,$87.17 ,90% of total billed charges for outpatient setting,$90.08 ,93% of total billed charges for outpatient setting,$36.81 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$36.81 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$82.33 ,85% of total billed charges for outpatient setting,$36.81 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$78.84 ,81.4% of total billed charges for outpatient setting,$87.17 ,90% of total billed charges for outpatient setting,$87.17 ,90% of total billed charges for outpatient setting,$36.81 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$36.81 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$36.81 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$72.65 ,75% of total billed charges for outpatient setting,$82.33 ,85% of total billed charges for outpatient setting,$36.81 ,$90.08 ,$72.65 
Outpatient Medical Services,Laboratory,84480,Blood test to evaluate thyroid function,300,$110.37 ,$99.33 ,90% of total billed charges for outpatient setting,$102.64 ,93% of total billed charges for outpatient setting,$41.94 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$41.94 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$93.81 ,85% of total billed charges for outpatient setting,$41.94 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$89.84 ,81.4% of total billed charges for outpatient setting,$99.33 ,90% of total billed charges for outpatient setting,$99.33 ,90% of total billed charges for outpatient setting,$41.94 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$41.94 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$41.94 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$82.78 ,75% of total billed charges for outpatient setting,$93.81 ,85% of total billed charges for outpatient setting,$41.94 ,$102.64 ,$82.78 
Outpatient Medical Services,Laboratory,84481,Free T3,300,$69.84 ,$62.86 ,90% of total billed charges for outpatient setting,$64.95 ,93% of total billed charges for outpatient setting,$26.54 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$26.54 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$59.36 ,85% of total billed charges for outpatient setting,$26.54 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$56.85 ,81.4% of total billed charges for outpatient setting,$62.86 ,90% of total billed charges for outpatient setting,$62.86 ,90% of total billed charges for outpatient setting,$26.54 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$26.54 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$26.54 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$52.38 ,75% of total billed charges for outpatient setting,$59.36 ,85% of total billed charges for outpatient setting,$26.54 ,$64.95 ,$52.38 
Outpatient Medical Services,Laboratory,84484,Blood test to measure a certain protein in the blood to determine heart muscle damage,300,$74.34 ,$66.91 ,90% of total billed charges for outpatient setting,$69.14 ,93% of total billed charges for outpatient setting,$28.25 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$28.25 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$63.19 ,85% of total billed charges for outpatient setting,$28.25 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$60.51 ,81.4% of total billed charges for outpatient setting,$66.91 ,90% of total billed charges for outpatient setting,$66.91 ,90% of total billed charges for outpatient setting,$28.25 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$28.25 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$28.25 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$55.76 ,75% of total billed charges for outpatient setting,$63.19 ,85% of total billed charges for outpatient setting,$28.25 ,$69.14 ,$55.76 
Outpatient Medical Services,Laboratory,84520,BUN,300,$36.04 ,$32.44 ,90% of total billed charges for outpatient setting,$33.52 ,93% of total billed charges for outpatient setting,$13.70 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$13.70 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$30.63 ,85% of total billed charges for outpatient setting,$13.70 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$29.34 ,81.4% of total billed charges for outpatient setting,$32.44 ,90% of total billed charges for outpatient setting,$32.44 ,90% of total billed charges for outpatient setting,$13.70 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$13.70 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$13.70 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$27.03 ,75% of total billed charges for outpatient setting,$30.63 ,85% of total billed charges for outpatient setting,$13.70 ,$33.52 ,$27.03 
Outpatient Medical Services,Laboratory,84550,Uric Acid,300,$36.04 ,$32.44 ,90% of total billed charges for outpatient setting,$33.52 ,93% of total billed charges for outpatient setting,$13.70 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$13.70 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$30.63 ,85% of total billed charges for outpatient setting,$13.70 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$29.34 ,81.4% of total billed charges for outpatient setting,$32.44 ,90% of total billed charges for outpatient setting,$32.44 ,90% of total billed charges for outpatient setting,$13.70 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$13.70 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$13.70 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$27.03 ,75% of total billed charges for outpatient setting,$30.63 ,85% of total billed charges for outpatient setting,$13.70 ,$33.52 ,$27.03 
Outpatient Medical Services,Laboratory,84703,Blood test to assess for pregnancy,300,$69.84 ,$62.86 ,90% of total billed charges for outpatient setting,$64.95 ,93% of total billed charges for outpatient setting,$26.54 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$26.54 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$59.36 ,85% of total billed charges for outpatient setting,$26.54 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$56.85 ,81.4% of total billed charges for outpatient setting,$62.86 ,90% of total billed charges for outpatient setting,$62.86 ,90% of total billed charges for outpatient setting,$26.54 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$26.54 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$26.54 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$52.38 ,75% of total billed charges for outpatient setting,$59.36 ,85% of total billed charges for outpatient setting,$26.54 ,$64.95 ,$52.38 
Outpatient Medical Services,Laboratory,85014,HCT,300,$18.02 ,$16.22 ,90% of total billed charges for outpatient setting,$16.76 ,93% of total billed charges for outpatient setting,$6.85 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$6.85 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$15.32 ,85% of total billed charges for outpatient setting,$6.85 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$14.67 ,81.4% of total billed charges for outpatient setting,$16.22 ,90% of total billed charges for outpatient setting,$16.22 ,90% of total billed charges for outpatient setting,$6.85 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$6.85 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$6.85 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$13.52 ,75% of total billed charges for outpatient setting,$15.32 ,85% of total billed charges for outpatient setting,$6.85 ,$16.76 ,$13.52 
Outpatient Medical Services,Laboratory,85018,Blood test to measure levels of hemoglobin,300,$18.02 ,$16.22 ,90% of total billed charges for outpatient setting,$16.76 ,93% of total billed charges for outpatient setting,$6.85 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$6.85 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$15.32 ,85% of total billed charges for outpatient setting,$6.85 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$14.67 ,81.4% of total billed charges for outpatient setting,$16.22 ,90% of total billed charges for outpatient setting,$16.22 ,90% of total billed charges for outpatient setting,$6.85 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$6.85 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$6.85 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$13.52 ,75% of total billed charges for outpatient setting,$15.32 ,85% of total billed charges for outpatient setting,$6.85 ,$16.76 ,$13.52 
Outpatient Medical Services,Laboratory,85025,"Complete blood cell count, with differential white blood cells, automated",300,$78.86 ,$70.97 ,90% of total billed charges for outpatient setting,$73.34 ,93% of total billed charges for outpatient setting,$29.97 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$29.97 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$67.03 ,85% of total billed charges for outpatient setting,$29.97 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$64.19 ,81.4% of total billed charges for outpatient setting,$70.97 ,90% of total billed charges for outpatient setting,$70.97 ,90% of total billed charges for outpatient setting,$29.97 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$29.97 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$29.97 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$59.15 ,75% of total billed charges for outpatient setting,$67.03 ,85% of total billed charges for outpatient setting,$29.97 ,$73.34 ,$59.15 
Outpatient Medical Services,Laboratory,85379,D-Dimer,300,$123.88 ,$111.49 ,90% of total billed charges for outpatient setting,$115.21 ,93% of total billed charges for outpatient setting,$47.07 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$47.07 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$105.30 ,85% of total billed charges for outpatient setting,$47.07 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$100.84 ,81.4% of total billed charges for outpatient setting,$111.49 ,90% of total billed charges for outpatient setting,$111.49 ,90% of total billed charges for outpatient setting,$47.07 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$47.07 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$47.07 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$92.91 ,75% of total billed charges for outpatient setting,$105.30 ,85% of total billed charges for outpatient setting,$47.07 ,$115.21 ,$92.91 
Outpatient Medical Services,Laboratory,85610,"Blood test, clotting time",300,$64.20 ,$57.78 ,90% of total billed charges for outpatient setting,$59.71 ,93% of total billed charges for outpatient setting,$24.40 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$24.40 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$54.57 ,85% of total billed charges for outpatient setting,$24.40 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$52.26 ,81.4% of total billed charges for outpatient setting,$57.78 ,90% of total billed charges for outpatient setting,$57.78 ,90% of total billed charges for outpatient setting,$24.40 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$24.40 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$24.40 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$48.15 ,75% of total billed charges for outpatient setting,$54.57 ,85% of total billed charges for outpatient setting,$24.40 ,$59.71 ,$48.15 
Outpatient Medical Services,Laboratory,85610,"Blood test, clotting time",300,$64.20 ,$57.78 ,90% of total billed charges for outpatient setting,$59.71 ,93% of total billed charges for outpatient setting,$24.40 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$24.40 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$54.57 ,85% of total billed charges for outpatient setting,$24.40 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$52.26 ,81.4% of total billed charges for outpatient setting,$57.78 ,90% of total billed charges for outpatient setting,$57.78 ,90% of total billed charges for outpatient setting,$24.40 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$24.40 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$24.40 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$48.15 ,75% of total billed charges for outpatient setting,$54.57 ,85% of total billed charges for outpatient setting,$24.40 ,$59.71 ,$48.15 
Outpatient Medical Services,Laboratory,85730,Coagulation assessment blood test,300,$51.82 ,$46.64 ,90% of total billed charges for outpatient setting,$48.19 ,93% of total billed charges for outpatient setting,$19.69 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$19.69 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$44.05 ,85% of total billed charges for outpatient setting,$19.69 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$42.18 ,81.4% of total billed charges for outpatient setting,$46.64 ,90% of total billed charges for outpatient setting,$46.64 ,90% of total billed charges for outpatient setting,$19.69 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$19.69 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$19.69 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$38.87 ,75% of total billed charges for outpatient setting,$44.05 ,85% of total billed charges for outpatient setting,$19.69 ,$48.19 ,$38.87 
Outpatient Medical Services,Laboratory,86038,ANA screen,300,$91.44 ,$82.30 ,90% of total billed charges for outpatient setting,$85.04 ,93% of total billed charges for outpatient setting,$34.75 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$34.75 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$77.72 ,85% of total billed charges for outpatient setting,$34.75 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$74.43 ,81.4% of total billed charges for outpatient setting,$82.30 ,90% of total billed charges for outpatient setting,$82.30 ,90% of total billed charges for outpatient setting,$34.75 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$34.75 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$34.75 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$68.58 ,75% of total billed charges for outpatient setting,$77.72 ,85% of total billed charges for outpatient setting,$34.75 ,$85.04 ,$68.58 
Outpatient Medical Services,Laboratory,86140,RCRP,300,$74.34 ,$66.91 ,90% of total billed charges for outpatient setting,$69.14 ,93% of total billed charges for outpatient setting,$28.25 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$28.25 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$63.19 ,85% of total billed charges for outpatient setting,$28.25 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$60.51 ,81.4% of total billed charges for outpatient setting,$66.91 ,90% of total billed charges for outpatient setting,$66.91 ,90% of total billed charges for outpatient setting,$28.25 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$28.25 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$28.25 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$55.76 ,75% of total billed charges for outpatient setting,$63.19 ,85% of total billed charges for outpatient setting,$28.25 ,$69.14 ,$55.76 
Outpatient Medical Services,Laboratory,86430,Rheumatoid Factor,300,$69.84 ,$62.86 ,90% of total billed charges for outpatient setting,$64.95 ,93% of total billed charges for outpatient setting,$26.54 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$26.54 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$59.36 ,85% of total billed charges for outpatient setting,$26.54 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$56.85 ,81.4% of total billed charges for outpatient setting,$62.86 ,90% of total billed charges for outpatient setting,$62.86 ,90% of total billed charges for outpatient setting,$26.54 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$26.54 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$26.54 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$52.38 ,75% of total billed charges for outpatient setting,$59.36 ,85% of total billed charges for outpatient setting,$26.54 ,$64.95 ,$52.38 
Outpatient Medical Services,Laboratory,86677,Blood test to if peptic ulcers are caused by a certain bacterium,300,$158.79 ,$142.91 ,90% of total billed charges for outpatient setting,$147.67 ,93% of total billed charges for outpatient setting,$60.34 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$60.34 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$134.97 ,85% of total billed charges for outpatient setting,$60.34 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$129.26 ,81.4% of total billed charges for outpatient setting,$142.91 ,90% of total billed charges for outpatient setting,$142.91 ,90% of total billed charges for outpatient setting,$60.34 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$60.34 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$60.34 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$119.09 ,75% of total billed charges for outpatient setting,$134.97 ,85% of total billed charges for outpatient setting,$60.34 ,$147.67 ,$119.09 
Outpatient Medical Services,Laboratory,86703,Blood test to diagnose HIV,300,$129.52 ,$116.57 ,90% of total billed charges for outpatient setting,$120.45 ,93% of total billed charges for outpatient setting,$49.22 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$49.22 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$110.09 ,85% of total billed charges for outpatient setting,$49.22 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$105.43 ,81.4% of total billed charges for outpatient setting,$116.57 ,90% of total billed charges for outpatient setting,$116.57 ,90% of total billed charges for outpatient setting,$49.22 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$49.22 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$49.22 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$97.14 ,75% of total billed charges for outpatient setting,$110.09 ,85% of total billed charges for outpatient setting,$49.22 ,$120.45 ,$97.14 
Outpatient Medical Services,Laboratory,86803,Blood test to determine infection with Hepatitis C,300,$159.93 ,$143.94 ,90% of total billed charges for outpatient setting,$148.73 ,93% of total billed charges for outpatient setting,$60.77 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$60.77 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$135.94 ,85% of total billed charges for outpatient setting,$60.77 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$130.18 ,81.4% of total billed charges for outpatient setting,$143.94 ,90% of total billed charges for outpatient setting,$143.94 ,90% of total billed charges for outpatient setting,$60.77 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$60.77 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$60.77 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$119.95 ,75% of total billed charges for outpatient setting,$135.94 ,85% of total billed charges for outpatient setting,$60.77 ,$148.73 ,$119.95 
Outpatient Medical Services,Laboratory,86850,Blood test to screen for antibodies that could harm red blood cells,300,$87.85 ,$79.07 ,90% of total billed charges for outpatient setting,$81.70 ,93% of total billed charges for outpatient setting,$33.38 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$33.38 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$74.67 ,85% of total billed charges for outpatient setting,$33.38 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$71.51 ,81.4% of total billed charges for outpatient setting,$79.07 ,90% of total billed charges for outpatient setting,$79.07 ,90% of total billed charges for outpatient setting,$33.38 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$33.38 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$33.38 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$65.89 ,75% of total billed charges for outpatient setting,$74.67 ,85% of total billed charges for outpatient setting,$33.38 ,$81.70 ,$65.89 
Outpatient Medical Services,Laboratory,87040,Blood test to screen for bacteria in the blood,300,$99.12 ,$89.21 ,90% of total billed charges for outpatient setting,$92.18 ,93% of total billed charges for outpatient setting,$37.67 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$37.67 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$84.25 ,85% of total billed charges for outpatient setting,$37.67 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$80.68 ,81.4% of total billed charges for outpatient setting,$89.21 ,90% of total billed charges for outpatient setting,$89.21 ,90% of total billed charges for outpatient setting,$37.67 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$37.67 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$37.67 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$74.34 ,75% of total billed charges for outpatient setting,$84.25 ,85% of total billed charges for outpatient setting,$37.67 ,$92.18 ,$74.34 
Outpatient Medical Services,Laboratory,87070,Test of body fluid other than blood to assess for bacteria,300,$73.22 ,$65.90 ,90% of total billed charges for outpatient setting,$68.09 ,93% of total billed charges for outpatient setting,$27.82 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$27.82 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$62.24 ,85% of total billed charges for outpatient setting,$27.82 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$59.60 ,81.4% of total billed charges for outpatient setting,$65.90 ,90% of total billed charges for outpatient setting,$65.90 ,90% of total billed charges for outpatient setting,$27.82 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$27.82 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$27.82 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$54.92 ,75% of total billed charges for outpatient setting,$62.24 ,85% of total billed charges for outpatient setting,$27.82 ,$68.09 ,$54.92 
Outpatient Medical Services,Laboratory,87070,Test of body fluid other than blood to assess for bacteria,300,$73.22 ,$65.90 ,90% of total billed charges for outpatient setting,$68.09 ,93% of total billed charges for outpatient setting,$27.82 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$27.82 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$62.24 ,85% of total billed charges for outpatient setting,$27.82 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$59.60 ,81.4% of total billed charges for outpatient setting,$65.90 ,90% of total billed charges for outpatient setting,$65.90 ,90% of total billed charges for outpatient setting,$27.82 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$27.82 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$27.82 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$54.92 ,75% of total billed charges for outpatient setting,$62.24 ,85% of total billed charges for outpatient setting,$27.82 ,$68.09 ,$54.92 
Outpatient Medical Services,Laboratory,87077,Test of a wound for type of bacterial infection,300,$27.60 ,$24.84 ,90% of total billed charges for outpatient setting,$25.67 ,93% of total billed charges for outpatient setting,$10.49 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$10.49 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$23.46 ,85% of total billed charges for outpatient setting,$10.49 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$22.47 ,81.4% of total billed charges for outpatient setting,$24.84 ,90% of total billed charges for outpatient setting,$24.84 ,90% of total billed charges for outpatient setting,$10.49 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$10.49 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$10.49 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$20.70 ,75% of total billed charges for outpatient setting,$23.46 ,85% of total billed charges for outpatient setting,$10.49 ,$25.67 ,$20.70 
Outpatient Medical Services,Laboratory,87088,Culture of the urine to determine bacterial infection,300,$73.22 ,$65.90 ,90% of total billed charges for outpatient setting,$68.09 ,93% of total billed charges for outpatient setting,$27.82 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$27.82 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$62.24 ,85% of total billed charges for outpatient setting,$27.82 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$59.60 ,81.4% of total billed charges for outpatient setting,$65.90 ,90% of total billed charges for outpatient setting,$65.90 ,90% of total billed charges for outpatient setting,$27.82 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$27.82 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$27.82 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$54.92 ,75% of total billed charges for outpatient setting,$62.24 ,85% of total billed charges for outpatient setting,$27.82 ,$68.09 ,$54.92 
Outpatient Medical Services,Laboratory,87205,A lab test used to detect bacteria or fungi in a sample taken from the site of a suspected infection,300,$46.18 ,$41.56 ,90% of total billed charges for outpatient setting,$42.95 ,93% of total billed charges for outpatient setting,$17.55 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$17.55 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$39.25 ,85% of total billed charges for outpatient setting,$17.55 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$37.59 ,81.4% of total billed charges for outpatient setting,$41.56 ,90% of total billed charges for outpatient setting,$41.56 ,90% of total billed charges for outpatient setting,$17.55 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$17.55 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$17.55 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$34.64 ,75% of total billed charges for outpatient setting,$39.25 ,85% of total billed charges for outpatient setting,$17.55 ,$42.95 ,$34.64 
Outpatient Medical Services,Laboratory,87340,HEPATITIS B SURFACE ANTIGEN,300,$85.60 ,$77.04 ,90% of total billed charges for outpatient setting,$79.61 ,93% of total billed charges for outpatient setting,$32.53 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$32.53 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$72.76 ,85% of total billed charges for outpatient setting,$32.53 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$69.68 ,81.4% of total billed charges for outpatient setting,$77.04 ,90% of total billed charges for outpatient setting,$77.04 ,90% of total billed charges for outpatient setting,$32.53 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$32.53 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$32.53 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$64.20 ,75% of total billed charges for outpatient setting,$72.76 ,85% of total billed charges for outpatient setting,$32.53 ,$79.61 ,$64.20 
Outpatient Medical Services,Laboratory,87430,Clinic Rapid Strep,300,$38.29 ,$34.46 ,90% of total billed charges for outpatient setting,$35.61 ,93% of total billed charges for outpatient setting,$14.55 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$14.55 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$32.55 ,85% of total billed charges for outpatient setting,$14.55 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$31.17 ,81.4% of total billed charges for outpatient setting,$34.46 ,90% of total billed charges for outpatient setting,$34.46 ,90% of total billed charges for outpatient setting,$14.55 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$14.55 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$14.55 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$28.72 ,75% of total billed charges for outpatient setting,$32.55 ,85% of total billed charges for outpatient setting,$14.55 ,$35.61 ,$28.72 
Outpatient Medical Services,Laboratory,87493,C.diff-  PCR,300,$156.55 ,$140.90 ,90% of total billed charges for outpatient setting,$145.59 ,93% of total billed charges for outpatient setting,$59.49 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$59.49 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$133.07 ,85% of total billed charges for outpatient setting,$59.49 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$127.43 ,81.4% of total billed charges for outpatient setting,$140.90 ,90% of total billed charges for outpatient setting,$140.90 ,90% of total billed charges for outpatient setting,$59.49 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$59.49 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$59.49 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$117.41 ,75% of total billed charges for outpatient setting,$133.07 ,85% of total billed charges for outpatient setting,$59.49 ,$145.59 ,$117.41 
Outpatient Medical Services,Laboratory,87506,Stool  GI  PCR Panel,300,$728.28 ,$655.45 ,90% of total billed charges for outpatient setting,$677.30 ,93% of total billed charges for outpatient setting,$276.75 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$276.75 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$619.04 ,85% of total billed charges for outpatient setting,$276.75 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$592.82 ,81.4% of total billed charges for outpatient setting,$655.45 ,90% of total billed charges for outpatient setting,$655.45 ,90% of total billed charges for outpatient setting,$276.75 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$276.75 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$276.75 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$546.21 ,75% of total billed charges for outpatient setting,$619.04 ,85% of total billed charges for outpatient setting,$276.75 ,$677.30 ,$546.21 
Outpatient Medical Services,Laboratory,87506,Stool GI PCR Panel,300,$728.28 ,$655.45 ,90% of total billed charges for outpatient setting,$677.30 ,93% of total billed charges for outpatient setting,$276.75 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$276.75 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$619.04 ,85% of total billed charges for outpatient setting,$276.75 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$592.82 ,81.4% of total billed charges for outpatient setting,$655.45 ,90% of total billed charges for outpatient setting,$655.45 ,90% of total billed charges for outpatient setting,$276.75 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$276.75 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$276.75 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$546.21 ,75% of total billed charges for outpatient setting,$619.04 ,85% of total billed charges for outpatient setting,$276.75 ,$677.30 ,$546.21 
Outpatient Medical Services,Laboratory,87522,"Hepatitis C RNA, Quant PCR",300,$612.20 ,$550.98 ,90% of total billed charges for outpatient setting,$569.35 ,93% of total billed charges for outpatient setting,$232.64 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$232.64 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$520.37 ,85% of total billed charges for outpatient setting,$232.64 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$498.33 ,81.4% of total billed charges for outpatient setting,$550.98 ,90% of total billed charges for outpatient setting,$550.98 ,90% of total billed charges for outpatient setting,$232.64 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$232.64 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$232.64 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$459.15 ,75% of total billed charges for outpatient setting,$520.37 ,85% of total billed charges for outpatient setting,$232.64 ,$569.35 ,$459.15 
Outpatient Medical Services,Laboratory,87633,Respiratory Virus panel with COVID-19,300,$836.34 ,$752.71 ,90% of total billed charges for outpatient setting,$777.80 ,93% of total billed charges for outpatient setting,$317.81 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$317.81 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$710.89 ,85% of total billed charges for outpatient setting,$317.81 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$680.78 ,81.4% of total billed charges for outpatient setting,$752.71 ,90% of total billed charges for outpatient setting,$752.71 ,90% of total billed charges for outpatient setting,$317.81 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$317.81 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$317.81 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$627.26 ,75% of total billed charges for outpatient setting,$710.89 ,85% of total billed charges for outpatient setting,$317.81 ,$777.80 ,$627.26 
Outpatient Medical Services,Laboratory,87635,CoVID-19 Molecular Rapid,300,$78.03 ,$70.23 ,90% of total billed charges for outpatient setting,$72.57 ,93% of total billed charges for outpatient setting,$29.65 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$29.65 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$66.33 ,85% of total billed charges for outpatient setting,$29.65 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$63.52 ,81.4% of total billed charges for outpatient setting,$70.23 ,90% of total billed charges for outpatient setting,$70.23 ,90% of total billed charges for outpatient setting,$29.65 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$29.65 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$29.65 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$58.52 ,75% of total billed charges for outpatient setting,$66.33 ,85% of total billed charges for outpatient setting,$29.65 ,$72.57 ,$58.52 
Outpatient Medical Services,Laboratory,87800,Rapid Strep,300,$63.08 ,$56.77 ,90% of total billed charges for outpatient setting,$58.66 ,93% of total billed charges for outpatient setting,$23.97 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$23.97 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$53.62 ,85% of total billed charges for outpatient setting,$23.97 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$51.35 ,81.4% of total billed charges for outpatient setting,$56.77 ,90% of total billed charges for outpatient setting,$56.77 ,90% of total billed charges for outpatient setting,$23.97 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$23.97 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$23.97 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$47.31 ,75% of total billed charges for outpatient setting,$53.62 ,85% of total billed charges for outpatient setting,$23.97 ,$58.66 ,$47.31 
Outpatient Medical Services,Laboratory,87804,Flu test,300,$104.74 ,$94.27 ,90% of total billed charges for outpatient setting,$97.41 ,93% of total billed charges for outpatient setting,$39.80 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$39.80 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$89.03 ,85% of total billed charges for outpatient setting,$39.80 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$85.26 ,81.4% of total billed charges for outpatient setting,$94.27 ,90% of total billed charges for outpatient setting,$94.27 ,90% of total billed charges for outpatient setting,$39.80 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$39.80 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$39.80 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$78.56 ,75% of total billed charges for outpatient setting,$89.03 ,85% of total billed charges for outpatient setting,$39.80 ,$97.41 ,$78.56 
Outpatient Medical Services,Laboratory,87804,Flu test,300,$104.74 ,$94.27 ,90% of total billed charges for outpatient setting,$97.41 ,93% of total billed charges for outpatient setting,$39.80 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$39.80 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$89.03 ,85% of total billed charges for outpatient setting,$39.80 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$85.26 ,81.4% of total billed charges for outpatient setting,$94.27 ,90% of total billed charges for outpatient setting,$94.27 ,90% of total billed charges for outpatient setting,$39.80 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$39.80 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$39.80 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$78.56 ,75% of total billed charges for outpatient setting,$89.03 ,85% of total billed charges for outpatient setting,$39.80 ,$97.41 ,$78.56 
Outpatient Medical Services,Laboratory,89051,"Body Fluid Count, and Differential",300,$83.65 ,$75.29 ,90% of total billed charges for outpatient setting,$77.79 ,93% of total billed charges for outpatient setting,$31.79 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$31.79 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$71.10 ,85% of total billed charges for outpatient setting,$31.79 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$68.09 ,81.4% of total billed charges for outpatient setting,$75.29 ,90% of total billed charges for outpatient setting,$75.29 ,90% of total billed charges for outpatient setting,$31.79 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$31.79 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$31.79 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$62.74 ,75% of total billed charges for outpatient setting,$71.10 ,85% of total billed charges for outpatient setting,$31.79 ,$77.79 ,$62.74 
Clinic Medical Services,Creede family practice clinic,90471,Immunization administration by a medical assistant or nurse,771,$37.14 ,$33.43 ,90% of total billed charges for outpatient setting,$34.54 ,93% of total billed charges for outpatient setting,$14.11 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$14.11 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$31.57 ,85% of total billed charges for outpatient setting,$14.11 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$30.23 ,81.4% of total billed charges for outpatient setting,$33.43 ,90% of total billed charges for outpatient setting,$33.43 ,90% of total billed charges for outpatient setting,$14.11 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$14.11 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$14.11 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$27.86 ,75% of total billed charges for outpatient setting,$31.57 ,85% of total billed charges for outpatient setting,$14.11 ,$34.54 ,$27.86 
Clinic Medical Services,Creede family practice clinic,90471,Immunization administration by a medical assistant or nurse,771,$38.29 ,$34.46 ,90% of total billed charges for outpatient setting,$35.61 ,93% of total billed charges for outpatient setting,$14.55 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$14.55 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$32.55 ,85% of total billed charges for outpatient setting,$14.55 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$31.17 ,81.4% of total billed charges for outpatient setting,$34.46 ,90% of total billed charges for outpatient setting,$34.46 ,90% of total billed charges for outpatient setting,$14.55 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$14.55 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$14.55 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$28.72 ,75% of total billed charges for outpatient setting,$32.55 ,85% of total billed charges for outpatient setting,$14.55 ,$35.61 ,$28.72 
Clinic Medical Services,Monte Vista Medical Clinic,90471,Immunization administration by a medical assistant or nurse,771,$37.14 ,$33.43 ,90% of total billed charges for outpatient setting,$34.54 ,93% of total billed charges for outpatient setting,$14.11 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$14.11 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$31.57 ,85% of total billed charges for outpatient setting,$14.11 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$30.23 ,81.4% of total billed charges for outpatient setting,$33.43 ,90% of total billed charges for outpatient setting,$33.43 ,90% of total billed charges for outpatient setting,$14.11 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$14.11 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$14.11 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$27.86 ,75% of total billed charges for outpatient setting,$31.57 ,85% of total billed charges for outpatient setting,$14.11 ,$34.54 ,$27.86 
Clinic Medical Services,Monte Vista Medical Clinic,90471,Immunization administration by a medical assistant or nurse,771,$38.29 ,$34.46 ,90% of total billed charges for outpatient setting,$35.61 ,93% of total billed charges for outpatient setting,$14.55 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$14.55 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$32.55 ,85% of total billed charges for outpatient setting,$14.55 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$31.17 ,81.4% of total billed charges for outpatient setting,$34.46 ,90% of total billed charges for outpatient setting,$34.46 ,90% of total billed charges for outpatient setting,$14.55 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$14.55 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$14.55 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$28.72 ,75% of total billed charges for outpatient setting,$32.55 ,85% of total billed charges for outpatient setting,$14.55 ,$35.61 ,$28.72 
Clinic Medical Services,Rio Grande Hospital Clinic,90471,Immunization administration by a medical assistant or nurse,771,$37.14 ,$33.43 ,90% of total billed charges for outpatient setting,$34.54 ,93% of total billed charges for outpatient setting,$14.11 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$14.11 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$31.57 ,85% of total billed charges for outpatient setting,$14.11 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$30.23 ,81.4% of total billed charges for outpatient setting,$33.43 ,90% of total billed charges for outpatient setting,$33.43 ,90% of total billed charges for outpatient setting,$14.11 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$14.11 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$14.11 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$27.86 ,75% of total billed charges for outpatient setting,$31.57 ,85% of total billed charges for outpatient setting,$14.11 ,$34.54 ,$27.86 
Clinic Medical Services,Rio Grande Hospital Clinic,90471,Immunization administration by a medical assistant or nurse,771,$38.29 ,$34.46 ,90% of total billed charges for outpatient setting,$35.61 ,93% of total billed charges for outpatient setting,$14.55 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$14.55 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$32.55 ,85% of total billed charges for outpatient setting,$14.55 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$31.17 ,81.4% of total billed charges for outpatient setting,$34.46 ,90% of total billed charges for outpatient setting,$34.46 ,90% of total billed charges for outpatient setting,$14.55 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$14.55 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$14.55 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$28.72 ,75% of total billed charges for outpatient setting,$32.55 ,85% of total billed charges for outpatient setting,$14.55 ,$35.61 ,$28.72 
Clinic Medical Services,South Fork Clinic,90471,Immunization administration by a medical assistant or nurse,771,$37.14 ,$33.43 ,90% of total billed charges for outpatient setting,$34.54 ,93% of total billed charges for outpatient setting,$14.11 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$14.11 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$31.57 ,85% of total billed charges for outpatient setting,$14.11 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$30.23 ,81.4% of total billed charges for outpatient setting,$33.43 ,90% of total billed charges for outpatient setting,$33.43 ,90% of total billed charges for outpatient setting,$14.11 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$14.11 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$14.11 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$27.86 ,75% of total billed charges for outpatient setting,$31.57 ,85% of total billed charges for outpatient setting,$14.11 ,$34.54 ,$27.86 
Clinic Medical Services,South Fork Clinic,90471,Immunization administration by a medical assistant or nurse,771,$38.29 ,$34.46 ,90% of total billed charges for outpatient setting,$35.61 ,93% of total billed charges for outpatient setting,$14.55 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$14.55 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$32.55 ,85% of total billed charges for outpatient setting,$14.55 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$31.17 ,81.4% of total billed charges for outpatient setting,$34.46 ,90% of total billed charges for outpatient setting,$34.46 ,90% of total billed charges for outpatient setting,$14.55 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$14.55 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$14.55 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$28.72 ,75% of total billed charges for outpatient setting,$32.55 ,85% of total billed charges for outpatient setting,$14.55 ,$35.61 ,$28.72 
Clinic Medical Services,Creede family practice clinic,90472,ADMIN vaccine  Addt.,771,$23.65 ,$21.29 ,90% of total billed charges for outpatient setting,$21.99 ,93% of total billed charges for outpatient setting,$8.99 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$8.99 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$20.10 ,85% of total billed charges for outpatient setting,$8.99 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$19.25 ,81.4% of total billed charges for outpatient setting,$21.29 ,90% of total billed charges for outpatient setting,$21.29 ,90% of total billed charges for outpatient setting,$8.99 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$8.99 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$8.99 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$17.74 ,75% of total billed charges for outpatient setting,$20.10 ,85% of total billed charges for outpatient setting,$8.99 ,$21.99 ,$17.74 
Clinic Medical Services,Monte Vista Medical Clinic,90472,ADMIN vaccine  Addt.,771,$23.65 ,$21.29 ,90% of total billed charges for outpatient setting,$21.99 ,93% of total billed charges for outpatient setting,$8.99 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$8.99 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$20.10 ,85% of total billed charges for outpatient setting,$8.99 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$19.25 ,81.4% of total billed charges for outpatient setting,$21.29 ,90% of total billed charges for outpatient setting,$21.29 ,90% of total billed charges for outpatient setting,$8.99 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$8.99 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$8.99 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$17.74 ,75% of total billed charges for outpatient setting,$20.10 ,85% of total billed charges for outpatient setting,$8.99 ,$21.99 ,$17.74 
Clinic Medical Services,Rio Grande Hospital Clinic,90472,ADMIN vaccine  Addt.,771,$23.65 ,$21.29 ,90% of total billed charges for outpatient setting,$21.99 ,93% of total billed charges for outpatient setting,$8.99 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$8.99 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$20.10 ,85% of total billed charges for outpatient setting,$8.99 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$19.25 ,81.4% of total billed charges for outpatient setting,$21.29 ,90% of total billed charges for outpatient setting,$21.29 ,90% of total billed charges for outpatient setting,$8.99 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$8.99 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$8.99 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$17.74 ,75% of total billed charges for outpatient setting,$20.10 ,85% of total billed charges for outpatient setting,$8.99 ,$21.99 ,$17.74 
Clinic Medical Services,South Fork Clinic,90472,ADMIN vaccine  Addt.,771,$23.65 ,$21.29 ,90% of total billed charges for outpatient setting,$21.99 ,93% of total billed charges for outpatient setting,$8.99 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$8.99 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$20.10 ,85% of total billed charges for outpatient setting,$8.99 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$19.25 ,81.4% of total billed charges for outpatient setting,$21.29 ,90% of total billed charges for outpatient setting,$21.29 ,90% of total billed charges for outpatient setting,$8.99 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$8.99 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$8.99 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$17.74 ,75% of total billed charges for outpatient setting,$20.10 ,85% of total billed charges for outpatient setting,$8.99 ,$21.99 ,$17.74 
Clinic Medical Services,Creede family practice clinic,90715,"Diphtheria, tetanus acellular, and pertussis vaccine for adults",636,$92.36 ,$83.12 ,90% of total billed charges for outpatient setting,$85.89 ,93% of total billed charges for outpatient setting,$35.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$35.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$78.51 ,85% of total billed charges for outpatient setting,$35.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$75.18 ,81.4% of total billed charges for outpatient setting,$83.12 ,90% of total billed charges for outpatient setting,$83.12 ,90% of total billed charges for outpatient setting,$35.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$35.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$35.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$69.27 ,75% of total billed charges for outpatient setting,$78.51 ,85% of total billed charges for outpatient setting,$35.10 ,$85.89 ,$69.27 
Clinic Medical Services,Monte Vista Medical Clinic,90715,"Diphtheria, tetanus acellular, and pertussis vaccine for adults",636,$92.36 ,$83.12 ,90% of total billed charges for outpatient setting,$85.89 ,93% of total billed charges for outpatient setting,$35.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$35.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$78.51 ,85% of total billed charges for outpatient setting,$35.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$75.18 ,81.4% of total billed charges for outpatient setting,$83.12 ,90% of total billed charges for outpatient setting,$83.12 ,90% of total billed charges for outpatient setting,$35.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$35.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$35.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$69.27 ,75% of total billed charges for outpatient setting,$78.51 ,85% of total billed charges for outpatient setting,$35.10 ,$85.89 ,$69.27 
Clinic Medical Services,Rio Grande Hospital Clinic,90715,"Diphtheria, tetanus acellular, and pertussis vaccine for adults",636,$92.36 ,$83.12 ,90% of total billed charges for outpatient setting,$85.89 ,93% of total billed charges for outpatient setting,$35.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$35.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$78.51 ,85% of total billed charges for outpatient setting,$35.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$75.18 ,81.4% of total billed charges for outpatient setting,$83.12 ,90% of total billed charges for outpatient setting,$83.12 ,90% of total billed charges for outpatient setting,$35.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$35.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$35.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$69.27 ,75% of total billed charges for outpatient setting,$78.51 ,85% of total billed charges for outpatient setting,$35.10 ,$85.89 ,$69.27 
Clinic Medical Services,South Fork Clinic,90715,"Diphtheria, tetanus acellular, and pertussis vaccine for adults",636,$92.36 ,$83.12 ,90% of total billed charges for outpatient setting,$85.89 ,93% of total billed charges for outpatient setting,$35.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$35.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$78.51 ,85% of total billed charges for outpatient setting,$35.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$75.18 ,81.4% of total billed charges for outpatient setting,$83.12 ,90% of total billed charges for outpatient setting,$83.12 ,90% of total billed charges for outpatient setting,$35.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$35.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$35.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$69.27 ,75% of total billed charges for outpatient setting,$78.51 ,85% of total billed charges for outpatient setting,$35.10 ,$85.89 ,$69.27 
Clinic Medical Services,Creede family practice clinic,93005,EKG,730,$132.90 ,$119.61 ,90% of total billed charges for outpatient setting,$123.60 ,93% of total billed charges for outpatient setting,$50.50 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$50.50 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$112.97 ,85% of total billed charges for outpatient setting,$50.50 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$108.18 ,81.4% of total billed charges for outpatient setting,$119.61 ,90% of total billed charges for outpatient setting,$119.61 ,90% of total billed charges for outpatient setting,$50.50 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$50.50 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$50.50 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$99.68 ,75% of total billed charges for outpatient setting,$112.97 ,85% of total billed charges for outpatient setting,$50.50 ,$123.60 ,$99.68 
Clinic Medical Services,Monte Vista Medical Clinic,93005,EKG,730,$132.90 ,$119.61 ,90% of total billed charges for outpatient setting,$123.60 ,93% of total billed charges for outpatient setting,$50.50 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$50.50 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$112.97 ,85% of total billed charges for outpatient setting,$50.50 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$108.18 ,81.4% of total billed charges for outpatient setting,$119.61 ,90% of total billed charges for outpatient setting,$119.61 ,90% of total billed charges for outpatient setting,$50.50 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$50.50 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$50.50 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$99.68 ,75% of total billed charges for outpatient setting,$112.97 ,85% of total billed charges for outpatient setting,$50.50 ,$123.60 ,$99.68 
Clinic Medical Services,Rio Grande Hospital Clinic,93005,EKG,730,$132.90 ,$119.61 ,90% of total billed charges for outpatient setting,$123.60 ,93% of total billed charges for outpatient setting,$50.50 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$50.50 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$112.97 ,85% of total billed charges for outpatient setting,$50.50 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$108.18 ,81.4% of total billed charges for outpatient setting,$119.61 ,90% of total billed charges for outpatient setting,$119.61 ,90% of total billed charges for outpatient setting,$50.50 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$50.50 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$50.50 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$99.68 ,75% of total billed charges for outpatient setting,$112.97 ,85% of total billed charges for outpatient setting,$50.50 ,$123.60 ,$99.68 
Clinic Medical Services,South Fork Clinic,93005,EKG,730,$132.90 ,$119.61 ,90% of total billed charges for outpatient setting,$123.60 ,93% of total billed charges for outpatient setting,$50.50 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$50.50 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$112.97 ,85% of total billed charges for outpatient setting,$50.50 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$108.18 ,81.4% of total billed charges for outpatient setting,$119.61 ,90% of total billed charges for outpatient setting,$119.61 ,90% of total billed charges for outpatient setting,$50.50 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$50.50 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$50.50 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$99.68 ,75% of total billed charges for outpatient setting,$112.97 ,85% of total billed charges for outpatient setting,$50.50 ,$123.60 ,$99.68 
Outpatient Medical Services,Ultrasound,93306,"Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function",483,"$1,385.31 ","$1,246.78 ",90% of total billed charges for outpatient setting,"$1,288.34 ",93% of total billed charges for outpatient setting,$526.42 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$526.42 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,177.51 ",85% of total billed charges for outpatient setting,$526.42 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,127.64 ",81.4% of total billed charges for outpatient setting,"$1,246.78 ",90% of total billed charges for outpatient setting,"$1,246.78 ",90% of total billed charges for outpatient setting,$526.42 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$526.42 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$526.42 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,038.98 ",75% of total billed charges for outpatient setting,"$1,177.51 ",85% of total billed charges for outpatient setting,$526.42 ,"$1,288.34 ","$1,038.98 "
Clinic Medical Services,Creede family practice clinic,93798,Use of EKG to monitor cardiac rehabilitation,943,$79.59 ,$71.63 ,90% of total billed charges for outpatient setting,$74.02 ,93% of total billed charges for outpatient setting,$30.24 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$30.24 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$67.65 ,85% of total billed charges for outpatient setting,$30.24 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$64.79 ,81.4% of total billed charges for outpatient setting,$71.63 ,90% of total billed charges for outpatient setting,$71.63 ,90% of total billed charges for outpatient setting,$30.24 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$30.24 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$30.24 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$59.69 ,75% of total billed charges for outpatient setting,$67.65 ,85% of total billed charges for outpatient setting,$30.24 ,$74.02 ,$59.69 
Clinic Medical Services,Monte Vista Medical Clinic,93798,Use of EKG to monitor cardiac rehabilitation,943,$79.59 ,$71.63 ,90% of total billed charges for outpatient setting,$74.02 ,93% of total billed charges for outpatient setting,$30.24 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$30.24 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$67.65 ,85% of total billed charges for outpatient setting,$30.24 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$64.79 ,81.4% of total billed charges for outpatient setting,$71.63 ,90% of total billed charges for outpatient setting,$71.63 ,90% of total billed charges for outpatient setting,$30.24 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$30.24 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$30.24 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$59.69 ,75% of total billed charges for outpatient setting,$67.65 ,85% of total billed charges for outpatient setting,$30.24 ,$74.02 ,$59.69 
Clinic Medical Services,Rio Grande Hospital Clinic,93798,Use of EKG to monitor cardiac rehabilitation,943,$79.59 ,$71.63 ,90% of total billed charges for outpatient setting,$74.02 ,93% of total billed charges for outpatient setting,$30.24 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$30.24 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$67.65 ,85% of total billed charges for outpatient setting,$30.24 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$64.79 ,81.4% of total billed charges for outpatient setting,$71.63 ,90% of total billed charges for outpatient setting,$71.63 ,90% of total billed charges for outpatient setting,$30.24 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$30.24 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$30.24 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$59.69 ,75% of total billed charges for outpatient setting,$67.65 ,85% of total billed charges for outpatient setting,$30.24 ,$74.02 ,$59.69 
Clinic Medical Services,South Fork Clinic,93798,Use of EKG to monitor cardiac rehabilitation,943,$79.59 ,$71.63 ,90% of total billed charges for outpatient setting,$74.02 ,93% of total billed charges for outpatient setting,$30.24 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$30.24 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$67.65 ,85% of total billed charges for outpatient setting,$30.24 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$64.79 ,81.4% of total billed charges for outpatient setting,$71.63 ,90% of total billed charges for outpatient setting,$71.63 ,90% of total billed charges for outpatient setting,$30.24 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$30.24 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$30.24 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$59.69 ,75% of total billed charges for outpatient setting,$67.65 ,85% of total billed charges for outpatient setting,$30.24 ,$74.02 ,$59.69 
Outpatient Medical Services,Ultrasound,93880,Study of vessels on both sides of the head and neck,402,$991.11 ,$892.00 ,90% of total billed charges for outpatient setting,$921.73 ,93% of total billed charges for outpatient setting,$376.62 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$376.62 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$842.44 ,85% of total billed charges for outpatient setting,$376.62 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$806.76 ,81.4% of total billed charges for outpatient setting,$892.00 ,90% of total billed charges for outpatient setting,$892.00 ,90% of total billed charges for outpatient setting,$376.62 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$376.62 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$376.62 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$743.33 ,75% of total billed charges for outpatient setting,$842.44 ,85% of total billed charges for outpatient setting,$376.62 ,$921.73 ,$743.33 
Outpatient Medical Services,Ultrasound,93970,Complete bilateral study of the extremities,402,$952.83 ,$857.55 ,90% of total billed charges for outpatient setting,$886.13 ,93% of total billed charges for outpatient setting,$362.08 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$362.08 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$809.91 ,85% of total billed charges for outpatient setting,$362.08 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$775.60 ,81.4% of total billed charges for outpatient setting,$857.55 ,90% of total billed charges for outpatient setting,$857.55 ,90% of total billed charges for outpatient setting,$362.08 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$362.08 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$362.08 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$714.62 ,75% of total billed charges for outpatient setting,$809.91 ,85% of total billed charges for outpatient setting,$362.08 ,$886.13 ,$714.62 
Clinic Medical Services,Creede family practice clinic,94060,Test to determine if wheezing is present,460,$171.20 ,$154.08 ,90% of total billed charges for outpatient setting,$159.22 ,93% of total billed charges for outpatient setting,$65.06 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$65.06 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$145.52 ,85% of total billed charges for outpatient setting,$65.06 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$139.36 ,81.4% of total billed charges for outpatient setting,$154.08 ,90% of total billed charges for outpatient setting,$154.08 ,90% of total billed charges for outpatient setting,$65.06 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$65.06 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$65.06 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$128.40 ,75% of total billed charges for outpatient setting,$145.52 ,85% of total billed charges for outpatient setting,$65.06 ,$159.22 ,$128.40 
Clinic Medical Services,Creede family practice clinic,94060,Test to determine if wheezing is present,976,$121.64 ,$79.73 ,130% of 2011 CMS RBRVS fee schedule,$79.73 ,130% of 2011 CMS RBRVS fee schedule,$40.41 ,100% of CMS RBRVS fee schedule for physician setting,$40.41 ,100% of CMS RBRVS fee schedule for physician setting,$57.56 ,119% CMS RBRVS fee schedule for physician setting,$40.41 ,100% of CMS RBRVS fee schedule for physician setting,$40.41 ,100% of CMS RBRVS fee schedule for physician setting,$109.48 ,90% of total billed charges for physician setting,$40.41 ,100% of CMS RBRVS fee schedule for physician setting,$40.41 ,100% of CMS RBRVS fee schedule for physician setting,$40.41 ,100% of CMS RBRVS fee schedule for physician setting,$40.41 ,100% of CMS RBRVS fee schedule for physician setting,$89.88 ,100% of SLVHMO physician fee schedule,$40.41 ,100% of CMS RBRVS fee schedule for physician setting,$40.41 ,$109.48 ,$91.23 
Clinic Medical Services,Monte Vista Medical Clinic,94060,Test to determine if wheezing is present,460,$171.20 ,$154.08 ,90% of total billed charges for outpatient setting,$159.22 ,93% of total billed charges for outpatient setting,$65.06 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$65.06 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$145.52 ,85% of total billed charges for outpatient setting,$65.06 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$139.36 ,81.4% of total billed charges for outpatient setting,$154.08 ,90% of total billed charges for outpatient setting,$154.08 ,90% of total billed charges for outpatient setting,$65.06 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$65.06 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$65.06 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$128.40 ,75% of total billed charges for outpatient setting,$145.52 ,85% of total billed charges for outpatient setting,$65.06 ,$159.22 ,$128.40 
Clinic Medical Services,Monte Vista Medical Clinic,94060,Test to determine if wheezing is present,976,$121.64 ,$79.73 ,130% of 2011 CMS RBRVS fee schedule,$79.73 ,130% of 2011 CMS RBRVS fee schedule,$40.41 ,100% of CMS RBRVS fee schedule for physician setting,$40.41 ,100% of CMS RBRVS fee schedule for physician setting,$57.56 ,119% CMS RBRVS fee schedule for physician setting,$40.41 ,100% of CMS RBRVS fee schedule for physician setting,$40.41 ,100% of CMS RBRVS fee schedule for physician setting,$109.48 ,90% of total billed charges for physician setting,$40.41 ,100% of CMS RBRVS fee schedule for physician setting,$40.41 ,100% of CMS RBRVS fee schedule for physician setting,$40.41 ,100% of CMS RBRVS fee schedule for physician setting,$40.41 ,100% of CMS RBRVS fee schedule for physician setting,$89.88 ,100% of SLVHMO physician fee schedule,$40.41 ,100% of CMS RBRVS fee schedule for physician setting,$40.41 ,$109.48 ,$91.23 
Clinic Medical Services,Rio Grande Hospital Clinic,94060,Test to determine if wheezing is present,460,$171.20 ,$154.08 ,90% of total billed charges for outpatient setting,$159.22 ,93% of total billed charges for outpatient setting,$65.06 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$65.06 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$145.52 ,85% of total billed charges for outpatient setting,$65.06 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$139.36 ,81.4% of total billed charges for outpatient setting,$154.08 ,90% of total billed charges for outpatient setting,$154.08 ,90% of total billed charges for outpatient setting,$65.06 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$65.06 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$65.06 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$128.40 ,75% of total billed charges for outpatient setting,$145.52 ,85% of total billed charges for outpatient setting,$65.06 ,$159.22 ,$128.40 
Clinic Medical Services,Rio Grande Hospital Clinic,94060,Test to determine if wheezing is present,976,$121.64 ,$79.73 ,130% of 2011 CMS RBRVS fee schedule,$79.73 ,130% of 2011 CMS RBRVS fee schedule,$40.41 ,100% of CMS RBRVS fee schedule for physician setting,$40.41 ,100% of CMS RBRVS fee schedule for physician setting,$57.56 ,119% CMS RBRVS fee schedule for physician setting,$40.41 ,100% of CMS RBRVS fee schedule for physician setting,$40.41 ,100% of CMS RBRVS fee schedule for physician setting,$109.48 ,90% of total billed charges for physician setting,$40.41 ,100% of CMS RBRVS fee schedule for physician setting,$40.41 ,100% of CMS RBRVS fee schedule for physician setting,$40.41 ,100% of CMS RBRVS fee schedule for physician setting,$40.41 ,100% of CMS RBRVS fee schedule for physician setting,$89.88 ,100% of SLVHMO physician fee schedule,$40.41 ,100% of CMS RBRVS fee schedule for physician setting,$40.41 ,$109.48 ,$91.23 
Clinic Medical Services,South Fork Clinic,94060,Test to determine if wheezing is present,460,$171.20 ,$154.08 ,90% of total billed charges for outpatient setting,$159.22 ,93% of total billed charges for outpatient setting,$65.06 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$65.06 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$145.52 ,85% of total billed charges for outpatient setting,$65.06 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$139.36 ,81.4% of total billed charges for outpatient setting,$154.08 ,90% of total billed charges for outpatient setting,$154.08 ,90% of total billed charges for outpatient setting,$65.06 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$65.06 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$65.06 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$128.40 ,75% of total billed charges for outpatient setting,$145.52 ,85% of total billed charges for outpatient setting,$65.06 ,$159.22 ,$128.40 
Clinic Medical Services,South Fork Clinic,94060,Test to determine if wheezing is present,976,$121.64 ,$79.73 ,130% of 2011 CMS RBRVS fee schedule,$79.73 ,130% of 2011 CMS RBRVS fee schedule,$40.41 ,100% of CMS RBRVS fee schedule for physician setting,$40.41 ,100% of CMS RBRVS fee schedule for physician setting,$57.56 ,119% CMS RBRVS fee schedule for physician setting,$40.41 ,100% of CMS RBRVS fee schedule for physician setting,$40.41 ,100% of CMS RBRVS fee schedule for physician setting,$109.48 ,90% of total billed charges for physician setting,$40.41 ,100% of CMS RBRVS fee schedule for physician setting,$40.41 ,100% of CMS RBRVS fee schedule for physician setting,$40.41 ,100% of CMS RBRVS fee schedule for physician setting,$40.41 ,100% of CMS RBRVS fee schedule for physician setting,$89.88 ,100% of SLVHMO physician fee schedule,$40.41 ,100% of CMS RBRVS fee schedule for physician setting,$40.41 ,$109.48 ,$91.23 
Clinic Medical Services,Creede family practice clinic,95115,Allergy shot-1 shot,521,$25.91 ,$23.32 ,90% of total billed charges for outpatient setting,$24.10 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$22.02 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$21.09 ,81.4% of total billed charges for outpatient setting,$23.32 ,90% of total billed charges for outpatient setting,$23.32 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$19.43 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$19.43 ,$185.84 ,$19.43 
Clinic Medical Services,Monte Vista Medical Clinic,95115,Allergy shot-1 shot,521,$25.91 ,$23.32 ,90% of total billed charges for outpatient setting,$24.10 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$22.02 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$21.09 ,81.4% of total billed charges for outpatient setting,$23.32 ,90% of total billed charges for outpatient setting,$23.32 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$19.43 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$19.43 ,$185.84 ,$19.43 
Clinic Medical Services,Rio Grande Hospital Clinic,95115,Allergy shot-1 shot,521,$25.91 ,$23.32 ,90% of total billed charges for outpatient setting,$24.10 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$22.02 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$21.09 ,81.4% of total billed charges for outpatient setting,$23.32 ,90% of total billed charges for outpatient setting,$23.32 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$19.43 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$19.43 ,$185.84 ,$19.43 
Clinic Medical Services,South Fork Clinic,95115,Allergy shot-1 shot,521,$25.91 ,$23.32 ,90% of total billed charges for outpatient setting,$24.10 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$22.02 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$21.09 ,81.4% of total billed charges for outpatient setting,$23.32 ,90% of total billed charges for outpatient setting,$23.32 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$19.43 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$19.43 ,$185.84 ,$19.43 
Clinic Medical Services,Creede family practice clinic,95811,Sleep monitoring of patient (6 years or older) in sleep lab using CPAP,740,"$2,933.29 ","$2,639.96 ",90% of total billed charges for outpatient setting,"$2,727.96 ",93% of total billed charges for outpatient setting,"$1,114.65 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,114.65 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,493.30 ",85% of total billed charges for outpatient setting,"$1,114.65 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,387.70 ",81.4% of total billed charges for outpatient setting,"$2,639.96 ",90% of total billed charges for outpatient setting,"$2,639.96 ",90% of total billed charges for outpatient setting,"$1,114.65 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,114.65 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,114.65 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,199.97 ",75% of total billed charges for outpatient setting,"$2,493.30 ",85% of total billed charges for outpatient setting,"$1,114.65 ","$2,727.96 ","$2,199.97 "
Clinic Medical Services,Monte Vista Medical Clinic,95811,Sleep monitoring of patient (6 years or older) in sleep lab using CPAP,740,"$2,933.29 ","$2,639.96 ",90% of total billed charges for outpatient setting,"$2,727.96 ",93% of total billed charges for outpatient setting,"$1,114.65 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,114.65 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,493.30 ",85% of total billed charges for outpatient setting,"$1,114.65 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,387.70 ",81.4% of total billed charges for outpatient setting,"$2,639.96 ",90% of total billed charges for outpatient setting,"$2,639.96 ",90% of total billed charges for outpatient setting,"$1,114.65 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,114.65 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,114.65 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,199.97 ",75% of total billed charges for outpatient setting,"$2,493.30 ",85% of total billed charges for outpatient setting,"$1,114.65 ","$2,727.96 ","$2,199.97 "
Clinic Medical Services,Rio Grande Hospital Clinic,95811,Sleep monitoring of patient (6 years or older) in sleep lab using CPAP,740,"$2,933.29 ","$2,639.96 ",90% of total billed charges for outpatient setting,"$2,727.96 ",93% of total billed charges for outpatient setting,"$1,114.65 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,114.65 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,493.30 ",85% of total billed charges for outpatient setting,"$1,114.65 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,387.70 ",81.4% of total billed charges for outpatient setting,"$2,639.96 ",90% of total billed charges for outpatient setting,"$2,639.96 ",90% of total billed charges for outpatient setting,"$1,114.65 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,114.65 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,114.65 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,199.97 ",75% of total billed charges for outpatient setting,"$2,493.30 ",85% of total billed charges for outpatient setting,"$1,114.65 ","$2,727.96 ","$2,199.97 "
Clinic Medical Services,South Fork Clinic,95811,Sleep monitoring of patient (6 years or older) in sleep lab using CPAP,740,"$2,933.29 ","$2,639.96 ",90% of total billed charges for outpatient setting,"$2,727.96 ",93% of total billed charges for outpatient setting,"$1,114.65 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,114.65 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,493.30 ",85% of total billed charges for outpatient setting,"$1,114.65 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,387.70 ",81.4% of total billed charges for outpatient setting,"$2,639.96 ",90% of total billed charges for outpatient setting,"$2,639.96 ",90% of total billed charges for outpatient setting,"$1,114.65 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,114.65 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,114.65 ",38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$2,199.97 ",75% of total billed charges for outpatient setting,"$2,493.30 ",85% of total billed charges for outpatient setting,"$1,114.65 ","$2,727.96 ","$2,199.97 "
Outpatient Medical Services,Emergency Services,96360,"IV infusion therapy, for hydration > 30",450,$265.79 ,$239.21 ,90% of total billed charges for outpatient setting,$247.18 ,93% of total billed charges for outpatient setting,$101.00 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$101.00 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$225.92 ,85% of total billed charges for outpatient setting,$101.00 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$216.35 ,81.4% of total billed charges for outpatient setting,$239.21 ,90% of total billed charges for outpatient setting,$239.21 ,90% of total billed charges for outpatient setting,$101.00 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$101.00 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$101.00 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$199.34 ,75% of total billed charges for outpatient setting,$225.92 ,85% of total billed charges for outpatient setting,$101.00 ,$247.18 ,$199.34 
Outpatient Medical Services,Emergency Services,96361,"IV infusion hydration, ea add hr",450,$82.22 ,$74.00 ,90% of total billed charges for outpatient setting,$76.46 ,93% of total billed charges for outpatient setting,$31.24 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$31.24 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$69.89 ,85% of total billed charges for outpatient setting,$31.24 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$66.93 ,81.4% of total billed charges for outpatient setting,$74.00 ,90% of total billed charges for outpatient setting,$74.00 ,90% of total billed charges for outpatient setting,$31.24 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$31.24 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$31.24 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$61.67 ,75% of total billed charges for outpatient setting,$69.89 ,85% of total billed charges for outpatient setting,$31.24 ,$76.46 ,$61.67 
Outpatient Medical Services,Emergency Services,96365,"Intravenous infusion, for therapy, prophylaxis, or diagnosis-initial infusion",450,$265.79 ,$239.21 ,90% of total billed charges for outpatient setting,$247.18 ,93% of total billed charges for outpatient setting,$101.00 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$101.00 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$225.92 ,85% of total billed charges for outpatient setting,$101.00 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$216.35 ,81.4% of total billed charges for outpatient setting,$239.21 ,90% of total billed charges for outpatient setting,$239.21 ,90% of total billed charges for outpatient setting,$101.00 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$101.00 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$101.00 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$199.34 ,75% of total billed charges for outpatient setting,$225.92 ,85% of total billed charges for outpatient setting,$101.00 ,$247.18 ,$199.34 
Outpatient Medical Services,Emergency Services,96366,"Intravenous infusion, for therapy, prophylaxis, or diagnosis-additional infusions",450,$82.22 ,$74.00 ,90% of total billed charges for outpatient setting,$76.46 ,93% of total billed charges for outpatient setting,$31.24 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$31.24 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$69.89 ,85% of total billed charges for outpatient setting,$31.24 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$66.93 ,81.4% of total billed charges for outpatient setting,$74.00 ,90% of total billed charges for outpatient setting,$74.00 ,90% of total billed charges for outpatient setting,$31.24 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$31.24 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$31.24 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$61.67 ,75% of total billed charges for outpatient setting,$69.89 ,85% of total billed charges for outpatient setting,$31.24 ,$76.46 ,$61.67 
Outpatient Medical Services,Emergency Services,96367,IV Therapy new drug,450,$34.91 ,$31.42 ,90% of total billed charges for outpatient setting,$32.47 ,93% of total billed charges for outpatient setting,$13.27 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$13.27 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$29.67 ,85% of total billed charges for outpatient setting,$13.27 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$28.42 ,81.4% of total billed charges for outpatient setting,$31.42 ,90% of total billed charges for outpatient setting,$31.42 ,90% of total billed charges for outpatient setting,$13.27 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$13.27 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$13.27 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$26.18 ,75% of total billed charges for outpatient setting,$29.67 ,85% of total billed charges for outpatient setting,$13.27 ,$32.47 ,$26.18 
Outpatient Medical Services,Emergency Services,96372,IM injection/SQ injection-Fac,450,$42.80 ,$38.52 ,90% of total billed charges for outpatient setting,$39.80 ,93% of total billed charges for outpatient setting,$16.26 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$16.26 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$36.38 ,85% of total billed charges for outpatient setting,$16.26 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$34.84 ,81.4% of total billed charges for outpatient setting,$38.52 ,90% of total billed charges for outpatient setting,$38.52 ,90% of total billed charges for outpatient setting,$16.26 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$16.26 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$16.26 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$32.10 ,75% of total billed charges for outpatient setting,$36.38 ,85% of total billed charges for outpatient setting,$16.26 ,$39.80 ,$32.10 
Outpatient Medical Services,Emergency Services,96374,"Intravenous infusion, for therapy, prophylaxis, or diagnosis-IV push",450,$153.16 ,$137.84 ,90% of total billed charges for outpatient setting,$142.44 ,93% of total billed charges for outpatient setting,$58.20 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$58.20 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$130.19 ,85% of total billed charges for outpatient setting,$58.20 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$124.67 ,81.4% of total billed charges for outpatient setting,$137.84 ,90% of total billed charges for outpatient setting,$137.84 ,90% of total billed charges for outpatient setting,$58.20 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$58.20 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$58.20 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$114.87 ,75% of total billed charges for outpatient setting,$130.19 ,85% of total billed charges for outpatient setting,$58.20 ,$142.44 ,$114.87 
Outpatient Medical Services,Emergency Services,96375,"Intravenous infusion, for treatment, prophylaxis, or diagnosis-new drug add on",450,$100.25 ,$90.23 ,90% of total billed charges for outpatient setting,$93.23 ,93% of total billed charges for outpatient setting,$38.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$38.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$85.21 ,85% of total billed charges for outpatient setting,$38.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$81.60 ,81.4% of total billed charges for outpatient setting,$90.23 ,90% of total billed charges for outpatient setting,$90.23 ,90% of total billed charges for outpatient setting,$38.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$38.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$38.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$75.19 ,75% of total billed charges for outpatient setting,$85.21 ,85% of total billed charges for outpatient setting,$38.10 ,$93.23 ,$75.19 
Outpatient Medical Services,Emergency Services,96376,"Intravenous infusion, for treatment, prophylaxis, or diagnosis-same drug add on",450,$101.37 ,$91.23 ,90% of total billed charges for outpatient setting,$94.27 ,93% of total billed charges for outpatient setting,$38.52 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$38.52 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$86.16 ,85% of total billed charges for outpatient setting,$38.52 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$82.52 ,81.4% of total billed charges for outpatient setting,$91.23 ,90% of total billed charges for outpatient setting,$91.23 ,90% of total billed charges for outpatient setting,$38.52 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$38.52 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$38.52 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$76.03 ,75% of total billed charges for outpatient setting,$86.16 ,85% of total billed charges for outpatient setting,$38.52 ,$94.27 ,$76.03 
Outpatient Medical Services,Therapy,97012,Form of decompression therapy of the spine,420,$46.82 ,$42.14 ,90% of total billed charges for outpatient setting,$43.54 ,93% of total billed charges for outpatient setting,$17.79 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$17.79 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$39.80 ,85% of total billed charges for outpatient setting,$17.79 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$38.11 ,81.4% of total billed charges for outpatient setting,$42.14 ,90% of total billed charges for outpatient setting,$42.14 ,90% of total billed charges for outpatient setting,$17.79 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$17.79 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$17.79 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$35.12 ,75% of total billed charges for outpatient setting,$39.80 ,85% of total billed charges for outpatient setting,$17.79 ,$43.54 ,$35.12 
Outpatient Medical Services,Therapy,97014,One time use unattended,420,$48.42 ,$43.58 ,90% of total billed charges for outpatient setting,$45.03 ,93% of total billed charges for outpatient setting,$18.40 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$18.40 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$41.16 ,85% of total billed charges for outpatient setting,$18.40 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$39.41 ,81.4% of total billed charges for outpatient setting,$43.58 ,90% of total billed charges for outpatient setting,$43.58 ,90% of total billed charges for outpatient setting,$18.40 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$18.40 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$18.40 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$36.32 ,75% of total billed charges for outpatient setting,$41.16 ,85% of total billed charges for outpatient setting,$18.40 ,$45.03 ,$36.32 
Outpatient Medical Services,Therapy,97033,Psychiatric treatment in which seizures are electrically induced in patients to provide relief from mental disorders,420,$46.82 ,$42.14 ,90% of total billed charges for outpatient setting,$43.54 ,93% of total billed charges for outpatient setting,$17.79 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$17.79 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$39.80 ,85% of total billed charges for outpatient setting,$17.79 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$38.11 ,81.4% of total billed charges for outpatient setting,$42.14 ,90% of total billed charges for outpatient setting,$42.14 ,90% of total billed charges for outpatient setting,$17.79 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$17.79 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$17.79 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$35.12 ,75% of total billed charges for outpatient setting,$39.80 ,85% of total billed charges for outpatient setting,$17.79 ,$43.54 ,$35.12 
Outpatient Medical Services,Therapy,97035,"Use of sound waves to treat medical problems, especially musculoskeletal problems like inflammation from injuries",420,$62.42 ,$56.18 ,90% of total billed charges for outpatient setting,$58.05 ,93% of total billed charges for outpatient setting,$23.72 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$23.72 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$53.06 ,85% of total billed charges for outpatient setting,$23.72 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$50.81 ,81.4% of total billed charges for outpatient setting,$56.18 ,90% of total billed charges for outpatient setting,$56.18 ,90% of total billed charges for outpatient setting,$23.72 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$23.72 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$23.72 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$46.82 ,75% of total billed charges for outpatient setting,$53.06 ,85% of total billed charges for outpatient setting,$23.72 ,$58.05 ,$46.82 
Outpatient Medical Services,Therapy,97039,Laser therapy/attended /15min,420,$86.59 ,$77.93 ,90% of total billed charges for outpatient setting,$80.53 ,93% of total billed charges for outpatient setting,$32.90 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$32.90 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$73.60 ,85% of total billed charges for outpatient setting,$32.90 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$70.48 ,81.4% of total billed charges for outpatient setting,$77.93 ,90% of total billed charges for outpatient setting,$77.93 ,90% of total billed charges for outpatient setting,$32.90 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$32.90 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$32.90 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$64.94 ,75% of total billed charges for outpatient setting,$73.60 ,85% of total billed charges for outpatient setting,$32.90 ,$80.53 ,$64.94 
Outpatient Medical Services,Therapy,97110,"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",420,$75.46 ,$67.91 ,90% of total billed charges for outpatient setting,$70.18 ,93% of total billed charges for outpatient setting,$28.67 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$28.67 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$64.14 ,85% of total billed charges for outpatient setting,$28.67 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$61.42 ,81.4% of total billed charges for outpatient setting,$67.91 ,90% of total billed charges for outpatient setting,$67.91 ,90% of total billed charges for outpatient setting,$28.67 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$28.67 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$28.67 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$56.60 ,75% of total billed charges for outpatient setting,$64.14 ,85% of total billed charges for outpatient setting,$28.67 ,$70.18 ,$56.60 
Outpatient Medical Services,Therapy,97112,A technique used by physical therapists to restore normal body movement patterns,420,$92.36 ,$83.12 ,90% of total billed charges for outpatient setting,$85.89 ,93% of total billed charges for outpatient setting,$35.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$35.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$78.51 ,85% of total billed charges for outpatient setting,$35.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$75.18 ,81.4% of total billed charges for outpatient setting,$83.12 ,90% of total billed charges for outpatient setting,$83.12 ,90% of total billed charges for outpatient setting,$35.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$35.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$35.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$69.27 ,75% of total billed charges for outpatient setting,$78.51 ,85% of total billed charges for outpatient setting,$35.10 ,$85.89 ,$69.27 
Outpatient Medical Services,Therapy,97116,A type of physical therapy,420,$62.42 ,$56.18 ,90% of total billed charges for outpatient setting,$58.05 ,93% of total billed charges for outpatient setting,$23.72 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$23.72 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$53.06 ,85% of total billed charges for outpatient setting,$23.72 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$50.81 ,81.4% of total billed charges for outpatient setting,$56.18 ,90% of total billed charges for outpatient setting,$56.18 ,90% of total billed charges for outpatient setting,$23.72 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$23.72 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$23.72 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$46.82 ,75% of total billed charges for outpatient setting,$53.06 ,85% of total billed charges for outpatient setting,$23.72 ,$58.05 ,$46.82 
Outpatient Medical Services,Therapy,97140,Manipulation of 1 or more regions of the body,420,$61.94 ,$55.75 ,90% of total billed charges for outpatient setting,$57.60 ,93% of total billed charges for outpatient setting,$23.54 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$23.54 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$52.65 ,85% of total billed charges for outpatient setting,$23.54 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$50.42 ,81.4% of total billed charges for outpatient setting,$55.75 ,90% of total billed charges for outpatient setting,$55.75 ,90% of total billed charges for outpatient setting,$23.54 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$23.54 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$23.54 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$46.46 ,75% of total billed charges for outpatient setting,$52.65 ,85% of total billed charges for outpatient setting,$23.54 ,$57.60 ,$46.46 
Outpatient Medical Services,Therapy,97161,Physical therapy Eval - low complex,420,$192.11 ,$172.90 ,90% of total billed charges for outpatient setting,$178.66 ,93% of total billed charges for outpatient setting,$73.00 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$73.00 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$163.29 ,85% of total billed charges for outpatient setting,$73.00 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$156.38 ,81.4% of total billed charges for outpatient setting,$172.90 ,90% of total billed charges for outpatient setting,$172.90 ,90% of total billed charges for outpatient setting,$73.00 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$73.00 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$73.00 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$144.08 ,75% of total billed charges for outpatient setting,$163.29 ,85% of total billed charges for outpatient setting,$73.00 ,$178.66 ,$144.08 
Outpatient Medical Services,Therapy,97162,Physical therapy eval- medium complex,420,$192.11 ,$172.90 ,90% of total billed charges for outpatient setting,$178.66 ,93% of total billed charges for outpatient setting,$73.00 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$73.00 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$163.29 ,85% of total billed charges for outpatient setting,$73.00 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$156.38 ,81.4% of total billed charges for outpatient setting,$172.90 ,90% of total billed charges for outpatient setting,$172.90 ,90% of total billed charges for outpatient setting,$73.00 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$73.00 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$73.00 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$144.08 ,75% of total billed charges for outpatient setting,$163.29 ,85% of total billed charges for outpatient setting,$73.00 ,$178.66 ,$144.08 
Outpatient Medical Services,Therapy,97163,Physical therapy Eval - high complex,420,$192.11 ,$172.90 ,90% of total billed charges for outpatient setting,$178.66 ,93% of total billed charges for outpatient setting,$73.00 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$73.00 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$163.29 ,85% of total billed charges for outpatient setting,$73.00 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$156.38 ,81.4% of total billed charges for outpatient setting,$172.90 ,90% of total billed charges for outpatient setting,$172.90 ,90% of total billed charges for outpatient setting,$73.00 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$73.00 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$73.00 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$144.08 ,75% of total billed charges for outpatient setting,$163.29 ,85% of total billed charges for outpatient setting,$73.00 ,$178.66 ,$144.08 
Outpatient Medical Services,Therapy,97530,"Incorporates the use of multiple parameters, such as balance, strength, and range of motion, for a functional activity",420,$92.36 ,$83.12 ,90% of total billed charges for outpatient setting,$85.89 ,93% of total billed charges for outpatient setting,$35.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$35.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$78.51 ,85% of total billed charges for outpatient setting,$35.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$75.18 ,81.4% of total billed charges for outpatient setting,$83.12 ,90% of total billed charges for outpatient setting,$83.12 ,90% of total billed charges for outpatient setting,$35.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$35.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$35.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$69.27 ,75% of total billed charges for outpatient setting,$78.51 ,85% of total billed charges for outpatient setting,$35.10 ,$85.89 ,$69.27 
Outpatient Medical Services,Hyperbaric,99183,Hyperbaric physician supervision,981,$216.48 ,$158.91 ,130% of 2011 CMS RBRVS fee schedule,$158.91 ,130% of 2011 CMS RBRVS fee schedule,$106.27 ,100% of CMS RBRVS fee schedule for physician setting,$106.27 ,100% of CMS RBRVS fee schedule for physician setting,$135.71 ,119% CMS RBRVS fee schedule for physician setting,$106.27 ,100% of CMS RBRVS fee schedule for physician setting,$106.27 ,100% of CMS RBRVS fee schedule for physician setting,$194.83 ,90% of total billed charges for physician setting,$106.27 ,100% of CMS RBRVS fee schedule for physician setting,$106.27 ,100% of CMS RBRVS fee schedule for physician setting,$106.27 ,100% of CMS RBRVS fee schedule for physician setting,$106.27 ,100% of CMS RBRVS fee schedule for physician setting,,Not seperately reimbursable per contract terms,$106.27 ,100% of CMS RBRVS fee schedule for physician setting,$106.27 ,$194.83 ,$162.36 
Outpatient Medical Services,Laboratory,99195,Therapeutic Phlebotamy,300,$132.90 ,$119.61 ,90% of total billed charges for outpatient setting,$123.60 ,93% of total billed charges for outpatient setting,$50.50 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$50.50 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$112.97 ,85% of total billed charges for outpatient setting,$50.50 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$108.18 ,81.4% of total billed charges for outpatient setting,$119.61 ,90% of total billed charges for outpatient setting,$119.61 ,90% of total billed charges for outpatient setting,$50.50 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$50.50 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$50.50 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$99.68 ,75% of total billed charges for outpatient setting,$112.97 ,85% of total billed charges for outpatient setting,$50.50 ,$123.60 ,$99.68 
Outpatient Medical Services,Wound Care,99201,Wound Care New Min - FAC,761,$40.53 ,$36.48 ,90% of total billed charges for outpatient setting,$37.69 ,93% of total billed charges for outpatient setting,$15.40 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$15.40 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,,Not seperately reimbursable per contract terms,$15.40 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$32.99 ,81.4% of total billed charges for outpatient setting,$36.48 ,90% of total billed charges for outpatient setting,$36.48 ,90% of total billed charges for outpatient setting,$15.40 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$15.40 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$15.40 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$30.40 ,75% of total billed charges for outpatient setting,$34.45 ,85% of total billed charges for outpatient setting,$15.40 ,$37.69 ,$30.40 
Outpatient Medical Services,Wound Care,99201,Wound Care New Min - Pro,982,$64.94 ,$34.66 ,130% of 2011 CMS RBRVS fee schedule,$34.66 ,130% of 2011 CMS RBRVS fee schedule,,Not seperately reimbursable per CMS guidelines,,Not seperately reimbursable per CMS guidelines,$32.31 ,119% CMS RBRVS fee schedule for physician setting,,Not seperately reimbursable per CMS guidelines,,Not seperately reimbursable per CMS guidelines,$58.45 ,90% of total billed charges for physician setting,,Not seperately reimbursable per CMS guidelines,,Not seperately reimbursable per CMS guidelines,,Not seperately reimbursable per CMS guidelines,,Not seperately reimbursable per CMS guidelines,$35.95 ,100% of SLVHMO physician fee schedule,,Not seperately reimbursable per CMS guidelines,$32.31 ,$58.45 ,$48.71 
Clinic Medical Services,Creede family practice clinic,99202,"New patient office or other outpatient visit, typically 10 minutes",521,$168.94 ,$152.05 ,90% of total billed charges for outpatient setting,$157.11 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$143.60 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$137.52 ,81.4% of total billed charges for outpatient setting,$152.05 ,90% of total billed charges for outpatient setting,$152.05 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$126.71 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$126.71 ,$185.84 ,$126.71 
Clinic Medical Services,Monte Vista Medical Clinic,99202,"New patient office or other outpatient visit, typically 10 minutes",521,$168.94 ,$152.05 ,90% of total billed charges for outpatient setting,$157.11 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$143.60 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$137.52 ,81.4% of total billed charges for outpatient setting,$152.05 ,90% of total billed charges for outpatient setting,$152.05 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$126.71 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$126.71 ,$185.84 ,$126.71 
Clinic Medical Services,Rio Grande Hospital Clinic,99202,"New patient office or other outpatient visit, typically 10 minutes",521,$168.94 ,$152.05 ,90% of total billed charges for outpatient setting,$157.11 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$143.60 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$137.52 ,81.4% of total billed charges for outpatient setting,$152.05 ,90% of total billed charges for outpatient setting,$152.05 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$126.71 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$126.71 ,$185.84 ,$126.71 
Clinic Medical Services,South Fork Clinic,99202,"New patient office or other outpatient visit, typically 10 minutes",521,$168.94 ,$152.05 ,90% of total billed charges for outpatient setting,$157.11 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$143.60 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$137.52 ,81.4% of total billed charges for outpatient setting,$152.05 ,90% of total billed charges for outpatient setting,$152.05 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$126.71 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$126.71 ,$185.84 ,$126.71 
Outpatient Medical Services,Wound Care,99202,"New patient office or other outpatient visit, typically 10 minutes",761,$47.30 ,$42.57 ,90% of total billed charges for outpatient setting,$43.99 ,93% of total billed charges for outpatient setting,$17.97 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$17.97 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,,Not seperately reimbursable per contract terms,$17.97 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$38.50 ,81.4% of total billed charges for outpatient setting,$42.57 ,90% of total billed charges for outpatient setting,$42.57 ,90% of total billed charges for outpatient setting,$17.97 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$17.97 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$17.97 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$35.48 ,75% of total billed charges for outpatient setting,$40.21 ,85% of total billed charges for outpatient setting,$17.97 ,$43.99 ,$35.48 
Outpatient Medical Services,Wound Care,99202,"New patient office or other outpatient visit, typically 10 minutes",982,$121.64 ,$66.22 ,130% of 2011 CMS RBRVS fee schedule,$66.22 ,130% of 2011 CMS RBRVS fee schedule,$48.42 ,100% of CMS RBRVS fee schedule for physician setting,$48.42 ,100% of CMS RBRVS fee schedule for physician setting,$61.62 ,119% CMS RBRVS fee schedule for physician setting,$48.42 ,100% of CMS RBRVS fee schedule for physician setting,$48.42 ,100% of CMS RBRVS fee schedule for physician setting,$109.48 ,90% of total billed charges for physician setting,$48.42 ,100% of CMS RBRVS fee schedule for physician setting,$48.42 ,100% of CMS RBRVS fee schedule for physician setting,$48.42 ,100% of CMS RBRVS fee schedule for physician setting,$48.42 ,100% of CMS RBRVS fee schedule for physician setting,$53.93 ,100% of SLVHMO physician fee schedule,$48.42 ,100% of CMS RBRVS fee schedule for physician setting,$48.42 ,$109.48 ,$91.23 
Clinic Medical Services,Creede family practice clinic,99203,"New patient office or other outpatient visit, typically 30 min",521,$225.26 ,$202.73 ,90% of total billed charges for outpatient setting,$209.49 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$191.47 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$183.36 ,81.4% of total billed charges for outpatient setting,$202.73 ,90% of total billed charges for outpatient setting,$202.73 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$168.95 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$168.95 ,$209.49 ,$168.95 
Clinic Medical Services,Monte Vista Medical Clinic,99203,"New patient office or other outpatient visit, typically 30 min",521,$225.26 ,$202.73 ,90% of total billed charges for outpatient setting,$209.49 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$191.47 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$183.36 ,81.4% of total billed charges for outpatient setting,$202.73 ,90% of total billed charges for outpatient setting,$202.73 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$168.95 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$168.95 ,$209.49 ,$168.95 
Clinic Medical Services,Rio Grande Hospital Clinic,99203,"New patient office or other outpatient visit, typically 30 min",521,$225.26 ,$202.73 ,90% of total billed charges for outpatient setting,$209.49 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$191.47 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$183.36 ,81.4% of total billed charges for outpatient setting,$202.73 ,90% of total billed charges for outpatient setting,$202.73 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$168.95 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$168.95 ,$209.49 ,$168.95 
Clinic Medical Services,South Fork Clinic,99203,"New patient office or other outpatient visit, typically 30 min",521,$225.26 ,$202.73 ,90% of total billed charges for outpatient setting,$209.49 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$191.47 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$183.36 ,81.4% of total billed charges for outpatient setting,$202.73 ,90% of total billed charges for outpatient setting,$202.73 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$168.95 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$168.95 ,$209.49 ,$168.95 
Outpatient Medical Services,Wound Care,99203,"New patient office or other outpatient visit, typically 30 min",761,$189.42 ,$170.48 ,90% of total billed charges for outpatient setting,$176.16 ,93% of total billed charges for outpatient setting,$71.98 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$71.98 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,,Not seperately reimbursable per contract terms,$71.98 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$154.19 ,81.4% of total billed charges for outpatient setting,$170.48 ,90% of total billed charges for outpatient setting,$170.48 ,90% of total billed charges for outpatient setting,$71.98 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$71.98 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$71.98 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$142.07 ,75% of total billed charges for outpatient setting,$161.01 ,85% of total billed charges for outpatient setting,$71.98 ,$176.16 ,$142.07 
Outpatient Medical Services,Wound Care,99203,"New patient office or other outpatient visit, typically 30 min",982,$91.23 ,$101.17 ,130% of 2011 CMS RBRVS fee schedule,$101.17 ,130% of 2011 CMS RBRVS fee schedule,$83.27 ,100% of CMS RBRVS fee schedule for physician setting,$83.27 ,100% of CMS RBRVS fee schedule for physician setting,$92.20 ,119% CMS RBRVS fee schedule for physician setting,$83.27 ,100% of CMS RBRVS fee schedule for physician setting,$83.27 ,100% of CMS RBRVS fee schedule for physician setting,$82.11 ,90% of total billed charges for physician setting,$83.27 ,100% of CMS RBRVS fee schedule for physician setting,$83.27 ,100% of CMS RBRVS fee schedule for physician setting,$83.27 ,100% of CMS RBRVS fee schedule for physician setting,$83.27 ,100% of CMS RBRVS fee schedule for physician setting,$89.88 ,100% of SLVHMO physician fee schedule,$83.27 ,100% of CMS RBRVS fee schedule for physician setting,$82.11 ,$101.17 ,$68.42 
Clinic Medical Services,Creede family practice clinic,99204,"New patient office of other outpatient visit, typically 45 min",521,$319.86 ,$287.87 ,90% of total billed charges for outpatient setting,$297.47 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$271.88 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$260.37 ,81.4% of total billed charges for outpatient setting,$287.87 ,90% of total billed charges for outpatient setting,$287.87 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$239.90 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$185.84 ,$297.47 ,$239.90 
Clinic Medical Services,Monte Vista Medical Clinic,99204,"New patient office of other outpatient visit, typically 45 min",521,$319.86 ,$287.87 ,90% of total billed charges for outpatient setting,$297.47 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$271.88 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$260.37 ,81.4% of total billed charges for outpatient setting,$287.87 ,90% of total billed charges for outpatient setting,$287.87 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$239.90 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$185.84 ,$297.47 ,$239.90 
Clinic Medical Services,Rio Grande Hospital Clinic,99204,"New patient office of other outpatient visit, typically 45 min",521,$319.86 ,$287.87 ,90% of total billed charges for outpatient setting,$297.47 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$271.88 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$260.37 ,81.4% of total billed charges for outpatient setting,$287.87 ,90% of total billed charges for outpatient setting,$287.87 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$239.90 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$185.84 ,$297.47 ,$239.90 
Clinic Medical Services,South Fork Clinic,99204,"New patient office of other outpatient visit, typically 45 min",521,$319.86 ,$287.87 ,90% of total billed charges for outpatient setting,$297.47 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$271.88 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$260.37 ,81.4% of total billed charges for outpatient setting,$287.87 ,90% of total billed charges for outpatient setting,$287.87 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$239.90 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$185.84 ,$297.47 ,$239.90 
Outpatient Medical Services,Wound Care,99204,"New patient office of other outpatient visit, typically 45 min",761,$127.28 ,$114.55 ,90% of total billed charges for outpatient setting,$118.37 ,93% of total billed charges for outpatient setting,$48.37 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$48.37 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,,Not seperately reimbursable per contract terms,$48.37 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$103.61 ,81.4% of total billed charges for outpatient setting,$114.55 ,90% of total billed charges for outpatient setting,$114.55 ,90% of total billed charges for outpatient setting,$48.37 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$48.37 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$48.37 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$95.46 ,75% of total billed charges for outpatient setting,$108.19 ,85% of total billed charges for outpatient setting,$48.37 ,$118.37 ,$95.46 
Outpatient Medical Services,Wound Care,99204,"New patient office of other outpatient visit, typically 45 min",982,$270.61 ,$171.28 ,130% of 2011 CMS RBRVS fee schedule,$171.28 ,130% of 2011 CMS RBRVS fee schedule,$134.25 ,100% of CMS RBRVS fee schedule for physician setting,$134.25 ,100% of CMS RBRVS fee schedule for physician setting,$157.71 ,119% CMS RBRVS fee schedule for physician setting,$134.25 ,100% of CMS RBRVS fee schedule for physician setting,$134.25 ,100% of CMS RBRVS fee schedule for physician setting,$243.55 ,90% of total billed charges for physician setting,$134.25 ,100% of CMS RBRVS fee schedule for physician setting,$134.25 ,100% of CMS RBRVS fee schedule for physician setting,$134.25 ,100% of CMS RBRVS fee schedule for physician setting,$134.25 ,100% of CMS RBRVS fee schedule for physician setting,$118.64 ,100% of SLVHMO physician fee schedule,$134.25 ,100% of CMS RBRVS fee schedule for physician setting,$118.64 ,$243.55 ,$202.96 
Clinic Medical Services,Creede family practice clinic,99205,"New patient office of other outpatient visit, typically 60 min",521,$370.54 ,$333.49 ,90% of total billed charges for outpatient setting,$344.60 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$314.96 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$301.62 ,81.4% of total billed charges for outpatient setting,$333.49 ,90% of total billed charges for outpatient setting,$333.49 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$277.91 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$185.84 ,$344.60 ,$277.91 
Clinic Medical Services,Monte Vista Medical Clinic,99205,"New patient office of other outpatient visit, typically 60 min",521,$370.54 ,$333.49 ,90% of total billed charges for outpatient setting,$344.60 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$314.96 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$301.62 ,81.4% of total billed charges for outpatient setting,$333.49 ,90% of total billed charges for outpatient setting,$333.49 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$277.91 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$185.84 ,$344.60 ,$277.91 
Clinic Medical Services,Rio Grande Hospital Clinic,99205,"New patient office of other outpatient visit, typically 60 min",521,$370.54 ,$333.49 ,90% of total billed charges for outpatient setting,$344.60 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$314.96 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$301.62 ,81.4% of total billed charges for outpatient setting,$333.49 ,90% of total billed charges for outpatient setting,$333.49 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$277.91 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$185.84 ,$344.60 ,$277.91 
Clinic Medical Services,South Fork Clinic,99205,"New patient office of other outpatient visit, typically 60 min",521,$370.54 ,$333.49 ,90% of total billed charges for outpatient setting,$344.60 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$314.96 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$301.62 ,81.4% of total billed charges for outpatient setting,$333.49 ,90% of total billed charges for outpatient setting,$333.49 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$277.91 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$185.84 ,$344.60 ,$277.91 
Outpatient Medical Services,Wound Care,99205,"New patient office of other outpatient visit, typically 60 min",761,$147.54 ,$132.79 ,90% of total billed charges for outpatient setting,$137.21 ,93% of total billed charges for outpatient setting,$56.07 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$56.07 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,,Not seperately reimbursable per contract terms,$56.07 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$120.10 ,81.4% of total billed charges for outpatient setting,$132.79 ,90% of total billed charges for outpatient setting,$132.79 ,90% of total billed charges for outpatient setting,$56.07 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$56.07 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$56.07 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$110.66 ,75% of total billed charges for outpatient setting,$125.41 ,85% of total billed charges for outpatient setting,$56.07 ,$137.21 ,$110.66 
Outpatient Medical Services,Wound Care,99205,"New patient office of other outpatient visit, typically 60 min",982,$324.73 ,$218.79 ,130% of 2011 CMS RBRVS fee schedule,$218.79 ,130% of 2011 CMS RBRVS fee schedule,$182.36 ,100% of CMS RBRVS fee schedule for physician setting,$182.36 ,100% of CMS RBRVS fee schedule for physician setting,$206.02 ,119% CMS RBRVS fee schedule for physician setting,$182.36 ,100% of CMS RBRVS fee schedule for physician setting,$182.36 ,100% of CMS RBRVS fee schedule for physician setting,$292.26 ,90% of total billed charges for physician setting,$182.36 ,100% of CMS RBRVS fee schedule for physician setting,$182.36 ,100% of CMS RBRVS fee schedule for physician setting,$182.36 ,100% of CMS RBRVS fee schedule for physician setting,$182.36 ,100% of CMS RBRVS fee schedule for physician setting,$143.80 ,100% of SLVHMO physician fee schedule,$182.36 ,100% of CMS RBRVS fee schedule for physician setting,$143.80 ,$292.26 ,$243.55 
Outpatient Medical Services,Wound Care,99211,Outpatient visit of established patient not requiring a physician,982,$55.18 ,$12.00 ,130% of 2011 CMS RBRVS fee schedule,$12.00 ,130% of 2011 CMS RBRVS fee schedule,$8.89 ,100% of CMS RBRVS fee schedule for physician setting,$8.89 ,100% of CMS RBRVS fee schedule for physician setting,$11.22 ,119% CMS RBRVS fee schedule for physician setting,$8.89 ,100% of CMS RBRVS fee schedule for physician setting,$8.89 ,100% of CMS RBRVS fee schedule for physician setting,$49.66 ,90% of total billed charges for physician setting,$8.89 ,100% of CMS RBRVS fee schedule for physician setting,$8.89 ,100% of CMS RBRVS fee schedule for physician setting,$8.89 ,100% of CMS RBRVS fee schedule for physician setting,$8.89 ,100% of CMS RBRVS fee schedule for physician setting,$28.76 ,100% of SLVHMO physician fee schedule,$8.89 ,100% of CMS RBRVS fee schedule for physician setting,$8.89 ,$49.66 ,$41.39 
Outpatient Medical Services,Wound Care,99211,Outpatient visit of established patient not requiring a physician,761,$27.06 ,$24.35 ,90% of total billed charges for outpatient setting,$25.17 ,93% of total billed charges for outpatient setting,$10.28 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$10.28 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,,Not seperately reimbursable per contract terms,$10.28 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$22.03 ,81.4% of total billed charges for outpatient setting,$24.35 ,90% of total billed charges for outpatient setting,$24.35 ,90% of total billed charges for outpatient setting,$10.28 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$10.28 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$10.28 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$20.30 ,75% of total billed charges for outpatient setting,$23.00 ,85% of total billed charges for outpatient setting,$10.28 ,$25.17 ,$20.30 
Clinic Medical Services,Creede family practice clinic,99212,Outpatient visit of established patient requiring a physician,521,$90.10 ,$81.09 ,90% of total billed charges for outpatient setting,$83.79 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$76.59 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$73.34 ,81.4% of total billed charges for outpatient setting,$81.09 ,90% of total billed charges for outpatient setting,$81.09 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$67.58 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$67.58 ,$185.84 ,$67.58 
Clinic Medical Services,Monte Vista Medical Clinic,99212,Outpatient visit of established patient requiring a physician,521,$90.10 ,$81.09 ,90% of total billed charges for outpatient setting,$83.79 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$76.59 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$73.34 ,81.4% of total billed charges for outpatient setting,$81.09 ,90% of total billed charges for outpatient setting,$81.09 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$67.58 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$67.58 ,$185.84 ,$67.58 
Clinic Medical Services,Rio Grande Hospital Clinic,99212,Outpatient visit of established patient requiring a physician,521,$90.10 ,$81.09 ,90% of total billed charges for outpatient setting,$83.79 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$76.59 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$73.34 ,81.4% of total billed charges for outpatient setting,$81.09 ,90% of total billed charges for outpatient setting,$81.09 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$67.58 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$67.58 ,$185.84 ,$67.58 
Clinic Medical Services,South Fork Clinic,99212,Outpatient visit of established patient requiring a physician,521,$90.10 ,$81.09 ,90% of total billed charges for outpatient setting,$83.79 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$76.59 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$73.34 ,81.4% of total billed charges for outpatient setting,$81.09 ,90% of total billed charges for outpatient setting,$81.09 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$67.58 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$67.58 ,$185.84 ,$67.58 
Outpatient Medical Services,Wound Care,99212,Outpatient visit of established patient requiring a physician,982,$81.18 ,$33.75 ,130% of 2011 CMS RBRVS fee schedule,$33.75 ,130% of 2011 CMS RBRVS fee schedule,$35.77 ,100% of CMS RBRVS fee schedule for physician setting,$35.77 ,100% of CMS RBRVS fee schedule for physician setting,$31.43 ,119% CMS RBRVS fee schedule for physician setting,$35.77 ,100% of CMS RBRVS fee schedule for physician setting,$35.77 ,100% of CMS RBRVS fee schedule for physician setting,$73.06 ,90% of total billed charges for physician setting,$35.77 ,100% of CMS RBRVS fee schedule for physician setting,$35.77 ,100% of CMS RBRVS fee schedule for physician setting,$35.77 ,100% of CMS RBRVS fee schedule for physician setting,$35.77 ,100% of CMS RBRVS fee schedule for physician setting,$35.95 ,100% of SLVHMO physician fee schedule,$35.77 ,100% of CMS RBRVS fee schedule for physician setting,$31.43 ,$73.06 ,$60.89 
Outpatient Medical Services,Wound Care,99212,Outpatient visit of established patient requiring a physician,761,$37.16 ,$33.44 ,90% of total billed charges for outpatient setting,$34.56 ,93% of total billed charges for outpatient setting,$14.12 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$14.12 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,,Not seperately reimbursable per contract terms,$14.12 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$30.25 ,81.4% of total billed charges for outpatient setting,$33.44 ,90% of total billed charges for outpatient setting,$33.44 ,90% of total billed charges for outpatient setting,$14.12 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$14.12 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$14.12 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$27.87 ,75% of total billed charges for outpatient setting,$31.59 ,85% of total billed charges for outpatient setting,$14.12 ,$34.56 ,$27.87 
Clinic Medical Services,Creede family practice clinic,99213,"Established patient office or other outpatient visit, typically 15 minutes",521,$121.64 ,$109.48 ,90% of total billed charges for outpatient setting,$113.13 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$103.39 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$99.01 ,81.4% of total billed charges for outpatient setting,$109.48 ,90% of total billed charges for outpatient setting,$109.48 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$91.23 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$91.23 ,$185.84 ,$91.23 
Clinic Medical Services,Monte Vista Medical Clinic,99213,"Established patient office or other outpatient visit, typically 15 minutes",521,$121.64 ,$109.48 ,90% of total billed charges for outpatient setting,$113.13 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$103.39 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$99.01 ,81.4% of total billed charges for outpatient setting,$109.48 ,90% of total billed charges for outpatient setting,$109.48 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$91.23 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$91.23 ,$185.84 ,$91.23 
Clinic Medical Services,Rio Grande Hospital Clinic,99213,"Established patient office or other outpatient visit, typically 15 minutes",521,$121.64 ,$109.48 ,90% of total billed charges for outpatient setting,$113.13 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$103.39 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$99.01 ,81.4% of total billed charges for outpatient setting,$109.48 ,90% of total billed charges for outpatient setting,$109.48 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$91.23 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$91.23 ,$185.84 ,$91.23 
Clinic Medical Services,South Fork Clinic,99213,"Established patient office or other outpatient visit, typically 15 minutes",521,$121.64 ,$109.48 ,90% of total billed charges for outpatient setting,$113.13 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$103.39 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$99.01 ,81.4% of total billed charges for outpatient setting,$109.48 ,90% of total billed charges for outpatient setting,$109.48 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$91.23 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$91.23 ,$185.84 ,$91.23 
Outpatient Medical Services,Wound Care,99213,"Established patient office or other outpatient visit, typically 15 minutes",982,$140.72 ,$67.08 ,130% of 2011 CMS RBRVS fee schedule,$67.08 ,130% of 2011 CMS RBRVS fee schedule,$66.54 ,100% of CMS RBRVS fee schedule for physician setting,$66.54 ,100% of CMS RBRVS fee schedule for physician setting,$62.51 ,119% CMS RBRVS fee schedule for physician setting,$66.54 ,100% of CMS RBRVS fee schedule for physician setting,$66.54 ,100% of CMS RBRVS fee schedule for physician setting,$126.65 ,90% of total billed charges for physician setting,$66.54 ,100% of CMS RBRVS fee schedule for physician setting,$66.54 ,100% of CMS RBRVS fee schedule for physician setting,$66.54 ,100% of CMS RBRVS fee schedule for physician setting,$66.54 ,100% of CMS RBRVS fee schedule for physician setting,$62.91 ,100% of SLVHMO physician fee schedule,$66.54 ,100% of CMS RBRVS fee schedule for physician setting,$62.51 ,$126.65 ,$105.54 
Outpatient Medical Services,Wound Care,99213,"Established patient office or other outpatient visit, typically 15 minutes",761,$47.30 ,$42.57 ,90% of total billed charges for outpatient setting,$43.99 ,93% of total billed charges for outpatient setting,$17.97 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$17.97 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,,Not seperately reimbursable per contract terms,$17.97 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$38.50 ,81.4% of total billed charges for outpatient setting,$42.57 ,90% of total billed charges for outpatient setting,$42.57 ,90% of total billed charges for outpatient setting,$17.97 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$17.97 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$17.97 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$35.48 ,75% of total billed charges for outpatient setting,$40.21 ,85% of total billed charges for outpatient setting,$17.97 ,$43.99 ,$35.48 
Clinic Medical Services,Creede family practice clinic,99214,"Established patient office or other outpatient visit, typically 25 minutes",521,$186.96 ,$168.26 ,90% of total billed charges for outpatient setting,$173.87 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$158.92 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$152.19 ,81.4% of total billed charges for outpatient setting,$168.26 ,90% of total billed charges for outpatient setting,$168.26 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$140.22 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$140.22 ,$185.84 ,$140.22 
Clinic Medical Services,Creede family practice clinic,99214,"Established patient office or other outpatient visit, typically 25 minutes",521,$124.85 ,$112.37 ,90% of total billed charges for outpatient setting,$116.11 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$106.12 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$101.63 ,81.4% of total billed charges for outpatient setting,$112.37 ,90% of total billed charges for outpatient setting,$112.37 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$93.64 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$93.64 ,$185.84 ,$93.64 
Clinic Medical Services,Monte Vista Medical Clinic,99214,"Established patient office or other outpatient visit, typically 25 minutes",521,$186.96 ,$168.26 ,90% of total billed charges for outpatient setting,$173.87 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$158.92 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$152.19 ,81.4% of total billed charges for outpatient setting,$168.26 ,90% of total billed charges for outpatient setting,$168.26 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$140.22 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$140.22 ,$185.84 ,$140.22 
Clinic Medical Services,Monte Vista Medical Clinic,99214,"Established patient office or other outpatient visit, typically 25 minutes",521,$124.85 ,$112.37 ,90% of total billed charges for outpatient setting,$116.11 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$106.12 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$101.63 ,81.4% of total billed charges for outpatient setting,$112.37 ,90% of total billed charges for outpatient setting,$112.37 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$93.64 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$93.64 ,$185.84 ,$93.64 
Clinic Medical Services,Rio Grande Hospital Clinic,99214,"Established patient office or other outpatient visit, typically 25 minutes",521,$186.96 ,$168.26 ,90% of total billed charges for outpatient setting,$173.87 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$158.92 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$152.19 ,81.4% of total billed charges for outpatient setting,$168.26 ,90% of total billed charges for outpatient setting,$168.26 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$140.22 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$140.22 ,$185.84 ,$140.22 
Clinic Medical Services,Rio Grande Hospital Clinic,99214,"Established patient office or other outpatient visit, typically 25 minutes",521,$124.85 ,$112.37 ,90% of total billed charges for outpatient setting,$116.11 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$106.12 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$101.63 ,81.4% of total billed charges for outpatient setting,$112.37 ,90% of total billed charges for outpatient setting,$112.37 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$93.64 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$93.64 ,$185.84 ,$93.64 
Clinic Medical Services,South Fork Clinic,99214,"Established patient office or other outpatient visit, typically 25 minutes",521,$186.96 ,$168.26 ,90% of total billed charges for outpatient setting,$173.87 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$158.92 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$152.19 ,81.4% of total billed charges for outpatient setting,$168.26 ,90% of total billed charges for outpatient setting,$168.26 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$140.22 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$140.22 ,$185.84 ,$140.22 
Clinic Medical Services,South Fork Clinic,99214,"Established patient office or other outpatient visit, typically 25 minutes",521,$124.85 ,$112.37 ,90% of total billed charges for outpatient setting,$116.11 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$106.12 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$101.63 ,81.4% of total billed charges for outpatient setting,$112.37 ,90% of total billed charges for outpatient setting,$112.37 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$93.64 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$93.64 ,$185.84 ,$93.64 
Outpatient Medical Services,Wound Care,99214,"Established patient office or other outpatient visit, typically 25 minutes",982,$189.42 ,$102.64 ,130% of 2011 CMS RBRVS fee schedule,$102.64 ,130% of 2011 CMS RBRVS fee schedule,$98.34 ,100% of CMS RBRVS fee schedule for physician setting,$98.34 ,100% of CMS RBRVS fee schedule for physician setting,$96.20 ,119% CMS RBRVS fee schedule for physician setting,$98.34 ,100% of CMS RBRVS fee schedule for physician setting,$98.34 ,100% of CMS RBRVS fee schedule for physician setting,$170.48 ,90% of total billed charges for physician setting,$98.34 ,100% of CMS RBRVS fee schedule for physician setting,$98.34 ,100% of CMS RBRVS fee schedule for physician setting,$98.34 ,100% of CMS RBRVS fee schedule for physician setting,$98.34 ,100% of CMS RBRVS fee schedule for physician setting,$98.50 ,100% of SLVHMO physician fee schedule,$98.34 ,100% of CMS RBRVS fee schedule for physician setting,$96.20 ,$170.48 ,$142.07 
Outpatient Medical Services,Wound Care,99214,"Established patient office or other outpatient visit, typically 25 minutes",761,$75.46 ,$67.91 ,90% of total billed charges for outpatient setting,$70.18 ,93% of total billed charges for outpatient setting,$28.67 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$28.67 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,,Not seperately reimbursable per contract terms,$28.67 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$61.42 ,81.4% of total billed charges for outpatient setting,$67.91 ,90% of total billed charges for outpatient setting,$67.91 ,90% of total billed charges for outpatient setting,$28.67 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$28.67 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$28.67 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$56.60 ,75% of total billed charges for outpatient setting,$64.14 ,85% of total billed charges for outpatient setting,$28.67 ,$70.18 ,$56.60 
Clinic Medical Services,Creede family practice clinic,99215,"Established patient office or other outpatient, visit typically 40 minutes",521,$282.69 ,$254.42 ,90% of total billed charges for outpatient setting,$262.90 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$240.29 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$230.11 ,81.4% of total billed charges for outpatient setting,$254.42 ,90% of total billed charges for outpatient setting,$254.42 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$212.02 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$185.84 ,$262.90 ,$212.02 
Clinic Medical Services,Creede family practice clinic,99215,"Established patient office or other outpatient, visit typically 40 minutes",510,$113.75 ,$102.38 ,90% of total billed charges for outpatient setting,$105.79 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,,Not seperately reimbursable per contract terms,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$92.59 ,81.4% of total billed charges for outpatient setting,$102.38 ,90% of total billed charges for outpatient setting,$102.38 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$85.31 ,75% of total billed charges for outpatient setting,$96.69 ,85% of total billed charges for outpatient setting,$85.31 ,$185.84 ,$85.31 
Clinic Medical Services,Monte Vista Medical Clinic,99215,"Established patient office or other outpatient, visit typically 40 minutes",521,$282.69 ,$254.42 ,90% of total billed charges for outpatient setting,$262.90 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$240.29 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$230.11 ,81.4% of total billed charges for outpatient setting,$254.42 ,90% of total billed charges for outpatient setting,$254.42 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$212.02 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$185.84 ,$262.90 ,$212.02 
Clinic Medical Services,Monte Vista Medical Clinic,99215,"Established patient office or other outpatient, visit typically 40 minutes",510,$113.75 ,$102.38 ,90% of total billed charges for outpatient setting,$105.79 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,,Not seperately reimbursable per contract terms,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$92.59 ,81.4% of total billed charges for outpatient setting,$102.38 ,90% of total billed charges for outpatient setting,$102.38 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$85.31 ,75% of total billed charges for outpatient setting,$96.69 ,85% of total billed charges for outpatient setting,$85.31 ,$185.84 ,$85.31 
Clinic Medical Services,Rio Grande Hospital Clinic,99215,"Established patient office or other outpatient, visit typically 40 minutes",521,$282.69 ,$254.42 ,90% of total billed charges for outpatient setting,$262.90 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$240.29 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$230.11 ,81.4% of total billed charges for outpatient setting,$254.42 ,90% of total billed charges for outpatient setting,$254.42 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$212.02 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$185.84 ,$262.90 ,$212.02 
Clinic Medical Services,Rio Grande Hospital Clinic,99215,"Established patient office or other outpatient, visit typically 40 minutes",510,$113.75 ,$102.38 ,90% of total billed charges for outpatient setting,$105.79 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,,Not seperately reimbursable per contract terms,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$92.59 ,81.4% of total billed charges for outpatient setting,$102.38 ,90% of total billed charges for outpatient setting,$102.38 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$85.31 ,75% of total billed charges for outpatient setting,$96.69 ,85% of total billed charges for outpatient setting,$85.31 ,$185.84 ,$85.31 
Clinic Medical Services,South Fork Clinic,99215,"Established patient office or other outpatient, visit typically 40 minutes",521,$282.69 ,$254.42 ,90% of total billed charges for outpatient setting,$262.90 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$240.29 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$230.11 ,81.4% of total billed charges for outpatient setting,$254.42 ,90% of total billed charges for outpatient setting,$254.42 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$212.02 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$185.84 ,$262.90 ,$212.02 
Clinic Medical Services,South Fork Clinic,99215,"Established patient office or other outpatient, visit typically 40 minutes",510,$113.75 ,$102.38 ,90% of total billed charges for outpatient setting,$105.79 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,,Not seperately reimbursable per contract terms,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$92.59 ,81.4% of total billed charges for outpatient setting,$102.38 ,90% of total billed charges for outpatient setting,$102.38 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$85.31 ,75% of total billed charges for outpatient setting,$96.69 ,85% of total billed charges for outpatient setting,$85.31 ,$185.84 ,$85.31 
Outpatient Medical Services,Wound Care,99215,"Established patient office or other outpatient, visit typically 40 minutes",982,$216.48 ,$144.42 ,130% of 2011 CMS RBRVS fee schedule,$144.42 ,130% of 2011 CMS RBRVS fee schedule,$144.52 ,100% of CMS RBRVS fee schedule for physician setting,$144.52 ,100% of CMS RBRVS fee schedule for physician setting,$135.92 ,119% CMS RBRVS fee schedule for physician setting,$144.52 ,100% of CMS RBRVS fee schedule for physician setting,$144.52 ,100% of CMS RBRVS fee schedule for physician setting,$194.83 ,90% of total billed charges for physician setting,$144.52 ,100% of CMS RBRVS fee schedule for physician setting,$144.52 ,100% of CMS RBRVS fee schedule for physician setting,$144.52 ,100% of CMS RBRVS fee schedule for physician setting,$144.52 ,100% of CMS RBRVS fee schedule for physician setting,$146.32 ,100% of SLVHMO physician fee schedule,$144.52 ,100% of CMS RBRVS fee schedule for physician setting,$135.92 ,$194.83 ,$162.36 
Clinic Medical Services,Creede family practice clinic,99243,"Patient office consultation, typically 40 min",521,$304.10 ,$273.69 ,90% of total billed charges for outpatient setting,$282.81 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$258.49 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$247.54 ,81.4% of total billed charges for outpatient setting,$273.69 ,90% of total billed charges for outpatient setting,$273.69 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$228.08 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$185.84 ,$282.81 ,$228.08 
Clinic Medical Services,Monte Vista Medical Clinic,99243,"Patient office consultation, typically 40 min",521,$304.10 ,$273.69 ,90% of total billed charges for outpatient setting,$282.81 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$258.49 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$247.54 ,81.4% of total billed charges for outpatient setting,$273.69 ,90% of total billed charges for outpatient setting,$273.69 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$228.08 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$185.84 ,$282.81 ,$228.08 
Clinic Medical Services,Rio Grande Hospital Clinic,99243,"Patient office consultation, typically 40 min",521,$304.10 ,$273.69 ,90% of total billed charges for outpatient setting,$282.81 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$258.49 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$247.54 ,81.4% of total billed charges for outpatient setting,$273.69 ,90% of total billed charges for outpatient setting,$273.69 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$228.08 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$185.84 ,$282.81 ,$228.08 
Clinic Medical Services,South Fork Clinic,99243,"Patient office consultation, typically 40 min",521,$304.10 ,$273.69 ,90% of total billed charges for outpatient setting,$282.81 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$258.49 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$247.54 ,81.4% of total billed charges for outpatient setting,$273.69 ,90% of total billed charges for outpatient setting,$273.69 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$228.08 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$185.84 ,$282.81 ,$228.08 
Clinic Medical Services,Creede family practice clinic,99244,"Patient office consultation, typically 60 min",521,$395.32 ,$355.79 ,90% of total billed charges for outpatient setting,$367.65 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$336.02 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$321.79 ,81.4% of total billed charges for outpatient setting,$355.79 ,90% of total billed charges for outpatient setting,$355.79 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$296.49 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$185.84 ,$367.65 ,$296.49 
Clinic Medical Services,Monte Vista Medical Clinic,99244,"Patient office consultation, typically 60 min",521,$395.32 ,$355.79 ,90% of total billed charges for outpatient setting,$367.65 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$336.02 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$321.79 ,81.4% of total billed charges for outpatient setting,$355.79 ,90% of total billed charges for outpatient setting,$355.79 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$296.49 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$185.84 ,$367.65 ,$296.49 
Clinic Medical Services,Rio Grande Hospital Clinic,99244,"Patient office consultation, typically 60 min",521,$395.32 ,$355.79 ,90% of total billed charges for outpatient setting,$367.65 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$336.02 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$321.79 ,81.4% of total billed charges for outpatient setting,$355.79 ,90% of total billed charges for outpatient setting,$355.79 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$296.49 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$185.84 ,$367.65 ,$296.49 
Clinic Medical Services,South Fork Clinic,99244,"Patient office consultation, typically 60 min",521,$395.32 ,$355.79 ,90% of total billed charges for outpatient setting,$367.65 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$336.02 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$321.79 ,81.4% of total billed charges for outpatient setting,$355.79 ,90% of total billed charges for outpatient setting,$355.79 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$296.49 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$185.84 ,$367.65 ,$296.49 
Outpatient Medical Services,Emergency Services,99281,Emergency Department Visit Minor-Fac,450,$130.64 ,$117.58 ,90% of total billed charges for outpatient setting,$121.50 ,93% of total billed charges for outpatient setting,$49.64 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$49.64 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$111.04 ,85% of total billed charges not to exceed $250,$49.64 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$106.34 ,81.4% of total billed charges for outpatient setting,$117.58 ,90% of total billed charges for outpatient setting,$117.58 ,90% of total billed charges for outpatient setting,$49.64 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$49.64 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$49.64 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$97.98 ,75% of total billed charges for outpatient setting,$201.00 ,100% UHC case rate for outpatient setting,$49.64 ,$201.00 ,$97.98 
Outpatient Medical Services,Emergency Services,99282,"Emergency Department Visit, Low Mod.-Fac",450,$247.78 ,$223.00 ,90% of total billed charges for outpatient setting,$230.44 ,93% of total billed charges for outpatient setting,$94.16 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$94.16 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$210.61 ,85% of total billed charges not to exceed $250,$94.16 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$201.69 ,81.4% of total billed charges for outpatient setting,$223.00 ,90% of total billed charges for outpatient setting,$223.00 ,90% of total billed charges for outpatient setting,$94.16 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$94.16 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$94.16 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$185.84 ,75% of total billed charges for outpatient setting,$353.00 ,100% UHC case rate for outpatient setting,$94.16 ,$353.00 ,$185.84 
Outpatient Medical Services,Emergency Services,99282,"Emergency Department  Visit, Low Moderate-PRO",981,$92.36 ,$53.98 ,130% of 2011 CMS RBRVS fee schedule,$53.98 ,130% of 2011 CMS RBRVS fee schedule,$41.84 ,100% of CMS RBRVS fee schedule for physician setting,$41.84 ,100% of CMS RBRVS fee schedule for physician setting,$52.75 ,119% CMS RBRVS fee schedule for physician setting,$41.84 ,100% of CMS RBRVS fee schedule for physician setting,$41.84 ,100% of CMS RBRVS fee schedule for physician setting,$83.12 ,90% of total billed charges for physician setting,$41.84 ,100% of CMS RBRVS fee schedule for physician setting,$41.84 ,100% of CMS RBRVS fee schedule for physician setting,$41.84 ,100% of CMS RBRVS fee schedule for physician setting,$41.84 ,100% of CMS RBRVS fee schedule for physician setting,$53.93 ,100% of SLVHMO physician fee schedule,$41.84 ,100% of CMS RBRVS fee schedule for physician setting,$41.84 ,$83.12 ,$69.27 
Outpatient Medical Services,Emergency Services,99283,"Emergency department visit, moderately severe problem",450,$342.38 ,$308.14 ,90% of total billed charges for outpatient setting,$318.41 ,93% of total billed charges for outpatient setting,$130.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$130.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$291.02 ,85% of total billed charges for outpatient setting,$130.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$278.70 ,81.4% of total billed charges for outpatient setting,$308.14 ,90% of total billed charges for outpatient setting,$308.14 ,90% of total billed charges for outpatient setting,$130.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$130.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$130.10 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$256.79 ,75% of total billed charges for outpatient setting,$892.00 ,100% UHC case rate for outpatient setting,$130.10 ,$892.00 ,$256.79 
Outpatient Medical Services,Emergency Services,99283,"Emergency department visit, moderately severe problem",981,$147.54 ,$80.98 ,130% of 2011 CMS RBRVS fee schedule,$80.98 ,130% of 2011 CMS RBRVS fee schedule,$71.80 ,100% of CMS RBRVS fee schedule for physician setting,$71.80 ,100% of CMS RBRVS fee schedule for physician setting,$78.90 ,119% CMS RBRVS fee schedule for physician setting,$71.80 ,100% of CMS RBRVS fee schedule for physician setting,$71.80 ,100% of CMS RBRVS fee schedule for physician setting,$132.79 ,90% of total billed charges for physician setting,$71.80 ,100% of CMS RBRVS fee schedule for physician setting,$71.80 ,100% of CMS RBRVS fee schedule for physician setting,$71.80 ,100% of CMS RBRVS fee schedule for physician setting,$71.80 ,100% of CMS RBRVS fee schedule for physician setting,$89.88 ,100% of SLVHMO physician fee schedule,$71.80 ,100% of CMS RBRVS fee schedule for physician setting,$71.80 ,$132.79 ,$110.66 
Outpatient Medical Services,Emergency Services,99284,"Emergency department visit, problem of high severity",450,$601.41 ,$541.27 ,90% of total billed charges for outpatient setting,$559.31 ,93% of total billed charges for outpatient setting,$228.54 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$228.54 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$511.20 ,85% of total billed charges not to exceed $250,$228.54 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$489.55 ,81.4% of total billed charges for outpatient setting,$541.27 ,90% of total billed charges for outpatient setting,$541.27 ,90% of total billed charges for outpatient setting,$228.54 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$228.54 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$228.54 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$451.06 ,75% of total billed charges for outpatient setting,"$2,508.00 ",100% UHC case rate for outpatient setting,$228.54 ,"$2,508.00 ",$451.06 
Outpatient Medical Services,Emergency Services,99284,"Emergency department visit, problem of high severity",981,$318.74 ,$152.43 ,130% of 2011 CMS RBRVS fee schedule,$152.43 ,130% of 2011 CMS RBRVS fee schedule,$120.88 ,100% of CMS RBRVS fee schedule for physician setting,$120.88 ,100% of CMS RBRVS fee schedule for physician setting,$144.78 ,119% CMS RBRVS fee schedule for physician setting,$120.88 ,100% of CMS RBRVS fee schedule for physician setting,$120.88 ,100% of CMS RBRVS fee schedule for physician setting,$286.87 ,90% of total billed charges for physician setting,$120.88 ,100% of CMS RBRVS fee schedule for physician setting,$120.88 ,100% of CMS RBRVS fee schedule for physician setting,$120.88 ,100% of CMS RBRVS fee schedule for physician setting,$120.88 ,100% of CMS RBRVS fee schedule for physician setting,$127.98 ,100% of SLVHMO physician fee schedule,$120.88 ,100% of CMS RBRVS fee schedule for physician setting,$120.88 ,$286.87 ,$239.06 
Outpatient Medical Services,Emergency Services,99285,"Emergency department visit, problem with significant threat to life or function",450,"$1,326.73 ","$1,194.06 ",90% of total billed charges for outpatient setting,"$1,233.86 ",93% of total billed charges for outpatient setting,$504.16 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$504.16 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,000.00 ",85% of total billed charges not to exceed $250,$504.16 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,079.96 ",81.4% of total billed charges for outpatient setting,"$1,194.06 ",90% of total billed charges for outpatient setting,"$1,194.06 ",90% of total billed charges for outpatient setting,$504.16 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$504.16 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$504.16 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$995.05 ,75% of total billed charges for outpatient setting,"$5,920.00 ",100% UHC case rate for outpatient setting,$504.16 ,"$5,920.00 ",$995.05 
Outpatient Medical Services,Emergency Services,99291,CRITICAL CARE; First Hour-Fac,450,"$1,441.63 ","$1,297.47 ",90% of total billed charges for outpatient setting,"$1,340.72 ",93% of total billed charges for outpatient setting,$547.82 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$547.82 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,000.00 ",85% of total billed charges not to exceed $250,$547.82 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,173.49 ",81.4% of total billed charges for outpatient setting,"$1,297.47 ",90% of total billed charges for outpatient setting,"$1,297.47 ",90% of total billed charges for outpatient setting,$547.82 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$547.82 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$547.82 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,081.22 ",75% of total billed charges for outpatient setting,"$5,920.00 ",100% UHC case rate for outpatient setting,$547.82 ,"$5,920.00 ","$1,081.22 "
Outpatient Medical Services,Emergency Services,99291,CRITICAL CARE First Hour-PRO,981,"$1,175.83 ",$288.55 ,130% of 2011 CMS RBRVS fee schedule,$288.55 ,130% of 2011 CMS RBRVS fee schedule,$214.05 ,100% of CMS RBRVS fee schedule for physician setting,$214.05 ,100% of CMS RBRVS fee schedule for physician setting,$270.02 ,119% CMS RBRVS fee schedule for physician setting,$214.05 ,100% of CMS RBRVS fee schedule for physician setting,$214.05 ,100% of CMS RBRVS fee schedule for physician setting,"$1,058.25 ",90% of total billed charges for physician setting,$214.05 ,100% of CMS RBRVS fee schedule for physician setting,$214.05 ,100% of CMS RBRVS fee schedule for physician setting,$214.05 ,100% of CMS RBRVS fee schedule for physician setting,$214.05 ,100% of CMS RBRVS fee schedule for physician setting,$215.70 ,100% of SLVHMO physician fee schedule,$214.05 ,100% of CMS RBRVS fee schedule for physician setting,$214.05 ,"$1,058.25 ",$881.87 
Clinic Medical Services,Creede family practice clinic,99308,Nursing Home Subse Pt;Low,521,$161.07 ,$144.96 ,90% of total billed charges for outpatient setting,$149.80 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$136.91 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$131.11 ,81.4% of total billed charges for outpatient setting,$144.96 ,90% of total billed charges for outpatient setting,$144.96 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$120.80 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$120.80 ,$185.84 ,$120.80 
Clinic Medical Services,Monte Vista Medical Clinic,99308,Nursing Home Subse Pt;Low,521,$161.07 ,$144.96 ,90% of total billed charges for outpatient setting,$149.80 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$136.91 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$131.11 ,81.4% of total billed charges for outpatient setting,$144.96 ,90% of total billed charges for outpatient setting,$144.96 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$120.80 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$120.80 ,$185.84 ,$120.80 
Clinic Medical Services,Rio Grande Hospital Clinic,99308,Nursing Home Subse Pt;Low,521,$161.07 ,$144.96 ,90% of total billed charges for outpatient setting,$149.80 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$136.91 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$131.11 ,81.4% of total billed charges for outpatient setting,$144.96 ,90% of total billed charges for outpatient setting,$144.96 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$120.80 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$120.80 ,$185.84 ,$120.80 
Clinic Medical Services,South Fork Clinic,99308,Nursing Home Subse Pt;Low,521,$161.07 ,$144.96 ,90% of total billed charges for outpatient setting,$149.80 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$136.91 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$131.11 ,81.4% of total billed charges for outpatient setting,$144.96 ,90% of total billed charges for outpatient setting,$144.96 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$120.80 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$120.80 ,$185.84 ,$120.80 
Clinic Medical Services,Creede family practice clinic,99309,Nursing Home Subsequent new,521,$218.50 ,$196.65 ,90% of total billed charges for outpatient setting,$203.21 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.73 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$177.86 ,81.4% of total billed charges for outpatient setting,$196.65 ,90% of total billed charges for outpatient setting,$196.65 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$163.88 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$163.88 ,$203.21 ,$163.88 
Clinic Medical Services,Monte Vista Medical Clinic,99309,Nursing Home Subsequent new,521,$218.50 ,$196.65 ,90% of total billed charges for outpatient setting,$203.21 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.73 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$177.86 ,81.4% of total billed charges for outpatient setting,$196.65 ,90% of total billed charges for outpatient setting,$196.65 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$163.88 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$163.88 ,$203.21 ,$163.88 
Clinic Medical Services,Rio Grande Hospital Clinic,99309,Nursing Home Subsequent new,521,$218.50 ,$196.65 ,90% of total billed charges for outpatient setting,$203.21 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.73 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$177.86 ,81.4% of total billed charges for outpatient setting,$196.65 ,90% of total billed charges for outpatient setting,$196.65 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$163.88 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$163.88 ,$203.21 ,$163.88 
Clinic Medical Services,South Fork Clinic,99309,Nursing Home Subsequent new,521,$218.50 ,$196.65 ,90% of total billed charges for outpatient setting,$203.21 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.73 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$177.86 ,81.4% of total billed charges for outpatient setting,$196.65 ,90% of total billed charges for outpatient setting,$196.65 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$163.88 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$163.88 ,$203.21 ,$163.88 
Clinic Medical Services,Creede family practice clinic,99310,Nursing Home Medium NH,521,$268.05 ,$241.25 ,90% of total billed charges for outpatient setting,$249.29 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$227.84 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$218.19 ,81.4% of total billed charges for outpatient setting,$241.25 ,90% of total billed charges for outpatient setting,$241.25 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$201.04 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$185.84 ,$249.29 ,$201.04 
Clinic Medical Services,Monte Vista Medical Clinic,99310,Nursing Home Medium NH,521,$268.05 ,$241.25 ,90% of total billed charges for outpatient setting,$249.29 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$227.84 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$218.19 ,81.4% of total billed charges for outpatient setting,$241.25 ,90% of total billed charges for outpatient setting,$241.25 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$201.04 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$185.84 ,$249.29 ,$201.04 
Clinic Medical Services,Rio Grande Hospital Clinic,99310,Nursing Home Medium NH,521,$268.05 ,$241.25 ,90% of total billed charges for outpatient setting,$249.29 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$227.84 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$218.19 ,81.4% of total billed charges for outpatient setting,$241.25 ,90% of total billed charges for outpatient setting,$241.25 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$201.04 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$185.84 ,$249.29 ,$201.04 
Clinic Medical Services,South Fork Clinic,99310,Nursing Home Medium NH,521,$268.05 ,$241.25 ,90% of total billed charges for outpatient setting,$249.29 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$227.84 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$218.19 ,81.4% of total billed charges for outpatient setting,$241.25 ,90% of total billed charges for outpatient setting,$241.25 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$201.04 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$185.84 ,$249.29 ,$201.04 
Clinic Medical Services,Creede family practice clinic,99385,Initial new patient preventive medicine evaluation (18–39 years),521,$339.01 ,$305.11 ,90% of total billed charges for outpatient setting,$315.28 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$288.16 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$275.95 ,81.4% of total billed charges for outpatient setting,$305.11 ,90% of total billed charges for outpatient setting,$305.11 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$254.26 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$185.84 ,$315.28 ,$254.26 
Clinic Medical Services,Monte Vista Medical Clinic,99385,Initial new patient preventive medicine evaluation (18–39 years),521,$339.01 ,$305.11 ,90% of total billed charges for outpatient setting,$315.28 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$288.16 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$275.95 ,81.4% of total billed charges for outpatient setting,$305.11 ,90% of total billed charges for outpatient setting,$305.11 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$254.26 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$185.84 ,$315.28 ,$254.26 
Clinic Medical Services,Rio Grande Hospital Clinic,99385,Initial new patient preventive medicine evaluation (18–39 years),521,$339.01 ,$305.11 ,90% of total billed charges for outpatient setting,$315.28 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$288.16 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$275.95 ,81.4% of total billed charges for outpatient setting,$305.11 ,90% of total billed charges for outpatient setting,$305.11 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$254.26 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$185.84 ,$315.28 ,$254.26 
Clinic Medical Services,South Fork Clinic,99385,Initial new patient preventive medicine evaluation (18–39 years),521,$339.01 ,$305.11 ,90% of total billed charges for outpatient setting,$315.28 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$288.16 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$275.95 ,81.4% of total billed charges for outpatient setting,$305.11 ,90% of total billed charges for outpatient setting,$305.11 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$254.26 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$185.84 ,$315.28 ,$254.26 
Clinic Medical Services,Creede family practice clinic,99386,Initial new patient preventive medicine evaluation (40–64 years),521,$364.91 ,$328.42 ,90% of total billed charges for outpatient setting,$339.37 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$310.17 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$297.04 ,81.4% of total billed charges for outpatient setting,$328.42 ,90% of total billed charges for outpatient setting,$328.42 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$273.68 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$185.84 ,$339.37 ,$273.68 
Clinic Medical Services,Creede family practice clinic,99386,Initial new patient preventive medicine evaluation (40–64 years),521,$117.13 ,$105.42 ,90% of total billed charges for outpatient setting,$108.93 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$99.56 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$95.34 ,81.4% of total billed charges for outpatient setting,$105.42 ,90% of total billed charges for outpatient setting,$105.42 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$87.85 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$87.85 ,$185.84 ,$87.85 
Clinic Medical Services,Monte Vista Medical Clinic,99386,Initial new patient preventive medicine evaluation (40–64 years),521,$364.91 ,$328.42 ,90% of total billed charges for outpatient setting,$339.37 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$310.17 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$297.04 ,81.4% of total billed charges for outpatient setting,$328.42 ,90% of total billed charges for outpatient setting,$328.42 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$273.68 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$185.84 ,$339.37 ,$273.68 
Clinic Medical Services,Monte Vista Medical Clinic,99386,Initial new patient preventive medicine evaluation (40–64 years),521,$117.13 ,$105.42 ,90% of total billed charges for outpatient setting,$108.93 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$99.56 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$95.34 ,81.4% of total billed charges for outpatient setting,$105.42 ,90% of total billed charges for outpatient setting,$105.42 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$87.85 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$87.85 ,$185.84 ,$87.85 
Clinic Medical Services,Rio Grande Hospital Clinic,99386,Initial new patient preventive medicine evaluation (40–64 years),521,$364.91 ,$328.42 ,90% of total billed charges for outpatient setting,$339.37 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$310.17 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$297.04 ,81.4% of total billed charges for outpatient setting,$328.42 ,90% of total billed charges for outpatient setting,$328.42 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$273.68 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$185.84 ,$339.37 ,$273.68 
Clinic Medical Services,Rio Grande Hospital Clinic,99386,Initial new patient preventive medicine evaluation (40–64 years),521,$117.13 ,$105.42 ,90% of total billed charges for outpatient setting,$108.93 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$99.56 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$95.34 ,81.4% of total billed charges for outpatient setting,$105.42 ,90% of total billed charges for outpatient setting,$105.42 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$87.85 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$87.85 ,$185.84 ,$87.85 
Clinic Medical Services,South Fork Clinic,99386,Initial new patient preventive medicine evaluation (40–64 years),521,$364.91 ,$328.42 ,90% of total billed charges for outpatient setting,$339.37 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$310.17 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$297.04 ,81.4% of total billed charges for outpatient setting,$328.42 ,90% of total billed charges for outpatient setting,$328.42 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$273.68 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$185.84 ,$339.37 ,$273.68 
Clinic Medical Services,South Fork Clinic,99386,Initial new patient preventive medicine evaluation (40–64 years),521,$117.13 ,$105.42 ,90% of total billed charges for outpatient setting,$108.93 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$99.56 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$95.34 ,81.4% of total billed charges for outpatient setting,$105.42 ,90% of total billed charges for outpatient setting,$105.42 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$87.85 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$87.85 ,$185.84 ,$87.85 
Clinic Medical Services,Creede family practice clinic,99392,Initial visit for new patients 1-4 years old,521,$101.37 ,$91.23 ,90% of total billed charges for outpatient setting,$94.27 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$86.16 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$82.52 ,81.4% of total billed charges for outpatient setting,$91.23 ,90% of total billed charges for outpatient setting,$91.23 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$76.03 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$76.03 ,$185.84 ,$76.03 
Clinic Medical Services,Monte Vista Medical Clinic,99392,Initial visit for new patients 1-4 years old,521,$101.37 ,$91.23 ,90% of total billed charges for outpatient setting,$94.27 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$86.16 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$82.52 ,81.4% of total billed charges for outpatient setting,$91.23 ,90% of total billed charges for outpatient setting,$91.23 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$76.03 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$76.03 ,$185.84 ,$76.03 
Clinic Medical Services,Rio Grande Hospital Clinic,99392,Initial visit for new patients 1-4 years old,521,$101.37 ,$91.23 ,90% of total billed charges for outpatient setting,$94.27 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$86.16 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$82.52 ,81.4% of total billed charges for outpatient setting,$91.23 ,90% of total billed charges for outpatient setting,$91.23 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$76.03 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$76.03 ,$185.84 ,$76.03 
Clinic Medical Services,South Fork Clinic,99392,Initial visit for new patients 1-4 years old,521,$101.37 ,$91.23 ,90% of total billed charges for outpatient setting,$94.27 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$86.16 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$82.52 ,81.4% of total billed charges for outpatient setting,$91.23 ,90% of total billed charges for outpatient setting,$91.23 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$76.03 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$76.03 ,$185.84 ,$76.03 
Clinic Medical Services,Creede family practice clinic,99393,New preventative visit in new patients 5-11 years old,521,$192.60 ,$173.34 ,90% of total billed charges for outpatient setting,$179.12 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$163.71 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$156.78 ,81.4% of total billed charges for outpatient setting,$173.34 ,90% of total billed charges for outpatient setting,$173.34 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$144.45 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$144.45 ,$185.84 ,$144.45 
Clinic Medical Services,Monte Vista Medical Clinic,99393,New preventative visit in new patients 5-11 years old,521,$192.60 ,$173.34 ,90% of total billed charges for outpatient setting,$179.12 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$163.71 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$156.78 ,81.4% of total billed charges for outpatient setting,$173.34 ,90% of total billed charges for outpatient setting,$173.34 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$144.45 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$144.45 ,$185.84 ,$144.45 
Clinic Medical Services,Rio Grande Hospital Clinic,99393,New preventative visit in new patients 5-11 years old,521,$192.60 ,$173.34 ,90% of total billed charges for outpatient setting,$179.12 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$163.71 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$156.78 ,81.4% of total billed charges for outpatient setting,$173.34 ,90% of total billed charges for outpatient setting,$173.34 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$144.45 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$144.45 ,$185.84 ,$144.45 
Clinic Medical Services,South Fork Clinic,99393,New preventative visit in new patients 5-11 years old,521,$192.60 ,$173.34 ,90% of total billed charges for outpatient setting,$179.12 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$163.71 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$156.78 ,81.4% of total billed charges for outpatient setting,$173.34 ,90% of total billed charges for outpatient setting,$173.34 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$144.45 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$144.45 ,$185.84 ,$144.45 
Clinic Medical Services,Creede family practice clinic,99394,New preventative visit in new patients 12-17 years old,521,$209.49 ,$188.54 ,90% of total billed charges for outpatient setting,$194.83 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$178.07 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$170.52 ,81.4% of total billed charges for outpatient setting,$188.54 ,90% of total billed charges for outpatient setting,$188.54 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$157.12 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$157.12 ,$194.83 ,$157.12 
Clinic Medical Services,Monte Vista Medical Clinic,99394,New preventative visit in new patients 12-17 years old,521,$209.49 ,$188.54 ,90% of total billed charges for outpatient setting,$194.83 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$178.07 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$170.52 ,81.4% of total billed charges for outpatient setting,$188.54 ,90% of total billed charges for outpatient setting,$188.54 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$157.12 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$157.12 ,$194.83 ,$157.12 
Clinic Medical Services,Rio Grande Hospital Clinic,99394,New preventative visit in new patients 12-17 years old,521,$209.49 ,$188.54 ,90% of total billed charges for outpatient setting,$194.83 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$178.07 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$170.52 ,81.4% of total billed charges for outpatient setting,$188.54 ,90% of total billed charges for outpatient setting,$188.54 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$157.12 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$157.12 ,$194.83 ,$157.12 
Clinic Medical Services,South Fork Clinic,99394,New preventative visit in new patients 12-17 years old,521,$209.49 ,$188.54 ,90% of total billed charges for outpatient setting,$194.83 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$178.07 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$170.52 ,81.4% of total billed charges for outpatient setting,$188.54 ,90% of total billed charges for outpatient setting,$188.54 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$157.12 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$157.12 ,$194.83 ,$157.12 
Clinic Medical Services,Creede family practice clinic,99395,Established patient periodic preventive medicine examination age 18-39 years,521,$280.44 ,$252.40 ,90% of total billed charges for outpatient setting,$260.81 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$238.37 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$228.28 ,81.4% of total billed charges for outpatient setting,$252.40 ,90% of total billed charges for outpatient setting,$252.40 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$210.33 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$185.84 ,$260.81 ,$210.33 
Clinic Medical Services,Monte Vista Medical Clinic,99395,Established patient periodic preventive medicine examination age 18-39 years,521,$280.44 ,$252.40 ,90% of total billed charges for outpatient setting,$260.81 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$238.37 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$228.28 ,81.4% of total billed charges for outpatient setting,$252.40 ,90% of total billed charges for outpatient setting,$252.40 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$210.33 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$185.84 ,$260.81 ,$210.33 
Clinic Medical Services,Rio Grande Hospital Clinic,99395,Established patient periodic preventive medicine examination age 18-39 years,521,$280.44 ,$252.40 ,90% of total billed charges for outpatient setting,$260.81 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$238.37 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$228.28 ,81.4% of total billed charges for outpatient setting,$252.40 ,90% of total billed charges for outpatient setting,$252.40 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$210.33 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$185.84 ,$260.81 ,$210.33 
Clinic Medical Services,South Fork Clinic,99395,Established patient periodic preventive medicine examination age 18-39 years,521,$280.44 ,$252.40 ,90% of total billed charges for outpatient setting,$260.81 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$238.37 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$228.28 ,81.4% of total billed charges for outpatient setting,$252.40 ,90% of total billed charges for outpatient setting,$252.40 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$210.33 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$185.84 ,$260.81 ,$210.33 
Clinic Medical Services,Creede family practice clinic,99497,Advanced Care Planning 30,521,$97.42 ,$87.68 ,90% of total billed charges for outpatient setting,$90.60 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$82.81 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$79.30 ,81.4% of total billed charges for outpatient setting,$87.68 ,90% of total billed charges for outpatient setting,$87.68 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$73.07 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$73.07 ,$185.84 ,$73.07 
Clinic Medical Services,Monte Vista Medical Clinic,99497,Advanced Care Planning 30,521,$97.42 ,$87.68 ,90% of total billed charges for outpatient setting,$90.60 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$82.81 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$79.30 ,81.4% of total billed charges for outpatient setting,$87.68 ,90% of total billed charges for outpatient setting,$87.68 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$73.07 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$73.07 ,$185.84 ,$73.07 
Clinic Medical Services,Rio Grande Hospital Clinic,99497,Advanced Care Planning 30,521,$97.42 ,$87.68 ,90% of total billed charges for outpatient setting,$90.60 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$82.81 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$79.30 ,81.4% of total billed charges for outpatient setting,$87.68 ,90% of total billed charges for outpatient setting,$87.68 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$73.07 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$73.07 ,$185.84 ,$73.07 
Clinic Medical Services,South Fork Clinic,99497,Advanced Care Planning 30,521,$97.42 ,$87.68 ,90% of total billed charges for outpatient setting,$90.60 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$82.81 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$79.30 ,81.4% of total billed charges for outpatient setting,$87.68 ,90% of total billed charges for outpatient setting,$87.68 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$73.07 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$73.07 ,$185.84 ,$73.07 
Clinic Medical Services,Surgery Physician,G0121,Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk,975,$352.52 ,$289.68 ,130% of 2011 CMS RBRVS fee schedule,$289.68 ,130% of 2011 CMS RBRVS fee schedule,$184.55 ,100% of CMS RBRVS fee schedule for physician setting,$184.55 ,100% of CMS RBRVS fee schedule for physician setting,$230.86 ,119% CMS RBRVS fee schedule for physician setting,$184.55 ,100% of CMS RBRVS fee schedule for physician setting,$184.55 ,100% of CMS RBRVS fee schedule for physician setting,$317.27 ,90% of total billed charges for physician setting,$184.55 ,100% of CMS RBRVS fee schedule for physician setting,$184.55 ,100% of CMS RBRVS fee schedule for physician setting,$184.55 ,100% of CMS RBRVS fee schedule for physician setting,$184.55 ,100% of CMS RBRVS fee schedule for physician setting,,Not seperately reimbursable per contract terms,$184.55 ,100% of CMS RBRVS fee schedule for physician setting,$184.55 ,$317.27 ,$264.39 
Outpatient Medical Services,Surgical Hospital,G0121,Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk,360,"$2,097.12 ","$1,887.41 ",90% of total billed charges for outpatient setting,"$1,950.32 ",93% of total billed charges for outpatient setting,$796.91 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$796.91 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,782.55 ",85% of total billed charges for outpatient setting,$796.91 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,707.06 ",81.4% of total billed charges for outpatient setting,"$1,887.41 ",90% of total billed charges for outpatient setting,"$1,887.41 ",90% of total billed charges for outpatient setting,$796.91 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$796.91 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$796.91 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,"$1,572.84 ",75% of total billed charges for outpatient setting,"$1,782.55 ",85% of total billed charges for outpatient setting,$796.91 ,"$1,950.32 ","$1,572.84 "
Outpatient Medical Services,Hyperbaric,G0277,Hyperbaric treatment per 30 min,413,$106.12 ,$95.51 ,90% of total billed charges for outpatient setting,$98.69 ,93% of total billed charges for outpatient setting,$40.33 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$40.33 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$90.20 ,85% of total billed charges for outpatient setting,$40.33 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$86.38 ,81.4% of total billed charges for outpatient setting,$95.51 ,90% of total billed charges for outpatient setting,$95.51 ,90% of total billed charges for outpatient setting,$40.33 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$40.33 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$40.33 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$79.59 ,75% of total billed charges for outpatient setting,$90.20 ,85% of total billed charges for outpatient setting,$40.33 ,$98.69 ,$79.59 
Outpatient Medical Services,CT Scan,G0297,CT Low dose screening for lung cancer,350,$110.16 ,$99.14 ,90% of total billed charges for outpatient setting,$102.45 ,93% of total billed charges for outpatient setting,$41.86 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$41.86 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$500.00 ,100% of CT case rate,$41.86 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$89.67 ,81.4% of total billed charges for outpatient setting,$99.14 ,90% of total billed charges for outpatient setting,$99.14 ,90% of total billed charges for outpatient setting,$41.86 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$41.86 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$41.86 ,38% of total billed charges for outpatient setting which is 100% of CMS OP CCR rate,$82.62 ,75% of total billed charges for outpatient setting,"$1,209.00 ",100% UHC case rate for outpatient setting,$41.86 ,"$1,209.00 ",$82.62 
Clinic Medical Services,Creede family practice clinic,G0438,Medicare Annual Wellness,521,$319.86 ,$287.87 ,90% of total billed charges for outpatient setting,$297.47 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$271.88 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$260.37 ,81.4% of total billed charges for outpatient setting,$287.87 ,90% of total billed charges for outpatient setting,$287.87 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$239.90 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$185.84 ,$297.47 ,$239.90 
Clinic Medical Services,Monte Vista Medical Clinic,G0438,Medicare Annual Wellness,521,$319.86 ,$287.87 ,90% of total billed charges for outpatient setting,$297.47 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$271.88 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$260.37 ,81.4% of total billed charges for outpatient setting,$287.87 ,90% of total billed charges for outpatient setting,$287.87 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$239.90 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$185.84 ,$297.47 ,$239.90 
Clinic Medical Services,Rio Grande Hospital Clinic,G0438,Medicare Annual Wellness,521,$319.86 ,$287.87 ,90% of total billed charges for outpatient setting,$297.47 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$271.88 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$260.37 ,81.4% of total billed charges for outpatient setting,$287.87 ,90% of total billed charges for outpatient setting,$287.87 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$239.90 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$185.84 ,$297.47 ,$239.90 
Clinic Medical Services,South Fork Clinic,G0438,Medicare Annual Wellness,521,$319.86 ,$287.87 ,90% of total billed charges for outpatient setting,$297.47 ,93% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$271.88 ,85% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$260.37 ,81.4% of total billed charges for outpatient setting,$287.87 ,90% of total billed charges for outpatient setting,$287.87 ,90% of total billed charges for outpatient setting,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$185.84 ,100% CMS Clinic case rate. Could also pay at 154.52 depending on the location,$239.90 ,75% of total billed charges for outpatient setting,,Not seperately reimbursable per Table 6 of the contract,$185.84 ,$297.47 ,$239.90 
Outpatient Medical Services,BEHAVIORAL,90832,"Psychotherapy, 30 minute",900,SERVICE NOT OFFERED,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,,
Outpatient Medical Services,BEHAVIORAL,90834,"Psychotherapy, 45 minutes",900,SERVICE NOT OFFERED,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,,
Outpatient Medical Services,BEHAVIORAL,90837,"Psychotherapy, 60 minutes",900,SERVICE NOT OFFERED,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,,
Outpatient Medical Services,BEHAVIORAL,90846,"Family psychotherapy, not including patient, 50 minutes",900,SERVICE NOT OFFERED,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,,
Outpatient Medical Services,BEHAVIORAL,90847,"Family psychotherapy, including patient, 50 min",900,SERVICE NOT OFFERED,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,,
Outpatient Medical Services,BEHAVIORAL,90853,Group psychotherapy,900,SERVICE NOT OFFERED,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,,
Outpatient Medical Services,Laboratory,81000,Manual urinalysis test with examination using microscope,300,SERVICE NOT OFFERED,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,,
Outpatient Medical Services,Laboratory,81002,Automated urinalysis test,300,SERVICE NOT OFFERED,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,,
Outpatient Medical Services,Laboratory,81003,Prostate specific antigen,300,SERVICE NOT OFFERED,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,,
Outpatient Medical Services,Laboratory,85027,"Complete blood count, automated",300,SERVICE NOT OFFERED,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,,
Outpatient Medical Services,RADIOLOGY,76805,"Abdominal ultrasound of pregnant uterus, greater or equal to 14 weeks 0 days, single or first fetus",402,SERVICE NOT OFFERED,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,,
Outpatient Medical Services,RADIOLOGY,77065,Mammography of one breast,403,SERVICE NOT OFFERED,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,,
Outpatient Medical Services,RADIOLOGY,77066,Mammography of both breasts,403,SERVICE NOT OFFERED,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,,
Outpatient Medical Services,RADIOLOGY,77067,"Mammography, screening, bilateral",403,SERVICE NOT OFFERED,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,,
Outpatient Medical Services,RADIOLOGY,19120,"Removal of 1 or more breast growth, open procedure",360,SERVICE NOT OFFERED,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,,
Outpatient Medical Services,OUTPATIENT SERVICES,29826,Shaving of shoulder bone using an endoscope,360,SERVICE NOT OFFERED,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,,
Outpatient Medical Services,OUTPATIENT SERVICES,42820,Removal of tonsils and adenoid glands patient younger than age 12,360,SERVICE NOT OFFERED,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,,
Outpatient Medical Services,OUTPATIENT SERVICES,43239,"Biopsy of the esophagus, stomach, and/or upper small bowel using an endoscope",360,SERVICE NOT OFFERED,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,,
Outpatient Medical Services,OUTPATIENT SERVICES,45391,Ultrasound examination of lower large bowel using an endoscope,360,SERVICE NOT OFFERED,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,,
Outpatient Medical Services,OUTPATIENT SERVICES,47562,Removal of gallbladder using an endoscope,360,SERVICE NOT OFFERED,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,,
Outpatient Medical Services,OUTPATIENT SERVICES,49505,Repair of groin hernia patient age 5 or older,360,SERVICE NOT OFFERED,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,,
Outpatient Medical Services,OUTPATIENT SERVICES,55700,Biopsy of prostate gland,360,SERVICE NOT OFFERED,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,,
Outpatient Medical Services,OUTPATIENT SERVICES,55866,Surgical removal of prostate and surrounding lymph nodes using an endoscope,360,SERVICE NOT OFFERED,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,,
Outpatient Medical Services,OUTPATIENT SERVICES,59400,"Routine obstetric care for vaginal delivery, including pre-and post-delivery care",720,SERVICE NOT OFFERED,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,,
Outpatient Medical Services,OUTPATIENT SERVICES,59510,"Routine obstetric care for cesarean delivery, including pre-and post-delivery care",720,SERVICE NOT OFFERED,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,,
Outpatient Medical Services,OUTPATIENT SERVICES,59610,Routine obstetric care for vaginal delivery after prior cesarean delivery including pre-and post-delivery care,720,SERVICE NOT OFFERED,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,,
Outpatient Medical Services,OUTPATIENT SERVICES,62323,Injection of substance into spinal canal of lower back or sacrum using imaging guidanc,360,SERVICE NOT OFFERED,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,,
Outpatient Medical Services,OUTPATIENT SERVICES,62322,Injection of substance into spinal canal of lower back or sacrum using imaging guidanc,360,SERVICE NOT OFFERED,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,,
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,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,,
Outpatient Medical Services,ECCG,93000,"Electrocardiogram, routine, with interpretation and report",730,SERVICE NOT OFFERED,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,,
Outpatient Medical Services,CARDIOLOGY,93452,Insertion of catheter into left heart for diagnosis,480,SERVICE NOT OFFERED,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,,
Outpatient Medical Services,SLEEP STUDY,95810,Sleep study,920,SERVICE NOT OFFERED,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,,
Inpatient Medical Services,INPATIENT PROCEDURES,216,Cardiac valve and other major cardiothoracic procedures with cardiac catheterization with major complications or comorbidities,100,SERVICE NOT OFFERED,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,,
Inpatient Medical Services,INPATIENT PROCEDURES,460,Spinal fusion except cervical without major comorbid conditions or complications,100,SERVICE NOT OFFERED,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,,
Inpatient Medical Services,INPATIENT PROCEDURES,470,Major joint replacement or reattachment of lower extremity without major comorbid conditions or complications,100,SERVICE NOT OFFERED,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,,
Inpatient Medical Services,INPATIENT PROCEDURES,473,Cervical spinal fusion without comorbid conditions or major comorbid conditions or complications,100,SERVICE NOT OFFERED,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,,
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,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,Not applicable. Service not offered,,,