hospital_name,last_updated_on,version,hospital_location,hospital_address,license_number|LA,"To the best of its knowledge and belief, the hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date indicated.",,,,,,,,,,,,,,,,,,,,
Franklin Medical Center,1/6/2025,2.0.0,Franklin Medical Center,"2106 Loop Rd, Winnsboro, LA 71295",721014937,TRUE,,,,,,,,,,,,,,,,,,,,
SERVICE DESCRIPTION,CATEGORY,BILLING MSDRG | CPT | HCPCS,ITEM/SERVICE DESCRIPTION,BILLING REVENUE CODE,GROSS CHARGES,AETNA PLAN,AETNA REIMBURSEMENT METHOD,BCBS HMO PLAN,BCBS HMO REIMBURSEMENT METHOD,BCBS PHYSICIAN PLAN,BCBS PHYSICIAN REIMBURSEMENT METHOD,BCBS PPO PLAN,BCBS PPO REIMBURSEMENT METHOD,HUMANA MEDICAID PLAN,HUMANA MEDICAID REIMBURSEMENT METHOD,MEDICAID PLAN,MEDICAID REIMBURSEMENT METHOD,MEDICARE PLAN,MEDICARE REIMBURSEMENT METHOD,UHC PLAN,UHC REIMBURSEMENT METHOD,UHC MEDICAID PLAN,UHC MEDICAID REIMBURSEMENT METHOD,De-Identified Minimum Negotiated Rate,De-Identified Maximum Negotiated Rate,DISCOUNTED CASH PRICE
Outpatient Medical Services,Evaluation & Management Services,90832,"Psychotherapy, 30 min",960,70,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,81.45,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,67.24,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,67.24,81.45,42
Outpatient Medical Services,Evaluation & Management Services,90834,"Psychotherapy, 45 min",960,90,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,108.38,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,88.87,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,88.87,108.38,54
Outpatient Medical Services,Evaluation & Management Services,90837,"Psychotherapy, 60 min",960,130,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,162.62,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,130,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,130,162.62,78
Outpatient Medical Services,Evaluation & Management Services,90846,"Family psychotherapy, w/o patient, 50 min",960,180,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,135.75,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,95.68,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,95.68,135.75,108
Outpatient Medical Services,Evaluation & Management Services,90847,"Family psychotherapy, w patient, 50 min",960,180,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,141.06,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,99.93,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,99.93,141.06,108
Outpatient Medical Services,Evaluation & Management Services,90853,Group psychotherapy,960,209,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,33.65,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,23.6,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,23.6,33.65,125.4
Outpatient Medical Services,Evaluation & Management Services,99201,"New patient office/outpatient visit, brief",960,110,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,110,100% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,110,110,66
Outpatient Medical Services,Evaluation & Management Services,99201,"New patient office/outpatient visit, brief",960,55,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,55,100% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,55,55,33
Outpatient Medical Services,Evaluation & Management Services,99201,"New patient office/outpatient visit, brief",960,55,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,55,100% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,55,55,33
Outpatient Medical Services,Evaluation & Management Services,99202,"New patient office/outpatient visit, limited",960,98,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,75.62,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,45.15,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,45.15,75.62,58.8
Outpatient Medical Services,Evaluation & Management Services,99202,"New patient office/outpatient visit, limited",960,101,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,75.62,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,45.15,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,45.15,75.62,60.6
Outpatient Medical Services,Evaluation & Management Services,99202,"New patient office/outpatient visit, limited",960,101,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,75.62,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,45.15,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,45.15,75.62,60.6
Outpatient Medical Services,Evaluation & Management Services,99203,"New patient office/outpatient visit, typically 30 min",960,149,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,108.01,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,78.14,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,78.14,108.01,89.4
Outpatient Medical Services,Evaluation & Management Services,99203,"New patient office/outpatient visit, typically 30 min",960,70,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,108.01,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,70,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,70,108.01,42
Outpatient Medical Services,Evaluation & Management Services,99203,"New patient office/outpatient visit, typically 30 min",960,112,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,108.01,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,78.14,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,78.14,108.01,67.2
Outpatient Medical Services,Evaluation & Management Services,99203,"New patient office/outpatient visit, typically 30 min",960,153,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,108.01,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,78.14,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,78.14,108.01,91.8
Outpatient Medical Services,Evaluation & Management Services,99204,"New patient office/other outpatient visit, typically 45 min",960,255,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,165.07,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,127.09,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,127.09,165.07,153
Outpatient Medical Services,Evaluation & Management Services,99204,"New patient office/other outpatient visit, typically 45 min",960,130,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,165.07,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,127.09,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,127.09,165.07,78
Outpatient Medical Services,Evaluation & Management Services,99204,"New patient office/other outpatient visit, typically 45 min",960,191,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,165.07,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,127.09,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,127.09,165.07,114.6
Outpatient Medical Services,Evaluation & Management Services,99204,"New patient office/other outpatient visit, typically 45 min",960,237,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,165.07,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,127.09,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,127.09,165.07,142.2
Outpatient Medical Services,Evaluation & Management Services,99205,"New patient office/other outpatient visit, typically 60 min",960,329,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,208.05,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,172.74,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,172.74,208.05,197.4
Outpatient Medical Services,Evaluation & Management Services,99205,"New patient office/other outpatient visit, typically 60 min",960,150,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,208.05,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,150,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,150,208.05,90
Outpatient Medical Services,Evaluation & Management Services,99205,"New patient office/other outpatient visit, typically 60 min",960,247,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,208.05,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,172.74,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,172.74,208.05,148.2
Outpatient Medical Services,Evaluation & Management Services,99205,"New patient office/other outpatient visit, typically 60 min",960,295,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,208.05,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,172.74,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,172.74,208.05,177
Outpatient Medical Services,Evaluation & Management Services,99243,"Patient office consultation, typically 40 min",960,288,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,108.01,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,84.13,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,84.13,108.01,172.8
Outpatient Medical Services,Evaluation & Management Services,99244,"Patient office consultation, typically 60 min",960,360,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,165.07,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,127.91,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,127.91,165.07,216
Outpatient Medical Services,Evaluation & Management Services,99385,New patient preventive medicine eval (18-39 years),960,193,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,121.57,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,89.32,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,89.32,121.57,115.8
Outpatient Medical Services,Evaluation & Management Services,99386,New patient preventive medicine eval (40-64 years),960,234,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,141.7,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,108.27,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,108.27,141.7,140.4
Outpatient Medical Services,Evaluation & Management Services,99201,"New patient office/outpatient visit, brief",510,55,46.75,85% Of Billed Charges,27.5,50% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,27.5,50% of Billed Charges,17.57,31.95% of Billed Charges,17.57,31.95% of Billed Charges,160.45,Pay As Per Visit,20.9,38% of Billed Charges,22,40% of Billed Charges,17.57,160.45,33
Outpatient Medical Services,Evaluation & Management Services,99201,"New patient office/outpatient visit, brief",510,55,N/A,NOT SEPERATELY REIMBURSABLE,27.5,50% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,27.5,50% of Billed Charges,17.57,31.95% of Billed Charges,17.57,31.95% of Billed Charges,160.45,Pay As Per Visit,20.9,38% of Billed Charges,22,40% of Billed Charges,17.57,160.45,33
Outpatient Medical Services,Evaluation & Management Services,99202,"New patient office/outpatient visit, limited",510,101,85.85,85% Of Billed Charges,177.36,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,177.36,136.60% of BCBS Fee Schedule,36.16,110% Of LA Fee Schedule,32.87,100% of LA Fee SChedule,160.45,Pay As Per Visit,38.38,38% of Billed Charges,32.87,100% of LA Fee Schedule,32.87,177.36,60.6
Outpatient Medical Services,Evaluation & Management Services,99202,"New patient office/outpatient visit, limited",510,101,85.85,85% Of Billed Charges,177.36,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,177.36,136.60% of BCBS Fee Schedule,36.16,110% Of LA Fee Schedule,32.87,100% of LA Fee SChedule,160.45,Pay As Per Visit,38.38,38% of Billed Charges,32.87,100% of LA Fee Schedule,32.87,177.36,60.6
Outpatient Medical Services,Evaluation & Management Services,99203,"New patient office/outpatient visit, typically 30 min",510,112,95.2,85% Of Billed Charges,204.05,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,204.05,136.60% of BCBS Fee Schedule,41.61,110% Of LA Fee Schedule,37.83,100% of LA Fee SChedule,160.45,Pay As Per Visit,42.56,38% of Billed Charges,37.83,100% of LA Fee Schedule,37.83,204.05,67.2
Outpatient Medical Services,Evaluation & Management Services,99203,"New patient office/outpatient visit, typically 30 min",510,153,130.05,85% Of Billed Charges,204.05,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,204.05,136.60% of BCBS Fee Schedule,41.61,110% Of LA Fee Schedule,37.83,100% of LA Fee SChedule,160.45,Pay As Per Visit,58.14,38% of Billed Charges,37.83,100% of LA Fee Schedule,37.83,204.05,91.8
Outpatient Medical Services,Evaluation & Management Services,99204,"New patient office/other outpatient visit, typically 45 min",510,191,162.35,85% Of Billed Charges,296.91,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,296.91,136.60% of BCBS Fee Schedule,62.45,110% Of LA Fee Schedule,56.77,100% of LA Fee SChedule,160.45,Pay As Per Visit,72.58,38% of Billed Charges,56.77,100% of LA Fee Schedule,56.77,296.91,114.6
Outpatient Medical Services,Evaluation & Management Services,99204,"New patient office/other outpatient visit, typically 45 min",510,237,201.45,85% Of Billed Charges,296.91,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,296.91,136.60% of BCBS Fee Schedule,62.45,110% Of LA Fee Schedule,56.77,100% of LA Fee SChedule,160.45,Pay As Per Visit,90.06,38% of Billed Charges,56.77,100% of LA Fee Schedule,56.77,296.91,142.2
Outpatient Medical Services,Evaluation & Management Services,99205,"New patient office/other outpatient visit, typically 60 min",510,247,209.95,85% Of Billed Charges,296.91,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,296.91,136.60% of BCBS Fee Schedule,62.45,110% Of LA Fee Schedule,56.77,100% of LA Fee SChedule,160.45,Pay As Per Visit,93.86,38% of Billed Charges,56.77,100% of LA Fee Schedule,56.77,296.91,148.2
Outpatient Medical Services,Evaluation & Management Services,99205,"New patient office/other outpatient visit, typically 60 min",510,295,250.75,85% Of Billed Charges,296.91,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,296.91,136.60% of BCBS Fee Schedule,62.45,110% Of LA Fee Schedule,56.77,100% of LA Fee SChedule,160.45,Pay As Per Visit,112.1,38% of Billed Charges,56.77,100% of LA Fee Schedule,56.77,296.91,177
Outpatient Medical Services,Laboratory & Pathology Services,80015,UA Micro Standard,300,21,17.85,85% Of Billed Charges,10.5,50% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,10.5,50% of Billed Charges,6.71,31.95% of Billed Charges,6.71,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,7.98,38% of Billed Charges,8.4,40% of Billed Charges,6.71,17.85,12.6
Outpatient Medical Services,Laboratory & Pathology Services,80048,Basic metabolic panel,300,48,40.8,85% Of Billed Charges,39.48,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,39.48,136.60% of BCBS Fee Schedule,9.31,110% Of LA Fee Schedule,8.46,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,18.24,38% of Billed Charges,8.46,100% of LA Fee Schedule,8.46,40.8,28.8
Outpatient Medical Services,Laboratory & Pathology Services,80053,Comprehensive blood chemicals test,300,60,51,85% Of Billed Charges,49.29,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,49.29,136.60% of BCBS Fee Schedule,11.62,110% Of LA Fee Schedule,10.56,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,22.8,38% of Billed Charges,10.56,100% of LA Fee Schedule,10.56,51,36
Outpatient Medical Services,Laboratory & Pathology Services,80061,"Blood test, lipids (cholesterol and triglycerides)",300,68,57.8,85% Of Billed Charges,55.69,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,55.69,136.60% of BCBS Fee Schedule,14.73,110% Of LA Fee Schedule,13.39,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,25.84,38% of Billed Charges,13.39,100% of LA Fee Schedule,13.39,57.8,40.8
Outpatient Medical Services,Laboratory & Pathology Services,80069,Kidney function panel,300,49,41.65,85% Of Billed Charges,40.47,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,40.47,136.60% of BCBS Fee Schedule,9.55,110% Of LA Fee Schedule,8.68,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,18.62,38% of Billed Charges,8.68,100% of LA Fee Schedule,8.68,41.65,29.4
Outpatient Medical Services,Laboratory & Pathology Services,80076,Liver function blood test panel,300,46,39.1,85% Of Billed Charges,38.1,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,38.1,136.60% of BCBS Fee Schedule,8.99,110% Of LA Fee Schedule,8.17,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,17.48,38% of Billed Charges,8.17,100% of LA Fee Schedule,8.17,39.1,27.6
Outpatient Medical Services,Laboratory & Pathology Services,36415,Venipuncture,300,12,10.2,85% Of Billed Charges,10.16,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,10.16,136.60% of BCBS Fee Schedule,3.29,110% Of LA Fee Schedule,2.99,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,4.56,38% of Billed Charges,2.99,100% of LA Fee Schedule,2.99,10.2,7.2
Outpatient Medical Services,Laboratory & Pathology Services,80305,Urine Drug Screen FMC,300,146,124.1,85% Of Billed Charges,41.85,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,41.85,136.60% of BCBS Fee Schedule,13.86,110% Of LA Fee Schedule,12.6,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,55.48,38% of Billed Charges,12.6,100% of LA Fee Schedule,12.6,124.1,87.6
Outpatient Medical Services,Laboratory & Pathology Services,80349,"Cannabinoid Confirmation, Ur LC",300,195,165.75,85% Of Billed Charges,26.01,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,26.01,136.60% of BCBS Fee Schedule,62.3,31.95% of Billed Charges,62.3,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,74.1,38% of Billed Charges,78,40% of Billed Charges,26.01,165.75,117
Outpatient Medical Services,Laboratory & Pathology Services,81003,Urinalysis w/ Culture if Ind,300,18,15.3,85% Of Billed Charges,10.48,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,10.48,136.60% of BCBS Fee Schedule,2.48,110% Of LA Fee Schedule,2.25,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,6.84,38% of Billed Charges,2.25,100% of LA Fee Schedule,2.25,15.3,10.8
Outpatient Medical Services,Laboratory & Pathology Services,81025,UA PREGNANCY TEST,300,36,30.6,85% Of Billed Charges,29.51,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,29.51,136.60% of BCBS Fee Schedule,8.97,110% Of LA Fee Schedule,8.15,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,13.68,38% of Billed Charges,8.15,100% of LA Fee Schedule,8.15,30.6,21.6
Outpatient Medical Services,Laboratory & Pathology Services,82140,Ammonia Level,300,83,70.55,85% Of Billed Charges,67.94,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,67.94,136.60% of BCBS Fee Schedule,16.03,110% Of LA Fee Schedule,14.57,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,31.54,38% of Billed Charges,14.57,100% of LA Fee Schedule,14.57,70.55,49.8
Outpatient Medical Services,Laboratory & Pathology Services,82150,AMYLASE,300,37,31.45,85% Of Billed Charges,30.24,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,30.24,136.60% of BCBS Fee Schedule,7.13,110% Of LA Fee Schedule,6.48,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,14.06,38% of Billed Charges,6.48,100% of LA Fee Schedule,6.48,31.45,22.2
Outpatient Medical Services,Laboratory & Pathology Services,82306,Vitamin D 25 Hydroxy Level,300,167.76,142.6,85% Of Billed Charges,138.02,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,138.02,136.60% of BCBS Fee Schedule,32.56,110% Of LA Fee Schedule,29.6,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,63.75,38% of Billed Charges,29.6,100% of LA Fee Schedule,29.6,142.6,100.656
Outpatient Medical Services,Laboratory & Pathology Services,82310,CALCIUM; SERUM,300,29,24.65,85% Of Billed Charges,24.03,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,24.03,136.60% of BCBS Fee Schedule,5.68,110% Of LA Fee Schedule,5.16,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,11.02,38% of Billed Charges,5.16,100% of LA Fee Schedule,5.16,24.65,17.4
Outpatient Medical Services,Laboratory & Pathology Services,82247,BILIRUBIN TOTAL,300,35,29.75,85% Of Billed Charges,16.24,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,16.24,136.60% of BCBS Fee Schedule,5.32,110% Of LA Fee Schedule,4.84,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,13.3,38% of Billed Charges,4.84,100% of LA Fee Schedule,4.84,29.75,21
Outpatient Medical Services,Laboratory & Pathology Services,82550,CREATINE KINASE; TOT,300,37,31.45,85% Of Billed Charges,30.35,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,30.35,136.60% of BCBS Fee Schedule,7.16,110% Of LA Fee Schedule,6.51,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,14.06,38% of Billed Charges,6.51,100% of LA Fee Schedule,6.51,31.45,22.2
Outpatient Medical Services,Laboratory & Pathology Services,82553,CREATINE KINASE;MB FRA,300,106,90.1,85% Of Billed Charges,53.83,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,53.83,136.60% of BCBS Fee Schedule,12.71,110% Of LA Fee Schedule,11.55,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,40.28,38% of Billed Charges,11.55,100% of LA Fee Schedule,11.55,90.1,63.6
Outpatient Medical Services,Laboratory & Pathology Services,82607,VITAMIN B 12,300,85.4,72.59,85% Of Billed Charges,70.28,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,70.28,136.60% of BCBS Fee Schedule,16.59,110% Of LA Fee Schedule,15.08,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,32.45,38% of Billed Charges,15.08,100% of LA Fee Schedule,15.08,72.59,51.24
Outpatient Medical Services,Laboratory & Pathology Services,82610,PROTHROMBIN TIME,300,22,18.7,85% Of Billed Charges,18.28,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,18.28,136.60% of BCBS Fee Schedule,7.11,110% Of LA Fee Schedule,6.46,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,8.36,38% of Billed Charges,6.46,100% of LA Fee Schedule,6.46,18.7,13.2
Outpatient Medical Services,Laboratory & Pathology Services,82728,FERRITIN,300,77,65.45,85% Of Billed Charges,63.49,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,63.49,136.60% of BCBS Fee Schedule,14.99,110% Of LA Fee Schedule,13.63,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,29.26,38% of Billed Charges,13.63,100% of LA Fee Schedule,13.63,65.45,46.2
Outpatient Medical Services,Laboratory & Pathology Services,82784,Celiac Disease Complete Panel LC,300,380,323,85% Of Billed Charges,43.36,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,43.36,136.60% of BCBS Fee Schedule,10.23,110% Of LA Fee Schedule,9.3,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,144.4,38% of Billed Charges,9.3,100% of LA Fee Schedule,9.3,323,228
Outpatient Medical Services,Laboratory & Pathology Services,82948,Blood Glucose Monitoring,300,32,27.2,85% Of Billed Charges,14.78,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,14.78,136.60% of BCBS Fee Schedule,4.48,110% Of LA Fee Schedule,4.07,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,12.16,38% of Billed Charges,4.07,100% of LA Fee Schedule,4.07,27.2,19.2
Outpatient Medical Services,Laboratory & Pathology Services,83036,HGB AIC,300,55,46.75,85% Of Billed Charges,45.26,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,45.26,136.60% of BCBS Fee Schedule,10.68,110% Of LA Fee Schedule,9.71,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,20.9,38% of Billed Charges,9.71,100% of LA Fee Schedule,9.71,46.75,33
Outpatient Medical Services,Laboratory & Pathology Services,83540,ASSAY OF IRON  83540,300,45,38.25,85% Of Billed Charges,25.01,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,25.01,136.60% of BCBS Fee Schedule,6.97,110% Of LA Fee Schedule,6.34,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,17.1,38% of Billed Charges,6.34,100% of LA Fee Schedule,6.34,38.25,27
Outpatient Medical Services,Laboratory & Pathology Services,83605,LACTIC ACID PLASMA,300,89,75.65,85% Of Billed Charges,49.76,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,49.76,136.60% of BCBS Fee Schedule,12.73,110% Of LA Fee Schedule,11.57,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,33.82,38% of Billed Charges,11.57,100% of LA Fee Schedule,11.57,75.65,53.4
Outpatient Medical Services,Laboratory & Pathology Services,83690,LIPASE,300,39,33.15,85% Of Billed Charges,32.1,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,32.1,136.60% of BCBS Fee Schedule,7.58,110% Of LA Fee Schedule,6.89,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,14.82,38% of Billed Charges,6.89,100% of LA Fee Schedule,6.89,33.15,23.4
Outpatient Medical Services,Laboratory & Pathology Services,83735,MAGNESIUM,300,38,32.3,85% Of Billed Charges,31.23,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,31.23,136.60% of BCBS Fee Schedule,7.37,110% Of LA Fee Schedule,6.7,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,14.44,38% of Billed Charges,6.7,100% of LA Fee Schedule,6.7,32.3,22.8
Outpatient Medical Services,Laboratory & Pathology Services,84132,POTASSIUM; SERUM,300,26,22.1,85% Of Billed Charges,21.41,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,21.41,136.60% of BCBS Fee Schedule,5.24,110% Of LA Fee Schedule,4.76,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,9.88,38% of Billed Charges,4.76,100% of LA Fee Schedule,4.76,22.1,15.6
Outpatient Medical Services,Laboratory & Pathology Services,84133,"Potassium, Urine LC",300,29,24.65,85% Of Billed Charges,20.05,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,20.05,136.60% of BCBS Fee Schedule,5.2,110% Of LA Fee Schedule,4.73,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,11.02,38% of Billed Charges,4.73,100% of LA Fee Schedule,4.73,24.65,17.4
Outpatient Medical Services,Laboratory & Pathology Services,83880,PRO-BRAIN NATRIURETIC PEPTIDE,300,193,164.05,85% Of Billed Charges,158.26,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,158.26,136.60% of BCBS Fee Schedule,43.19,110% Of LA Fee Schedule,39.26,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,73.34,38% of Billed Charges,39.26,100% of LA Fee Schedule,39.26,164.05,115.8
Outpatient Medical Services,Laboratory & Pathology Services,84153,PSA Screen,300,104,88.4,85% Of Billed Charges,85.76,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,85.76,136.60% of BCBS Fee Schedule,20.23,110% Of LA Fee Schedule,18.39,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,39.52,38% of Billed Charges,18.39,100% of LA Fee Schedule,18.39,88.4,62.4
Outpatient Medical Services,Laboratory & Pathology Services,84402,"Testosterone, Free, Direct LC",300,144.28,122.64,85% Of Billed Charges,118.69,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,118.69,136.60% of BCBS Fee Schedule,28.02,110% Of LA Fee Schedule,25.47,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,54.83,38% of Billed Charges,25.47,100% of LA Fee Schedule,25.47,122.64,86.568
Outpatient Medical Services,Laboratory & Pathology Services,84403,"Testosterone, Serum, LC",300,146.28,124.34,85% Of Billed Charges,120.41,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,120.41,136.60% of BCBS Fee Schedule,28.39,110% Of LA Fee Schedule,25.81,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,55.59,38% of Billed Charges,25.81,100% of LA Fee Schedule,25.81,124.34,87.768
Outpatient Medical Services,Laboratory & Pathology Services,84439,Thyroxine Free,300,51.08,43.42,85% Of Billed Charges,42.03,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,42.03,136.60% of BCBS Fee Schedule,9.92,110% Of LA Fee Schedule,9.02,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,19.41,38% of Billed Charges,9.02,100% of LA Fee Schedule,9.02,43.42,30.648
Outpatient Medical Services,Laboratory & Pathology Services,84443,"Blood test, thyroid stimulating hormone",300,95,80.75,85% Of Billed Charges,78.33,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,78.33,136.60% of BCBS Fee Schedule,18.48,110% Of LA Fee Schedule,16.8,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,36.1,38% of Billed Charges,16.8,100% of LA Fee Schedule,16.8,80.75,57
Outpatient Medical Services,Laboratory & Pathology Services,84480,Triiodothyronine (T3) LC,300,113,96.05,85% Of Billed Charges,29.94,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,29.94,136.60% of BCBS Fee Schedule,8.61,110% Of LA Fee Schedule,7.83,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,42.94,38% of Billed Charges,7.83,100% of LA Fee Schedule,7.83,96.05,67.8
Outpatient Medical Services,Laboratory & Pathology Services,84484,Troponin I 1,300,56,47.6,85% Of Billed Charges,45.88,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,45.88,136.60% of BCBS Fee Schedule,13.72,110% Of LA Fee Schedule,12.47,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,21.28,38% of Billed Charges,12.47,100% of LA Fee Schedule,12.47,47.6,33.6
Outpatient Medical Services,Laboratory & Pathology Services,85025,"Complete blood cell count, w/diff white blood cells, automated",300,44,37.4,85% Of Billed Charges,36.24,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,36.24,136.60% of BCBS Fee Schedule,8.55,110% Of LA Fee Schedule,7.77,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,16.72,38% of Billed Charges,7.77,100% of LA Fee Schedule,7.77,37.4,26.4
Outpatient Medical Services,Laboratory & Pathology Services,85027,"Complete blood count, automated",300,51,43.35,85% Of Billed Charges,30.17,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,30.17,136.60% of BCBS Fee Schedule,7.12,110% Of LA Fee Schedule,6.47,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,19.38,38% of Billed Charges,6.47,100% of LA Fee Schedule,6.47,43.35,30.6
Outpatient Medical Services,Laboratory & Pathology Services,85379,D-DIMER,300,80,68,85% Of Billed Charges,47.45,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,47.45,136.60% of BCBS Fee Schedule,11.2,110% Of LA Fee Schedule,10.18,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,30.4,38% of Billed Charges,10.18,100% of LA Fee Schedule,10.18,68,48
Outpatient Medical Services,Laboratory & Pathology Services,85610,"Blood test, clotting time",300,22,18.7,85% Of Billed Charges,18.32,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,18.32,136.60% of BCBS Fee Schedule,4.72,110% Of LA Fee Schedule,4.29,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,8.36,38% of Billed Charges,4.29,100% of LA Fee Schedule,4.29,18.7,13.2
Outpatient Medical Services,Laboratory & Pathology Services,85651,SED RATE ERYTHROCYTE N,300,20,17,85% Of Billed Charges,16.54,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,16.54,136.60% of BCBS Fee Schedule,4.7,110% Of LA Fee Schedule,4.27,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,7.6,38% of Billed Charges,4.27,100% of LA Fee Schedule,4.27,17,12
Outpatient Medical Services,Laboratory & Pathology Services,85730,Coagultion assessment blood test,300,34,28.9,85% Of Billed Charges,27.96,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,27.96,136.60% of BCBS Fee Schedule,6.61,110% Of LA Fee Schedule,6.01,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,12.92,38% of Billed Charges,6.01,100% of LA Fee Schedule,6.01,28.9,20.4
Outpatient Medical Services,Laboratory & Pathology Services,86003,F013-IgE Peanut LC,300,36,30.6,85% Of Billed Charges,24.34,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,24.34,136.60% of BCBS Fee Schedule,5.74,110% Of LA Fee Schedule,5.22,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,13.68,38% of Billed Charges,5.22,100% of LA Fee Schedule,5.22,30.6,21.6
Outpatient Medical Services,Laboratory & Pathology Services,86140,C-REATIVE PROTEIN,300,29,24.65,85% Of Billed Charges,24.12,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,24.12,136.60% of BCBS Fee Schedule,5.7,110% Of LA Fee Schedule,5.18,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,11.02,38% of Billed Charges,5.18,100% of LA Fee Schedule,5.18,24.65,17.4
Outpatient Medical Services,Laboratory & Pathology Services,86304,Cancer Antigen (CA) 125 LC,300,118,100.3,85% Of Billed Charges,97,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,97,136.60% of BCBS Fee Schedule,22.89,110% Of LA Fee Schedule,20.81,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,44.84,38% of Billed Charges,20.81,100% of LA Fee Schedule,20.81,100.3,70.8
Outpatient Medical Services,Laboratory & Pathology Services,86735,Measles/Mumps/Rubella Immunity LC,300,275,233.75,85% Of Billed Charges,60.84,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,60.84,136.60% of BCBS Fee Schedule,14.36,110% Of LA Fee Schedule,13.05,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,104.5,38% of Billed Charges,13.05,100% of LA Fee Schedule,13.05,233.75,165
Outpatient Medical Services,Laboratory & Pathology Services,86769,"SARS-CoV-2 (COVID-19) Antibody, IgA LC",300,150,N/A,NOT SEPERATELY REIMBURSABLE,57.55,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,57.55,136.60% of BCBS Fee Schedule,34.76,110% Of LA Fee Schedule,31.6,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,57,38% of Billed Charges,31.6,100% of LA Fee Schedule,31.6,57.55,90
Outpatient Medical Services,Laboratory & Pathology Services,86769,"SARS-CoV-2 (COVID-19) Antibody, IgG LC",300,150,N/A,NOT SEPERATELY REIMBURSABLE,57.55,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,57.55,136.60% of BCBS Fee Schedule,34.76,110% Of LA Fee Schedule,31.6,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,57,38% of Billed Charges,31.6,100% of LA Fee Schedule,31.6,57.55,90
Outpatient Medical Services,Laboratory & Pathology Services,86769,"SARS-CoV-2 (COVID-19) Antibody, IgM LC",300,150,N/A,NOT SEPERATELY REIMBURSABLE,57.55,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,57.55,136.60% of BCBS Fee Schedule,34.76,110% Of LA Fee Schedule,31.6,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,57,38% of Billed Charges,31.6,100% of LA Fee Schedule,31.6,57.55,90
Outpatient Medical Services,Laboratory & Pathology Services,87040,"Blood Culture, Routine LC",300,58,N/A,NOT SEPERATELY REIMBURSABLE,48.11,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,48.11,136.60% of BCBS Fee Schedule,11.35,110% Of LA Fee Schedule,10.32,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,22.04,38% of Billed Charges,10.32,100% of LA Fee Schedule,10.32,48.11,34.8
Outpatient Medical Services,Laboratory & Pathology Services,87070,"Body Fluid Culture, Sterile LC",300,49,N/A,NOT SEPERATELY REIMBURSABLE,40.15,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,40.15,136.60% of BCBS Fee Schedule,9.48,110% Of LA Fee Schedule,8.62,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,18.62,38% of Billed Charges,8.62,100% of LA Fee Schedule,8.62,40.15,29.4
Outpatient Medical Services,Laboratory & Pathology Services,87077,Bill Organism ID,300,45,N/A,NOT SEPERATELY REIMBURSABLE,37.69,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,37.69,136.60% of BCBS Fee Schedule,8.89,110% Of LA Fee Schedule,8.08,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,17.1,38% of Billed Charges,8.08,100% of LA Fee Schedule,8.08,37.69,27
Outpatient Medical Services,Laboratory & Pathology Services,87086,"Urine Culture, Routine LC",300,64,N/A,NOT SEPERATELY REIMBURSABLE,37.63,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,37.63,136.60% of BCBS Fee Schedule,8.88,110% Of LA Fee Schedule,8.07,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,24.32,38% of Billed Charges,8.07,100% of LA Fee Schedule,8.07,37.63,38.4
Outpatient Medical Services,Laboratory & Pathology Services,87088,URINE CX W PRESUMP ID,300,45,N/A,NOT SEPERATELY REIMBURSABLE,37.76,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,37.76,136.60% of BCBS Fee Schedule,8.9,110% Of LA Fee Schedule,8.09,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,17.1,38% of Billed Charges,8.09,100% of LA Fee Schedule,8.09,37.76,27
Outpatient Medical Services,Laboratory & Pathology Services,87186,"Susceptibility, Aer + Anaerob LC",300,59,N/A,NOT SEPERATELY REIMBURSABLE,40.32,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,40.32,136.60% of BCBS Fee Schedule,9.52,110% Of LA Fee Schedule,8.65,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,22.42,38% of Billed Charges,8.65,100% of LA Fee Schedule,8.65,40.32,35.4
Outpatient Medical Services,Laboratory & Pathology Services,87486,Chlamydia pneumoniae -BioFire,300,136.5,N/A,NOT SEPERATELY REIMBURSABLE,163.65,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,163.65,136.60% of BCBS Fee Schedule,38.6,110% Of LA Fee Schedule,35.09,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,51.87,38% of Billed Charges,35.09,100% of LA Fee Schedule,35.09,163.65,81.9
Outpatient Medical Services,Laboratory & Pathology Services,87491,"Chlamydia trachomatis, NAA LC",300,240,N/A,NOT SEPERATELY REIMBURSABLE,163.65,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,163.65,136.60% of BCBS Fee Schedule,38.6,110% Of LA Fee Schedule,35.09,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,91.2,38% of Billed Charges,35.09,100% of LA Fee Schedule,35.09,163.65,144
Outpatient Medical Services,Laboratory & Pathology Services,87581,Mycoplasma pneumoniae -BioFire,300,136.5,N/A,NOT SEPERATELY REIMBURSABLE,163.65,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,163.65,136.60% of BCBS Fee Schedule,38.6,110% Of LA Fee Schedule,35.09,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,51.87,38% of Billed Charges,35.09,100% of LA Fee Schedule,35.09,163.65,81.9
Outpatient Medical Services,Laboratory & Pathology Services,87591,"Neisseria gonorrhoeae, NAA LC",300,240,N/A,NOT SEPERATELY REIMBURSABLE,163.65,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,163.65,136.60% of BCBS Fee Schedule,38.6,110% Of LA Fee Schedule,35.09,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,91.2,38% of Billed Charges,35.09,100% of LA Fee Schedule,35.09,163.65,144
Outpatient Medical Services,Laboratory & Pathology Services,87633,Resp virus 12-25 targets,300,926,N/A,NOT SEPERATELY REIMBURSABLE,1613.52,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,1613.52,136.60% of BCBS Fee Schedule,295.86,31.95% of Billed Charges,295.86,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,351.88,38% of Billed Charges,370.4,40% of Billed Charges,295.86,1613.52,555.6
Outpatient Medical Services,Laboratory & Pathology Services,87635,2019 Novel Coronavirus (CoVID-19),300,160,N/A,NOT SEPERATELY REIMBURSABLE,105.18,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,105.18,136.60% of BCBS Fee Schedule,42.33,110% Of LA Fee Schedule,38.48,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,60.8,38% of Billed Charges,38.48,100% of LA Fee Schedule,38.48,105.18,96
Outpatient Medical Services,Laboratory & Pathology Services,87635,COVID 19 TESTING,300,115,N/A,NOT SEPERATELY REIMBURSABLE,105.18,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,105.18,136.60% of BCBS Fee Schedule,42.33,110% Of LA Fee Schedule,38.48,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,43.7,38% of Billed Charges,38.48,100% of LA Fee Schedule,38.48,105.18,69
Outpatient Medical Services,Laboratory & Pathology Services,87635,SARS-CoV-2 (COVID-19) (BioFire),300,115,N/A,NOT SEPERATELY REIMBURSABLE,105.18,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,105.18,136.60% of BCBS Fee Schedule,42.33,110% Of LA Fee Schedule,38.48,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,43.7,38% of Billed Charges,38.48,100% of LA Fee Schedule,38.48,105.18,69
Outpatient Medical Services,Laboratory & Pathology Services,87635,SARS-CoV-2 (COVID-19) RNA (ID Now),300,115,N/A,NOT SEPERATELY REIMBURSABLE,105.18,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,105.18,136.60% of BCBS Fee Schedule,42.33,110% Of LA Fee Schedule,38.48,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,43.7,38% of Billed Charges,38.48,100% of LA Fee Schedule,38.48,105.18,69
Outpatient Medical Services,Laboratory & Pathology Services,86615,"Bordetella Pertussis Ab, IgA,IgG,IgM LC",300,162,N/A,NOT SEPERATELY REIMBURSABLE,61.5,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,61.5,136.60% of BCBS Fee Schedule,14.51,110% Of LA Fee Schedule,13.19,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,61.56,38% of Billed Charges,13.19,100% of LA Fee Schedule,13.19,61.56,97.2
Outpatient Medical Services,Laboratory & Pathology Services,87798,Bordetella pertussis -BioFire,300,136.5,N/A,NOT SEPERATELY REIMBURSABLE,163.65,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,163.65,136.60% of BCBS Fee Schedule,38.6,110% Of LA Fee Schedule,35.09,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,51.87,38% of Billed Charges,35.09,100% of LA Fee Schedule,35.09,163.65,81.9
Outpatient Medical Services,Laboratory & Pathology Services,81001,Manual urinalysis test with examination using microscope,300,18,N/A,NOT SEPERATELY REIMBURSABLE,14.78,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,14.78,136.60% of BCBS Fee Schedule,3.49,110% Of LA Fee Schedule,3.17,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,6.84,38% of Billed Charges,3.17,100% of LA Fee Schedule,3.17,14.78,10.8
Outpatient Medical Services,Laboratory & Pathology Services,81002,Automated urinalysis test,300,15,N/A,NOT SEPERATELY REIMBURSABLE,11.91,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,11.91,136.60% of BCBS Fee Schedule,3.61,110% Of LA Fee Schedule,3.28,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,5.7,38% of Billed Charges,3.28,100% of LA Fee Schedule,3.28,11.91,9
Outpatient Medical Services,Laboratory & Pathology Services,84153,PSA (prostate specific antigen),300,104,N/A,NOT SEPERATELY REIMBURSABLE,85.76,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,85.76,136.60% of BCBS Fee Schedule,20.23,110% Of LA Fee Schedule,18.39,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,39.52,38% of Billed Charges,18.39,100% of LA Fee Schedule,18.39,85.76,62.4
Outpatient Medical Services,Laboratory & Pathology Services,G0480,ETHANOL BLOOD (ETOH)  80320,300,229,N/A,NOT SEPERATELY REIMBURSABLE,225.14,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,225.14,136.60% of BCBS Fee Schedule,97.43,110% Of LA Fee Schedule,88.57,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,87.02,38% of Billed Charges,88.57,100% of LA Fee Schedule,87.02,225.14,137.4
Outpatient Medical Services,Laboratory & Pathology Services,,,300,$115.00 ,57.5,50% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,57.5,50% of Billed Charges,36.74,31.95% of Billed Charges,36.74,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,43.7,38% of Billed CHarges,46,38% of Billed Charges,36.74,100% of Billed Charges,36.74,57.5,#VALUE!
Outpatient Medical Services,Radiology Services,70450,CT Head or Brain w/o Contrast,320,800,N/A,NOT SEPERATELY REIMBURSABLE,545.57,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,545.57,136.60% of BCBS Fee Schedule,281.2,35.15% of LA Fee Schedule,255.6,31.95% of LA Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,155,Pay As Per Visit,255.6,31.95% of LA fee Schedule,155,545.57,480
Outpatient Medical Services,Radiology Services,70553,MRI Brain w/ + w/o Contrast,320,2135,N/A,NOT SEPERATELY REIMBURSABLE,1579.22,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,1579.22,136.60% of BCBS Fee Schedule,750.45,35.15% of LA Fee Schedule,682.13,31.95% of LA Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,155,Pay As Per Visit,682.13,31.95% of LA fee Schedule,155,1579.22,1281
Outpatient Medical Services,Radiology Services,72110,XR Spine Lumbosacral Minimum 4 Views,320,364,N/A,NOT SEPERATELY REIMBURSABLE,168.85,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,168.85,136.60% of BCBS Fee Schedule,127.95,35.15% of LA Fee Schedule,116.3,31.95% of LA Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,155,Pay As Per Visit,116.3,31.95% of LA fee Schedule,116.3,168.85,218.4
Outpatient Medical Services,Radiology Services,72148,MRI Spine Lumbar w/o Contrast,320,1550,N/A,NOT SEPERATELY REIMBURSABLE,1089.28,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,1089.28,136.60% of BCBS Fee Schedule,544.83,35.15% of LA Fee Schedule,495.23,31.95% of LA Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,155,Pay As Per Visit,495.23,31.95% of LA fee Schedule,155,1089.28,930
Outpatient Medical Services,Radiology Services,72193,CT Pelvis w/ Contrast,320,1200,N/A,NOT SEPERATELY REIMBURSABLE,790.3,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,790.3,136.60% of BCBS Fee Schedule,421.8,35.15% of LA Fee Schedule,383.4,31.95% of LA Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,155,Pay As Per Visit,383.4,31.95% of LA fee Schedule,155,790.3,720
Outpatient Medical Services,Radiology Services,73721,MRI Lower extremetry,320,1650,N/A,NOT SEPERATELY REIMBURSABLE,1089.28,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,1089.28,136.60% of BCBS Fee Schedule,579.98,35.15% of LA Fee Schedule,527.18,31.95% of LA Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,155,Pay As Per Visit,527.18,31.95% of LA fee Schedule,155,1089.28,990
Outpatient Medical Services,Radiology Services,74177,CT Abdomen/Pelvis w/ Contrast,320,1950,N/A,NOT SEPERATELY REIMBURSABLE,1013.12,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,1013.12,136.60% of BCBS Fee Schedule,685.43,35.15% of LA Fee Schedule,623.03,31.95% of LA Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,155,Pay As Per Visit,623.03,31.95% of LA fee Schedule,155,1013.12,1170
Outpatient Medical Services,Radiology Services,76700,US Abdomen Complete,320,386,N/A,NOT SEPERATELY REIMBURSABLE,228.48,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,228.48,136.60% of BCBS Fee Schedule,135.68,35.15% of LA Fee Schedule,123.33,31.95% of LA Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,155,Pay As Per Visit,123.33,31.95% of LA fee Schedule,123.33,228.48,231.6
Outpatient Medical Services,Radiology Services,76805,US Pregnancy After 1st Trimester,320,450,N/A,NOT SEPERATELY REIMBURSABLE,243.91,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,243.91,136.60% of BCBS Fee Schedule,158.18,35.15% of LA Fee Schedule,143.78,31.95% of LA Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,155,Pay As Per Visit,143.78,31.95% of LA fee Schedule,143.78,243.91,270
Outpatient Medical Services,Radiology Services,76830,US Transvaginal,320,386,N/A,NOT SEPERATELY REIMBURSABLE,216.01,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,216.01,136.60% of BCBS Fee Schedule,135.68,35.15% of LA Fee Schedule,123.33,31.95% of LA Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,155,Pay As Per Visit,123.33,31.95% of LA fee Schedule,123.33,216.01,231.6
Outpatient Medical Services,Radiology Services,77065,MA Mammogram Diagnostic unlat.,320,471,N/A,NOT SEPERATELY REIMBURSABLE,168.89,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,168.89,136.60% of BCBS Fee Schedule,165.56,35.15% of LA Fee Schedule,150.48,31.95% of LA Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,155,Pay As Per Visit,150.48,31.95% of LA fee Schedule,150.48,168.89,282.6
Outpatient Medical Services,Radiology Services,77066,MA Mammogram Diagnostic Bilateral.,320,597,N/A,NOT SEPERATELY REIMBURSABLE,198.43,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,198.43,136.60% of BCBS Fee Schedule,209.85,35.15% of LA Fee Schedule,190.74,31.95% of LA Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,155,Pay As Per Visit,190.74,31.95% of LA fee Schedule,155,209.85,358.2
Outpatient Medical Services,Radiology Services,77067,MA Mammogram Routine Screening Bilat.,320,540,N/A,NOT SEPERATELY REIMBURSABLE,189.75,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,189.75,136.60% of BCBS Fee Schedule,189.81,35.15% of LA Fee Schedule,172.53,31.95% of LA Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,155,Pay As Per Visit,172.53,31.95% of LA fee Schedule,155,189.81,324
Outpatient Medical Services,Radiology Services,70220,XR SINUSES,320,230,N/A,NOT SEPERATELY REIMBURSABLE,99.23,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,99.23,136.60% of BCBS Fee Schedule,80.85,35.15% of LA Fee Schedule,73.49,31.95% of LA Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,155,Pay As Per Visit,73.49,31.95% of LA fee Schedule,73.49,155,138
Outpatient Medical Services,Radiology Services,70486,CT FACIAL BONES,320,800,N/A,NOT SEPERATELY REIMBURSABLE,545.57,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,545.57,136.60% of BCBS Fee Schedule,281.2,35.15% of LA Fee Schedule,255.6,31.95% of LA Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,155,Pay As Per Visit,255.6,31.95% of LA fee Schedule,155,545.57,480
Outpatient Medical Services,Radiology Services,71045,X-ray exam chest 1 view,320,230,N/A,NOT SEPERATELY REIMBURSABLE,99.23,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,99.23,136.60% of BCBS Fee Schedule,80.85,35.15% of LA Fee Schedule,73.49,31.95% of LA Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,155,Pay As Per Visit,73.49,31.95% of LA fee Schedule,73.49,155,138
Outpatient Medical Services,Radiology Services,71046,X-ray exam chest 2 views,320,230,N/A,NOT SEPERATELY REIMBURSABLE,99.23,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,99.23,136.60% of BCBS Fee Schedule,80.85,35.15% of LA Fee Schedule,73.49,31.95% of LA Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,155,Pay As Per Visit,73.49,31.95% of LA fee Schedule,73.49,155,138
Outpatient Medical Services,Radiology Services,71250,CT CHEST WO,320,800,N/A,NOT SEPERATELY REIMBURSABLE,586.77,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,586.77,136.60% of BCBS Fee Schedule,281.2,35.15% of LA Fee Schedule,255.6,31.95% of LA Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,155,Pay As Per Visit,255.6,31.95% of LA fee Schedule,155,586.77,480
Outpatient Medical Services,Radiology Services,71260,CT CHEST W,320,1200,N/A,NOT SEPERATELY REIMBURSABLE,796.77,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,796.77,136.60% of BCBS Fee Schedule,421.8,35.15% of LA Fee Schedule,383.4,31.95% of LA Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,155,Pay As Per Visit,383.4,31.95% of LA fee Schedule,155,796.77,720
Outpatient Medical Services,Radiology Services,71275,CTA CHEST,320,1355,N/A,NOT SEPERATELY REIMBURSABLE,927.15,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,927.15,136.60% of BCBS Fee Schedule,476.28,35.15% of LA Fee Schedule,432.92,31.95% of LA Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,155,Pay As Per Visit,432.92,31.95% of LA fee Schedule,155,927.15,813
Outpatient Medical Services,Radiology Services,72040,XR C SPINE 2/3,320,230,N/A,NOT SEPERATELY REIMBURSABLE,99.23,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,99.23,136.60% of BCBS Fee Schedule,80.85,35.15% of LA Fee Schedule,73.49,31.95% of LA Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,155,Pay As Per Visit,73.49,31.95% of LA fee Schedule,73.49,155,138
Outpatient Medical Services,Radiology Services,72052,XR C SPINE 5 VI,320,403,N/A,NOT SEPERATELY REIMBURSABLE,168.85,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,168.85,136.60% of BCBS Fee Schedule,141.65,35.15% of LA Fee Schedule,128.76,31.95% of LA Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,155,Pay As Per Visit,128.76,31.95% of LA fee Schedule,128.76,168.85,241.8
Outpatient Medical Services,Radiology Services,72070,XR T SPINE 2 VI,320,175,N/A,NOT SEPERATELY REIMBURSABLE,99.23,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,99.23,136.60% of BCBS Fee Schedule,61.51,35.15% of LA Fee Schedule,55.91,31.95% of LA Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,155,Pay As Per Visit,55.91,31.95% of LA fee Schedule,55.91,155,105
Outpatient Medical Services,Radiology Services,72100,XR L SPINE 2/3,320,230,N/A,NOT SEPERATELY REIMBURSABLE,99.23,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,99.23,136.60% of BCBS Fee Schedule,80.85,35.15% of LA Fee Schedule,73.49,31.95% of LA Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,155,Pay As Per Visit,73.49,31.95% of LA fee Schedule,73.49,155,138
Outpatient Medical Services,Radiology Services,72125,CT C SPINE WO 7,320,925,N/A,NOT SEPERATELY REIMBURSABLE,586.77,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,586.77,136.60% of BCBS Fee Schedule,325.14,35.15% of LA Fee Schedule,295.54,31.95% of LA Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,155,Pay As Per Visit,295.54,31.95% of LA fee Schedule,155,586.77,555
Outpatient Medical Services,Radiology Services,73030,XR SHOULDER COM,320,230,N/A,NOT SEPERATELY REIMBURSABLE,99.23,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,99.23,136.60% of BCBS Fee Schedule,80.85,35.15% of LA Fee Schedule,73.49,31.95% of LA Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,155,Pay As Per Visit,73.49,31.95% of LA fee Schedule,73.49,155,138
Outpatient Medical Services,Radiology Services,73080,XR ELBOW 3 VIEW,320,230,N/A,NOT SEPERATELY REIMBURSABLE,99.23,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,99.23,136.60% of BCBS Fee Schedule,80.85,35.15% of LA Fee Schedule,73.49,31.95% of LA Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,155,Pay As Per Visit,73.49,31.95% of LA fee Schedule,73.49,155,138
Outpatient Medical Services,Radiology Services,73090,XR FOREARM,320,230,N/A,NOT SEPERATELY REIMBURSABLE,99.23,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,99.23,136.60% of BCBS Fee Schedule,80.85,35.15% of LA Fee Schedule,73.49,31.95% of LA Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,155,Pay As Per Visit,73.49,31.95% of LA fee Schedule,73.49,155,138
Outpatient Medical Services,Radiology Services,73110,XR WRIST 3 VIEW,320,230,N/A,NOT SEPERATELY REIMBURSABLE,99.23,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,99.23,136.60% of BCBS Fee Schedule,80.85,35.15% of LA Fee Schedule,73.49,31.95% of LA Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,155,Pay As Per Visit,73.49,31.95% of LA fee Schedule,73.49,155,138
Outpatient Medical Services,Radiology Services,73130,XR HAND 3 VIEWS,320,230,N/A,NOT SEPERATELY REIMBURSABLE,99.23,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,99.23,136.60% of BCBS Fee Schedule,80.85,35.15% of LA Fee Schedule,73.49,31.95% of LA Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,155,Pay As Per Visit,73.49,31.95% of LA fee Schedule,73.49,155,138
Outpatient Medical Services,Radiology Services,73140,XR FINGERS 3 VI,320,230,N/A,NOT SEPERATELY REIMBURSABLE,99.23,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,99.23,136.60% of BCBS Fee Schedule,80.85,35.15% of LA Fee Schedule,73.49,31.95% of LA Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,155,Pay As Per Visit,73.49,31.95% of LA fee Schedule,73.49,155,138
Outpatient Medical Services,Radiology Services,73221,MRI UPPER EXT W,320,1700,N/A,NOT SEPERATELY REIMBURSABLE,1089.28,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,1089.28,136.60% of BCBS Fee Schedule,597.55,35.15% of LA Fee Schedule,543.15,31.95% of LA Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,155,Pay As Per Visit,543.15,31.95% of LA fee Schedule,155,1089.28,1020
Outpatient Medical Services,Radiology Services,73502,XR HIP UNILATERAL 2-3 VIEWS,320,244,N/A,NOT SEPERATELY REIMBURSABLE,74.15,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,74.15,136.60% of BCBS Fee Schedule,85.77,35.15% of LA Fee Schedule,77.96,31.95% of LA Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,155,Pay As Per Visit,77.96,31.95% of LA fee Schedule,74.15,155,146.4
Outpatient Medical Services,Radiology Services,73522,x-ray exam hips bi 3-4 fiews,320,403,N/A,NOT SEPERATELY REIMBURSABLE,83.01,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,83.01,136.60% of BCBS Fee Schedule,141.65,35.15% of LA Fee Schedule,128.76,31.95% of LA Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,155,Pay As Per Visit,128.76,31.95% of LA fee Schedule,83.01,155,241.8
Outpatient Medical Services,Radiology Services,73562,KNEE 3 VIEWS 73,320,230,N/A,NOT SEPERATELY REIMBURSABLE,99.23,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,99.23,136.60% of BCBS Fee Schedule,80.85,35.15% of LA Fee Schedule,73.49,31.95% of LA Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,155,Pay As Per Visit,73.49,31.95% of LA fee Schedule,73.49,155,138
Outpatient Medical Services,Radiology Services,73564,XR KNEE 4 VIEWS,320,230,N/A,NOT SEPERATELY REIMBURSABLE,99.23,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,99.23,136.60% of BCBS Fee Schedule,80.85,35.15% of LA Fee Schedule,73.49,31.95% of LA Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,155,Pay As Per Visit,73.49,31.95% of LA fee Schedule,73.49,155,138
Outpatient Medical Services,Radiology Services,73565,XR KNEES BILATE,320,230,N/A,NOT SEPERATELY REIMBURSABLE,99.23,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,99.23,136.60% of BCBS Fee Schedule,80.85,35.15% of LA Fee Schedule,73.49,31.95% of LA Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,155,Pay As Per Visit,73.49,31.95% of LA fee Schedule,73.49,155,138
Outpatient Medical Services,Radiology Services,73590,XR TIBIA/FIBULA,320,230,N/A,NOT SEPERATELY REIMBURSABLE,99.23,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,99.23,136.60% of BCBS Fee Schedule,80.85,35.15% of LA Fee Schedule,73.49,31.95% of LA Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,155,Pay As Per Visit,73.49,31.95% of LA fee Schedule,73.49,155,138
Outpatient Medical Services,Radiology Services,73610,XR ANKLE 3 VIEW,320,230,N/A,NOT SEPERATELY REIMBURSABLE,99.23,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,99.23,136.60% of BCBS Fee Schedule,80.85,35.15% of LA Fee Schedule,73.49,31.95% of LA Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,155,Pay As Per Visit,73.49,31.95% of LA fee Schedule,73.49,155,138
Outpatient Medical Services,Radiology Services,73630,XR FOOT 3 VIEWS,320,230,N/A,NOT SEPERATELY REIMBURSABLE,99.23,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,99.23,136.60% of BCBS Fee Schedule,80.85,35.15% of LA Fee Schedule,73.49,31.95% of LA Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,155,Pay As Per Visit,73.49,31.95% of LA fee Schedule,73.49,155,138
Outpatient Medical Services,Radiology Services,74018,X-ray exam abdomen 1 view,320,230,N/A,NOT SEPERATELY REIMBURSABLE,99.23,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,99.23,136.60% of BCBS Fee Schedule,80.85,35.15% of LA Fee Schedule,73.49,31.95% of LA Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,155,Pay As Per Visit,73.49,31.95% of LA fee Schedule,73.49,155,138
Outpatient Medical Services,Radiology Services,74019,X-ray exam abdomen 3+ views,320,230,N/A,NOT SEPERATELY REIMBURSABLE,99.23,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,99.23,136.60% of BCBS Fee Schedule,80.85,35.15% of LA Fee Schedule,73.49,31.95% of LA Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,155,Pay As Per Visit,73.49,31.95% of LA fee Schedule,73.49,155,138
Outpatient Medical Services,Radiology Services,74022,X-ray exam series abdomen,320,364,N/A,NOT SEPERATELY REIMBURSABLE,168.85,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,168.85,136.60% of BCBS Fee Schedule,127.95,35.15% of LA Fee Schedule,116.3,31.95% of LA Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,155,Pay As Per Visit,116.3,31.95% of LA fee Schedule,116.3,168.85,218.4
Outpatient Medical Services,Radiology Services,74176,CT ABD/PELVIS W,320,1600,N/A,NOT SEPERATELY REIMBURSABLE,745.25,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,745.25,136.60% of BCBS Fee Schedule,562.4,35.15% of LA Fee Schedule,511.2,31.95% of LA Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,155,Pay As Per Visit,511.2,31.95% of LA fee Schedule,155,745.25,960
Outpatient Medical Services,Radiology Services,74178,CT ABD/PELVIS W,320,2450,N/A,NOT SEPERATELY REIMBURSABLE,1319.28,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,1319.28,136.60% of BCBS Fee Schedule,861.18,35.15% of LA Fee Schedule,782.78,31.95% of LA Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,155,Pay As Per Visit,782.78,31.95% of LA fee Schedule,155,1319.28,1470
Outpatient Medical Services,Radiology Services,76536,US exam of head & neck,320,538,N/A,NOT SEPERATELY REIMBURSABLE,216.01,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,216.01,136.60% of BCBS Fee Schedule,189.11,35.15% of LA Fee Schedule,171.89,31.95% of LA Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,155,Pay As Per Visit,171.89,31.95% of LA fee Schedule,155,216.01,322.8
Outpatient Medical Services,Radiology Services,76641,US BREAST UNILA,320,285,N/A,NOT SEPERATELY REIMBURSABLE,135.04,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,135.04,136.60% of BCBS Fee Schedule,100.18,35.15% of LA Fee Schedule,91.06,31.95% of LA Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,155,Pay As Per Visit,91.06,31.95% of LA fee Schedule,91.06,155,171
Outpatient Medical Services,Radiology Services,76705,US SINGLE ORGAN,320,386,N/A,NOT SEPERATELY REIMBURSABLE,216.01,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,216.01,136.60% of BCBS Fee Schedule,135.68,35.15% of LA Fee Schedule,123.33,31.95% of LA Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,155,Pay As Per Visit,123.33,31.95% of LA fee Schedule,123.33,216.01,231.6
Outpatient Medical Services,Radiology Services,76770,US RETROPERITON,320,386,N/A,NOT SEPERATELY REIMBURSABLE,228.48,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,228.48,136.60% of BCBS Fee Schedule,135.68,35.15% of LA Fee Schedule,123.33,31.95% of LA Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,155,Pay As Per Visit,123.33,31.95% of LA fee Schedule,123.33,228.48,231.6
Outpatient Medical Services,Radiology Services,76856,US PELVIS  7685,320,386,N/A,NOT SEPERATELY REIMBURSABLE,216.01,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,216.01,136.60% of BCBS Fee Schedule,135.68,35.15% of LA Fee Schedule,123.33,31.95% of LA Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,155,Pay As Per Visit,123.33,31.95% of LA fee Schedule,123.33,216.01,231.6
Outpatient Medical Services,Radiology Services,93880,US CAROTID DOPPLER,320,612,N/A,NOT SEPERATELY REIMBURSABLE,514.82,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,514.82,136.60% of BCBS Fee Schedule,215.12,35.15% of LA Fee Schedule,195.53,31.95% of LA Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,155,Pay As Per Visit,195.53,31.95% of LA fee Schedule,155,514.82,367.2
Outpatient Medical Services,Radiology Services,93925,US ARTERIAL DOP,320,612,N/A,NOT SEPERATELY REIMBURSABLE,514.82,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,514.82,136.60% of BCBS Fee Schedule,215.12,35.15% of LA Fee Schedule,195.53,31.95% of LA Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,155,Pay As Per Visit,195.53,31.95% of LA fee Schedule,155,514.82,367.2
Outpatient Medical Services,Radiology Services,93971,US VENOUS DOPPL,320,425,N/A,NOT SEPERATELY REIMBURSABLE,320.12,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,320.12,136.60% of BCBS Fee Schedule,149.39,35.15% of LA Fee Schedule,135.79,31.95% of LA Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,155,Pay As Per Visit,135.79,31.95% of LA fee Schedule,135.79,320.12,255
Outpatient Medical Services,Radiology Services,70450,CT Head or Brain w/o Contrast,960,127,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,146.27,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,60.72,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,60.72,146.27,76.2
Outpatient Medical Services,Radiology Services,70553,MRI Brain w/ + w/o Contrast,960,343,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,465.83,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,193.89,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,193.89,465.83,205.8
Outpatient Medical Services,Radiology Services,72110,XR Spine Lumbosacral Minimum 4 Views,960,49,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,64.3,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,34.91,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,34.91,64.3,29.4
Outpatient Medical Services,Radiology Services,72148,MRI Spine Lumbar w/o Contrast,960,222,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,278.51,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,111.76,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,111.76,278.51,133.2
Outpatient Medical Services,Radiology Services,72193,CT Pelvis w/ Contrast,960,174,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,291.98,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,158.97,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,158.97,291.98,104.4
Outpatient Medical Services,Radiology Services,73721,MRI Lower extremetry,960,203,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,292.46,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,127.3,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,127.3,292.46,121.8
Outpatient Medical Services,Radiology Services,74177,CT Abdomen/Pelvis w/ Contrast,960,275,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,399.64,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,199.15,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,199.15,399.64,165
Outpatient Medical Services,Radiology Services,76700,US Abdomen Complete,960,121,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,153.24,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,69.24,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,69.24,153.24,72.6
Outpatient Medical Services,Radiology Services,76805,US Pregnancy After 1st Trimester,960,154,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,177.98,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,78.33,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,78.33,177.98,92.4
Outpatient Medical Services,Radiology Services,76830,US Transvaginal,960,106,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,153.01,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,76.57,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,76.57,153.01,63.6
Outpatient Medical Services,Radiology Services,77065,MA Mammogram Diagnostic unlat.,960,105,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,138.82,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,76.85,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,76.85,138.82,63
Outpatient Medical Services,Radiology Services,77066,MA Mammogram Diagnostic Bilateral.,960,131,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,175,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,98.56,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,98.56,175,78.6
Outpatient Medical Services,Radiology Services,77067,MA Mammogram Routine Screening Bilat.,960,148,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,139.73,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,81.24,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,81.24,139.73,88.8
Outpatient Medical Services,Radiology Services,70220,XR SINUSES,960,38,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,49.15,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,24.06,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,24.06,49.15,22.8
Outpatient Medical Services,Radiology Services,70486,CT FACIAL BONES,960,127,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,174.76,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,80.36,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,80.36,174.76,76.2
Outpatient Medical Services,Radiology Services,71045,X-ray exam chest 1 view,960,28,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,31.5,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,15.26,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,15.26,31.5,16.8
Outpatient Medical Services,Radiology Services,71046,X-ray exam chest 2 views,960,33,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,39.92,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,20.54,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,20.54,39.92,19.8
Outpatient Medical Services,Radiology Services,71250,CT CHEST WO,960,153,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,200.49,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,75.38,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,75.38,200.49,91.8
Outpatient Medical Services,Radiology Services,71260,CT CHEST W,960,186,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,246.69,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,102.67,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,102.67,246.69,111.6
Outpatient Medical Services,Radiology Services,71275,CTA CHEST,960,273,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,365.27,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,179.23,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,179.23,365.27,163.8
Outpatient Medical Services,Radiology Services,72040,XR C SPINE 2/3,960,35,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,45.97,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,25.52,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,25.52,45.97,21
Outpatient Medical Services,Radiology Services,72052,XR C SPINE 5 VI,960,55,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,75.37,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,42.53,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,42.53,75.37,33
Outpatient Medical Services,Radiology Services,72070,XR T SPINE 2 VI,960,35,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,42.94,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,20.54,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,20.54,42.94,21
Outpatient Medical Services,Radiology Services,72100,XR L SPINE 2/3,960,35,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,45.97,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,25.82,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,25.82,45.97,21
Outpatient Medical Services,Radiology Services,72125,CT C SPINE WO 7,960,160,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,207.18,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,76.26,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,76.26,207.18,96
Outpatient Medical Services,Radiology Services,73030,XR SHOULDER COM,960,30,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,37.98,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,22.89,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,22.89,37.98,18
Outpatient Medical Services,Radiology Services,73080,XR ELBOW 3 VIEW,960,28,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,37.49,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,21.71,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,21.71,37.49,16.8
Outpatient Medical Services,Radiology Services,73090,XR FOREARM,960,26,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,35.28,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,19.07,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,19.07,35.28,15.6
Outpatient Medical Services,Radiology Services,73110,XR WRIST 3 VIEW,960,28,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,45.68,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,28,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,28,45.68,16.8
Outpatient Medical Services,Radiology Services,73130,XR HAND 3 VIEWS,960,27,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,41.81,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,25.52,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,25.52,41.81,16.2
Outpatient Medical Services,Radiology Services,73140,XR FINGERS 3 VI,960,21,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,42.01,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,21,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,21,42.01,12.6
Outpatient Medical Services,Radiology Services,73221,MRI UPPER EXT W,960,204,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,292.46,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,127.6,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,127.6,292.46,122.4
Outpatient Medical Services,Radiology Services,73502,XR HIP UNILATERAL 2-3 VIEWS,960,34,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,53.73,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,32.56,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,32.56,53.73,20.4
Outpatient Medical Services,Radiology Services,73522,x-ray exam hips bi 3-4 fiews,960,46,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,62.9,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,35.2,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,35.2,62.9,27.6
Outpatient Medical Services,Radiology Services,73562,KNEE 3 VIEWS 73,960,30,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,46.6,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,28.16,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,28.16,46.6,18
Outpatient Medical Services,Radiology Services,73564,XR KNEE 4 VIEWS,960,37,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,52,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,31.98,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,31.98,52,22.2
Outpatient Medical Services,Radiology Services,73565,XR KNEES BILATE,960,29,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,46.49,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,28.16,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,28.16,46.49,17.4
Outpatient Medical Services,Radiology Services,73590,XR TIBIA/FIBULA,960,27,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,37,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,21.13,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,21.13,37,16.2
Outpatient Medical Services,Radiology Services,73610,XR ANKLE 3 VIEW,960,28,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,41.81,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,24.94,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,24.94,41.81,16.8
Outpatient Medical Services,Radiology Services,73630,XR FOOT 3 VIEWS,960,26,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,39.22,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,23.18,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,23.18,39.22,15.6
Outpatient Medical Services,Radiology Services,74018,X-ray exam abdomen 1 view,960,28,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,35.82,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,19.07,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,19.07,35.82,16.8
Outpatient Medical Services,Radiology Services,74019,X-ray exam abdomen 3+ views,960,40,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,43.86,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,22.89,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,22.89,43.86,24
Outpatient Medical Services,Radiology Services,74022,X-ray exam series abdomen,960,49,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,58.75,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,30.8,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,30.8,58.75,29.4
Outpatient Medical Services,Radiology Services,74176,CT ABD/PELVIS W,960,262,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,255.06,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,93.58,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,93.58,255.06,157.2
Outpatient Medical Services,Radiology Services,74178,CT ABD/PELVIS W,960,302,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,451.05,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,224.97,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,224.97,451.05,181.2
Outpatient Medical Services,Radiology Services,76536,US exam of head & neck,960,83,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,143.94,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,73.91,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,73.91,143.94,49.8
Outpatient Medical Services,Radiology Services,76641,US BREAST UNILA,960,111,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,135.09,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,60.13,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,60.13,135.09,66.6
Outpatient Medical Services,Radiology Services,76705,US SINGLE ORGAN,960,89,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,114.33,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,52.5,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,52.5,114.33,53.4
Outpatient Medical Services,Radiology Services,76770,US RETROPERITON,960,109,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,142.06,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,64.82,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,64.82,142.06,65.4
Outpatient Medical Services,Radiology Services,76856,US PELVIS  7685,960,102,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,137.9,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,64.53,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,64.53,137.9,61.2
Outpatient Medical Services,Radiology Services,93880,US CAROTID DOPPLER,960,118,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,251.75,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,118,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,118,251.75,70.8
Outpatient Medical Services,Radiology Services,93925,US ARTERIAL DOP,960,119,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,318.79,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,119,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,119,318.79,71.4
Outpatient Medical Services,Radiology Services,93971,US VENOUS DOPPL,960,68,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,150.82,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,68,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,68,150.82,40.8
Inpatient Medical Services,Medicine and Surgery Services,,ICU Room,100,,1300,Pay As Per Per day Rate,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,2737.25,Pay As Per Per Day Rate,40386.44,100% of CMS IPPS Rate,2400,38% of Billed Charges,2737.25,Pay As Per Per Day Rate,1300,40386.44,N/A
Inpatient Medical Services,Medicine and Surgery Services,470,Knee replacement or Hip replacement,100,42576.54,1300,Pay As Per Per day Rate,41682.43,97.90% of Billed Vharges,N/A,NOT SEPERATELY REIMBURSABLE,41682.43,97.90% of Billed Charges,2737.25,Pay As Per Per Day Rate,2737.25,Pay As Per Per Day Rate,16809.21,100% of CMS IPPS Rate,2400,38% of Billed Charges,2737.25,Pay As Per Per Day Rate,1300,41682.43,25545.924
Inpatient Medical Services,Medicine and Surgery Services,552,Medical back problems w/o MCC,100,43835.02,1300,Pay As Per Per day Rate,42914.48,97.90% of Billed Vharges,N/A,NOT SEPERATELY REIMBURSABLE,42914.48,97.90% of Billed Charges,2737.25,Pay As Per Per Day Rate,2737.25,Pay As Per Per Day Rate,9505.94,100% of CMS IPPS Rate,2400,38% of Billed Charges,2737.25,Pay As Per Per Day Rate,1300,42914.48,26301.012
Inpatient Medical Services,Medicine and Surgery Services,554,BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,100,16176.58,1300,Pay As Per Per day Rate,15836.87,97.90% of Billed Vharges,N/A,NOT SEPERATELY REIMBURSABLE,15836.87,97.90% of Billed Charges,2737.25,Pay As Per Per Day Rate,2737.25,Pay As Per Per Day Rate,8353.08,100% of CMS IPPS Rate,2400,38% of Billed Charges,2737.25,Pay As Per Per Day Rate,1300,15836.87,9705.948
Inpatient Medical Services,Medicine and Surgery Services,602,Cellulitis w MCC,100,21242.36,1300,Pay As Per Per day Rate,20796.27,97.90% of Billed Vharges,N/A,NOT SEPERATELY REIMBURSABLE,20796.27,97.90% of Billed Charges,2737.25,Pay As Per Per Day Rate,2737.25,Pay As Per Per Day Rate,13664.19,100% of CMS IPPS Rate,2400,38% of Billed Charges,2737.25,Pay As Per Per Day Rate,1300,20796.27,12745.416
Inpatient Medical Services,Medicine and Surgery Services,603,CELLULITIS WITHOUT MCC,100,11853.33,1300,Pay As Per Per day Rate,11604.41,97.90% of Billed Vharges,N/A,NOT SEPERATELY REIMBURSABLE,11604.41,97.90% of Billed Charges,2737.25,Pay As Per Per Day Rate,2737.25,Pay As Per Per Day Rate,8854.93,100% of CMS IPPS Rate,2400,38% of Billed Charges,2737.25,Pay As Per Per Day Rate,1300,11604.41,7111.998
Inpatient Medical Services,Medicine and Surgery Services,637,Diabetes w MCC,100,14911.3,1300,Pay As Per Per day Rate,14598.16,97.90% of Billed Vharges,N/A,NOT SEPERATELY REIMBURSABLE,14598.16,97.90% of Billed Charges,2737.25,Pay As Per Per Day Rate,2737.25,Pay As Per Per Day Rate,13359.42,100% of CMS IPPS Rate,2400,38% of Billed Charges,2737.25,Pay As Per Per Day Rate,1300,14598.16,8946.78
Inpatient Medical Services,Medicine and Surgery Services,638,DIABETES WITH CC,100,10948.52,1300,Pay As Per Per day Rate,10718.6,97.90% of Billed Vharges,N/A,NOT SEPERATELY REIMBURSABLE,10718.6,97.90% of Billed Charges,2737.25,Pay As Per Per Day Rate,2737.25,Pay As Per Per Day Rate,8972.2,100% of CMS IPPS Rate,2400,38% of Billed Charges,2737.25,Pay As Per Per Day Rate,1300,10718.6,6569.112
Inpatient Medical Services,Medicine and Surgery Services,639,Diabetes w/o CC/MCC,100,2980.12,1300,Pay As Per Per day Rate,2917.54,97.90% of Billed Vharges,N/A,NOT SEPERATELY REIMBURSABLE,2917.54,97.90% of Billed Charges,2737.25,Pay As Per Per Day Rate,2737.25,Pay As Per Per Day Rate,6763.03,100% of CMS IPPS Rate,2400,38% of Billed Charges,2737.25,Pay As Per Per Day Rate,1300,6763.03,1788.072
Inpatient Medical Services,Medicine and Surgery Services,640,"MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W MCC",100,14197.38,1300,Pay As Per Per day Rate,13899.24,97.90% of Billed Vharges,N/A,NOT SEPERATELY REIMBURSABLE,13899.24,97.90% of Billed Charges,2737.25,Pay As Per Per Day Rate,2737.25,Pay As Per Per Day Rate,12289.54,100% of CMS IPPS Rate,2400,38% of Billed Charges,2737.25,Pay As Per Per Day Rate,1300,13899.24,8518.428
Inpatient Medical Services,Medicine and Surgery Services,641,"MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W/O MCC",100,12493.66,1300,Pay As Per Per day Rate,12231.29,97.90% of Billed Vharges,N/A,NOT SEPERATELY REIMBURSABLE,12231.29,97.90% of Billed Charges,2737.25,Pay As Per Per Day Rate,2737.25,Pay As Per Per Day Rate,8030.77,100% of CMS IPPS Rate,2400,38% of Billed Charges,2737.25,Pay As Per Per Day Rate,1300,12231.29,7496.196
Inpatient Medical Services,Medicine and Surgery Services,683,Renal failure w CC,100,12308.12,1300,Pay As Per Per day Rate,12049.65,97.90% of Billed Vharges,N/A,NOT SEPERATELY REIMBURSABLE,12049.65,97.90% of Billed Charges,2737.25,Pay As Per Per Day Rate,2737.25,Pay As Per Per Day Rate,8983.37,100% of CMS IPPS Rate,2400,38% of Billed Charges,2737.25,Pay As Per Per Day Rate,1300,12049.65,7384.872
Inpatient Medical Services,Medicine and Surgery Services,689,Kidney & urinary tract infections w MCC,100,15992.42,1300,Pay As Per Per day Rate,15656.58,97.90% of Billed Vharges,N/A,NOT SEPERATELY REIMBURSABLE,15656.58,97.90% of Billed Charges,2737.25,Pay As Per Per Day Rate,2737.25,Pay As Per Per Day Rate,11166.21,100% of CMS IPPS Rate,2400,38% of Billed Charges,2737.25,Pay As Per Per Day Rate,1300,15656.58,9595.452
Inpatient Medical Services,Medicine and Surgery Services,690,KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,100,13826.27,1300,Pay As Per Per day Rate,13535.92,97.90% of Billed Vharges,N/A,NOT SEPERATELY REIMBURSABLE,13535.92,97.90% of Billed Charges,2737.25,Pay As Per Per Day Rate,2737.25,Pay As Per Per Day Rate,8234.21,100% of CMS IPPS Rate,2400,38% of Billed Charges,2737.25,Pay As Per Per Day Rate,1300,13535.92,8295.762
Inpatient Medical Services,Medicine and Surgery Services,871,SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,100,22479.05,1300,Pay As Per Per day Rate,22006.99,97.90% of Billed Vharges,N/A,NOT SEPERATELY REIMBURSABLE,22006.99,97.90% of Billed Charges,2737.25,Pay As Per Per Day Rate,2737.25,Pay As Per Per Day Rate,17614.21,100% of CMS IPPS Rate,2400,38% of Billed Charges,2737.25,Pay As Per Per Day Rate,1300,22006.99,13487.43
Inpatient Medical Services,Medicine and Surgery Services,872,SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,100,17157.75,1300,Pay As Per Per day Rate,16797.44,97.90% of Billed Vharges,N/A,NOT SEPERATELY REIMBURSABLE,16797.44,97.90% of Billed Charges,2737.25,Pay As Per Per Day Rate,2737.25,Pay As Per Per Day Rate,10013.35,100% of CMS IPPS Rate,2400,38% of Billed Charges,2737.25,Pay As Per Per Day Rate,1300,16797.44,10294.65
Inpatient Medical Services,Medicine and Surgery Services,947,SIGNS AND SYMPTOMS WITH MCC,100,20956.4,1300,Pay As Per Per day Rate,20516.32,97.90% of Billed Vharges,N/A,NOT SEPERATELY REIMBURSABLE,20516.32,97.90% of Billed Charges,2737.25,Pay As Per Per Day Rate,2737.25,Pay As Per Per Day Rate,11782.12,100% of CMS IPPS Rate,2400,38% of Billed Charges,2737.25,Pay As Per Per Day Rate,1300,20516.32,12573.84
Inpatient Medical Services,Medicine and Surgery Services,948,SIGNS AND SYMPTOMS WITHOUT MCC,100,29374.06,1300,Pay As Per Per day Rate,28757.2,97.90% of Billed Vharges,N/A,NOT SEPERATELY REIMBURSABLE,28757.2,97.90% of Billed Charges,2737.25,Pay As Per Per Day Rate,2737.25,Pay As Per Per Day Rate,8187.14,100% of CMS IPPS Rate,2400,38% of Billed Charges,2737.25,Pay As Per Per Day Rate,1300,28757.2,17624.436
Outpatient Medical Services,Medicine and Surgery Services,19120,,360,3588,N/A,NOT SEPERATELY REIMBURSABLE,4865.45,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,4865.45,136.60% of BCBS Fee Schedule,1146.37,31.95% of Billed Charges,1146.37,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,1450,100% ASC Tier Groupings,1435.2,40% of Billed Charges,1146.37,4865.45,2152.8
Outpatient Medical Services,Medicine and Surgery Services,10160,PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,360,1300,N/A,NOT SEPERATELY REIMBURSABLE,650,50% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,650,50% of Billed Charges,415.35,31.95% of Billed Charges,415.35,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,520,40% of Billed Charges,385,650,780
Outpatient Medical Services,Medicine and Surgery Services,20520,Removal of Foreign Body,360,500,N/A,NOT SEPERATELY REIMBURSABLE,1038.45,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,1038.45,136.60% of BCBS Fee Schedule,159.75,31.95% of Billed Charges,159.75,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,500,100% ASC Tier Groupings,200,40% of Billed Charges,159.75,1038.45,300
Outpatient Medical Services,Medicine and Surgery Services,20526,"Injection, therapeutic (eg, local anesthetic, corticosteroid), carpal tunnel",360,500,N/A,NOT SEPERATELY REIMBURSABLE,567.44,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,567.44,136.60% of BCBS Fee Schedule,159.75,31.95% of Billed Charges,159.75,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,200,40% of Billed Charges,159.75,567.44,300
Outpatient Medical Services,Medicine and Surgery Services,20550,"Injection(s); single tendon sheath, or ligament",360,500,N/A,NOT SEPERATELY REIMBURSABLE,567.44,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,567.44,136.60% of BCBS Fee Schedule,159.75,31.95% of Billed Charges,159.75,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,200,40% of Billed Charges,159.75,567.44,300
Outpatient Medical Services,Medicine and Surgery Services,20551,Injection(s); single tendon origin/insertion Tendon Sheath,360,500,N/A,NOT SEPERATELY REIMBURSABLE,567.44,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,567.44,136.60% of BCBS Fee Schedule,159.75,31.95% of Billed Charges,159.75,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,200,40% of Billed Charges,159.75,567.44,300
Outpatient Medical Services,Medicine and Surgery Services,20552,INJ TRIGGER POINT 1/2 MUSCL,360,740,N/A,NOT SEPERATELY REIMBURSABLE,567.44,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,567.44,136.60% of BCBS Fee Schedule,236.43,31.95% of Billed Charges,236.43,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,296,40% of Billed Charges,236.43,567.44,444
Outpatient Medical Services,Medicine and Surgery Services,20552,INJ TRIGGER POINT 1/2 MUSCL,360,500,N/A,NOT SEPERATELY REIMBURSABLE,567.44,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,567.44,136.60% of BCBS Fee Schedule,159.75,31.95% of Billed Charges,159.75,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,200,40% of Billed Charges,159.75,567.44,300
Outpatient Medical Services,Medicine and Surgery Services,20553,Injection(s); single or multiple trigger point(s) three or more muscle(s),360,500,N/A,NOT SEPERATELY REIMBURSABLE,567.44,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,567.44,136.60% of BCBS Fee Schedule,159.75,31.95% of Billed Charges,159.75,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,200,40% of Billed Charges,159.75,567.44,300
Outpatient Medical Services,Medicine and Surgery Services,20600,"Arthrocentesis, aspiration and/or injection; small joint or bursa (eg, fingers, toes) Joint/Bursa",360,500,N/A,NOT SEPERATELY REIMBURSABLE,567.44,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,567.44,136.60% of BCBS Fee Schedule,159.75,31.95% of Billed Charges,159.75,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,200,40% of Billed Charges,159.75,567.44,300
Outpatient Medical Services,Medicine and Surgery Services,20605,"Arthrocentesis, aspiration and/or injection, intermediate joint or bursa; without ultrasound guidance",360,500,N/A,NOT SEPERATELY REIMBURSABLE,567.44,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,567.44,136.60% of BCBS Fee Schedule,159.75,31.95% of Billed Charges,159.75,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,200,40% of Billed Charges,159.75,567.44,300
Outpatient Medical Services,Medicine and Surgery Services,20610,"Arthrocentesis, aspiration and/or injection, major joint or bursa; without ultrasound guidance",360,500,N/A,NOT SEPERATELY REIMBURSABLE,567.44,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,567.44,136.60% of BCBS Fee Schedule,159.75,31.95% of Billed Charges,159.75,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,200,40% of Billed Charges,159.75,567.44,300
Outpatient Medical Services,Medicine and Surgery Services,20612,Aspiration and/or injection of ganglion cyst(s) any location,360,500,N/A,NOT SEPERATELY REIMBURSABLE,567.44,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,567.44,136.60% of BCBS Fee Schedule,159.75,31.95% of Billed Charges,159.75,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,200,40% of Billed Charges,159.75,567.44,300
Outpatient Medical Services,Medicine and Surgery Services,25560,Treat fracture radius & ulna,360,500,N/A,NOT SEPERATELY REIMBURSABLE,861.18,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,861.18,136.60% of BCBS Fee Schedule,159.75,31.95% of Billed Charges,159.75,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,200,40% of Billed Charges,159.75,861.18,300
Outpatient Medical Services,Medicine and Surgery Services,25600,Treat fracture radius/ulna,360,500,N/A,NOT SEPERATELY REIMBURSABLE,861.18,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,861.18,136.60% of BCBS Fee Schedule,159.75,31.95% of Billed Charges,159.75,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,200,40% of Billed Charges,159.75,861.18,300
Outpatient Medical Services,Medicine and Surgery Services,26600,Treat metacarpal fracture,360,500,N/A,NOT SEPERATELY REIMBURSABLE,430.58,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,430.58,136.60% of BCBS Fee Schedule,159.75,31.95% of Billed Charges,159.75,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,200,40% of Billed Charges,159.75,430.58,300
Outpatient Medical Services,Medicine and Surgery Services,27786,Treatment of ankle fracture,360,500,N/A,NOT SEPERATELY REIMBURSABLE,430.58,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,430.58,136.60% of BCBS Fee Schedule,159.75,31.95% of Billed Charges,159.75,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,200,40% of Billed Charges,159.75,430.58,300
Outpatient Medical Services,Medicine and Surgery Services,29065,"Application, cast; shoulder to hand (long arm)",360,500,N/A,NOT SEPERATELY REIMBURSABLE,250,50% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,250,50% of Billed Charges,159.75,31.95% of Billed Charges,159.75,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,200,40% of Billed Charges,159.75,385,300
Outpatient Medical Services,Medicine and Surgery Services,29075,"Application, cast; elbow to finger (short arm)",360,500,N/A,NOT SEPERATELY REIMBURSABLE,250,50% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,250,50% of Billed Charges,159.75,31.95% of Billed Charges,159.75,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,200,40% of Billed Charges,159.75,385,300
Outpatient Medical Services,Medicine and Surgery Services,29085,"Application, cast; hand and lower forearm (gauntlet)",360,250,N/A,NOT SEPERATELY REIMBURSABLE,125,50% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,125,50% of Billed Charges,79.88,31.95% of Billed Charges,79.88,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,100,40% of Billed Charges,79.88,385,150
Outpatient Medical Services,Medicine and Surgery Services,29105,Apply long arm splint,360,250,N/A,NOT SEPERATELY REIMBURSABLE,501.61,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,501.61,136.60% of BCBS Fee Schedule,79.88,31.95% of Billed Charges,79.88,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,100,40% of Billed Charges,79.88,501.61,150
Outpatient Medical Services,Medicine and Surgery Services,29125,Apply long arm splint,360,250,N/A,NOT SEPERATELY REIMBURSABLE,383.56,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,383.56,136.60% of BCBS Fee Schedule,79.88,31.95% of Billed Charges,79.88,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,100,40% of Billed Charges,79.88,385,150
Outpatient Medical Services,Medicine and Surgery Services,29130,Application of finger splint,360,250,N/A,NOT SEPERATELY REIMBURSABLE,235.32,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,235.32,136.60% of BCBS Fee Schedule,79.88,31.95% of Billed Charges,79.88,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,100,40% of Billed Charges,79.88,385,150
Outpatient Medical Services,Medicine and Surgery Services,29260,Strapping; elbow or wrist,360,500,N/A,NOT SEPERATELY REIMBURSABLE,250,50% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,250,50% of Billed Charges,159.75,31.95% of Billed Charges,159.75,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,200,40% of Billed Charges,159.75,385,300
Outpatient Medical Services,Medicine and Surgery Services,29405,Application of short leg cast (below knee to toes),360,500,N/A,NOT SEPERATELY REIMBURSABLE,250,50% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,250,50% of Billed Charges,159.75,31.95% of Billed Charges,159.75,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,200,40% of Billed Charges,159.75,385,300
Outpatient Medical Services,Medicine and Surgery Services,29505,"APPLICATION LONG LEG SPLINT, BILATERAL",360,250,N/A,NOT SEPERATELY REIMBURSABLE,501.61,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,501.61,136.60% of BCBS Fee Schedule,79.88,31.95% of Billed Charges,79.88,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,100,40% of Billed Charges,79.88,501.61,150
Outpatient Medical Services,Medicine and Surgery Services,29515,Application of short leg splint (calf to foot),360,250,N/A,NOT SEPERATELY REIMBURSABLE,501.61,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,501.61,136.60% of BCBS Fee Schedule,79.88,31.95% of Billed Charges,79.88,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,100,40% of Billed Charges,79.88,501.61,150
Outpatient Medical Services,Medicine and Surgery Services,29530,Strapping of knee,360,250,N/A,NOT SEPERATELY REIMBURSABLE,125,50% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,125,50% of Billed Charges,79.88,31.95% of Billed Charges,79.88,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,100,40% of Billed Charges,79.88,385,150
Outpatient Medical Services,Medicine and Surgery Services,29705,Removal or bivalving; full arm or full leg cast,360,500,N/A,NOT SEPERATELY REIMBURSABLE,270.44,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,270.44,136.60% of BCBS Fee Schedule,159.75,31.95% of Billed Charges,159.75,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,200,40% of Billed Charges,159.75,385,300
Outpatient Medical Services,Medicine and Surgery Services,64455,"Injection(s), anesthetic agent and/or steroid, plantar common digital nerve(s)",360,500,N/A,NOT SEPERATELY REIMBURSABLE,691.14,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,691.14,136.60% of BCBS Fee Schedule,159.75,31.95% of Billed Charges,159.75,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,200,40% of Billed Charges,159.75,691.14,300
Outpatient Medical Services,Medicine and Surgery Services,11055,TRIM SKIN LESION,360,340,N/A,NOT SEPERATELY REIMBURSABLE,212.22,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,212.22,136.60% of BCBS Fee Schedule,108.63,31.95% of Billed Charges,108.63,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,136,40% of Billed Charges,108.63,385,204
Outpatient Medical Services,Medicine and Surgery Services,11056,TRIM SKIN LESIONS 2 TO 4,360,360,N/A,NOT SEPERATELY REIMBURSABLE,212.22,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,212.22,136.60% of BCBS Fee Schedule,115.02,31.95% of Billed Charges,115.02,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,144,40% of Billed Charges,115.02,385,216
Outpatient Medical Services,Medicine and Surgery Services,11057,TRIM SKIN LESIONS OVER 4,360,380,N/A,NOT SEPERATELY REIMBURSABLE,265.43,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,265.43,136.60% of BCBS Fee Schedule,121.41,31.95% of Billed Charges,121.41,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,152,40% of Billed Charges,121.41,385,228
Outpatient Medical Services,Medicine and Surgery Services,11719,TRIM NAIL(S) ANY NUMBER,360,188,N/A,NOT SEPERATELY REIMBURSABLE,188.07,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,188.07,136.60% of BCBS Fee Schedule,60.07,31.95% of Billed Charges,60.07,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,75.2,40% of Billed Charges,60.07,385,112.8
Outpatient Medical Services,Medicine and Surgery Services,11720,DEBRIDE NAIL 1-5 PRO,360,188,N/A,NOT SEPERATELY REIMBURSABLE,188.07,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,188.07,136.60% of BCBS Fee Schedule,60.07,31.95% of Billed Charges,60.07,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,75.2,40% of Billed Charges,60.07,385,112.8
Outpatient Medical Services,Medicine and Surgery Services,11721,DEBRIDE NAIL 6 OR MORE,360,250,N/A,NOT SEPERATELY REIMBURSABLE,188.07,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,188.07,136.60% of BCBS Fee Schedule,79.88,31.95% of Billed Charges,79.88,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,100,40% of Billed Charges,79.88,385,150
Outpatient Medical Services,Medicine and Surgery Services,11730,REMOVAL OF NAIL BED,360,590,N/A,NOT SEPERATELY REIMBURSABLE,265.43,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,265.43,136.60% of BCBS Fee Schedule,188.51,31.95% of Billed Charges,188.51,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,236,40% of Billed Charges,188.51,385,354
Outpatient Medical Services,Medicine and Surgery Services,36573,INSERTION PICC 5YR+ W/ IMAGING,360,3281,N/A,NOT SEPERATELY REIMBURSABLE,4600.57,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,4600.57,136.60% of BCBS Fee Schedule,1048.28,31.95% of Billed Charges,1048.28,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,1300,100% ASC Tier Groupings,1312.4,40% of Billed Charges,1048.28,4600.57,1968.6
Outpatient Medical Services,Medicine and Surgery Services,36569,INSERTION PICC WO PORT 5YR> W/O IMAGING,360,2190,N/A,NOT SEPERATELY REIMBURSABLE,2060.64,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,2060.64,136.60% of BCBS Fee Schedule,699.71,31.95% of Billed Charges,699.71,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,500,100% ASC Tier Groupings,876,40% of Billed Charges,500,2060.64,1314
Outpatient Medical Services,Medicine and Surgery Services,11042,"DEBRIDEMENT SKIN, SUBCUTANEOUS TISSUE",360,1100,N/A,NOT SEPERATELY REIMBURSABLE,1307.44,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,1307.44,136.60% of BCBS Fee Schedule,351.45,31.95% of Billed Charges,351.45,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,440,40% of Billed Charges,351.45,1307.44,660
Outpatient Medical Services,Medicine and Surgery Services,11042,"DEBRIDEMENT SKIN, SUBCUTANEOUS TISSUE",360,585,N/A,NOT SEPERATELY REIMBURSABLE,1307.44,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,1307.44,136.60% of BCBS Fee Schedule,186.91,31.95% of Billed Charges,186.91,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,234,40% of Billed Charges,186.91,1307.44,351
Outpatient Medical Services,Medicine and Surgery Services,11043,DEBRIDE MUSCLE/FASCIA FIRST 20 CM,360,906,N/A,NOT SEPERATELY REIMBURSABLE,2053.7,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,2053.7,136.60% of BCBS Fee Schedule,289.47,31.95% of Billed Charges,289.47,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,362.4,40% of Billed Charges,289.47,2053.7,543.6
Outpatient Medical Services,Medicine and Surgery Services,11046,DEBRIDE MUSCLE/FASCIA Ea Addl 20 CM,360,114,N/A,NOT SEPERATELY REIMBURSABLE,57,50% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,57,50% of Billed Charges,36.42,31.95% of Billed Charges,36.42,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,45.6,40% of Billed Charges,36.42,385,68.4
Outpatient Medical Services,Medicine and Surgery Services,11056,TRIM SKIN LESION 2 to 4,360,340,289,85% Of Billed Charges,212.22,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,212.22,136.60% of BCBS Fee Schedule,108.63,31.95% of Billed Charges,108.63,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,136,40% of Billed Charges,108.63,385,204
Outpatient Medical Services,Medicine and Surgery Services,11057,TRIM SKIN LESION over 4,360,380,323,85% Of Billed Charges,265.43,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,265.43,136.60% of BCBS Fee Schedule,121.41,31.95% of Billed Charges,121.41,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,152,40% of Billed Charges,121.41,385,228
Outpatient Medical Services,Medicine and Surgery Services,17250,CHEMICAL CAUTERY TISSUE,360,306,260.1,85% Of Billed Charges,265.43,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,265.43,136.60% of BCBS Fee Schedule,97.77,31.95% of Billed Charges,97.77,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,122.4,40% of Billed Charges,97.77,385,183.6
Outpatient Medical Services,Medicine and Surgery Services,29581,APPLY MULTLAY COMPRS LWR LEG,360,250,212.5,85% Of Billed Charges,298.8,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,298.8,136.60% of BCBS Fee Schedule,79.88,31.95% of Billed Charges,79.88,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,100,40% of Billed Charges,79.88,385,150
Outpatient Medical Services,Medicine and Surgery Services,29580,APPLICATION OF UNNA BOOT,360,250,212.5,85% Of Billed Charges,501.61,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,501.61,136.60% of BCBS Fee Schedule,79.88,31.95% of Billed Charges,79.88,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,100,40% of Billed Charges,79.88,501.61,150
Outpatient Medical Services,Medicine and Surgery Services,97605,NEG PRESS WOUND TX </=50 CM,360,306,260.1,85% Of Billed Charges,212.22,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,212.22,136.60% of BCBS Fee Schedule,97.77,31.95% of Billed Charges,97.77,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,500,100% ASC Tier Groupings,122.4,40% of Billed Charges,97.77,500,183.6
Outpatient Medical Services,Medicine and Surgery Services,97597,SLCTV WND DEBRMENT 20CM/<,360,306,260.1,85% Of Billed Charges,170.87,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,170.87,136.60% of BCBS Fee Schedule,97.77,31.95% of Billed Charges,97.77,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,122.4,40% of Billed Charges,97.77,385,183.6
Outpatient Medical Services,Medicine and Surgery Services,97598,SLCTV WND DEBRIDEM ADDL 20CM,360,75,63.75,85% Of Billed Charges,213.7,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,213.7,136.60% of BCBS Fee Schedule,23.96,31.95% of Billed Charges,23.96,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,30,40% of Billed Charges,23.96,385,45
Outpatient Medical Services,Medicine and Surgery Services,10060,Incision and drainage of abscess,360,639,543.15,85% Of Billed Charges,495.68,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,495.68,136.60% of BCBS Fee Schedule,204.16,31.95% of Billed Charges,204.16,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,255.6,40% of Billed Charges,204.16,543.15,383.4
Outpatient Medical Services,Medicine and Surgery Services,10120,"Incision and removal of foreign body, subcutaneous tissues",360,,N/A,NOT SEPERATELY REIMBURSABLE,948.82,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,948.82,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,N/A,NOT SEPERATELY REIMBURSABLE,385,948.82,N/A
Outpatient Medical Services,Medicine and Surgery Services,10140,"Incision and drainage of hematoma, seroma or fluid collection",360,2689,2285.65,85% Of Billed Charges,3962.6,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,3962.6,136.60% of BCBS Fee Schedule,859.14,31.95% of Billed Charges,859.14,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,1300,100% ASC Tier Groupings,1075.6,40% of Billed Charges,859.14,3962.6,1613.4
Outpatient Medical Services,Medicine and Surgery Services,10160,Puncture drainage of lesion,360,639,543.15,85% Of Billed Charges,319.5,50% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,319.5,50% of Billed Charges,204.16,31.95% of Billed Charges,204.16,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,255.6,40% of Billed Charges,204.16,543.15,383.4
Outpatient Medical Services,Medicine and Surgery Services,11730,"Avulsion of Nail Plate, Partial or Complete, Simple; Single",360,590,501.5,85% Of Billed Charges,265.43,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,265.43,136.60% of BCBS Fee Schedule,188.51,31.95% of Billed Charges,188.51,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,236,40% of Billed Charges,188.51,501.5,354
Outpatient Medical Services,Medicine and Surgery Services,12001,"Repair Simple  Scalp, Neck, Axillae, Ext. Genital, Trunk and/or Extrem; 2.5 cm >",360,276,234.6,85% Of Billed Charges,495.68,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,495.68,136.60% of BCBS Fee Schedule,88.18,31.95% of Billed Charges,88.18,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,110.4,40% of Billed Charges,88.18,495.68,165.6
Outpatient Medical Services,Medicine and Surgery Services,12002,"Repair Simple  Scalp, Neck, Axillae, Ext. Genital, Trunk and/or Extrem; 2.6 cm t",360,276,234.6,85% Of Billed Charges,495.68,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,495.68,136.60% of BCBS Fee Schedule,88.18,31.95% of Billed Charges,88.18,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,110.4,40% of Billed Charges,88.18,495.68,165.6
Outpatient Medical Services,Medicine and Surgery Services,12004,"Repair Simple  Scalp, Neck, Axillae, Ext. Genital, Trunk and/or Extrem; 7.6 cm t",360,300,255,85% Of Billed Charges,495.68,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,495.68,136.60% of BCBS Fee Schedule,95.85,31.95% of Billed Charges,95.85,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,120,40% of Billed Charges,95.85,495.68,180
Outpatient Medical Services,Medicine and Surgery Services,12011,"Repair Simple  Face, Ears, Eyelids, Nose, Lips and/or Mucous Membranes; 2.5 cm >",360,276,234.6,85% Of Billed Charges,495.68,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,495.68,136.60% of BCBS Fee Schedule,88.18,31.95% of Billed Charges,88.18,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,110.4,40% of Billed Charges,88.18,495.68,165.6
Outpatient Medical Services,Medicine and Surgery Services,12013,"Repair Simple  Face, Ears, Eyelids, Nose, Lips and/or Mucous Membranes; 2.6 cm t",360,276,234.6,85% Of Billed Charges,495.68,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,495.68,136.60% of BCBS Fee Schedule,88.18,31.95% of Billed Charges,88.18,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,110.4,40% of Billed Charges,88.18,495.68,165.6
Outpatient Medical Services,Medicine and Surgery Services,12014,"Repair Simple  Face, Ears, Eyelids, Nose, Lips and/or Mucous Membranes; 5.1 cm t",360,300,255,85% Of Billed Charges,150,50% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,150,50% of Billed Charges,95.85,31.95% of Billed Charges,95.85,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,120,40% of Billed Charges,95.85,385,180
Outpatient Medical Services,Medicine and Surgery Services,20600,Drain/inj joint/bursa w/o us,360,809,687.65,85% Of Billed Charges,567.44,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,567.44,136.60% of BCBS Fee Schedule,258.48,31.95% of Billed Charges,258.48,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,323.6,40% of Billed Charges,258.48,687.65,485.4
Outpatient Medical Services,Medicine and Surgery Services,20600,Drain/inj joint/bursa w/o us,360,,N/A,NOT SEPERATELY REIMBURSABLE,567.44,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,567.44,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,N/A,NOT SEPERATELY REIMBURSABLE,385,567.44,N/A
Outpatient Medical Services,Medicine and Surgery Services,20605,Drain/inj joint/bursa w/o us,360,,N/A,NOT SEPERATELY REIMBURSABLE,567.44,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,567.44,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,N/A,NOT SEPERATELY REIMBURSABLE,385,567.44,N/A
Outpatient Medical Services,Medicine and Surgery Services,20605,Drain/inj joint/bursa w/o us,360,,N/A,NOT SEPERATELY REIMBURSABLE,567.44,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,567.44,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,N/A,NOT SEPERATELY REIMBURSABLE,385,567.44,N/A
Outpatient Medical Services,Medicine and Surgery Services,20610,Drain/inj joint/bursa w/o us,360,,N/A,NOT SEPERATELY REIMBURSABLE,567.44,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,567.44,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,N/A,NOT SEPERATELY REIMBURSABLE,385,567.44,N/A
Outpatient Medical Services,Medicine and Surgery Services,26010,Drainage of finger abscess,360,530,450.5,85% Of Billed Charges,378,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,378,136.60% of BCBS Fee Schedule,169.34,31.95% of Billed Charges,169.34,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,212,40% of Billed Charges,169.34,450.5,318
Outpatient Medical Services,Medicine and Surgery Services,29505,"APPLICATION LONG LEG SPLINT, BILATERAL",360,,N/A,NOT SEPERATELY REIMBURSABLE,501.61,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,501.61,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,N/A,NOT SEPERATELY REIMBURSABLE,385,501.61,N/A
Outpatient Medical Services,Medicine and Surgery Services,30901,"Control nasal hemorrhage, anterior, simple (limited cautery and/or packing) any method",360,235,199.75,85% Of Billed Charges,306.45,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,306.45,136.60% of BCBS Fee Schedule,75.08,31.95% of Billed Charges,75.08,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,94,40% of Billed Charges,75.08,385,141
Outpatient Medical Services,Medicine and Surgery Services,31500,Insert emergency airway,360,639,543.15,85% Of Billed Charges,615.38,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,615.38,136.60% of BCBS Fee Schedule,204.16,31.95% of Billed Charges,204.16,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,255.6,40% of Billed Charges,204.16,615.38,383.4
Outpatient Medical Services,Medicine and Surgery Services,36556,C-line over 5 years,360,2350,1997.5,85% Of Billed Charges,2060.64,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,2060.64,136.60% of BCBS Fee Schedule,750.83,31.95% of Billed Charges,750.83,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,500,100% ASC Tier Groupings,940,40% of Billed Charges,500,2060.64,1410
Outpatient Medical Services,Medicine and Surgery Services,51702,Insert temp bladder cath,360,393,334.05,85% Of Billed Charges,153.63,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,153.63,136.60% of BCBS Fee Schedule,125.56,31.95% of Billed Charges,125.56,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,157.2,40% of Billed Charges,125.56,385,235.8
Outpatient Medical Services,Medicine and Surgery Services,51702,Insert temp bladder cath,360,,N/A,NOT SEPERATELY REIMBURSABLE,153.63,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,153.63,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,N/A,NOT SEPERATELY REIMBURSABLE,153.63,385,N/A
Outpatient Medical Services,Medicine and Surgery Services,69200,Removal foreign body from external auditory canal,360,214,181.9,85% Of Billed Charges,153.62,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,153.62,136.60% of BCBS Fee Schedule,68.37,31.95% of Billed Charges,68.37,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,85.6,40% of Billed Charges,68.37,385,128.4
Outpatient Medical Services,Medicine and Surgery Services,99281,ER Visit Level 1,360,520,442,85% Of Billed Charges,249.91,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,249.91,136.60% of BCBS Fee Schedule,166.14,31.95% of Billed Charges,166.14,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,500,100% ASC Tier Groupings,208,40% of Billed Charges,166.14,500,312
Outpatient Medical Services,Medicine and Surgery Services,99282,ER Visit Level 2,360,710,603.5,85% Of Billed Charges,249.91,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,249.91,136.60% of BCBS Fee Schedule,226.85,31.95% of Billed Charges,226.85,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,500,100% ASC Tier Groupings,284,40% of Billed Charges,226.85,603.5,426
Outpatient Medical Services,Medicine and Surgery Services,99283,ER Visit Level 3,360,1220,1037,85% Of Billed Charges,437.49,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,437.49,136.60% of BCBS Fee Schedule,389.79,31.95% of Billed Charges,389.79,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,500,100% ASC Tier Groupings,488,40% of Billed Charges,389.79,1037,732
Outpatient Medical Services,Medicine and Surgery Services,99284,ER Visit Level 4,360,2800,2380,85% Of Billed Charges,761.27,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,761.27,136.60% of BCBS Fee Schedule,894.6,31.95% of Billed Charges,894.6,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,500,100% ASC Tier Groupings,1120,40% of Billed Charges,500,2380,1680
Outpatient Medical Services,Medicine and Surgery Services,99285,ER Visit Level 5,360,5310,4513.5,85% Of Billed Charges,761.27,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,761.27,136.60% of BCBS Fee Schedule,1696.55,31.95% of Billed Charges,1696.55,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,500,100% ASC Tier Groupings,2124,40% of Billed Charges,500,4513.5,3186
Outpatient Medical Services,Medicine and Surgery Services,29826,Shaving of shoulder bone using an endoscope,360,,N/A,NOT SEPERATELY REIMBURSABLE,11067.06,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,11067.06,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,385,100% ASC Tier Groupings,N/A,NOT SEPERATELY REIMBURSABLE,385,11067.06,N/A
Outpatient Medical Services,Medicine and Surgery Services,29881,Removal of one knee cartilage using an endoscope,360,7030,5975.5,85% Of Billed Charges,7026.8,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,7026.8,136.60% of BCBS Fee Schedule,2246.09,31.95% of Billed Charges,2246.09,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,3050,100% ASC Tier Groupings,2812,40% of Billed Charges,2246.09,7026.8,4218
Outpatient Medical Services,Medicine and Surgery Services,43235,"Diagnostic examination of esophagus, stomach, and/or upper small bowel using an endoscope",360,3938,3347.3,85% Of Billed Charges,2019.33,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,2019.33,136.60% of BCBS Fee Schedule,1258.19,31.95% of Billed Charges,1258.19,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,1300,100% ASC Tier Groupings,1575.2,40% of Billed Charges,1258.19,3347.3,2362.8
Outpatient Medical Services,Medicine and Surgery Services,43239,"Biopsy of the esophagus, stomach, and/or upper small bowel using an endoscope",360,4205,3574.25,85% Of Billed Charges,2019.33,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,2019.33,136.60% of BCBS Fee Schedule,1343.5,31.95% of Billed Charges,1343.5,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,1300,100% ASC Tier Groupings,1682,40% of Billed Charges,1300,3574.25,2523
Outpatient Medical Services,Medicine and Surgery Services,45378,Diagnostic examination of large bowel using an endoscope,360,4559,3875.15,85% Of Billed Charges,2142.63,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,2142.63,136.60% of BCBS Fee Schedule,1456.6,31.95% of Billed Charges,1456.6,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,1300,100% ASC Tier Groupings,1823.6,40% of Billed Charges,1300,3875.15,2735.4
Outpatient Medical Services,Medicine and Surgery Services,45380,Biopsy of large bowel using an endoscope,360,3925,3336.25,85% Of Billed Charges,2142.63,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,2142.63,136.60% of BCBS Fee Schedule,1254.04,31.95% of Billed Charges,1254.04,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,1300,100% ASC Tier Groupings,1570,40% of Billed Charges,1254.04,3336.25,2355
Outpatient Medical Services,Medicine and Surgery Services,45385,Removal of polyps or growths of large bowel using an endoscope,360,3649,3101.65,85% Of Billed Charges,2142.63,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,2142.63,136.60% of BCBS Fee Schedule,1165.86,31.95% of Billed Charges,1165.86,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,1300,100% ASC Tier Groupings,1459.6,40% of Billed Charges,1165.86,3101.65,2189.4
Outpatient Medical Services,Medicine and Surgery Services,47562,Removal of gallbladder using an endoscope,360,7413,6301.05,85% Of Billed Charges,10777.26,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,10777.26,136.60% of BCBS Fee Schedule,2368.45,31.95% of Billed Charges,2368.45,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,5000,100% ASC Tier Groupings,2965.2,40% of Billed Charges,2368.45,10777.26,4447.8
Outpatient Medical Services,Medicine and Surgery Services,49505,Repair of groin hernia patient age 5 years or older,360,8086,6873.1,85% Of Billed Charges,7170.67,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,7170.67,136.60% of BCBS Fee Schedule,2583.48,31.95% of Billed Charges,2583.48,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,3050,100% ASC Tier Groupings,3234.4,40% of Billed Charges,2583.48,7170.67,4851.6
Outpatient Medical Services,Medicine and Surgery Services,55700,Biopsy of prostate gland,360,4090,3476.5,85% Of Billed Charges,1112.33,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,1112.33,136.60% of BCBS Fee Schedule,1306.76,31.95% of Billed Charges,1306.76,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,1300,100% ASC Tier Groupings,1636,40% of Billed Charges,1112.33,3476.5,2454
Outpatient Medical Services,Medicine and Surgery Services,93000,"Electrocardiogram, routine, with interpretation and report",730,50,42.5,85% Of Billed Charges,164.11,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,164.11,136.60% of BCBS Fee Schedule,17.58,35.15% of LA Fee Schedule,15.98,31.95% of LA Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,60,Pay As Per Visit,15.98,31.95% of LA fee Schedule,15.98,164.11,30
Outpatient Medical Services,Medicine and Surgery Services,95805,Multiple Sleep Latency Test,760,3500,2975,85% Of Billed Charges,1796.36,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,1796.36,136.60% of BCBS Fee Schedule,1118.25,31.95% of Billed Charges,1118.25,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,1400,40% of Billed Charges,1118.25,2975,2100
Outpatient Medical Services,Medicine and Surgery Services,95807,Daytime Sleep Study,760,3500,2975,85% Of Billed Charges,1796.36,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,1796.36,136.60% of BCBS Fee Schedule,1118.25,31.95% of Billed Charges,1118.25,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,1400,40% of Billed Charges,1118.25,2975,2100
Outpatient Medical Services,Medicine and Surgery Services,95810,Sleep Study,760,4500,3825,85% Of Billed Charges,1796.36,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,1796.36,136.60% of BCBS Fee Schedule,1437.75,31.95% of Billed Charges,1437.75,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,1800,40% of Billed Charges,1437.75,3825,2700
Outpatient Medical Services,Medicine and Surgery Services,95811,Sleep Study,760,4950,4207.5,85% Of Billed Charges,1796.36,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,1796.36,136.60% of BCBS Fee Schedule,1581.53,31.95% of Billed Charges,1581.53,31.95% of Billed Charges,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,1980,40% of Billed Charges,1581.53,4207.5,2970
Outpatient Medical Services,Medicine and Surgery Services,97110,"PT, therapeutic exercise",420,92,78.2,85% Of Billed Charges,79.9,136.60% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,79.9,136.60% of BCBS Fee Schedule,17.83,110% Of LA Fee Schedule,16.21,100% of LA Fee SChedule,N/A,NOT SEPERATELY REIMBURSABLE,80,Pay As Per Visit,16.21,100% of LA Fee Schedule,16.21,80,55.2
Outpatient Medical Services,Medicine and Surgery Services,19120,,960,1150,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,556.36,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,397.02,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,397.02,556.36,690
Outpatient Medical Services,Medicine and Surgery Services,10160,PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,960,310,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,140.06,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,90.54,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,90.54,140.06,186
Outpatient Medical Services,Medicine and Surgery Services,20520,Removal of Foreign Body,960,350,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,307.38,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,139.06,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,139.06,307.38,210
Outpatient Medical Services,Medicine and Surgery Services,20526,"Injection, therapeutic (eg, local anesthetic, corticosteroid), carpal tunnel",960,350,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,117.72,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,53.84,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,53.84,117.72,210
Outpatient Medical Services,Medicine and Surgery Services,20550,"Injection(s); single tendon sheath, or ligament",960,350,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,81.13,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,37.14,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,37.14,81.13,210
Outpatient Medical Services,Medicine and Surgery Services,20551,Injection(s); single tendon origin/insertion Tendon Sheath,960,350,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,81.93,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,36.83,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,36.83,81.93,210
Outpatient Medical Services,Medicine and Surgery Services,20552,INJ TRIGGER POINT 1/2 MUSCL,960,170,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,83.17,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,34.99,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,34.99,83.17,102
Outpatient Medical Services,Medicine and Surgery Services,20552,INJ TRIGGER POINT 1/2 MUSCL,960,350,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,83.17,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,34.99,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,34.99,83.17,210
Outpatient Medical Services,Medicine and Surgery Services,20553,Injection(s); single or multiple trigger point(s) three or more muscle(s),960,350,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,95.81,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,39.76,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,39.76,95.81,210
Outpatient Medical Services,Medicine and Surgery Services,20600,"Arthrocentesis, aspiration and/or injection; small joint or bursa (eg, fingers, toes) Joint/Bursa",960,350,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,73.94,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,34.13,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,34.13,73.94,210
Outpatient Medical Services,Medicine and Surgery Services,20605,"Arthrocentesis, aspiration and/or injection, intermediate joint or bursa; without ultrasound guidance",960,350,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,77.04,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,35.09,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,35.09,77.04,210
Outpatient Medical Services,Medicine and Surgery Services,20610,"Arthrocentesis, aspiration and/or injection, major joint or bursa; without ultrasound guidance",960,350,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,91.81,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,43.21,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,43.21,91.81,210
Outpatient Medical Services,Medicine and Surgery Services,20612,Aspiration and/or injection of ganglion cyst(s) any location,960,350,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,90.72,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,39,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,39,90.72,210
Outpatient Medical Services,Medicine and Surgery Services,25560,Treat fracture radius & ulna,960,350,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,421.54,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,250.06,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,250.06,421.54,210
Outpatient Medical Services,Medicine and Surgery Services,25600,Treat fracture radius/ulna,960,350,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,491.68,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,310.39,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,310.39,491.68,210
Outpatient Medical Services,Medicine and Surgery Services,26600,Treat metacarpal fracture,960,350,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,439.61,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,275.6,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,275.6,439.61,210
Outpatient Medical Services,Medicine and Surgery Services,27786,Treatment of ankle fracture,960,350,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,472.22,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,275.86,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,275.86,472.22,210
Outpatient Medical Services,Medicine and Surgery Services,29065,"Application, cast; shoulder to hand (long arm)",960,350,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,142.88,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,64.12,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,64.12,142.88,210
Outpatient Medical Services,Medicine and Surgery Services,29075,"Application, cast; elbow to finger (short arm)",960,350,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,129.02,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,58.71,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,58.71,129.02,210
Outpatient Medical Services,Medicine and Surgery Services,29085,"Application, cast; hand and lower forearm (gauntlet)",960,100,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,141.72,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,63.52,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,63.52,141.72,60
Outpatient Medical Services,Medicine and Surgery Services,29105,Apply long arm splint,960,200,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,122.42,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,40.07,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,40.07,122.42,120
Outpatient Medical Services,Medicine and Surgery Services,29125,Apply long arm splint,960,150,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,95.05,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,37.89,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,37.89,95.05,90
Outpatient Medical Services,Medicine and Surgery Services,29130,Application of finger splint,960,110,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,62.34,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,27.63,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,27.63,62.34,66
Outpatient Medical Services,Medicine and Surgery Services,29260,Strapping; elbow or wrist,960,350,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,45.11,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,18.01,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,18.01,45.11,210
Outpatient Medical Services,Medicine and Surgery Services,29405,Application of short leg cast (below knee to toes),960,350,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,121.1,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,55.27,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,55.27,121.1,210
Outpatient Medical Services,Medicine and Surgery Services,29505,"APPLICATION LONG LEG SPLINT, BILATERAL",960,401,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,126.33,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,49.25,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,49.25,126.33,240.6
Outpatient Medical Services,Medicine and Surgery Services,29515,Application of short leg splint (calf to foot),960,100,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,106.76,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,47.05,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,47.05,106.76,60
Outpatient Medical Services,Medicine and Surgery Services,29530,Strapping of knee,960,120,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,45.42,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,17.11,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,17.11,45.42,72
Outpatient Medical Services,Medicine and Surgery Services,29705,Removal or bivalving; full arm or full leg cast,960,350,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,98.55,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,42.2,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,42.2,98.55,210
Outpatient Medical Services,Medicine and Surgery Services,64455,"Injection(s), anesthetic agent and/or steroid, plantar common digital nerve(s)",960,350,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,75.52,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,32.09,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,32.09,75.52,210
Outpatient Medical Services,Medicine and Surgery Services,11055,TRIM SKIN LESION,960,168,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,58.78,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,14.92,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,14.92,58.78,100.8
Outpatient Medical Services,Medicine and Surgery Services,11056,TRIM SKIN LESIONS 2 TO 4,960,168,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,70.68,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,21.1,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,21.1,70.68,100.8
Outpatient Medical Services,Medicine and Surgery Services,11057,TRIM SKIN LESIONS OVER 4,960,191,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,79.02,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,27.58,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,27.58,79.02,114.6
Outpatient Medical Services,Medicine and Surgery Services,11719,TRIM NAIL(S) ANY NUMBER,960,122,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,15.58,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,7.14,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,7.14,15.58,73.2
Outpatient Medical Services,Medicine and Surgery Services,11720,DEBRIDE NAIL 1-5 PRO,960,122,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,35.37,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,13.63,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,13.63,35.37,73.2
Outpatient Medical Services,Medicine and Surgery Services,11721,DEBRIDE NAIL 6 OR MORE,960,204,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,49.16,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,22.73,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,22.73,49.16,122.4
Outpatient Medical Services,Medicine and Surgery Services,11730,REMOVAL OF NAIL BED,960,260,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,116.42,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,51.22,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,51.22,116.42,156
Outpatient Medical Services,Medicine and Surgery Services,36573,INSERTION PICC 5YR+ W/ IMAGING,960,1100,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,623.85,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,78.55,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,78.55,623.85,660
Outpatient Medical Services,Medicine and Surgery Services,36569,INSERTION PICC WO PORT 5YR> W/O IMAGING,960,290,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,164.22,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,89.8,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,89.8,164.22,174
Outpatient Medical Services,Medicine and Surgery Services,11042,"DEBRIDEMENT SKIN, SUBCUTANEOUS TISSUE",960,400,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,130,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,57.28,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,57.28,130,240
Outpatient Medical Services,Medicine and Surgery Services,11042,"DEBRIDEMENT SKIN, SUBCUTANEOUS TISSUE",960,150,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,130,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,57.28,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,57.28,130,90
Outpatient Medical Services,Medicine and Surgery Services,11043,DEBRIDE MUSCLE/FASCIA FIRST 20 CM,960,322,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,252.45,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,145.63,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,145.63,252.45,193.2
Outpatient Medical Services,Medicine and Surgery Services,11046,DEBRIDE MUSCLE/FASCIA Ea Addl 20 CM,960,116,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,81.79,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,52.17,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,52.17,81.79,69.6
Outpatient Medical Services,Medicine and Surgery Services,11056,TRIM SKIN LESION 2 to 4,960,136,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,70.68,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,21.1,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,21.1,70.68,81.6
Outpatient Medical Services,Medicine and Surgery Services,11057,TRIM SKIN LESION over 4,960,191,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,79.02,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,27.58,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,27.58,79.02,114.6
Outpatient Medical Services,Medicine and Surgery Services,17250,CHEMICAL CAUTERY TISSUE,960,76,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,85.87,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,35.24,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,35.24,85.87,45.6
Outpatient Medical Services,Medicine and Surgery Services,29581,APPLY MULTLAY COMPRS LWR LEG,960,27,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,126.53,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,25.56,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,25.56,126.53,16.2
Outpatient Medical Services,Medicine and Surgery Services,29580,APPLICATION OF UNNA BOOT,960,73,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,92.89,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,25.16,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,25.16,92.89,43.8
Outpatient Medical Services,Medicine and Surgery Services,97605,NEG PRESS WOUND TX </=50 CM,960,66,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,33.68,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,23.3,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,23.3,33.68,39.6
Outpatient Medical Services,Medicine and Surgery Services,97597,SLCTV WND DEBRMENT 20CM/<,960,47,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,69.6,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,33.93,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,33.93,69.6,28.2
Outpatient Medical Services,Medicine and Surgery Services,97598,SLCTV WND DEBRIDEM ADDL 20CM,960,70,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,22.13,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,23.48,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,22.13,23.48,42
Outpatient Medical Services,Medicine and Surgery Services,10060,Incision and drainage of abscess,960,310,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,127.86,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,99.46,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,99.46,127.86,186
Outpatient Medical Services,Medicine and Surgery Services,10120,"Incision and removal of foreign body, subcutaneous tissues",960,350,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,162,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,98.61,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,98.61,162,210
Outpatient Medical Services,Medicine and Surgery Services,10140,"Incision and drainage of hematoma, seroma or fluid collection",960,326,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,180.5,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,111.28,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,111.28,180.5,195.6
Outpatient Medical Services,Medicine and Surgery Services,10160,Puncture drainage of lesion,960,350,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,140.06,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,90.54,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,90.54,140.06,210
Outpatient Medical Services,Medicine and Surgery Services,11730,"Avulsion of Nail Plate, Partial or Complete, Simple; Single",960,295,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,116.42,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,51.22,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,51.22,116.42,177
Outpatient Medical Services,Medicine and Surgery Services,12001,"Repair Simple  Scalp, Neck, Axillae, Ext. Genital, Trunk and/or Extrem; 2.5 cm >",960,137,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,95.79,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,42.87,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,42.87,95.79,82.2
Outpatient Medical Services,Medicine and Surgery Services,12002,"Repair Simple  Scalp, Neck, Axillae, Ext. Genital, Trunk and/or Extrem; 2.6 cm t",960,270,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,117.36,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,56.47,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,56.47,117.36,162
Outpatient Medical Services,Medicine and Surgery Services,12004,"Repair Simple  Scalp, Neck, Axillae, Ext. Genital, Trunk and/or Extrem; 7.6 cm t",960,340,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,138.21,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,70.67,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,70.67,138.21,204
Outpatient Medical Services,Medicine and Surgery Services,12011,"Repair Simple  Face, Ears, Eyelids, Nose, Lips and/or Mucous Membranes; 2.5 cm >",960,168,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,117.28,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,53.24,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,53.24,117.28,100.8
Outpatient Medical Services,Medicine and Surgery Services,12013,"Repair Simple  Face, Ears, Eyelids, Nose, Lips and/or Mucous Membranes; 2.6 cm t",960,290,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,123.35,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,55.94,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,55.94,123.35,174
Outpatient Medical Services,Medicine and Surgery Services,12014,"Repair Simple  Face, Ears, Eyelids, Nose, Lips and/or Mucous Membranes; 5.1 cm t",960,360,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,148.85,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,72.41,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,72.41,148.85,216
Outpatient Medical Services,Medicine and Surgery Services,20600,Drain/inj joint/bursa w/o us,960,150,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,73.94,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,34.13,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,34.13,73.94,90
Outpatient Medical Services,Medicine and Surgery Services,20600,Drain/inj joint/bursa w/o us,960,150,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,73.94,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,34.13,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,34.13,73.94,90
Outpatient Medical Services,Medicine and Surgery Services,20605,Drain/inj joint/bursa w/o us,960,170,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,77.04,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,35.09,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,35.09,77.04,102
Outpatient Medical Services,Medicine and Surgery Services,20605,Drain/inj joint/bursa w/o us,960,115,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,77.04,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,35.09,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,35.09,77.04,69
Outpatient Medical Services,Medicine and Surgery Services,20610,Drain/inj joint/bursa w/o us,960,190,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,91.81,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,43.21,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,43.21,91.81,114
Outpatient Medical Services,Medicine and Surgery Services,26010,Drainage of finger abscess,960,400,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,397.37,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,132.82,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,132.82,397.37,240
Outpatient Medical Services,Medicine and Surgery Services,29505,"APPLICATION LONG LEG SPLINT, BILATERAL",960,401,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,126.33,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,49.25,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,49.25,126.33,240.6
Outpatient Medical Services,Medicine and Surgery Services,30901,"Control nasal hemorrhage, anterior, simple (limited cautery and/or packing) any method",960,290,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,201.99,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,54.21,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,54.21,201.99,174
Outpatient Medical Services,Medicine and Surgery Services,31500,Insert emergency airway,960,570,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,225.41,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,134.84,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,134.84,225.41,342
Outpatient Medical Services,Medicine and Surgery Services,36556,C-line over 5 years,960,350,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,341.46,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,80.31,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,80.31,341.46,210
Outpatient Medical Services,Medicine and Surgery Services,51702,Insert temp bladder cath,960,195,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,100.06,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,24.06,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,24.06,100.06,117
Outpatient Medical Services,Medicine and Surgery Services,51702,Insert temp bladder cath,960,195,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,100.06,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,24.06,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,24.06,100.06,117
Outpatient Medical Services,Medicine and Surgery Services,69200,Removal foreign body from external auditory canal,960,200,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,90.18,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,44.86,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,44.86,90.18,120
Outpatient Medical Services,Medicine and Surgery Services,99281,ER Visit Level 1,960,90,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,23.61,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,11,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,11,23.61,54
Outpatient Medical Services,Medicine and Surgery Services,99282,ER Visit Level 2,960,170,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,46.07,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,40.2,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,40.2,46.07,102
Outpatient Medical Services,Medicine and Surgery Services,99283,ER Visit Level 3,960,260,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,69.03,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,68.48,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,68.48,69.03,156
Outpatient Medical Services,Medicine and Surgery Services,99284,ER Visit Level 4,960,490,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,131.05,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,116.58,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,116.58,131.05,294
Outpatient Medical Services,Medicine and Surgery Services,99285,ER Visit Level 5,960,740,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,193.3,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,168.99,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,168.99,193.3,444
Outpatient Medical Services,Medicine and Surgery Services,29826,Shaving of shoulder bone using an endoscope,960,550,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,280.26,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,162.35,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,162.35,280.26,330
Outpatient Medical Services,Medicine and Surgery Services,29881,Removal of one knee cartilage using an endoscope,960,1685,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,839.54,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,513.92,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,513.92,839.54,1011
Outpatient Medical Services,Medicine and Surgery Services,42820,Removal of tonsils and adenoid glands patient younger than age 12,960,,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,448.35,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,448.35,448.35,N/A
Outpatient Medical Services,Medicine and Surgery Services,43235,"Diagnostic examination of esophagus, stomach, and/or upper small bowel using an endoscope",960,670,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,420.63,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,115.14,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,115.14,420.63,402
Outpatient Medical Services,Medicine and Surgery Services,43239,"Biopsy of the esophagus, stomach, and/or upper small bowel using an endoscope",960,778,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,559.47,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,130.17,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,130.17,559.47,466.8
Outpatient Medical Services,Medicine and Surgery Services,45378,Diagnostic examination of large bowel using an endoscope,960,890,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,514.64,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,173.39,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,173.39,514.64,534
Outpatient Medical Services,Medicine and Surgery Services,45380,Biopsy of large bowel using an endoscope,960,1066,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,654.51,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,188.4,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,188.4,654.51,639.6
Outpatient Medical Services,Medicine and Surgery Services,45385,Removal of polyps or growths of large bowel using an endoscope,960,900,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,695.01,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,238.63,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,238.63,695.01,540
Outpatient Medical Services,Medicine and Surgery Services,45391,Ultrasound examination of lower large bowel using an endoscope,960,,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,413.66,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,413.66,413.66,N/A
Outpatient Medical Services,Medicine and Surgery Services,47562,Removal of gallbladder using an endoscope,960,1926,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,1053.85,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,629.78,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,629.78,1053.85,1155.6
Outpatient Medical Services,Medicine and Surgery Services,49505,Repair of groin hernia patient age 5 years or older,960,1587,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,829.53,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,498.61,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,498.61,829.53,952.2
Outpatient Medical Services,Medicine and Surgery Services,55700,Biopsy of prostate gland,960,614,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,421.44,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,123.58,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,123.58,421.44,368.4
Outpatient Medical Services,Medicine and Surgery Services,55866,Surgical removal of prostate and surrounding lymph nodes using an endoscope,960,,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,2586.48,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,2586.48,2586.48,N/A
Outpatient Medical Services,Medicine and Surgery Services,59400,"Routine obstetric care for vaginal delivery, including pre-and post- delivery care",960,,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,2238.5,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,2238.5,2238.5,N/A
Outpatient Medical Services,Medicine and Surgery Services,59510,"Routine obstetric care for cesarean delivery, including pre-and post-delivery care",960,,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,2238.5,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,2238.5,2238.5,N/A
Outpatient Medical Services,Medicine and Surgery Services,59610,Routine obstetric care for vaginal delivery after prior cesarean delivery including pre-and post-delivery care,960,,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,2686.2,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,2686.2,2686.2,N/A
Outpatient Medical Services,Medicine and Surgery Services,62322,Injection of substance into spinal canal of lower back or sacrum using imaging guidance,960,,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,242.98,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,242.98,242.98,N/A
Outpatient Medical Services,Medicine and Surgery Services,64483,Injections of anesthetic and/or steroid drug into lower or sacral spine nerve root using imaging guidance,960,,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,339.59,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,339.59,339.59,N/A
Outpatient Medical Services,Medicine and Surgery Services,66821,Removal of recurring cataract in lens capsule using laser,960,,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,476.79,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,476.79,476.79,N/A
Outpatient Medical Services,Medicine and Surgery Services,66984,Removal of cataract with insertion of lens,960,,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,932.94,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,932.94,932.94,N/A
Outpatient Medical Services,Medicine and Surgery Services,93000,"Electrocardiogram, routine, with interpretation and report",960,30,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,29.27,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,13.31,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,13.31,29.27,18
Outpatient Medical Services,Medicine and Surgery Services,93452,Insertion of catheter into left heart for diagnosis,960,,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,N/A,N/A
Outpatient Medical Services,Medicine and Surgery Services,95805,Multiple Sleep Latency Test,960,,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,482.1,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,482.1,482.1,N/A
Outpatient Medical Services,Medicine and Surgery Services,95807,Daytime Sleep Study,960,,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,493.84,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,493.84,493.84,N/A
Outpatient Medical Services,Medicine and Surgery Services,95810,Sleep Study,960,,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,708.81,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,708.81,708.81,N/A
Outpatient Medical Services,Medicine and Surgery Services,95811,Sleep Study,960,,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,743.03,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,743.03,743.03,N/A
Outpatient Medical Services,Medicine and Surgery Services,97110,"PT, therapeutic exercise",960,,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,25.09,100% of BCBS Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,27.6,100% OF CMS Physician Fee Schedule,N/A,NOT SEPERATELY REIMBURSABLE,N/A,NOT SEPERATELY REIMBURSABLE,25.09,27.6,N/A
Outpatient Medical Services,LAB,80055,Obstetric blood test panel,300,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,N/A
Outpatient Medical Services,LAB,81000,Manual urinalysis test with examination using microscope,300,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,N/A
Outpatient Medical Services,OUTPATIENT SERVICES,62323,Injection of substance into spinal canal of lower back or sacrum using imaging guidanc,360,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,N/A
Inpatient Medical Services,INPATIENT PROCEDURES,216,Cardiac valve and other major cardiothoracic procedures with cardiac catheterization with major complications or comorbidities,100,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,N/A
Inpatient Medical Services,INPATIENT PROCEDURES,460,Spinal fusion except cervical without major comorbid conditions or complications,100,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,N/A
Inpatient Medical Services,INPATIENT PROCEDURES,473,Cervical spinal fusion without comorbid conditions or major comorbid conditions or complications,100,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,N/A
Inpatient Medical Services,INPATIENT PROCEDURES,743,Uterine and adnexa procedures for non-malignancy without comorbid conditions or major comorbid conditions or complications,100,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,SERVICE NOT OFFERED,N/A